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EndoRepro 2 Exam 1 > DSA: Early Pregnancy Loss - Moulton > Flashcards

DSA: Early Pregnancy Loss - Moulton Flashcards

1
Q

what is considered first trimester?

A

first day of LMP - 13+6 weeks

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2
Q

what is considered 2nd trimester?

A

14 weeks - 27+6 weeks

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3
Q

what is considered 3rd trimester?

A

28 weeks - 42 weeks

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4
Q

what is EDC?

A

estimated date of confinement

- 40 weeks after LMP

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5
Q

what is considered a preterm delivery?

A

20 - 36+6 weeks

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6
Q

what is considered full term?

A

37 - 42 weeks

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7
Q

when is hCG first detected in serum?

A

6-8 days after ovulation

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8
Q

what is a negative hCG titer?

A

<5 mIU/L

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9
Q

what level of hCG can a urine pregnancy detect?

A

25 mIU/L

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10
Q

when does the level of hCG reach its peak?

A

10 weeks at 100,000 IU/L

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11
Q

when can a gestational sac be seen on transvaginal ultrasound (TVUS)?

A

1500-2000 mIU/L
- considered the discriminatory level
KNOW THIS

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12
Q

when can the fetal pole be seen?

A

around 5 weeks, hCG at 5200 mIU/L

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13
Q

refers to the presence of hCG 7-10 days after ovulation but in whom menstruation occurs when expected

A

biochemical pregnancy

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14
Q

when do 80% of SAB’s occur?

A

first trimester

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15
Q

what are most common causes of first trimester SAB?

A
  • 45 XO Turner syndrome most common CHROMOSOMAL

- Trisomy 16 most common TRISOMY

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16
Q
  • vaginal bleeding and closed cervix
  • 25-50% of threatened abortions eventually result in loss of pregnancy
  • tx: expectant management
A

threatened abortion

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17
Q
  • vaginal bleeding and cervix is partially dilated

- loss is inevitable

A

inevitable abortion

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18
Q
  • vaginal bleeding, cramping lower abd pain with dilated cervix
  • passage of some but not all of the products of conception
  • tx: usually D&C
A

incomplete abortion

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19
Q
  • passage of all products of conception (fetus and placenta) with a closed cervix
  • with resolution of pain, bleeding, and pregnancy symptoms
  • no tx needed
A

complete abortion

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20
Q
  • 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
A

missed abortion

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21
Q
  • 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
A

septic abortion

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22
Q
  • “anembryonic gestation”
  • gestational sac too large to not have embryo (>25mm)
  • US reveals empty gestational sac
  • tx: expectant management, medical (Misoprostol), or D&C
A

Blighted ovum

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23
Q

what is the most common form of elective abortion?

A

suction D&C first trimester

- more successful than medical or expectant management

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24
Q
  • infection
  • smoking and alcohol
  • medical disorders
  • maternal age
A

general maternal factors causing recurrent abortions

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25
Q

what is the main symptom of cervical incompetence that Moulton wants us to know?

A

“painless dilation”

  • usually seen with second trimester loss
  • risk factors; uterine anomalies, previous trauma, hx of conization (LEEP)
  • tx: cervical cerclage
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26
Q

when is karyotyping recommended?

A

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

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27
Q

what is the most common immunologic factor causing recurrent abortions?

A

antiphospholipid syndrome

- has been associated with recurrent fetal loss, preeclampsia, venous and arterial thromboembolism and stroke

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28
Q

where is the most common site for ectopic pregnancy to implant?

A

ampulla of the fallopian tube

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29
Q

what is the leading cause of maternal death in the first trimester?

A

ectopic pregnancy

- MUST have a high index of suspicion; diagnose early

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30
Q

what can happen if bleeding is extensive in ectopic pregnancy?

A

it can create a pressure necrosis of the overlying tubal serosa, resulting in acute rupture and significant hemoperitoneum

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31
Q

what are the risk factors of ectopic pregnancy?

A
  • pregnancy with IUD
  • IVF or ART (d/t slowed tubal motility)
  • hx of tubal infection (gonorrhea, chlamydia)
  • previous ectopic
  • cigarette smoking
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32
Q

what is the classic triad of ectopic pregnancy sx?

A
  • prior missed menses
  • vaginal bleeding
  • lower abdominal pain
33
Q

what is seen on physical exam and US during ectopic pregnancy?

A

PE: uterus soft & normal size, may not feel adnexal mass
US: thickened endometrial strip (Arias-Stella reaction)

34
Q
  • 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
A

ectopic pregnancy

35
Q
  • 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
A

acutely ruptured ectopic pregnancy

36
Q

what is the diagnostic test for ectopic pregnancy?

A

quantitative hCG

37
Q

what does it mean when hCG double in 48 hours?

A

a normally developing intrauterine pregnancy

38
Q

what does it indicate if hCG is inappropriately rising? (<53%)

A

consistent with ectopic pregnancy or nonviable IUP

NOTE: 17% of ectopic pregnancies have a normal rising hCG

39
Q

what does it mean if there is a falling hCG concentration?

A

most likely blighted ovum, spontaneously resolving ectopic, or abnormal pregnancy

40
Q

what level of hCG is considered the discriminatory zone?

A

1500-2000 IU/L should be seen in intrauterine gestational sac

41
Q

what can a transvaginal ultrasound reveal?

