Module 3 Unit C 1 Flashcards
What subjective and objective findings would reassure you that pregnancy is intrauterine and developing as it should be, even though a patient is experiencing first trimester bleeding?
We identify a readily apparent reason for bleeding
The pregnant person is physiologically stable
Beta HCG levels are rising appropriately
Ultrasound shows a gestational sac, yolk sac, embryonic pole, and cardiac activity at the expected gestational ages
There is congruence between beta HCG levels and ultrasound findings
What are the subjective and objective data that you must assess to investigate the possibility of serious causes of first trimester bleeding for ectopic pregnancy,
Subjective:
Pain may be present especially unilateral adnexal pain, referred shoulder pain
Objective:
-Cervical motion, tenderness and/or adnexal tenderness or mass may be present
-Adnexal mass may or may not be visible on U/S
-Beta HCG often does not double as expected every 48 hours
To investigate: Draw CBC, blood type/RH
What are the subjective and objective data that you must assess to investigate the possibility of serious causes of first trimester bleeding for molar pregnancy,
Subjective:
-Significant N/V often present
-Brown vaginal discharge may be present
Objective:
-Characteristic molar pregnancy features can be seen
-Uterus often larger than expected
-Beta HCG often much higher than expected
To investigate:
- should draw CBC, Blood type/Rh
What are the subjective and objective data that you must assess to investigate the possibility of serious causes of first trimester bleeding for incomplete/inevitable early pregnancy loss (pregnancy loss in progress)?
Subjective:
- Bleeding can be heavy
-cramping/pain often present
Objective:
- Cervical os open, pregnancy tissue may be visible
- Ultrasound often definitively shows structures that are lagging behind what they should be and no cardiac activity
- Beta HCG usually not rising s expected or may be falling
To investigate:
- should draw CBC, Blood type/Rh
What is the role of serial quantitative beta hCG testing in the setting of first trimester bleeding?
It increase/multiplication indicate that the pregnancy is viable
What are the less serious caused of first trimester bleeding and how will you assess for those
-Implantation bleeding
-Cervical irritation from infection or intercourse
-subchorionic hemorrhage
-fibroids or endometrial polyps
In which situations will you manage first trimester bleeding collaboratively with a physician colleague?
-patients who have any significant amount of bleeding (anything more than spotting)
-Pregnancy cannot be definitively determined to be intrauterine
Suspicion for an ectopic pregnancy
How will you remain patient-centered, promote health equity, and provide anticipatory guidance to patients experiencing first trimester bleeding?
For a patient 5 weeks from a sure LMP who has an ultrasound that does not show a definitive intrauterine pregnancy, what are the differential diagnoses?
How will you proceed clinically?
How will you decide whether/when to attempt to hear fetal heart tones with a doppler in early pregnancy?
What are the prenatal genetic testing options in the first trimester
-Nuchal translucency ultrasound + serum analytes
-Blood draw #1 of integrated and sequential screens
which first trimester prenatal genetic testing options are screening tests and which are diagnostic?
Screening:
- Ultrasound to measure nuchal translucency (NT) + blood draw for maternal serum markers
-Cell-free DNA (cfDNA)
* Noninvasive prenatal testing (NIPT)
* Noninvasive prenatal screening (NIPS)
Diagnostic:
- Chorionic villus sampling (CVS)
For which conditions do the first trimester prenatal genetic testing option test
which conditions do they NOT test for?
NT:
- Test for:
* Aneuploidies (trisomies 13, 18, 21)
- Not test for
* Neural tube defects
CVS:
- Test for
* Aneuploidies and other chromosomal conditions
- Not test for:
* Neural tube detects
cfDNA:
- Test for
* Aneuploidies (trisomies 13, 18, 21)
- Not test for
* Neural tube defects
What are some techniques to avoid giving a patient a long lecture of options and details about each? ie, how will you remain patient-centered in your counseling?
