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FMB > 1st Trimester Bleeding > Flashcards

1st Trimester Bleeding Flashcards

1
Q

1) What % of pregnancies will experience 1st trimester bleeding?

2) What % of pregnancies with 1st trimester bleeding end in miscarriage?

A

1) 25%
2) 50%

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2
Q

What is the basic differential for 1st trimester bleeding (4 main categories)?

A
  1. Early pregnancy loss
  2. Ectopic pregnancy
  3. Benign OB causes (subchorionic hemorrhage, implantation bleeding)
  4. Non-OB causes (vaginal bleeding, intercourse, cervical polyp, UTI, fibroids, etc.)
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3
Q

What percentage of miscarriages occur in the 1st trimester?

A

80%

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4
Q

In the first 8 weeks of pregnancy, b-hCG should increase _____% every 48 hours

A

80%

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5
Q

In incomplete abortion and embryonic demise, the overall rate of success of expectant management is ____% at 8 weeks

A

80%

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6
Q

Step 1 of 1st trimester bleeding: what HISTORY do you need to obtain?

A
  • Pregnancy desired or no
  • LMP (or 1st trimester US dating if available)
  • Quantification of bleeding (bleeding through 2 thick maxi-pads per hour for 2 hours is bad)
  • Blood loss symptoms (presyncope)
  • Abdominal cramping or no?
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7
Q

Step 2 of 1st trimester bleeding: what PHYSICAL EXAM do you need to do and what are you looking for (after history)?

A
  • VS: signs of volume depletion (high HR, low BP)
  • Speculum exam: cervix open or closed, products visible?, blood visible?, identifiable non-OB causes of bleeding?
    **Note that speculum exam only tells us if incomplete abortion or not. Does NOT tell us about viability of pregnancy
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8
Q

Step 3 of 1st trimester bleeding: what STUDIES do you obtain (after history and physical exam)

A
  • Labs: CBC, Rh status, quantitative b-hCG
  • Imaging: TVUS
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9
Q

At what GA should we see gestational sac?

A

4-5 weeks

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10
Q

At what GA should we see yolk sac?

A

5-6 weeks

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11
Q

1) At what GA should we see cardiac activity?
2) At what crown-rump length should we see cardiac activity?

A

1) 6.5 weeks
2) 7 mm (if >= 7 mm and no cardiac activity, diagnostic of EPL)

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12
Q

Where can you find a table of findings suggestive of and diagnostic of EPL?

A

AAFP article, Table 2 (https://www.aafp.org/pubs/afp/issues/2019/0201/p166.html)

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13
Q

If IUP of uncertain viability is seen, what does follow-up look like?

A
  • B-hCG every 48 hours
  • TVUS in 7-14 days
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14
Q

If pregnancy of unknown location is diagnosed, what does follow-up look like?

A
  • B-hCG level at 48 hours
  • If increased >40%, perform TVUS
  • Otherwise, trend to B-hCG <5
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15
Q

At what B-hCG level should you see gestational sac?

A

1500-3000

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16
Q

Ectopic precautions: Return to clinic if:
1)
2)
3)
4)

A

1) lightheaded/presyncopal
2) bleeding through 2 maxi-pads per hour for 2+ hours
3) new/worsening abdominal pain, especially if unilateral
4) fever, chills, vomiting

17
Q

How does mifepristone work?

A

1) Antiprogesterone:
- decidual breakdown –> blastocyst detachment –> ↓ b-hCG
- ↓ b-hCG –> ↓ progesterone –> further decidual breakdown
2) Also stimulates prostaglandins –> uterine contractions and cervical ripening

18
Q

How does misoprostol work?

A

Misoprostol is a prostaglandin analogue that induces uterine contractions and induces cervical ripening

19
Q

Mifepristone + misoprostol protocol for EPL management

A

1) mifepristone 200 mg PO once
2) misoprostol 800 mcg PO/buccal/vaginal 10-24 hours after mifepristone
3) if minimal-to-no bleeding 24 hours after first misoprostol, give additional 800 mcg dose

20
Q

Mifepristone and misoprostol side effects

A

Mifepristone: basically none (rare N/V)
Misoprostol: nausea (50%), vomiting, diarrhea, HA, hot flashes

Obviously there will be abdominal cramping and vaginal bleeding; this is to be expected. Concerning bleeding is enough to soak 2 pads in an hour –> go to the ED

21
Q

3 options for EPL management. Also, regardless of management option, what tx should be considered for everyone?

A

1) Expectant management (80% in first trimester over 8 weeks)
2) Medical management
3) Surgical management

RhoGAM should be given if Rh neg (though some say that if <12w, this isn’t necessary)

22
Q

Expectant management ____% effective at 1 month for INCOMPLETE abortion

A

90%

23
Q

Expectant management ____% effective at 1 month for IUFD

A

75%

24
Q

Medical management increases success for management of EPL compared to expectant mangaement in which one: incomplete abortion or IUFD?

A

IUFD
mife + miso is 84% effective at 2 days, compared with 75% at 1 month with expectant management. Medication doesn’t make much of a difference for incomplete abortion.

25
Q

What % of patients need to go the ED for evaluation of bleeding for medication management of EPL?

A

<1%

26
Q

In general, we don’t recommend expectant management after _____ wks due to increased rate of complications

A

13 wks

27
Q

Efficacy of mife + miso for first trimester EPL

A

~90%

FMB (8 decks)

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