Ectopic, Abortion, HTN, 3rd Trimester Bleeding - PANCE Pearls Flashcards
Where is the most common implantation site in ectopic pregnancy?
Fallopian tube (amopulla)
What are high risk factors for ectopic pregnancy?
previous abdominal or tubal surgery (adhesions) PID previous ectopic history of tubal ligations endometriosis IUD use assisted reproduction
What are intermediate risk factors for ectopic pregnancy?
infertility
history of genital infections
multiple partners
Classic triad in the clinical presentation for ectopic pregnancy
unilateral pelvic/abdominal pain
vaginal bleeding
amenorrhea
What do you want to differate from ectopic pregnancy in a patient presenting with unilateral pain, vaginal bleeding, and amenorrhea?
threatened abortion
What are signs of shock in a ruptured ectopic pregnancy?
syncope, tachycardia, hypotension
What are the signs of ruptured ectopic pregnancy?
severe abdominal pain, dizziness, nausea, vomitting
What will you see on physical exam for ectopic pregnancy?
cervical motion tenderness, adnexal mass, +/- uterine enlargement
How does the B-hCG in ectopic pregnancy differ from normal?
should double q24-48 hours
doesn’t double in ectopic (rises < 66% expected)
What do you do if B-hCG initial value is < 1,500?
repeat q2-3 days
absence of gestational sac on transvaginal ultrasound with B-hCG levels > 5,000 could indicate
ectopic pregnancy or nonviable intrauterine pregnancy (IUP)
What procedure can be done to diagnose ectopic pregnancy?
laparoscopy
MOA of methotrexate
destroys trophoblastic tissue (disrupts cell multiplication)
What circumstances would you treat an ectopic pregnancy with?
hemodynamically stable, early gestation (< 4cm), B-hCG < 5,000, no fetal tones
When would methotrexate be contraindicated?
ruptured ectopic and h/o TB
what would indicate successful treatment with methotrexate?
B-hCG drops >15% between 2 successive draws
Treatment for stable ectopic pregnancy if the mother is Rh negative
RhoGAM
1st choice in treating unstable ectopic pregnancy
laparoscopic salpingostomy
Spontaneous abortion is the termination of pregnancy before
20 weeks
Which type of abortion is the only associated with possible fetal viability?
treatened
MC etiology for spontaneois abortion
fetal chromosomal abnormalities
MC cause of first trimester bleeding and pregnancy may be viable or abortion may follow
threatened abortion
Patient presents with bloody vaginal discharge, profuse spotting, uterine contractions and uterus size is compatible with gestational date
threatened abortion
Treatment for threatened abortion
supportive - rest at home and return to ER is symptoms persist or passage of POC
check B-hCG for doubling
What is inevitable abortion?
progressive cervix dilation (> 3cm)
no POC expelled
pregnancy is not salvageable
Patient presents with moderate bleeding > 7 days and moderate to severe uterine cramping
inevitable abortion
Management of inevitable abortion
dilation and evacuation (2nd trimester) suction curettage (1st trimester)
Cervical os dilates and some POC are expelled and some are retained - patient presents with heavy bleeding, moderate to severe cramping, boggy uterus on exam
incomplete abortion
Management of incomplete abortion
D&E (1st trimester)
pitocin
Patient expells all POC from the uterus and the cervical os is usually closed - pain, cramps, bleeding subsidie and uterus returns to prepregnancy size
complete abortion
Fetal demise but still remains in the uterus - loss of pregnancy symptoms and +/- brown discharge
missed abortion
Management for missed abortion
D&E (1st trimester)
Misotrostol
Retained POC becomes infected and spreads to uterus and other organs - cervical motion tenderness, foul brown discharge, fever, chills, spotting/heavy bleed
septic abortion
Management of septic abortion
D&E to remove POC
broad spectrum antibiotics
Medical method for elective abortion
Mifepristone → misoprostol 24-72 hours after (safe up to 9 weeks)
methotrexate → misoprostol 3-7 days later (safe up to 7 weeks)
MOA of mifepristone
anti-progestin
MOA of methotrexate
antimetabolite (folic antagonist)
MOA of misoprostol
prostaglandin that cuases uterine contractions
Surgery can be performed for elective abortion up to ____ from LMP
24 weeks
Surgical procedure for elective abortion during 4-12 weeks gestation
dilation and curettage
Surgical procedure for elective abortion if it is > 12 weeks gestation
dilation and evacuation
HTN without proteinuria after 20 weeks gestation and resolves 12 weeks post partum
gestational HTN
HTN + proteinuria +/- edema after 20 weeks gestation (may be earlier in multiple gestation or molar pregnancy)
Preeclampsia
Preeclampsia + seizures or coma
eclampsia
HTN before 20 weeks gestation or before pregnancy - persists > 6 weeks post partum
chronic/prexisting HTN
HTN in gestational HTN is thought to be due to
arteriolar vasocontriction
Management of gestational HTN
may withhold meds
+/- hydralazine or labetalol
Clinical manifestation of preeclampsia
headache, vision symptoms, fetal growth restriction, edema
Mild preeclampsia is what two criteria
> 140/90 on 2 separate occasions (less than 1 week apart)
proteinuria (>300mg/24hr)
Severe preeclampsia is
BP >160/110 Proteinuria >5g/24hr oliguria thrombocytopenia +/- DIC HELLP syndrome
What is HEELP syndrome?
