abortion, ectopic, choriocarcinoma, mole, hyperemesis Flashcards
parts of fallopian tube?? (from ovarie to uterus)
which is the MC site of ectopic pregnancy?
- Fimbria - Infundibulum - Ampulla - Isthmus
- AMPULLA (70-80%)
ectopic pregnancy - risk factors (which is the strongest?)
- pelvic inflammatory disease
- intrauterine devices
- Previous ectopic pregnancies (strongest)
- smoking
- prior tubal surgery
ectopic pregnancy - presentation
- unilateral lower abdominal or pelvic pain
- vaginal bleeding
- if ruptured –> hypotensive with peritoneal irritation
ectopic pregnancy - diagnostic test
- β-HCG: to comfirm the presence of a pregnancy
- US: to locate the site of implantation (transvaginal)
- Laparoscopy: invasive test + treatment to visualize the ectopic pregnancy
(HCG and TRANSVAGINAL U/S)
ectopic pregnancy - treatment (generally)
- IF not ruptured: medical or surgical treatment
2. IF ruptured: surgery if stable, IV fluids, blood products, dopamine if unstable and then surgery
ectopic pregnancy - medical exam should begin with baseline exams such as
- CBC to monitor anemia
- Blood type/screen
- Transaminases to detect changes indicating hepatotoxicity from medications
- β-HCG to assess for success of treatment via decrease it
ectopic pregnancy - medical treatment after baseline exams
methotrexate
- β-HCG is followed to see if there is 15% decrease in 4-7 days
IF decreased: continue to observe for side effects, no other treatment necessary
IF not decreased: 2nd dose and evaluate again. IF drop observe for side effects without other treatment. IF not surgery
exclusion criteria for methotrexate
- immunodeficiency (is immunosuppressive drugs)
- noncompliant patient
- liver disease
- Ectopic is 3.5 cm or larger
- fetal heartbeat auscultated
ectopic pregancy - surgery
surgery is done to try + preserve the fallopian tube BY CUTTING A HOLE IN IT (SALPINGOSTOMY). However, REMOVAL OF THE WHOLE FALLOPIAN TUBE (SALPINGECTOMY) may be necessary
beside medical or surgical treatment for ectopic pregnancy - what else?
mothers who are Rh (-) should receive anti-D Rh immunoglobulin (RhoGAM)
suspected ectopic pregnancy but transvaginal is nondiagnostic - next step
serum HCG levels
if less than 1500: repeat it in 2 days
more: repeat it and also repeat transvaginal U/S
abortion - definition
pregnancy that ends 20 wks gestation or fetus less than 500g. Almost 80% f spontaneous abortion occur prior to 12 weeks gestation
etiological factor for abortion (MC?)
- chromosomal abnormalities (60-80%)
- anatomic abnormalities
- STDs
- immunological factors (antiphospholipid syndrome)
- endocrinological factors (uncontrolled hyperthyroidism or diabetes)
- Malnutrition
- Traume
- Rh isoimmunization
abortion - presentation
- cramping abd pain
- vaginal bleeding
- may be stable or unstable, depending on the amount of blood loss
abortion - diagnostic tests
- CBC: to evaluate blood loss / need of transfusion
- Blood type Rh screen: should blood need to be transfused, evaluation for anti-D Rh globulin
- US: to distinguish between types of abortion
value of US on abortion diagnosis
you cannot answer the “most likely diagnosis” question about abortion without US
spontaneous abortion - treatment
hemod stable: expectant or medical induction
unstable –> suction curretage if infection oR unstable
types of abortion
- complete 2. incomplete 3. inevitable
4. threatened 5. missed 6. septic
complete abortion - US findings / treatment
US: no products of conception found
treatment: follow up in office
Incomplete abortion - US findings / treatment
US: some products of conception found
treatment: Dilation and curettage (D&C) / medical
inevitable abortion - US findings / treatment
US: products of conception intact, but intrauterine bleeding present and dilation of cervix
treatment: D&C/medical
threatened abortion - US findings / treatment
US: products of conception intact, intrauterine bleeding present, NO dilation of cervix
