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OG9.1-6 | Early Pregnancy Complications — Graded Quiz
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A 26-year-old G2P1 at 9 weeks presents with heavy vaginal bleeding and severe cramping for 4 hours. On examination: BP 90/60 mmHg, HR 118/min, uterus is 9-week size, cervical os is widely open, and fragmented tissue is visible at the os. Ultrasound shows an irregular heterogeneous intrauterine collection. What is the most appropriate immediate management?
Correct. This is haemodynamically unstable incomplete abortion (open os, tissue at os, hypotension, tachycardia). Immediate management is fluid/blood resuscitation followed by urgent suction evacuation (MVA) to remove retained products and achieve haemostasis.
Haemodynamically unstable incomplete abortion: IV access + fluids/blood transfusion + urgent MVA. The open os confirms the POC are not retained against a closed os — evacuation is safe and life-saving. Delay risks worsening haemorrhagic shock.
The haemodynamic compromise (BP 90/60, HR 118) combined with open os and tissue at the os defines haemodynamically unstable incomplete abortion. The imperative is resuscitation then surgical evacuation. Expectant or outpatient medical management is contraindicated in haemodynamic instability.
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A 29-year-old woman at 11 weeks is found on routine ultrasound to have an intrauterine sac with a fetal pole but no cardiac activity. There is no bleeding and the cervical os is closed. She is clinically stable. Which term correctly describes this diagnosis?
Correct. Missed abortion (also called early fetal demise) is defined by intrauterine fetal death with a retained fetus, a closed os, and no expulsion. Blighted ovum refers specifically to an anembryonic sac (no fetal pole formed). Here, a fetal pole is present but non-viable.
Missed abortion vs blighted ovum: missed abortion has a fetal pole with no cardiac activity; blighted ovum has only a gestational sac without a visible fetal pole. Both are managed by expectant, medical (misoprostol), or surgical evacuation. Do not assert viability without documented cardiac activity.
Missed abortion: dead fetus + closed os + no expulsion. The distinction from blighted ovum is important: blighted ovum = empty gestational sac (no embryo developed); missed abortion = embryo/fetus present but dead. Both have a closed os. Threatened abortion requires a living fetus.
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A 34-year-old woman has experienced four consecutive pregnancy losses, all before 10 weeks. Investigation reveals lupus anticoagulant positive on two occasions 12 weeks apart, and IgG anticardiolipin antibodies at high titre. Her uterine cavity on saline infusion sonography is normal. What is the evidence-based treatment for her next pregnancy?
Correct. This is antiphospholipid syndrome (APS) — the definitive treatable cause of RPL. Evidence-based treatment is low-dose aspirin (75 mg) combined with LMWH (e.g., enoxaparin) from the time of positive pregnancy test. This combination reduces miscarriage rate from ~90% to ~75% live birth rate.
APS management in RPL: low-dose aspirin (from positive pregnancy test) + LMWH (from 6-7 weeks). Start aspirin pre-conceptionally if possible. Avoid unfractionated heparin long-term (osteoporosis risk). Steroids are NOT first-line — they worsen maternal morbidity without benefit.
APS is diagnosed by: clinical criterion (3+ pregnancy losses) + laboratory criterion (aPL positive on 2 occasions ≥12 weeks apart). The proven treatment is aspirin + LMWH. Prednisolone increases maternal complications without improving outcomes. IVIg and progesterone alone are not evidence-based for APS-RPL.
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A 23-year-old woman at 8 weeks of gestation requests medical termination of pregnancy in India. She is an adult woman with no specified medical or social vulnerability category. Under the MTP (Amendment) Act 2021, how many registered medical practitioners are required to authorise this termination?
Correct. Under the MTP (Amendment) Act 2021, any pregnancy up to 20 weeks can be terminated with the opinion of ONE registered medical practitioner. Two RMPs are required only for 20-24 weeks, and only for the specified categories (rape/incest survivors, minors, fetal anomaly, change in marital status, disability).
MTP Act 2021 is an important legal topic for examinations. The 2021 amendment extended the upper limit to 24 weeks for special categories. Key: PCPNDT 1994 prohibits sex determination — never frame any diagnostic test as sex-determination in MTP counselling.
The MTP Act 2021 framework: up to 20 weeks = 1 RMP; 20-24 weeks = 2 RMPs (for specified categories only); >24 weeks = State Medical Board. At 8 weeks, only one RMP's opinion is needed. The previous law required 1 RMP up to 12 weeks and 2 RMPs from 12-20 weeks — this has been superseded.
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A 27-year-old woman with 6 weeks of amenorrhoea presents with mild left iliac fossa ache. Serum beta-hCG is 1,800 mIU/mL. Transvaginal ultrasound shows an empty uterus with no adnexal mass. She is haemodynamically stable. What is the most appropriate initial management?
Correct. When the uterus is empty and beta-hCG is <2000 mIU/mL (below the discriminatory zone), an intrauterine pregnancy may not yet be visible — this may be a very early IUP or an ectopic. The safe protocol is serial hCG (48-hour interval): a rise <53% suggests ectopic; a rise >53% suggests normal IUP. Urgent surgery or methotrexate is not indicated without localising the pregnancy.
