IUI Pregnancy Flashcards
Pregnancy
Goal/Dream of many patients
Testing for pregnancy~ 2 weeks after TIC/IUI
Home pregnancy test (HPT)->positive/negative
Blood test (recommended)
Quantitative Beta HCG
It is used toconfirmpregnancy and to track the progression of thepregnancy in early stages
Pregnancy test results- what dates for 1st and 2nd beta tests?
At Spring we check the first beta HCG level attwo weeksfrom TIC or IUI/TDI
Anything greater than 5 is considered positivehowever
~2 weeks post IUI/TIC you would expect a level of 50 or greater..
Gestation~4 weeks
If the result is positive recheck in ~ 2-4 days (avoidweekends and holidays).
Result should increase by 66% every two days
Original Value x 1.66 =Minimum Value 2 days later
Example:
Bhcg#1: 568
Bhcg#2 (2 days later): 1,112
Calculate to confirm this is a proper rise:
568x 1.66 =942
1,112>942, therefore confirmed proper rise
Recommend both tests be completed at same lab to ensure same assay being used.
NOTE: if the initial result is >3,000theexpectedrise is only 40%
Pregnancy test results, lower than expected..
If thefirstbhcgresults are greater than 5 but less than thedesired value, implantation hasoccurred,and the patient is pregnant.However, the pregnancy is likely abnormal. A repeated check 2-4 dayslater is still needed. Be cautiously optimistic when giving results…
If the repeated result is about the samevalue or has decrease this is likely abiochemical pregnancy(early miscarriage)
Abiochemical pregnancyis a pregnancyloss before being seen on ultrasound (its not really a true preg).Typicallythis is due to chromosomalabnormalities of the embryo/fetus
If thefirstbhcgresult is in the desired range but the repeatedresult did not increase by 66% (or 40%)then this is a red flagthat the pregnancy may be progressing abnormally.Nothing to do in this case except make sure bhcg is going down.
In thiscaseanother check (3rd bhcg) should be completed 2-4 days later.
NOTE: even ifbhcg is dropping, we must follow to negative<5 SPRING,some labs<2..don’t want to miss ectopic pregnancy..
Negative Pregnancy test..
What to tell the pt when they have a neg result:
If negative results for IUI (1stor 2nd):Discuss options for another IUIcycle. If interested the patient will need to call with full flow period tobaseline and begin treatment again
If negative for final IUI (3rd): Discuss options toschedulefollow upappointment (F30) with provider to review IVF treatment
Beta HCG results shouldalways be a phone call –never an email/portalmessage
Be sensitive and aware when providing theseresults. Every patient will react differently!
if you can’t get a hold of pt by the end of the day, apologize about leaving the message, leave a detailed message about results and let them know the next steps and to call the office the next day.
Pregnancy Dating
In most pregnancies, the exact date of ovulation and implantation is not known. Therefore, the traditional way of dating pregnancy is to calculate from cycle day one last menstrual period.
If we know the date of ovulation, that is the most correct way to date the pregnancy rather than from the patients actualLMP.
We can assign the cLMP (calculated LMP based on date of ovulation).
Ferring app - will date the preg
put in date of IUI
preg ultrasound - when is this done
Early pregnancy ultrasounds will be completed at 6 weeks 4 days or later and then repeated in two weeks
Normal/Abnormal Symptoms - bleeding
heavy bleeding after 6 weeks?
Spotting and even a light flow can be very normal and does not mean anything is wrong with the pregnancy. Bleeding occurs naturally in about 30% of normal pregnancies. It is important to reassure t
he patient. Encourage the patient to use pads instead of tampons to better track the amount of bleeding.
If full flow, like that of a period, then (if 6+ weeks) we can schedule them same day for a PUS.
Vaginal exams and vaginal intercourse can also cause some light spotting after.
heavy bleeding does NOT always mean a miscarriage
spotting can occur w/ implantion
Normal/Abnormal Symptoms - cramping - where would you feel normal cramping?
Cramps during early pregnancy often feel like period cramps, located in the lower abdomen and last only a few minutes at a time. These are normal and a response to the uterus growth and accommodating the pregnancy.
Encourage hydration, rest and light stretching/exercise.
