Early Pregnancy Extra Questions

1. The incidence of clinically recognised miscarriage in pregnancy is about

2. most common indication for women attending gynaecology emergency in theUK is:

3. Which of the following routes of administration is inappropriate for the drugmisoprostol:

4. Which one of the following ultrasound descriptions is diagnostic of miscarriage
(GS, gestational sac; CRL, crown-rump length; FHR, fetal heart rate)?

5. A 20-year-old, who is at 12 weeks’ gestation, has a 2-day history of vaginal bleeding and lower abdominal pain. Ultrasound shows a 25 mm fetal pole with absentfetal heart rate. Pelvic examination reveals her cervix to be 4 cm dilated with bulging intact membranes. Which one of the following is the most likely diagnosis?

6. A 29-year-old, who is at 6 weeks’ gestation, is diagnosed to have a right tubal ectopic pregnancy by transvaginal pelvic ultrasound. Which one of the following factorswould enable systematic methotrexate to be offered as a medical treatment optionfor the ectopic pregnancy?

7. A 29-year-old, who is at 6 weeks’ gestation, presents with slight vaginal spotting.Transvaginal pelvic ultrasound shows no evidence of any intrauterine or extrauterine pregnancy. A serum βhCG is measured at initial presentation and repeated 48 hlater. Which one of the following βhCG results is suspicious for a clinically significant ectopic pregnancy?

8. A patient with a positive pregnancy test, small amount of PV bleeding and noabdominal pain present has a single transvaginal ultrasound scan, showing an intrauterine gestational sac, with a crown-rump length (CRL) of 5 mm, with no fetalheart beat. Which of the following would be the most appropriate management plan?

9. A 25-year-old woman presents to the A+E department with left iliac fossa pain,vaginal bleeding and a positive pregnancy test. Which symptoms may be associatedwith an ectopic pregnancy?

10. 25-year-old woman presents to the A + E department with abdominal pain and apositive pregnancy test (8/40). USS is performed to rule out a miscarriage. USSshows an intrauterine gestational sac with the ratio of transverse to anteroposterior dimension, greater than 1.5 with cystic spaces in the placenta. What is the likelyultrasonographic diagnosis?

11. XY is a primigravida who presents to the A + E department with dark-browndischarge PV for 1 day and mild lower abdominal discomfort. She is 7/40 pregnantas per her LMP. Her TV scan shows the presence of a gestational sac and yolk sacwith a fetal pole of 7.5 mm and no fetal heart activity.Which of the following treatment options are best suited to her?

12. XY is a primigravida who is 9/40 weeks’ pregnant and has confirmed diagnosisof missed miscarriage (she had 2 transvaginal scans a week apart). After discussion of the various options, she opts for medical management for missed miscarriage.She is extremely anxious about the discomfort associated with the procedure andhas a low pain threshold.Which of the following is appropriate for medical management of missedmiscarriage?

13. XY is a primigravida who presents to the A + E department with dark-browndischarge PV for 1 day and mild lower abdominal discomfort. She is 7/40 pregnantas per her LMP. Hertransvaginal scan shows the presence of a gestational sacmeasuring 26 mm with no fetal pole. Which of the following treatment options arebest suited to her?

14. XY is 9/40 weeks’ pregnant. She presents to the early pregnancy clinic with ahistory of a painful vaginal heavy bleed 96 h ago. Ultrasound reveals a live fetus at9/40 weeks with a 5 × 5 cm subchorionichaematoma. Booking bloods reveal she is A negative with no atypical antibodies.Which of the following treatment options are best suited to her with regard toadministration of anti-D?

15. A 25-year-old woman diagnosed with a complete mole (16/40) is scheduled toundergo surgical evacuation in theatre. Which is the only acceptable managementplan in her case?

16. Which of the following statements is appropriate in women presenting with earlypregnancy with bleeding:

17. Medical management for an ectopic pregnancy can be considered if:

19. The incidence of gestational trophoblastic disease in the UK is calculated as:

19. Which of the following is not an example of gestational trophoblastic disease:

20. Which of the following statements is correct about molar pregnancy:

21. A woman who is nine weeks pregnant comes to the early pregnancy assessment unit complaining of severe nausea and occasional vomiting. She is not keen on drug therapy. What is your advice?

