Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) A7–A13

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Best Practice & Research Clinical

Obstetrics and Gynaecology
journal homepage: www.elsevier.com/locate/bpobgyn

Acute Gynaecology Volume 1: Early Pregnancy Complications

Answers to Multiple Choice Questions
for Vol. 23, No. 4
1. (a) T (b) F (c) F (d) F (e) F

Explanations:
Compared to laparotomy, a laparoscopic procedure is not associated with increased bleeding.
Bleeding can be controlled effectively by either approach. Fimbrial expression is a very effective
method in removing fimbrial pregnancy. Most cases do not recur. Salpingostomy is associated with
increased risk of recurrent ectopic pregnancy compared to salpingectomy. However, recurrence
depends mainly on the condition of the tube. Although earlier studies demonstrated higher rate of
intrauterine pregnancy after salpingostomy, recent studies showed no difference between salpingec-
tomy and salpingostomy. Laparoscopy carries less risk of subsequent intraperitoneal adhesion
formation compared to laparotomy. However, tubal patency is not affected.

2. (a) F (b) F (c) T (d) T (e) F

Explanations:
Salpingectomy does not eliminate the risk of developing future interstitial (cornual) pregnancy.
Clinically stable patients with interstitial pregnancy should be treated with methotrexate. Surgical
resection of interstitial pregnancy is very effective. The problem with surgical evacuation of cervical
pregnancy is the risk of intractable hemorrhage during the procedure. All precautionary measures
must be taken before attempting surgery. The occurrence of Caesarean scar ectopic pregnancy is
mainly due to a defective uterine scar. Although methotrexate can treat this form of ectopic pregnancy
effectively, complete resection decreases the chance of recurrence.

3. (a) F (b) T (c) F (d) F (e) F

Explanations:
5.9% of women with ultrasound appearances of a complete miscarriage are eventually found to have
an ectopic pregnancy. If an intrauterine pregnancy has not previously been demonstrated, this preg-
nancy should be considered to have an unknown location and be investigated with serial quantitative
bhCG levels and ultrasound as required. The absence of RPOC at ERPC should not be used to diagnose an
ectopic pregnancy. Also endometrial echoes of <15 mm is the accepted cut off for a complete
miscarriage. Even with a proven intrauterine pregnancy, the chance of obtaining products of
conception is low in this situation. The use of medical management is not indicated and increases the

1521-6934/$ – see front matter

doi:10.1016/j.bpobgyn.2009.08.006
A8 Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) A7–A13

risk of tubal rupture if the pregnancy is subsequently shown to be ectopic. Laparoscopy should only be
performed if EP is diagnosed on TVS or if clinical symptoms are of concern.

4. (a) F (b) T (c) F (d) F (e) T

Explanations:
Psychological outcomes are better when women have chosen their preferred treatment. A serum
progesterone threshold of 20 IU predicts spontaneous resolution of pregnancy with a specificity of 94%.
If the patient is willing, it is reasonable to wait for resolution which may take up to 8 weeks without an
increase in the risk of infection. A clear plan and time frame should be decided with the patient. A
serum bhCG threshold of 295 IU predicts the spontaneous resolution of pregnancy with a sensitivity of
41% and a specificity of 63%; values too low for clinical use. ‘Care based’ counselling has been shown to
improve emotional wellbeing.

5. (a) F (b) T (c) F (d) F (e) F

Explanations:
ERPC can be performed under local anaesthesia. This is used more commonly in the USA than UK
however. A study has shown that 70% women managed medically complained of gastrointestinal side
effects, whilst this was true of only 10% of surgically managed women. In a study comparing women
who had undergone medical and surgical management of miscarriage, there was no difference in the
interval to pregnancy. Cervical priming with prostaglandins, not an anti-progestogen, softens the
cervix reducing the risk of cervical lacerations and uterine perforation. Studies have either shown no
significant difference in recuperation times for the different management options, or that women
managed medically require a slightly longer period to recover.