Tylenol ONLY – no Ibuprofen
No heating packs directly applied to the abdomen
If the cramping pains are more severe, intense and persistent, especially if one sided – then the patient should go to urgent care immediately!
starts to feel like a pulling sensation
Nausea (“Morning Sickness”) - what hormone causes it? and what vitamin helps?
Due to increased hormone levels in early pregnancy (estrogen) patients may experience nausea.
Encourage eating small frequent meals and drinking small amounts of water throughout the day to avoid dehydration.
First encourage over the counter options including Vit B6, Unisom, Aromatherapy & Ginger
If necessary, can prescribe per MD: Zofran, Diclegis/Bonjesta (this is basically B6 and unisom)
NOTE: Symptoms of nausea/vomiting generally haveno bearing on the health of the pregnancy
Abnormal pregnancy - abortions - when do they occur?
Abortions (Spontaneous & Missed)
Often referred to as SAB, a spontaneous abortion is a loss of a pregnancy (miscarriage) without intervention before 20 weeks gestation. This will require tracking of beta HCG levels to negative and potentially a repeated SIS before attempting conception again.
Manual Uterine Aspiration (MUA) - how soon after do you get your period?
A procedure completed to aspirate early pregnancy from the uterus with vacuum pressure mechanism
typically scheduled within in a few days following confirmed missed SAB
Standard pre-, intra- and post-operative care provided. Can be with anesthesia or without per patient preference
Cervical dilation may be required prior to catheter placement
PUS will be completed interim and post to confirm all tissue has been removed. 2 to 5 “sweeps”/suctions may need to ensure a clean uterine cavity before ending procedure.
Beta HCG will need to be checked after procedure and continued until confirmed negative. Menses expected in 2-4 weeks
Misoprostol (Cytotec)
This medication is synthetic prostaglandin that is used to induce and augment uterine contractions and cause cervical ripening (dilation and softening
800 ug (200 ug x 4) sublingual or vaginal once
After administration uterine contractions typically start within a few hours.
Heavy bleeding is expected and may last about 14 days with continued spotted after. Large blood clots and clumps of tissue are expected.
The pregnancy tissue typically passes within 4-5 hours but cramping on and off may continue for 1-2 more days.
Will need to take NSAIDs and often prescribed Norco in conjunction for pain relief.
Beta HCG results will need to be tracked down until negative
This can all occur at home, however, encourage them to prepare and ensure they will have time to relax, stay in and rest the day of administration
Methotrexate
(meth is chemo)
A chemotherapy medication that interferes with the cells ability to absorb folate (necessary for cell growth) thereby killing and stopping fetal cell growth
Rh status and Rhogam
“Rh,” or “Rhesus,” is the name of a protein that can be found on red blood cells. People who have this protein have a “Rh-positive” blood type. People who do not have this protein have a “Rh-negative” blood type. Having a Rh-positive or Rh-negative blood type does not affect your health. But problems can happen during pregnancy if you have Rh-negative blood and your baby has Rh-positive blood.
Rho(D) immune globulin (RhoGAM) is a medication is recommended to prevent maternal antibodies that could form and attack Rh-positive blood in a future fetus.
This is a human blood product and requires a consent before administration
IM injection given in the clinic within 72 hours of miscarriage/MUA/bleeding to any patients who are Rh negative
As of 10/14/24- Spring will no longer administer RhoGAM in the first 12 wks gestation due to nationwide shortage and need to prioritize higher risk patients and new ACOG recommendations
Rhogam advised for RH negative individual at the following intervals:
Within 72 hrs of bleeding after 12 weeks of gestation.
28 weeks gestation
After delivery of a D-positive newborn
rhogam
New guidance as of 10/14/24 regarding RhoGAM– Due to national shortage of RhoGAM-and in accordance of ACOG recommendations-SPRING will no longer be providing RhoGAM in the first12 weeks of pregnancy. Currently post partum patients are prioritized followed by those at 28 weeks.
national guidelines on Rh D alloimmunization do not recommend the use of Rhogam in cases of bleeding before 12 weeks of gestation
what date do we do the pregnancy ultrasound?
