167 Early Pregnancy Complications: Ectopic Pregnancy, Abortion Types, and GTD

Hello and welcome to episode 167 of the Physician Assistant Exam Review Podcast. This week we’re going to be covering early pregnancy complications. This is kind of a sad episode, but something we do need to cover: ectopic pregnancies, classifications of abortion, and GTD. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review, where I’ve been behind this microphone for almost 15 years now. Holy crow.

The last month, I’m just looking up, we didn’t really have any episodes. I took June off, it looks like. And that happens largely because the June cohort was amazing, 33 Days to Pass the PANCE. We moved the entire system onto a new software platform, so that was a big lift. And with that, and with how great the cohort was, I just spent a lot of time in there with them and didn’t do a whole lot else, quite frankly. So that’s why there were no episodes last month, and we’re back to it this month, hoping to be back on a regular schedule at this point.

Like I said, this week we’re going to jump back into reproduction with early pregnancy complications, and then we’ll keep moving along through there. As you know, what we do here is a little bit different. Yes, we do cover medical content, but if you’re looking for just the facts, just straight medical content, this is not the podcast for you. There are plenty of other people out there who will just read textbooks to you or just give you the facts. That’s not what we do here. We try to get you to think differently and work differently so that your scores go up. The main thing that we do here is train skills so that students can improve what they’re doing overall and watch their scores go up while their workload and their anxiety go down.

With that in mind, I’m hosting a 100% free masterclass on July 23rd on the six skill areas that PA students need for success in PA school and on the PANCE. These are the six areas of focus that I have come to rely on when I’m training students, when I was a student who failed, when I was a student who was struggling. I walk them through this six-part format to see where they’re losing points, where the problem is. Everybody comes in thinking it’s a content problem. That’s one of the six pillars of success, but it is not the only one by any stretch. You can register for that at physicianassistantexamreview.com/masterclass. I’ll be hosting that July 23rd and 26th at 8 p.m. Eastern time, so it’s a little ways off, but I just want to give you a heads up as to what’s going on there.

I’ll also be hosting the next cohort of the 33 Days to Pass the PANCE program, which begins August 1st, but registration begins July 23rd. If you want to be sure you have a seat in that class, you can go over and sign up for the early waitlist at physicianassistantexamreview.com/33 and you can get all the information there.

I think that pretty much covers everything. Let’s jump into our priming questions. A snowstorm pattern on ultrasound with a beta-hCG over 100,000 should make you think of what diagnosis? Man, these are going to be easy at the end. Really, really easy. But see if you can think about it. What is snowstorm pattern the key term for? What is the treatment for a stable, unruptured ectopic pregnancy with a beta-hCG under 5,000 and no fetal cardiac activity? Vaginal bleeding with a closed cervical os and a viable fetus on ultrasound is what type of abortion? What is the most common cause of first-trimester spontaneous abortion? Does an IUD protect against ectopic pregnancies?

All right, we’re going to begin with ectopics. Again, we’re going to move through abortion classifications, then we’re going to finish up with gestational trophoblastic disease, and that’ll be it for today. So a little bit on the short side, but it’s a lot of terms to cover, a lot of things to go through. All the notes will be over on the website, physicianassistantexamreview.com/167, if you want to go hit on these. It’s maybe really valuable to go over there and just review this stuff. I try to put the notes together in a very tight formation so you can get through it quickly with just the most important stuff for your exams. Today’s in particular is just a lot of terms. It’s a lot of memorization.

All right, so what’s an ectopic pregnancy? This is implantation outside the uterine cavity. So this really could be anywhere within the abdomen, and I have seen them implanted within the abdomen. There are different surgeons who have seen all kinds of things we talk about with GYN surgeons, but the most common is within the fallopian tube. That’s what we’re most used to hearing, when a fertilized egg implants inside of the fallopian tube, but really just anywhere outside the uterus. Now obviously, you can’t carry to term a pregnancy that’s not inside the uterus. It’s going to lead to some serious problems. Another thing is a ruptured ectopic. So let’s pretend you have a pregnancy going forward inside of a fallopian tube. As it grows, at some point it’s going to rupture. It’s going to cause significant bleeding, pain, all kinds of issues. This is a surgical emergency. It can be fatal.

