1st trimesterloss-Table 1 Flashcards
What defines 1st trimester loss?
Termination of pregnancy before 20 weeks, loss before viability outside of the womb
When do the majority of spontaneous miscarriages happen (SAB)?
What are the causes of 1st trimester loss?
Infectious, immune, environmental, endocrine, structural
What is a major endocrine cause of 1st trim loss?
Uncontrolled glucose from type I DM
When is SAB most commonly caused by ETOH?
High doses in the first 8 weeks
What might be some concerning hx symptoms that could indicate 1st trimester loss?
Cramps, backache, vaginal blood or discharge, and uterine contractions
What diagnostics should be run to confirm a viable pregnancy?
Serum B-hCG should double q 48 hrs up to 60-80 days post last menstrual cycle
US: should have gestational sac 4-5 weeks and fetal pole at 5-6 weeks
Spotting or a light bleed around the time of expected pregnancy is normal or abnormal?
Normal if light flow, if heavy like an actual period more likely SAB
Always work them up regardless
What are some benign reasons for spotting?
Corpus luteum dissolution, implantation
What are the types of spontaneous miscarriages?
Threatened, inevitable, missed
What are emergent conditions associated with spotting?
Ectopic or molar
What might your pt present with if threatened abortion?
Hx of spotting and absence of ab/pelvic issues
All the PE is normal
What should you check for if mom is past 12 weeks and threatened abortion?
Check for FHT with doppler
What should you be checking if pt has threatened?
B-hCG, US,
How is a threatened abortion managed?
Reassurance and precautions
What does a threatened abortion mean?
May or may not abort… body is deciding
Have them call if bleeding intensifies or ab and pelvic pain…. No sex no tampons maybe stay off her feet (that probs wont help in real life)
If threatened progresses to inevitable, what s/s might mom present with?
Dilated or open cervix dilted, bleeding, and uterine contractions , low back ache
what is incomplete?
Partially expelled POC, cervix is dilated and there is bleeding and abdominal pain
What is complete?
Os closed, canal clear, uterus has expelled all of the POC, +/- adnexal mass, uterus smaller than GA
How is an incomplete AB managed?
In office… ring forceps to remove visible POC and send to path….monitor B-hCG levels until 0-5.. weekly for about 5 weeks to make sure tissue is gone
KEY: if there is any chorionic villi in sample confirms that POC is out
Hospital: suction curettage to remove POC- monitor B-hCG, will drop quickly
What is a missed AB?
Embryo fails to develop but POC is retained… no pain or symptoms really
May have brown discharge
What do you check in missed AB?
US and Doppler…. Verify no heart beats or nothing in sac
How is missed AB tx?
Need to do hospital outpt suction curettage to remove the POC
What are other managements for missed AB?
- Monitor bleeding/pain symptoms until B-hCG levels 0-5; analgesia PRN
- Minimize infection risk: monitor temp, pelvic rest
- Rh immunoglobulin (Rh negative mothers)
- Emotional support….. these pts will be angry because they were pregnant and had viable pregnancy past 6-8wks
What are the types of induced abortions?
1- Maternal choice: elective termination
2- therapeutic termination
How long do you have to induce abortions with medical option?
Depends on state…. 63 days
What are the medications used in medical abortion?
1st, Oral mifepristone: reverses UC inhibition & causes uterine lining to thin & prevents embryo from remaining implanted
next give misoprostol combo: causes contraction and expulsion, 24-48hrs after mife
when should women be rechecked to make sure there has been complete expulsion?
With in 2 weeks
What is the surgical procedure for abortion?
Vacuum aspiration 13 wks
What are post surgical complications you should have your women come back in for?
Severe abdominal or back pain Heavy bleeding (soaking 2 maxipads per hour x 2 consecutive hours) Foul-smelling discharge; Temp > 100.4°F Rh immunoglobulin (Rh negative mothers) Emotional support
What defines recurrent loss?
> /= 2 consecutive pregnancies or SAB btwn full term IUP
What are the different causes depending on timing for recurrent loss?
??????
1st trimester: parent karyotypes - genetics
2nd trimester-Cervical insufficiency: painless effacement & dilation
Common hx: cervical conization
How is cervical insufficient tx?
Cervical cerclage
Where are the majority of ectopic pregnancies located?
Fallopian tube
What are risk factors for ectopic pregnancy?
Prior abd’l or pelvic surgery Tubal scarring 2ndary PID/salpingitis Prior ectopic or tubal surgery Hx STD Hx infertility & ART procedures
What are the S/S of ectopic pregnancies?
Asymptomatic or vaginal some bleeding or emergent d/t hemodynamic compromise (rare) - might have ab pain
- might have mass
- might have bleeding
- +/- N, V, breast fullness … not really
What will be s/sof emergent ectopic preggo?
If shoulder pain… HOSPITAL ASAP will need emergent surgical handling
Ab guarding, hypotension, tachy, dizzy, fever
What should be used to diagnose?
TVUS to look for sac
B-hCG
If no sac and beta >2000, diagnostic of ectopic until proven otherwise
What is stable and early ectopic and how is it managed?
Asymptomatic, beta
If you have expectant management what kind of pts do you have to have??
RELIABLE and have easy access to your clinic
If your ectopic mom is not stable, how is it managed?
1- need informed consent
2- give one dose methotrexate
3- follow up to confirm termination
What are the CI to methotrexate?
Breastfeeding, immunodef’cy, alcoholism or liver dz d/t EtoH, pre-existent bone marrow/blood dyscrasias, active pulmonary dz, PUD
What does mom need to avoid when taking the metho?
Avoid ETOH, NSAIDS, folic acid supplements, sun exposure (photosensitivity), no coitus until beta negative, no strenuous exercise
What do you need to get pre-tx for ectopic?
serum creatinine, LFTs, CBC & repeat 1 week s/p methotrexate
How is the methotrexate given?
Single IM dose
How long do you need to recheck beta quant after methotrexate?
days 4 & 7 post injection (expect 15% drop in level) then weekly until undetectable
What are the surgical options for ectopic pregnancy?
Laparoscopic linear salpingostomy -Removes pregnancy – preserves tube Laparoscopic segmental resection -Removes portion of tube w/pregnancy Salpingectomy -Remove entire tube
What is gestational trophoblastic neoplasia?
spectrum abnormal placental proliferation (trophoblastic tissue)
What are the types of GTN?
Benign: : hydatidiform mole (aka molar pregnancy)
Persistent or malignant dz
What happens to the chorionic villi in benign GTN?
Villi continue to grow & become swollen & visible as “drops of water” - placenta develops into abnormal mass of cysts