1st PUS (preg ultrasound) (~ 6w5days) FHR (fetal heart rate should be~110+bpm
Chance of miscarriage 6w4d w/+FHT ~ 9.4%
2nd PUS (~8-9 weeks gestation)–stronger FHT/fetal movement
Chance of miscarriage 8+ weeks ~ 1.5%:
preg documentation
- (neg sign) = Failed (negative beta HCG)
white heart = Chemical pregnancy (positive beta HCG)
red heart = Clinical pregnancy (confirmed FHR)
X = cancelled cycle
broken heart = miscarriage
pacifier = Live birth
black heart = Still birth
A common cause of bleeding is a subchorionic hemorrhage (hematoma)
A common cause of bleeding is a subchorionic hemorrhage (hematoma). This is an accumulation of blood between the placenta and the uterus that can be seen on ultrasound. The majority will resolve on their own and have no impact on the pregnancy.
Ibprofen during preg?
NOT ok
symtpoms of abortion
Symptoms include abnormal beta HCG rise/results, sharp pains, light bleeding, or may be asymptomatic
after abortion, how quickly can pt try again?
Tracking Beta HCG levels down after a loss can take 4-6 weeks. Typically treatment would not be started until the period following this negative (another month later)
Misoprostol (Cytotec) - If no bleeding occurs
will recommend second dose the next day, same dose
Ectopic - when do symptoms occur?
Occurs when the embryo implants and grows outside the main uterine cavity (most commonly the fallopian tube).
These pregnancies cannot proceed normally and can be life threatening if left untreated.
Diagnosis with include PUS to confirm if in fallopian tube however if too early to see on US may need to complete
MUA for diagnosis.
Once confirmed, treatment options include laparoscopic surgery or methotrexate administration
shoulder pain, shooting pain, one sided pain, rectal pressure - need to be seen.
sx won’t occur until 7 weeks or later, might have other signs. Beta lower -
ectopic preg - risk factors - think STD
Risk Factors: History of STIs (Chlamydia & Gonorrhea), PID, pelvic/abdominal surgery, elective abortions, endometriosis, tubal ligation or tubal abnormalities/occultations
methotrexate - day 0
(0 bloodwork)
bloodwork panel - Panel includes CBC w/ platelets, AST, Creatine and Beta HCG
methotrexate - day 1
(inject one)
methotrexate IM injection - To be completed in the clinic with proper precautions (chemo)
methotrexate - day 4
(four is rising)
beta HCG - Not expected to yet decrease and may still be rising
methotrexate - day 7
(Meth at 7:15)
Beta HCG & Repeated panel, Looking for >15% decrease in bHCG, if <15% decrease a second dose or surgery will need to be discussed
methotrexate - Calculate dosage based on patient body surface area
(meth at 50)
Calculate dosage based on patient body surface area (therefore need to confirm height and weight with patient. 50 mg x BSA (body surface area) = mg for IM dose
methotrexate - precautions
(sex and other)
no intercourse until negative bHCG, no alcohol until after Day 7 AST confirmed normal, no Ibuprofen, need to discontinue folic acid (prenatal supplement)
during ectopic preg
Always concerned for risk of rupture during this time! Therefore the patient should be sure to monitor pain and if pain worsens they must contact MD immediately. Once methotrexate decrease is confirmed will need to continue to track bHCG weekly until negative
rhogam is a
human blood product and requires consent for administration
the first ultrasound (and what about size?)
The first ultrasound is important to confirm intrauterine pregnancy (IUP), number of fetus(s), fetal heart rate (FHR) and crown to rump length (CRL)
the second ultrasound - what is it for?
The second ultrasound is to confirm proper growth. Once this is confirmed they will “graduate” onto care with their OBGYN
if you do the ultasound too early, you won’t be able to see anything
missed abortion - what is left over?
A missed abortion(MAB) is when the fetus has stopped growing or has died but the embryonic tissue and placenta are still within the uterine cavity. This will require an MUA (manual uterine aspiration) procedure or Misoprostol administration and then tracking of beta HCG levels to negative and potentially a repeated SIS before attempting conception again.
is cramping a sign of miscarriage?
Cramping is not typically a sign of miscarriage unless accompanied with heavy bleeding.
