1 Flashcards
What is the physiologic source of human chorionic gonadotropin (hCG)?
Produced by placental syncytiotrophoblasts, first appears in maternal blood 10 d after fertilization, peaking at 9–10 wks, then falling to a plateau at 20–22 wks. Glycoprotein with 2 subunits. Alpha–subunit is similar to LH, FSH, TSH. Beta is specific.
What are the purposes of beta–hCG?
Maintains corpus luteum production of progesterone until placenta can synthesize progesterone and take over maintenance of pregnancy. Regulates steroid biosynthesis in placenta and fetal adrenal.
What is the signifiance of beta–hCG levels in pregnancy?
Inadequate beta–hCG levels indicate ectopic, threatened abortion, missed abortion.
What is the structure of human placental lactogen?
Structure is similar to anterior pituitary growth hormone and prolactin. The level of HPL parallels placental growth, rising throughout pregnancy.
What is the role of human placental lactogen?
Antagonizes cellular action of insulin, decreasing insulin utilization, thereby contributing to the predisposition of pregnancy to glucose intolerance and diabetes. Low levels indicate a risk of threatened abortion, intrauterine growth restriction (IUGR).
What is progesterone?
Steroid hormone produced after ovulation by the luteal cells of the corpus luteum. Induces endometrial secretory changes favorable for blastocyst implantation.
What is the source of progesterone?
Initially produced exclusively by the corpus luteum up to menstrual weeks 6–7. Between 7 and 9 weeks, both the corpus luteum and the placenta produce progesterone. After 9 wks, corpus luteum involutes, and progesterone is exclusively made by placenta.
What is the significance of an elevated progesterone level during pregnancy?
Twin pregnancy, hydatidiform mole, choriocarcinoma, embryonal carcinoma
What are the purposes of progesterone?
In early pregnancy, progesterone induces endometrial secretory changes favorable for blastocyst implantation. In later pregnancy, progesterone induces immune tolerance for the pregnancy and prevents myometrial contractions.
What are estrogens?
Steroid hormones, which occur in three forms, estradiol, estriol, and estrone.
What is estradiol?
Predominant moiety during nonpregnant reproductive years is estradiol. It is converted from androgens in follicular theca cells; androgens diffuse into follicular granulosa cells where aromatase completes the transformation into estradiol.
What is estriol?
Main estrogen during pregnancy. Dehydroepiandrosterone–sulfate (DHEAS) from the fetal adrenal gland is the precursor for 90% of estriol converted by sulfatase enzyme in the placenta.
What is estrone?
Main form of estrogen during menopause. Postmenopausal adrenal androstenedione is converted in peripheral adipose tissue to estrone.
What are the skin changes during pregnancy?
Striae gravidarum are stretch marks” on abdomen. Spider angiomata and palmer erythema from increased skin vascularity. Linea nigra is pigmentation of from pubis to umbilicus. Chloasma is blotchy pigmentation of nose and face.”
What is the Chadwick sign?
Bluish or purplish discoloration of the vagina and cervix as a result of increased vascularity.
What are the blood pressure changes during pregnancy?
Systolic and diastolic decline early in 1st trimester, nadir by 24–28 weeks, then pressures gradually rise toward term but never return completely to prepregnancy baseline. Diastolic falls more than systolic. Elevated BP is never normal in pregnancy.
What are the plasma volume changes during pregnancy?
Plasma volume increases up to 50% with a significant increase by the first trimester. Maximum increase is by 30 weeks. Plasma volume increases with multiple fetuses.
What are the systemic vascular resistance changes during pregnancy?
SVR equals blood pressure (BP) divided by cardiac output (CO). Because BP decreases and CO increases, SVR declines by 30%, reaching its nadir by 20 weeks, enhancing uteroplacental perfusion.
What are the cardiac output changes during pregnancy?
CO increases up to 50%. HR increases by 20 beats/min by 3rd trimester. SV increases by 30% by end of 1st trimester. CO is lowest supine because of inferior vena cava compression. CO is highest in left lateral position.
What is the effect of pregnancy on heart murmurs?
A systolic ejection murmur along the left sternal border is normal in pregnancy because of increased CO through the aortic and pulmonary valves. Diastolic murmurs are never normal in pregnancy and must be investigated.
What are the red blood cells mass changes during pregnancy?
RBC mass increases by 30%; O2–capacity increases. Because plasma volume increases by 50%, the calculated hemoglobin and hematocrit values decrease by 15%. Nadir of Hb is at 28–30 weeks’ gestation. Decreases in Hb and Hct are dilutional effects.
What are the white blood cell changes during pregnancy?
WBC count increases progressively during pregnancy with a mean value of up to 16,000/mm3 in the third trimester. ESR increases in pregnancy because of the increased gamma globulins. Platelet count is unchanged in pregnancy.
What is the effect of pregnancy on coagulation factors?
