MRCOG Part 2 – Early Pregnancy Care EMQs

For each case described below, choose the single most appropriate diagnosis option from the above list. Each option may be used once, more than once or not at all.

• An 18 year old nulliparous woman presents with lower abdominal pain and vaginal spotting. Her last menstrual period was 6 weeks ago and she has a positive urinary pregnancy test.  Transvaginal ultrasound shows a retroverted uterus with empty uterine cavity.  A small gestational sac measuring 21mm in diameter is seen below the internal cervical os but there is no evidence of a yolk sac or fetal pole.  There is no blood flow seen on Colour Doppler around the gestational sac and sliding sign is present.  The ovaries appear normal with a corpus luteum seen on the left ovary and there is no free fluid in the Pouch of Douglas.

For each case described below, choose the single most appropriate diagnosis option from the above list. Each option may be used once, more than once or not at all.

• A 41 year old nulliparous woman presents with recurrent painless vaginal bleeding and severe nausea and vomiting of pregnancy at 9 weeks gestation. A transvaginal ultrasound scan is performed which shows an anteverted uterus, with a closed cervix. There was a complex intrauterine mass measuring 60 x55x54 mm containing multiple cystic areas and an area of fluid collection within the uterine cavity. There is no evidence of any fetal tissue. Both ovaries appear morphologically normal with a corpus luteum on the right ovary.

For each case described below, choose the single most appropriate diagnosis option from the above list. Each option may be used once, more than once or not at all.

• A 28 year old nulliparous woman presents with lower abdominal pain and vaginal spotting. Her last menstrual period was 8 weeks ago and she has a positive urinary pregnancy test.  She has a history of severe endometriosis for which she has had three previous laparoscopies requiring excision and adhesiolysis. Transvaginal ultrasound shows a retroverted uterus with empty uterine cavity.  The ovaries appear normal, there are no adnexal masses and there is no evidence of free fluid in the Pouch of Douglas. Initial serum b-HCG measurement is 2200 IU/L.

For each case described below, choose the single most appropriate diagnosis option from the above list. Each option may be used once, more than once or not at all.

• A 28 year old nulliparous woman presents with severe lower abdominal pain and vaginal spotting. Her last menstrual period was 8 weeks ago and she has a positive urinary pregnancy test.  She has a history of severe endometriosis for which she has had three previous laparoscopies requiring excision and adhesiolysis. Transvaginal ultrasound shows a retroverted uterus with empty uterine cavity.  Posterior to the uterus in the Pouch of Douglas, there appears to be a gestational sac surrounding by loops of bowel measuring 35x40x33mm with a fetal pole visible with fetal heart beat. The ovaries appear normal, there are no adnexal masses and there is no evidence of free fluid in the Pouch of Douglas.

For each scenario described below, choose the single most appropriate management option from the above list. Each option may be used once, more than once or not at all.

• A 28-year-old woman presents with a positive urine pregnancy test and mild vaginal spotting. Transvaginal ultrasound shows no evidence of intrauterine or ectopic pregnancy. Her serum β-hCG level is 700 IU/L. She is haemodynamically stable with no significant pain.

For each scenario described below, choose the single most appropriate management option from the above list. Each option may be used once, more than once or not at all.

• A 30-year-old woman presents with mild lower abdominal pain in her first pregnancy.  She is approximately 7 weeks pregnant by her last menstrual period.  Transvaginal ultrasound shows no evidence of an intrauterine pregnancy and no adnexal masses or free fluid are detected.  Initial serum β-hCG is 1,200 IU/L and on repeat 48 hours later, it is 1800 IU/L.

For each scenario described below, choose the single most appropriate management option from the above list. Each option may be used once, more than once or not at all.

• A 30-year-old woman presents with severe lower abdominal pain in her first pregnancy.  She is approximately 7 weeks pregnant by her last menstrual period.  Transvaginal ultrasound shows no evidence of an intrauterine pregnancy and no adnexal masses are detected but there is a large volume of free fluid seen in the Pouch of Douglas.  Initial serum β-hCG is 1,200 IU/L.

