Early Pregnancy Loss, Ectopic Pregnancy, Rh Isoimmunization (Moulton) Flashcards
1) When is first trimester?
2) Second Trimester?
3) Third Trimester?
1) First day of Last menstrual period- 13 weeks +6 days
2) 14 weeks-27 weeks+ 6 days
3) 28-42 weeks
Estimated date of confinement (delivery) is ___ weeks after first day of last menstrual period.
40
1) Preterm delivery occurs at a range of ___ weeks.
2) Full term delivery occurs at a range of ___ weeks.
1) 20-36
3) 37-42
Up to 40% of women will have some vaginal bleeding during early pregnancy known as ___.
Implantation Bleeding
1) What is the Discriminatory level of hCG?
2) What does it reveal?
1) 1500-2000
2) Gestational Sac
If abnormal rise in hCG of less than 53% in 48 hrs, this confirms an ____?
Ectopic pregnancy
__1__ pregnancy refers to the presence of hCG 7-10 days after ovulation but in whom menstruation occurs when expected.
Majority of this type of pregnancy will result in __2__.
1) Biochemical
2) Miscarriage
*Implantation occured, but so did miscarriage early on
Spontaneous abortions are characterized by the fetus being lost before __1__ weeks gestation and less than __2__ grams.
3) 80% of SAB’s occur in which trimester?
1) 20 weeks
2) 500 grams
3) First
1) What are most common cause of first trimester SAB’s?
2) What is the most common type of this abnormality?
Trisomy class is the most common class of this occurring with trisomy __3__ being the most common.
1) Chromosome Abnormalities
2) 45 XO (Turner syndrome)
3) Trisomy 16
__1__ is a type of SAB characterized by vaginal bleeding and a closed cervix
__2__ is a type of SAB characterized by vaginal bleeding and the cervix is partially dilated.
__3__ is a type of SAB characterized by vaginal bleeding, cramping with lower abdominal pain, and the cervix is dilated leading to passage of some but not all of the products of conception?
__4__ is a type of SAB characterized by passage of all products of conception (fetus and placenta) with a closed cervix.
__5__ is a type of SAB characterized by fetus has expired and remains in the uterus which may result in coagulation problems.
__6__ is a type of SAB characterized by motion tenderness, purulent discharge, hemorrhage, and rarely renal failure along with retained infected products of conception.
__7__ is a type of SAB characterized by gestational sac too large to not have embryo.
1) Threatened abortion
2) Inevitable abortion
3) Incomplete abortion
4) Complete Abortion
5) Missed abortion
6) Septic Abortion
7) Anembryonic Gestation (Blighted ovum)
* fertilized egg implantation occurs in uterus but NO gestational sac forms
With majority of the SAB types, what should you proceed with?
Suction Dilation and curettage
Anembryonic Gestation (Blighted ovum) is when the fertilized egg develops what?
Placenta but no embryo
Recurrent abortions are defined as?
This excludes?
1) Three successive SABs
2) Ectopic and molar pregnancies
What infectious agents are general maternal factors for recurrent abortions?
Chlamydia
Listeria
Mycoplasma
Toxoplasma
CLMT
1) What substances are general maternal factors for recurrent abortions?
2) What is the most common immunologic factor for recurrent abortions?
1) Smoking and alcohol
2) Antiphospholipid Antibody Syndrome
What uterine abnormalities are local maternal factors for recurrent abortions?
1) Congenital issues from DES exposure
2) Submucosal fibroids, uterine septum
3) Intrauterine synechiae (Asherman syndrome)
CSI
What local maternal factor for recurrent abortions is usually seen with second trimester loss and presents with painless dilation and delivery.
Cervical incompetence
Cervix is incompetent and dilates and lets go of fetus
What should you test for with immunologic factors for recurrent abortions?
1) Lupus anticoagulant
2) Anticardiolipin Ab (IgG and IgM)
3) Anti-B2-glycoprotein 1 Ab (IgG and IgM)
Lupus
Anti-CAB
Anti B2
Lupin took a CAB to a B2
What is the prophylactic treatment with immunologic factors for recurrent abortions?
Heparin and low dose aspirin
With ectopic pregnancy, the ____ implant into the mucosa of the fallopian tube and rapidly erode through to the underlying blood vessels.
Trophoblasts
In regards to ectopic pregnancy, why is it important to have a high index of suspicion and diagnose early?
Leading cause of maternal death in the first trimester
A risk factor for ectopic pregnancy is a history of tubal infection with ___ or ___ which can cause the tube to become distended with purulent material, clubbed fibria, and torous.
Gonorrhea or chlamydia
*PID
Previous ___ or ___ are risk factors for ectopic pregnancy.
Tubal reconstructive surgery or sterilizations
What is the classic triad of ectopic pregnancy?
What are the 3 presentations of ectopic pregnancy?