A
  • IUP
  • extrauterine pregnancy
  • or be nondiagnostic (follow closely with serial hCG and give strong ectopic precautions -> repeat US with hCG is within discriminatory zone)
42
Q

what can be used in COMPLIANT women who are hemodynamically stable with an unruptured ectopic?

A

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%
43
Q

what do you do if hCG levels decrease by 15% from day 4-7 on methotrexate?

A

continue to follow weekly until negative

44
Q

what if hCG level plateau or fall slowly from day 4-7 on methotrexate?

A

give another dose of MTX

45
Q

what if patient becomes symptomatic or if hCG titers increase from day 4-7 on methotrexate?

A

proceed with surgical intervention

46
Q
  • intrauterine pregnancy
  • breastfeeding
  • overt immunodeficiency
  • alcoholism, alcoholic liver disease, any chronic liver dz
  • active pulmonary disease
  • peptic ulcer disease
  • hepatic, renal, or hematologic dysfunction
A

ABSOLUTE contraindications of MTX

47
Q
  • gestational sac >3.5cm
  • embryonic cardiac motion
  • hCG levels > 600 mIU/L
A

RELATIVE contraindications

48
Q

up to 80% of ectopics with what level of hCG will not rupture and will resolve spontaneously?

A

<1000 mIU/mL

49
Q

what is the preferred approach for ectopic pregnancy patients who are hemodynamically unstable ?

A

laparotomy

50
Q

what is the preferred approach for stable patients with ectopic pregnancy?

A

laparoscopy

51
Q

what method removes the entire fallopian tube, and is recommended with significant damage to the tube is noted?

A

salpingectomy

52
Q

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

A

salpingostomy

53
Q

incision is sutured closed

A

salpingotomy

54
Q

what is the post-op procedure for ectopic pregnancy?

A
  • repeast hCG 3-7 days

NOTE: up to 20% risk of residual trophoblastic tissue when salpingostomy is performed

55
Q

what does it mean when a woman is Rh positive?

A

she carries the D antigen

56
Q

what does it mean when a woman is Rh negative?

A

she lacks the D antigen

- >90% of cases of Rh isoimmunization are due to antibodies to D antigens

57
Q

what is the incidence of Rh D negative for:

  • African americans
  • Asians
  • Caucasians
A
  • African Americans: 8%
  • Asians: 1-2%
  • Caucasians: 15% (these women have 85% chance of mating with an Rh-positive man)
58
Q

which antibodies freely cross the placenta and enter fetal circulation?

A

IgG

59
Q

what happens if the fetus has Rh antigen?

A

the antibodies will bind to the fetal red blood cells antigenic sites and cause hemolysis

60
Q

can the fetus compensate for mild hemolysis?

A

yes, by increasing erythropoiesis

61
Q

what can lead to profound anemia?

A

severe hemolysis -> results in hydrops fetalis from congestive heart failure and intrauterine fetal death

62
Q

what does feto-maternal hemorrhage lead to?

A

isoimmunization

  • most commonly during routine uncomplicated vaginal deliveries
  • 1-2% of Rh isoimmunization occurs in the antepartum period
63
Q

what is RhoGAM?

A

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
64
Q

when would you give RhoGAM?

A

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

65
Q

when might more than 1 dose of RhoGAM be required?

A

certain high risk situations (placental abruption, or manual removal of the placenta)

66
Q

what is the Kleinhauer-Betke test?

A
  • identifies fetal red blood cells in maternal blood

- will determine if additional RhoGAM is necessary

67
Q

what should you do for an Rh-neg woman whose anti-D antibody titers are POSITIVE?

A
  • test father of baby for antigen status

- if Rh-neg, no further workup

68
Q

what if mom is Rh-neg, and partner is homozygous Rh-positive?

A

all fetuses will be Rh positive and could be affected

69
Q

what is mom is Rh-neg, and partner is heterozygous Rh-positive?

A
  • 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)
70
Q

what does it indicate if Rh isoimmunization titers are < 1:8?

A

good thing! fetus is not in serious jeopardy

- recheck titers q 4 weeks

71
Q

what does it indicate if Rh isoimmunization titers > 1:16?

A

required further evaluation

- detailed ultrasound to detect hydrops and doppler studies of the MCA

72
Q

what sx are seen on US of fetus with fetal hydrops?

A
  • ascites
  • pleural effusion
  • pericardial effusion
  • skin or scalp edema
  • polyhydramnios
73
Q

when should US evaluation be performed in isoimmunization?

A

1-2 weeks from 18-35 weeks

74
Q

what is the most valuable tool for detecting fetal anemia?

A

doppler assessment of peak systolic velocity in fetal MCA

75
Q

what should the peak systolic fetal velocity be at?

A

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
76
Q

what is the main disadvantage of using amniotic fluid spectrophotometry to determine hemolytic disease?

A

amniocentesis can increase the severity of feto-maternal transfusion and worse the disease

77
Q

Hematocrit (Hct) below 30% or 2 standard deviations below the mean Hct for the gestational age

A

severe fetal anemia

  • intrauterine transfusions usually performed between 18-35 weeks
  • use fresh group O, Rh-neg packed red blood cells
78
Q

what needs to be performed in addition to serial ultrasounds with MCA dopplers?

A
  • 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)

EndoRepro 2 Exam 1 (25 decks)

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