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Endo/Repro > Ectopic Pregnancy Loss and Rh Isoimmunization > Flashcards

Ectopic Pregnancy Loss and Rh Isoimmunization Flashcards

1
Q

What is the first trimester?

A
  • First day of last menstrual period to 13 + 6 weeks
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2
Q

What is the second trimester?

A
  • 14-27 weeks
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3
Q

What is the third trimester?

A
  • 28-42 weeks
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4
Q

What is an abortion?

A
  • <20 weeks
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5
Q

What is a preterm delivery?

A
  • 20-36+6 weeks
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6
Q

What is a full term delivery?

A
  • 37-42 weeks
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7
Q

What is tested with hCG?

A
  • First detected in serum 6-8 days after ovulation
  • Titer <5 IU/L is negative
  • Urine pregnancy test can detect 25 IU/L
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8
Q

What is the hCG levels when the gestational sac can be seen?

A
  • 1500-2000 ml IU/L with transvaginal ultrasound
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9
Q

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

A
  • Seen around 5 weeks or at hCG levels of 5200 mLU/L
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10
Q

What is a biochemical pregnancy?

A
  • The presence of hCG 7-10 days after ovulation but in whom menstruation occurs when expected
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11
Q

What is the expected risk of fetal loss if there is a live, appropriately grown fetus at 8 weeks gestations?

A
  • Decreased to 2 %
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12
Q

What is a spontaneous abortion?

A
  • Fetus lost before 20 weeks gestation and less than 500 gram
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13
Q

When do most spontaneous abortions occur?

A
  • First trimester
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14
Q

What are some causes for spontaneous abortions?

A
  • Chromosome abnormalities like Turner and trisomies
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15
Q

What are the different types of spontaneous abortions defined by?

A
  • Any or all of the products of conception have passed

- The cervix is dilated or not

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16
Q

What is seen in a threatened abortion?

A
  • Vaginal bleeding and closed cervix
  • 25-50% of threatened abortions eventually result in loss of pregnancy
  • Treatment is expected management
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17
Q

What is seen in an inevitable abortion?

A
  • Vaginal bleeding and the cervix is partially dilated

- Loss is inevitable

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18
Q

What is seen in an incomplete abortion?

A
  • Vaginal bleeding, cramping lower abdominal pain with dilated cervix
  • Passage of some but not all of the products of conception
  • Treatment is usually suction D&C
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19
Q

What is seen in a complete abortion?

A
  • Passage of all products of conception (fetus and placenta) with a closed cervix
  • With resolution of pain, bleeding, and pregnancy symptoms
  • No treatment needed
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20
Q

What is seen in a missed abortion?

A
  • Fetus has expired and remains in uterus
  • Usually no symptoms
  • Coagulation problems may develop, check fibrinogen levels weekly until SAB occurs or proceed with a D&C
  • Expectant management vs misoprostol vs D&C
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21
Q

What is seen in a septic abortion?

A
  • Fever, uteine, and cervical motion tenderness, purulent discharge, hemorrhage, and rarely renal failure
  • Retained infected products of conception
  • Start IV antibiotics
  • Proceed with suction D&C
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22
Q

What is a blighted ovum?

A
  • “Anembryonic gestation”
  • Gestational sac too large to not have embryo (>25mm)
  • Fertilized egg develops a placenta but no embryo
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23
Q

What is an induce or elective abortion?

A
  • Roe v Wade 1973

- Suction D&C is most common in first trimester

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24
Q

What is the treatment for a blighted ovum?

A
  • Expectant management
  • Medical management (misoprostol)
  • D&C
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25
Q

What is a suction D&C?

A
  • Uses suction to remove products of conception

- Surgical D&C is a more successful primary therapy than medical or expectant managment

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26
Q

What are recurrent abortions?

A
  • Defined as three successive SAB

- Excluding ectoping and molar pregnancies

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27
Q

What infections may cause recurrent abortions?

A
  • Mycoplasma
  • Chlamydia
  • Listeria
  • Toxoplasma
  • Can be treated with antibiotics
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28
Q

How does smoking and ETOH affect recurrent abortions?

A
  • Both are associated with increase in SAB’s

- 4 fold increase if smoking 20 cigs per day and consume 7 alcoholic beverages per day

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29
Q

What are some medical disorders that may affect recurrent abortions?