For each scenario described below, choose the single most appropriate management option from the above list. Each option may be used once, more than once or not at all.

• A 26-year-old woman presents with a positive pregnancy test and vaginal spotting. Ultrasound shows no evidence of either intrauterine or ectopic pregnancy. Her serum β-hCG level is 300 IU/L, and a repeat test after 48 hours shows a decline to 150 IU/L.

For each scenario described below, choose the single most appropriate management option from the above list. Each option may be used once, more than once or not at all.

• An 18 year old nulliparous woman presents with lower abdominal pain and light vaginal bleeding. Her last menstrual period was 6 weeks ago and she has a positive urinary pregnancy test.  Transvaginal ultrasound shows a retroverted uterus with empty uterine cavity.  A small gestational sac measuring 21mm in diameter is seen below the internal cervical os but there is no evidence of a yolk sac or fetal pole.  There is no blood flow seen on Colour Doppler around the gestational sac and sliding sign is present.  The ovaries appear normal with a corpus luteum seen on the left ovary and there is no free fluid in the Pouch of Douglas.

For each scenario described below, choose the single most appropriate management option from the above list. Each option may be used once, more than once or not at all.

• An 18 year old nulliparous woman presents with lower abdominal pain and vaginal spotting. Her last menstrual period was 6 weeks ago and she has a positive urinary pregnancy test.  Transvaginal ultrasound shows a retroverted uterus with empty uterine cavity.  A small gestational sac measuring 21mm in diameter is seen below the internal cervical os but there is no evidence of a yolk sac or fetal pole.  There is blood flow seen on Colour Doppler around the gestational sac and sliding sign is absent.  The ovaries appear normal with a corpus luteum seen on the left ovary and there is no free fluid in the Pouch of Douglas.

For each scenario described below, choose the single most appropriate management option from the above list. Each option may be used once, more than once or not at all.

• A 40 year old woman attends her local Early Pregnancy Unit for a reassurance scan due to a history of recurrent miscarriage.  She is Para 2 having had two previous emergency Caesarean sections at full dilation.  She is currently approximately 7 weeks pregnant based on her last menstrual period and is asymptomatic.  Transvaginal scan shows an anteverted uterus with a closed cervix. A gestational sac is seen within the uterine cavity, medial to the interstitial portion of the fallopian tubes measuring 28 x 21 x 29mm. Within the gestational sac is a yolk sac and a fetal pole with a CRL measuring 6 mm but no fetal cardiac activity is seen. The adnexae appear normal and there is no free fluid in the Pouch of Douglas.

For each case described below, choose the single most appropriate diagnosis option from the above list. Each option may be used once, more than once or not at all.

• An 18 year old nulliparous woman presents with lower abdominal pain and vaginal spotting. Her last menstrual period was 6 weeks ago and she has a positive urinary pregnancy test.  Transvaginal ultrasound shows a retroverted uterus with empty uterine cavity.  A small gestational sac measuring 21mm in diameter is seen below the internal cervical os but there is no evidence of a yolk sac or fetal pole.  There is blood flow seen on Colour Doppler around the gestational sac and sliding sign is absent.  The ovaries appear normal with a corpus luteum seen on the left ovary and there is no free fluid in the Pouch of Douglas.

For each scenario described below, choose the single most appropriate management option from the above list. Each option may be used once, more than once or not at all.

• A 40 year old woman attends her local Early Pregnancy Unit for a reassurance scan due to a history of recurrent miscarriage.  She is Para 2 having had two previous emergency Caesarean sections at full dilation.  She is currently approximately 7 weeks pregnant based on her last menstrual period and is asymptomatic.  Transvaginal scan shows an anteverted uterus with empty cavity and a closed cervix. A gestational sac is seen anteriorly at the level of the internal cervical os and there is prominent blood flow seen on Colour Doppler around the gestational sac.  There is a very thin layer of myometrium between the gestational sac and bladder. She is very anxious about the possibility of bleeding at home and would prefer treatment to reduce the risk of this.

