Chapter 2 (Obstetrics): Early pregnancy complications Flashcards
What is ectopic pregnancy? where does it most commonly implant and where does it less commonly implant? and where in that structure in descending frequencies?
What: An ectopic pregnancy is one that implants outside the uterine cavity
Where:
Most common-> Follopian tube (95-99%)
Less commonly-> Ovary, cervix, abdominal wall and bowel
Where in the tube-> Ampulla (70%), Ishtmus (12%) and fibriae (11%)
Why is it so important to diagnose and treat ectopic pregnancy early? What are the risk factors for ectopic pregnancy and which one is the strongest risk factor?
Why: Because ruptured ectopic pregnancy can result in rapid hemorrhage, leading to shock and eventually death.
Risk factors (DESI PIIPE)
- DES exposure
- Endometriosis
- Smoking
- Infections (STDs and PID)
- Previous ectopic pregnancy (Strongest risk )
- IVF
- IUD for birth control
- Previous surgery (tubal, pelvic or abdominal)
- Exogenous hormones (including progesterone and estrogen)
How do we diagnose ectopic pregnancy and what do we find?
The diagnosis of ectopic pregnancy is made by history, physical examination (including speculum and bimanual examination), laboratory tests, and ultrasound.
History-> Unilateral pelvic or lower abdominal pain and vaginal bleeding.
Physical examination->
- Adnexal mass that is often tender, a uterus that is small for gestational age, and bleeding from the cervix
- Ruptured ectopic pregnancies may be hypotensive, tachycardic, unresponsive, or show signs of peritoneal irritation secondary to hemoperitoneum
Laboratory tests->
β-hCG level that is low for gestational age and does not increase at the expected rate (should double every 48h, or at least increase by 2/3 normally)
Ultrasound->
Reveal an adnexal mass or an extrauterine pregnancy
What is management for ectopic pregnancy?
Ruptured ectopic pregnancy with unstable patient:
- First priority is to stabilize with intravenous fluids, blood products, and vasopressor medications if necessary.
- The patient should then be taken to the operating room where exploratory laparotomy can be performed to stop the bleeding and remove the ectopic pregnancy.
Ruptured ectopic pregnancy with stable patient:
- The procedure of choice at many institutions is an exploratory laparoscopy, which can be performed to evacuate the hemoperitoneum, coagulate any ongoing bleeding, and resect the ectopic pregnancy
Unruptured ectopic pregnancy:
- Can be treated either surgically (as described above) or medically (with methotrexate)
- Methotrexate is used mainly for small ectopic pregnancies (<5 cm, serum β-hCG level <5,000, and without a fetal heartbeat) and for those patients who will be reliable with follow-up
What is spontaneous abortion? How do we divide them into types and what types do we have? how do we define the different types?
What: A spontaneous abortion (SAB), or miscarriage, is a pregnancy that ends before 20 weeks’ gestation
How do we divide: The type of SAB is defined by whether any or all of the products of conception (POC) have passed and whether or not the cervix is dilated
What types:
Abortus-> Fetus lost before 20 weeks’ gestation or less than 500 g
Complete abortion-> Complete expulsion of all POC before 20 weeks’ gestation
Incomplete abortion-> Partial expulsion of some but not all POC before 20 weeks’ gestation.
Inevitable abortion-> No expulsion of products, but vaginal bleeding and dilation of the cervix such that a viable pregnancy is unlikely.
Threatened abortion-> Any vaginal bleeding before 20 weeks, without dilation of the cervix or expulsion of any POC (i.e., a normal pregnancy with bleeding).
Missed abortion-> Death of the embryo or fetus before 20 weeks with complete retention of all POC.
What factors are associated with first trimester abortions
- Abnormal chromosomes (most commonly trisomy) that is due to errors in maternal gametogenesis in 95% of cases
- Maternal anatomic defects
- Infections
- Immunologic factors
- Environmental exposures
- Endocrine factors
What are the symptoms? and what should you do to diagnose first trimester abortions?
