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Women's Health Final > Abnormal Pregnancy Part 1 > Flashcards

Abnormal Pregnancy Part 1 Flashcards

1
Q

Implantation other than in the endometrial cavity

A

Ectopic pregnancy

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2
Q

Most common implantation site for ectopic pregnancies

A

Ampullary portion of the Fallopian tube (80%)

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3
Q

Ectopic pregnancies that implant in the ampullary portion of the Fallopian tube typically rupture when?

A

8-12 weeks

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4
Q

Ectopic pregnancies that implant in the isthmic portion of the Fallopian tube typically rupture when?

A

6-8 weeks (12% of ectopic pregnancies implant here)

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5
Q

What is a heterotopic pregnancy?

A

One embryo implanted properly in the endometrial cavity with a second ectopically implanted embryo

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6
Q

Ectopic pregnancies account for ____% of all pregnancies but _____% of all pregnancy-related deaths

A

1.2-2%

4-10%

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7
Q

Why is the incidence of ectopic pregnancy increasing?

A

IVF and more frequent advanced maternal age (both are risk factors for ectopic)

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8
Q

Incidence of ectopic pregnancies is increasing but…

A

Morbidity and mortality associated with ectopic pregnancy has decreased dramatically due to EARLIER DX PRIOR TO RUPTURE

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9
Q

High risk factors for ectopic pregnancy

A

Tubal surgery

Tubal ligation

Previous ectopic pregnancy

In utero exposure to DES (but most of these are out of childbearing age)

Use of IUD

Tubal pathology

Assisted reproduction

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10
Q

Moderate risk factors for ectopic pregnancy

A

Infertility
Previous genital infections
Multiple sex partners
Salpingitis isthmica nodosa

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11
Q

Low risk factors for ectopic pregnancy

A

Previous pelvic infection
Cigarette smoking
Vaginal douching
First intercourse <18y

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12
Q

Pelvic/abdominal pain and bleeding are _______ until proven otherwise

A

Ectopic pregnancy

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13
Q

Sx of ectopic pregnancy

A

Pelvic/abdominal pain (100%)

Bleeding (75%)

Sx of hemoperitoneum (shoulder pain, subdiaphragmatic pain)

Orthostatic Sx (dizziness, fainting, weakness due to blood loss)

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14
Q

What are the PE findings in ectopic pregnancy?

A

VS: Orthostatic changes, signs of shock if rupture

Abdomen: tenderness +/- prior to rupture

Pelvic: Unilateral adnexal fullness/mass palpable in 1/3-1/2 of patients, adnexal tenderness, cervical motion tenderness

No specific SSx are pathognomonic

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15
Q

DDx for ectopic pregnancy

A

Threatened or incomplete abortion

Ovarian cyst rupture

Ovarian torsion

Gastroenteritis

Appendicitis

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16
Q

What lab tests do you want to order for ectopic pregnancies?

A

CBC (assess hemodynamic status)

Serum quantitative hCG (QhCG or “quant”)

Serum progesterone

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17
Q

Serum QhCG should rise a minimum of ______ in a normal pregnancy

A

53% over 48 hours

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18
Q

Serum progesterone of _____ has a 100% specificity for identifying an abnormal pregnancy but does not ID location

A

<5 ng/mL

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19
Q

Serum progesterone of ______ is associated with normal intrauterine pregnancy

A

> 20 ng/mL

All values between 5-20 are equivocal

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20
Q

What imaging should you order if you suspect an ectopic pregnancy?

A

Transvaginal ultrasound (TVUS)

Need to correlate physical findings and labs with TVUS findings

Used to visualize an IUP or definite ectopic pregnancy

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21
Q

What happens if you do a transvaginal U/S for a suspected ectopic but are unable to definitively diagnose either an intrauterine or ectopic pregnancy?

A

Consider it a “pregnancy of unknown location”

25-50% of ectopic pregnancies present in this manner

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22
Q

When should TVUS be able to detect an intrauterine pregnancy?

A

When the QhCG value is within or surpasses the “discriminatory zone”, defined as a QhCG value between 1500-2000 mlU/mL

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23
Q

Gestational sac can been seen in the uterus as a “double ring” at _____ was gestation

A

~5 weeks

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24
Q

Fetal pole with cardiac activity can be seen at _______ wks gestation

A

5 1/2 - 6 weeks

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25
Q

What should you do next if TVUS shows “pregnancy of unknown location”?

A

Follow with serial QhCG levels q48hrs and TVUS until either an ectopic pregnancy, IUP, or abortion is confirmed

+/- laparoscopy, MRI

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26
Q

What is the medical treatment for ectopic pregnancy?

