Early pregnancy complications Flashcards
Risk of ectopic following 1 episode? 2?
10% with one prior, 25% after more
How to diagnose intrauterine vs. ectopic pregnancy?
IUP b-HCG doubles every 48 hours.
At what b-HCG level do you see an IUP on transvaginal U/S?
1500 to 2000 mIU/mL
At what b-HCG level do you see fetal heartbeat on transvaginal U/S?
> 5000 mIU/mL
What to do for an UNSTABLE patient with ruptured ectopic
1) Stabilize with IV fluids, blood products, vasopressor meds if needed
2) Ex-lap to stop bleeding
If patient with ruptured ectopic is stable then you…
…proceed with ex-lap right away then
1) evacuate the hemoperitoneum
2) coagulate ongoing bleeding
3) Resect the ectopic pregnancy
Salpingostomy vs. salpingectomy?
For removing ectopic.
- OSTOMY is when you LEAVE TUBE IN PLACE
- ECTOMY is removal of tube
How do you treat enraptured ectopic? Parameters for that?
Methotrexate!
-Small ectopic < 5000
-No fetal heartbeat
(Can still use it outside these parameter but with higher failure rates)
How is the mtx administered?
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
Not-so-obvious risk factors for ectopic pregnancy?
-Current use of exogenous hormones like progesterone or estrogen
- DES or congenital abnormalities
- Smoking
- IVF or assisted reproduction
Spontaneous abortion? Rates?
Before 20 wks
15-25% of all pregs
60-80% of these are associated with CHROMOSOME ABNORMALITIES
Differential dx of first trimester bleeding
- Spontaneous abortion
- Ectopic pregnancy
- Extrusion of molar pregnancy
- Postcoital bleeding
- Vaginal or cervical lacerations (eg STDs)
- Nonpregnancy causes
What do you do when someone comes in with bleeding likely due to first trimester abortion?
- Pelvic exam to look for source
- Lab tests: quantitative b-HCG, CBC, blood type, antibody screen
- U/s to look at baby, placenta
Options with incomplete abortion?
- Expectant management
- Surgery: D&C (this is the only option if the patient is hemodynamically unstable)
- Medical: Prostaglandins +/- Mifepristone
Threatened abortion treatment?
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)
What are the most common etiologies of 2nd trimester abortions?
Infection
Maternal uterine or cervical anatomic defects
Exposure to fetotoxic agents
Trauma
NOT CHROMOSOMAL ABNORMALITIES USUALLY
What can you do about fetal loss occurring between 16-24 wks?
- 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
Preterm labor vs. incompetent cervix?
PTL starts with contractions leading to cervical change. Rx: TOCOLYSIS.
Incompetent cervix is PAINLESS DILATION and EFFACEMENT. Rx: Cerclage.
Risk factors for cervical incompetence
- Cervical trauma like D&C, LEEP, or cervical conization
- Hx of cervical lacerations with vaginal delivery
- Uterine anomalies
- Hx of DES exposure
Timing of cerclage placement?
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.
Risk of SAB following 1? 2? 3?
20-25%; 25-30%; 30-35%
Weird reasons for recurrent pregnancy loss? (that are actually the 2 most common diagnosed ones)
- Antiphospholipid syndrome
- Luteal phase defect
5 things to look for with recurrent pregnancy loss?
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%
Rx of luteal phase defect
Progesterone
Rx of APA syndrome
low-dose aspirin
Rx of thrombophilia
SQ heparin (either LMW or unfractionated)
Presentation that makes you want to r/o ectopic right away?
Vaginal bleeding & abdominal pain
Incompetent cervix can lead to…
Preterm labor, infection, or ROM
Recurrent pregnancy loss is…
3 OR MORE CONSECUTIVE SABs
2/3 of subsequent pregnancies will be totally normal without therapy. Yay.
