BP Chapter 2 Flashcards
Ectopic pregnancy definition
implants outside the uterine cavity
ampula > isthmus > fimbriae
why increase in ectopic pregnancy?
increased assisted fertility, STIs, PID
Risk factors for ectopic
- prior ectopic (10%)
- assisted reproductive technology
- IUD (if they actually get pregnant)
Presentation
- u/l abd pain, VB
- tender adnexal mass
- uterus small for GA
- bleeding from cervix
- beta HCG low for GA, doesn’t inc as expected
Why doesn’t beta hcg double every 48hrs?
poorly implanted placenta with less blood supply than in the endometrium
What indicates IUP on US?
gestational sac with a yolk sac seen in the uterus
Heterotopic pregnancy
one IUP and one ectopic (IVF pregnancies)
Ectopic tx
ruptured, unstable - IV fluids, blood, vasopressor meds, and then to OR for exploratory laparotomy
ruptured, stable - exploratory lap (salpingostomy or salpingectomy)
enruptured, stable - methotrexate or surgery
When to use methotrexate?
- small ectopics( <4cm, beta hcg <5000, no fetal heartbeat) and reliable f/u
- monitor baseline transaminases, creatinine
- beta hcg level will rise first few days post tx, but fall 10-15% b/t days 4 and 7 (if it doesn’t fall, need second dose)
- continue to monitor for signs of rupture (and pain, VB, shock)
Risk Factors for ectopic (chart!)
hx of STI or PID
prior ectopic
previous tubal surgery
prior pelvic/abd surgery leaving adhesions
endometriosis
current use of exogenous hormones (including prog and estrogen)
IVF and other ART
DES exposure with congenital abnormalities
congenital abnormalities of the Fallopian tubes
IUD use
smoking
SAB def
pregnancy that ends before 20 weeks gestation
15-25% of all pregnancies
Abortus
fetus lost before 20 weeks or less than 500g
Complete abortion
complete expulsion of all POC before 20 weeks
Incomplete abortion
partial expulsion of some but not all PCO before 20 weeks
Inevitable abortion
no expulsion of products, but vaginal bleeding and cervical dilation such that viable pregnancy is unlikely
Threatened abortion
any VB before 20 weeks without dilation of cervix or expulsion of any POC
Missed abortion
death of the embryo or fetus before 20 weeks with complete retention of POC
Main cause of abortions
abnormal chromosomes
95% due to errors in maternal gametogenesis (trisomy 16)
other factors: infections, maternal anatomic defects, immunologic factors, environmental exposures, endocrine factors
Dx of SAB
present with VB
cramping, abd pain, dec sx of pregnancy
labs: quantitative level of beta hcg, cbc, blood type, AB screen
- US for fetal viability and placentation
Medical management of inevitable, missed, and incomplete SABs - T1
misoprostol with or without mifepristone to induce cervical dilation, uterine contractions, and expulsion of POC
Tx of threatened abortion
followed for continued bleeding, placed on pelvic rest
if Rh -, give RhoGAM
DDX of first trimester bleeding (chart!)
SAB postcoital bleeding ectopic pregnancy vaginal or cervical lesions or lacerations extrusion of molar pregnancy non pregnancy causes of bleeding
Second trimester abortion etiology
infection, maternal or cervical anatomic defects, maternal systemic disease, exposure to fetotoxic agents, and trauma
Tx of incomplete and missed abortions - T2
- finish on their own
- D&C or D&E (second)
- 16-24 weeks –> D&E or labor induction with oxytocin or prostaglandins
- DE is faster, but laminaria may perf uterus; labor takes longer, but allows genetic analysis
PTL vs. Incompetent cervix
PTL - contractions leading to cervical change (tocolysis may help)
IC - painless dilation of the cervix (emergent cerclage can help)
What bad things are associated with incomp cervix? RFS?
infection, vaginal discharge, rupture of membranes, cramping, contracting
RFs: surgery or other cervical trauma (d&c, LEEP, cervical conization), congenital abnormality (DES)
Incompetent cervix tx
previable: expectant management or elective termination, emergent cerclage
viable: betamethasone, strict bed rest
McDonald cerclage vs. Shirodka cerclage vs. Transabd cerclage
M - cervical-vaginal junction
S - internal os
T - failure of M or S; around cervix at level of internal os during a laparotomy (have to be delivered via c/s)
complications: rupture of membranes, PTL, infection
Elective cerclage
placed at 12-14 weeks
removed at 36-36 weeks
RFs for Cervical Incompetence
hx of cervical surgery (cone bx, d/c)
hx of cervical lacerations with vag delivery
uterine anomalies
hx of DES exposure
Recurrent / habitual aborter
3 or more consecutive SABs
reasons: chromosomal abnormalities, maternal systemic disease, maternal anatomic defects, and infection, antiphospholipid antibody syndrome, luteal phase defect (not enough progesterone)
W/u of habitual aborters
- karyotype of both parents and POC* from each SAB
- Maternal anatomy examination with hysterosalpinogram (if abnormal or nondx–> hysteroscopic or laparoscopic exploration)
- Screening tests for hypothyroidism, DM, APA syndrome, hyper coagulability, SLE
- serum progesterone level in luteal phase
- cultures of cervix, vagina, and endometrium to r/o infection
*array complete genome hybridization (CGH) can be used to id chromo abs on POC if you can’t get karyotype
Tests to order in recurrent SAB w/u
lupus anticoagulant factor V Leiden deficiency prothrombin G20210A mutation ANA, anticardiolipin antibody Russell viper venom antithrombin III protein S protein C
Tx of recurrent SAB
- IVF with donated sperm/ova for trisomies
- Preimplanation diagnosis
- cerclage
- progesterone
- low dose ASA if APA syndrome
- SQ heparin for thrombophilia
- tx of maternal diseases
