DSA: Early Pregnancy Loss - Moulton Flashcards
what is considered first trimester?
first day of LMP - 13+6 weeks
what is considered 2nd trimester?
14 weeks - 27+6 weeks
what is considered 3rd trimester?
28 weeks - 42 weeks
what is EDC?
estimated date of confinement
- 40 weeks after LMP
what is considered a preterm delivery?
20 - 36+6 weeks
what is considered full term?
37 - 42 weeks
when is hCG first detected in serum?
6-8 days after ovulation
what is a negative hCG titer?
<5 mIU/L
what level of hCG can a urine pregnancy detect?
25 mIU/L
when does the level of hCG reach its peak?
10 weeks at 100,000 IU/L
when can a gestational sac be seen on transvaginal ultrasound (TVUS)?
1500-2000 mIU/L
- considered the discriminatory level
KNOW THIS
when can the fetal pole be seen?
around 5 weeks, hCG at 5200 mIU/L
refers to the presence of hCG 7-10 days after ovulation but in whom menstruation occurs when expected
biochemical pregnancy
when do 80% of SAB’s occur?
first trimester
what are most common causes of first trimester SAB?
- 45 XO Turner syndrome most common CHROMOSOMAL
- Trisomy 16 most common TRISOMY
- vaginal bleeding and closed cervix
- 25-50% of threatened abortions eventually result in loss of pregnancy
- tx: expectant management
threatened abortion
- vaginal bleeding and cervix is partially dilated
- loss is inevitable
inevitable abortion
- vaginal bleeding, cramping lower abd pain with dilated cervix
- passage of some but not all of the products of conception
- tx: usually D&C
incomplete abortion
- passage of all products of conception (fetus and placenta) with a closed cervix
- with resolution of pain, bleeding, and pregnancy symptoms
- no tx needed
complete abortion
- fetus has expired and remains in utero
- usually no sx
- coagulation problems may develop, check fibrinogen levels weekly until SAB occurs, or proceed with suction D&C
- expectant management vs. misoprostol (Cytotec) vs D&C
missed abortion
- fever, uterine and cervical motion tenderness, purulent discharge, hemorrhage, and rarely renal failure
- retained infected products of conception
- start IV abx (ampicillin 2g q4, gentamycin 5mg/kg q4, clindamycin 900mg q 8 hrs)
- proceed with suction D&C
septic abortion
- “anembryonic gestation”
- gestational sac too large to not have embryo (>25mm)
- US reveals empty gestational sac
- tx: expectant management, medical (Misoprostol), or D&C
Blighted ovum
what is the most common form of elective abortion?
suction D&C first trimester
- more successful than medical or expectant management
- infection
- smoking and alcohol
- medical disorders
- maternal age
general maternal factors causing recurrent abortions
what is the main symptom of cervical incompetence that Moulton wants us to know?
“painless dilation”
- usually seen with second trimester loss
- risk factors; uterine anomalies, previous trauma, hx of conization (LEEP)
- tx: cervical cerclage
when is karyotyping recommended?
if recurrent abortions have happened- recommended for both parents because there is 3% chance that one parent is asymptomatic carrier of genetically balanced chromosomal translocation
what is the most common immunologic factor causing recurrent abortions?
antiphospholipid syndrome
- has been associated with recurrent fetal loss, preeclampsia, venous and arterial thromboembolism and stroke
where is the most common site for ectopic pregnancy to implant?
ampulla of the fallopian tube
what is the leading cause of maternal death in the first trimester?
ectopic pregnancy
- MUST have a high index of suspicion; diagnose early
what can happen if bleeding is extensive in ectopic pregnancy?
it can create a pressure necrosis of the overlying tubal serosa, resulting in acute rupture and significant hemoperitoneum
what are the risk factors of ectopic pregnancy?
- pregnancy with IUD
- IVF or ART (d/t slowed tubal motility)
- hx of tubal infection (gonorrhea, chlamydia)
- previous ectopic
- cigarette smoking
what is the classic triad of ectopic pregnancy sx?
- prior missed menses
- vaginal bleeding
- lower abdominal pain
what is seen on physical exam and US during ectopic pregnancy?
PE: uterus soft & normal size, may not feel adnexal mass
US: thickened endometrial strip (Arias-Stella reaction)
- sx: lower abd pain/pelvic pain and vaginal spotting or bleeding
- PE: abdominal, adnexal tenderness, or cervical motion tenderness
- US: variable amounts of fluid in the cul de sac, may (or may not) see ectopic
ectopic pregnancy
- sx: severe abdominal pain and dizziness (secondary to intraperitoneal hemorrhage)
- PE: distended and acutely tender abdomen (guarding and rebound), usually has cervical motion tenderness, signs of hemodynamic instability (diaphoresis, tachy, LOC)
- US: reveals an empty uterus with significant amount of free fluid
acutely ruptured ectopic pregnancy
what is the diagnostic test for ectopic pregnancy?
quantitative hCG
what does it mean when hCG double in 48 hours?
a normally developing intrauterine pregnancy
what does it indicate if hCG is inappropriately rising? (<53%)
consistent with ectopic pregnancy or nonviable IUP
NOTE: 17% of ectopic pregnancies have a normal rising hCG
what does it mean if there is a falling hCG concentration?
most likely blighted ovum, spontaneously resolving ectopic, or abnormal pregnancy
what level of hCG is considered the discriminatory zone?
1500-2000 IU/L should be seen in intrauterine gestational sac
what can a transvaginal ultrasound reveal?
