First Trimester Bleeding MCQ

First Trimester Bleeding - Multiple Choice Questions (MCQs)

Question 1

A 29-year-old woman at 7 weeks gestation presents with vaginal bleeding and left iliac fossa pain. Vital signs: BP 110/70, pulse 90. Transvaginal ultrasound shows an empty uterus and free fluid in the pouch of Douglas. β-hCG is 2500 mIU/mL. What is the most appropriate next step?

A. Repeat β-hCG in 48 hours
B. Laparoscopy
C. Methotrexate administration
D. Expectant management
E. Repeat ultrasound in 1 week

Answer: B - Laparoscopy

Explanation: Empty uterus with β-hCG above discriminatory zone plus free fluid strongly suggests ectopic pregnancy. Although hemodynamically stable, presence of free fluid indicates possible bleeding from ectopic. Surgical intervention is most appropriate. Methotrexate is contraindicated with free fluid suggesting rupture.

Question 2

A 26-year-old Rh-negative woman undergoes suction curettage for incomplete miscarriage at 9 weeks gestation. What dose of anti-D immunoglobulin should be given?

A. Not required at this gestation
B. 50 IU
C. 250 IU
D. 500 IU
E. 1500 IU

Answer: C - 250 IU

Explanation: For Rh-negative women at <12 weeks gestation, 250 IU of anti-D should be given following any sensitizing event including miscarriage (threatened or actual) or surgical/medical management. At ≥12 weeks, 500 IU is given.

Question 3

Which of the following β-hCG patterns over 48 hours is most consistent with a viable intrauterine pregnancy?

A. Rise from 500 to 650 mIU/mL
B. Rise from 1000 to 1500 mIU/mL
C. Rise from 2000 to 2800 mIU/mL
D. Fall from 1000 to 700 mIU/mL
E. Plateau at 1500 mIU/mL

Answer: C - Rise from 2000 to 2800 mIU/mL

Explanation: In viable IUP, β-hCG should rise by at least 66% in 48 hours in early pregnancy. Option C shows 40% rise which meets this criterion (2800/2000 = 1.4 = 40% increase). Option A is 30% rise, Option B is 50% rise - both suboptimal. Options D and E suggest non-viable pregnancy.

Question 4

A 32-year-old woman is diagnosed with complete hydatidiform mole at 10 weeks gestation. After evacuation, which of the following is MOST important?

A. Immediate chemotherapy
B. Hysterectomy
C. β-hCG monitoring for 6 months
D. Repeat evacuation in 2 weeks
E. Prophylactic cranial irradiation

Answer: C - β-hCG monitoring for 6 months

Explanation: Following evacuation of complete mole, β-hCG monitoring is essential to detect persistent GTD. Monitoring continues weekly until negative for 3 weeks, then monthly for 6 months. Chemotherapy is only given if persistent GTD develops (15-20% of cases). Most women do not need chemotherapy.

Question 5

Which ultrasound finding is diagnostic of miscarriage?

A. Empty gestational sac measuring 20 mm
B. Crown-rump length of 5 mm without cardiac activity
C. Crown-rump length of 8 mm without cardiac activity
D. Yolk sac measuring 7 mm
E. Gestational sac without yolk sac at 6 weeks

Answer: C - Crown-rump length of 8 mm without cardiac activity

Explanation: Current criteria for definite miscarriage are: CRL ≥7 mm without cardiac activity, OR mean gestational sac diameter ≥25 mm without embryo. Options A, B, and E require repeat scanning. Option D (large yolk sac) is associated with poor prognosis but not diagnostic of miscarriage.