6. (a) F (b) F (c) T (d) F (e) T

Explanations:
There is no identifiable cut off value for endometrial thickness to diagnose an incomplete miscar-
riage and the diagnosis is made on the finding of irregular heterogenous mixed echoes within the
endometrial cavity. If an intrauterine pregnancy has previously been visualized then a complete
miscarriage may be diagnosed by the finding of an empty uterus. The diagnosis of an empty sac can
indeed be reliably made when the mean sac diameter is less than 20 mm but there has been no growth
over an interval of 7 days. A diagnosis of fetal or early pregnancy loss should not be made unless the
fetus is at least 6 mm in size with no visible cardiac activity. A pregnancy implanted within the cervix is
likely to show low impedance, high velocity peripheral trophoblastic flow.

7. (a) F (b) T (c) F (d) F (e) T

Explanations:
When the embryonic size is 2-5 mm the embryonic heart rate in a normal pregnancy may be less
than 100beats per minute but rises rapidly thereafter. Low progesterone has been shown to reliably
predict pregnancy failure. Although the ‘empty amnion sign’ is a recognized phenomenon, it is not
included in the published diagnostic criteria for miscarriage. The rate of miscarriage increases sharply
from 35 years so the rate at 35 years is 20% and is 55% at 42 years (nearly three times the risk).
Gestational trophoblastic disease is indeed confirmed histologically in 50% of cases where the diag-
nosis is suspected ultrasonographically.

8. (a) T (b) F (c) T (d) F (e) T

Explanations:
All women with a history suggestive of a complete miscarriage who have not had a previous TVS
showing an intra-uterine sac in this pregnancy should be managed as PULs, as up to 6% of them will
 Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) A7–A13 A9

subsequently be diagnosed with an ectopic pregnancy. A small intra-uterine gestational sac containing
a yolk sac visualised on TVS by definition is an IUP. A pseudosac is a misnomer, as it simply refers to
a collection of fluid within the endometrial cavity and is not diagnostic of an ectopic pregnancy. An
intra-uterine gestational sac containing a fetal pole with a crown-rump length of 5 mm but with no
obvious fetal cardiac activity needs follow up for viability. A thickened endometrium on TVS but with
no obvious gestational sac or retained products of conception visualized is also managed as a PUL.

9. (a) F (b) F (c) F (d) F (e) T

Explanations:
The term ‘pregnancy of unknown location’ is not synonymous with ectopic pregnancy. Most women
will subsequently be found to have failing pregnancies or intra-uterine pregnancies. Serum proges-
terone levels are useful in the prediction of pregnancy viability rather than location. Uterine curettage
should not be used routinely in the management of PULs. Some ectopic pregnancies will behave like
intra-uterine pregnancies and have an hCG that increases >66% in 48 hours. However, not all intra-
uterine pregnancies will have an hCG that increases by >66% in 48 hours.

10. (a) T (b) F (c) F (d) T (e) F

Explanations:
The most reliable USS feature for DC is the lambda sign ‘‘l’’ with sensitivity and specificity of 97.4%
and 100%, respectively. In MC, the most useful feature is the ‘‘T’’ sign with a sensitivity of 100% and
specificity of 98.2%. The cut-off point of 2.0 mm thickness of the membrane can determine the
chorionicity as early as 7–9 weeks’ gestation with a sensitivity of 75.7–83%, and a specificity of
83–85.7%. MC has 4-5 fold greater morbidity and mortality compared to DC; the most common
problems are discordant fetal growth (41.6% vs 22.8%), and preterm delivery (66.6% vs 32.6%). The
perinatal mortality rate in MC versus DC is 93.7 per thousand vs 21.7 per thousand.