Factors VII, VIII, LX, and X increase progressively in pregnancy, resulting in a hypercoagulable state.
How does pregnancy affect the stomach?
Gastric motility decreases and emptying time increases from progesterone effect. Increase in stomach residual volume and upward displacement of intraabdominal contents by gravid uterus predisposes to aspiration pneumonia with anesthesia.
What is the effect of pregnancy on the large bowel?
Colonic motility decreases and transit time increases from the progesterone effect on smooth muscle. These changes predispose to increased colonic fluid absorption, resulting in constipation.
How does pregnancy affect tidal volume?
Tidal volume (Vt) is volume of air that moves in and out of the lungs at rest. Vt increases with pregnancy to 40%. Tidal volume is the only lung volume that does not decrease with pregnancy.
How does pregnancy affect minute ventilation?
Te increases up to 40%, with the major increase by 20 weeks. Te is the product of respiratory rate (RR) and Vt. RR remains unchanged with Vt increasing steadily throughout the pregnancy into the third trimester.
How does pregnancy affect residual volume?
RV is the volume of air trapped in the lungs after deepest expiration. RV decreases up to 20% by the third trimester because of the upward displacement of intraabdominal contents against diaphragm by the gravid uterus.
How does pregnancy affect blood gases?
The rise in Vt produces a respiratory alkalosis with a decrease in Pco2 from 40 to 35 mm Hg, and an increase in pH from 7.40 to 7.45. An increased renal loss of bicarbonate compensates for the alkalosis, resulting in alkalotic urine.
How does pregnancy affect the kidneys?
The kidneys increase in size during pregnancy because of increased renal blood flow. Ureteral diameter increases because of the progesterone effect on smooth muscle. GFR, renal plasma flow, creatinine clearance increase 50% at end 1st trimester.
What is the effect of pregnancy on blood urea nitrogen, creatinine, and uric acid?
25% decrease in serum blood urea nitrogen, creatinine, and uric acid.
How does pregnancy affect urine glucose?
Glucosuria. Urine glucose normally increases. Glucose is freely filtered and actively reabsorbed. Urine protein remains unchanged.
What hormones stimulate breast development in females?
From infancy to puberty, there is no difference between female and male breasts. With beginning of female puberty, release of estrogen, and then progesterone, causes the breasts to change into mature form over 3 to 4 years, and complete by 16.
What is the anatomy of the female breast?
Fibrous and fatty tissue and 15–20 lobes in each breast. 80% of breast is fat during reproductive years. Lobes are further divided into lobules containing alveoli of secretory cells with ducts that conduct to a reservoir under the nipple.
What are the breast structure changes of pregnancy?
During pregnancy, the alveoli enlarge; and during lactation, the cells secrete milk proteins and lipids. With the release of oxytocin, the muscular cells surrounding the alveoli contract to express the milk during lactation.
What are Cooper?s ligaments?
Cooper’s ligaments keep the breasts in the characteristic shape and position and support breast tissue. In the elderly or during pregnancy, these ligaments become loose or stretched.
What is the effect of estrogen on the breasts?
Estrogen, released from the ovarian follicle, promotes the growth ducts.
What is the effect of progesterone on the breasts?
Progesterone, released from the corpus luteum, stimulates the development of milk– producing alveolar cells.
What is the effect of prolactin on the breasts?
Prolactin, released from the anterior pituitary gland, stimulates milk production.
What is the purpose of oxytocin?
Released from the posterior pituitary in response to suckling, causes milk ejection from the lactating breast.
What are the breasts changes during pregnancy?
Breasts become fully developed under influence of estrogen, progesterone, and prolactin during pregnancy. Prolactin causes production of milk. Oxytocin release from suckling reflex causes ducts to eject milk from the nipple.
What is the first secretion of the mammary gland after delivery?
Colostrum, which contains more protein and less fat than milk. Contains IgA that impart passive immunity to infant. Milk production occurs 1 to 3 days after delivery. Expulsion of placenta initiates milk production; causes drop in E and P.
What is the effect of suckling on milk production?
Physical stimulation of suckling causes the release of oxytocin and stimulates prolactin secretion, causing increased milk production.
What is the most significant event of postconceptional week 1?
Implantation of the blastocyst on the endometrium. Week 1 begins with fertilization of the egg and ends with implantation of the blastocyst onto the endometrial surface. Fertilization usually occurs in the distal part of the oviduct.
For what period of time is the egg fertilizable?
The egg is capable of being fertilized for 12–24 hours. The sperm is capable of fertilizing for 24–48 hours.
What events occur in postconception of week 2?
Development of bilaminar germ disk with epiblast and hypoblast layers. Layers give rise to 3 germ layers. Invasion of maternal sinusoids by syncytiotrophoblast occurs. beta–hCG is produced in syncytiotrophoblast and enters maternal blood.
What event occurs during postconception week 3?
