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OG9.1-6 | Early Pregnancy Complications — Practice Quiz
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A 24-year-old primigravida at 10 weeks presents with mild vaginal spotting for 1 day. The uterus is 10-week size. On per-speculum examination, the cervical os is closed and no tissue is seen. Transvaginal ultrasound shows a live embryo with cardiac activity. What is the correct diagnosis?
Correct. Threatened abortion is defined by vaginal bleeding before 20 weeks with a closed cervical os and a viable (live) fetus on ultrasound. The os remains closed, distinguishing it from inevitable abortion.
Threatened abortion: closed os + live fetus + bleeding. Management is expectant with pelvic rest; bed rest has no proven benefit. Follow-up with serial ultrasound to confirm viability.
Recall the key differentiator: the status of the cervical os and fetal viability. In threatened abortion the os is closed and the fetus is alive. Inevitable abortion has an open os; incomplete has partially passed tissue; missed abortion has a dead fetus with a closed os.
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A 28-year-old patient at 12 weeks presents with heavy vaginal bleeding and cramping. Examination reveals an open cervical os with soft tissue at the os. Ultrasound shows heterogeneous material in the uterine cavity. What is the immediate priority in management?
Correct. This is incomplete abortion (open os, heterogeneous uterine contents, bleeding). The immediate priority is uterine evacuation — suction curettage or MVA — to remove retained products and stop haemorrhage.
Incomplete abortion: open os + partially expelled POC + bleeding. Treatment is surgical evacuation (MVA or suction curettage) in a haemodynamically unstable or symptomatic patient. Medical management (misoprostol) is reserved for selected stable cases.
This presentation describes incomplete abortion with an open os and retained tissue. The risk is ongoing haemorrhage. Evacuation is urgently needed; expectant management or medical only is inappropriate when tissue is visible at the os.
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A 22-year-old woman is brought to the emergency department with fever (38.8°C), lower abdominal tenderness, and offensive vaginal discharge. She is 10 weeks pregnant and admits to an attempt to terminate the pregnancy outside a medical facility. Cervical os is open with foul-smelling products. Which antibiotic regimen is most appropriate?
Correct. Septic abortion requires IV broad-spectrum antibiotics (e.g., IV ampicillin + gentamicin + metronidazole) started BEFORE evacuation to reduce bacteraemia from the procedure and cover the polymicrobial infection.
Septic abortion triad: fever + offensive discharge + uterine tenderness after instrumentation. Treatment: IV broad-spectrum antibiotics first (ampicillin + gentamicin + metronidazole), then urgent uterine evacuation once antibiotic cover is established.
Septic abortion is polymicrobial (anaerobes, gram-negatives, Chlamydia). Broad-spectrum IV antibiotics must be started BEFORE uterine evacuation — evacuation alone without antibiotics risks septicaemia. Oral amoxicillin alone is inadequate coverage.
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A 30-year-old woman has had three consecutive first-trimester pregnancy losses. Karyotyping of the products of conception from her second loss showed trisomy 16. Which investigation is most likely to identify a TREATABLE cause in this couple?
Correct. Antiphospholipid syndrome (APS) is the most important treatable cause of recurrent pregnancy loss. aPL testing (anticardiolipin antibodies + lupus anticoagulant + anti-beta2-glycoprotein I) identifies a cause amenable to treatment with aspirin + LMWH.
RPL investigation priority: aPL testing (treatable with aspirin + LMWH), uterine assessment (saline infusion sonography), thyroid function (TSH), parental karyotype (detects balanced translocation). NK cell assays are NOT recommended — no proven utility.
While parental karyotyping detects balanced translocations (~3-5% of RPL couples), this finding is largely non-treatable (PGT-A is the option but not always successful). NK cell assays and HLA typing have no proven clinical utility in RPL. APS is the major treatable cause.
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Under which definition is recurrent pregnancy loss (RPL) classified as two or more clinical pregnancy losses, relaxing the traditional three-loss threshold?
Correct. The ASRM defines RPL as two or more clinical pregnancy losses. RCOG and ESHRE use the more stringent three or more consecutive losses before 20 weeks.
RPL definitions: RCOG/ESHRE = 3+ consecutive losses (<20 weeks); ASRM = 2+ clinical losses. The ASRM threshold is less stringent, allowing earlier investigation. Aetiology is identified in approximately 50% of couples.
RCOG and ESHRE define RPL as three or more consecutive losses; ASRM uses two or more clinical losses. Knowing which body uses which threshold is commonly tested in theory examinations.
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Under the MTP (Amendment) Act 2021 in India, up to which gestational age can a medical termination of pregnancy be performed on the opinion of ONE registered medical practitioner (RMP)?
Correct. Under the MTP (Amendment) Act 2021, a termination up to 20 weeks of gestation requires the opinion of ONE registered medical practitioner. From 20 to 24 weeks, TWO RMPs are required (for specified categories). Beyond 24 weeks requires a State Medical Board.