- IUP
- extrauterine pregnancy
- or be nondiagnostic (follow closely with serial hCG and give strong ectopic precautions -> repeat US with hCG is within discriminatory zone)
what can be used in COMPLIANT women who are hemodynamically stable with an unruptured ectopic?
methotrexate
- folic acid antagonist which inhibits DNA synthesis and cell replication (is a chemotherapeutic agent)
- CHECK HCG LEVELS ON DAYS 4 &7
- instruct patient to avoid folate containing vitamins
- overall success rate 71-94%
what do you do if hCG levels decrease by 15% from day 4-7 on methotrexate?
continue to follow weekly until negative
what if hCG level plateau or fall slowly from day 4-7 on methotrexate?
give another dose of MTX
what if patient becomes symptomatic or if hCG titers increase from day 4-7 on methotrexate?
proceed with surgical intervention
- intrauterine pregnancy
- breastfeeding
- overt immunodeficiency
- alcoholism, alcoholic liver disease, any chronic liver dz
- active pulmonary disease
- peptic ulcer disease
- hepatic, renal, or hematologic dysfunction
ABSOLUTE contraindications of MTX
- gestational sac >3.5cm
- embryonic cardiac motion
- hCG levels > 600 mIU/L
RELATIVE contraindications
up to 80% of ectopics with what level of hCG will not rupture and will resolve spontaneously?
<1000 mIU/mL
what is the preferred approach for ectopic pregnancy patients who are hemodynamically unstable ?
laparotomy
what is the preferred approach for stable patients with ectopic pregnancy?
laparoscopy
what method removes the entire fallopian tube, and is recommended with significant damage to the tube is noted?
salpingectomy
incision made parallel to the axis of the tube over the site of implantation and incision is left open to heal by secondary intention
- most studies reveal salpingostomy results in better long-term tubal function
salpingostomy
incision is sutured closed
salpingotomy
what is the post-op procedure for ectopic pregnancy?
- repeast hCG 3-7 days
NOTE: up to 20% risk of residual trophoblastic tissue when salpingostomy is performed
what does it mean when a woman is Rh positive?
she carries the D antigen
what does it mean when a woman is Rh negative?
she lacks the D antigen
- >90% of cases of Rh isoimmunization are due to antibodies to D antigens
what is the incidence of Rh D negative for:
- African americans
- Asians
- Caucasians
- African Americans: 8%
- Asians: 1-2%
- Caucasians: 15% (these women have 85% chance of mating with an Rh-positive man)
which antibodies freely cross the placenta and enter fetal circulation?
IgG
what happens if the fetus has Rh antigen?
the antibodies will bind to the fetal red blood cells antigenic sites and cause hemolysis
can the fetus compensate for mild hemolysis?
yes, by increasing erythropoiesis
what can lead to profound anemia?
severe hemolysis -> results in hydrops fetalis from congestive heart failure and intrauterine fetal death
what does feto-maternal hemorrhage lead to?
isoimmunization
- most commonly during routine uncomplicated vaginal deliveries
- 1-2% of Rh isoimmunization occurs in the antepartum period
what is RhoGAM?
Anti-D immunoglobulin
- decreases availability of RhD to the maternal immune system
- single dose = 300 mcg
- can prevent isoimmunization after an exposire up to 30mL or RhD in whole blood, or 15mL of fetal red blood cells
when would you give RhoGAM?
Rh-neg woman at 28 weeks, and within 72 hours afte delivery of a Rh D positive baby
- or with any other factor that could increase the change of fetomaternal hemorrhage
when might more than 1 dose of RhoGAM be required?
certain high risk situations (placental abruption, or manual removal of the placenta)
what is the Kleinhauer-Betke test?
- identifies fetal red blood cells in maternal blood
- will determine if additional RhoGAM is necessary
what should you do for an Rh-neg woman whose anti-D antibody titers are POSITIVE?
- test father of baby for antigen status
- if Rh-neg, no further workup
what if mom is Rh-neg, and partner is homozygous Rh-positive?
all fetuses will be Rh positive and could be affected
what is mom is Rh-neg, and partner is heterozygous Rh-positive?
- 50% of children will be Rh neg
- fetal RhD status needs to be determined: non-invasively with cell-free fetal DNA in maternal plasma, or invasively with fetal antigen testing (amniocentesis)
what does it indicate if Rh isoimmunization titers are < 1:8?
good thing! fetus is not in serious jeopardy
- recheck titers q 4 weeks
what does it indicate if Rh isoimmunization titers > 1:16?
required further evaluation
- detailed ultrasound to detect hydrops and doppler studies of the MCA
what sx are seen on US of fetus with fetal hydrops?
- ascites
- pleural effusion
- pericardial effusion
- skin or scalp edema
- polyhydramnios
when should US evaluation be performed in isoimmunization?
1-2 weeks from 18-35 weeks
what is the most valuable tool for detecting fetal anemia?
doppler assessment of peak systolic velocity in fetal MCA
what should the peak systolic fetal velocity be at?
fetal MCA > 1.5 mom’s for gestational age
- predicts moderate to severe fetal anemia
- need to proceed with percutaneous umbilical blood sampling to assess true hemoglobin concentration
what is the main disadvantage of using amniotic fluid spectrophotometry to determine hemolytic disease?
amniocentesis can increase the severity of feto-maternal transfusion and worse the disease
Hematocrit (Hct) below 30% or 2 standard deviations below the mean Hct for the gestational age
severe fetal anemia
- intrauterine transfusions usually performed between 18-35 weeks
- use fresh group O, Rh-neg packed red blood cells
what needs to be performed in addition to serial ultrasounds with MCA dopplers?
- antepartum testing: twice weekly non-stress test or biophysical profiles
- serial growth scans q 3-4 weeks
- consider delivery or neonate after 35 weeks (risk of transfusion may be greater than that of preterm delivery)