Migration of cells through the primitive streak between the epiblast and hypoblast to form the trilaminar germ disk with ectoderm, mesoderm, and endoderm layers. These layers will give rise to the major organs and organ systems.
What event occurs during postconception weeks 4–8?
Major organs are formed. Period of major teratogenic risk. Ectoderm forms central and peripheral nervous systems; organs of seeing, hearing; integument. Mesoderm: muscles, cartilage, CVS, urogenital. Endoderm forms lining GI, respiratory tracts.
What happens to the paramesonephric (Mullerian) duct in males?
Present in all early embryos and is primordium of female system. In males, Y chromosome induces gonadal secretion of Mullerian inhibitory factor, which causes Mullerian duct to involute.
What happens to the paramesonephric (Mullerian) duct in females?
In females, without Mullerian inhibitory factor, the Mullerian duct develops into the fallopian tubes, uterus, cervix, and proximal vagina.
What hormonal stimulation is needed for differentiation of the external female genitalia?
No hormonal stimulation is needed for differentiation of the external genitalia into labia majora, labia minora, clitoris, and distal vagina.
What is the mesonephric (Wolffian) duct?
Present in early embryos and is primordium of male system. T causes development of vas deferens, seminal vesicles, epididymis, efferent ducts. In females, Wolffian duct regresses.
What will happen to the Wolffian duct if a genetic male has absence of testosterone receptors?
If a genetic male has absence of androgen receptors, the Wolffian duct will regress and there will be absence of vas deferens, seminial vesicles, epidymis, and efferent ducts.
What hormonal stimulation is causes differentiation of the male external genitalia?
Dihydrotestosterone stimulation is needed for differentiation of the external genitalia into a penis and scrotum. If a genetic male has an absence of androgen receptors, external genitalia will differentiate into a female phenotype.
What are the infectious teratogens?
Bacteria (eg, chlamydia and gonorrhea cause neonatal eye and ear infections), viral (eg, rubella, cytomegalovirus, herpes virus), spirochetes (eg, syphilis), or protozoa (eg, toxoplasmosis).
What weeks of gestation are associated with greatest risk of teratogenicity from ionizing radiation?
No increase is seen in fetal anomalies or pregnancy losses with exposure of
What are the adverse pregnancy effects of cocaine?
Tobacco is associated with intrauterine growth restriction (IUGR) and preterm delivery, but no specific syndrome.
What are the teratogenic effects of alcohol?
Fetal alcohol syndrome: midfacial hypoplasia, microcephaly, mental retardation, and IUGR.
What are the adverse pregnancy effects of cocaine?
Placental abruption, preterm delivery, intraventricular hemorrhage, and IUGR. Marijuana is associated with preterm delivery but not with any syndrome.
What is a FDA pregnancy category A drug?
Controlled studies show no risk. Adequate studies show no risk to the fetus in any pregnancy trimester. Category A includes acetaminophen, thyroxine, folic acid, and magnesium sulfate.
What is a FDA pregnancy category B drug?
No evidence of risk in humans. Controlled studies show no risk to humans despite adverse findings in animals. Category B includes penicillin, cephalosporins, methyldopa, insulin, Pepcid, Reglan, Tagamet, Vistaril, Paxil, Prozac, Benadryl, and Dramamine.
What is a FDA category C drug?
Risk cannot be ruled out. Controlled studies are lacking in humans and animals. Category C includes codeine, Decadron, methadone, Bactrim, Cipro, AZT, beta–blockers, Prilosec, heparin, Protamine, Thorazine, Robitussin, and Sudafed.
What is a FDA category D drug?
Positive evidence of risk. Studies demonstrate fetal risk, but potential benefits of the drug may outweigh the risk. Category D includes aspirin, Valium, tetracycline, Dilantin, Depakote, and lithium.
What is a FDA category X drug?
Contraindicated in pregnancy. Studies demonstrate fetal risk, which outweighs any possible benefit. Category X includes Accutane (isotretinoin), Danocrine, Pravachol, coumadin, and Cafergot.
What is the teratogenic effect of alcohol?
Fetal alcohol syndrome: IUGR, midfacial hypoplasia, developmental delay, short palpebral fissures, long philtrum, joint anomalies, cardiac defects.
What is the teratogenic effect of diethylstilbestrol?
DES syndrome: T–shaped uterus, vaginal adenosis (predisposition to vaginal clear cell carcinoma), cervical hood, incompetent cervix, preterm delivery.
What is the teratogenic effect of dilantin?
Fetal hydantoin syndrome: IUGR, craniofacial dysmorphism (epicanthal folds, depressed nasal bridge, oral clefts), mental retardation, microcephaly, nail hypoplasia, heart defects.
What is the teratogenic effect of isotretinoin (Accutane)?
Congenital deafness, microtia, CNS defects, congenital heart defects.
What is the teratogenic effect of lithium?
Ebstein’s anomaly (right heart defect).