Risk factors for ectopic pregnancies. Now the way that I think about this, and I try to do this with a lot of different things, is I don’t try to memorize lists. What I try to do is group things together in my head so that they can be reconstructed later, because my memory stinks. Just memorizing lists is not my strongest way to learn something. I’m much better off if I take some time to group things together and hold on to the group and then be able to rebuild the structure of that group. Let me explain what I mean here. Risk factors for ectopic pregnancy are essentially anything that’s going to cause scarring within the uterus, or within the fallopian tubes even. It’s anything that’s going to make it hard for that fertilized egg to migrate down the fallopian tube and into the uterus and implant there. If you know that, most of your things are going to be very obvious. Previous PID, pelvic inflammatory disease, if you’ve had an infection inside the uterus, inside the fallopian tubes, that’s going to cause scarring. There’s tubal surgery, so if you have a tubal ligation and the person doing the surgery didn’t do a great job, it can have an increased risk here. Anything that causes scarring in there can be a problem. Endometriosis can be a problem, same idea. A prior ectopic is your highest risk factor. An IUD is a risk factor. Smoking is a risk factor, and age greater than 35 is a risk factor. So anything that makes the uterus less hospitable. That may not be, by the way, 100% medically accurate and true, but it helps me remember what I’m looking for in my test question. I hope you understand the difference there. That’s really important. Sometimes it doesn’t have to be medically true. So if I say anything that causes an inhospitable uterus, I know what that means, and that helps me to discern the right answer on a test. Someone may come back and say, you know, smoking or age greater than 35 doesn’t really affect the lining of the uterus. That’s not technically accurate. I’m good with that. That’s fine. I don’t need to be technically accurate to be right on my test. I hope that makes sense.

Clinical presentation, how is this patient going to present? What do you think a patient who’s having an ectopic pregnancy is going to look like? Well, number one, they’re going to have amenorrhea, right? They’re going to be pregnant, so they’re going to have amenorrhea. They’re also going to usually have unilateral pelvic pain, not always, but usually. I think that makes sense. They may also have some spotting or bleeding vaginally. They can weirdly get some shoulder pain and some hypotension. What does that mean? If they have some shoulder pain or hypotension in the same setting, what are you thinking? Well, you’re thinking that this may be a ruptured ectopic, because what happens is they get some bleeding and that might pool up under the diaphragm and irritate it, and then you get some referred shoulder pain. This is something we see in laparoscopic surgery, not a lot, but you can get some referred shoulder pain from pressure on the phrenic nerve, from inflating the abdomen with the CO2. It’s not uncommon. That’s something that comes up with ectopic pregnancies. If you get adnexal tenderness or a mass, you’re going to be thinking about an ectopic pregnancy. Your question stem is likely going to be a positive pregnancy test with unilateral pelvic pain, maybe some spotting, in a reproductive-age woman. You’re going to get something like, what’s the next best test, what’s the next best thing?

Well, what are the two diagnostic things you’re going to do next? Number one, you’re going to get a beta-hCG. A normal intrauterine pregnancy doubles every 48 to 72 hours. An ectopic is going to be a subnormal rise or plateau. It’s not going to go up as sharply. What else are you going to get? What else would you order on this patient who walks through the door, who’s of childbearing age, who has some spotting, thinks she may be pregnant, and has pelvic pain? Well, you’re going to get an ultrasound, right? You’re going to get a transvaginal ultrasound. What you’re going to see is that the uterus is empty. That’s where you’re going to start to be concerned, because the beta-hCG is going to be positive and the uterus is going to be empty.

