Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

ACOG Pub Review > PB#135: Second-Trimester Abortion > Flashcards

PB#135: Second-Trimester Abortion Flashcards

1
Q

Potential circumstances that could lead to eAB in 2nd tri (4)

A

Delay in suspecting/testing for pregnancy, delay in obtaining insurance/funding, delay in obtaining referral, difficulty locating/traveling to available provider

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Factors associated w/ higher rates of seeking 2nd tri eAB (3)

A

Poverty, lower education level, multiple disruptive life events

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Percentage of pts who choose to terminate pregnancies if major anatomic/genetic anomalies are detected in 2nd tri

A

47-95%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Possible OB/medical indications for 2nd tri termination/ evacuation (4)

A

Pre-E, PPROM, pregnancy failure <20wga, IUFD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

IUFD rate at >20wga

A

6.22 deaths per 1,000 live births + fetal deaths

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Demographics w/ higher IUFD rates (3)

A

Teenage, AMA, Black/Hispanic/Native American pts

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Two general management options for 2nd tri eAB

A

Medical, surgical

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Most common method of performing 2nd tri eAB

A

D&E (~95% of cases)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Percentage of abortion providers that offer services at >12wga, percentage of abortion providers that offer services at >20wga

A

64%, 23%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Percentage of clinics providing 2nd tri eABs that also offer medical termination

A

33%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Description of “partial-birth abortion”; year that federal ban on “partial-birth abortion” was passed

A

Vaguely defined, though widely interpreted as ban on intact D&E unless IUFD occurs prior to surgery; 2003

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Reason multiple states have banned eABs at >20wga; what medical evidence suggests to refute this

A

Concerns related to fetal pain; fetal perception of pain may not occur until 3rd tri

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Methods for cervical prep (2)

A

Osmotic dilators, prostaglandin analogs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Most common prostaglandin analog used in cervical prep

A

Miso

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Reason cervical prep is recommended prior to D&E

A

Reduce risk of cervical trauma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

General technique used in D&E

A

Aspirating amniotic fluid and removing fetus w/ forceps through cervix and vagina, fetal disarticulation/dismemberment commonly occurs, final suction curettage performed to ensure complete evacuation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

General technique used in intact D&E

A

Requires more advanced cervical dilation over several days, followed by removal of intact fetus except for possible decompression of calvarium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

When is intact D&E preferable?

A

When preservation of fetal anatomy is desired

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Lower risks associated w/ intact D&E (2)

A

Uterine perf, infection 2/2 retained fetal tissue

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Disadvantages of 2nd tri induction-termination vs D&E (3)

A

Less cost-effective, associated w/ greater risk of complications (ie incomplete AB), may be prolonged

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Conditions in which medical induction-termination may be preferable over D&E (3)

A

Pregnancies w/ fetal anomalies, genetic disorders, maternal health issues

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Meds/Techniques for medical abortion (5)

A

Prostaglandin analogs (miso), mife, osmotic dilators, Foley catheters, pit

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Why is miso (alone or in combo) recommended over other agents alone (3)?

A

High efficacy, low cost, ease of use

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Mife + vaginal miso induction-termination protocol

A

Mife 200mg PO > miso 800mcg vaginally 24-48h later > miso 400mcg vaginally/sublingually q3h x5 doses max

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Next step if eAB has not completed after 5 doses of miso under mife > vaginal miso induction-termination protocol

A

Pt may be rest x12h then resume cycle again

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Mife + buccal miso induction-termination protocol

A

Mife 200mg PO > miso 400mcg bucally 24-48h later and q3h x5 doses max

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Miso only induction-termination protocol w/o miso loading dose (if mife unavailable)

A

Miso 400mcg vaginally/sublingually q3h x5 doses max

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Next step if eAB has not completed after 5 doses of miso under miso only induction-termination protocol

A

Pt may be rest x12h then resume cycle again

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Superior route of miso placement for nullip pts

A

Vaginal (over sublingual)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Miso only induction-termination protocol w/ miso loading dose (if mife unavailable)

A

Miso 600-800mcg vaginal loading dose > miso 400mcg vaginally/sublingually q3h

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Induction-termination protocol if both mife and miso unavailable

A

Pit 20-100U IV q3h > 1h w/o pit (to allow for diuresis) > dose slowly increased to max of 300U over 3h

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Why is high-dose pit not commonly used in 2nd tri?

A

Inefficient uterine response to pit 2/2 fewer oxytocin receptors at this gestational period

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Do osmotic dilators provide added benefit to induction w/ prostaglandin analogs?

