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Endrocrine & Reproduction II Exam #1 > Early Pregnancy Loss, Ectopic Pregnancy and Rh Immunization > Flashcards

Early Pregnancy Loss, Ectopic Pregnancy and Rh Immunization Flashcards

1
Q

What is the first trimester?

What is the second trimester?

What is the third trimester?

When is the estimated date of confinement?

A

1st: FDLMP to 13 wks
2nd: 14 wks to 27 wks
3rd: 28-42 wks

EDC = 40 wks after FDLMP

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2
Q

Abortion =

Pre-term delivery

Full-term delivery

Postdates

A

Abortion = < 20 wks

Pre-term delivery: 20-36 wks

Full-term delivery: 37-42 wks

Postdates: > 42 wks

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3
Q

Negative hCG level =

Level at time of expected menstruation =

How does hCG increase during pregnancy?
When does it peak?
When is gestational sac seen?

A

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”).

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4
Q

When is the fetal pole seen? What level of hCG?

A

5 wks or hCG level of 5200 mIU/L

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5
Q

What changes in hCG confirms an abnormal IUP or ectopic pregnancy?

A

Abnormal rise in hCG of less than 53% in the first 48 hrs.

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6
Q

What is a biochemical pregnancy?

A

The presence of hCG 7-10 days after ovulation, but in women where menstruation occurs normally.

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7
Q

What 2 things will decrease the risk of fetal loss in the US?

A

Live appropriately grown fetus at 8 wks and + cardiac activity

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8
Q

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)

A

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

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9
Q

Presentation of a threatened abortion:

What us the outcome?

What is the treatment?

A

Vaginal bleeding and closed cervix

25-50% eventually result in loss of the pregnancy

Treatment is expected management

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10
Q

Presentation of inevitable abortion:

What is the outcome?

A

Vaginal bleeding and the cervix is partially dilated

Loss is inevitable

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11
Q

Presentation of incomplete abortion:

How much of the products of conception are passed?

What is the treatment?

A

Vaginal bleeding, lower abdominal cramping and a dilated cervix

Passage of some, but not all products

Suction D&C

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12
Q

How much of the products of conception are passed in a complete abortion?

What is the outcome?

What is the treatment?

A

Passage of all products of conception (fetus and placenta) with a closed cervix

Resolution of pain, bleeding and pregnancy symptoms

No treatment needed

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13
Q

What is a missed abortion?

What are the symptoms?

What might develop as a consequence? What is the treatment/course of action?

A

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.

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14
Q

Presentation of septic abortion:

What causes it?

What is the treatment?

A

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.

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15
Q

What is a blighted ovum?

What is seen on US?

What are 3 modes of therapy?

A

Fertilized egg develops a placenta but NO embryo.

US reveals empty gestational sac

Expectant management
Medical management (misoprostol)
D&C

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16
Q

What “general maternal factors” can play a role in recurrent abortions? (4)

A

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

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17
Q

What is the definition of “recurrent abortions”?

What does it exclude? (2)

A

3 successive SAB

Excludes ectopic and molar pregnancies

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18
Q

What are 2 “local maternal factors” that can play a role in recurrent abortions?

A

Uterine abnormalities: congenital, fibroids, intrauterine synechiae (Asherman syndrome)

Cervical incompetence: 2nd trimester loss, “painless dilation” and delivery. Treated with cervical cerclage.

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19
Q

What is the major fetal factor for recurrent abortions?

A

Chromosomal abnormalities

20
Q

What is the recommendation of karyotyping for parents?

What is the purpose?

A

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.

21
Q

What is the most common immunological disease contributing to recurrent abortions?

What is the treatment?

A

Anti-phospholipid syndrome

Prophylactic dose of heparin and low dose aspirin

22
Q

What is the pathogenesis of an ectopic pregnancy?

What is a complication?

A

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.

23
Q

What is the leading cause of maternal death in the first trimester?

A

Ectopic pregnancy

24
Q

What are risk factors for ectopic pregnancy?

A

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

25
Q

Classic triad of ectopic pregnancy

A

Prior missed menses

Vaginal bleeding

Lower abdominal pain

26
Q

Most common clinical presentation of ectopic pregnancy?

A

“Possible ectopic pregnancy”

27
Q

“Possible ectopic pregnancy” symptoms:

Exam of the uterus:

US findings:

A

Mild non-specific symptoms - abdominal pain, vaginal spotting or bleeding.

Uterus is soft and normal size.

Thickened endometrial stripe. Ectopic is rarely seen.

28
Q

“Probable ectopic pregnancy” symptoms:

GU exam findings (3)

US findings:

A

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.

29
Q

“Acutely ruptured ectopic pregnancy” symptoms:

GU exam findings (3)

US findings:

A

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

30
Q

Quantitative hCG levels:

hCG doubles in 48 hrs
hCG inappropriately rises (<53%)
Falling hCG concentration
Discriminatory zone

A

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

31
Q

What can transvaginal US reveal?

A

IUP

Extrauterine pregnancy

Non-diagnostic: follow closely with serial hCG and give precautions
Repeat US when hCG is in discriminatory zone (1500-2000)

32
Q

MOA of methotrexate

Who is a good candidate?

How often should hCG be checked?

What must be avoided?

A

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

33
Q

What is expectant management of ectopic pregnancy include?

What level of hCG suggests the ectopic pregnancy will not rupture?

A

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.

34
Q

Patients for laparotomy

A

Hemodynamically stable

35
Q

Patients for laparoscopy

A

Stable patients

36
Q

What is a salpingostomy?

A

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

37
Q

How often should hCG be repeated postop?

A

3-7 days

38
Q

What genetic makeup puts a woman at risk for rhesus isoimmunization?

What antigen makes a women Rh+/Rh-?

A

Rh- mom with a Rh+ fetus

D antigen makes woman Rh+

39
Q

When should RhoGAM be given?

A

At 28 wks and within 72 hrs after delivery of a Rh D+ infant

40
Q

What is the Kleinhauer-Betke test?

A

It identifies fetal RBCs in maternal blood. It determines if additional RhoGAM is needed.

41
Q

What is used as a screening tool to estimate the severity of fetal hemolysis in Rh disease?

A

Maternal Rh-antibody titers

42
Q

If maternal Rh-antibody titers are less than 1:8, what is suggested? When should titers be rechecked?

A

The fetus is not likely in serious jeopardy. Recheck titers every 4 wks.

43
Q

If maternal Rh-antibody titers are > 1:16, what is needed?

A

Further eval to detect hydrops and Doppler studies of the MCA.

44
Q

Most valuable tool for detecting feta anemia in isoimmunization:

A

Peak systolic velocity in the fetal MCA

45
Q

What is seen on US in fetal hydrops?

A

Ascites, pleural effusion, pericardial effusion, skin/scalp edema, polyhydramnios

46
Q

What suggests severe fetal anemia in isoimmunization?

What is the treatment?

A

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.

Endrocrine & Reproduction II Exam #1 (17 decks)

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