What is the teratogenic effect of streptomycin?
Cranial nerve VIII damage, hearing loss.
What is the teratogenic effect of tetracycline?
Deciduous teeth discoloration after the fourth month.
What is the teratogenic effect of thalidomide?
Phocomelia, limb reduction defects, ear/nasal anomalies, cardiac defects, pyloric or duodenal stenosis.
What is the teratogenic effect of trimethadione?
Facial dysmorphism (short upturned nose, slanted eyebrows), cardiac defects, IUGR, mental retardation.
What is the teratogenic effect of valproic acid (Depakote)?
Neural tube defects (spina bifida), cleft lip, renal defects.
What is the teratogenic effect of warfarin (Coumadin)?
Chondrodysplasia (stippled epiphysis), microcephaly, mental retardation, optic atrophy.
What is gravidity?
The total number of pregnancies, irrespective of pregnancy duration. A nulligravida is a woman who is not currently pregnant and has never been pregnant. A primigravida is a woman who is pregnant currently for first time.
What is a multigravida?
Woman who is pregnant for more than first time. Parity is total number of pregnancies achieving >20 weeks’ gestation.
What is a nullipara?
A nullipara is a woman who has never carried a pregnancy achieving 20 weeks’ gestation. A primipara is a woman who has carried one pregnancy to 20 weeks’ gestation.
What is multipara?
A woman who has carried more than one pregnancy to 20 weeks’ gestation.
What is puerpera?
Woman who has just given birth.
What is an abortion?
Pregnancy loss prior to 20 menstrual weeks.
What is an antepartum death?
Fetal death between 20 menstrual weeks and the onset of labor.
What is an intrapartum death?
Fetal death from onset of labor to birth.
What is a fetal death?
Fetal death between 20 menstrual weeks and birth.
What is a perinatal death?
Fetal/neonatal death from 20 menstrual weeks to 28 days after birth.
What is a neonatal death?
Newborn death between birth and the first 28 days of life.
What is birth rate?
Number of live births per 1,000 total population.
What is the fetal mortality rate?
Number of fetal deaths per 1,000 total births.
What is the neonatal mortality rate?
Number of neonatal deaths per 1,000 live births.
What is a perinatal mortality rate?
Number of fetal plus neonatal deaths per 1,000 total births.
What is infant mortality rate?
Number of infant deaths per 1,000 live births.
What is the maternal mortality rate?
Number of maternal deaths per 100,000 live births.
What is an advanced maternal age?
Women
What is aneuploidy?
Cells do not contain 2 complete sets of 23 chromosomes. Most common aneuploidy is trisomy, presence of an extra chromosome. Most trisomies result in spontaneous abortions.
What is the most common trisomy at term?
The most common trisomy at term is trisomy 21. The most common trisomy in first–trimester losses is trisomy 16.
What is polyploidy?
Cells contain complete sets of extra chromosomes. Most common polyploidy is triploidy, with 69 chromosomes, followed by tetraploidy, with 92 chromosomes. Incomplete mole is a triploidy caused by fertilization of 1 egg by 2 sperm.
What are structural chromosomal alterations?
Conditions in which chromosomal material is deleted, gained, or rearranged. Alterations can involve single or multiple chromosomes. An example of a chromosomal deletion is cri du chat syndrome, which is a deletion of short arm of chromosome 5.
What is mosaicism?
Two or more cytogenetically distinct cell lines in the same individual. Mosaicism can involve the placenta, the fetus, or both. Gonadal mosaicism can result in premature ovarian failure and predispose to gonadal malignancies.
What is a reciprocal translocation?
Involves any 2 or more nonhomologous chromosomes when there is a breakage and reunion of portions of chromosomes to yield new products.
What is the chromosomal composition of carriers of balanced reciprocal translocations?
Carriers of balanced reciprocal translocations have 46 chromosomes, with both derivative chromosomes present.
What is a Robertsonian translocation?
Involves acrocentric chromosomes, and centric fusion after loss of satellite region of short arms of original chromosome. Karyotype will have 45 chromosomes; however, full complement of genetic material is present; no clinical effects.
What percentage of miscarried abortuses have abnormal chromosomes?
At least 50% of 1st trimester abortuses have abnormal chromosomes. 2 most common aneuploidies in miscarriages are trisomy 16 and monosomy X. Fifty percent of these abnormalities are autosomal trisomies, with trisomy 16 most common.
What is Turner syndrome?
Also known as gonadal dysgenesis. Seen in 1 in 10,000 births. In most cases it is the result of loss of the paternal X chromosome. 98% of these conceptions abort spontaneously. Ultrasound shows nuchal skin–fold thickening, cystic hygroma.
What are the clinical manifestations of Turner syndrome?
Absence of secondary sexual, short stature, streak gonads, primary amenorrhea, infertility, broad chest, web neck. Urinary tract anomalies, aortic coarctation are common. Intelligence is usually normal.
