OB 3 Flashcards
Implantation of developing oocyte outside the endometrial cavity
Dx? and 3 RFs?
Ectopic Pregnancy
- Prior ectopic pregnancy
- Previous tubal surgery
- Hx of PID
98% of ectopic occur in Fallopian Tube, if they do not occur here what is the next likely location?
Ampullary portion of tube
3 sxs of ectopic?
- Pelvic/abd pain (95%)
- Vaginal bleeding (60-80%)
- Orthostatic sxs: dizziness, fainting, wkness d/t blood loss
Medical tx for ectopic pregnancy?
- RhoGAM in Rh neg women
-
Methotrexate IM
- inhibits DNA synthesis & fetal cell reproduction
- MUST HAVE these 3 criteria: HCG <5,000, no cardiac activity, sac ,4cm
- Repeat HCG on days 4 & 7 after Methotrexate (if HCG did not drop by 15%, meds did not work!)
What are contraindications to medical tx for ectopic w/ Methotrexate?
- Renal, liver, pulm compromise
- At risk for loss to FU (risk of death)
- Breastfeeding
- Heterotopic pregnancy
- Immunodeficiency
Surgical tx for ectopic pregnancy & indications for
- RhoGAM in Rh neg women
- Laparoscopy vs. Laparotomy (Salpingostomy vs. Salpingectomy)
- No difference in future reproductive outcomes (based on contralateral tube)
- Indications: hemodynamically unstable, impending/active rupture, failure of methotrexate, heterotopic pregnancy
Abnormal proliferation of placental epithelium secondary to abnormal fertilization
Gestational Trophoblastic Disease
3 RF of Gestational Trophoblastic Disease
- Previous molar pregnancy
- Advanced maternal age >40
- Asian/American Indian ancestry
4 types of Gestational Trophoblastic Disease
- Hydatiform Mole
- Invasive Mole
- Placental site nodule
- Choriocarcinoma
Describe a Hydatiform Mole (Gestational Trophoblastic Disease)
- Most common (80% of Gestational Trophoblastic Disease)
- Paternal genes control placental growth
- ↑ Genes = ↑proliferation
- Complete vs. Partial
Describe a complete Hydatiform Mole
(Gestational Trophoblastic Disease)
- Sperm fertilizes an abnormal ooctye = no chromosomes
- Chromosomes from the sperm duplicate = 2 copies of paternal chrom, 0 maternal chrom
Describe a partial hydatiform mole
- 2 sperm fertilize normal oocyte at same time
- 2 paternal DNA vs. 1 maternal DNA
Villi from Hydatiform Molar pregnancy invade deeply into myometrium of uterus
- Is complete or partial more common?
Invasive Mole
(Gestational Trophoblastic Disease)
What occurs following a FT pregnancy?
(Gestational Trophoblastic Disease)
Placental site nodule
Dx? Tx?
- Abnormal uterine bleeding or amenorrhea
- Uterine size greater than dates
- Absent fetal heart tones
- Hyperemesis
- Pre-eclampsia “like” sxs prior to 20 weeks
Choriocarcinoma (gestational troph dz)
- Caused by persistent complete Hydatiform Mole
- Can follow any type of pregnancy (abortion, ectopic, normal)
- HIGHLY malignant epithelial tumor (vascular invasion w/ widespread mets)
Tx: chemo vs. hysterectomy + chemo
What is PE of Choriocarcinoma?
Uterine enlargement
+/- adnexal masses
b HCG
US:“snow storm” or “grape like clusters” within the endometrium
Tx for Hydatiform Mole? (4)
- Dilation & Curettage
- Pelvic rest 4-6 weeks
- Monitor HCG closely x6-12 months
- Avoid pregnancy for 12 months
Describe a placental abruption and the cause
Premature separation of a normally implanted placenta after 20th week
- Cause: rupture of maternal vessels –> accumulation of blood leading to separation of decidua from placental attachment
- Detached placenta is unable to exchange gas and nutrients leading to fetal compromise
Dx? How dx? Tx?
