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Obstetrics and Gynecology > Early Pregnancy Complications > Flashcards

Early Pregnancy Complications Flashcards

1
Q

what is an ectopic pregnancy

A

one that implants outside the uterine cavity

implantation in the fallopian tubes occurs in 95-99% of patients

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2
Q

where is the most common site of ectopic pregnancy implantation?

A

ampulla (70%)

then its the isthmus (12%) and fimbriae (11%)

implantation can also occur on the ovary, cervix, outside of the fallopian tube, abdominal wall or bowel

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3
Q

what is the rate of ectopic pregnancy

A

1 in 100 of all pregnancies

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4
Q

why is the rate of ectopic pregnancy increasing

A

secondary to increase in assisted fertility, STIs, and PID

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5
Q

who should be evaluated for an ectopic pregnancy

A

patients who present with vaginal bleeding and/or abdo pain–> ruptured ectopic is a TRUE EMERGENCY

can result in rapid hemorrhage, leading to shock and eventually death

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6
Q

what % of all maternal deaths in the US are accounted for by ruptured ectopics

A

6%

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7
Q

what are the risk factors for ectopic pregnancy

A

tubal scarring or decreased peristalsis of tubes

prior ectopic –> risk of subsequent is 10% after one prior ectopic and increases to 25% after two

increased risk (up to 1.8%) of ectopics with assisted reproductive technology

increased rate of ectopics in women who become pregnant with IUDs implanted because it prevents normal uterine implantation (may be as high as 25-50% risk)

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8
Q

how do you diagnose ectopic pregnancy

A

history
physical
lab test
US

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9
Q

typical history for ectopic pregnancy

A

unilateral pelvic or lower abdo pain

vaginal bleeding

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10
Q

typical exam for ectopic pregnancy

A

adnexal mass that is often tender
uterus small for gestational age
bleeding from cervix

patients with ruptured ectopics may be hypotensive, tachy, unresponsive or show signs of peritoneal irritation secondary to hemoperitoneum

remember that many women with ectopics are otherwise well and young and so signs of intra-abdo hemorrhage may not occur until patient has lost a large amount of blood

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11
Q

classic findings on lab tests for ectopics

A

B-hCG level that is low for gestational age and does not increase at expected rate

normally, should double approx every 48 hours –> ectopic does not do this as ectopics have poorly implanted placenta and thus bad blood supply compared to endometrium

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12
Q

what do you see on US in an ectopic pregnancy

A

adnexal mass or extrauterine pregnancy

a normal pregnancy that has implanted in the uterus (IUP) will show a gestational sac with a yolk sac in the uterus on US

*remember there is always the risk of a heterotopic pregnancy, where a multiple gestation has at least one IUP and one ectopic pregnancy–> of particular concern in setting of IVF when more than one embryo transferred

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13
Q

after what B-hCG level should you see a fetal heartbeat on US

A

above 5000 mIU/mL

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14
Q

how do you manage a ruptured ectopic pregnancy

A

first priority–> stabilize with IV fluids, blood products and vasopressor meds if unstable

take to OR for exploratory laparotomy to stop bleeding and remove ectopic pregnancy

if patient stable with likely ruptured ectopic, many institutions will do exploratory laparoscopy which can be performed to evacuate the hemoperitoneum, coagulate any ongoing bleeding, and resect the ectopic pregnancy

resection can be either through salpingostomy (where ectopic pregnancy is removed leaving fallopian tube intact//or salpingectomy where entire ectopic pregnancy is removed

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15
Q

how do you manage an unruptured ectopic

A

either surgically (same as ruptured) or medically

medical Rx is methotrexate in order to treat uncomplicated, nonthreatening, ectopics –> can use for small ( less than 4cm, B-hCG below 5000 and no FHR) and for those who will be reliable with followup

must evaluate baseline transaminases and creatinine, intramuscular methotrexate and serial measurement of B-hCG

single and multidose methotrexate regimens are acceptable –> B-hCG will initially rise but then should start falling over 4-7 days; if doesnt, give second treatment

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16
Q

what is a single dose regiment for methotrexate

A

50 mg/m2 dose of IM methotrexate

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17
Q

define spontaneous abortion

A

“miscarriage”

pregnancy that ends before 20 weeks GA

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18
Q

how common are SAs

A

occur in 15-20% of all pregnancies

may be even higher because losses at 4-6 weeks are often confused with late menses

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19
Q

how do you define the types of SAs

A

by whether any or all of the products of conception have passed and whether the cervix is dilated

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20
Q

define abortus

A

fetus lost before 20 weeks GA or less than 500g

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21
Q

define complete abortion

A

complete expulsion of all POC before 20 weeks GA

22
Q

define incomplete abortion

A

partial expulsion of some but not all of the POC before 20 weeks GA

23
Q

define inevitable abortion

A

no expulsion of products, but vaginal bleeding and dilation of the cervix such that a viable pregnancy is unlikely

24
Q

define threatened abortion

A

any vaginal bleeding before 20 weeks without dilation of the cervix or expulsion of the POC (normal pregnancy with bleeding)

