1st trimester complications Flashcards
Oocyte is swept into lumen of the fallopian tube by the fimbria
Fertilization occurs in the_____ portion of the tube
After fertilization the blastocyst reaches the uterine cavity by day ____and implantation begins day ____ when embryo is at the blastocyst stage Implantation is complete by day 9-10
ampullary
4-5
5-7
Detection of _____in maternal blood and urine provides the basis for endocrine tests of pregnancy.
βhCG ; sim alpha as: luteinizing hormone (LH), follicle-stimulating hormone (FSH), and thyroid-stimulating hormone (TSH)
Promotes the maintenance of the progesterone secreting corpus luteum during the beginning of pregnancy
BhCG
hCGs levels roughly double every ____in early pregnancy
Peak levels occurs at 10 weeks gestation at about _____
48 hours
100,000 mIU/mL
Because of its similarity to____, hCG can be used to induce ovulation in the female ovary during fertility treatment as well as _stimulate testosterone pr_oduction in the male testes
LH
• hCG and LH bind to the same receptor (LHCGR)
How does urine pregnacy test work
Employ a monoclonal antibody specific to the β subunit of hCG (human chorionic gonadotropin)
Employ a chromatographic immunoassay. Detection thresholds range from 20 to 100 mIU/ml depending on the brand.
At the time of the missed menses the hCG level is about 100 mIU/mL
- Most sensitive and precise measure
- Negative if < 3-5 mIU/mL
- Roughly doubles every 48 hours in normal pregnancy (minimum rise is 53% in 48 hrs)
Quantitative serum hCG
With transvaginal ultrasound should be able to visualize the pregnancy when a quantitative hCG level is 1500-2000 mIU/mL – referred to as
discriminatory zone of hCG
Fetal loss before 20 weeks calculated from last menstrual period (LMP) or delivery of fetus <500 grams
Occurs in approximately 15% of clinically recognized pregnancies
80% occur in first trimester
Spontaneous Abortion/Miscarriage/Pregnancy Loss
Bleeding or cramping with no passage of tissue, closed os, intrauterine pregnancy, fetal heart tones present (if age appropriate)
Threatened
Bleeding, open os, without passage of products of conception, nonviable pregnancy
Inevitable abortion
Partial passage of products of conception, open os, variable bleeding, nonviable pregnancy
Incomplete:
Intrauterine demise < 20 weeks without any passage of fetal or placental tissue: Embryonic vs Anembryonic
Embryonic demise– embryonic pole visible on ultrasound, no cardiac activity
Anembryonic demise– gestational sac without corresponding embryo identified on ultrasound
Products of conception completely passed, closed os, minimal bleeding, uterus well contracted
Complete abortion/miscarriage
Stipulations for “Recurrent Pregnancy Loss”
- 3 or more spontaneous pregnancy losses before 20 weeks
- Occurs in less than 1% of couples attempting to have children
- After evaluation etiology unexplained in 50%
- Future live pregnancy rates can be as high as 70%
Causes of recurrent pregnancy loss
• Anatomic
– Uterine anomalies, fibroids, intrauterine adhesions
• Endocrine
– Diabetes, thyroid dysfunction, PCOS
• Genetic
– Translocations or aneuploidy
• Immunologic
– Antiphospholipid syndrome, infection
• Environmental
– Smoking, toxins, medications
16 yo girl with + pregnancy test:
Quantitative hCG 1400 mIU/ml and repeat level 2 days later is 1900 mIU/ml
Ultrasound shows no intrauterine pregnancy
A gestational sac with a yolk sac is seen in the right adnexa.
ectopic pregnancy
Blastocyst implants in a location outside of the endometrial cavity
2% of all pregnancies and 98% are located in the fallopian tube and the remainder in a cervical, ovarian, interstitial, hysterotomy scar, or abdominal locationm, majority of tubal pregnancies are located in the ampullary region.
Ectopic pregnancy
is defined as a co-existing intrauterine and extrauterine pregnancy and occurs in an estimated 1 in 30,000 pregnancies. Risk factors include in vitro fertilization and ovulation induction
A heterotopic pregnancy
Risk for ectopic pregnancy
Pelvic inflammatory disease,
Gonorrhea or chlamydia
Previous tubal ligation, previous tubal pregnancy
Assisted reproductive technologies
Smoking
Pregnancy with IUD in situ
Tx for ectopic pregnancy
• Surgical
– Laparoscopic salpingostomy or salpingectomy
– Laparotomy
• Medical
– Methotrexate
• Expectant : just happens but make sure hCG goes back down
A 28 yo woman presents for prenatal care with her second pregnancy. She had a positive urine pregnancy test 2 weeks ago. She reports some light vaginal bleeding. She has noticed that her nausea is much worse than with her first pregnancy. Her exam shows minimal amount of blood in the vagina, closed cervix, 12 week size uterus, no adnexal masses. Quantitative serum hCG 640,00 mIU/ml
Gestational trophoblastic disease (GTD)
• All forms of GTD are associated with
elevated levels of human chorionic gonadotropin.
persistent or invasive GTD, choriocarcinoma, and placental site trophoblastic tumor (PSTT) disease.
Malignant forms of gestational
trophoblastic neoplasia
Benign form of GTD
hydatiform mole
Trophoblastic proliferation and hydropic grape like chorionic villi
Classic snowstorm appearance on ultrasound
Complete molar pregnancy
Pathosphysiology of complete molar pregnancy
Results from fertilization of an enucleate egg.
Paternally derived diploid genotype – 46,XX or rarely 46,XY
Without maternal DNA, no fetal structures are able to develop.
**Up to 15-20 % of complete moles result in persistent GTD or malignancy
contains fetal tissue: fertilization of a haploid ovum by two sperm or by a single sperm that then duplicates
Genotype 69,XXX, 69, XYY or 69, XXY (triploidy)
Risk of persistent GTD or malignancy 1-2% or LOW
Partial molar pregnancy
It is used to treat rapidly dividing trophoblastic tissue and is used in the treatment of ectopic pregnancy, hydatiform molar pregnancy, and choriocarcinoma.,
Methotrexate
An anti-metabolite chemotherapeutic agent that binds to the enzyme dihydrofolate reductase (DHFR), Acts as a competitive antagonist to DHFR thereby interference in DNA synthesis and replication
Methotrexate
hCG rapidly rises in early pregnancy roughly doubling every 48 hours with peak at 10 weeks gestation of about ____and then declines and plateaus for the remainder of pregnancy
100,000 mIU/ml
Discriminatory zone of 1500-2000 mIU/ml is when an intrauterine pregnancy should be
visualized on transvaginal ultrasound
hCG that fails to increase by minimum of 53% over 48 hours is seen with a
failing intrauterine pregnancy or an ectopic pregnancy