11. (a) T (b) T (c) F (d) F (e) F

Explanations:
The gold standard for diagnosis of TTTS is ultrasound. This can be done as early as the first trimester.
It occurs exclusively in monochorionic twins irrespective of amniocity. However, dichorionic twins can
develop some features of inter-twin discordance without TTTS. The donor twin becomes hypovolemic
and oliguric or anuric as a result of hypoperfusion. The recipient twin becomes hypervolemic, polyuric,
and may develop polyhydramnios due to hyperperfusion. Severe untreated TTTS has a 60–100% fetal or
neonatal mortality rate. Mild-to-moderate TTTS is frequently associated with premature delivery. Fetal
demise of one twin is associated with neurologic sequelae in 25% of surviving twins. On those unaf-
fected monochorionic twins, the shunt of blood between twins is bidirectional and balanced.

12. (a) F (b) T (c) F (d) T (e) F

Explanations:
Early signs of this condition is nuchal translucency discordant >20%, discordant bladder filling,
differences in amniotic fluid compartments, and decreased pulsatility index (PI) in the renal artery of
the recipient. It is the result of inter-twin transfusion through deep unidirectional arterio-venous
anastomoses (AVA) from one twin (donor) to another twin (recipient). Arterio-arterio anastomoses are
bi-directional and are therefore protective.

13. (a) T (b) F (c) T (d) T (e) F

Explanations:
The recent use of early ultrasound has made the documentation of early human fetal loss in
multiple gestation possible. The increased rate of this phenomenon in induced/IVF pregnancies is
A10 Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) A7–A13

explained by the fact that early TVS are routinely performed at fertility clinics. The occurence of this
phenomenon is likely to be under-estimated as it undoubtedly occurs in many pregnancies which are
unscanned as they are asymptomatic. The associated morbidity to the surviving twin increases with
increasing gestational age. The disappearance of a second gestation sac may be associated with vaginal
bleeding with an incidence range between 7.8 and 76.5%.

14. (a) F (b) F (c) F (d) F (e) F

Explanations:
Fetal growth is often not uniform among even healthy twin pregnancies. If discrepancy occurs, CRL
from the larger twin should be used to date the pregnancy as the smaller twin may have potentially
decreased growth and can lead to underestimation of gestational age. However, if the inter-twin
discrepancy exceeds the 95th percentile, this was shown to be a predictor of poor outcome for the
smaller twin, generally resulting from aneuploidy or subsequent fetal demise. It can occur for other
reasons e.g. TTTS. Twins with unequally shared placentas at early pregnancy significantly more often
have severe weight discordance at birth.

15. (a) T (b) F (c) T (d) F (e) F

Explanations:
The gestational sac is anterior covering the visible or presumed site of the previous lower uterine
segment Caesarean section scar. Medical management with methotrexate is up to 80% successful.
Shirodkar sutures greatly reduce the need for blood transfusions. There are case reports of uterine
artery embolisation used to treat severe haemorrhage in management of caesarean scar pregnancies.
Methotrexate has been used as a local injection of 25 mg directly into the gestational sac.

16. (a) F (b) F (c) T (d) F (e) T

Explanations:
The two are differing entities. An interstitial pregnancy is on in the interstitial portion of the fal-
lopian tube and a cornual pregnancy is in the rudimentary horn of unicornuate uterus. An hCG level of
less than 9,000 IU/L is associated with successful medical management. Vasopressin injection followed
by endoloop closure has been successful in early gestations. There are still concerns about the effect on
future fertility after selective uterine artery embolisation. The diagnosis of an interstitial pregnancy is
made by visualisation of the interstitial line adjoining the gestational sac and the lateral aspect of the
uterine cavity and continuation of the myometrial mantle around the ectopic sac.

17. (a) F (b) F (c) T (d) T (e) T

Explanations:
Only the last three are considered malignant with different prognosis and management. However,
there is a risk of malignant sequelae with hydatidform mole pregnancy. It is more common after a CHM
(15%–20%) than following PHM (4%–10%).