Short Answer Questions (SAQs)

Question 1

A 30-year-old woman presents at 8 weeks gestation with heavy vaginal bleeding. Outline your initial assessment and immediate management. (10 marks)

Model Answer:

Initial Assessment (5 marks):

  • History: Amount/duration of bleeding, pain, shoulder tip pain, dizziness, passage of tissue, LMP certainty, risk factors for ectopic

  • Vital signs: BP, pulse, temperature, respiratory rate (signs of hemodynamic compromise)

  • Abdominal examination: Tenderness, peritonism, mass

  • Speculum examination: Quantify bleeding, cervical os status, products visible

  • Bimanual examination: Uterine size, cervical motion tenderness, adnexal masses

Immediate Management (5 marks):

  • IV access if hemodynamically compromised

  • Bloods: FBC, blood group and cross-match, β-hCG

  • Urgent transvaginal ultrasound: Confirm location and viability

  • Resuscitation if unstable: fluids, O-negative blood if needed

  • Analgesia: As required

  • Anti-D: If Rh-negative

  • Senior review: If ectopic suspected or hemodynamically unstable

  • Definitive management: Based on diagnosis (surgical if incomplete miscarriage with heavy bleeding)

Question 2

Discuss the management options for missed miscarriage, including the advantages and disadvantages of each approach. (10 marks)

Model Answer:

Three Management Options (3 marks):

  1. Expectant (conservative)

  2. Medical

  3. Surgical

Expectant Management (2 marks):

  • Advantages: Non-invasive, no anesthesia, patient control, avoids medication side effects

  • Disadvantages: Unpredictable timing (may take weeks), prolonged bleeding, risk of heavy bleeding requiring emergency surgery, psychological stress of waiting, 30% ultimately require intervention

Medical Management (2 marks):

  • Method: Mifepristone 200 mg oral + misoprostol 800 mcg vaginal 24-48h later

  • Advantages: Avoids surgery and anesthesia, can be done at home, patient control over timing

  • Disadvantages: Pain and bleeding (may be heavy), gastrointestinal side effects, 15-20% failure requiring surgery, seeing products of conception may be distressing

Surgical Management (2 marks):

  • Method: Suction curettage or manual vacuum aspiration under local or general anesthesia

  • Advantages: Quick, definite, predictable, minimal bleeding afterward, histology available

  • Disadvantages: Anesthesia risks, surgical complications (perforation <1%, infection <2%, Asherman's syndrome rare), requires procedure/admission

Patient Factors in Decision-Making (1 mark):

  • Previous experience, anxiety levels, practical considerations (work, childcare), distance from hospital, personal preference

Case-Based Discussion

Complex Case

A 35-year-old woman, G4P1, presents to the emergency department with 7 weeks amenorrhea and vaginal spotting for 3 days. She has a history of one previous miscarriage and one ectopic pregnancy (treated with methotrexate). She underwent IVF for this pregnancy. Initial β-hCG is 8,500 mIU/mL. Transvaginal ultrasound shows an empty uterus and a 3 cm complex right adnexal mass with minimal free fluid.

Discussion Points:

  1. What is your diagnosis?

    • Ectopic pregnancy (right tubal)

    • High-risk patient (previous ectopic, IVF)

    • Hemodynamically stable but ectopic confirmed

  2. What are the management options?

    • Medical: Methotrexate (single or multi-dose)

    • Surgical: Laparoscopic salpingectomy vs. salpingostomy

    • Expectant: Not appropriate given β-hCG level

  3. Which option would you recommend and why?

    • Surgical management preferred:

      • β-hCG >5000 mIU/mL (medical more likely to fail)

      • Mass 3 cm (relatively large)

      • Presence of free fluid (concern for rupture)

      • Fertility completed (G4P1, may consider salpingectomy)

      • Previous methotrexate treatment

    • However, if patient strongly desires medical, single-dose methotrexate could be considered with very close follow-up

  4. What specific counseling is needed?

    • Risk of treatment failure

    • Risk of rupture requiring emergency surgery

    • Follow-up plan with serial β-hCG

    • Signs requiring immediate return

    • Future fertility implications

    • Psychological impact of third pregnancy loss

  5. What if she were only 25 years old with no children?

    • Would lean toward salpingostomy if technically feasible

    • Counsel about persistent trophoblast risk (5-10% with salpingostomy)

    • Consider referral to fertility specialist for future management