MTP Act 2021 thresholds: up to 20 weeks = 1 RMP; 20-24 weeks = 2 RMPs (specified categories only); >24 weeks = State Medical Board (substantial fetal abnormality). PCPNDT Act 1994 prohibits sex determination — no MTP for sex selection.
The MTP Amendment Act 2021 extended the previous 12-week limit. Up to 20 weeks: one RMP. 20 to 24 weeks: two RMPs for specified categories (rape survivors, minors, fetal abnormality, etc.). Beyond 24 weeks: State Medical Board only. Do not quote pre-2021 law.
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A 25-year-old woman with 6 weeks of amenorrhoea presents with sudden-onset left iliac fossa pain and fainting. Serum beta-hCG is 3,200 mIU/mL. Transvaginal ultrasound shows an empty uterus and a left adnexal mass with free fluid in the pouch of Douglas. What is the next step?
Correct. This is a haemodynamically unstable ectopic pregnancy (syncopal episode = haemoperitoneum). Emergency surgery — laparoscopic or open salpingectomy — is mandatory. Methotrexate is absolutely contraindicated in haemodynamic instability.
Ectopic pregnancy management: haemodynamically UNSTABLE → emergency surgery (laparoscopic salpingectomy preferred). Methotrexate criteria (STRICT): stable, unruptured, hCG <5000, no fetal cardiac activity. Empty uterus + positive hCG = ectopic until proven otherwise.
Syncopal episode indicates haemoperitoneum from ruptured ectopic pregnancy. This is a surgical emergency. Methotrexate requires haemodynamic stability, an unruptured ectopic, beta-hCG <5000 mIU/mL, no fetal cardiac activity, and patient compliance for follow-up. None of these conditions are met here.
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Which site of ectopic implantation is associated with the highest risk of catastrophic haemorrhage due to its dual blood supply and late rupture?
Correct. Cornual (interstitial) ectopics account for 2-3% of ectopics but are the most dangerous — they have a dual blood supply (uterine and ovarian arteries) and rupture late (8-12 weeks) with massive haemorrhage. The ampullary site is most common (~70%).
Ectopic sites: ampullary 70% (most common), isthmic 12% (earliest rupture), cornual/interstitial 2-3% (most dangerous — dual blood supply, late + massive rupture). Cervical and abdominal ectopics are rare. Know each site's risk profile.
While ampullary ectopics are most common (~70%), isthmic rupture is earliest. Cornual/interstitial ectopics (~2-3%) are the most dangerous because of their dual blood supply and late rupture presenting with catastrophic haemorrhage.
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A 28-year-old woman undergoes suction evacuation for complete hydatidiform mole at 14 weeks. Post-evacuation serum beta-hCG is 42,000 mIU/mL. Which is the most important next step in her management?
Correct. After suction evacuation of a molar pregnancy, structured serial beta-hCG surveillance is the cornerstone of follow-up. This identifies the 15-20% of complete moles that transform to gestational trophoblastic neoplasia (GTN) requiring chemotherapy.
Post-molar surveillance: weekly beta-hCG until undetectable, then monthly for 6-12 months. GTN diagnosis criteria: hCG plateau (3 readings over 3 weeks) or rise (2 readings over 2 weeks). No pregnancy during surveillance (OCP recommended). Chemotherapy only if GTN criteria met.
Chemotherapy is not started immediately after mole evacuation — it is reserved for GTN diagnosed by the beta-hCG surveillance criteria (plateau over 3 weeks, rise over 2 weeks, persistent elevation at 6 months for partial mole, or metastatic disease). The first step is structured serial hCG monitoring.
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A 10-week pregnant woman is admitted with severe vomiting, weight loss of 6% from pre-pregnancy weight, ketonuria 3+, and serum sodium of 128 mEq/L. Before starting IV fluid replacement, which supplement must be given first to prevent a serious neurological complication?
Correct. In hyperemesis gravidarum, thiamine (vitamin B1) must be given BEFORE dextrose-containing IV fluids. Administering glucose without thiamine in a thiamine-depleted patient precipitates Wernicke's encephalopathy (pyruvate dehydrogenase failure). This is the most critical sequence in HG management.
Thiamine-before-dextrose rule: In HG, thiamine (100 mg IV) must precede any dextrose infusion. Thiamine is needed by pyruvate dehydrogenase; glucose load without thiamine drives pyruvate into the Wernicke pathway. HG is defined by >5% weight loss + ketonuria ≥2+ + electrolyte disturbance.
The neurological complication at risk is Wernicke's encephalopathy (confusion, ophthalmoplegia, ataxia). It is caused by thiamine deficiency — depleted by prolonged vomiting — precipitated by glucose load without thiamine replacement. Thiamine BEFORE dextrose is the cardinal rule.
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