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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
What should you do next if TVUS shows “pregnancy of unknown location”?
Follow with serial QhCG levels q48hrs and TVUS until either an ectopic pregnancy, IUP, or abortion is confirmed +/- laparoscopy, MRI
26
What is the medical treatment for ectopic pregnancy?
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
27
What will the medical treatment for ectopic pregnancy do to the patient’s pain?
Pain may worsen due to tubal abortion and distention Bummer
28
What are the surgical treatment options for ectopic pregnancy?
Laparoscopy vs Laparotomy Salpingectomy (partial or total) vs salpingostomy (up to 20% persistent ectopic)
29
What are the factors used when deciding medical vs surgical treatment for ectopic pregnancy?
Size <3.5cm QhCG levels <5000 Cardiac activity Ruptured vs unruptured Reliable for f/u
30
What is a lithopedion?
“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 😳🤯😳🤯
31
Tumors that develop from an aberrant fertilization event and derive from abnormal placental (trophoblastic) proliferation
Gestational Trophoblastic Disease (GTD)
32
What is the unique and characteristic tumor marker for Gestational Trophoblastic Disease (GTD)?
hCG
33
What are the different classifications of Gestational Trophoblastic Disease (GTD)?
Hydatidiform moles (complete or partial) Gestational trophoblastic neoplasia Choriocarcinomas Placental-site trophoblastic tumors
34
What is the most common form of Gestational Trophoblastic Disease (GTD)?
Hydatidiform mole
35
At what age(s) is a woman most at risk of a hydatidiform mole?
<20 yo >35 yo Also if she’s had a previous GTD
36
Choriocarcinoma can accompany or follow what type of pregnancy?
ANY! But 50% hydatidiform mole, 25% abortion, 25% normal pregnancy
37
Hydatidiform Moles are characterized by abnormalities of the ________ consisting of varying degrees of _______ and ________
Chorionic villi Trophoblastic proliferation Edema of billows stroma
38
How will complete moles appear?
Clear vesicles resembling grapes
39
Clear vesicles resembling grapes
Complete mole
40
What type of mole: Higher QhCG levels Uterus larger than expected in 50% Increased medical complications
Complete mole
41
What are the increased medical complications that come along with complete moles?
Gestational hypertension Hyperthyroidism (b/c high levels of hCG) Hyperemesis gravidarum
42
What type of mole: Less advanced Milder focal changes/complications Fetal/embryonic structures present
Partial mole
43
What type of hydatidiform mole: Karyotype is usually diploid 46XX
Complete mole
44
What type of hydatidiform mole: No fetal tissue present
Complete mole
45
What type of hydatidiform mole: Risk of persistent choriocarcinoma 20%
Complete mole
46
What type of hydatidiform mole: Karyotype usually triploidy 69XXX
Partial mole
47
What type of hydatidiform mole: Fetal tissue usually present but not compatible with life
Partial mole
48
What type of hydatidiform mole: Risk of persistent choriocarcinoma <5%
Partial mole
49
How is a hydatidiform mole diagnosed?
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
What is the definitive treatment for hydatidiform mole?
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
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?
Evaluate and treat for gestational choriocarcinoma
52
Highly malignant epithelial tumor arising from any type of trophoblastic tissue
Choriocarcinoma Most common with complete molar pregnancy
53
Why do we wanna catch choriocarcinomas so quickly?
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
SSx of choriocarcinoma
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
Why are choriocarcinomas frequently missed until after they have already metastasized?
B/c unless you have a molar pregnancy, we don’t normally continue monitoring serial quant levels
56
How is choriocarcinoma diagnosed?
High QhCG levels and a “SNOWSTORM” appearance on U/S CT scan of abdomen, pelvis, and head (looking for mets)
57
How is choriocarcinoma treated?
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
You’ve treated your patient with choriocarcinoma with methotrexate but her QhCG levels have still not fallen. What you do next?