A

Methotrexate 50 mg/m2 given in a single dose to “dissolve” the pregnancy

14% failure rate so may need 2nd dose

Monitor serial QhCG levels

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27
Q

What will the medical treatment for ectopic pregnancy do to the patient’s pain?

A

Pain may worsen due to tubal abortion and distention

Bummer

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28
Q

What are the surgical treatment options for ectopic pregnancy?

A

Laparoscopy vs Laparotomy

Salpingectomy (partial or total) vs salpingostomy (up to 20% persistent ectopic)

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29
Q

What are the factors used when deciding medical vs surgical treatment for ectopic pregnancy?

A

Size <3.5cm

QhCG levels <5000

Cardiac activity

Ruptured vs unruptured

Reliable for f/u

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30
Q

What is a lithopedion?

A

“Stone” + “Child”

Fetus dies during an ectopic pregnancy and is too large to be re-absorbed so it becomes a foreign body that the mother’s immune system encases and calcifies

😳🤯😳🤯

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31
Q

Tumors that develop from an aberrant fertilization event and derive from abnormal placental (trophoblastic) proliferation

A

Gestational Trophoblastic Disease (GTD)

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32
Q

What is the unique and characteristic tumor marker for Gestational Trophoblastic Disease (GTD)?

A

hCG

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33
Q

What are the different classifications of Gestational Trophoblastic Disease (GTD)?

A

Hydatidiform moles (complete or partial)

Gestational trophoblastic neoplasia

Choriocarcinomas

Placental-site trophoblastic tumors

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34
Q

What is the most common form of Gestational Trophoblastic Disease (GTD)?

A

Hydatidiform mole

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35
Q

At what age(s) is a woman most at risk of a hydatidiform mole?

A

<20 yo

> 35 yo

Also if she’s had a previous GTD

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36
Q

Choriocarcinoma can accompany or follow what type of pregnancy?

A

ANY!

But 50% hydatidiform mole, 25% abortion, 25% normal pregnancy

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37
Q

Hydatidiform Moles are characterized by abnormalities of the ________ consisting of varying degrees of _______ and ________

A

Chorionic villi

Trophoblastic proliferation

Edema of billows stroma

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38
Q

How will complete moles appear?

A

Clear vesicles resembling grapes

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39
Q

Clear vesicles resembling grapes

A

Complete mole

40
Q

What type of mole:

Higher QhCG levels
Uterus larger than expected in 50%
Increased medical complications

A

Complete mole

41
Q

What are the increased medical complications that come along with complete moles?

A

Gestational hypertension
Hyperthyroidism (b/c high levels of hCG)
Hyperemesis gravidarum

42
Q

What type of mole:

Less advanced
Milder focal changes/complications
Fetal/embryonic structures present

A

Partial mole

43
Q

What type of hydatidiform mole:

Karyotype is usually diploid 46XX

A

Complete mole

44
Q

What type of hydatidiform mole:

No fetal tissue present

A

Complete mole

45
Q

What type of hydatidiform mole:

Risk of persistent choriocarcinoma 20%

A

Complete mole

46
Q

What type of hydatidiform mole:

Karyotype usually triploidy 69XXX

A

Partial mole

47
Q

What type of hydatidiform mole:

Fetal tissue usually present but not compatible with life

A

Partial mole

48
Q

What type of hydatidiform mole:

Risk of persistent choriocarcinoma <5%

A

Partial mole

49
Q

How is a hydatidiform mole diagnosed?

A

Abnormal bleeding in >90%

Enlarged uterus larger than due date (50%)

+/- absent fetal heart tones

Characteristic U/S appearance = “SNOW STORM”*****

QhCG levels higher than normal

Preeclampsia before 20wks

Medical complications (hyperemesis, thyroid storm)

50
Q

What is the definitive treatment for hydatidiform mole?

A

Prompt evacuation of the uterine contents with close monitoring of QhCG levels for 6-12 months after removal

Pregnancy should be avoided at this time (OCPs are ok)

51
Q

Your patient had a hydatidiform mole and you sucked that sucker out. It’s six months later and she has persistent QhCG tigers in the absence of pregnancy. What you do?

A

Evaluate and treat for gestational choriocarcinoma

52
Q

Highly malignant epithelial tumor arising from any type of trophoblastic tissue

A

Choriocarcinoma

Most common with complete molar pregnancy

53
Q

Why do we wanna catch choriocarcinomas so quickly?