- Abrupt PAINFUL vag bleeding
- Abd/back pain
- Contractions
Placental Abruption
Dx: clinical and US showing retroplacental hematoma
Tx:
- Monitor fluids, blood products
- Continuous fetal monitoring
- Expectant management (stable mothers w/ no fetal distress)
- C-section (unstable mother/fetus)
Definition of what?
- Abnormal location of the placenta over or in close proximity to the internal cervical os
Placenta Previa
What are 4 RF of Placenta Previa?
- Prior C-section
- Multiple gestation
- Prior hx of previa
- Advanced maternal age
Presentation of what?
- PAINLESS vaginal bleeding after 20 weeks gestation
Placenta Previa
Which type pf Placenta Previa?
- Located near, but NOT directly adjacent to internal os (can have a normal vag delivery)
Low Lying
Which type pf Placenta Previa?
- Internal os is partially covered
Partial
Which type pf Placenta Previa?
- Internal os is completely covered (worse one = NO VAG DELIVERY)
Complete
How is Placenta Previa diagnosed?
- US
- NEVER do cervical exam bc/ it can hemorrhage!!!
Tx for pt w/ PAINLESS vag bleeding after 20 weeks?
Placenta Previa
-
Asymptomatic:
- avoid intercourse & ↓ physical activity
- educate pt it may resolve w/ advanced gestational age
-
Symptomatic:
- Admit for close maternal/fetal monitoring
- Deliver via C-section
What is PROM?
Premature Rupture of Membranes
- Rupture of membranes before onset of uterine contractions
(normal)
What is Pre-PROM?
Rupture of membranes before 37 weeks gestation w/o presence of uterine contractions
(abnormal)
What is the MC cause for pre-term delivery?
Pre-PROM
(rupture of membranes before 37 weeks gestation w/o presence of uterine contractions)
What are the 3 RF of Pre-PROM?
Which one is the biggest RF??
- Genital Tract Infection (Bacterial Vaginosis)***
- Smoking
- Previous pre-term delivery
Woman at 35 weeks gestation presents w/ “gush” of clear/pale yellow fluid, initially thought it was urine, and is now realizing it is coming from vagina.
What is the dx? How is it diagnosed? (4)
Pre-PROM
- Speculum exam reveals amniotic fluid coming out of cervical os / pooling of fluid in vaginal fornix
- Sample vaginal fluid & look for “ferning” under microscope
- pH of vag fluid = 7 - 7.3
- alpha-fetoprotein (amniotic fluid)
Woman at 33 weeks presents w/ gush of yellow fluid, speculum exam reveals amniotic fluid coming from os, under microscope “ferning” is seen.
What is the dx and tx? (3)
Pre-PROM
- Administer corticosteroids to promote lung maturity bc/ gestation is <34 weeks
- GBS status unknown: abx prophylaxis (Ampicillin 2g or Clinda if pcn allergy)
- Expectant management until delivery
What is the definition of Post-Partum Hemorrhage? (2)
- Vaginal delivery w/ 500cc+ blood loss
- C-section w/ 1,000cc+ blood loss
What is the #1 etiology for Post-Partum Hemorrhage?
What are 2 other causes?
- #1: Uterine Atony (lack of effective contractions following delivery)
- Trauma (lacerations, uterine rupture)
- Coagulopathy
Dx? What is seen on PE? (4)
- Weakness
- Palpitations
Confusion - SOB
- Syncope
Post-Partum Hemorrhage
PE:
- Tachycardia
- Oliguria
- ↓ O2 sats
- Hypotension
Patient w/ uterine atony loses 600 CC of blood after vag delivery and is now tachycardic, hypotensive, weak, confused.
What is dx & tx? (4 things + 3 meds)
Post-Partum Hemorrhage
- Uterine massage
- IV fluids
- Oxytocin/Misoprostol/Methergine
- Blood transfusion
- Surgery