For each scenario described below, choose the single most appropriate management option from the above list. Each option may be used once, more than once or not at all.

• A 40 year old woman attends her local Early Pregnancy Unit for a reassurance scan due to a history of recurrent miscarriage.  She is Para 2 having had two previous emergency Caesarean sections at full dilation.  She is currently approximately 7 weeks pregnant based on her last menstrual period and is asymptomatic.  Transvaginal scan shows an anteverted uterus with empty cavity and a closed cervix. A gestational sac measuring 21mm in diameter is seen at the far upper right lateral aspect of the uterus with a thin echogenic line extending from the central uterine cavity echo to the periphery of the sac.  The sac is surrounded by myometrium measuring a maximum of 4mm in thickness. The adnexa appear normal and there is no free fluid in the Pouch of Douglas.  Initial b-HCG is 320 and repeat b-HCG 48 hours later is 200.

For each scenario described below, choose the single most appropriate management option from the above list. Each option may be used once, more than once or not at all.

• A 40 year old woman attends her local Early Pregnancy Unit for a reassurance scan due to a history of recurrent miscarriage.  This is an IVF donor egg pregnancy and she is currently 7 weeks pregnant based following the transfer of two blastocysts.  Transvaginal scan shows an anteverted uterus with empty cavity and a closed cervix. Both ovaries appear morphologically normal. Adjacent to the right ovary is an echogenic ring measuring 18x24x19 mm. There is no evidence of free fluid in the pouch of Douglas. Initial b-HCG is 320 and repeat b-HCG 48 hours later is 200.

For each scenario described below, choose the single most appropriate management option from the above list. Each option may be used once, more than once or not at all.

• A 40 year old woman attends her local Early Pregnancy Unit for a reassurance scan due to a history of recurrent miscarriage.  This is an IVF donor egg pregnancy and she is currently 7 weeks pregnant based following the transfer of two blastocysts. Transvaginal scan shows an anteverted uterus with a closed cervix. A gestational sac is seen within the uterine cavity, medial to the interstitial portion of the fallopian tubes measuring 28 x 21 x 29mm. Within the gestational sac is a yolk sac and a fetal pole with a CRL measuring 6 mm with fetal cardiac activity seen. Both ovaries appear morphologically normal.  Adjacent to the right ovary is an echogenic ring measuring 18x24x19 mm. There is moderate free fluid in the pouch of Douglas.  Maternal observations show a maternal tachycardia of 120bpm.

For each scenario described below, choose the single most appropriate management option from the above list. Each option may be used once, more than once or not at all.

• An 28 year old nulliparous woman presents with severe lower abdominal pain and vaginal spotting. Her last menstrual period was 8 weeks ago and she has a positive urinary pregnancy test.  She has a history of severe endometriosis for which she has had three previous laparoscopies requiring excision and adhesiolysis. Transvaginal ultrasound shows a retroverted uterus with empty uterine cavity.  The right ovary could not be visualised but the left adnexa shows a complex left adnexal mass with mixed echogenicity arising from the left ovary which is tender during scanning.  There is a large amount of free fluid in the Pouch of Douglas. Initial b-HCG is 820 and repeat b-HCG 48 hours later is 800.

For each scenario described below, choose the single most appropriate management option from the above list. Each option may be used once, more than once or not at all.

• A 41 year old nulliparous woman presents with recurrent painless vaginal bleeding and severe nausea and vomiting of pregnancy at 11 weeks gestation. She has previously had a transvaginal ultrasound which demonstrated a single live intra-uterine pregnancy. A further transabdominal ultrasound confirms absent fetal heart activity with mean gestational sac diameter 45mm of which had previously been seen and abnormal enlarged cystic appearances of the placenta.

For each scenario described below, choose the single most appropriate management option from the above list. Each option may be used once, more than once or not at all.

