Early Pregnancy Complications Flashcards
incidence of ectopic pregnancy
1 in 100
why has the incidence of ectopic pregnancy increased over the past 10 years?
increase in assisted fertility, STDs and PID
RFs for ectopic pg’y
hx of STs or PID Previous ectopic pg'y previous tubal surgery prior pelvic or ab'l surgery (adhesions) endometriosis current use of exogenous hrms IVF/assisted repro DES-exposed pts w/congenital abnormalities congenital abnormalities of fallopian tubes use of an IUD
presenting sx’s of ectopic pg’y
unilateral pelvic or lower ab’l pain
vag bleeding
may be hypotensive or w/peritoneal signs
lab findings of ectopic pg’y
b-hCG levels low for GA, does not increase at expected rate (doesn’t double q48h)
how is ectopic pg’y definitively dx’d?
urine pg’y test is +
u/s shows extrauterine pg’y. If too early to show on u/s, then follow serial b-hCGs and see that it does not double q48h
at what b-hCG level should you be able to see an intrauterine pg’y
1500-2000
tx of ruptured ectopic pg’y
stabilize first w/IVF, blood, pressors PRN
ex lap after stabilization to remove pg’y
If they were stable to begin w/, then do ex laparoscopy
tx of unruptured ectopic pg’y
monitor for signs of rupture
MTX
ex laparoscopy
what kind of f/u is required if MTX is used to tx unruptured ectopic pg’y?
obtain baseline AST and ALT and Cr, then give IM MTX, then serially follow b-hCG levels. Will at first rise, then will drop by 10-15% by 4-7d. If not, give second MTX dose.
what is a SAB? Incidence?
pg’y that ends before 20 weeks. 15-25% of all pg’ies end in SAB.
abortus =
the fetus lost before 20 weeks, or weighing < 500g, or < 25cm long
complete abortion =
complete expulsion of all POC before 20 weeks
incomplete abortion =
partial expulsion of POC
inevitable abortion =
no expulsion of products, but bleeding & dilation of cervix, making a viable pg’y unlikely
threatened abortion =
any intrauterine bleeding before 20 weeks, w/o cervical dilatation or expulsion of POC
missed abortion =
death of fetus/embryo but with no expulsion of POC. Usually proceed to complete abortions in 1-3 weeks.
Most first-trimester SABs are due to what?
chromosomal abnormalities
DDx of first-tri bleeding:
SAB postcoital bleeding ectopic pg'y vaginal or cervical lesions or lacerations extrusion of molar pg'y nonpg'y bleeding
sx’s of first trimester abortion:
bleeding
cramping
ab’l pain
decreased sx’s of pg’y
how do you w/u a pt presenting w/vaginal bleeding & cramping in 1st tri?
Hx of sx’s
Physical - pelvic exam, vitals to r/o infection & shock
labs - b-hCG, CBC, blood type & screen
u/s to assess fetal viability & placentation
tx of 1st-tri complete abortion
1) stabilize if hypotensive
2) follow for recurrent bleeding and signs of infection
3) send any expelled tissue to pathology
tx of 1st-tri incomplete abortions
1) stabilize
2) either do expectant mgt or D&C or admin of misoprostol
3) send tissue to pathology
mgt of inevitable abortion & missed abortion
1) stabilize if hypotensive
2) either do expectant mgt, or D&C
3) send tissue to pathology
mgt of threatened abortion
1) monitor for bleeding
2) bedrest, nothing per vagina
3) give RhoGam if Rh-
what are pts w/threatened abortion at increased risk for?
PTL
PPROM
most common causes of 2nd-tri abortions
maternal systemic dis, infection, fetotoxic agents, trauma, uterine or cervical abnormalities. Chromosomes not a common cause.
tx of 2nd-tri abortion
1) r/o ectopic pg’y, stabilize
2) follow for recurrent bleeding, signs of infection,
3) expectant mgt, or D&E or labor induction if retained POC
D&C vs. D&E
D&C = done during 1st tri D&E = done during 2nd tri
D&E vs. labor induction
D&E is faster, but aggressive dilation w/laminaria is necessary. Increased risk of uterine perforation & cervical laceration. Labor induction takes longer, uses high doses of oxytocin & PG’s. Lower risk of trauma 2/2 instrumentation.
PTL vs. incompetent cervix
PTL = ctr’ns w/cervical dilation
incompetent cervix = painless cervical dilatation
mgt of PTL
tocolytics
mgt of incompetent cervix
emergent cerclage
CP of incompetent cervix:
painless cervical dilation, expsoure of fetal membranes. short-tem cramping or ctr’ns. Maybe infection. Vaginal discharge.
RFs for cervical insufficiency:
surgery/cervical trauma/previous cervical dilation
hx of cervical lacerations w/prior vag delivery
uterine anomalies
hx of DES exposure
dx of cervical insufficiency:
dilated cervix seen on exam or u/s. Level of dilation is more than expected for level of ctr’ns.
tx of cervical insufficiency
if < 24 weeks, expectant mgt or elective termination. If viable: 1) betamethasone 2) strict bed rest 3) tocolytics if ctr'ns are occurring - or- immediate cerclage
what is cerclage
suture placed around the cervix.
McDonald cerclage = suture placed at cervical-vaginal jct
Shirodkar cerclage = suture placed at internal os
mgt of a subsequent pg’y in a pt w/hx of cervical insufficiency
elective cerclage offered at 12-14 weeks. Maintained till 36-38 weeks, then rmoved & pt is followed till labor occurs
mgt of subsequent pg’y in a pt in whom previous vaginal cerclage has failed
transabdominal cerclage. Then they’ll need C-sections.
cervical insufficiency carries increased risk of:
infection
PPROM
PTL
what is a recurrent or habitual aborter
a pt who has had 3 or more consecutive SABs
what is the risk of a SAB after one prior? Two prior? Three?
20-25%. 25-30%. 30-35%
causes of recurrent pg’y loss:
chromosomal abnormalities maternal systemic dis infection maternal anatomic defects antiphospholipid antibody syndrome luteal phase defect (low progesterone)
screening of habitual aborters:
1) karyotype both parents
2) karoytype of POC from previous SABs
3) hysterosalpingogram
4) if HSG is abnormal, then f/u w/hysteroscopy or laparoscopy
5) screen for hypothyroidism, DM, antiphlipid Ig’s, hypercoagulability, SLE
6) check serum progesterone level
7) cx’s of cervix, vagina, endometrium
8) endometrial bx during luteal phase
labs to check for habitual aborters:
TSH, free T3/T4 factor V Leiden mutation prothrombin mutation ANA anticardiolipin antibody Russell viper venom antithrombin III levels protein C and S levels
tx of luteal phase defect:
supplemental progesterone
tx of antiphospholipid antibody syndrome
low-dose aspirin
tx of thrombophilia
SQH
pts w/3 prior SABs will have a subsequent normal pg’y how often?
2/3 of the time
cause of recurrent SABs is undiagnosed in how many cases?
1/3
