abnml first trimester Flashcards
RF for 1st trimester bleeding
advanced age smoking chemical exposure caffeine multiple gestations hypertension incomplete cervix endocrine (DM, thyroid dx) connective tissue disorder Lupuis infection-STI UTI or vaginitis medications (antidepressants, aproxetine, venlafaxine)
caffeine is a risk factor over what amt
> 200mg/qd
risk of miscarriage if there is a heart beat
depends on maternal age
2% <35
>35 16%
Gestational sac >2 cm should contain
embryo
TVUS shows a gestational sac with bleeding
must follow for threatened abortion
Subchorionic Hemorrhage- what is this
- hematoma between CHORION and uterine wall
4-30% risk of miscarriage depending on size
when would you suspect ectopic pregnancy
Quantitative B-hcg <1800 to 2000….
or if no gestational sac in the uterus
what is the definition of a threatened abortion
Bleeding before 20 weeks’ gestation in the presence of an embryo with cardiac activity and CLOSED cervix
tx is rest
what is a missed abortion
An embryo larger than 5 mm without cardiac activity
Retained non-viable conception products up to 4 weeks
spontaneous abortion management
Consider intravenous hydration
Consider complications (e.g. septic abortion)
CBC
Blood type/AB screen - RhoGAM (rh-)
Follow serial quantitative b-hcgs until 0
management of a missed abortion
can give misopro (cytotec) 800 vag or 600 PO
prostaglandin that causes contractions and ripening
risk of uterine rupture and amniotic fluid aneurysm
OR d&c
When would you do D and C for missed abortion
what would you need to give pts before hand
Gestational age 8 to 14 weeks
would use for SAB with Excessive intrauterine bleeding (>1 pad/hour) or pain
Prolonged symptoms or delayed passage of tissue - risk of Asherman’s syndrome- SCARRING
Can confirm intrauterine pregnancy (chorionic villi)
Pts usually given antibiotic prophylaxis
spontaenous abortion managment in 14-20 weeks gestation
pitocin until contractions are adequate
avoiding hyperstimulation
PG for cervicle ripening (intravaginal or intramaniotic)
dilation and evacuation is done
later in second trimester
removes products of vervix
methergine what is it and what is it used fro
methergine is used for post partum hemorrhage ONLY and not
contracts lower uterus
Spontaneous Abortion Risk Factors
Maternal age - age 20 to 30 years (9 -17%), age 35 years (20%), age 40 years (40%), and age 45 years (80%)
Gravidity ? - Some studies have shown an increased risk with increasing gravidity, but others have not
Prolonged ovulation to implantation interval/prolonged time to conception
Smoking, EtoH, cocaine, NSAIDS, caffeine
Low folate level (NT stuff)
Extremes of maternal weight
Fever
Celiac disease
Chromosomal abnormalities - 50% of all miscarriages (trisomies, monosomy X)
Congenital anomalies - amniotic bands, teratogens (poor maternal glycemic control, isotretinoin, mercury)
Trauma - CVS, amniocentesis, blunt trauma
Uterine structural issues
Maternal disease - TORCH infections, endocrinopathies
Unexplained ??
Gestational Trophoblastic Disease
made of placental tissue only
usually 1st time pregnant women
<20
and >40
fluid filled vessicles in the uterus wiht fast growing fundus
high Hcg and big uterus
hyperemesisi and hyperthyroidism
preeclampsia will present earlier than 20 weeks
serial quatitiavie hcg aevery 1-2 mo after for a year
risk of recurrence
risk with hydratidiform mole (Gestational Trophoblastic Disease )
coriocarcenoma
D&C and monitor the women for a year
need to make sure that the uterus inviluted
what is the window that we usually see ectopic
2% of pregnancies and 6% of maternal deaths
6-8 weeks form last menstrual period
RF for ectopic pregnancy
Current IUD
History of ectopic pregnancy
History of in utero exposure to diethylstilbestrol
History of genital infection, including PID, CT/GC
History of tubal surgery, including tubal ligation or reanastomosis of the tubes after
tubal ligation
In vitro fertilization
Infertility
Smoking (disrupts cilia)
is there always vag bleeding with ectopics? is it the most common presenting sx?
