First Trimester Bleeding -Nelson

Question 1

What are the features of a threatened abortion?

Answer 1

Uterine bleeding and contractions but the cervical os is CLOSED

Question 2

What is the difference between an inevitable abortion and an incomplete abortion?

Answer 2

inevitable=NO POCs (products of conception) have been passed

incomplete=some but not all products of conception have passed

Question 3

What are the possible etiologies of spontaneous abortions?

Answer 3

• intrinsic abnormalities of the fetus (genetic, structural)
• maternal medical conditions (thrombophilias, uterine anomalies, diabetes)
• environmental exposure (radiation)

Question 4

what percentage of threatened abortions survive? What is the risk of congenital anomalies?

Answer 4

50%

no higher risk for congenital anomalies

Question 5

What are the risks associated with an inevitable abortion?

Answer 5

infection, hypoplastic lung, amniotic band formation

Question 6

What must be done in a patient who experiences an incomplete abortion? What are the risks?

Answer 6

evacuation of the uterus completely (medically by misoprostol or surgically with a vacuum, suction)

risks of infection and hemorrhage

Question 7

What is the most difficult abortion diagnosis to make clinically?

Answer 7

complete abortion (hard to say if the whole placenta was lost or not

Question 8

What should be done in a septic abortion?

Answer 8

IV antibiotics and fluid resuscitation

rapid evacuation of the uterine contents (high risk for perforation, denuding endometrium, hemorrhage)

Question 9

Is it ok for a woman to attempt to get pregnant immediately after an abortion?

Answer 9

sure! she doesn’t need to allow time for grieving and there is no increased risk of recurrent loss

Question 10

What is a complete mole?

Answer 10

Sperm (1 or 2) fertilize an egg without DNA –> genotype 46 xx

greatest malignant potential

Question 11

What is a partial mole?

Answer 11

egg fertilized by 2 sperm or by 1 sperm that duplicated itself

genotype 69, XXY or 92 XXXY

Question 12

What are the findings associated with a molar pregnancy?

Answer 12

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

Question 13

What should be included in the evaluation of a molar pregnancy?

Answer 13

• 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

Question 14

What is an ectopic pregnancy?

Answer 14

implantation of the embryo outside the uterine cavity (93-97% in the fallopian tube)

Question 15

What are risk factors for ectopic pregnancy?

Answer 15

• factors that alter tubal morphology (prior ectopic, PID, tubal ligation)
• factors that alter embryo transport (progestin contraception, IUD, DES)

Question 16

What are the 3 presentations of a tubal pregnancy?

Answer 16

• acute shock
• probably ectopic
• possible ectopic vs threatened abortion, missed abortion or early pregnancy

Question 17

What will happen to the hCG and progesterone levels in an ectopic pregnancy?

Answer 17

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

Question 18

What are some signs of acute shock in a tubal pregnancy? What is the management?

Answer 18

Complains of severe abdominal pain, dizziness, LOC, shoulder pain. Hemodynamically unstable. Rebound tenderness, CMT

Emergency surgery***

Question 19

What will the ultrasound findings be in a ruptured ectopic pregnancy?

Answer 19

No intrauterine pregnancy (thickened endometrial stripe)

± adnexal mass

Free fluid in cul-de-sac

Question 20

What is the management of a probable ectopic pregnancy?

Answer 20

laparoscopic evaluation and removal (less successful than open surgery but less costly)

Question 21

What is a pregnancy of unknown location? How should it be managed?

Answer 21

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 +

Question 22

At what rate do hCG titers normally rise? What is considered abnormal?

Answer 22

double every 1.98 days in a normally progressing pregnancy

abnormal= < 53% increase in 48 hours

Question 23

What lab result is diagnostic of a nonviable pregnancy? What are the treatment options?

Answer 23

hCG rise <53% in 2 days

ectopic (60%)
or
abnormal intrauterine pregnancy (40%)

uterine evacuation or methotrexate without intrauterine evacuation

Question 24

When is methotrexate excluded in the treatment an ectopic pregnancy? (11)

Answer 24

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

Question 25

What are some of the follow-up instructions for methotrexate treated patients?

Answer 25

• 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

Question 26

What are the predictors of methotrexate failure?

Answer 26

• 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