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A. Repro II - Pharm and CLMD > Lecture 10: Early Pregnancy Loss, Ectopic, and Rh Isoimmunization > Flashcards

Lecture 10: Early Pregnancy Loss, Ectopic, and Rh Isoimmunization Flashcards

1
Q

Which weeks constitute the first, second, and third trimesters?

A
  • First = first day of last menstrual period - 13 + 6 weeks
  • Second = 14 weeks - 27 + 6 weeks
  • Third = 28 weeks - 42 weeks
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2
Q

A full term delivery is between which weeks of gestation?

A

37-42 weeks

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3
Q

What is the “discriminatory level” of hCG where a gestational sac be seen with transvaginal ultrasound (TVUS)?

A

1500-2000 mIU/L

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4
Q

Which abnormal rise of hCG in 48 hours confirms a nonviable IUP or ectopic pregnancy?

A

Abnormal rise in hCG of <53% in 48 hrs

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5
Q

80% of spontaneous abortions occur during which trimester?

A

First

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6
Q

What are the most common cause of first trimester SAB’s?

A

Chromosomal abnormalities

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7
Q

What is the most common chromosomal abnormality and most common class of chromosomal abnormality responsible for first trimester SAB’s?

A
  • 45 XO (Turner Syndrome) is most common chromosomal abnormality
  • Most common class is the Trisomy class, with trisomy 16 most common
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8
Q

What constitutes a threatened abortion; how are they managed?

A
  • Vaginal bleeding + closed cervix
  • Treatment is expectant management
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9
Q

What constitutes an inevitable abortion; how are they managed?

A
  • Vaginal bleeding + the cervix is partially dilated
  • Loss is inevitable
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10
Q

What constitutes an incomplete abortion; how are they managed?

A
  • Vaginal bleeding, cramping lower abdominal pain w/ dilated cervix
  • Passage of some but not all products of conception
  • Treatment is usually suction D&C
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11
Q

What constitutes a complete abortion; how are they managed?

A
  • Passage of all products of conception (fetus + placenta) with a closed cervix
  • With resolution of pain, bleeding, and sx’s of pregnancy
  • No tx needed
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12
Q

What constitutes a missed abortion; how are they managed?

A
  • Fetus has expired and remains in uterus; typically no symptoms
  • Coagulation problems may develop, check fibrinogen levels weekly until SAB occurs or proceed w/ suction D&C
  • Expected management vs. misoprostol vs. D&C
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13
Q

What constitutes a septic abortion; how are they managed?

A
  • Fever, uterine and cervical motion tenderness + purulent discharge + hemorrhage and rarely renal failure
  • Retained infected products of conception
  • Start IV antibiotics (Ampicillin + Gentamycin + Clindamycin)
  • Proceed w/ suction D&C
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14
Q

What is anembryonic gestation (blighted ovum); how is it managed?

A
  • Fertilized egg develops a placenta, but no embryo
  • U/S reveals gestational sac too large to not have embryo (>25 mm)
  • Tx: expected management vs. misoprostol vs. D&C
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15
Q

How are induced or elective abortions most often carried out in the first semester?

A

Suction D&C

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16
Q

Recurrent abortions are defined as what?

A
  • Defined as 3 successive SAB
  • Excluding (ectopic and molar pregnancies)
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17
Q

How many cigarettes a day and alcoholic beverages a week are associted with a 4-fold increased risk for SAB?

A
  • 20-cigs a day
  • 7 alcoholic drinks/week
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18
Q

What are some underlying medical disorders which are associated with recurrent abortions?

A
  • Diabetes
  • Hypothyroidism
  • SLE
  • Antiphospholipid Ab syndrome
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19
Q

How does the % rate of spontaneous abortion change from women <30 yo to women >40?

A
  • Women <30 = 11.2%
  • Women >40 = 56%
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20
Q

Which cause of second trimester pregnancy loss is associated with “painless dilation” and delivery?

A

Incompetent cervix

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21
Q

What is the treatment for incompetent cervix as a cause of recurrent SAB’s?

A

Cervical cerclage

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22
Q

What is the purpose of karyotyping both parents whom are trying to get pregnant?

A

To detect balanced reciprocal and Robertsonian translocations that could be passed onto the fetus unbalanced

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23
Q

What is the most common immunologic abnormality contributing to recurrent and SAB’s?

A

Antiphospholipid Syndrome

24
Q

What is the treatment of antiphospholipid syndrome for patient trying to conceive?

A

Prophylactic dose of heparin and low dose aspirin

25
Q

Tests for what 3 serum markers can be done for antiphospholipid syndrome?

A
  • Lupus anticoagulant
  • Anticardiolipin antibodies (IgG and IgM)
  • Anti-B2-glycoprotein 1 antibodies (IgG and IgM)
26
Q

What is the leading cause of maternal death in the first trimester?

A

Ectopic pregnancy

27
Q

Who’s at greater risk of ectopic pregnancy someone with an IUD or someone without?

A
  • Women without an IUD are at greatest risk
  • But IF woman with IUD gets pregnant they are at an ↑ risk of having an ectopic pregnancy
28
Q

Classic triad of ectopic pregnancy signs/sx’s includes?

A
  • Prior missed menses
  • Vaginal bleeding
  • Lower abdominal pain
29
Q

What is the most common clinical presentation of ectopic pregnancy?

A
  • Possible ectopic
  • Often pt is seen more than 1 visit before diagnosis is confirmed: follow serial B-hCG quants and TVUS accordingly
  • Mild non-specific sx’s
30
Q

What is seen on ultrasound of pt with possible ectopic pregnancy?