A
  • Diabetes
  • Hypothyroidism
  • Systemic lupus erythematosus
  • Antiphospholipid ab syndrome
  • Hypercoagulable state
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30
Q

What hypercoagulability sources may cause recurrent abortions?

A
  • Factor V leiden
  • Antithrombin III
  • Protein C & S
  • Prothrombin G20210A
  • ANA
  • Anticardiolipin antibody
  • Methylenetetrahydrofolate reductase
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31
Q

How can maternal age affect the incidence of recurrent abortions?

A
  • As age increases, the percentage of pregnancies decreases as spontaneous abortions increases causing the percentage of spontaneous abortions to increase
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32
Q

What are some uterine abnormalities that could cause recurrent abortions?

A
  • Congenital anomalies
  • Submucosal fibroids, uterine septum
  • Intrauterine synechiae (Asherman syndrome)
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33
Q

How does cervical incompetence cause recurrent abortions?

A
  • Usually seen with second trimester loss

- “Painless dilation” and delivery

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34
Q

What are some risk factors for cervical incompetence?

A
  • Uterine anomalies
  • Previous trauma
  • History of conization
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35
Q

What is the treatment for cervical incompetence?

A
  • Cervical cerclage
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36
Q

How could chromosomal abnormalities cause recurrent abortions?

A
  • One parent may be the carrier of a genetically balance translocation that may become unbalanced when given to the fetus
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37
Q

What is the most common immunologic cause for recurrent abortions?

A
  • Antiphospholipid syndrome

- Associated with recurrent fetal loss, preeclampsia, venous and arterial thromboembolism and stroke

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38
Q

What tests are done if there is a suspected immunologic cause for recurrent abortions?

A
  • Lupus anticoagulant
  • Anticardiolipin antibodies (IgG and IgM)
  • Anti-B2-glycoprotein 1 antibodies (IgG and IgM)
39
Q

What is the treatment for an immunologic cause of recurrent abortions?

A
  • Prophylactic dose of heparin and low dose aspirin
40
Q

What is an ectopic pregnancy?

A
  • Gestation that implants outside of the uterus

- Trophoblasts implant into the mucosa of the fallopian tube and rapidly erodes through the underlying blood vessel

41
Q

What can an ectopic pregnancy cause?

A
  • If bleeding is extensive, it can create a pressure necrosis of the overlying tubal serosa resulting in acute rupture and significant hemoperitoneum
  • Leading cause of maternal death in first trimester
42
Q

What are some risk factors for ectopic pregnancy?

A
  • History of tubal infection (gonorrhea or chlamydia)
  • Previous ectopic
  • Previous tubal reconstructive surgery or sterilizations
  • In utero exposure to DES
  • Pregnancy with concurrent IUD
  • IVF or ART
  • Cigarette smoking
43
Q

What is the classic triad for ectopic pregnancy?

A
  • Prior missed menses
  • Vaginal bleeding
  • Lower abdominal pain
44
Q

What does a possible ectopic pregnancy look like?

A
  • Patient has often been seen once before diagnosis and follows serial B-hCG and TVUS
  • Has mild nonspecific symptoms like abdominal pain, vaginal spotting or bleeding
45
Q

What does the PE show in a possible ectopic pregnancy?

A
  • Uterus is soft and normal size
  • May not feel any adnexal mass
  • Ultrasound shows thickened endometrial stripe and rarely shows ectopic pregnancy
46
Q

What are the symptoms of a probable ectopic pregnancy?

A
  • Lower abdominal pain/pelvic pain and vaginal spotting/bleeding
47
Q

What does a PE show in a probable ectopic pregnancy?

A
  • Abdominal, adnexal tenderness, and cervical motion tenderness
48
Q

What may be seen on ultrasound in a probable ectopic pregnancy?

A
  • Variable amounts of fluid in the cul de sac

- May see ectopic

49
Q

What are the symptoms of an acutely ruptured ectopic pregnancy?

A
  • Severe abdominal pain and dizziness secondary to intraperitoneal hemorrhage
50
Q

What does a PE show in an acutely ruptured ectopic pregancy?