What is Klinefelter syndrome?
Klinefelter syndrome is seen in 1 in 2,000 births. Diagnosis is made at puberty. Tall stature, testicular atrophy, azoospermia, gynecomastia, and truncal obesity. Learning disorders and low IQ.
What is incidence of Down syndrome?
Trisomy 21. One in 800 births; 50% of cytogenetic diseases at term. Increases with maternal age.
What are the clinical signs of trisomy 21?
Mental retardation, short stature, hypotonia, brachycephaly, short neck. Oblique orbital fissures, flat nasal bridge, small ears, nystagmus, protruding tongue. Endocardial cushion defects, duodenal atresia.
What is Edward syndrome?
Trisomy 18 causes profound mental retardation, rocker–bottom feet and clenched fists. Survival to 1 year of age by only 40%. Seen more frequently with advancing maternal age.
What is Patau syndrome?
Trisomy 13 is profound mental retardation, cyclopia, proboscis, holoprosencephaly, and severe cleft lip with palate. Survival to 1 year of age by only 40%. Seen more frequent with advancing maternal age.
What is the triad of Down syndrome?
Short stature, mental retardation, endocardial cushion cardiac defects.
What percentage of live born infants have a congenital Mendelian genetic disorder?
1% of liveborn infants have a Mendelian disorder. 15% of all birth defects are Mendelian disorders. 70% of Mendelian disorders are autosomal dominant. Remainder are autosomal recessive, X–linked, or multifactorial.
What are the genetics of autosomal dominant disorders?
Transmission equally to males, females; serial generations are affected. Each affected individual has affected parent. Affected individuals will transmit disease to 50% of offspring. Unaffected individuals bear unaffected children. No carrier states.
What are the most common clinical manifestations of autosomal dominant disorders?
Most common findings are anatomic abnormalities. Age of onset is delayed, with variability in expression.
What are the most common autosomal dominant disorders?
Polydactyly, Marfan syndrome, Huntington chorea, myotonic dystrophy, achondroplasia, polycystic kidneys, neurofibromatosis, osteogenesis imperfecta.
What are the genetics of autosomal recessive disorder?
Transmission equally to males and females; often skips generations. Enzyme deficiencies most common. Age of onset is earlier. If both parents are heterozygous, 25% of offspring affected, 50% are carriers, 25% are normal. Carrier states common.
What is the heritance pattern if one parent is homozygous and one parent is heterozygous for autosomal recessive disorders?
If one parent homozygous and one heterozygous, 50% of offspring affected, and 50% will be carriers. If both parents homozygous, 100% of children affected.
What are the most common autosomal recessive disorders?
Deafness, cystic fibrosis, Thalassemia, albinism, sickle cell anemia, Tay–Sachs disease, phenylketonuria, congenital adrenal hyperplasia, Wilson disease
What are the genetics of X–linked recessive disorders?
Conditions are dominant in men, but dominant or recessive in women.
What is the transmission pattern for X–linked recessive disorders?
No male–to–male transmission (because father gives only his Y to his son). Transmission is 100% male–to–female. Transmission from heterozygous females to male offspring in an autosomally dominant pattern.
What is the the pattern of expression for X–linked recessive disorders?
Disease is expressed in all males who carry gene, and disease is expressed only in male relatives with the gene.
What are the most common X–linked recessive disorders?
Hemophilia A, color blindness, diabetes insipidus, G–6–PD deficiency, hydrocephalus, Duchenne muscular dystrophy, complete androgen insensitivity.
What is the triad of autosomal dominant disorders?
Transmitted by both sexes. All generations affected. No carrier states.
What is the triad of autosomal recessive disorders?
Transmitted by both sexes. Often skips generations. Male and female carriers.
What is the triad of X–Linked recessive disorders?
No male–male transmission. Expressed only in males. Female carriers.
What are the genetics of X–linked dominant disorders?
The disease is manifested in female heterozygotes as well as carrier males (hemizygotes); hypophosphatemic rickets. The disease is manifested in female heterozygotes, but is lethal in males, causing abortion; incontinentia pigmenti.
What is the prevalence of multifactorial birth defects?
Majority of birth defects (70%) are multifactorial; caused by interaction of multiple genes with environmental factors. Increased frequency of disorder in families. Recurrence rate is 2–3%. The more severe the malformation, the higher the recurrence.
What are the most common multifactorial birth defects?
Neural tube defects, congenital heart disease, cleft lip and palate, and pyloric stenosis.
What are neural tube defects?
Incidence is 2 per 1,000 births. Failure of neural tube closure. Anencephaly and spina bifida occur with equal frequency. Preconception folic acid supplementation decreases incidence NTD.
What is the incidence of congenital heart disease?
1% of births. Majority multifactorial. Distinguish isolated defects should be distinguished from those that are part of a syndrome with a higher recurrence risk. Preconception folate reduces the risk of CHD and neural tube defects.