Hemolytic anemia, Elevated Liver enzymes, Low Platelets
If a patient presents with mild preeclampsia after 37 weeks gestation, what is the best management?
delivery
If patient presents with mild preeclampsia at <34 weeks, what is the best management?
conservative (daily weights, BP and dipstick weekly, bedrest)
if elective delivery → may need steroids to mature lungs
If patient presents with severe preeclampsia what is the best management?
prompt delivery + magnesium sulfate
What BP meds are approved in acute severe HTN?
hydralazine, labetalol, nifedipine
Clinical presentation of eclampsia
abrupt tonic-clonic seizures 1-2 min → postical state
hyperreflexia
First line treatment for seizures in eclampsia
magnesium sulfate
Treatment for eclampsia once the monther is stabilized
deliver the fetus
Mild HTN
Moderate HTN
Severe HTN
> 140/90
150/100
160/110
How should you monitor a pregnant patient with mild chronic HTN?
q 2-4 weeks → weekly @ 34 - 36 weeks → deliver @ 37 weeks
Treatment of choice for moderate/severe HTN in pregnant patients
Methyldopa (1st line) → labetalol (BB), hydralazine, nifedipine (CCB)
What HTN meds should be avoided in pregnant patients?
ACE inhibitors and diuretics
abnormal placena placement on or close to the cervical os
placenta previa
placenta covers cervix ahead of fetal presenting part
partial placenta previa
placenta totally covers the cervical os
complete placenta previa
placenta is within 2-3 cm of cervical os
marginal placenta previa
Patient presents in third trimester with sudden onset of painless bright red bleeding → no abdominal pain present and the uterus is soft and nontender
placenta previa
What will the fetal HR be with placenta previa?
normal
How do you diagnose placenta previa?
pelvic US to localize placenta
Premature separation of placenta from the uterine wall after 20 weeks gestation → bloody vaginal discharge (ranked I, II, III)
abruptio placentae
Patient presents with third trimester bleeding that is continuous and dark red → severe abdominal pain, rigid uterus
abruptio placentae
In abruptio placentea, how will the fetus present?
bradycardia → fetal distress because it interferes with fetal oxigenation
How do you diagnose abruptio placentae?
pelvic US
Fetal vessels transverse the fetal membranes over the cervical os → membranes rupture → painless vaginal bleed results
vasa previa
How will fetus present with vasa previa?
bradycardic → fetal distress
Management for vasa previa
immediate C-section
How can you stabilize a fetus in the instance of placenta previa?
tocolytics or amniocentesis
MOA of magnesium sulfate in pregnancy
inhibits uterine contractions (preterm labor)
In partial or marginal placenta previa, how should you deliver the baby?
vaginal
In complete placenta previa how should you deliver the baby?
C-section
How do you manage a patient with abruptio placentae?
hospitalize to hemodynamically stablize and deliver imediately
what is a complication of abruptio placentae?
may lead to DIC (disseminated intravascular coagulation)
Risk factors for placenta previa
multiparity, increasing age, smoking
risk factors for abruptio placentae
MC is maternal HTN
smoking, EtOH, cocaine, folate deficiency, high parity, increased age, trauma, chorioamnionitis
2 most common causes of third thrimester bleeding
abruptio placentae and placenta previa
Abruptio →
Previa →
Abdominal pain
Painless