25
Q

define missed abortion

A

death of the embryo or fetus before 20 weeks with complete retention of all POC

26
Q

what causes most SAs in the first trimester

A

60-80% are associated with abnormal chromosomes –> 95% of these are due to errors in maternal gametogenesis –> in these 95%, autosomal trisomy is the most common abnormality

other factors that increase risk as infections, maternal anatomic defects, immunologic factors, environmental exposures, endocrine factors

large number of first trimester abortions have no obvious cause

27
Q

how do you diagnose first trimester abortions

A

most present with vaginal bleeding

can also have cramping, abdo pain, decreased symptoms of pregnancy

rule out shock and febrile illness on exam

look for other sources of bleeding on pelvic exam and for changes in cervix suggestive of inevitable abortion

28
Q

what lab tests should you order in a SA

A

antibody screen
B-hCG
CBC
blood type

29
Q

ddx of first trimester bleeding

A 
SA
postcoital bleeding
ectopic pregnancy
vaginal or cervical lesions or lacerations 
extrusion of molar pregnancy
non pregnancy causes
30
Q

surgical tx of first trimester incomplete or missed abortion

A

dilation and curretage

if hemodynamically unstable, often require urgent surgical management

31
Q

medical tx of first trimester incomplete or missed abortions

A

progtaglandins like misoprostol with or without mifepristone to induce cervical dilation, uterine contractions and expulsion of the pregnancy

32
Q

how should a threatened abortion be managed

A

followed for continued bleeding and placed on pelvic rest with nothing per vagina

often, bleeding will resolve

these patients are at increased risk of preterm labour and PPROM

all Rh- women who have preterm vaginal bleeding should get rhoGAM to prevent isoimmunization

33
Q

define second trimester abortion

A

between 12-20 weeks

34
Q

what causes second trimester abortions

A 
infection
maternal uterine or cervical anatomic defects
maternal systemic disease
exposure to fetotoxic agents
trauma

abnormal chromosomes are NOT a common cause of late abortions

35
Q

how are incomplete or missed late second trimester abortions managed

A

usually with surgical dilation and evacuation

between 16-24 weeks, either D&E or labor induced with high doses of oxytocin or prostaglandins

D&E is more self limited, but aggressive dilation is required–> significant risk of uterine perforation and cervical lacerations

36
Q

how is dilation achieved in a D&E

A

with laminaria (seaweed rods placed in the cervix the day before that expand as they absorb water thus dilating the cervix)

37
Q

how do you distinguish pre term labor from incompetent cervix

A

PTL starts with contractions leading to cervical change

incompetent cervix describes painless dilation of the cervix

38
Q

what % of all second trimester abortions are caused by incompetent cervix

A

15%

39
Q

risk factors for cervical incompetence

A

surgery or other cervical trauma is most common (ie. D&C, loop electrocautery excisional procedure–LEEP, or cervical conization)

can also be caused by genetic abnormality of cervix

may have no known risk factors

40
Q

how are patients with viable pregnancies (above 24 weeks) with suspected pre term labour or incompetent cervix managed

A

betamethasone to decrease risk of prematurity

manage expectantly with strict bed rest

41
Q

what is cerclage

A

option for management of incompetent cervix in previable pregnancy

the cerclage is a suture placed vaginally around the cervix either at cervico-vaginal juction (McDonald) or at internal os (Shirodkar)

intent is to close the cervix

complications include ROM, PTL and infection

can place elective cerclage at 12-14 weeks GA if incompetent cervix was suspected cause of pregnancy loss in previous pregnancy –> maintained until 36-38 weeks is possible

both types assoc with 85-90% successful pregnancy rate

42
Q

what is a “habitual aborter”

A

a woman who has had three or more consecutive SAs

less than 1% of the population has been diagnosed with recurrent pregnancy loss

43
Q

what is the risk of SA after one prior SA?
after 2?
after 3?

A

after 1–> 20-25%

after 2–> 25-30%

after 3–> 30-35%

44
Q

etiology of recurrent pregnancy loss

A

generally similar to SAs

chromosomal abnormalities
maternal systemic disease
maternal anatomic defects
infection

45
Q

what % of patients with recurrent pregnancy loss have antiphospholipid antibody syndrome (APA)

A

15%

(another group are thought to have a luteal phase defect and lack an adequate level of progesterone to maintain the pregnancy)

46
Q

how should you evaluate a woman with recurrent pregnancy loss

A

obtain karyotype of both patents

examine maternal anatomy (i.e with hysterosalpingogram–HSG)

screening tests for hypothyroid, DM, APA syndrome, hypercoagulability, SLE

test serum progesterone in luteal phase of menstrual cycle

culture of cervix, vagina and endometrium

47
Q

what lab tests do you order to evaluate a woman with recurrent pregnancy loss

A 
lupus anticoagulant 
factor V leiden 
ANA
anticardiolipin antibody
Russell viper venom
antithrombin III
protein S and C
prothrombin G20210A mutation test

level of serum progesterone

48
Q

how do you treat patients with APA syndrome

A

low dose aspirin

49
Q

how do you treat patients with thrombophilia

A

SQ heparin (either LMWH or unfractionated)

50
Q

what % of patients with three prior consecutive SAs will have a normal pregnancy after?

A

2/3

Obstetrics and Gynecology (21 decks)

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