What is the incidence of cleft lip and palate?
The incidence is 1 per 1,000 births. The risk of cleft lip in a second child of unaffected parents is 4%. If two children are affected, the risk of the third child being affected is 10%.
What is the heritance pattern for pyloric stenosis?
More common in males. The risk of the condition in the offspring of an affected parent is much greater if the affected parent is female.
What is the epidemiology of induced abortions?
Nearly half of all pregnancies among American women are unintended, and four in 10 of these are terminated by abortion. A quarter of all pregnancies end in abortion.
What are the risks associated with induced abortion?
Early first–trimester abortions pose virtually no long–term risk of infertility, ectopic pregnancy, spontaneous abortion. 0.3% of abortion patients experience a complication that requires hospitalization.
What is vacuum curettage–dilation and curettage?
D&C is most common abortion procedure (90%), and is performed before 13 weeks’. Prophylactic antibiotics, conscious sedation, paracervical block. The cervical canal is dilated with cervical dilators or hygroscopic/osmotic dilators.
What are the complications of vacuum curettage?
Complications are rare but include endometritis, treated with outpatient antibiotics; and retained products of conception, treated by repeat curettage. Maternal mortality rate is 1 per 100,000 women.
What is a medical abortion?
Induction of abortion using oral mifepristone (Mifeprex; a progesterone antagonist) and buccal misoprostol (Cytotec; prostaglandin E1). Limited to first 63 days of amenorrhea. 85% abort within 3 days.
What are the complications of mifepristone/misoptostol induction of abortion?
2% abort incompletely and require vacuum curettage. Clostridium sordellii sepsis is a rare complication.
What is dilation and evacuation?
Most common 2nd trimester abortion procedure. Laminaria dilators placed 24 hours. Early 2nd trimester abortions can be performed by vacuum aspiration alone. If the fetus is more than 14 weeks, the fetus is morcellated with ultrasound guidance.
What is an intact D&E?
Involves more advanced pregnancies. 2 days of Laminaria for wide cervical dilation, allowing assisted breech delivery under ultrasound. Decompression of calvaria with the fetus delivered intact. Also called a partial birth” abortion.”
What are the complications of induced abortions?
Immediate complications may include uterine perforation, retained tissue, hemorrhage, infection, and, rarely, disseminated intravascular coagulation.
What labor induction methods are used for intact induced abortion?
Hypertonic, intra–amniotic saline or urea, prostaglandins (intraamniotic PGF2a), vaginal PGE2 (dinoprostone), IM 15–methyl PGF2a (Hemabate), PGE1 (misoprostol). Delivery of a live fetus may require feticidal, intracardiac KCl or digoxin.
What is spontaneous abortion?
Bleeding that occurs before 12 weeks’ gestation. The most common cause of early pregnancy loss is fetal abnormalities.
What is the etiology of most cases of spontaneous abortion?
Cytogenetic abnormalities cause the majority of early pregnancy losses because of gross chromosomal abnormalities of the fetus. Other losses may be caused by Mendelian autosomal or X–linked dominant or recessive diseases.
What antibody is associated with repeat spontaneous abortions?
Anticardiolipin antibody is an uncommon cause of early pregnancy loss. Some women with SLE produce antibodies against vascular system and fetoplacental tissues. This is known as antiphospholipid syndrome.
What is the treatment of spontaneous abortion?
Speculum exam for vaginal or cervical lesions. RhoGAM for all Rh–negative gravidas who undergo dilatation and curettage. Molar and ectopic pregnancy should be ruled out by ultrasound in all patients with early pregnancy bleeding.
What are the signs of missed abortion?
Ultrasound finding of a nonviable pregnancy without vaginal bleeding, uterine cramping, or cervical dilation.
What is the management of missed abortion?
Scheduled suction D&C, conservative management awaiting a spontaneous completed abortion, or induce contractions with misoprostol (Cytotec).
What are the signs of threatened abortion?
Ultrasound finding of a viable pregnancy with vaginal bleeding but absence of cervical dilation. Half of threatened abortions will continue to term successfully. Management is observation.
What is the presentation of inevitable abortion?
Vaginal bleeding and uterine cramping leading to cervical dilation, but no product of conception has been passed.
What is the management of inevitable abortion?
Emergency suction D&C to prevent further blood loss and anemia.
What is an incomplete abortion?
Vaginal bleeding and uterine cramping leading to cervical dilation, with some, but not all, product of conception have been passed. Management is emergency suction D&C to prevent further blood loss and anemia.
What is the presentation of completed abortion?
Vaginal bleeding and uterine cramping after all product of conception has been passed. Confirmed by a sonogram showing no intrauterine contents or debris.
What is the management of completed abortion?
Conservative. If an intrauterine pregnancy has been previously confirmed. Otherwise, serial beta–human chorionic gonadotropin levels should be obtained weekly until negative to verify that an ectopic pregnancy has not been missed.
