Early Pregnancy Loss, Ectopic pregnancies and RH Isoimmunizations

Question 1

1-3 trimesters

Answer 1

• 1- FDLMP- 13 (+6) wks
• 2- 14 wks- 27 (+6) wks
• 3- 28 wks- 42 wks

Question 2

abortion, preterm delivery, full term delivery

Answer 2

• abortion- < 20 wks
• preterm- 20-36 +6 wks
• fullterm- 37-42 wks

Question 3

vaginal bleeding

Answer 3

• pregnancy (40%)

- HCG!!

Question 4

HCG

Answer 4

• first detected 6-8 days after ovulation
• level dbls every 2 days (peaks at 10 wks at 100,000)
• gestational sac can be seen at 1500-2000 with TVUS!!!!

Question 5

discriminatory level

Answer 5

-HCG levels of 1500-2000 will see a gestational sac!!

Question 6

if abnormal rise in HCG < 53% in 48 hrs

Answer 6

-abnormal IUP or ectopic pregnancy

Question 7

Spontaneous abortions

Answer 7

< 20 wks, less than 500 gm

• 80% occur in 1st trimester
• most common cause- chromosome abnormalities- 45XO most common; trisomy is most common class (trisomy 16)

Question 8

types of SAB defined by

Answer 8

• any or all of products of conception have passed

- cervix is dilated or not

Question 9

Threatened abortion

Answer 9

• vaginal bleeding and closed cervix
• 25-50% result in loss of pregnancy
• tx- expected management

Question 10

Inevitable abortion

Answer 10

• vaginal bleeding and cervix is partially dilated

- loss is inevitable

Question 11

Incomplete abortion

Answer 11

• vaginal bleeding, cramping lower abd pain, dilated cervix
• passage of some products of contraception
• tx- suction D&C

Question 12

Complete abortion

Answer 12

• passage of all products of contraception, closed cervix

- no tx

Question 13

Missed abortion

Answer 13

fetus has expired and remains in uterus

Question 14

Septic Abortion

Answer 14

• fever, uterine and cervical motion tenderness, purulent discharge, hemorrhage, rarely renal failure
• retained infected products of contraception
• start IV abx
• suction D&C

Question 15

Blighted Ovum

Answer 15

(anembryonic gestation)

-empty gestational sac- no embr

Question 16

Suction D&C- used for

Answer 16

-remove products of conception

Question 17

Recurrent abortions

Answer 17

3 successive SAB

• general maternal factors
• local maternal factors
• fetal factors
• chromosomal factors- most common!!!
• immunologic factors

Question 18

Recurrent abortions- general maternal factors

Answer 18

• infection
• smoking and ETOH
• medical- antiphospholipid ab syndrome
• maternal age

Question 19

Recurrent abortions- local maternal factors

Answer 19

• uterine abnormalities

- cervical incompetence- painless dilation!!

Question 20

Recurrent abortions- fetal factors

Answer 20

-chromosomal- 45XO (turner) and most common class is trisomy (16)

Question 21

Recurrent abortions- immunologic factors

Answer 21

-antiphospholipid syndrome!!

Question 22

ectopic pregnancy

Answer 22

• fallopian tube (98%)

- leading cause of maternal death in first trimester

Question 23

ectopic pregnancy- risk factors

Answer 23

• tubal infection
• prev ectopic
• tubal reconstructive surgery
• DES
• IUD
• IVF or ART
• cig smoking

Question 24

ectopic pregnancy- classic triad

Answer 24

• prior missed menses
• vaginal bleeding
• lower abd pain

Question 25

Possible ectopic pregnancy

Answer 25

• most common
• abd pain, vaginal spotting/bleeding
• follow serial B-HCG and TVUS!!

Question 26

Probable ectopic pregnancy

Answer 26

• abd pain, vaginal spotting/bleeding
• adnexal tenderness!!
• US- may see ectopic

Question 27

Acutely Ruptured ectopic pregnancy

Answer 27

• surgical emergency
• severe abd pain, dizziness (hemorrhage)
• acutely ender abd
• hemodynamic instability!!
• US- empty uterus, free fluid

Question 28

ectopic pregnancy- dx tests

Answer 28

• HCG inappropriately rises (<53%)
• discriminatory zone- HCG of 1500-2000- should see intrauterine gest sac
• TVUS (when in discriminatory zone)

Question 29

ectopic pregnancy- medical mangement

Answer 29

when hemodynamically stable w/ an unruptured ectopic

• Methotrexate!!
• recheck HCG

Question 30

ectopic pregnancy- expectant management

Answer 30

• if stable, and sx’s are spontaneously resolving

- follow HCG

Question 31

ectopic pregnancy- surgical management

Answer 31

• laparotomy- if hemodynamically unstable!!
• laparoscopy- if stable
• salpingectomy, salpingostomy, salpingotomy

Question 32

Rhesus isoimmunization

Answer 32

• Rh-neg women carring an Rh-positive fetus!!!
• mother’s ab’s cross placenta, attach to fetal Rh antigen- cause hemolysis
• 15% of caucasions are Rh D negative!

Question 33

Rh sensitization

Answer 33

-prod of IgM ab’s- then IgG ab’s which cross placenta

Question 34

Fetomaternal hemorrhage resulting in isoimmunization

Answer 34

• fetal blood enters into maternal circulation

- routine uncomplicated vaginal deliveries- most common

Question 35

prevention of Rh isoimmunization

Answer 35

RhoGAM (anti-D Ig)

• dec RhD to maternal immune system
• administer in a Rh-neg women at 28 wks and within 72 hrs after delivery of a Rh D positive infant

Question 36

Fetal hydrops- US

Answer 36

• ascites
• pleural effusion
• pericardial effusion
• skin or scalp edema
• polyhydramnios

Question 37

detect fetal anemia

Answer 37

• doppler assessment of fetal MCA

- perform q 1-2 wks from 18-35 wks

Question 38

severe fetal anemia

Answer 38

• HCT < 30%

- intrauterine infusions!- group O Rh-neg packed RBCs