How do we treat this? Well, treatment is basically two things. One, you can use methotrexate. And two, you can surgically go in and do a salpingectomy and remove the entire tube. Those are your two options. Now, why would you pick either one? This comes down to what we talk about, clinical decision-making. These are both right answers. Neither of them is a wrong answer. But methotrexate is for a stable, unruptured ectopic, and especially if you have a mass less than 3.5 centimeters, beta-hCG less than 5,000, there’s no cardiac activity, no contraindications. You give methotrexate and then you follow with hCG tests pretty much every week. Now, if you have a ruptured or unstable situation, this is where I see this in the OR, patients come into the emergency department with pain, bleeding, et cetera, and we’re concerned about rupture, we take them to the OR immediately. This is an emergency. Things start getting bumped in the OR for this. Or if you have a mass greater than 3.5 to 4 centimeters, if you have cardiac activity or a high beta-hCG, you may consider this. Or if they’ve done methotrexate and failed it, or it’s contraindicated. But that’s what you’re deciding between. So your test question may be a couple of things identifying this, or it’s going to be how to treat it, but my guess is it’s going to ask you a clinical decision-making question of which treatment to use.

What are your exam keys? Amenorrhea, unilateral pain, spotting, positive hCG, you’re thinking ectopic. You have an empty uterus with a beta-hCG of around 2,000, you’re thinking ectopic. And then again, consider the methotrexate versus surgery. Oh, the one other point is an IUD does not protect against an ectopic. It actually increases the risk of ectopic.

All right, let’s move on and talk about abortions. What is the definition for abortion? It’s a spontaneous loss before 20 weeks. Now, when I studied these in PA school, these lent themselves to flashcards. This was 100% a flashcard question. In fact, when I give workshops now, and I talk about active versus passive studying, and I talk about flashcards, this is an example that I use, because these are so clearly just memorization of a table and being able to spit back the facts and answer the questions based on definitions. There’s a little thinking involved, but really it’s just spitting back facts. So we’ll get to that in just one second.

First, chromosomal abnormality is the most common cause. It’s like 60% to 70% of first-trimester losses. If you have recurrent losses, you want to think about antiphospholipid syndrome. You may want to think about thrombophilias, uncontrolled diabetes, thyroid disease, smoking, cocaine use, all these things could cause abortions. Advanced maternal age, uterine anomalies, things like scarring in the uterus or fibroids in the uterus. So there’s all kinds of things that can lead to this and be the risk factors for it. But as far as the actual event goes, we’re not going to talk about working up the uterus and working up the mom. I think you can probably walk through that yourself as to what would make it a more difficult situation and things that might increase loss, which is what we just talked about. But we’re going to walk through the different types here.

So clinical presentation by type. First we’re just going to run through threatened, inevitable, incomplete, complete, missed, septic, and recurrent. Those are the definitions that you need to memorize for this section. Number one is threatened abortion. This is a closed cervical os with a viable fetus inside. Nothing passed. So this is some spotting maybe, some bleeding, but the os is closed and the fetus is still inside the uterus. This is a pregnancy that may continue. It’s a threatened abortion. An inevitable abortion is an open os, but nothing has passed yet. If the os is open before 20 weeks, we’re going to be in trouble here. An incomplete abortion is an open os and some products of conception have passed and some are retained. A complete abortion is all products of conception have passed and the os is closed. The uterus is now empty. A missed abortion is a fetal demise. The os is closed, but the products of conception are still within the uterus. A septic abortion is when you have a uterine infection, right? So you have fever, tenderness, foul discharge from the vagina, all those things. Recurrent seems to be now classified as two-plus consecutive losses. It used to be three, but I think they just dropped it to two. I don’t think you’re even going to need to know that per se. Just know it’s a concern. And once we hit that point, we’re going to do a workup for antiphospholipid antibodies, karyotypes for both partners, uterine anatomy, thrombophilia, thyroid disease, all kinds of other things too. Now understand that this also gets changed around a little bit. If a patient is getting older and wants to have kids, we might do this workup after one loss and so on, but it is a little bit flexible.