22. A 33-year-old woman, gravida 3, para 2, comes to the emergency department complaining of excessive vomiting for the last three days. She is otherwise asymptomatic with a normal past medical history. She is admitted and her thyroid function tests showed a low thyroid stimulating hormone (TSH) level with raised free thyroxine (T4). What is the most important feature to differentiate transient hyperthyroidism of hyperemesisgravidarum (THHG) from hyperthyroidism?

23. A primigravida who is 10 weeks pregnant is complaining of slight vaginal bleeding and the occasional abdominal colic. Ultrasound showed a live singleton pregnancy 3 of corresponding to her last menstrual period. She is worried about losing this pregnancy and asks for any medication to help keep the pregnancy. She has read something about progesterone treatment. How will you counsel her?

24. A 20-year-old woman who was nine weeks into her first pregnancy has just had a complete miscarriage. She is distressed and very tearful. You have explained that miscarriage does not affect her future fertility. Her partner is worried her anxiety may persist and be a possible cause of a delayed pregnancy. What else will you tell them?

25. A woman who is 11+3 weeks pregnant complained of abdominal colic and an attack of brisk vaginal bleeding. A repeat ultrasound confirmed fetal demise. You diagnosed inevitable miscarriage. She is considering expectant management. How will you counsel her?

26. A woman who is 11 weeks pregnant with confirmed miscarriage was very hesitant in deciding on medical or surgical management. She was still keen on avoiding the anaesthetic and surgical risks, if possible. What will you tell her about her chances of not having surgery if she opts for medical management?

27. A 20-year-old woman comes to the early pregnancy assessment unit with 7+6 weeks amenorrhea and mild to moderate vaginal bleeding with the occasional abdominal pain. She has a positive pregnancy test but refuses a transvaginal ultrasound scan. How will you handle the situation?

28. A woman who is eight weeks pregnant complains of vaginal bleeding. An ultrasound scan showed a crown rump length of 7 mm but no visible fetal heart. You advised her to come for a follow-up scan after seven days. She expressed her concern that waiting that long may harm the pregnancy or her health. How will you counter her concern?

29. The community midwife calls you about an eight-week pregnant woman who is complaining of vaginal bleeding and abdominal colic. A repeat scan confirmed fetal demise. She opted for expectant management. Her bleeding and abdominal pains have resolved. The woman wants to know how to confirm that miscarriage is complete. What is your advice?

30. A woman who is 11 weeks pregnant is diagnosed with incomplete miscarriage. She opts for medical management. What will you offer her?

31. A pregnant woman is diagnosed with miscarriage based on absent cardiac pulsation in repeat scans. She opted for surgical management as her work commitments would not allow for a long wait and she feels she may not be able to cope with bleeding and pain if she opts for medical management. She was undecided, however, about an outpatient setting manual vacuum aspirating (MVA) under a local anaesthetic or a hospital evacuation curettage (EVA) under a general anaesthetic. How will you counsel her?

32. A 23-year-old woman in her second pregnancy presents to you requesting surgical termination of the pregnancy. She is 11 weeks pregnant, verified by ultrasound scan. What is the risk of uterine perforation in this case?

34. A 31-year-old woman is booked for surgical termination of pregnancy at nine weeks’ gestation. Which of the following options is correct regarding prevention of infective complications?

34. The general practitioner calls you out of hours to ask what to do because she has an eight-week pregnant woman who is complaining of moderate right abdominal pain and slight vaginal bleeding. What is your advice?

35. The midwife in the early pregnancy assessment unit asks you to review a woman who has seven weeks of amenorrhea but the previous and current ultrasound could not locate the pregnancy. The human chorionic gonadotropin (BhCG) increased from 800 IU/L to 1600 IU/L after 48 hours. The woman is fit and well with no signs or symptoms. What is your next plan?

36. The serum BhCG of a symptomless woman with a pregnancy of unknown location (PUL) has dropped by more than 50% after 48 hours. What is the next step you advise?

37. A woman who is eight weeks pregnant is offered laparoscopic surgical management of an ectopic pregnancy. She had a previous normal pregnancy and vaginal delivery. How will you justify laparoscopic salpingectomy as opposed to salpingostomy?

