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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
Definition: anembryonic gestation
embryo never formed
26
Presentation of anembryonic
* Amenorrhea * +hcG * +/- early pregnancy symptoms * NO FHT * No uterine/fundal growth * Decreasing hcG * US: empty gestational sac present in uterus
27
Definition: ectopic pregnancy
pregnancy that occurs outside of the uterus
28
Most common site of ectopic pregnancy
96% occur in the tube
29
Definition: heterotopic
IUP and ectopic at the same time - more common with ovulation induction
30
Definition: GTN/GTD
benign and malignant tumors originating from trophoblastic tissue
31
Types of hydatidiform moles
Complete and Partial
32
Which type of mole has a greater risk of metastasizing?
Complete
33
What is cancerous - GTN or GTD?
GTN
34
What are the 4 types of GTN?
1) invasive mole 2) choriocarcinoma 3) Placental site trophoblastic tumor (PSTT) 4) Epithelioid trophoblastic tumor (ETT)
35
Characteristics: Choriocarcinoma
*Can occur after ANY pregnancy (approx. 50% cases after molar pregnancy) *Most aggressive type of GTN *Often metastasize to the lungs or vagina
36
Characteristics: Placental site trophoblastic tumor (PSTT)
* Most common after non-molar pregnancy or abortion * Remains localized to uterus for long periods and can be diagnosed months-years after pregnancy
37
Characteristics: Epithelioid trophoblastic tumor (ETT)
* Rare for of PSTT * Diagnosis typically late d/t slow growth and low/absent hcg production * ~50% present with metastatic disease
38
Pathophysiology of GTN/GTD
All of them arise from abnormalities in fertilization
39
Characteristic: Partial Mole
identifiable fetal tissue but not viable
40
Characteristic: Complete mole
- no identifiable fetal tissue - no chromosomal material in ovum
41
What does trophoblastic tissue do?
Secretes HcG
42
When dose an invasive mole develop?
Post molar pregnancy
43
What occurs during an invasive mole?
Myometrial invasion
44
How often does an invasive mole occur in patients with a complete mole? Partial mole?
Complete - 15-20% Partial - 1-4%
45
How often does an invasive mole metastasize?
~5% of all cases
46
Definition pregnancy of unknown location (PUL)
o Positive pregnancy test - TVUS does not show IUP or ectopic gestation or retention of conception products
47
Diagnostic criteria of hyperemesis gravidarum
 Persistent vomiting before 9 weeks gestation  Dehydration and/or ketonuria  Weight loss greater than 5% of initial body weight  Electrolyte imbalance
48
Risks factors: Spontaneous abortion
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
Risk factors: Ectopic pregnancy
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
Risk factors: GTN/GTD
i. Prior hx molar pregnancy ii. Extremes of age: >40 or <15 iii. Prior SAB or hx infertility
51
Risk factors: Hyperemesis Gravidarum
i. Previous HG ii. Molar pregnancy iii. Multifetal gestation iv. Pre-pregnancy hx of GI disorders v. Hyperthyroid disorder
52
Early pregnancy US findings suggesting impending loss
i. Abnormal size/shape of gestational or yolk sac ii. Embryo small for dates iii. Slow HR (<80-100 BPM)
53
Presenting signs/symptoms of GTN/GTD
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
Signs/symptoms GTN/GTD
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
Signs/symptoms ectopic pregnancy
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
Pertinent Hx questions when patient presents with early pregnancy bleeding:
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
PE: key items to look for when assessing for early pregnancy bleeding
i. Assess cervix: dilation? Bleeding? s/s infection?
58
Lab tests/diagnostics when assessing early pregnancy/bleeding
i. Ultra sound: IUP visible? Cardiac activity? ii. Labs: blood type and screen; serial hCG; CBC
59
Differential diagnosis for early pregnancy bleeding
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
Reasons for hyperemia cervical bleeding
d/t increased vascularity  post coital spotting
61
What can you do during pregnancy for cervical dysplasia?
- can perform pap and colpo in pregnancy - biopsy is avoided unless worried about malignancy
62
S/s cervical polyp
- bright red - post coital painless bleeding
63
Types of placental implantation issues (2)
o Lying low or covering the cervix (placenta previa) o Subchorionic hematoma
64
Threatened abortion: labs, diagnostics, monitoring, PE
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
Inevitable abortion: labs, diagnostics, monitoring, PE
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
Incomplete abortion: labs, diagnostics, monitoring, PE
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
Complete abortion: labs, diagnostics, monitoring, PE
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
Anembryonic/demise management
Similar inevitable/incomplete AB
69
Ectopic: labs, diagnostics, monitoring, PE
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
Ectopic Treatment
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
GTN/GTD: labs, diagnostics, monitoring, PE
a. Diagnosis made with ultrasound “grape like” b. Pathologic evaluation c. Baseline labs: hcg, kidney, liver thyroid d. CXR r/o lung mets
72
GTN/GTD treatment: -invasive mole/choriocarcinoma -ETT/PSTT
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
PUL: diagnostic
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
HG treatment: Mild and severe
a. Mild nausea ginger products, vitamin B6, acupressure bands b. Severe: IV nor IM antiemetic s/a metoclopramide or ondansetron
75
Consultations for recurrent miscarriage
a. Genetic counseling b. Maternal fetal medicine

Women's Health Theory (7 decks)

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