Diagnostics here. We’re going to do this with a transvaginal ultrasound to look for contents inside of the uterus, and a serial beta-hCG to see if it’s coming down, in which case we would have a non-viable fetus. Treatments, what are we going to do? Well, this is kind of straightforward, right? For a threatened abortion, we’re going to do rest and hope for the best. For an inevitable or incomplete abortion, we’re going to need to do something like misoprostol or a D&C, something to get the tissue to come out of the uterus. For a complete abortion, there’s really not much to do. We’re going to confirm the uterus is empty through that ultrasound, but that’s really going to be it. For a missed abortion, it’s going to be the same as for inevitable. We have to get the uterine contents out of there, so it’s going to usually be misoprostol or D&C. For a septic abortion, same thing, except we’re going to add IV broad-spectrum antibiotics. And the key here on your exams is going to be just that cervical os. What’s going on there? If it’s open, if it’s closed, those are the things to know. So I would be making flashcards out of all that.

And right along, gestational trophoblastic disease, GTD. This is abnormal trophoblastic proliferation, benign mole to malignant choriocarcinoma. The main defining characteristic that I would be focused on if I were you is hCG out of proportion to dates. Here we have the hCGs through the roof. What are our risk factors? Less than 20 years old or greater than 35 years old mother, a prior molar pregnancy. So honestly, if you ever see that they’ve had something before, you’re almost always at greater risk for that. I’m going through psych now, right? And one of the questions that came up was, what’s the biggest risk factor for a suicide attempt? It’s a previous suicide attempt, right? That should always come up, that’s a dark thing to move to, from abortions to suicide, but that should always come up, the idea that if it’s happened before, you’re at greater risk for it. Asian or Latin American descent, those are risk factors too.

Clinical presentations. So if we have a complete molar pregnancy, this is the most common type. This is a 46,XX. So it’s all paternal, no fetus. Uterus is large for the dates. You get some excessive vomiting, dark watery bleeding. Sometimes the key term that goes with this is grape-like vesicles can pass. You can get some hyperthyroid-type features. You can get some preeclampsia before 20 weeks, which is weird, but it should definitely make you think of GTD. It’s as high as like 15 to 20%. In a partial mole, it’s a triploid, it’s a 69,XXX or XXY. You can get some fetal tissue, but it looks like a missed or incomplete abortion. These can also be malignant, so you can get an invasive molar pregnancy, like a choriocarcinoma. I don’t know too much about these except for what I read here. Some of the keys as far as your test might go: lungs are the number one place for metastasis, following any pregnancy. But in general, for gestational trophoblastic disease, you’re looking at the question stem being something like a woman that thinks she’s pregnant, has an hCG, and a couple of weeks later comes in and the hCG is just going up very, very large. The uterus is very, very large. Maybe she has signs of preeclampsia before 20 weeks.

Again, our diagnosis here is going to be a beta-hCG. Here it’s going to be greater than 100,000, disproportionate to dates, way out of whack. On transvaginal ultrasound, you’re going to see a snowstorm appearance. That’s the key term. There’s going to be no fetus inside of the uterus. It’s going to look like a snowstorm. I honestly don’t know what that means, I’ve never seen a picture of it, but I know that’s the word that goes with it. The treatment here is going to be a suction D&C. We have to remove the contents of the uterus. Then you’re going to follow with serial hCGs weekly.

All right, our exam keys here. Preeclampsia before 20 weeks or new hyperthyroid features, you’re going to think GTD until proven otherwise. Snowstorm plus an hCG greater than 100,000, you’re definitely thinking GTD. The one key from the choriocarcinoma would be that lungs are the first met. I think that might be the only thing they might ask in that range.

All right, moving on. Sorry, it’s just a crappy section I have to teach you about, especially if you’ve ever experienced it or had someone who’s gone through it. It’s just not easy.