Pregnancy of unknown location (PUL): empty uterus + positive hCG. Protocol: serial beta-hCG at 0 and 48 hours. Expected IUP rise: >53% in 48h (doubles in 48-72h). Ectopic: <53% or plateau. Failing IUP: declining hCG. Do not treat with methotrexate until ectopic is confirmed — methotrexate terminates IUP.
At hCG 1800 with empty uterus, the pregnancy has not been located — this is a pregnancy of unknown location (PUL). The discriminatory zone (where an IUP should be visible on TVS) is approximately 1500-2000 mIU/mL. Serial hCG at 48 hours determines the trajectory: >53% rise → likely IUP; <53% → likely ectopic or failing IUP. Do not give methotrexate without confirming ectopic.
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A 31-year-old woman with a history of pelvic inflammatory disease presents at 7 weeks with right-sided ache and brownish vaginal discharge. On examination her uterus is normal size and a right adnexal tenderness is noted. TVS shows an empty uterus and a right tubal ring sign with a fetal pole and cardiac activity. Beta-hCG is 6,800 mIU/mL. She is haemodynamically stable. Why is methotrexate contraindicated in this patient?
Correct. Both fetal cardiac activity and beta-hCG >5000 mIU/mL are independent absolute contraindications to single-dose methotrexate for ectopic pregnancy. Either criterion alone disqualifies the patient. Here, both are present. Surgical management (laparoscopic salpingectomy) is indicated.
Methotrexate eligibility for ectopic (ALL criteria must be met): haemodynamically stable, unruptured ectopic, hCG <5000 mIU/mL, NO fetal cardiac activity, compliant for follow-up. Failure on any single criterion → surgery. Cardiac activity is the strongest single disqualifier.
Methotrexate criteria for ectopic: haemodynamically stable + unruptured + beta-hCG <5000 mIU/mL + NO fetal cardiac activity + no contraindication to methotrexate (liver disease, renal impairment, immunodeficiency). This patient fails on two counts: hCG 6800 AND cardiac activity. Surgery is required.
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A 32-year-old G3P2 presents at 15 weeks with excessive vomiting, uterus large for dates (18-week size), and vaginal bleeding. Serum beta-hCG is 320,000 mIU/mL. TVS shows a snowstorm pattern occupying the entire uterine cavity with bilateral theca lutein cysts. Which pre-operative risk is associated with bilateral theca lutein cysts in this condition?
Correct. Bilateral theca lutein cysts arise from FSH receptor stimulation by very high beta-hCG. In complete molar pregnancy, extreme hCG levels can cross-react with TSH receptors (structural homology between hCG and TSH), causing gestational thyrotoxicosis. Pre-operative thyroid function tests are essential.
Complete mole high-risk features (requiring tertiary referral): uterus >20 weeks, hCG >100,000, theca lutein cysts >6 cm, pre-eclampsia before 20 weeks. Theca lutein cysts = hCG-FSH cross-stimulation; resolve after evacuation. Screen for thyrotoxicosis (hCG-TSH cross-reaction) and pre-eclampsia pre-operatively.
Theca lutein cysts are a marker of very high hCG stimulation (not a direct risk of perforation or embolism). The clinical importance is gestational thyrotoxicosis: hCG-TSH cross-reactivity at very high hCG levels suppresses TSH and elevates free T4. Check TFTs pre-operatively. Anti-D is relevant but not the specific risk of theca lutein cysts.
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After suction evacuation of a complete hydatidiform mole, serial beta-hCG surveillance shows the following: Week 2 post-evacuation: 12,000; Week 6: 8,400; Week 10: 8,200; Week 14: 8,350 mIU/mL. According to GTN diagnosis criteria, what does this pattern represent?
Correct. A plateau is defined as four measurements over 3 weeks showing less than 10% change. From Weeks 6-14, the hCG has essentially plateaued (8400 → 8200 → 8350 over 8 weeks). This meets the FIGO/RCOG criterion for gestational trophoblastic neoplasia and requires referral for chemotherapy.
GTN surveillance criteria: plateau (4 values, 3 weeks) OR rise (3 values, 2 weeks) OR persistent hCG at 6 months OR histological diagnosis. A second evacuation is NOT routinely recommended before chemotherapy (risk of perforation and does not reliably cure GTN). Refer to GTN centre.
GTN criteria include: (1) plateau of hCG over 4 values across 3 weeks; (2) rise of hCG (>10%) over 3 values across 2 weeks; (3) hCG still elevated at 6 months post-evacuation; (4) diagnosis of choriocarcinoma or invasive mole. This pattern (minimal change 8400-8200-8350 over 8 weeks) is a classic plateau. Treatment (single-agent methotrexate for low-risk GTN) should be initiated.
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A 9-week pregnant woman is admitted with hyperemesis gravidarum. She has been vomiting for 5 weeks and has eaten almost nothing for 2 days. On examination she is dehydrated. Lab: Na 126 mEq/L, K 2.8 mEq/L, urine ketones 3+. The intern orders 5% dextrose IV. The ward nurse asks you to confirm the order. What is your response?