18. (a) F (b) T (c) F (d) T (e) F

Explanations:
The classical features of PHM are increased transverse GSD ratio, Swiss cheese or placentomegaly
and fetal malformation. A ‘‘snowstorm’’ pattern is characteristic of CHM. Increased uterine vascularity
is usually a feature of gestational trophoblastic neoplasia (GTN).
 Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) A7–A13 A11

19. (a) F (b) F (c) F (d) T (e) F

Explanations:
Oxytocin can increase the intrauterine pressure causing embolisation of trophoblastic tissue to
other organs and increased risk of subsequent chemotherapy. Any uterine evacuation should aim to
empty the uterus at the first procedure and surgical suction evacuation is the best way of achieving
this. Molar pregnancies also have an increased risk of failed expectant management which will only
delay uterine evacuation. Hysterectomy is only really necessary (due to the low risk of malignancy)
when there is intractable haemorrhage or in the presence of gestational trophoblastic neoplasia (GTN).

20. (a) F (b) T (c) T (d) F (e) F

Explanations:
Data about the prevalence of ovarian masses in pregnancy and the risk of malignancy are limited to
retrospective cohorts or population-based studies. Few studies are prospective longitudinal follow-up
studies. According to these studies, the prevalence of ovarian masses in pregnancy varies between
0.19% and 8.8%. Most cysts found in early pregnancy spontaneously resolve and therefore decrease with
advancing gestational age.

21. (a) T (b) T (c) T (d) F (e) F

Explanations:
Functional ovarian cysts include follicular, corpus luteum, and theca-lutein cysts. Among functional
cysts the most common are pregnancy-related corpus luteal cysts, which tend to resolve by 16 weeks of
gestation. After functional cysts, the most common ovarian tumors diagnosed in pregnancy include, in
descending order: benign cystic teratomas, serous cystadenomas, paraovarian cysts, mucinous cys-
tadenomas, endometriomas, and malignant tumors. This reflects the fact that the pregnant population
is young where the incidence of malignancy is low to begin with. Due to increasing uterine size as
pregnancy progresses, identifying separate ovaries becomes increasingly difficult.

22. (a) F (b) F (c) T (d) F (e) F

Explanations:
During pregnancy, the clinical significance of an abnormally high CA-125 is reduced because this
marker is elevated during pregnancy, especially in the first trimester, and declines with advancing
gestational age. Furthermore, CA-125 is not as commonly elevated in non-epithelial ovarian cancers.
Consequently, because germ cell tumors are proportionately more common in pregnant women, the
sensitivity of CA-125 may not be as sensitive during pregnancy.

23. (a) F (b) F (c) T (d) F (e) T

Explanations:
Although two-thirds of persistent benign ovarian masses in non-pregnant women are comprised of
endometriomas and dermoids, this is not the case in the pregnant state. Further imaging is unnec-
essary with high quality TVS as the diagnosis of a physiological cyst is straightforward. Most ovarian
cysts in pregnancy are physiological in nature and therefore should be managed non-surgically unless
symptoms warrant removal or there is a suspicion of malignancy.

24. (a) F (b) F (c) T (d) F (e) T

Explanations:
Organogensis is essentially complete after 10 weeks gestation. The greatest embryonic length
cannot be measured until the true crown and rump can be identified, which is around 8 weeks
A12 Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) A7–A13

gestation. After 14 weeks, the biparietal diameter and femur length become more reliable for esti-
mating gestational age. Evidence suggests that ultrasound dating is more accurate than menstrual
dating even in women with certain dates and guidelines now recommend ultrasound dating of all
pregnancies between 11 and 14 weeks. Ultrasound dating of pregnancy does indeed result in a reduced
post term delivery rate.

25. (a) F (b) T (c) F (d) F (e) T

Explanations:
First trimester growth may be reduced in both chromosomally abnormal pregnancies, those
destined to miscarry and those at risk of subsequent IUGR. There is some evidence that first trimester
growth is also influenced by maternal factors such as age and ethnicity. Pregnancies that are small for
gestational age at 12 weeks gestation have a higher incidence of developing intrauterine growth
retardation and preterm delivery. IUGR appears to be present from the first trimester in many cases.
Early growth restriction has been demonstrated in association with trisomy 18 and triploidies but not
trisomy 21 or monosomy X. Growth failure is usually present in chromosomally normal pregnancies
that go on to subsequently miscarry. Fetuses with an increased gestational size in the first trimester
tend to remain normal–large.