treatment: bed rest, pelvic rest
missed abortion - US findings / treatment
death of fetus, but all products of conception present in the uterus
treatment: D&C/medical
septic abortion - US findings / treatment
infection of the uterus and the surrounding areas
treatment: D&C and antibiotics (such as levofloxacin and metronidazole)
spetic abortion - RF
retained product of conception from
- elective abortion with nonsterile techinge
- missed or incomplete abortion
spetic abortion - clinical presentation
- fever, chills, abdominal pain
sanguinopurulent vaginal discharge
boggy tender uterus, dilated cervix
pelvic U/S retained product of abortion, thick endometrial stripe
spetic abortion management
IV fluids
broad spectrum antibiotics
suction curettage
medical treatment of abortion
- can occur via giving medications that induce labor such as misoprostol (prostagladin E1 analog) –> help open the cervix + expulse the fetus
- also anti-D is needed in Rh (-) mothers)
how to confirm the diagnosis of choriocarcinoma
elevated HCG
choriocarcinoma - RF / treatment
advanced maternal age
prior complete hydatidiform mole
treatment: chemo
management of hydatidiform mole management
suction currettage –> weekly β-HCG until undetectable:
- increasing/plateauing –> diagnosis of gestational trophoblsastic neoplasia
- decreasing –> monthly β-HCG levels for 6 months –> if detectable it is gestational troph neoplasia. If undetectable then surveillance complete and can attempt pregnancy
contraception during the surveillance period (so can estimate the HCG)
Hydatidiform mole - presentation
- vaginal bleeding
- uterine enlargement more than expected
- pelvic pressure/pain
- hCG-mediated sequelae (a. early preeeclampsia (before 20wk), b. theca-lutein cysts) c. hyperthyroidism, d. hyperemesis gravidarum)
- Sometimes vaginal passage of grape-like cysts
Hydatidiform mole - hCG-mediated sequelae
a. early preeeclampsia (before 20wk)
b. theca-lutein cysts
c. hyperthyroidism
d. hyperemesis gravidarum
Hydatidiform mole - management
- dilation and curettage and methotrexate
2. Monitor β-hCG
Hydatidiform mole - types and definition of each type
- complete mole –> no embryo or normal placental tissue
2. partial mole –> there’s an abnormal embryo and possibly some normal placental tissue
Hydatidiform mole - complete vs partial according to mechanism
complete –> Most commonly enucleated egg + single sperm (subsequently duplicates paternal DNA) or 2 sperm + 1 egg (enucleated)
partial –> 2 sperm + 1 egg (nucleated)`
Hydatidiform mole - complete vs partial according to karyotype
complete –> 46, XX, 46, XY
partial –> 69 XXX, 69 XXY, 69 XYY
Hydatidiform mole - complete vs partial according to fetal parts
complete –> no
partial –> yes
Hydatidiform mole - complete vs partial according to uterine size
complete –> increased
partial –> normal
Hydatidiform mole - complete vs partial according to imaging
complete –> “Honeycombed uterus or clustes of grapes, snowstorm on US
partial –> fetal parts
Hydatidiform mole - complete vs partial according to risk of malignancy (gestational trophoblastic neoplasia)
complete –> 15-20%
partial –> less than 5%
Hydatidiform mole - complete vs partial according to risk of choriocarcinoma
complete –> 2%
partial –> rare
Hydatidiform mole - classically present … (when)
in the 2nd trimester as passage of grape like masses through the vaginal canal
hyperemesis gravidarum - RF
- hydatidiform mole
- multifetal gestation
- history of hyperemesis gravidarum
Hyperemesis gravidarum - cliical features
- severe persistent vomiting
- loss of more than 5% of prepragnancy weight
- dehydration
- ortostatic hypotension
Hyperemesis gravidarum - labs
- KETONURIA
- hypochloeremic metabolic alkalosis
- hypokalemia
- hemoconcentration
hyperemesis gravidorum - treatmnet
admission
antiemetics
IV fluids
pregnant with hyperemesis and nystagmus - think …
thiamine def (treat with IV thiamine followed by glucose
