Early pregnancy complications

Question 1

Risk of ectopic following 1 episode? 2?

Answer 1

10% with one prior, 25% after more

Question 2

How to diagnose intrauterine vs. ectopic pregnancy?

Answer 2

IUP b-HCG doubles every 48 hours.

Question 3

At what b-HCG level do you see an IUP on transvaginal U/S?

Answer 3

1500 to 2000 mIU/mL

Question 4

At what b-HCG level do you see fetal heartbeat on transvaginal U/S?

Answer 4

> 5000 mIU/mL

Question 5

What to do for an UNSTABLE patient with ruptured ectopic

Answer 5

1) Stabilize with IV fluids, blood products, vasopressor meds if needed
2) Ex-lap to stop bleeding

Question 6

If patient with ruptured ectopic is stable then you…

Answer 6

…proceed with ex-lap right away then

1) evacuate the hemoperitoneum
2) coagulate ongoing bleeding
3) Resect the ectopic pregnancy

Question 7

Salpingostomy vs. salpingectomy?

Answer 7

For removing ectopic.

• OSTOMY is when you LEAVE TUBE IN PLACE
• ECTOMY is removal of tube

Question 8

How do you treat enraptured ectopic? Parameters for that?

Answer 8

Methotrexate!
-Small ectopic < 5000
-No fetal heartbeat
(Can still use it outside these parameter but with higher failure rates)

Question 9

How is the mtx administered?

Answer 9

Single dose - 50mg/m2 of INTRAMUSCULAR mtx
Monitor b-HCG which should fall by 10-15% in the first week of rx. If not, give a second dose.

Should also record baseline transaminases and creatinine

Question 10

Not-so-obvious risk factors for ectopic pregnancy?

Answer 10

-Current use of exogenous hormones like progesterone or estrogen

• DES or congenital abnormalities
• Smoking
• IVF or assisted reproduction

Question 11

Spontaneous abortion? Rates?

Answer 11

Before 20 wks

15-25% of all pregs

60-80% of these are associated with CHROMOSOME ABNORMALITIES

Question 12

Differential dx of first trimester bleeding

Answer 12

• Spontaneous abortion
• Ectopic pregnancy
• Extrusion of molar pregnancy
• Postcoital bleeding
• Vaginal or cervical lacerations (eg STDs)
• Nonpregnancy causes

Question 13

What do you do when someone comes in with bleeding likely due to first trimester abortion?

Answer 13

• Pelvic exam to look for source
• Lab tests: quantitative b-HCG, CBC, blood type, antibody screen
• U/s to look at baby, placenta

Question 14

Options with incomplete abortion?

Answer 14

• Expectant management
• Surgery: D&C (this is the only option if the patient is hemodynamically unstable)
• Medical: Prostaglandins +/- Mifepristone

Question 15

Threatened abortion treatment?

Answer 15

Pelvic rest with nothing per vagina. Bleeding often resolves.
Note that pt is at inc risk of PRETERM LABOR & PPROM.
Give the Rh-negative moms RhoGAM (in any bleeding situation)

Question 16

What are the most common etiologies of 2nd trimester abortions?

Answer 16

Infection
Maternal uterine or cervical anatomic defects
Exposure to fetotoxic agents
Trauma

NOT CHROMOSOMAL ABNORMALITIES USUALLY

Question 17

What can you do about fetal loss occurring between 16-24 wks?

Answer 17

• D&E (use laminaria to aggressively dilate the cervix; placed the day before and dilate by absorbing water)
• Induction of labor with high doses of prostaglandins or oxytocin

Question 18

Preterm labor vs. incompetent cervix?

Answer 18

PTL starts with contractions leading to cervical change. Rx: TOCOLYSIS.

Incompetent cervix is PAINLESS DILATION and EFFACEMENT. Rx: Cerclage.

Question 19

Risk factors for cervical incompetence

Answer 19

• Cervical trauma like D&C, LEEP, or cervical conization
• Hx of cervical lacerations with vaginal delivery
• Uterine anomalies
• Hx of DES exposure

Question 20

Timing of cerclage placement?

Answer 20

Around 12 to 15 weeks placed, taken out at 36 to 38 wks

Transabdominal cerclage is an option if the vaginal ones have failed. It’s at internal os. C/s needed.

Question 21

Risk of SAB following 1? 2? 3?

Answer 21

20-25%; 25-30%; 30-35%

Question 22

Weird reasons for recurrent pregnancy loss? (that are actually the 2 most common diagnosed ones)

Answer 22

• Antiphospholipid syndrome

- Luteal phase defect

Question 23

5 things to look for with recurrent pregnancy loss?

Answer 23

1) Karyotypes of mom, dad, POC (via CGH)
2) Maternal anatomy inspection (via HSG)
3) Screening tests for hypothyroidism, DM, APA syndrome, hypercoagulability, and SLE (Lupus anticoagulant, Factor V leiden deficiency, prothrombin G202…mutn, ANA, anticardiolipin antibody, Russel viper venom, antithrombin III, protein S, protein C
4) Serum progesterone level in luteal phase (also an EMB to look for proliferative endometrium in luteal phase).
5) Cultures of cervix, vagina, endometrium (to r/o infection

NO ETIOLOGY FOUND IN 30-50%

Question 24

Rx of luteal phase defect

Answer 24

Progesterone

Question 25

Rx of APA syndrome

Answer 25

low-dose aspirin

Question 26

Rx of thrombophilia

Answer 26

SQ heparin (either LMW or unfractionated)

Question 27

Presentation that makes you want to r/o ectopic right away?

Answer 27

Vaginal bleeding & abdominal pain

Question 28

Incompetent cervix can lead to…

Answer 28

Preterm labor, infection, or ROM

Question 29

Recurrent pregnancy loss is…

Answer 29

3 OR MORE CONSECUTIVE SABs

2/3 of subsequent pregnancies will be totally normal without therapy. Yay.