• A 41 year old nulliparous woman presents with recurrent painless vaginal bleeding and severe nausea and vomiting of pregnancy at 9 weeks gestation. A transvaginal ultrasound scan is performed which shows an anteverted uterus, with a closed cervix. There was a complex intrauterine mass measuring 60 x55x54 mm containing multiple cystic areas and an area of fluid collection within the uterine cavity. There is no evidence of any fetal tissue. Both ovaries appear morphologically normal with a corpus luteum on the right ovary.

For each scenario described below, choose the single most appropriate management option from the above list. Each option may be used once, more than once or not at all.

• A 28 year old nulliparous woman presents with lower abdominal pain and vaginal spotting. Her last menstrual period was 8 weeks ago and she has a positive urinary pregnancy test.  She has a history of severe endometriosis for which she has had three previous laparoscopies requiring excision and adhesiolysis. Transvaginal ultrasound shows a retroverted uterus with empty uterine cavity.  The ovaries appear normal, there are no adnexal masses and there is no evidence of free fluid in the Pouch of Douglas. Initial serum b-HCG measurement is 2200 IU/L and repeat b-HCG 48 hours later shows a level of 4000 IU/L.  She reports worsening abdominal pain and repeat transvaginal ultrasound confirms no evidence of intra-uterine or extra-uterine pregnancy.

For each scenario described below, choose the single most appropriate management option from the above list. Each option may be used once, more than once or not at all.

• A 28 year old nulliparous woman presents with severe lower abdominal pain and vaginal spotting. Her last menstrual period was 8 weeks ago and she has a positive urinary pregnancy test.  She has a history of severe endometriosis for which she has had three previous laparoscopies requiring excision and adhesiolysis. Transvaginal ultrasound shows a retroverted uterus with empty uterine cavity.  Posterior to the uterus in the Pouch of Douglas, there appears to be a gestational sac surrounding by loops of bowel measuring 35x40x33mm with a fetal pole visible with fetal heart beat. The ovaries appear normal, there are no adnexal masses and there is no evidence of free fluid in the Pouch of Douglas.

For each scenario described below, choose the single most appropriate management option from the above list. Each option may be used once, more than once or not at all.

• A 28 year old nulliparous woman presents with severe lower abdominal pain and vaginal spotting. She is unsure of her last menstrual period date as her periods are irregular and she has a positive urinary pregnancy test.  She has a history of severe endometriosis for which she has had three previous laparoscopies requiring excision and adhesiolysis. Transvaginal ultrasound shows a retroverted uterus with empty uterine cavity.  Posterior to the uterus in the Pouch of Douglas, there appears to be a large gestational sac surrounding by loops of bowel containing a live singleton fetus with CRL of 38mm with fetal heart beat seen. The ovaries appear normal and there are no adnexal masses. There is a large volume of free fluid in the Pouch of Douglas.  Whilst admitted on the gynaecology, she has a vasovagal episode and collapses but is resuscitated with IV fluids.  Subsequently haemoglobin levels shows a significant drop to 83 from 122 g/dL.

For each case described below, choose the single most appropriate diagnosis option from the above list. Each option may be used once, more than once or not at all.

• A 40 year old woman attends her local Early Pregnancy Unit for a reassurance scan due to a history of recurrent miscarriage.  She is Para 2 having had two previous emergency Caesarean sections at full dilation.  She is currently approximately 7 weeks pregnant based on her last menstrual period and is asymptomatic.  Transvaginal scan shows an anteverted uterus with a closed cervix. A gestational sac is seen within the uterine cavity, medial to the interstitial portion of the fallopian tubes measuring 28 x 21 x 29mm. Within the gestational sac is a yolk sac and a fetal pole with a CRL measuring 6 mm but no fetal cardiac activity is seen. The adnexae appear normal and there is no free fluid in the Pouch of Douglas.

For each case described below, choose the single most appropriate diagnosis option from the above list. Each option may be used once, more than once or not at all.

