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Women's Health Theory > Early pregnancy complications > Flashcards

Early pregnancy complications Flashcards

1
Q

Hcg trend post implantation

A

levels increase exponentially

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2
Q

When can you detect hcg?

A

7-10 days after fertilization (21 days from LMP)

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3
Q

What is the discriminatory zone {hcg level you’d expect to see an IUP}
-TVUS
-Transabdominal US

A

-TVUS = 2000-3000
-transabdominal US = 5000

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4
Q

How often should you be seeing the HCG increase?

A

double every 48 hours

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5
Q

differentials for inadequate rise in hcg?

A

-ectopic
-demise
-anembryonic

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6
Q

Differentials: rise greater than expected

A

-multiple gestation
-GTN

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7
Q

What does the hcg peak at?

A

10,000

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8
Q

At what level will a urine pregnancy test pick up hcg?

A

25

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9
Q

When is a pregnancy visible via TVUS?

A

4.5-5.5 weeks since LMP

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10
Q

What is the first thing that is visible via TVUS?

A

 Gestational sac is the first thing that is visible – anechoic and round (dark and round)

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11
Q

What should you be able to see around 5.5 weeks?

A

 Double decidual ring should be visible around ~5.5 w
* This verifies an IUP

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12
Q

What can you see from 5-6 weeks up until 10 weeks?

A

yolk sac

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13
Q

When can you pick up cardiac activity

A

6 weeks

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14
Q

What is the crown rump length at 6 weeks?

A

2-5 mm CRL

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15
Q

What part of the embryo is visible at the end of 6 weeks?

A

embryonic pole = hyperechoic, linear structure

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16
Q

What should the embryo be measuring at 7 weeks gestation?

A

7 mm

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17
Q

Implantation bleeding:
-when do you see it
-characteristics

A

timing: occurs 1-2 weeks post conception
characteristics: not as heavy or as long as a period; Painless!; resolves spontaneously

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18
Q

Definition: Subchorionic hematoma & when is it dangerous

A

o When blood forms between the wall of the uterus and the chorionic membrane during pregnancy
o Risk factor when ts is >25% of the gestational sac size

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19
Q

Definition threatened abortion

A

 Vaginal bleeding +/- cramping/back ache
 NO cervical changes

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20
Q

Definition: inevitable abortion

A

 Bleeding and cramps
 +cervical changes OR + ROM
 +/- FHR
 Fetal membranes or placenta may be present at the os
 “just a matter of time”

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21
Q

Definition: complete abortion

A

 Uterus completely evacuates all POC
 Bleeding stops after passage of all tissue
 On exam: uterus is firm, os is closed

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22
Q

Definition: incomplete abortion

A

 Pregnancy passed but some POC remain in uterus
 Increased risk of infection, hemorrhage
 Presentation: spotting, passing clots, bleeding heavily for days

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23
Q

Definition: missed abortion aka “demise”

A

 Embryo forms then in utero failure to develop
 Can take up to 4-8 weeks to detect

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24
Q

Presentation of a missed abortion

A
  • Amenorrhea
    • hcG
  • Early pregnancy symptoms are present the REGRESS
  • No FHT
  • No uterine/fundal growth
  • Decreasing hcG
  • US: + sac with embryo in uterus, no cardiac activity
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25
Q

Definition: anembryonic gestation

A

embryo never formed

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26
Q

Presentation of anembryonic

A
  • Amenorrhea
  • +hcG
  • +/- early pregnancy symptoms
  • NO FHT
  • No uterine/fundal growth
  • Decreasing hcG
  • US: empty gestational sac present in uterus
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27
Q

Definition: ectopic pregnancy

A

pregnancy that occurs outside of the uterus

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28
Q

Most common site of ectopic pregnancy

A

96% occur in the tube

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29
Q

Definition: heterotopic

A

IUP and ectopic at the same time - more common with ovulation induction

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30
Q

Definition: GTN/GTD

A

benign and malignant tumors originating from trophoblastic tissue

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31
Q

Types of hydatidiform moles

A

Complete and Partial

32
Q

Which type of mole has a greater risk of metastasizing?

A

Complete

33
Q

What is cancerous - GTN or GTD?

A

GTN

34
Q

What are the 4 types of GTN?

