Early Pregnancy Loss, Ectopic Pregnancy and Rh Immunization Flashcards
What is the first trimester?
What is the second trimester?
What is the third trimester?
When is the estimated date of confinement?
1st: FDLMP to 13 wks
2nd: 14 wks to 27 wks
3rd: 28-42 wks
EDC = 40 wks after FDLMP
Abortion =
Pre-term delivery
Full-term delivery
Postdates
Abortion = < 20 wks
Pre-term delivery: 20-36 wks
Full-term delivery: 37-42 wks
Postdates: > 42 wks
Negative hCG level =
Level at time of expected menstruation =
How does hCG increase during pregnancy?
When does it peak?
When is gestational sac seen?
Neg. = < 5 mlU/L titer
100 IU/L at time of expected menstruation
hCG doubles every 2 days.
Peaks at 10 wks at 1000K IU/L.
Gestational sac seen at 1500-2000 mIU/L with TVUS (“discriminatory level”).
When is the fetal pole seen? What level of hCG?
5 wks or hCG level of 5200 mIU/L
What changes in hCG confirms an abnormal IUP or ectopic pregnancy?
Abnormal rise in hCG of less than 53% in the first 48 hrs.
What is a biochemical pregnancy?
The presence of hCG 7-10 days after ovulation, but in women where menstruation occurs normally.
What 2 things will decrease the risk of fetal loss in the US?
Live appropriately grown fetus at 8 wks and + cardiac activity
Spontaneous abortion (SAB) abortus:
When do they occur?
What is the most common cause of SABs in that time period?
What defines the type of SAB? (2)
Fetus lost before 20 wks gestation and is less than 500 g.
80% of SABs occur in the first trimester.
Chromosomal abnormalities (45 XO -Turner’s is most common, also trisomy 16)
Any or all of the products of conception have passed
Whether the cervix is dilated
Presentation of a threatened abortion:
What us the outcome?
What is the treatment?
Vaginal bleeding and closed cervix
25-50% eventually result in loss of the pregnancy
Treatment is expected management
Presentation of inevitable abortion:
What is the outcome?
Vaginal bleeding and the cervix is partially dilated
Loss is inevitable
Presentation of incomplete abortion:
How much of the products of conception are passed?
What is the treatment?
Vaginal bleeding, lower abdominal cramping and a dilated cervix
Passage of some, but not all products
Suction D&C
How much of the products of conception are passed in a complete abortion?
What is the outcome?
What is the treatment?
Passage of all products of conception (fetus and placenta) with a closed cervix
Resolution of pain, bleeding and pregnancy symptoms
No treatment needed
What is a missed abortion?
What are the symptoms?
What might develop as a consequence? What is the treatment/course of action?
Fetus has expired and remains in the uterus
Asymptomatic
Coagulation problems may develop. Check fibrinogen levels weekly until SAB occurs or proceed with suction D&C.
Presentation of septic abortion:
What causes it?
What is the treatment?
Fever, uterine and cervical motion tenderness, purulent discharge, hemorrhage and renal failure (rare).
Retained infected products of conception.
IV abx and proceed with suction D&C.
What is a blighted ovum?
What is seen on US?
What are 3 modes of therapy?
Fertilized egg develops a placenta but NO embryo.
US reveals empty gestational sac
Expectant management
Medical management (misoprostol)
D&C
What “general maternal factors” can play a role in recurrent abortions? (4)
Infection - treated with abx
Smoking and EtOH
Medical disorders - DM, HTN, SLE, anti-phospholipid antibody syndrome and hypercoagubility conditions (Factor V leiden def., antithrombin II, protein C and S, etc.)
Maternal age
What is the definition of “recurrent abortions”?
What does it exclude? (2)
3 successive SAB
Excludes ectopic and molar pregnancies
What are 2 “local maternal factors” that can play a role in recurrent abortions?
Uterine abnormalities: congenital, fibroids, intrauterine synechiae (Asherman syndrome)
Cervical incompetence: 2nd trimester loss, “painless dilation” and delivery. Treated with cervical cerclage.
What is the major fetal factor for recurrent abortions?
Chromosomal abnormalities
What is the recommendation of karyotyping for parents?
What is the purpose?
Recommended for both parents (3% risk that one parent is an asymptomatic carrier of something bad).
Purpose is to detect balanced reciprocal or Robertsonian translocations that could be passed onto the fetus unbalanced.
What is the most common immunological disease contributing to recurrent abortions?
What is the treatment?
Anti-phospholipid syndrome
Prophylactic dose of heparin and low dose aspirin
What is the pathogenesis of an ectopic pregnancy?
What is a complication?
