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a_GYNGU > 11/4- Complications of Early Pregnancy > Flashcards

11/4- Complications of Early Pregnancy Flashcards

1
Q

How is gestational age determined?

A
  • Full-term human pregnancy lasts 37-42 weeks (average is 40 weeks)
  • Calculated from first day of last menstrual period (LMP)
  • Developmental (conceptional) age is 2 weeks less than menstrual age
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2
Q

What are the time ranges for each trimester?

A
  • First TM = 0-12 wks
  • Second TM = 13-27 wks
  • Third TM = 28-40 wks
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3
Q

What are the terms for pregnancy loss in terms of time frame?

A
  • 0-20 wks = Abortion
  • 20-36+6 wks = Preterm delivery
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4
Q

Case 1)

  • Mrs. Adams comes to your office for her initial prenatal visit. - Her last menstrual period was 6 weeks ago, and she had a positive home pregnancy test 3 days ago.
  • She has had one previous pregnancy which resulted in spontaneous miscarriage at approximately 7 weeks gestation.
  • What is the likelihood of her current pregnancy resulting in a liveborn infant?
A

?

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5
Q

Define the following:

  • Spontaneous abortion:
  • Incomplete abortion:
  • Threatened abortion:
  • Missed abortion:
  • Induced abortion (elective ab):
  • Recurrent abortion:
A

- Incomplete abortion: retention of parts of products of conception

- Threatened abortion: patient presents with some vaginal bleeding, and the cervix is not dilated; abortion may or may not occur

  • Vaginal bleeding in the 1st trimester is never considered normal but it does not necessarily mean morbidity

- Missed abortion: retention in the uterus of an abortus that had been dead for at least eight weeks

- Induced (elective) abortion: abortion brought on by medications or instruments

  • Recurrent abortion: >3 spontaneous abortions
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6
Q

Fetal viability is only achieved in __% of all conceptions

  • __-__% clinically diagnosed are lost in the 1st and 2nd TM
A

Fetal viability is only achieved in 30% of all conceptions

- 15-20% clinically diagnosed are lost in the 1st and 2nd TM

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7
Q

T/F: a spontaneous abortion may present with or without physical symptoms

A

True

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8
Q

When is the likelihood of spontaneous abortion lower?

A

Once fetal heart activity is visualized on USG

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9
Q

What are the recurrence risks of abortion if the woman has had prior abortions?

  • With/without other liveborn children?
A
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10
Q

Another risk chart for spontaneous abortion

A
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11
Q

What are etiologies of spontaneous abortion?

A
  • Chromosome abnormalities
  • Abnormal morphology
  • Placental mosaicism
  • Luteal phase defects
  • Metabolic disease
  • Uterine anomalies
  • Infection
  • Other
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12
Q

What is the most common genotype involved in spontaneous abortion?

A

46,XX or 46, XY

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13
Q

What are the common chromosomal abnormalities responsible for spontaneous abortion?

A

- Normal 46,XX or 46, XY (54%)

  • Monosomy X (45x) (9%)
  • Tripoloidy (68, XXX or 69, XXY) (8%)
  • Tetraploidy (3%)
  • Structural abnormalities (2%)

- Autosomal trisomy (22%)

  • Mosaic trisomy (1%)
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14
Q

What is the most common group of aneuploidy in spontaneous abortion?

A

Autosomal trisomies

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15
Q

Describe autosomal trisomies in terms of spontaneous abortion

  • Prognosis
  • Beneficial factors
  • Most common one
  • Caused by
A
  • Most common group of aneuploidy in spontaneous abortion
  • Most are lethal in early pregnancy
  • Mosaics may have higher survival
  • Single most common trisomy in spontaneous abortion: Trisomy 16
  • 90-95% result of maternal non-disjunction
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16
Q

What is the single most common aneuploidy in abortuses?

A

45X

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17
Q

What causes 45X genotype (mostly)?

A

>80% are due to loss of paternal sex chromosome (no maternal effect!)

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18
Q

Look at this picture for confined placental mosaicism.

A
19
Q

What are maternal diseases that may contribute to spontaneous abortion?

A
  • Thyroid disease
  • Diabetes (insulin-dependent)
  • Chronic HTN (later losses)
  • Collagen vascular diseases (e.g. Lupus)
20
Q

What are uterine factors that may contribute to spontaneous abortion?

A
  • Intrauterine synechiae (adhesions)
  • Mullerian anomalies
  • Bicornate or T shaped uterus, etc.
  • Fibroids (benign, large masses within the uterus
  • Incompetent cervix
21
Q

What are common exposures that may contribute to spontaneous abortion?

A
  • Radiation (way higher SAb if > 10 rads)
  • Smoking (increased SAb if moderate/more)
  • Alcohol ( but teratogenic)
  • Caffeine ( if moderate)
  • Trauma (unlikely)
22
Q

What are the different management methods of spontaneous abortion?