A

1) invasive mole
2) choriocarcinoma
3) Placental site trophoblastic tumor (PSTT)
4) Epithelioid trophoblastic tumor (ETT)

35
Q

Characteristics: Choriocarcinoma

A

*Can occur after ANY pregnancy (approx. 50% cases after molar pregnancy)
*Most aggressive type of GTN
*Often metastasize to the lungs or vagina

36
Q

Characteristics: Placental site trophoblastic tumor (PSTT)

A
  • Most common after non-molar pregnancy or abortion
  • Remains localized to uterus for long periods and can be
    diagnosed months-years after pregnancy
37
Q

Characteristics: Epithelioid trophoblastic tumor (ETT)

A
  • Rare for of PSTT
  • Diagnosis typically late d/t slow growth and low/absent
    hcg production
  • ~50% present with metastatic disease
38
Q

Pathophysiology of GTN/GTD

A

All of them arise from abnormalities in fertilization

39
Q

Characteristic: Partial Mole

A

identifiable fetal tissue but not viable

40
Q

Characteristic: Complete mole

A
  • no identifiable fetal tissue
  • no chromosomal material in ovum
41
Q

What does trophoblastic tissue do?

A

Secretes HcG

42
Q

When dose an invasive mole develop?

A

Post molar pregnancy

43
Q

What occurs during an invasive mole?

A

Myometrial invasion

44
Q

How often does an invasive mole occur in patients with a complete mole? Partial mole?

A

Complete - 15-20%
Partial - 1-4%

45
Q

How often does an invasive mole metastasize?

A

~5% of all cases

46
Q

Definition pregnancy of unknown location (PUL)

A

o Positive pregnancy test
- TVUS does not show IUP or ectopic gestation or retention of conception products

47
Q

Diagnostic criteria of hyperemesis gravidarum

A

 Persistent vomiting before 9 weeks gestation
 Dehydration and/or ketonuria
 Weight loss greater than 5% of initial body weight
 Electrolyte imbalance

48
Q

Risks factors: Spontaneous abortion

A

i. Age > 35
1. Increased age of oocytes
2. Greater risk of aneuploidy
ii. Prior pregnancy loss
iii. Maternal medical conditions
1. Infection, DM, HTN, BMI > 25, thyroid, stress, inherited thrombophilia
2. Medications
3. SUD
iv. Environmental factors/exposures
v. Race ethnicity WOC > white
1. d/t SDOH, cumulative stressors (non biological)
vi. Subchorionic hematoma

49
Q

Risk factors: Ectopic pregnancy

A

i. Prior ectopic
ii. Hx tubal surgery
iii. Uterine or tubal abnormalities
iv. Moderate
1. Hx PID/STIs
2. Hx infertility, ART
3. Multiple sex partners
v. Slight
1. Smoking
2. Pelvic sx

50
Q

Risk factors: GTN/GTD

A

i. Prior hx molar pregnancy
ii. Extremes of age: >40 or <15
iii. Prior SAB or hx infertility

51
Q

Risk factors: Hyperemesis Gravidarum

A

i. Previous HG
ii. Molar pregnancy
iii. Multifetal gestation
iv. Pre-pregnancy hx of GI disorders
v. Hyperthyroid disorder

52
Q

Early pregnancy US findings suggesting impending loss

A

i. Abnormal size/shape of gestational or yolk sac
ii. Embryo small for dates
iii. Slow HR (<80-100 BPM)

53
Q

Presenting signs/symptoms of GTN/GTD

A

i. Size > dates
ii. Possible thyroid abnormalities
iii. Subjective s/s
1. “feels bigger” than dates
2. Spotting/bleeding – dark or even “grape-like”
iv. Increased nausea/vomiting d/t increased hcg
v. No FHT by expected dates (cardiac activity at week 6)
vi. Hyperemesis
vii. Signs of preeclampsia before 24 weeks
viii. Decreased Hct/Hgb

54
Q

Signs/symptoms GTN/GTD

A

i. Size > dates
ii. Possible thyroid abnormalities
iii. Subjective s/s
1. “feels bigger” than dates
2. Spotting/bleeding – dark or even “grape-like”
iv. Increased nausea/vomiting d/t increased hcg
v. No FHT by expected dates (cardiac activity at week 6)
vi. Hyperemesis
vii. Signs of preeclampsia before 24 weeks
viii. Decreased Hct/Hgb

55
Q

Signs/symptoms ectopic pregnancy

A
  1. Vertigo/syncope
  2. Shoulder pain
  3. BP: normal, hypotensive or postural changes
  4. Pule: tachycardic or thready
  5. May have decreased bowel sounds
56
Q

Pertinent Hx questions when patient presents with early pregnancy bleeding:

A

i. LMP/EDD
ii. Amount duration, quality of bleeding
iii. Pain
iv. Dizziness/faintness?
v. Previous hx of ectopic or risk factors for ectopic?

