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Phillips - Pregnancy Flashcards

1
Q

What things need to happen to make L and D successful?

A
  • Review records for medical problems, risk factors: ex, GBS+ patient will get penicillin during labor
  • Routine labs: CBC, type/screen for blood products
  • IVF: D5LR for fluid replacement
  • Anesthesia consult for epidural: discuss this prior to delivery (bedridden following administration)
    1. NO total pain relief, so pts should be ready for some degree of pain and discomfort
  • Pitocin (dilute solution) almost routine: promotes normal contraction pattern (pts may abstain)
  • NPO in labor process, but frowned upon in some more “natural” settings: DEC risks w/ anesthesia
  • Comfort, and questions answered
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2
Q

What kind of monitoring is done during a typical L and D?

A
  • Fetal monitoring: external monitors continuously
    1. Freq review of fetal heart tracing: most units have central monitoring capacity via a screen w/all laboring pts and fetal HR at that time
  • Periodic exams (of cervix) for progress: try to keep these at a MINIMUM because more exams lead to INC risk of infection
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3
Q

What do you see here?

A
  • Intrapartum fetal (top) and contraction monitoring
  • FHR: baseline 132 bpm; moderate variability (normal: external monitoring)
    1. Qualitative, not quantitative if external
    2. Quantitative FHR on time: variability normal, even acceleration (going way above baseline)
  • Contraction pattern: q3-4 minutes (normal)
    1. Dark, vertical bars designate 1 minute so you can count how frequent the contractions are
    2. #’s on vertical axis give you some basic info concerning contraction strength -> this can’t be measured via external monitor (body habitus), so internal monitoring via catheter in uterus can be used for better values
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4
Q

What is the typical recovery time for a vaginal birth?

A
  • Recovery 24-36 hours on floor, then discharge
  • Depends on pt energy level, and what kind of help she has at home
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5
Q

What is the estimated blood loss in vaginal birth?

A
  • 500cc
  • Very normal, considering that pt goes into labor process with 40-50% excess cardiac volume
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6
Q

What is an episiotomy? Is it routine in vaginal birth?

A
  • Episiotomy: incision in vagina to allow room for baby to come out
  • NOT routine, although it was in the past
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7
Q

What happens to the baby post-L and D?

A
  • Baby in room with mom!
  • Mom should be responsible for caring for baby from delivery on (with exception of small amount of time in nursery for routine blood work, etc.)
  • Breastfeeding IMPORTANT
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8
Q

What are the indications for Cesarean birth (10)?

A
  • Malpresentation of the fetus (breech): anything other than the head
  • Failure to dilate/descend: understand labor curve, and have same person examine pt time and again (pt can’t be in labor forever)
  • Abnormal fetal heart tones: might predispose baby to lack of oxygen and acidemia, which pose risks of cerebral palsy and brain damage
    1. Monitor to prevent these, and do cesarean earlier rather than later (malpractice, yo; cerebral palsy actually more complicated)
  • Some birth defects: NTD babies better off with cesarean delivery; gastroschisis babies CAN be born vaginally (doesn’t matter)
  • Previous C-section or scarred uterus: MOST COMMON REASON -> safe to attempt vaginal birth after 1 C-section, but risks to fetus and mother of uterine rupture (risk 1%, so women given choice)
  • Triplets or higher: twins can be born vaginally or cesarean, depending on presenting fetus -> if 1st is vertex, vaginal delivery; if breech, then cesarean
  • Active herpes simplex virus at due date: neonatal herpes happens as baby is passing through vagina where lesion is present, producing virus -> women given prophylactic anti-virals at 26 wks gestation, so less likely moms will have outbreak near term
  • High viral load and HIV: if comes in with labor or ruptured membranes, fetus already exposed, and no advantage to cesarean birth
  • Placenta previa: usually implants high, but if low, then covers cervical os, and C-section necessary -> high risk for bleeding, and can be emergency, requiring hysterectomy, or causing maternal death (placenta can bleed as cervix dilating)
  • Patient request: remind pt there are risks assoc w/major sx, but most physicians honor this request
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9
Q

How common is C-section?

A
  • Quite common:
    1. <1/4th at public hospitals
    2. May be up to ½ in some private hospitals
  • INC rate in previous decades
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10
Q

What do you see here? What do you want to do?

A
  • FHR w/baseline of 170 bpm, minimal variability
  • Late deceleration: following contraction, slight downward trend of FHR, then slope upward
    1. Indication that fetus might be becoming hypoxic and acidemic
    2. Indication for expedited cesarean delivery to get baby out as soon as possible
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11
Q

How are incision/closure decided in C-section?

A
  • Abdominal and uterine incision type depends on indication
  • Type of closure and suture according to best evidence and surgeon preference
  • Don’t really need to know details about these things yet
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12
Q

What MUST be given in the case of a C-section?