1. Removing the diseased tube is easier and quicker to perform.
2. Removal of the diseased tube will not affect her future fertility.
3. Removing the ectopic pregnancy and keeping the tube will have a significantly higher incidence of a recurrent ectopic pregnancy requiring repeat surgery.
4. Removing the ectopic pregnancy and keeping the tube will require more followup visits and tests, currently.
5. There are no differences in the management options for the current or future pregnancies.

38. A 15-year-old single teenage girl comes to see you because she had an unplanned pregnancy. She is nine weeks pregnant after failure of an emergency post-coital contraception. She explains her great inability to handle either the pregnancy care or the child, if born, for personal and social reasons. How will you handle the situation?

39. The general practitioner calls to ask about the immediate follow-up of a woman who had a suction evacuation of a complete molar pregnancy. What is your advice?

40. A woman has an evacuation of a partial molar pregnancy. She was 11 weeks pregnant. What is your follow-up plan?

41. Following appropriate treatment of complete and partial molar pregnancies, what percentage of women need additional chemotherapy in each case, respectively?

42. A 36-year-old woman has had a suction evacuation because of a complete molar pregnancy. Her chorionic gonadotropin (hCG) levels started to rise six months after treatment. Her FIGO 2000 score was assessed as 6. What is your management?

43. A 28-year-old woman who has received single-agent chemotherapy because of a persistent rise in her chorionic gonadotropin levels after evacuation of a complete molar pregnancy asks about her future fertility options. What will you tell her?

44. To improve the results of treatment of gestational trophoblastic disease (GTD), what audit topic would you recommend?

45. You are counselling a couple who have had two consecutive miscarriages. She is 22 years old and wants to know if there are any age-related risks of miscarriage. Which of the following age groups is associated with the smallest risk of miscarriage?

46. There are cases of women who have recurrent miscarriages. What percentage of these women have antiphospholipid antibodies?

47. Your foundation year 2 trainee enquires about the different types of thrombophilia. Which of the following is an acquired thrombophilia?

48. A couple who have had three consecutive miscarriages have come to see you for advice after having a thrombophilia screen. The result showed that she was positive to one of the antiphospholipid antibodies. Which of the following is an antiphospholipid antibody?

49. A couple who have had three consecutive miscarriages have come to see you for counselling. Genetic screening showed a paternal balanced translocation. What is their chance of having a healthy baby?

50. A 20-year-old woman presents to the family planning clinic. She is requesting termination of a 10-week pregnancy. She had a surgical termination of a 14-week pregnancy six months previously. She had problems attending and complying with the different family planning options offered to her after completion of the termination of her previous pregnancy. What is your advice for an effective contraception in her situation?

51. A 25-year-old woman is referred to the clinic. She has a pituitary macroprolactinoma and has been treated with bromocriptine for a year. Her prolactin levels have been normal for the past six months. She is now 11 weeks pregnant and was advised to continue this medication. She is worried about any risks if she continues this medication while pregnant. What will you tell her?

52. A woman attends her first ultrasound scan in pregnancy. What is the maximum crown rump length (CRL) that is accurate for dating before you measure gestational age by head circumference (HC)

53. At what gestational age is chorionic villus sampling (CVS) usually performed?

54. A woman is currently being treated for acne with oral retinoids and finds herself pregnant in the first trimester. What is her chance of miscarrying?

55. A 30-year-old woman visits her GP at 8 weeks gestation in her second pregnancy with mild symptoms of nausea and vomiting of pregnancy (NVP). She had severe NVP in her first pregnancy requiring hospital admission and is concerned that her symptoms will worsen. What is the most appropriate advice from her GP?

56. What percentage of pregnant women with hyperemesis gravidarum in early pregnancy experience transient hyperthyroidism?

57. A woman has undergone surgical management of miscarriage and a partial molar pregnancy has been confirmed. Referral to a specialist centre is advised. Where are the three specialist referral centres in the United Kingdom?

58. A woman has undergone surgical management of miscarriage and the histology confirms Gestational Trophoblastic Disease (GTD). What is the expected incidence of GTD in the United Kingdom?

59. A woman has been diagnosed with high-risk gestational trophoblastic neoplasia (GTN) and is about to receive multiagent chemotherapy. What is the expected cure rate?