57
Q

PE: key items to look for when assessing for early pregnancy bleeding

A

i. Assess cervix: dilation? Bleeding? s/s infection?

58
Q

Lab tests/diagnostics when assessing early pregnancy/bleeding

A

i. Ultra sound: IUP visible? Cardiac activity?
ii. Labs: blood type and screen; serial hCG; CBC

59
Q

Differential diagnosis for early pregnancy bleeding

A

i. Implantation bleeding
ii. Hyperemia of cervix
iii. Placental implantation
iv. Spontaneous abortion
v. Ectopic pregnancy
vi. Molar pregnancy/GTN
vii. Vaginal/cervical infection
viii. Cervical dysplasia/CA
ix. Cervical polyp
x. Sexual assault
xi. Unexplained

60
Q

Reasons for hyperemia cervical bleeding

A

d/t increased vascularity  post coital spotting

61
Q

What can you do during pregnancy for cervical dysplasia?

A
  • can perform pap and colpo in pregnancy
  • biopsy is avoided unless worried about malignancy
62
Q

S/s cervical polyp

A
  • bright red
  • post coital painless bleeding
63
Q

Types of placental implantation issues (2)

A

o Lying low or covering the cervix (placenta previa)
o Subchorionic hematoma

64
Q

Threatened abortion: labs, diagnostics, monitoring, PE

A

i. Ultrasound: checking if IUP visible; cardiac activity
ii. Labs: blood type and screen; Beta hcG; CBC (anemia)
iii. Monitor for: cervical changes, increased bleeding, infection
iv. Pelvic rest  no penetrative activities
v. Support! This is not their fault
vi. Pelvic exam to assess cervix

65
Q

Inevitable abortion: labs, diagnostics, monitoring, PE

A

i. US
ii. Pelvic rest
iii. Labs: same as threatened; add a coagulation study if there is a lot of bleeding
iv. 3 M’s of management
1. Mother nature = expectant
2. Medicine = misoprostol
3. MVA = aspiration (procedural)

66
Q

Incomplete abortion: labs, diagnostics, monitoring, PE

A

i. Tx similar to “inevitable” but intervention is more common
ii. If expectant management: monitor for infection and DIC
1. You normally do not watch and wait…
iii. Send POC to pathology for workup

67
Q

Complete abortion: labs, diagnostics, monitoring, PE

A

i. Occasionally remove necrotic tissue (in cervix or uterus)
ii. If unclear resolution or IUP was not definitive
1. US 7-10 days post passage of tissue
2. Serial hcG (follow until 0)

68
Q

Anembryonic/demise management

A

Similar inevitable/incomplete AB

69
Q

Ectopic: labs, diagnostics, monitoring, PE

A

a. Serial hcGs
i. If less than 66% increase in 49 hr = high suspicion ectopic
b. US – if 6 weeks ~ remember you need to consider discriminatory zone for IUP
c. Serum progesterone: low is abnormal (<20) doesn’t add much beyond hcg and US
d. Uterine sampling: look for chorionic villi
e. Hemodynamically unstable/shock = medical emergency
f. High suspicion  transfer care!

70
Q

Ectopic Treatment

A

i. Expectant management: can only do this if have falling hcg
ii. Medical: Methotrexate
1. This is the safest
2. Preserves future fertility
3. Labs: must be at a certain EGA and renal function

71
Q

GTN/GTD: labs, diagnostics, monitoring, PE

A

a. Diagnosis made with ultrasound “grape like”
b. Pathologic evaluation
c. Baseline labs: hcg, kidney, liver thyroid
d. CXR r/o lung mets

72
Q

GTN/GTD treatment:
-invasive mole/choriocarcinoma
-ETT/PSTT

A

e. Uterine evacuation or hysterectomy
f. Invasive mole and choriocarcinoma –> highly responsive to single agent chemo
g. ETT and PSTT
i. Resistant to chemo –> hysterectomy preferred

73
Q

PUL: diagnostic

A

a. Ultrasound (pelvic/abdominal)
b. If not able to see on a 2d US  perform a 3D US before MRI
c. If the pregnancy cannot be found then step to an MRI

74
Q

HG treatment: Mild and severe

A

a. Mild nausea ginger products, vitamin B6, acupressure bands
b. Severe: IV nor IM antiemetic s/a metoclopramide or ondansetron

75
Q

Consultations for recurrent miscarriage

A

a. Genetic counseling
b. Maternal fetal medicine

Women's Health Theory (7 decks)

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