Trophoblasts implant into the mucosa of the fallopian tube and rapidly erode through the underlying blood vessels.
If bleeding is extensive enough, it can create a pressure necrosis of the overlying tubal serosa resulting in acute rupture and hemoperitoneum.
What is the leading cause of maternal death in the first trimester?
Ectopic pregnancy
What are risk factors for ectopic pregnancy?
History of tubal infection: Gonorrhea, Chlamydia
Previous ectopic
Previous tubal surgery/sterilization
In utero exposure to DES
Pregnancy with concurrent IUD
IVF or ART
Smoking
Classic triad of ectopic pregnancy
Prior missed menses
Vaginal bleeding
Lower abdominal pain
Most common clinical presentation of ectopic pregnancy?
“Possible ectopic pregnancy”
“Possible ectopic pregnancy” symptoms:
Exam of the uterus:
US findings:
Mild non-specific symptoms - abdominal pain, vaginal spotting or bleeding.
Uterus is soft and normal size.
Thickened endometrial stripe. Ectopic is rarely seen.
“Probable ectopic pregnancy” symptoms:
GU exam findings (3)
US findings:
Lower abdominal/pelvic pain and vaginal spotting or bleeding.
Abdominal, adnexal tenderness and/or cervical motion tenderness.
Variable amounts of fluid in the culdesac. Might see ectopic.
“Acutely ruptured ectopic pregnancy” symptoms:
GU exam findings (3)
US findings:
Severe abdominal pain and dizziness (secondary to intraperitoneal hemorrhage).
Distended and acutely tender abdomen
Cervical motion tenderness
Signs of hemodynamic instability
Empty uterus with significant free fluid
Quantitative hCG levels:
hCG doubles in 48 hrs
hCG inappropriately rises (<53%)
Falling hCG concentration
Discriminatory zone
hCG doubles in 48 hrs: normal pregnancy
hCG inappropriately rises (<53%): ectopic pregnancy or nonviable IUP
Falling hCG concentration: blighted ovum, resolving ectopic or abnormal pregnancy
Discriminatory zone: hCG is 1500-2000 IU/L should see intrauterine gestational sac
What can transvaginal US reveal?
IUP
Extrauterine pregnancy
Non-diagnostic: follow closely with serial hCG and give precautions
Repeat US when hCG is in discriminatory zone (1500-2000)
MOA of methotrexate
Who is a good candidate?
How often should hCG be checked?
What must be avoided?
Folic acid antagonist which inhibits DNA synthesis and cell replication.
Compliant women who are hemodynamically stable with an unruptured ectopic.
Check hCG 4-7 days
- if hCG decrease by 15%, continue to follow weekly until negative (MTX is working)
- if hCG levels plateau or fall slowly, give another dose of MTX
- if patient is symptomatic or if hCG titers increase then proceed with surgery
Folate-containing vitamins
What is expectant management of ectopic pregnancy include?
What level of hCG suggests the ectopic pregnancy will not rupture?
Serial hCG testing and strong ectopic precautions.
Up to 80% of ectopics with hCG levels of <1000 mIU/mL will not rupture and resolve spontaneously.
Patients for laparotomy
Hemodynamically stable
Patients for laparoscopy
Stable patients
What is a salpingostomy?
Procedure done with a parallel incision to the axis of the tube over the site of implantation and incision is left open to heal by secondary intention
How often should hCG be repeated postop?
3-7 days
What genetic makeup puts a woman at risk for rhesus isoimmunization?
What antigen makes a women Rh+/Rh-?
Rh- mom with a Rh+ fetus
D antigen makes woman Rh+
When should RhoGAM be given?
At 28 wks and within 72 hrs after delivery of a Rh D+ infant
What is the Kleinhauer-Betke test?
It identifies fetal RBCs in maternal blood. It determines if additional RhoGAM is needed.
What is used as a screening tool to estimate the severity of fetal hemolysis in Rh disease?
Maternal Rh-antibody titers
If maternal Rh-antibody titers are less than 1:8, what is suggested? When should titers be rechecked?
The fetus is not likely in serious jeopardy. Recheck titers every 4 wks.
If maternal Rh-antibody titers are > 1:16, what is needed?
Further eval to detect hydrops and Doppler studies of the MCA.
Most valuable tool for detecting feta anemia in isoimmunization:
Peak systolic velocity in the fetal MCA
What is seen on US in fetal hydrops?
Ascites, pleural effusion, pericardial effusion, skin/scalp edema, polyhydramnios
What suggests severe fetal anemia in isoimmunization?
What is the treatment?
Hct is below 30% or 2 SDs below mean Hct for gestational age.
Intrauterine transfusions between 18-35 wks. and fresh group O, Rh- packed RBCs.
