2: Early complications

Question 1

most common site of ectopic pregnancy

Answer 1

ampulla of fallopian tube

Question 2

hCG levels in ectopic pregnancies

Answer 2

low for gestational age, does not increase at expected rate (doubling every 48 hrs); due to poorly implanted placenta with less blood supply than in the endometrium

Question 3

fetal heartbeat should be seen at what hCG levels

Answer 3

> 5000 mIU/mL

Question 4

heterotopic pregnancy

Answer 4

multiple gestation with at least one IUP and at least one ectopic pregnancy

Question 5

unstable ectopic management

Answer 5

IVF, blood products, vasopressors

exploratory laparotomy

Question 6

stable ectopic management

Answer 6

exploratory laparoscopy

Question 7

salpingostomy vs salpingectomy

Answer 7

former, ectopic removed, tube in place; the latter entire ectopic pregnancy is removed

Question 8

uncomplicated, nonthreatening ectopic management;

Answer 8

MTX, 50mg/m2 IM
for all: follow AST/ALT, Cr, hCG
hCG should rise then fall

Question 9

complete abortion

Answer 9

complete expulsion of all POC before 20 wks gestation

Question 10

Incomplete abortion

Answer 10

partial expulsion of some but not all POC before 20 weeks’ gestation

Question 11

Inevitable abortion

Answer 11

no expulsion of products, but vaginal bleeding and dilation of the cervix such that a viable pregnancy is unlikely

Question 12

Threatened abortion

Answer 12

any vaginal bleeding before 20 weeks, without dilation of the cervix or expulsion of any POC (i.e., a normal pregnancy with bleeding).

Question 13

Missed abortion

Answer 13

death of the embryo or fetus before 20 weeks with complete retention of all POC.

Question 14

ddx for first trimester bleeding

Answer 14

SAB
postcoital bleeding
ectopic pregnancy
vaginal or cervical lesions/lacerations
extrusion of molar preg
nonpreg causes of bleeding

Question 15

surgical management of a first-trimester abortion

Answer 15

D&C
if unstable, prostaglandins (e.g., misoprostol) with or without mifepristone to induce cervical dilatation, uterine contractions, and expulsion of the pregnancy

Question 16

difference between D&C and D&E

Answer 16

D&E for 2nd trimester Between 16 and 24 weeks, either a D&E may be performed or labor may be induced with high doses of oxytocin or prostaglandins

Question 17

incompetent cervix

Answer 17

painless dilation and effacement of the cervix, often in the second trimester of pregnancy
-infection, vaginal discharge, and rupture of the membranes are common findings

Question 18

management of incompetent cervix

Answer 18

expectant management (+betamethasone and tocolysis), elective termination, emergent cerclage (may place in subsequent pregnancies at 12-14 wks)

Question 19

cerclage

Answer 19

a suture placed vaginally around the cervix either at the cervical–vaginal junction (McDonald cerclage) or at the internal os (Shirodkar cerclage).
-to close the cervix. Complications: ROM, PTL, and infection

Question 20

15% of pts with recurrent preg losses have ? condition

Answer 20

antiphospholipid antibody (APA) syndrome

others: luteal phase defect, lack of adequate progesterone levels
- may tx with ASA

Question 21

dx of recurrent pregnancy loss (3+)

Answer 21

• karyotype of both parents and POC–>complete genome hybridization (CGH)
• examine anatomy with hysterosalpingogram (HSG)
• screen for DM, hypothyroidism, SLE, APA syndrome, hyper coagulability: lupus anticoagulant, factor V Leiden deficiency, prothrombin G20210A mutation, ANA, anticardiolipin antibody, Russell viper venom, antithrombin III, protein S, and protein C
• level of serum progesterone during luteal phase, possibly endometrial biopsy
• cx of cervix, vagina, endometrium

Question 22

Most second-trimester abortions are secondary to ??

Answer 22

uterine or cervical abnormalities, trauma, systemic disease, or infection.