How do you assess for implantation bleeding
Most relevant history:
- Timing usually limited to approx 2 weeks after ovulation
-Usually small amount of bleeding for short duration
Most relevant PE
- May not need to do PE and there are usually no specific PE findings
Ultrasound:
- Usually occurs when it’s too early for ultrasound to be definitive
Labs:
- May or may not choose to draw beta hCG but if it is drawn, should rise appropriately
How to assess for cervical irritation from infection or intercourse
Most relevant history:
- Timing in relation to intercourse or exam;
- STI symptoms
Most relevant PE
- Cervix may or may not appear erythematous
Ultrasound:
- No specific ultrasound findings
Labs:
STI testing may be indicated
How to assess for subchorionic hemorrhage
Most relevant history:
- Timing in relation to gestational age: unusual to have subchorionic hemorrhage prior to 8-10 weeks
- usually painless bleeding
Most relevant PE
- No specific PE finding
Ultrasound:
- Identified by ultrasound:
- Usually not worrisome unless large
Labs:
- Beta hCG should rise appropriately
How to assess for fibroids or endometrial polyps
Most relevant history:
- Pt may report history of fibroids or endometrial polyps
Most relevant PE:
- Uterus may be enlarged and irregular if fibroids
Ultrasound:
- Identified by ultrasound.
- Usually not worrisome unless large
Labs:
- May or may not choose to draw beta hCG but if it is drawn should rise appropriately
Sensitivity
True positives
High sensitivity = few false negatives
The ability of the test to correctly identify the people who have the condition
specificity
True Negatives
High specificity = few false positives
The ability of the test to correctly identify people who do NOT have the conditio
Positive predictive value
The likelihood that someone with a positive test really has the condition
Negative predictive value
The likelihood that someone with a negative test really does not have the condition
Which genetic tests are screening tests
First trimester screen (nuchal translucency ultrasound + serum analytes)
Triple, quad, and penta screens
Integrated and sequential screens
Noninvasive prenatal testing (cell-free DNA)
Which genetic tests are diagnostic tests
Chorionic villus sampling (CVS)
Amniocentesis (amnio)
Which genetic tests can only be completed in 1st trimester
First trimester screen (nuchal translucency ultrasound + serum analytes)
Blood draw #1 of integrated and sequential screens
Which genetic tests can only be completed in 2nd trimester
Triple screen
Quad screen
Penta screen
Blood draw #2 of integrated and sequential screens
Which genetic tests can only be completed anytime
carrier screening
Noninvasive prenatal testing (cell free DNA): Anytime from 10 weeks through term
Which genetics tests are aneuploidy tests
Nuchal translucency ultrasound + serum analytes
Triple,quad and penta screens
Integrated and sequential screens
Noninvasive prenatal testing (cell-free DNA)
Which genetic tests are structural anomaly (neural tube defect) test
Alpha-fetoprotein (AFP) component of triple, quad, penta, integrated and sequential screens
what is cell-free (cfDNA)
most sensitive and specific screening test for common fetal aneuploidies
Can identify fetal sex
what is cfDNA assessing
In maternal blood, there are fragments of maternal DNA that exist outside cells and fragments of fetal DNA (it’s actually placental origin) that exist outside cells.
The test analyzes the “fetal fraction,” the DNA fragments that originate with the pregnancy rather than the mother.
A fetal fraction that is lower than expected can be due to an elevated maternal BMI, earlier gestational age, certain fetal aneuploidies and other causes
Due to BMI effect of cfDNA what is the recommendation
some clinicians recommend that patients with higher BMIs wait a bit later in pregnancy (later than 10 weeks, which is considered the beginning of the testing window), to minimize the chance for a BMI related false-positive/abnormal test
timeframe ultrasound to measure nuchal translucency (NT) + blood draw for maternal serum markers
10(or 11) -14 weeks
Time frame for chorionic villus sampling (CVS)
10-13 (or 14) weeks
Time frame for cell-free DNA (cfDNA)
Anytime between 10 weeks and term
when is the gestational sac seen/beta HCG/clinical significance
4.5-5 weeks
1000
if seen intrauterine and there are no adnexal masses, ectopic is unlikely
when is the Yolk Sac seen/beta HCG/clinical significance
5-5.5 weeks
1,000-7,200
If seen intrauterine, ectopic is unlikely. Until cardiac activity is seen, does not confirm viability
when is the Embryonic/fetal pole seen/beta HCG/clinical significance
5-7 weeks
7,200-10,800
if fetal pole is intrauterine, ectopic is unlikely. Until cardiac activity is seen, does not confirm viability
when is the Embryonic/fetal cardiac activity seen/beta HCG/clinical significance
6-7 weeks
>10,800
if fetal is intrauterine, ectopic is unlikely. Cardiac activity confirms viability of early pregnancy. Once cardiac activity is seen, risk for early pregnancy loss decreases dramatically