60. A woman has attended the gynaecology clinic to discuss a diagnosis of a molar pregnancy. What is the definitive method of diagnosis?

61. A woman underwent medical management of miscarriage but no specimen was sent for histological analysis. What would be the advice to the patient following this procedure?

62. During a routine surgical evacuation of miscarriage when should oxytocic agents be used?

63. A woman has had surgical management of miscarriage and a molar pregnancy has been confirmed. Which immunohistochemistry marker is useful for distinguishing between partial and complete molar pregnancies?

64. A woman has had surgical management of miscarriage and a molar pregnancy has been confirmed. Which immunohistochemistry marker is useful for distinguishing between partial and complete molar pregnancies?

65. A woman has had an ultrasound scan and the possibility of a molar pregnancy with a co-existing twin has been raised by the sonographer. The woman has been referred to a regional fetal medicine centre for further investigations. What would be the most appropriate investigation?

66. A 25-year-old woman attends the Early Pregnancy Unit with vomiting and bleeding. An ultrasound scan is performed, which is strongly suggestive of a molar pregnancy. What is the optimal method of uterine evacuation?

67. . A woman has had an ultrasound scan and the possibility of a molar pregnancy with a co-existing twin has been raised by the sonographer. The woman has been referred to a regional fetal medicine centre for further investigations. What would be the most appropriate investigation?

68. A 30-year-old woman attends the preconception counselling clinic. She has completed follow-up with the regional trophoblastic screening centre following a partial molar pregnancy. She is keen to try and conceive again, but wishes to know the risk of a further molar pregnancy. What would you tell her the risk is?

69. A woman attends the early pregnancy unit having experienced her second successive miscarriage. She has been researching miscarriage on the internet and has read that most miscarriages are due to genetic problems. What percentage of first-trimester miscarriages are due to chromosomal abnormalities?

70. What is the age-related risk of miscarriage in women under 20 years of age?

71. A woman attends the miscarriage clinic having experienced her third consecutive first-trimester loss. Which investigations should be undertaken?

72. Which B vitamin has been shown to be effective in the reduction of nausea and vomiting of pregnancy (NVP)?

73. A 30-year-old woman attends the early pregnancy unit with a positive pregnancy test and some lower abdominal pain. Her last menstrual period was approximately 8 weeks ago, but her menstrual cycle is irregular. A transvaginal ultrasound scan is organised, which demonstrates an intrauterine gestation sac with fetal pole and yolk sac, but no fetal heartbeat is identified. The crown-rump length (CRL) is 6mm. What is the correct course of action?

74. A woman who has had a left salpingectomy previously for ectopic pregnancy has now been diagnosed with an ectopic pregnancy in the right fallopian tube. A laparoscopy is performed and the surgeon opts for a salpingotomy as the woman still wishes to become pregnant. What is the possibility that she will require further treatment (methotrexate or salpingectomy)

75. A woman attends the early pregnancy unit and has a confirmed diagnosis of miscarriage. She is fit and well, and all observations are normal. What is the recommended first line management?

76. A woman who has blood group A Rh negative undergoes a laparoscopic salpingectomy for a ruptured ectopic pregnancy. What anti-D rhesus prophylaxis is required?

77. A woman underwent a surgical evacuation of the uterus following a failed intrauterine pregnancy. The products of conception were sent for histological analysis and a diagnosis of complete molar pregnancy was made. The woman was referred to the regional trophoblastic disease centre for follow-up, and subsequently required treatment with single-agent chemotherapy. She returns to clinic after completion of treatment as she wishes to conceive again. How long should she wait?

78. A woman attends for her first trimester dating scan at 12 weeks gestation and all appears well. Both fetal heart and fetal movements are seen. What is the chance that she will miscarry before 24 weeks of gestation?

79. What investigation is indicated for women following a second-trimester miscarriage, which is not indicated in recurrent first-trimester loss?

80. A healthy 30-year-old woman with recurrent first-trimester miscarriage attends the clinic for investigation and all tests recommended in the RCOG guideline are reported as normal. The woman is a member of an internet support group for miscarriage and has heard from other members that there may be other adjunctive treatments that can be used. What treatment would you recommend?