A

No

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Most effective regimen for 2nd tri medical eAB; percent efficacy of this method

A

Mife > miso; up to 91% within 24h of initiation of miso

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Rare alternative method of performing 2nd tri eAB (instead of medical eAB or D&E); indications for this method (2)

A

Hyst/Hysterotomy; if other methods are contraindicated or have failed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Does inducing fetal demise increase safety of 2nd tri medical/surgical eAB?

A

No, although limited evidence does suggest that induced fetal demise prior to medical eAB may shorten induction time

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Techniques used to case fetal demise (3)

A

Umbilical cord division, intraamniotic/intrafetal digoxin injection, fetal intracardiac KCl injection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Reasons some providers may induce fetal demise prior to 2nd tri eAB

A

May cause maceration (prior to D&E), may avoid transient fetal survival following expulsion

39
Q

Mortality rate associated w/ eAB; relative risk of mortality in childbirth compared to mortality rate associated w/ eAB

A

0.6/100,000 legal induced eABs; 14x higher in childbirth

40
Q

Does eAB-related mortality increase or decrease w/ each week of gestation?

A

Increase (rate of 0.1 per 100,000 procedures at <8wga compared to 8.9 per 100,000 procedures at >21wga)

41
Q

Definition of postabortion hemorrhage

A

Clinical response to excessive bleeding (ie transfusion, hemorrhage) and/or bleeding >500mL

42
Q

Percentage of D&Es c/b hemorrhage requiring transfusion; percentage of 2nd tri medical eABs c/b hemorrhage requiring transfusion

A

0.1-0.6%; 0.7%

43
Q

Risk factors for eAB-related hemorrhage (4)

A

AMA, insufficient cervical dilation, general anesthesia, hx of >1 prior C/S

44
Q

Most common etiologies for refractory hemorrhage (6)

A

In order: atony (52%), abnormal placentation (17%), cervical lac (12%), uterine perf (7%), LUS bleeding w/o atony (5%), DIC (5%)

45
Q

Percentage of D&Es c/b retained tissue/incomplete AB; percentage of mife medical eABs c/b retained tissue/incomplete AB

A

<1%; at least 8%

46
Q

Percentage of D&Es c/b atony

A

2.6%

47
Q

Risk factors for eAB-related atony (3)

A

Increasing pt age, increasing EGA, prior C/S

48
Q

Percentage of 2nd tri eABs (both surgical and medical) c/b cervical lac

A

3.3%

49
Q

Risk factors for eAB-related cervical lac (4)

A

Mechanical dilation, nulliparity, advanced gestational age, provider inexperience

50
Q

Percentage of D&Es c/b uterine perf

A

0.2-0.5%

51
Q

Risk factors for eAB-related uterine perf (3); protective measure to decrease risk of uterine perf

A

Advanced gestational age, multiparity, provider inexperience; cervical prep

52
Q

Entities that may alert provider of uterine perf (2)

A

Severe pain, visualization of extrauterine tissue in vagina (brisk bleeding not usually seen unless artery is lacerated)

53
Q

Complications to always consider if perf is suspected in 2nd tri

A

Bowel/bladder injury

54
Q

Percentage of 2nd tri eABs c/b uterine rupture in pts w/ prior C/S; percentage of 2nd tri eABs c/b uterine rupture in pts w/o prior C/S

A

0.28%; 0.04%

55
Q

Is miso safe for use in 2nd tri medical eAB w/ hx of C/S; why or why not?

A

Yes, if one prior C/S; risk of uterine rupture is approximately the same w/ and w/o one prior C/S

56
Q

US finding + pt hx factor w/ highest suspicion for abnormal placentation

A

Low-lying placenta/previa + hx of C/S

57
Q

Preferred method of 2nd tri eAB in pts where abnormal placentation is suspected

A

D&E (w/ prep made for hemorrhage)

58
Q

Is preop UAE recommended in 2nd tri eABs where abnormal placentation is suspected; why or why not?

A

No; PPV of US in diagnosing abnormal placentation is as low as 65%

59
Q

Method to help confirm abnormal placentation

A

MRI

60
Q

Complication that is increased w/ 2nd tri fetal demise

A

DIC

61
Q

Management of postabortion hemorrhage w/ c/f coagulopathy

A

Serial CBCs and coags > if clinical/lab suspicion for coagulopathy, maintain low threshold to give FFP/cryo

62
Q

Percentage of 2nd tri eABs c/b postabortion infection

A

0.1-4%

63
Q

Source/Composition of most postabortion infections; percentage risk decrease of infection 2/2 ppx abx in setting of D&E

A

Ascending genital tract/polymicrobial (so should be treated w/ broad-spectrum abx); 40%

64
Q

Recommended ppx abx prior to D&E

A

Tetracycline or metronidazole

65
Q

Most effective and inexpensive ppx abx regimen prior to D&E

A

100mg PO doxy taken 1h prior to D&E, followed by 200mg post-D&E

66
Q

Are ppx abx recommended for 2nd tri medical eAB?