A
  • Thickened endometrial stripe (Arias-Stella rxn)
  • Rarely do you see the ectopic pregnancy
31
Q

Which type of ectopic pregnancy is a surgical emergency?

A

Acutely ruptured ectopic pregnancy

32
Q

What will an U/S of an acutely ruptured ectopic pregnancy show?

A

Empty uterus w/ significant amount of free fluid

33
Q

Transvaginal U/S for ectopic pregnancy may be nondiagnostic, what is the importance of following closely with serial hCG?

A

Wait until hCG is in 1500-2000 IU/L discriminatory zone and then repeat U/S to see if there is a gestational sac

34
Q

In compliant women who are hemodynamically stable what can be used as medical management for ectopic pregnancy; how often are hCG levels checked?

A
  • Methotrexate = folic acid antagonist; DNA synthesis and cell wall inhibitor
  • Check hCG levels on day 4 and 7 –> levels ↓ 15%, continue to follow weekly; if levels plateua or fall slowly give another dose
35
Q

Patient with ectopic pregnancy taking methotrexate should be instructed to avoid what?

A

Folate containing vitamins

36
Q

What are some of the absolute contraindications for using methotrexate in medical management of ectopic pregnancy?

A
  • Non-compliant pt
  • Intrauterine pregnancy
  • Breastfeeding
  • Active pulmonary disease or PUD
  • Hepatic, renal, or hematologic dysf.
  • Alcoholic
  • Ruptured ectopic or hemodynamically unstable
37
Q

Which patients may qualify for expected managment of an ectopic pregnancy?

A
  • If they are stable and sx’s are spontaneously resolving
  • Follow closely w/ serial hCG testing and give strong ectopic precautions
38
Q

What is the preferred surgical approach for an ectopic pregnancy in hemodynamically stable vs. unstable pt?

A
  • Stable = laparoscopy
  • Unstable= laparotomy
39
Q

Which surgical approach to ectopic pregnancies has been associatd with better long-term tubal function?

A

Salpingostomy

40
Q

How soon following surgery for ectopic pregnancy should you repeat hCG titers?

A

3-7 days post-op

41
Q

What is Rhesus Isoimmunization?

A
  • Immunologic disorder that occurs when Rh-negative women is carrying an Rh-positive fetus
  • Ab’s to fetal Rh antigen can cross placenta and destroy fetal RBC’s —> severe hemolytic disease in the fetus/newborn
42
Q

Which antigen is most commonly involved in Rhesus Isoimmunization?

A
  • Rh D antigen
  • Women who carry Rh D antigen are “Rh positive”
  • Women who lack the Rh D antigen are “Rh negative”
43
Q

Which prophylactic treatment is used to prevent maternal production of antibodies to Rh antigen?

A

Rh immune globulin (RhoGAM)

44
Q

Who should RhoGAM be administered to and when is it given?

A
  • Rh-negative woman who is not Rh D-alloimmunized
  • Give at 28 weeks and within 72 hrs after delivery of a Rh D positive infant
45
Q

Which test can identify fetal RBC’s in maternal blood and will determine if additional RhoGAM is necessary?

A

Kleinhauer-Betke test

46
Q

For prevention of Rh isoimmunization every pregnant women should get what 3 things at her first prenatal visit?

A
  • ABO blood group
  • Rh D type
  • Antibody screen
47
Q

If pregnant women is Rh-negative and has anti-D antibody titers that are positive, what does this mean; what should be done next?

A
  • She is Rh D sensitized
  • Next test the father of baby for the Antigen status in question
  • If he is Rh-D negative then no further workup or tx is necessary
  • If he is Rh-D positive, will either be homo- or heterozygous
48
Q

Which titers are used as a screening tool to estimate the severeity of fetal hemolysis in Rh disease?

A

Maternal Rh-antibody titers

49
Q

What do maternal Rh-antibody titers of <1:8 and >1:16 indicate; what is management for each of these situations?

A
  • <1:8 = indicates fetus not in serious jeopardy; recheck titers q 4 wks
  • >1:16 will require further eval.; detailed U/S to detect hydrops and Doppler studies of the Middle Cerebral Artery (MCA)
50
Q

What is the most valuable tool for detecting fetal anemia; how often should it be performed?

A
  • Doppler assessment of peak systolic velocity in the fetal MCA in cm/sec
  • Should perform this test q 1-2 wks from 18-35 wks
51
Q

Which fetal MCA value peak systolic velocity for gestational age is predictive of moderate to severe fetal anemia?

A

>1.5 MOM

52
Q

Which Hct level is considered severe fetal anemia; when are intrauterine transfusions done and with what?

A
  • Hct is below 30% or 2 standard deviations below the mean Hct for the gestational age
  • Intrauterine transfusions using fresh group O, Rh-negative packed RBC’s performed between 18-35 weeks
53
Q

What type of transfusions for severe fetal anemia are preferrd due to more rapid and reliable therapeutic benefits?

A

Intravascular transfusions into umbilical vein

54
Q

What is the management of Rh-isoimmunization after 35 weeks gestation?

A

Consider delivery and transfuse the neonate

55
Q

What is the risk of hydrops with subsequent pregnancies after the first affected pregnancy?

A

90%

56
Q

If father is heterozygous for Rh-D antigen, what 2 ways can the fetal RhD status be determined?

A
  • Non-invasively w/ cell-free fetal DNA in maternal plasma

or

  • Invasively w/ fetal antigen testing (amniocentesis)
57
Q

In addition to serial ultrasounds with MCA dopplers, what other 2 tests should be used in the management of Rh-isoimmunization?

A
  • Antepartum testing: 2x weekly non-stress test or biophysical profiles
  • Serial growth scans q 3-4 weeks

A. Repro II - Pharm and CLMD (20 decks)

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