30% of patients with ectopic pregnancies have no vaginal bleeding
most common presenting symptom is PAIN
ddx for extopic
Acute appendicitis Miscarriage Ovarian torsion Pelvic inflammatory disease Ruptured corpus luteum cyst or follicle Tubo-ovarian abscess UTI or Urinary calculi (twice as common in preg) Diverticulitis
dx test of choice for pregnancy
ULS
Occasionally, diagnostic curettage used:
rare =, really only when hcg levels are falling
> 25 exclude extrauterine pregnancy
transabd uls beta hcg needs to be greater than in order to rule out ectopic
transabdominal ultrasonography does not show an intrauterine gestational sac and the patient’s beta-hCG level is greater than 6,500 mIU per mL (6,500 IU per L)
transvag beta hcg ectopic suspicious if this number
transvaginal ultrasonography does not show an intrauterine gestational sac and the patient’s beta-hCG level is 1,500 mIU per mL (1,500 IU per L) or greater
Expectant Management Indications
who is a candidate for this ectopic management (beta hcg level)
No evidence of tubal rupture
Minimal pain or bleeding
Patient reliable for follow-up
Starting β-hCG level less than 1,000 mIU per mL and falling
Ectopic or adnexal mass less than 3 cm or not detected
No embryonic heartbeat
Medical Management Indications for ectopic
Stable vital signs and few symptoms
No medical contraindication for methotrexate therapy (e.g., normal liver enzymes, CBC/platelet count)
(stops dividing cells)
what do you need inorder to give methotrexate for ectopic
Medical Management with Methotrexate: (90% effective in appropriate pts)
Ectopic mass of 3.5 cm or less
unruptured
no cardiac activity
Ectopic mass of 3.5 cm or less
Starting β-hCG levels less than 5,000 mIU per mL
check hcg on 4th and 7th days
f/u for pt after administering hcg
measure β-hCG on the fourth and seventh posttreatment days, then weekly until undetectable, which usually takes several weeks
Special consideration: prompt availability of surgery if patient does not respond to treatment
surgical management indications
Unstable/signs of hemoperitoneum
Uncertain diagnosis
Advanced ectopic pregnancy (high hCG levels, large mass, cardiac activity)
Patient unreliable for follow-up
Contraindications to observation or methotrexate
what ois the perferred method of Surgical Management
for ectopic
Laparoscopy with
Salpingostomy, without fallopian tube removal, has become the preferred method of surgical treatment
small failure rate managed with methotrexate
what is fetal demise
The delivery of a fetus showing no signs of life as indicated by the absence of breathing, heartbeat, umbilical cord pulsation, or definite movements of voluntary muscles
- fetal loss after 20 weeks gestational age (EGA), or of fetal weight of > 350 g when gestational age is unsure with no evidence of life at birth
maternal causes of fetal demise
Race Advanced maternal age (AMA) multiple gestations pervious pregnancy complications obesity smoking, drugs, alcohol diabetes HTN
fetal causes of fetal demise
Multiple gestations
Intrauterine growth restrictions (uterine abnormalities)
Congenital abnormality (Abnormal karyotype in approximately 8-13% of fetal deaths Most common are monosomy X, trisomy 21, trisomy 18 and trisomy 13)
Infection
Hydrops fetalis -immmune or non immune
placental causes
Cord accident
Dx should be made with caution
Cord abnormalities found in approx. 30%
of normal births, and may be incidental
Should be evidence of obstruction or
circulatory compromise and other
causes excluded
Placental abruption
Premature rupture of membranes
Vasa previa/velamentous insertion
Fetomaternal hemorrhage
Placental insufficiency
how does obesity present with increase fetal demise
BMI >30 - 5.5/1000; BMI >40 - 11/1000
Independent risk factor after controlling for smoking, gestational diabetes and preeclampsia
developing countries causes of fetal demise
Obstructed/prolonged labor (asphyxia, infection, birth injury)
Infections - syphilis and gram negative infections
HTN diseases
Congenital anomalies
Poor nutrition
Malaria
Sickle cell disease
how frequently are there unexplained still births
An unexplained stillbirth is a fetal death that cannot be attributed to an identifiable fetal, placental, maternal, or obstetrical etiology. It accounts for 25 to 60 percent of all fetal deaths
infections that can cause fetal demise
- human parvovirus B19, Syphilis, streptococcal infection, listeria
evaluationlabs of fetal demise
Thorough maternal, FH, OB hx
Fetal autopsy, fetal karyotype
Placental evaluation
Indirect Coomb’s test- Ab test
RPR, parvo testing, CBC/platelets, TSH
Maternal-fetal hemorrhage (Kleinhauer-Betke)
Urine tox screen
how do you treat fetal demise
most pts. desire prompt delivery
80-90% labor spontaneously within 2 weeks
Dilation and evacuation may be offered in 2nd trimester
Experienced provider
May limit efficacy of autopsy
*Labor induction - Later gestational ages
If D&E unavailable
Patient preference
Before 28 weeks vaginal misoprostol (Cytotec) most efficient method of induction
Cesarean delivery reserved for unusual circumstances (maternal)
when should you not use PG E2 and misoprost for fetal demise delivery
not be used in women with hx of prior uterine incision due to risk of uterine rupture
Kleinhauer-Betke
Maternal-fetal hemorrhage
looking at how many fetal cells are in the maternal blood