A

They can metastatisize very quickly - to lung, vagina, liver, kidneys, spleen, brain, ovaries

Higher potential in patients with a normal pregnancy (b/c we don’t keep measuring their quants and catch them too late)

54
Q

SSx of choriocarcinoma

A

Most SSx present after metastasis already has occurred

IRREGULAR VAGINAL BLEEDING***
Dyspnea
Cough
Hemoptysis
CNS findings
Rectal bleeding

PE: often reveals enlarged uterus

If these signs occur in a woman who was recently pregnant —> prompt eval of QhCG levels

55
Q

Why are choriocarcinomas frequently missed until after they have already metastasized?

A

B/c unless you have a molar pregnancy, we don’t normally continue monitoring serial quant levels

56
Q

How is choriocarcinoma diagnosed?

A

High QhCG levels and a “SNOWSTORM” appearance on U/S

CT scan of abdomen, pelvis, and head (looking for mets)

57
Q

How is choriocarcinoma treated?

A

Chemotherapy with Methotrexate (more effective if the choriocarcinoma follows complete molar pregnancy)

May need more chemo/radiation if brain/liver mets

Monitor QhCG levels to confirm remission

58
Q

You’ve treated your patient with choriocarcinoma with methotrexate but her QhCG levels have still not fallen. What you do next?

A

Hysterectomy

59
Q

Unexplained, intractable nausea/vomiting beginning in teh 1st trimester resulting in DEHYDRATION, KETONURIA, WEIGHT LOSS >5%

A

Hyperemesis Gravidarum

Must have all three of the Sx

60
Q

Sx of hyperemesis gravidarum typically begin between ______ weeks gestation and 80% resolve by ______

A

3-5 weeks (vs 5-6 weeks normally)

20 weeks (vs 9-10 weeks normally)

Basically starts earlier and lasts longer than NVP

61
Q

How do you treat Hyperemesis Gravidarum?

A

Antiemetics and hydration, possible hospitalization

Rarely requires parenteral nutrition

The key is to treat EARLY not wait til they’re in the hospital

62
Q

How does Rh incompatibility arise?

A

Rh (-) woman conceives an Rh (+) fetus

RBCs from fetus enter woman’s circulation during pregnancy or birth —> production of maternal IgG antibodies against the Rh (+) —> concern for subsequent pregnancy

63
Q

What happens if an Rh (-) mother has an Rh (+) baby, then gets pregnant a second time?

A

Maternal IgG antibodies to the D antigen cross the placenta and destroy fetal RBCs —> fetal hemolytic anemia (ERYTHROBLASTOSIS FETALIS)

AKA hemolytic disease of the newborn (HDN) when it occurs in a neonate

64
Q

SSx of Rh D alloimmunization

A

No SSx in mother***

Typically 1st affected pregnancy has mild anemia and elevated bilirubin at birth

Marked increased in neonatal bilirubin —> kernicterus —> decreased tone, poor feeding, apnea, seizures, death

Hydrosphere Fetal is and fetal demise can occur in subsequent pregnancy

65
Q

How do we identify Rh D alloimmunization?

A

Draw antibody tigers at first prenatal visit and at week 26-28

High tigers suggest sensitization

Doppler U/S to measure the peak velocity of fetal middle cerebral artery flow (in fetal anemia, blood less viscous so higher velocity)

66
Q

Treatment for Rh D Alloimmunization

A

Follow with peak flow velocities in the MCA; if significantly elevated, treat with fetal transfusion

67
Q

How do you prevent Rh D alloimmunization?

A

Screen for Rh type of first prenatal visit

If mother is Rh (-) draw antibody tigers early in pregnancy and at 26-28 weeks

Inject mother with Anti-D immune globulin (RhoGAM) at 28 weeks and again within 72 hours of delivery

68
Q

How does RhoGAM work to prevent RhD alloimmunization?

A

Binds the fetal Rh factor and prevents the mother from developing anti-Rh antibodies

69
Q

When should RhoGAM be administered?

A

At 28 weeks gestation

At time of procedures associated with possible fetal-to-maternal bleeding (amniocentesis, chorionic villus sampling)

After ectopic pregnancy

After a threatened, spontaneous, or induced abortion

Within 72 hours of delivery of an Rh D positive infant

Conditions associated with fetal-maternal hemorrhage (trauma)

Unexplained vaginal bleeding during pregnancy

70
Q

How much RhoGAM do patients get at 28weeks?

A

300 µg

71
Q

What are the different hypertensive disorders in pregnancy?