What is intrauterine fetal demise?
In utero death of a fetus after 20 weeks’ gestation before birth. Antenatal demise occurs before labor. Intrapartum demise occurs after the onset of labor.
What is the most serious complication of intrauterine fetal demise?
Disseminated intravascular coagulation may occur with prolonged fetal demise (>2 weeks), resulting from release of tissue thromboplastin from deteriorating fetal organs.
What are the causes of intrauterine fetal demise?
Most commonly idiopathic. Other causes include antiphospholipid syndrome, overt maternal diabetes, maternal trauma, severe maternal isoimmunization, fetal aneuploidy, and fetal infection.
What is the presentation of intrauterine fetal demise?
Before 20 weeks’ gestation, the most common finding is uterine fundus less than dates. After 20 weeks’ gestation, the most common symptom is maternal report of absence of fetal movements.
How is intrauterine fetal demise diagnosed?
Ultrasound demonstrates lack of fetal cardiac activity.
What is the management of intrauterine fetal demise if DIC is present?
Coagulopathy should be assessed with platelet count, d–dimer, fibrinogen, prothrombin time, partial thromboplastin time. If DIC is identified, immediate delivery is necessary with selective blood product transfusion if indicated.
What is the management of intrauterine fetal demise if DIC is not present?
A dilatation and evacuation may be appropriate in pregnancies of 20 weeks or if a fetal autopsy is indicated.
What tests may identify the cause of intrauterine fetal demise?
Cervical and placental cultures for suspected infection, autopsy for suspected lethal anatomic syndrome, karyotype for aneuploidy, total body x–ray for suspected osteochondrodysplasia, maternal blood for Kleihauer–Betke.
What is ectopic pregnancy?
Pregnancy in which implantation has occurred outside of the uterine cavity. The most common location is in the oviduct.
What is the differential diagnosis of abnormal vaginal bleeding with a positive pregnancy test?
Threatened abortion, incomplete abortion, ectopic pregnancy, and hydatidiform mole. The possibility of pregnancy or a complication of pregnancy should always be considered.
What are the risk factors for ectopic pregnancy?
Scarring from PID, IUD, tubal ligation, tubal surgery, or congenital (diethylstilbestrol exposure). 1% of pregnancies are ectopic pregnancies, and if the patient has had one ectopic pregnancy, the incidence becomes 15%.
What is the triad of ectopic pregnancy?
Secondary amenorrhea. Unilateral abdominal/pelvic pain. Vaginal bleeding.
What are the symptoms of ectopic pregnancy?
The classic triad with an unruptured ectopic pregnancy is amenorrhea, vaginal bleeding, and unilateral pelvic–abdominal pain. Ruptured ectopic pregnancy causes symptoms of intraperitoneal bleeding and irritation.
What are the signs of ectopic pregnancy?
Unilateral adnexal and cervical motion tenderness. Uterine enlargement and fever are absent. Ruptured ectopic pregnancy, causes signs of peritoneal irritation (guarding/rigidity), hypovolemia. Hypotension, tachycardia indicate significant blood loss.
What are the laboratory abnormalities in ectopic pregnancy?
Beta–hCG test will be positive. Sonography may reveal an adnexal mass; but no intrauterine pregnancy will be seen even though the beta–HCG is positive.
How is ectopic pregnancy diagnosed?
Failure to see a normal intrauterine gestational sac when the serum beta–hCG titer is >1,500 mIU is presumptive diagnosis of an ectopic pregnancy.
What are the signs of ruptured ectopic pregnancy?
The diagnosis of ruptured ectopic pregnancy is presumed with a history of amenorrhea, vaginal bleeding, and abdominal pain in the presence of a hemodynamically unstable patient. Laparoscopic intervention to stop the bleeding is necessary.
What is the management of intrauterine pregnancy with bleeding?
If the sonogram reveals an IUP, the diagnosis is threatened abortion, the patient should be placed on bed rest. If the diagnosis is hydatidiform mole, the patient should be treated with a suction curettage and followed up on a weekly basis with beta–hCG.
What is the management of a possible ectopic pregnancy?
If sonogram does not reveal IUP, but beta–hCG is 1,500 mIU.
What is the management of unruptured ectopic pregnancy?
Medical management with methotrexate is preferred.
What is the criteria for use of methotrexate for ectopic pregnancy?
Folate antagonist attacks proliferating tissues including trophoblastic villi. Criteria: pregnancy mass
What is the follow–up management after methotrexate for ectopic pregnancy?
Follow–up serial beta–hCG levels to ensure pregnancy resolution. Rh–negative women should receive RhoGAM.
What is the treatment of ectopic pregnancy if methotrexate is contraindicated?
Salpingostomy. Isthmic tubal pregnancies are managed with segmental resection. Salpingectomy is for ruptured ectopic pregnancy or if no desire for further fertility.