A
  • Expectant
  • Medical
  • Surgical
23
Q

Case 2)

  • Miss Burke, a 22 year old college student, presents to the ER with severe LLQ pain. The pain has been getting steadily worse over the past 10 days.
  • She thinks she started her period a couple days ago.
  • She states she “likes to party”, is sexually active, and not using contraception. Her pregnancy test is positive.
  • During the evaluation, she becomes tachycardic and hypotensive.
  • What is the most likely diagnosis?
A

Ectopic pregnancy

24
Q

What is an ectopic pregnancy?

A

Any pregnancy implanted outside of endometrial cavity

25
Q

What are common sites of ectopic pregnancy?

A

- Tubal (96%)

  • Ampullary (most common)
  • Isthmus (2nd most common)
  • Interstitial, cornual (rare, 2-5%)
  • Ovary (0.5-1%)
  • Fimbria (very rare)
  • Cervix (0.1%): very rare but very dangerous
26
Q

Look at this picture of a tubal pregnancy.

A

This camera is coming from the anterior abdominal wall

27
Q

T/F: the incidence of ectopic pregnancies is increasing?

A

True

28
Q

What are contributing factors to ectopic pregnancies?

A
  • More conservative PID therapies (rather than surgical excision)
  • Successful tubal surgeries
  • Increased use of assisted reproduction, such as IVF
29
Q

What are risk factors for ectopic pregnancy?

A
  • Previous pelvic infection
  • Previous tubal surgery
  • Intrauterine device in place
  • Previous tubal pregnancy
30
Q

What is the clinical presentation of an ectopic pregnancy?

A
  • Abdominal pain (90-100%)
  • Amenorrhea (75-85%)
  • Vaginal bleeding (50-80%)
  • Dizziness
  • Pregnancy symptoms
  • Tissue passed
31
Q

What are physical findings with an ectopic pregnancy?

A
  • Adnexal tenderness (75-90%)
  • Abdominal tenderness (80-95%)
  • Adnexal mass (50%)
  • Uterine enlargement
  • Orthostatic bp changes
  • Fever
32
Q

How is an ectopic pregnancy diagnosed?

A
  • Monitor hCG levels (normally doubles every 48 hrs in the 1st TM)
  • High-resolution ultrasonography
33
Q

How should an ectopic pregnancy be managed?

A
  • Vaginal ultrasonography to look for intrauterine gestational sac
  • If intrauterine gestation sac visualized: routine follow up (repeat US in 1 wk)
  • If no intrauterine gestational sac seen: look for tubal pregnancy
    • When looking for tubal pregnancy, if none visualized, do quantitative hCG (if > 2000 than treat for ectopic pregnancy, otherwise follow up)
    • If tubal pregnancy visualized, treat for ectopic pregnancy
34
Q

What are treatment options for ectopic pregnancy?

A

Surgical

  • Laparoscopy with salpingectomy or salpingotomy

Medical

  • Methotrexate (single or mutliple dose); recall, this inhibits DHFR (stop prenatal vitamins with folate)
35
Q

Case 3)

  • Mrs. Chang, a 42 year old librarian, presents to the Emergency Room with heavy vaginal bleeding and passage of tissue she describes as “lots of tiny sacs”.
  • Her menstrual periods are irregular, and the last one was 4 months ago.
  • On physical exam, her uterus reaches to the level of her umbilicus.
  • What is your next step in her evaluation and treatment?
A

Molar pregnancy (hydatidiform mole)

36
Q

What is a molar pregnancy (hydatidiform mole)?

A
  • Definition: abnormal development of chorionic villi in pregnancy (with or without fetal tissue)
  • Can persist and develop into gestational trophoblastic disease (GTD)
37
Q

What are features of molar pregnancy?

A

Features of complete mole:

  • Trophoblastic proliferation
  • Cystic villi
  • No fetal tissue
38
Q

What is a partial mole?

A
  • Fetus or fetal tissue present
  • Non-viable: multiple structural anomalies of fetus with major growth lag
39
Q

What is the clinical presentation for a molar pregnancy?

A
  • Vaginal bleeding
  • Uterine size discrepant from dates
  • Hypertension
  • Hyperemesis
  • Thyroid dysfunction
  • Theca lutein cysts of ovaries
40
Q

What is seen here?

A

Ultrasonographic findings of a molar pregnancy:

  • Left: 11 wk fetus
  • Right: hydatidiform mole
41
Q

What groups are most affected by molar pregnancies?

A

Asian

  • Vietnamese
  • Japanese

American…

42
Q

What are risk factors for molar pregnancy?

A
  • Maternal age < 20 or > 40 yo
  • Asian ethnicity
  • Prior molar pregnancy
  • Low SES (possible nutritional factors)
43
Q

Look at this flowchart for therapy of molar pregnancies

A

a_GYNGU (17 decks)

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