Early Pregnancy Complications

Question 1

Ectopic pregnancy signs/symptoms

Answer 1

Unilateral pelvic/ lower abdominal pain
Vaginal bleeding
SGA uterus
Peritoneal signs if ruptured
If bhCG <2000 and no IUP on US, repeat bhCG in 48 hours- will not double if ectopic 2/2 poorly implanted placenta

Question 2

Ectopic treatment

Answer 2

if unstable–STABILIZE
ABC, fluids, blood products, pressors
If stable– laparoscopy
If crashing– laparotomy

Question 3

Ectopic treatment: Methotrexate criteria

Answer 3

• Hemodynamic stability
• Nonruptured ectopic pregnancy
• Size of ectopic mass < 4 cm w/o fetal HR
• Size of ectopic mass < 3.5 cm + fetal HR
• Normal liver enzymes and renal function, normal white cell count
• Ability to FOLLOW UP
• Must follow up with bhCG ( should be 10-15% drop after 4-7d), if not 2nd dose MTX

Question 4

Spontaneous Abortions:

• Complete
• Incomplete
• Inevitable
• Threatened
• Missed

Answer 4

• Complete: all POC out before 20 weeks
• Incomplete: some but not all POC out by 20 weeks
• Inevitable: no POC but VB/cervical dilation
• Threatened: VB w/o POC expulsion or cervical dilation
• Missed: embryo/fetus dies with retention of all POC

Question 5

Causes and treatments of 1st trimester abortions:

Answer 5

Cause: CHROMOSOMES
Rx: treat pt if hypotensive, check cervix/ get bhCG quant, CBC, type and screen, US, r/o ectopic
If complete: follow if no signs of infection, send tissue to path
In incomplete, inevitable, or missed: can finish on own or do D&C or give misoprostol (prostaglandin) to induce cervical dilation/ctx
If threatened: follow up as op, pelvic rest
If Rh negative: give RhoGAM

Question 6

Causes and treatments of 2nd trimester abortions:

Answer 6

Causes: infection, maternal dz, trauma, cervical defects like insufficiency
If incomplete/missed: can finish on own, induce with high dose oxytoxin/prostaglandins or go to D&E (dilation and evacuation)- need to use laminaria first
Need to rule out preterm labor (painful ctx, cervical change)/ incompetent cervix (painless cervical change)

Question 7

Incompetent cervix

Answer 7

2/2 trauma, surgery, ?DES, idiopathic
Can do cerclage if hx in prev pregnancy or in emergency
If elective, place at 14 weeks (for chance of 1st trim SAB)
Consider betamethasone (steroids)/tocolysis (labor suppressants) if close to 24 weeks

Question 8

Habitual aborters

Answer 8

3+ consecutive SAB

Question 9

Work up for habitual aborters

Answer 9

1) Hysterosalpingogram (HSG): fertility test for tubal patency and normalcy of the uterine cavity
2) karyotypes for translocations (parents/ POC)
3) screen for hypoT, DM, hypercoag (Factor V Leiden, prothrombin G20210A, antiphospholipid ab, protein c/s)
4) R/o infection (cx cervix, vagina, endometrium)

Question 10

Antiphospholipid antibodies… consider if:

Answer 10

History of DVT, prolonged DRVVT, anticardiolipin abs, recurrent 1st tri losses

Question 11

Rx for Antiphospholipid antibodies

Answer 11

Heparin and aspirin

Question 12

Luteal phase defect? (controversial)

Answer 12

? not enough progesterone

Get luteal phase serum progesterone and or endometrial bx in luteal phase to look for proliferative endometrium

Question 13

Factor V Leiden

Answer 13

Consider if late fetal demise (late 3rd trimester), with head >abdominal, fetal, humerus lengths, pt with hx of DVT in past

Question 14

Treatment for habitual aborters

Answer 14

May need IVF (translocations, etc), surgery for anomalies, heparin/ASA, maternal treatment

Question 15

Septic abortion presentation

Answer 15

miscarriage with fever, uterine tenderness

Question 16

Rx for septic abortion

Answer 16

Need uterine evacuation and broad spectrum ABX