A
  • Distended and acutely tender abdomen with guarding and rebound
  • Usually has cervical motion tenderness
  • Signs of hemodynamic instability (diaphoresis, tachycardia, LOC)
51
Q

What may an ultrasound show in an acutely ruptured ectopic pregnancy?

A
  • Reveal an empty uterus with significant amount of free fluid
52
Q

What are some diagnostic tests for ectopic pregnancy?

A
  • Quantitative hCG
  • It double every 48 hours for a normal pregnancy
  • If hCG inappropriately rises, it is consistent with ectopic or nonviable IUP
53
Q

What may a falling hCG level indicate?

A
  • Blighted ovum
  • Spontaneously resolving ectopic
  • Abnormal pregnancy
54
Q

What can a transvaginal ultrasound reveal?

A
  • IUP
  • Extrauterine pregnancy
  • Or be nondiagnostic (nothing inside or outside uterus)
55
Q

What is the medical management of an ectopic pregnancy?

A
  • Given to women who are hemodynamically stable with an unruptured ectopic
  • Methotrexate is given
56
Q

What is the procedure when giving methotrexate to a women with an ectopic pregnancy?

A
  • Dosage is 50 mg/M2 IM x 1
  • Check hCG levels on days 4 and 7
  • If decrease, watch weekly
  • If plateau, then give another dose
  • If increase, then go to surgical intervention
  • Instruct patients to avoid vitamins with folate
57
Q

What are some relative contraindications to methotrexate?

A
  • IUP
  • Breastfeeding
  • Overt immunodeficiency
  • Alcoholism/alcoholic liver disease
  • Preexisting blood dyscrasias
  • Known sensitivity to MTX
  • Active pulmonary disease
  • Peptic ulcer disease
  • Hepatic, renal, or hematologic dysfunction
  • Ruptured ectopic
  • Noncompliant patient
58
Q

What are some relative contraindications to methotrexate?

A
  • Gestational sac ≥ 3.5 cm
  • Embryonic cardiac motion
  • hCG levels > 6000
59
Q

What is the expectant management for ectopic pregnancy?

A
  • May qualify if they are stable and symptoms are spontaneously resolving
  • Follow closely with serial hCG testing and give strong ectopic precautions
  • Up to 80% of ectopics with hCG levels <1000 will not rupture and will resolve spontaneously
60
Q

When is a laparotomy performed?

A
  • Patients who are hemodynamically unstable
61
Q

When is a laparoscopy performed?

A
  • Stable patients
62
Q

When is a salpingectomy performed?

A
  • Removal of entire fallopian tube

- Recommended when significant damage to the tube is noted

63
Q

When is a salpingostomy performed?

A
  • Incision is made parallel to the axis of the tube over the site of implantation and incision is left open to heal by secondary intention
  • Better in long term tubal function
64
Q

When is a salpingotomy performed?

A
  • Incision to sutured closed
65
Q

What is rhesus isoimmunization?

A
  • An immunologic disorder that occurs in a pregnant, RH- women carrying an Rh+ fetus
66
Q

What does rhesus isoimmunization result in?

A
  • Results in the mothers immune system to produce antibodies to the fetal Rh antigen, which can cross the placenta and destroy fetal RBCs resulting in serious hemolytic disease in the fetus/newborn
67
Q

What antigens are in the Rh complex?

A
  • CDE

- cde

68
Q

What antigen does a Rh positive woman have?

A
  • Rh D antigen
69
Q

What antigen does a Rh negative woman have?

A
  • Lacks Rh D antigen
70
Q

What is the incidence of the RhD antigens?

A
  • 8% of African Americans are Rh neg
  • 1-2% of asians and native americans are Rh neg
  • 15% of caucasians are Rh neg
71
Q

What is Rh sensititization?

A
  • Initial response to Rh antigen is the production of IgM antibodies for a short period of time followed by IgG antibodies that freely cross the placenta and enter the fetal circulation
72
Q

What happens if the fetus has Rh antigen?

A
  • Antibodies will bind to the fetal RBC’s antigenic sites and cause hemolysis
  • Mild hemolysis the fetus can compensate by increasing erythropoiesis
  • Severe hemolysis may lead to profound anemia resulting in hydrops fetalis from CHF and intrauterine fetal death
73
Q

What is given to prevent the maternal production of antibodies?