1) Prior missed menses
2) Vaginal bleeding
3) Lower abdominal pain
Possible, Probable, Acutely Ruptured
__1__ ectopic pregnancy is the most common clinical presentation for ectopic pregnancy and
- Result in mild non specific findings such as abdominal pain and vaginal spotting along with
- Physical exam findings such as the uterus being soft/normal size.
__2__ is an ultrasound finding seen in this type of presentation.
1) Possible
2) Thickened endometrial stripe (Arias-Stella reaction)
__1__ ectopic pregnancy presents with
- Lower abdominal pain and vaginal bleeding along with
- Physical findings such as adnexal tenderness and/or vertical motion tenderness.
Variable amounts of fluid in the __2__ is an ultrasound finding seen in this type of presentation.
1) Probable
2) Cul de sac
__1__ ectopic pregnancy is a
- surgical emergency
- symptoms: severe abdominal pain and dizziness (secondary to intraperitoneal hemorrhage)
- Physical findings such as distended abdomen, cervical motion tenderness, and hemodynamic instability (diaphoresis, tachycardia, loss of consciousness).
__2__ with a significant amount of __2__ is an ultrasound finding seen in this type of presentation.
1) Acutely ruptured
2) Empty uterus; free fluid
1) What is the diagnostic finding for Ectopic Pregnancy?
2) What diagnostic hCG finding for blighted ovum?
1) hCG inappropriately rises
2) Falling hCG levels
In the surgical management of ectopic pregnancy
1) Laparotomy is for which patients?
2) Laparoscopy is the preferred approach for __2__ patients.
1) Hemodynamically unstable
2) Stable
In the surgical management of ectopic pregnancy
1) What is recommended when significant damage to the tube is noted?
2) What helps with long term tubal function and is performed by making incision parallel to axis of tube over site of implantation and incision is left open to heal?
1) Salpingectomy (removal of entire fallopian tube)
2) Salpingostomy (just an incision)
What results in the mother’s immune system to produce antibodies to the fetal Rh antigen, which can cross the placenta and destroy fetal red blood cells resulting in serious hemolytic disease in the fetus/newborn?
Rhesus isoimmunization
Rhesus isoimmunization occurs in a pregnant, Rh __1__ women carrying an Rh __2__ fetus.
1) Negative
2) Positive
The Rh complex is made up of a number of antigens, women who carry which antigen are RH positive?
Rh D antigen
Initial response to Rh antigen is the production of __1__ antibodies for a short period of time, followed by __2__ antibodies that freely cross the placenta & enter the fetal circulation.
If the fetus has Rh antigen, then the antibodies will bind to the fetal __3__ antigenic sites and cause hemolysis.
Severe hemolysis may lead to profound anemia resulting in __4__.
1) IgM
2) IgG
3) Red blood cells
4) Hydrops fetalis
* (And thus dystocia b/c huge baby= bad passenger P)
Prophylactic ____ is used to prevent maternal production of antibodies to Rh.
Rh immune globulin (RhoGAM)
Cesarean section, placenta previa or abruption and manual extraction of placenta can all cause ____ which can then lead to isoimmunization.
Fetomaternal hemorrhage
Who should be administered with RhoGAM?
When should it be given?
1) Rh-negative woman
2) At 28 weeks and also within 72 hours after delivery of a Rh D positive infant
1) Which test is used to identify fetomaternal hemorrhage?
2) What does it look for?
3) It will determine if additional __3__ is necessary.
1) Kleinhauer-Betke
2) Fetal RBCs in maternal blood
3) RhoGAM
If a Rh negative women whose anti-D antibody titers are positive (Rh D sensitized) and the father of the baby is Rh-D negative, what should be done?
Why?
1) No further workup or treatment is necessary
2) The fetus will be Rh negative
1) If a Rh negative women whose anti-D antibody titers are positive (Rh D sensitized)
Father of the baby is Rh-D positive which results in homozygosity for D antigen, how will it be passed?
2) If this scenario results in heterozygosity for D antigen?
1) All fetuses will be Rh positive
2) 50% of the children will be Rh negative and 50% Rh positive
If a maternal Rh- Antibody titer is less than 1:8 this usually indicates that?
If titers are more than 1:16 this requires what?
1) The fetus is fine
2) US to detect hydrops
Because when Rh-Ab amount is increased,
Goes to fetal blood and binds leading to hemolytic anemia
Hemolytic anemia leads to hydrops fetalis
What US findings point towards fetal hydrops?
Skin/scalp edema Ascites Pleural effusion Pericardial Effusion Polyhydramnios
SAPPP
Doppler assessment of peak systolic velocity in the fetal ____ in cm/sec is the most valuable tool for detecting What?
1) Middle cerebral artery
2) Fetal Anemia
Hematocrit below 30% or 2 standard deviations below the mean Hct for the gestational age is suggestive of?
Severe fetal anemia
In the management of isoimmunization, intrauterine transfusions usually performed between 18-35 weeks using fresh group ___ packed red blood cells.
O, Rh negative