Our study tip for today, let’s move right along, is putting it all together. How is this going to come up on your test? What are the test questions going to be? Well, like we say, don’t learn this stuff individually. Learn it as a group. That’s why we put them together, because all of these patients are going to present in a similar way. All right, your GTD isn’t going to have vaginal bleeding, I get it, but what we’re talking about is complications of early pregnancy. So all three are going to have essentially a positive pregnancy test and an hCG. And then they’re going to be uncomfortable for one reason or another, or the ultrasound is going to come back funny, or the hCG is going to come back funny. If the hCG is low or isn’t rising and the uterus is empty, you’re thinking ectopic. If they have pain, you’re really thinking ectopic. If the hCG is falling, and depending on the os, if it’s closed or open, and what you see on ultrasound, this may be an abortion. If the hCG is greater than 100,000, and you see a snowstorm appearance on a large uterus, this is a molar pregnancy.

So if the hCG is low, you’re thinking ectopic. If it’s falling, you’re thinking abortion. If it’s really high, you’re thinking a molar pregnancy. I love to take all of the notes and all the information and boil it down to that one line. Low hCG is ectopic. Falling is abortion. High is a molar pregnancy. That one line, in addition to what you can probably piece together about what the ultrasound’s going to look like, will get you 70% of the questions on this right. Maybe 80% of the questions on this right. Either way, you’re going to get a lot of the questions on this section right if you know that one line. Do you need everything else in here? No. Is it helpful? Yeah, of course. If you have a better understanding and a better picture of all of this stuff, it’s 100% better. But everyone talks about how little time they have. To me, I’m looking for the one line that’s going to tie everything together, and that’s it.

So our study tip for today is to try to tie all of the information you can together and to see how it’s going to come on your exam. Now, you may get a question about how to treat one of these, but a lot of times your questions are going to be which one is it. Is this GTD? Is this an ectopic? Or is it some type of abortion? And you have to decide between them. And then quite frankly, if it’s a treatment question, the treatments are relatively straightforward. It’s usually either D&C or nothing. So where I’m going to save time, I’m going to study these as a group so that they’re all together and I can just picture the whole thing running together. So what I would do is write some test questions going over exactly that. What would it look like if I’m comparing these diseases?

All right, let’s answer our priming questions. A snowstorm pattern on ultrasound with a beta-hCG over 100,000 should make you think of what diagnosis? I told you this one was going to be easy when we got to the end. This is going to be a complete hydatidiform mole. What’s the treatment for a stable, unruptured ectopic pregnancy with a beta-hCG under 5,000 and no fetal cardiac activity? Methotrexate. Vaginal bleeding with a closed cervical os and a viable fetus on ultrasound is what type of abortion? Threatened. The os is closed and there’s viable tissue, so threatened abortion. If you have some bleeding, it may still continue. What’s the most common cause of a first-trimester spontaneous abortion? 60 to 70% are chromosomal abnormalities. And does an IUD protect against ectopic pregnancy? No, it does not. It protects against intrauterine pregnancy but not ectopics. So usually you’re not going to get an ectopic, but it’s something just to keep in mind. You always, always, always want to consider ectopic, because even if people have IUDs, that’s really the key. It’s kind of a trick question.

Fantastic. All right, that wraps us up for today. I’m so excited to be back behind the microphone. Excited to see you guys this week. Excited to talk to you next week. I want you to understand that what we do here is so different. We’re not just talking about the facts. We’re talking about how to think about them, your clinical decision-making, the way to move through them, the way to study them, all these things that tie together to increase your scores. And one of the mottos of this show is think different, work different, score different. That’s exactly what we teach within the 33 Days to Pass the PANCE program. It’s exactly what I’m going to be teaching in the masterclass. You can find out more about that at physicianassistantexamreview.com/masterclass, in order to learn about those six different skill areas and which one’s holding you back and how to improve in that area. If you find this helpful, if you think that masterclass might be helpful, please pass this show and the class along to your classmates, to your faculty, to other people in your cohort, to anyone else you think might be able to utilize this information. My goal is to impact as many PA students as possible, to help reduce their anxiety and help boost their scores. And the more you can help me do that, the better off we all are. All right, take care. Have a great day, and I’ll see you next week.