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OB > abnml first trimester > Flashcards

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
Q

transvag beta hcg ectopic suspicious if this number

A

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
Q

Expectant Management Indications

who is a candidate for this ectopic management (beta hcg level)

A

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
Q

Medical Management Indications for ectopic

A

Stable vital signs and few symptoms

No medical contraindication for methotrexate therapy (e.g., normal liver enzymes, CBC/platelet count)

(stops dividing cells)

28
Q

what do you need inorder to give methotrexate for ectopic

A

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
Q

f/u for pt after administering hcg

A

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
Q

surgical management indications

A

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
Q

what ois the perferred method of Surgical Management

for ectopic

A

Laparoscopy with

Salpingostomy, without fallopian tube removal, has become the preferred method of surgical treatment

small failure rate managed with methotrexate

32
Q

what is fetal demise

A

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
Q

maternal causes of fetal demise

A 
Race
Advanced maternal age (AMA)
multiple gestations
pervious pregnancy complications
obesity 
smoking, drugs, alcohol 
diabetes
HTN
34
Q

fetal causes of fetal demise

A

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
Q

placental causes

A

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
Q

how does obesity present with increase fetal demise

A

BMI >30 - 5.5/1000; BMI >40 - 11/1000

Independent risk factor after controlling for smoking, gestational diabetes and preeclampsia

37
Q

developing countries causes of fetal demise

A

Obstructed/prolonged labor (asphyxia, infection, birth injury)
Infections - syphilis and gram negative infections
HTN diseases
Congenital anomalies
Poor nutrition
Malaria
Sickle cell disease

38
Q

how frequently are there unexplained still births

A

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
Q

infections that can cause fetal demise

A
  • human parvovirus B19, Syphilis, streptococcal infection, listeria
40
Q

evaluationlabs of fetal demise

A

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
Q

how do you treat fetal demise

A

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
Q

when should you not use PG E2 and misoprost for fetal demise delivery

A

not be used in women with hx of prior uterine incision due to risk of uterine rupture

43
Q

Kleinhauer-Betke

A

Maternal-fetal hemorrhage

looking at how many fetal cells are in the maternal blood

OB (14 decks)

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