A
  • Prophylactic Rh immune globulin (RhoGAM)
74
Q

When does most fetomaternal hemorrhage occur?

A
  • During routine uncomplicated vaginal deliveries
75
Q

What are some factors that increase the volume of fetomaternal hemorrhage?

A
  • C section
  • Placenta previa or abruption
  • Manual extraction of placenta
76
Q

What can fetomaternal hemorrhage lead to?

A
  • Isoimmunization
77
Q

What are some causes of Rh isoimmunization occuring in the antepartum stage?

A
  • Spontaneous, threatened, or induced abortions
  • Abdominal trauma
  • Ectopic pregnancy
  • Obstetrical procedures (CVS and amniocentesis)
78
Q

What does RhoGAM do?

A
  • Decreases the availability of the RhD to the maternal immune system
  • Has reduced the rate of isoimmunization dramatically
79
Q

What can a single dose of RhoGAM do?

A
  • Prevent isoimmunization after an exposure up to 30ml of RhD + whole blood or 15 ml fetal RBCs
80
Q

Who is given RhoGAM?

A
  • Administer in a Rh-neg woman who is not Rh D-alloimmunized
  • At 28 weeks and within 72 hours after delivery of a Rh D positive infant
  • Or with any other factor that could increase the chance of fetomaternal hemorrhage (ECV, amniocentesis, CVS< MVA)
81
Q

What is the Kleinhauer-Betke test?

A
  • Identifies fetal red blood cells in maternal blood

- Will determine if additional RhoGAM is necessay

82
Q

What should happen to every women during their first prenatal appointment?

A
  • Get a ABO blood group
  • Rh D type
  • Antibody screen
83
Q

What should be done if a woman is positive for anti-D antibodies?

A
  • Test father of baby, if he is Rh neg than no worries as the baby will be Rh neg
  • If he is homozygous pos, all fetuses will be pos and could be affected
  • If he is heterozygous pos, then 50% will be Rh neg and 50% will be Rh pos
84
Q

What are the maternal Rh antibody titers for? What do they indicate?

A
  • Used as a screening tool to estimate the severity of fetal hemolysis in Rh disease
  • Less than 1:8 usually indicated the fetus is not in serious jeopardy; recheck in 4 weeks
  • > 1:16 requires further evaluation with detailed ultrasound to detect hydrops and doppler studies of the MCA
85
Q

What is fetal hydrops?

A
  • Ascites
  • Pleural effusion
  • Pericardial effusion
  • Skin or scalp edema
  • Polyhydramnios
86
Q

What does the doppler assessment do?

A
  • Looks at peak systolic velocity in the fetal middle cerebral artery
  • Most valuable tool for detecting fetal anemia
87
Q

How often should the doppler assessment be done?

A
  • Every 1-2 weeks from 18-35 weeks
88
Q

What was used before doppler studies were used?

A
  • Amniotic fluid bilirubin analysis was used
  • Measured the amniotic fluid bilirubin levels excreted by the fetus using spectral analysis which correlates with cord blood hemoglobin of the newborn at birth
89
Q

What is the main disadvantage to the amniotic fluid analysis?

A
  • Amniocentesis can increase the severity of fetomaternal hemorrhage and worsen the disease
90
Q

What is the management for severe fetal anemia?

A
  • If Hct is below 30% or 2 standard deviations below mean Hct for the gestational age, give intrauterine transfusions between 18-35 weeks
91
Q

What is given to deal with severe fetal anemia?

A
  • Fresh, group O, Rh-negative packed RBCs
  • <20 weeks intraperitoneal transfusions
  • Intravascular transfusions into umbilical vein are preferred secondary to therapeutic effects are more rapid and reliable
92
Q

What else is done in the management of isoimmunization other than ultrasound and MCA doppler?

A
  • Antepartum testing - twice weekly NST or biophysical profiles
  • Serial growth scans every 3-4 weeks
93
Q

What is better at 35 weeks, transfusions or preterm delivery?

A
  • Preterm delivery may have better benefits
94
Q

What is the risk of hydrops in subsequent pregnancies?

A
  • 90%

- Each subsequent pregnancy will likely manifest more severe reactions and at earlier stages

Endo/Repro (31 decks)

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