First Trimester Bleeding -Nelson Flashcards
What are the features of a threatened abortion?
Uterine bleeding and contractions but the cervical os is CLOSED
What is the difference between an inevitable abortion and an incomplete abortion?
inevitable=NO POCs (products of conception) have been passed
incomplete=some but not all products of conception have passed
What are the possible etiologies of spontaneous abortions?
- intrinsic abnormalities of the fetus (genetic, structural)
- maternal medical conditions (thrombophilias, uterine anomalies, diabetes)
- environmental exposure (radiation)
what percentage of threatened abortions survive? What is the risk of congenital anomalies?
50%
no higher risk for congenital anomalies
What are the risks associated with an inevitable abortion?
infection, hypoplastic lung, amniotic band formation
What must be done in a patient who experiences an incomplete abortion? What are the risks?
evacuation of the uterus completely (medically by misoprostol or surgically with a vacuum, suction)
risks of infection and hemorrhage
What is the most difficult abortion diagnosis to make clinically?
complete abortion (hard to say if the whole placenta was lost or not
What should be done in a septic abortion?
IV antibiotics and fluid resuscitation
rapid evacuation of the uterine contents (high risk for perforation, denuding endometrium, hemorrhage)
Is it ok for a woman to attempt to get pregnant immediately after an abortion?
sure! she doesn’t need to allow time for grieving and there is no increased risk of recurrent loss
What is a complete mole?
Sperm (1 or 2) fertilize an egg without DNA –> genotype 46 xx
greatest malignant potential
What is a partial mole?
egg fertilized by 2 sperm or by 1 sperm that duplicated itself
genotype 69, XXY or 92 XXXY
What are the findings associated with a molar pregnancy?
swollen chorionic villi–> grow into clusters “grapes”, absence of fetal vessels, hyperplasia of syncytiotrophoblasts and cytotrophoblasts
exaggerated signs and symptoms of pregnancy:
- nausea and vomiting
- hyperthyroidism
- larger than normal
ultrasound: “snowstorm” appearance
abnormally high hCG levels (>100K) in a complete mole
abnormally low hCG levels in a partial mole
What should be included in the evaluation of a molar pregnancy?
- Evaluate for thyroid storm, DIC, HTN, pulmonary compromise
- CXR
- Baseline hCG titer, CBC
- Evacuate uterus –>
- Increased risk for hemorrhage intra-op
- Pulmonary insufficiency post-op
- Post-op-monitor serial hCG levels for 12 months (should decline logarithmically)
- poor prognosis with brain or liver involvement
What is an ectopic pregnancy?
implantation of the embryo outside the uterine cavity (93-97% in the fallopian tube)
What are risk factors for ectopic pregnancy?
- factors that alter tubal morphology (prior ectopic, PID, tubal ligation)
- factors that alter embryo transport (progestin contraception, IUD, DES)
What are the 3 presentations of a tubal pregnancy?
- acute shock
- probably ectopic
- possible ectopic vs threatened abortion, missed abortion or early pregnancy
What will happen to the hCG and progesterone levels in an ectopic pregnancy?
hCG levels plateau or fall
progesterone levels may be low –> absence of trophoblastic signaling
vaginal bleeding from inadequately supported endometrium and invasion of trophoblasts into fallopian tube
What are some signs of acute shock in a tubal pregnancy? What is the management?
Complains of severe abdominal pain, dizziness, LOC, shoulder pain. Hemodynamically unstable. Rebound tenderness, CMT
Emergency surgery***
What will the ultrasound findings be in a ruptured ectopic pregnancy?
No intrauterine pregnancy (thickened endometrial stripe)
± adnexal mass
Free fluid in cul-de-sac
What is the management of a probable ectopic pregnancy?
laparoscopic evaluation and removal (less successful than open surgery but less costly)
What is a pregnancy of unknown location? How should it be managed?
Missed menses
Complains of adnexal pain and/or vaginal spotting.
Hemodynamically stable, enlarged or soft uterus, no or slight CMT, questionable adnexal mass or tenderness
management: serial hCG, titers, progesterone, US localization when hCG titers +
At what rate do hCG titers normally rise? What is considered abnormal?
double every 1.98 days in a normally progressing pregnancy
abnormal= < 53% increase in 48 hours
What lab result is diagnostic of a nonviable pregnancy? What are the treatment options?
hCG rise <53% in 2 days
ectopic (60%)
or
abnormal intrauterine pregnancy (40%)
uterine evacuation or methotrexate without intrauterine evacuation
When is methotrexate excluded in the treatment an ectopic pregnancy? (11)
Hemodynamically unstable
Unable to comply with follow-up visit schedule or to return if complications develop
Immunocompromised (WBC < 3000)
Anemia (HBG < 8)
active plum disease
renal compromise (creatinine >1.3)
hepatic compromise (elevated LFTs)
bleeding diatheses
thrombocytopenia
ectopic pregnancy >3.5-4 cm
hCG > 10,000-15,000
What are some of the follow-up instructions for methotrexate treated patients?
- Avoid sexual intercourse (may rupture ectopic pregnancy)
- Avoid sun exposure (photosensitivity reaction possible)
- Avoid consuming gas-producing foods: leeks, beans, corn, cabbage (abdominal bloating may worsen)
- No alcohol
- No ibuprofen, naproxen, aspirin or other non-steroidal antiinflammatory agents
- No penicillin
- No prenatal vitamins or folate supplements
- return to clinic in 4 days to repeat tests
- may experience pain and cramping –> be aware that tube may rupture and would need surgery
What are the predictors of methotrexate failure?
- Adnexal fetal cardiac activity
- Diameter of gestational mass > 4cm
- Initial hCG > 5000 mIU/ml
- Free fluid in cul-de-sac
- Rapid increase (> 50%/48 hours) hCG prior to methotrexate
- Continued rapid rise of hCG on methotrexate