A

No

67
Q

Incidence of fatal/nonfatal PE in setting of 2nd tri eAB

A

10-20/100,000

68
Q

Incidence of AFE in all pregnancies; mortality rate of AFE associated w/ 2nd tri eAB

A

1/10,000-1/80,000; 80%

69
Q

Advantages of D&E (5)

A

Scheduled timing, typically faster/more cost-effective, fewer complications (~4% compared to up to 29% w/ miso medical eAB), less pt-reported pain, pts more likely to say they would opt for same procedure again

70
Q

Most common complication of medical eAB, and percent of cases in which this complication occurs

A

Retained placenta (21%)

71
Q

Advantages of intact D&E (2)

A

Ability to perform autopsy, preferable when uterine instrumentation should be minimized (ie chorio, fetal anomalies such as severe hydrocephalus)

72
Q

Advantage of medical eAB

A

Ability to perform autopsy

73
Q

Initial assessment/management of post-abortion hemorrhage

A

Immediate visual and digital cervical exam to assess for cervical lacs, bimanual exam to assess tone, US to identify reaccumulation of blood/retained tissue

74
Q

Initial management of post-abortion hemorrhage if atony is suspected (2)

A

Prompt uterine massage, administration of uterotonics

75
Q

First-line agent for atony in 2nd tri; second-line agent for atony in 2nd tri

A

Methergine, unless contraindicated (ie pts w/ HTN); miso 800-1000mcg

76
Q

Management of refractory/excessive post-AB bleeding

A

Obtain additional IV access, begin fluid resuscitation, consider serial CBCs/coags, obtain T&S for poss transfusion (of both blood and coag factors, as DIC is possible in setting of post-AB hemorrhage)

77
Q

Lab to obtain in anticipation of possible UAE

A

Cr (BMP)

78
Q

Mechanical methods of controlling post-AB hemorrhage (2)

A

Foley catheter (inflated to 30-60mL saline), intrauterine balloon (infalted to 120-250mL saline)

79
Q

Management of persistent refractory post-AB bleeding (2)

A

UAE, laparoscopy/laparotomy/hyst

80
Q

In cases where hemorrhage was 2/2 atony/cervical lac/DIC/LUS bleeding, percentage of cases in which UAE successfully avoids need for hyst; in cases where hemorrhage was 2/2 abnormal placentation, percentage of cases in which UAE successfully avoids need for hyst

A

100%; 43%

81
Q

Rate of hyst among 2nd tri eABs; most common cause of post-AB hemorrhage leading to hyst

A

1.4/10,000 ABs; uterine perf

82
Q

Management of minor abrasions during eAB (2)

A

Basic ferric subsulfate solution, silver nitrate

83
Q

Entity to consider if bleeding continues s/p repair of high cervical tear; management option in such a case

A

Uterine artery lac; targeted UAE (or laparotomy, if UAE not possible)

84
Q

Preop methods to reduce risk of excessive blood loss/hemorrhage and cervical lacs associated w/ D&E (2)

A

Vasopressin in paracervical block; routine cervical prep

85
Q

Is intraop US necessary for 2nd tri eAB?

A

While helpful, not required

86
Q

Is grief resolution better for pts who choose D&E or medical eAB in cases of fetal demise/termination for fetal anomalies?

A

Similar between D&E and medical eAB

87
Q

Demographics more likely to report delays in accessing AB care (3)

A

Poor pts, Black pts, teen pts

88
Q

What percentage of pts seeking AB have had prior ABs?

A

~50%

89
Q

Earliest that ovulation can resume s/p eAB procedure

A

21 days (so contraception should be started immediately after)

90
Q

Options that cannot be considered for 2nd tri eAB and initiated on day of procedure (2)

A

Diaphragm, cervical cap

91
Q

Advantages of immediate IUD insertion over interval insertion s/p 2nd tri D&E (3)

A

Higher adherence, lower pregnancy rates, high pt satisfaction

92
Q

Post-AB IUD expulsion rate in immediate post-AB group vs interval-insertion group

A

6.8% vs 5.0%

93
Q

Are PID and IUD perf rates higher w/ immediate post-AB IUD insertion vs interval-insertion?

A

No

ACOG Pub Review (12 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions