Gynecological Emergencies/First Trimester Bleeding Flashcards
Nonpregnancy related causes of first trimester bleeding
polyps, vaginal trauma/laceration, STI
number one ddx on first trimester bleeding
ectopic pregnancy! then spontaneous abortion, implantation bleed, ot GTN
risk factors for sponatenous abortion
- age
- previous miscarriage
- chronic conditions
- uterine or cervical problems
- smoking, alcohol and illicit drugs
- weight
- invasice prenatal tests
How does the cervix differ in a threatened vs incomplete spontaneous abortion?
threatened: cervix still closed.
Always rule out ___ ___ on PE when evaluating a first trimester bleed
acute abdoment
Role of beta HCG during investigations of first trimester bleeding
Role of Beta HCG: increases 2x every 48-96 hours in a viable pregnancy. Quantitative value correlates with gestational age and ultrasound findings.
If BHCG>2000 → should see a viable pregnancy on transvaginal U/S.
If serum BHCG <2000 and U/S inconclusive:
- falling bHCG= non-viable or ectopiv
doubling BHCG= viable OR ectopic (dependent on US)
- plateau or slow rising = ectopic.
role of ultrasound during investigations of first trimester bleeding
Role of Transvaginal Ultrasound
Determines if: intrauterine to extrauterine pregnancy, viability, dating, adnexal masses.
If beta HCG >2000, and no intrauterine pregnancy → ectopic pregnancy.
Maagement of spontaneous abortion (expectant and surgical and medical management)
Expectant management: follow closely if stable, assume complete if tissue passed and no further bleeding or cramping. There is no role for repeat U/S unless increased symptoms.
Dilation and Curettage: in OR with IV sedation. Risk of infection, bleeding and perforation
Medical Management; misoprostol, dose via pill → 70-90% expulsion rate.
WHen can you assume complete passage of a sponatenous abortion?
assume complete if tissue passed and no further bleeding or cramping. There is no role for repeat U/S unless increased symptoms.
Ectopic Pregnancy Definition: pregnancy implanted outside of uterine cavity→ 95% occur in __ __ (85% in __ portion), 1% is ovarian.
Definition: pregnancy implanted outside of uterine cavity→ 95% occur in fallopian tube (85% in ampullary portion), 1% is ovarian.
Factors that aid in the diagnosis of an ectopic pregnancy (6)
- nothing in uterus on US
- high beta HCG
- pain+++/shock/hemorrage/acute abdomen
- cystic adnexal mass
- fetal heart rate outside of uterine cavity
- fluid in cul de sac
risk factors for ectopic pregnancy
Previous ectopic pregnancy.
Prior fallopian tube surgery.
Previous pelvic or abdominal surgery.
Certain sexually transmitted infections (STIs)
Pelvic inflammatory disease.
Endometriosis.
treatment of ectopic pregnancy
methotrexate or surgical: salpingostomy, laparoscopic appraoch
criteria to use methotrexate as a method of management of ectopic pregnancy
Treatment: methotrexate, avoid folic acid.
Must be hemodynamically stable, no renal/hepatic disease, small ectopic pregnancy, no fetal HR, bHCG<5000, pt must be able to have follow up
GTN definition
Definition: spectrum of disease processes arising from the placenta (abnormal trophoblastic proliferation)
Symptoms: 1st trimester vaginal bleeding, hyperemesis ( high BhCG)