26. (a) F (b) T (c) F (d) T (e) F

Explanations:
Although there may be TVS findings suggestive of a haemoperitoneum, it is not diagnostic of an
ectopic pregnancy. It may be found in both non-pregnant women and women with intra-uterine
pregnancies who have ruptured ovarian cysts. An empty uterus is normally seen in women with an
ectopic pregnancy, but it is possible to have a co-existing intra-uterine pregnancy (heterotopic preg-
nancy). A pseudosac is a misnomer, as it simply refers to a collection of fluid within the endometrial
cavity and is not diagnostic of an ectopic pregnancy. b and d are criteria that can be used to diagnose
a tubal ectopic pregnancy on TVS.

27. (a) F (b) F (c) F (d) T (e) F

Explanations:
Ovarian ectopic pregnancies can be visualised on TVS prior to treatment, but diagnosis is more
difficult than with other types of ectopic pregnancy. Care must be taken not to mistake it with other
ovarian pathology. The absence of the ’sliding sign’ may be used to distinguish between a miscarrying
intra-uterine pregnancy and an implanted cervical pregnancy. When pressure is applied to the cervix
using a TVS probe, in a miscarriage the gestational sac slides against the endocervical canal but does not
in an implanted cervical pregnancy. It is not essential to visualise a sac containing a fetal pole. As with
tubal ectopic pregnancies there may be an inhomogeneous mass or an empty gestational sac. The
endometrium may be thickened and a co-existing intra-uterine pregnancy (heterotopic) may be present.

28. (a) F (b) F (c) T (d) F (e) T

Explanations:
66% of women with HG have biochemical thyrotoxicosis. Thyroid function outside the normal range
in early pregnancy is described as transient gestational thyrotoxicosis. Further investigation or treat-
ment is only indicated if there are other clinical symptoms or signs of thyrotoxicosis. Studies of
abnormal thyroid function in women with HG show return to normal levels of both T4 and TSH by 19
weeks gestation. Electrolyte abnormalities have been correlated with degree of thyroid dysfunction but
treatment of HG has not been shown to correct thyroid dysfunction. Changes in iodine metabolism,
serum thyroid binding proteins and maternal goitre development occur in normal pregnancy.
 Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) A7–A13 A13

29. (a) T (b) T (c) F (d) T (e) F

Explanations:
Antihistamine antiemetics have a strong safety record for treatment of HG with no adverse
outcomes being proven over several decades of use. Pyridoxine (vitamin B6) has been shown to be
effective in reducing nausea and vomiting and is commonly used in combination formula with dox-
ylamine, an antihistamine antiemetic. Ondansetron, an alternative 5HT3 antagonist has been used
fairly extensively in HG with no adverse safety concerns. However there is insufficient data on gra-
nisetron to advocate its management. Phenothiazines are commonly used for HG with no safety
concerns, though acute dystonic reactions may classically occur and need treatment with discontin-
uation of the drug and administration of procyclidine. There is insufficient safety data to support the
use of domperidone in early pregnancy.

30. (a) T (b) T (c) F (d) F (e) F

Explanations:
Caution is needed in not correcting hyponatraemia too rapidly to avoid iatrogenic osmotic demy-
elination syndrome. Hypokalaemia occurs as a result of excessive vomiting causing increase in
extracellular potassium to compensate for the loss of hydrogen ions in the Gastrointestinal tract. This
should be corrected with cautious intravenous potassium administration with the saline infusion.
Although raised urea and creatinine may occur in severe dehydration, urea is usually decreased in HG
due to decreased oral intake. Calcium is usually normal in HG. Metabolic alkalosis occurs due to
excessive vomiting.