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abnml first trimester Flashcards

1
Q

RF for 1st trimester bleeding

A 
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)
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2
Q

caffeine is a risk factor over what amt

A

> 200mg/qd

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3
Q

risk of miscarriage if there is a heart beat

A

depends on maternal age

2% <35
>35 16%

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4
Q

Gestational sac >2 cm should contain

A

embryo

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5
Q

TVUS shows a gestational sac with bleeding

A

must follow for threatened abortion

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6
Q

Subchorionic Hemorrhage- what is this

A
  • hematoma between CHORION and uterine wall

4-30% risk of miscarriage depending on size

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7
Q

when would you suspect ectopic pregnancy

A

Quantitative B-hcg <1800 to 2000….

or if no gestational sac in the uterus

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8
Q

what is the definition of a threatened abortion

A

Bleeding before 20 weeks’ gestation in the presence of an embryo with cardiac activity and CLOSED cervix

tx is rest

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9
Q

what is a missed abortion

A

An embryo larger than 5 mm without cardiac activity

Retained non-viable conception products up to 4 weeks

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10
Q

spontaneous abortion management

A

Consider intravenous hydration
Consider complications (e.g. septic abortion)
CBC
Blood type/AB screen - RhoGAM (rh-)
Follow serial quantitative b-hcgs until 0

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11
Q

management of a missed abortion

A

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

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12
Q

When would you do D and C for missed abortion

what would you need to give pts before hand

A

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

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13
Q

spontaenous abortion managment in 14-20 weeks gestation

A

pitocin until contractions are adequate
avoiding hyperstimulation

PG for cervicle ripening (intravaginal or intramaniotic)

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14
Q

dilation and evacuation is done

A

later in second trimester

removes products of vervix

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15
Q

methergine what is it and what is it used fro

A

methergine is used for post partum hemorrhage ONLY and not

contracts lower uterus

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16
Q

Spontaneous Abortion Risk Factors

A

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 ??

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17
Q

Gestational Trophoblastic Disease

A

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

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18
Q

risk with hydratidiform mole (Gestational Trophoblastic Disease )

A

coriocarcenoma

D&C and monitor the women for a year

need to make sure that the uterus inviluted

19
Q

what is the window that we usually see ectopic

A

2% of pregnancies and 6% of maternal deaths

6-8 weeks form last menstrual period

20
Q

RF for ectopic pregnancy

A

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)

21
Q

is there always vag bleeding with ectopics? is it the most common presenting sx?

A

30% of patients with ectopic pregnancies have no vaginal bleeding

most common presenting symptom is PAIN

22
Q

ddx for extopic

A 
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
23
Q

dx test of choice for pregnancy

A

ULS

Occasionally, diagnostic curettage used:
rare =, really only when hcg levels are falling

> 25 exclude extrauterine pregnancy

24
Q

transabd uls beta hcg needs to be greater than in order to rule out ectopic

A

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)

25
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
26
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
27
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)
28
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
29
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
30
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
31
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
32
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
33
maternal causes of fetal demise
``` Race Advanced maternal age (AMA) multiple gestations pervious pregnancy complications obesity smoking, drugs, alcohol diabetes HTN ```
34
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
35
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
36
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
37
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
38
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
39
infections that can cause fetal demise
- human parvovirus B19, Syphilis, streptococcal infection, listeria
40
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
41
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)
42
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
43
Kleinhauer-Betke
Maternal-fetal hemorrhage looking at how many fetal cells are in the maternal blood

OB (14 decks)

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