Symptoms->
- Most patients present with bleeding from the vagina
- Other findings include cramping, abdominal pain, and decreased symptoms of pregnancy
Diagnosis:
- Do physical examination (including vitals signs and pelvic examination)
- Take laboratory tests (β-hCG, CBC, blood type, and antibody screen)
- Do ultrasound
What are the differential diagnosis of first-trimester bleeding?
- SAB
- Postcoital bleeding
- Ectopic pregnancy
- Vaginal or cervical lesions or lacerations
- Extrusion of molar pregnancy
- Non-pregnancy causes of bleeding
What factors are associated with second semester abortion?
- Infection
- Maternal uterine or cervical anatomic defects
- Maternal systemic disease
- Exposure to fetotoxic agents
- Trauma
- PTL and cervical insufficiency (Late second-trimester)
How should we manage first and second trimester abortion?
The treatment plan is based on specific diagnosis and on the decisions made by the patient and her caregivers.;
- Initially, all pregnant and bleeding patients need to be stabilized if hypotensive
- An incomplete abortion can be allowed to finish on its own if the patient prefers expectant management, but can also be taken to completion either surgically by dilation and evacuation (D&C) or medically.
- Medical management includes administration of prostaglandins (e.g., misoprostol) with or without mifepristone to induce cervical dilatation, uterine contractions, and expulsion of the pregnancy.
- Inevitable abortions and missed abortions are similarly managed
- A patient with a threatened abortion should be followed for continued bleeding and placed on pelvic rest with nothing per vagina
What is the symptom of cervical insufficiency?
- Painless dilation and effacement of the cervix, often in the second trimester of pregnancy
- Occasionally, patients experience mild cramping or pressure in the lower abdomen or vagina.
What are the risk factors of cervical insufficiency?
- History of cervical surgery or cervical lacerations with vaginal delivery
- History of DES exposure
- Uterine anomalies
What is the management of cervical insufficiency?
- If the fetus is previable (i.e., <23 to 24 weeks’ gestational age), expectant management and elective termination are options
- Patients with viable pregnancies are treated with betamethasone to decrease the risk of prematurity and are managed expectantly with strict bed rest.
- If there is a component of preterm contractions or PTL, tocolysis may be used during administration of betamethasone with viable pregnancies. - One alternative course of management for cervical insufficiency in a previable pregnancy is the placement of an emergent cerclage. The cerclage is a suture placed vaginally around the cervix either at the cervical–vaginal junction (McDonald cerclage) or at the internal os (Shirodkar cerclage).
What is recurrent aborter? What are the etiologies? and what are the two factors specifically linked with recurrent pregnancy losses?
What-> A recurrent or habitual aborter is a woman who has had three or more
consecutive SABs
Etiologies-> Same as SAB
- Chromosomal abnormalities
- Maternal systemic disease
- Maternal anatomic defects
- Infection
Factors->
- Fifteen percent of patients with recurrent pregnancy loss have antiphospholipid antibody (APA) syndrome
- Another group of patients are thought to have a luteal phase defect and lack an adequate level of progesterone to maintain the pregnancy
How do we diagnose/deal with recurrent pregnancy losses?
Patients with recurrent pregnancy loss should be evaluated for the etiology:
1. A karyotype of both parents is obtained, as well as the karyotypes of the POC from each of the SABs if possible (array complete genome hybridization can be used to identify chromosomal abnormalities)
- Maternal anatomy should be examined, initially with a hysterosalpingogram (HSG). If the HSG is abnormal or nondiagnostic, a hysteroscopic or laparoscopic exploration may be performed
- Screening tests for hypothyroidism, diabetes mellitus, APA syndrome, hypercoagulability, and systemic lupus erythematosus should be performed. (these tests should include lupus anticoagulant, factor V Leiden deficiency, prothrombin G20210A mutation, ANA, anticardiolipin antibody, Russell viper venom, antithrombin III, protein S, and protein C)
- A level of serum progesterone should be obtained in the luteal phase of the menstrual cycle.
- Cultures of the cervix, vagina, and endometrium can be taken to rule out infection.