Correct. This is the clinical scenario for Wernicke's encephalopathy prevention. Thiamine (vitamin B1) 100 mg IV MUST be given before any dextrose-containing fluid in a malnourished/thiamine-depleted patient. Glucose load without thiamine precipitates Wernicke's encephalopathy by exhausting residual pyruvate dehydrogenase activity.
Wernicke's encephalopathy triad: confusion, ophthalmoplegia, ataxia. Prevention: thiamine 100 mg IV before ANY dextrose. In HG, ALL patients requiring IV fluids should receive thiamine. Wernicke's is rare but irreversible if missed — it is a clinical governance issue in HG management.
The critical sequence is thiamine THEN dextrose. Normal saline alone is acceptable initially (no glucose), but the complete management still requires thiamine supplementation before introducing dextrose. Confirming the dextrose order without thiamine pre-treatment is a serious error. Option C is safer than A/D but incomplete — thiamine must still be given before dextrose is introduced.
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A 12-week pregnant woman presents with persistent vomiting and is diagnosed with hyperemesis gravidarum. She is started on IV fluids and anti-emetics. Despite ondansetron and metoclopramide, vomiting persists. Her liver function tests show mild transaminase elevation (AST 68, ALT 72 U/L). What is the significance of these LFT findings?
Correct. Mild transaminase elevation (typically AST/ALT <200 U/L) is a recognised complication of severe hyperemesis gravidarum itself — likely due to hepatocellular stress from starvation and dehydration. It does not indicate a separate liver disease and resolves with treatment of HG. It should prompt investigation to exclude alternative diagnoses but is commonly intrinsic to severe HG.
HG complications: dehydration + electrolyte imbalance (hyponatraemia, hypokalaemia) + Wernicke's encephalopathy + mild transaminase elevation + Mallory-Weiss tear. Mild transaminitis in severe HG resolves with treatment. If bilirubin is significantly elevated or transaminases >200, investigate for alternate hepatic pathology.
Intrahepatic cholestasis of pregnancy (ICP) presents later in pregnancy (2nd-3rd trimester) with pruritus and elevated bile acids — not with vomiting in the first trimester. Viral hepatitis is possible but at 12 weeks with known HG, mild transaminitis is a recognised HG complication. Ondansetron rarely causes significant hepatotoxicity at therapeutic doses in this context.
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A 30-year-old woman undergoes a termination of pregnancy at 8 weeks in a private clinic under inadequate anaesthesia. Twelve hours later she develops temperature 39.2°C, lower abdominal pain, and a purulent offensive vaginal discharge. On examination: uterus is tender, soft, 8-week size; cervical os is open; no tissue at the os. Blood cultures are drawn. Which statement about management is MOST accurate?
Correct. In septic abortion, broad-spectrum IV antibiotics (ampicillin + gentamicin + metronidazole) must be started immediately — do not wait for culture results. Delay worsens septicaemia. Uterine evacuation follows once antibiotic cover is established. Evacuation before antibiotics risks bacteraemia from disruption of infected tissue.
Septic abortion management sequence: blood cultures → immediate IV broad-spectrum antibiotics (triple therapy: ampicillin + gentamicin + metronidazole) → uterine evacuation once antibiotic cover established. Tetanus prophylaxis if induced outside medical facility. Admit to ITU if haemodynamically compromised. Never delay antibiotics for culture results in sepsis.
Septic abortion is a medical emergency. The sequence is: (1) IV access + blood cultures; (2) start broad-spectrum IV antibiotics IMMEDIATELY (do not wait for results — this delays treatment by 48-72 hours while septicaemia progresses); (3) evacuation after 4-6 hours of antibiotic cover. Oral antibiotics are inadequate for established septic abortion.
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A hysterosalpingogram (HSG) performed during investigation for RPL in a 33-year-old woman shows a fundal filling defect with an indentation of 1.1 cm depth dividing the cavity. The external uterine contour is normal on 3D ultrasound. What is the most likely uterine structural diagnosis and the appropriate management?
Correct. A fundal filling defect with a normal external contour defines a uterine septum. The septum is avascular fibromuscular tissue that impairs implantation. Hysteroscopic metroplasty (septal resection) corrects this and improves live birth rates in RPL. Bicornuate uterus has an abnormal external contour (fundal notch).
Uterine structural causes of RPL: septum (most common, correctable by hysteroscopic resection) > submucous fibroid (myomectomy) > intrauterine adhesions (Asherman — hysteroscopic lysis) > incompetent cervix (cervical cerclage). Distinguish septum (internal only) from bicornuate (external notch) on imaging — management differs completely.
Key distinction: uterine septum = internal indentation, NORMAL external contour; bicornuate uterus = external fundal notch, two partially fused horns. The septum is correctable hysteroscopically. Bicornuate uterus requires abdominal metroplasty (rarely performed). Arcuate uterus (<1 cm indentation) is a normal variant not requiring treatment.
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