What is the follow–up management after a salpingostomy for ectopic pregnancy?
After a salpingostomy, beta–hCG titers should be obtained weekly. Rh–negative women receive Rho GAM.
What is chorionic villus sampling?
Performed under ultrasound without anesthesia. Catheter is placed transcervically or transabdominally into placenta. Chorionic villi (placental precursors) are aspirated between 10–12 wks, and sent for karyotyping. Loss in 0.7%.
What is amniocentesis?
Performed after 15 wks under ultrasound without anesthesia. Needle is placed into amniotic fluid under ultrasound guidance, aspirating fluid containing desquamated fetal amniocytes. Pregnancy loss rate 0.5%.
What tests are done on fetal amniocytes after amniocentesis?
Fetal karyotyping is performed on amniocytes. Neural tube defect screening is performed on amniotic fluid with biochemical analysis (AF–AFP and acetylcholinesterase).
What is percutaneous umbilical blood sampling?
PUBS is a transabdominal procedure under ultrasound; aspirates fetal blood from umbilical vein after 20 wks’. Blood gases, karyotype, IgG and IgM antibodies; intrauterine transfusion with fetal anemia. Loss rate 2%.
What is fetoscopy?
Transabdominal with a fiberoptic scope in operating room after 20 weeks under anesthesia. Intrauterine surgery or fetal skin biopsy for ichthyosis. Laser of placental vessels in twin–twin transfusion syndrome. Pregnancy loss rate 2–5%.
What is cervical cerclage?
Transvaginal therapeutic procedure performed between 14 and 24 weeks’ gestation, placing a suture that encircles the cervix to prevent cervical dilation. Performed under either regional or general anesthesia in cervical insufficiency.
What are the presumptive signs of pregnancy?
Presumptive signs of pregnancy include amenorrhea, breast tenderness, nausea and vomiting, increased skin pigmentation, and skin striae.
What are probable signs of pregnancy?
Enlargement of the uterus, maternal sensation of uterine contractions or fetal movement, Hegar sign (softening of the junction between the corpus and cervix), and positive beta–hCG.
What are the positive signs of pregnancy?
Hearing fetal heart tones, sonographic visualization of a fetus, perception of fetal movements by an external examiner, and x–ray showing a fetal skeleton.
What is normal pregnancy duration postconception?
266 days or 38 weeks. However, most women can’t identify conception date accurately.
What is the normal duration of pregnancy from the last menstrual period?
280 days or 40 weeks from the LMP. Assumes a 28–day menstrual cycle in which ovulation occurs on day 14 after the beginning of the LMP. Only 10% of women have a 28–day cycle.
What is Naegele’s Rule?
Assuming 28–day cycles, the due date can be estimated as the LMP minus 3 months plus 7 days.
What is the duration of the first trimester?
Assuming a 40 menstrual week pregnancy, the first trimester is assumed to extend from conception through to 13 weeks.
What are the common complaints associated with the first trimester?
Nausea, vomiting, fatigue, breast tenderness, frequent urination are normal. Spotting and bleeding in 20% of pregnancies, 50% of which will continue successfully. Average weight gain is 5–8 pounds.
What are the normal symptoms during the second trimester?
2nd trimester extends from 13 to 26 wks. Normal symptoms are sense of well–being, round ligament pain, Braxton–Hicks contractions (painless, low–intensity, long–duration contractions). Avg weight gain is 1 lb/wk after 20 wks.
When does quickening occur during pregnancy?
Quickening (maternal awareness of fetal movement) is detected at 18–20 weeks by primigravidas and 16–20 weeks by multigravidas.
What complications can occur in the second trimester?
Complications include incompetent cervix (painless cervical dilation leading to delivery of a nonviable fetus); premature membrane rupture, and premature labor.
What are the normal symptoms during the third trimester?
3rd trimester extends from 26 to 40 wks. Decreased libido, lower back/leg pain, frequency, Braxton–Hicks. Lightening is descent of head, resulting in pelvic pressure. Bloody show is passage of bloody mucus from cervical dilation before labor.
What is the average weight gain during the third trimester?
Average weight gain is 1 pound per week after 20 weeks.
What are the complications of the third trimester?
Complications include premature membrane rupture, premature labor, preeclampsia, urinary tract infection, anemia, and gestational diabetes.
What are the breast changes in pregnancy?
Breast enlargement. Each breast increases in size by 400 grams. Management is a support bra.
What percentage of women develop carpal tunnel syndrome during pregnancy?
50% of pregnant women will experience numbness, tingling, burning, or pain in at least two of the three digits supplied by the median nerve. Management is a wrist splint (resolves after delivery).
What are the complexion changes of pregnancy?
Some women develop brownish or yellowish patches called chloasma on their faces. Linea nigra may develop on lower abdominal midline. Hyperpigmentation of nipples and genitalia may also occur.