• A 40 year old woman attends her local Early Pregnancy Unit for a reassurance scan due to a history of recurrent miscarriage.  She is Para 2 having had two previous emergency Caesarean sections at full dilation.  She is currently approximately 7 weeks pregnant based on her last menstrual period and is asymptomatic.  Transvaginal scan shows an anteverted uterus with empty cavity and a closed cervix. A gestational sac is seen anteriorly at the level of the internal cervical os and there is prominent blood flow seen on Colour Doppler around the gestational sac.  There is a very thin layer of myometrium between the gestational sac and bladder.

For each case described below, choose the single most appropriate diagnosis option from the above list. Each option may be used once, more than once or not at all.

• A 40 year old woman attends her local Early Pregnancy Unit for a reassurance scan due to a history of recurrent miscarriage.  She is Para 2 having had two previous emergency Caesarean sections at full dilation.  She is currently approximately 7 weeks pregnant based on her last menstrual period and is asymptomatic.  Transvaginal scan shows an anteverted uterus with empty cavity and a closed cervix. A gestational sac measuring 21mm in diameter is seen at the far upper right lateral aspect of the uterus with a thin echogenic line extending from the central uterine cavity echo to the periphery of the sac.  The sac is surrounded by myometrium measuring a maximum of 4mm in thickness. The adnexa appear normal and there is no free fluid in the Pouch of Douglas.

For each case described below, choose the single most appropriate diagnosis option from the above list. Each option may be used once, more than once or not at all.

• A 40 year old woman attends her local Early Pregnancy Unit for a reassurance scan due to a history of recurrent miscarriage.  This is an IVF donor egg pregnancy and she is currently 7 weeks pregnant based following the transfer of two blastocysts.  Transvaginal scan shows an anteverted uterus with empty cavity and a closed cervix. Both ovaries appear morphologically normal. Adjacent to the right ovary is an echogenic ring measuring 18x24x19 mm. There is no evidence of free fluid in the pouch of Douglas.

For each case described below, choose the single most appropriate diagnosis option from the above list. Each option may be used once, more than once or not at all.

• A 40 year old woman attends her local Early Pregnancy Unit for a reassurance scan due to a history of recurrent miscarriage.  This is an IVF donor egg pregnancy and she is currently 7 weeks pregnant based following the transfer of two blastocysts. Transvaginal scan shows an anteverted uterus with a closed cervix. A gestational sac is seen within the uterine cavity, medial to the interstitial portion of the fallopian tubes measuring 28 x 21 x 29mm. Within the gestational sac is a yolk sac and a fetal pole with a CRL measuring 6 mm but no fetal cardiac activity is seen. Both ovaries appear morphologically normal.  Adjacent to the right ovary is an echogenic ring measuring 18x24x19 mm. There is no evidence of free fluid in the pouch of Douglas.

For each case described below, choose the single most appropriate diagnosis option from the above list. Each option may be used once, more than once or not at all.

• An 28 year old nulliparous woman presents with severe lower abdominal pain and vaginal spotting. Her last menstrual period was 8 weeks ago and she has a positive urinary pregnancy test.  She has a history of severe endometriosis for which she has had three previous laparoscopies requiring excision and adhesiolysis. Transvaginal ultrasound shows a retroverted uterus with empty uterine cavity.  The right ovary could not be visualised but the left adnexa shows a complex left adnexal mass with mixed echogenicity arising from the left ovary which is tender during scanning.  There is a large amount of free fluid in the Pouch of Douglas.

For each case described below, choose the single most appropriate diagnosis option from the above list. Each option may be used once, more than once or not at all.

• A 41 year old nulliparous woman presents with recurrent painless vaginal bleeding and severe nausea and vomiting of pregnancy at 11 weeks gestation. She has previously had a transvaginal ultrasound which demonstrated a single live intra-uterine pregnancy. A further transabdominal ultrasound confirms absent fetal heart activity which had previously been seen and abnormal enlarged cystic appearances of the placenta.