Hysterectomy
59
Unexplained, intractable nausea/vomiting beginning in teh 1st trimester resulting in DEHYDRATION, KETONURIA, WEIGHT LOSS >5%
Hyperemesis Gravidarum Must have all three of the Sx
60
Sx of hyperemesis gravidarum typically begin between ______ weeks gestation and 80% resolve by ______
3-5 weeks (vs 5-6 weeks normally) 20 weeks (vs 9-10 weeks normally) Basically starts earlier and lasts longer than NVP
61
How do you treat Hyperemesis Gravidarum?
Antiemetics and hydration, possible hospitalization Rarely requires parenteral nutrition The key is to treat EARLY not wait til they’re in the hospital
62
How does Rh incompatibility arise?
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
What happens if an Rh (-) mother has an Rh (+) baby, then gets pregnant a second time?
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
SSx of Rh D alloimmunization
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
How do we identify Rh D alloimmunization?
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
Treatment for Rh D Alloimmunization
Follow with peak flow velocities in the MCA; if significantly elevated, treat with fetal transfusion
67
How do you prevent Rh D alloimmunization?
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
How does RhoGAM work to prevent RhD alloimmunization?
Binds the fetal Rh factor and prevents the mother from developing anti-Rh antibodies
69
When should RhoGAM be administered?
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
How much RhoGAM do patients get at 28weeks?
300 µg
71
What are the different hypertensive disorders in pregnancy?
Chronic HTN Gestational HTN Preeclampsia Eclampsia Superimposed preeclampsia/eclampsia
72
HTN present before pregnancy or before 20 weeks gestation
Chronic HTN
73
HTN detected for the first time after 20 weeks gestation in the absence of proteinuria
Gestational HTN
74
HTN that occurs after 20 weeks gestation with previously normal BP and (+) proteinuria
Preeclampsia
75
Preeclampsia with new-onset convulsions
Eclampsia
76
Preeclampsia or eclampsia in a woman with preexisting chronic HTN
Superimposed preeclampsia/eclampsia
77
Hematological consequences of HTN in pregnancy
Hemoconcentration Thrombocytopenia +/- DIC Third spacing due to HTN and decreased plasma oncotic pressure
78
Renal consequences of HTN in pregnancy
Decreased renal perfusion and glomerular filtration leading to increased uric acid Proteinuria develops due to glomerulopathy
79
Hepatic consequences of HTN in pregnancy
Periportal hemorrhagic necrosis in periphery of liver lobule leads to increased ALT, AST
80
What is HELLP Syndrome
Hemolysis Elevated Liver enzymes Low Platelets Associated with severe preeclampsia KNOW THIS*******
81
Risk factors for preeclampsia
``` 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
SSx of Preeclampsia
``` 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
What are the diagnostic criteria for preeclampsia?
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
Patients get a diagnosis of SEVERE preeclampsia if any of the following:
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
What are the goals of therapy for preeclampsia?
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
What all do we do to treat preeclampsia?
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
What does IUGR stand for?
Intrauterine Growth Restriction AKA Fetal Growth Restriction (FGR) (Small for Gestational Age (SGA) refers to the infant)
88
What is the definition of IUGR?
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
Why do IUGR fetuses have more morbidity and mortality?
Vulnerable to asphyxia, acidemia, and intolerance to labor (not enough of an O2 reserve)
90
Maternal etiologies for IUGR?
Extremes of reproductive age (<16 or >35) Smoking/substance abuse HTN Anemia DM SLE Malnutrition Renal disease
91
Placental etiologies of IUGR
Primary placental disease Uterine anomalies Not enough blood flow through the placenta —> fetus receives lower amounts of O2
92
Fetal etiologies of IUGR
Multiple gestation Genetic disorders Teratogens ``` Infection (TORCH) • Toxoplasmosis • Other (Syphilis, varicella) • Rubella • CMV • Herpes ```
93
_______ is 46-86% sensitive for detecting IUGR
Fundal height
94
Of the fetal measurements made with U/S, which is most sensitive for IUGR?
Abdominal circumference Doppler velocimetry of umbilical artery blood flow helpful once IUGR is diagnosed Mean cerebellum artery Doppler studies most accurate
95
How do you manage IUGR?
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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