A

Chronic HTN

Gestational HTN

Preeclampsia

Eclampsia

Superimposed preeclampsia/eclampsia

72
Q

HTN present before pregnancy or before 20 weeks gestation

A

Chronic HTN

73
Q

HTN detected for the first time after 20 weeks gestation in the absence of proteinuria

A

Gestational HTN

74
Q

HTN that occurs after 20 weeks gestation with previously normal BP and (+) proteinuria

A

Preeclampsia

75
Q

Preeclampsia with new-onset convulsions

A

Eclampsia

76
Q

Preeclampsia or eclampsia in a woman with preexisting chronic HTN

A

Superimposed preeclampsia/eclampsia

77
Q

Hematological consequences of HTN in pregnancy

A

Hemoconcentration
Thrombocytopenia
+/- DIC
Third spacing due to HTN and decreased plasma oncotic pressure

78
Q

Renal consequences of HTN in pregnancy

A

Decreased renal perfusion and glomerular filtration leading to increased uric acid

Proteinuria develops due to glomerulopathy

79
Q

Hepatic consequences of HTN in pregnancy

A

Periportal hemorrhagic necrosis in periphery of liver lobule leads to increased ALT, AST

80
Q

What is HELLP Syndrome

A

Hemolysis
Elevated Liver enzymes
Low Platelets

Associated with severe preeclampsia

KNOW THIS***

81
Q

Risk factors for preeclampsia

A 
Age <20 or >35
Nulliparity***
Multiple gestation
DM
Thyroid disease
Chronic HTN
Renal disease
Collagen vascular disease
Antiphospholid syndrome
Obesity
Family Hx of preeclampsia
82
Q

SSx of Preeclampsia

A 
HTN
Proteinuria
Edema
H/A
N/V
Hyperreflexia
Oliguria
Blurred vision/Scotomata (reduced blood flow to eyes)
Epigastric pain (2˚ to reduced liver perfusion)
83
Q

What are the diagnostic criteria for preeclampsia?

A

BP of ≥140 systolic or ≥90 diastolic

BP must be elevated on second reading at least 6 hours later

≥300mg in a 24 hour urine (~2+ on urine dipstick)

84
Q

Patients get a diagnosis of SEVERE preeclampsia if any of the following:

A

BP of ≥160/≥110 on 2 occasions at least 6 hours apart

Severe proteinuria (≥5g/24 hours)

SSx of end organ damage

Fetal growth restriction

85
Q

What are the goals of therapy for preeclampsia?

A

Termination of pregnancy with the least amount of trauma to mother and fetus

Birth of infant who survives/thrives

Complete restoration of mother’s health

KEY: early prenatal detection with appropriate management

Delivery is the definitive treatment

86
Q

What all do we do to treat preeclampsia?

A

Reduced activity

Serial CBC, CMP, uric acid

Glucocorticoids if <37 weeks

Mag Sulfate to prevent seizures

Antihypertensives for severe HTN (LABETALOL, Hydralazine, Nifedipine)

Fetal surveillance (NST, BPP, U/S)

Prompt delivery if severe

87
Q

What does IUGR stand for?

A

Intrauterine Growth Restriction

AKA Fetal Growth Restriction (FGR)

(Small for Gestational Age (SGA) refers to the infant)

88
Q

What is the definition of IUGR?

A

Birth weight or estimated fetal weight at or below the 10th percentile for gestational age

Includes the constitutionally small but healthy babies (about 70% of this group)

Complications and neonatal death significantly increase when ≤3rd percentile

89
Q

Why do IUGR fetuses have more morbidity and mortality?

A

Vulnerable to asphyxia, acidemia, and intolerance to labor (not enough of an O2 reserve)

90
Q

Maternal etiologies for IUGR?

A

Extremes of reproductive age (<16 or >35)

Smoking/substance abuse

HTN

Anemia

DM

SLE

Malnutrition

Renal disease

91
Q

Placental etiologies of IUGR

A

Primary placental disease

Uterine anomalies

Not enough blood flow through the placenta —> fetus receives lower amounts of O2

92
Q

Fetal etiologies of IUGR

A

Multiple gestation

Genetic disorders

Teratogens

Infection (TORCH)
• Toxoplasmosis
• Other (Syphilis, varicella)
• Rubella
• CMV
• Herpes
93
Q

_______ is 46-86% sensitive for detecting IUGR

A

Fundal height

94
Q

Of the fetal measurements made with U/S, which is most sensitive for IUGR?

A

Abdominal circumference

Doppler velocimetry of umbilical artery blood flow helpful once IUGR is diagnosed

Mean cerebellum artery Doppler studies most accurate

95
Q

How do you manage IUGR?

A

Careful fetal surveillance to ID stress, hypoxia, acidosis and prevent stillbirth
• Non-stress test (NST)
• Biophysical Profile (BPP) with UA Doppler

Glucocorticoids if <37 weeks

Avoid smoking

+/- bed rest

+/- nutritional supplements

Delivery when risk of fetal death exceeds that of neonatal death

Women's Health Final (2 decks)

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