Early Pregnancy Complications Flashcards
what is an ectopic pregnancy
one that implants outside the uterine cavity
implantation in the fallopian tubes occurs in 95-99% of patients
where is the most common site of ectopic pregnancy implantation?
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
what is the rate of ectopic pregnancy
1 in 100 of all pregnancies
why is the rate of ectopic pregnancy increasing
secondary to increase in assisted fertility, STIs, and PID
who should be evaluated for an ectopic pregnancy
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
what % of all maternal deaths in the US are accounted for by ruptured ectopics
6%
what are the risk factors for ectopic pregnancy
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)
how do you diagnose ectopic pregnancy
history
physical
lab test
US
typical history for ectopic pregnancy
unilateral pelvic or lower abdo pain
vaginal bleeding
typical exam for ectopic pregnancy
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
classic findings on lab tests for ectopics
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
what do you see on US in an ectopic pregnancy
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
after what B-hCG level should you see a fetal heartbeat on US
above 5000 mIU/mL
how do you manage a ruptured ectopic pregnancy
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
how do you manage an unruptured ectopic
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
what is a single dose regiment for methotrexate
50 mg/m2 dose of IM methotrexate
define spontaneous abortion
“miscarriage”
pregnancy that ends before 20 weeks GA
how common are SAs
occur in 15-20% of all pregnancies
may be even higher because losses at 4-6 weeks are often confused with late menses
how do you define the types of SAs
by whether any or all of the products of conception have passed and whether the cervix is dilated
define abortus
fetus lost before 20 weeks GA or less than 500g
define complete abortion
complete expulsion of all POC before 20 weeks GA
define incomplete abortion
partial expulsion of some but not all of the POC before 20 weeks GA
define inevitable abortion
no expulsion of products, but vaginal bleeding and dilation of the cervix such that a viable pregnancy is unlikely
define threatened abortion
any vaginal bleeding before 20 weeks without dilation of the cervix or expulsion of the POC (normal pregnancy with bleeding)
define missed abortion
death of the embryo or fetus before 20 weeks with complete retention of all POC
what causes most SAs in the first trimester
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
how do you diagnose first trimester abortions
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
what lab tests should you order in a SA
antibody screen
B-hCG
CBC
blood type
ddx of first trimester bleeding
SA postcoital bleeding ectopic pregnancy vaginal or cervical lesions or lacerations extrusion of molar pregnancy non pregnancy causes
surgical tx of first trimester incomplete or missed abortion
dilation and curretage
if hemodynamically unstable, often require urgent surgical management
medical tx of first trimester incomplete or missed abortions
progtaglandins like misoprostol with or without mifepristone to induce cervical dilation, uterine contractions and expulsion of the pregnancy
how should a threatened abortion be managed
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
define second trimester abortion
between 12-20 weeks
what causes second trimester abortions
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
how are incomplete or missed late second trimester abortions managed
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
how is dilation achieved in a D&E
with laminaria (seaweed rods placed in the cervix the day before that expand as they absorb water thus dilating the cervix)
how do you distinguish pre term labor from incompetent cervix
PTL starts with contractions leading to cervical change
incompetent cervix describes painless dilation of the cervix
what % of all second trimester abortions are caused by incompetent cervix
15%
risk factors for cervical incompetence
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
how are patients with viable pregnancies (above 24 weeks) with suspected pre term labour or incompetent cervix managed
betamethasone to decrease risk of prematurity
manage expectantly with strict bed rest
what is cerclage
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
what is a “habitual aborter”
a woman who has had three or more consecutive SAs
less than 1% of the population has been diagnosed with recurrent pregnancy loss
what is the risk of SA after one prior SA?
after 2?
after 3?
after 1–> 20-25%
after 2–> 25-30%
after 3–> 30-35%
etiology of recurrent pregnancy loss
generally similar to SAs
chromosomal abnormalities
maternal systemic disease
maternal anatomic defects
infection
what % of patients with recurrent pregnancy loss have antiphospholipid antibody syndrome (APA)
15%
(another group are thought to have a luteal phase defect and lack an adequate level of progesterone to maintain the pregnancy)
how should you evaluate a woman with recurrent pregnancy loss
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
what lab tests do you order to evaluate a woman with recurrent pregnancy loss
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
how do you treat patients with APA syndrome
low dose aspirin
how do you treat patients with thrombophilia
SQ heparin (either LMWH or unfractionated)
what % of patients with three prior consecutive SAs will have a normal pregnancy after?
2/3