A
  • ANTIBIOTICS REQUIRED to prevent surgical site infection
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13
Q

What is the estimated blood loss (EBL) in C-section? Recovery time?

A
  • EBL: 1000cc
    1. Some pts come into process with low Hct or anemic, and may need blood transfusion with this much blood loss (even though this is normal for this type of procedure)
  • Recovery time 24-48 hours: usually go home on post-op day 2
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14
Q

What are some complications associated with C-section?

A
  • Hemorrhage
  • Surgical injury to bladder/bowel: can occur
  • Surgical site infection: give AB’s intra-operatively to try and prevent this
  • Adhesions: prone to these, as are all pelvic surgeries
  • Need for repeat CD: adhesions can present real problems in subsequent C-sections for both mom and baby (in terms of trying to get baby out)
  • Try to avoid cesarean delivery if possible b/c great deal of morbidity and mortality associated
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15
Q

What counseling should happen post-partum (5)?

A
  • Lochia: vaginal bleeding/discharge persists 3-8 wks -> heavy + bloody initially, like a period; tell pt!
    1. Occasionally a heavy bleed at day 7-14 pp b/c eschar (scab) at placental site sheds; warn pt this is NOT a menstrual period
    2. Exercise, sex, driving, work can resume when pt is comfortable (except in extreme circumstances)
  • Birth control can be addressed, given in hospital
  • Breastfeeding encouraged, supported in hospital and in post-partum period with lactation advisers
  • Baby care: neonatology folks usually come by, and suggest 2-week return visit
  • Warnings about depression: baby blues common, but depression a very serious issue -> seek attention if there are any concerns
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16
Q

What is post-partum depression?

A
  • DSM-classified mental illness
  • >10% of women have depression w/in first 3 mos post-partum
  • Different than ‘baby blues,’ which have to do with excitement of delivery fading, and “cheerleaders” leaving mom to fend for crying baby by herself
    1. Women usually come to grips with this sort of scenario and recover just fine
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17
Q

What are the risk factors for post-partum depression?

A
  • Previous episodes
  • Inner city women
  • Mothers of preterm babies
  • Adolescent mothers
  • NOTE: life stresses might make you more prone, but this illness affects people of ALL SES and ethnic gps
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18
Q

What kind of screening is done for PP depression?

A
  • Routine screening on ALL moms: Edinburgh Depression Scale
  • Pediatricians sometimes recognize this before OB/GYNs, who don’t see moms until about 6 wks (peds sees them at 2-4 weeks)
  • Important for baby that the mom is not depressed, and care for/feeding of baby can be impacted
    1. BONDING
  • Moms may also present to OB with specific complaints of trouble coping
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19
Q

What is the physiologic basis for PP depression?

A
  • Withdrawal of hormones at delivery may be what pushes people into these depressive episodes
  • People with predisposing mental illness more prone to these types of problems
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20
Q

What are the symptoms of PP depression?

A
  • Crying
  • Helplessness
  • Exaggerated worry about baby: may stay awake to watch baby breathe
  • Sleeplessness: exhaustion, crying, feeling of helplessness
  • Different than baby blues, which is a realization that life is forever changed, frustrated with new duties or lack of support
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21
Q

What are the biggest concerns in PP depression?

A
  • Biggest concern for baby is lack of bonding at a critical time
  • Psychosis, suicide, even homicide are the biggest concersn for the mom
    1. This is extreme, but it has happened
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22
Q

PP depression dx and treatment?

A
  • SSRIs (Sertraline): works, safe, can be used during breastfeeding -> benefit far outweighs the risk
  • Continue breast-feeding: crucial for bonding process to continue, and mom to climb out of this “helpless” state
  • Frequent OB visits: seldom need psychiatric care, unless severe or has pre-existing disease, in which case they would get back with routine counselor
  • Hospitalization sometimes necessary: pt will often tell you that she needs this to detach completely, recover, and come back
  • Symptoms usually remit around 8 weeks post-partum, but may continue to 3 months and beyond
    1. Pt may need assistance with psychiatrist if anything out of the ordinary
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23
Q

Physiology of lactation during pregnancy?

A
  • Progesterone influences growth in size of alveoli and lobes of breast tissue
  • Estrogen stimulates the milk duct system to grow and differentiate
  • Prolactin causes differentiation of the alveoli and ductal structures
  • Human placental lactogen (HPL) produced by the placenta, and causes breast, nipple, areola to grow
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24
Q

What are the benefits of breast feeding for the infant?

A
  • Passive immunity: fully functional IgA, IgG and IgM passed from mom to baby, preventing infections, and starting baby off on good foot
  • Nutrition: formula-fed have higher, faster weight gain in newborn period and INC # of fat cells (these never go away)
    1. Protects against obesity
  • Protects against allergies/asthma
  • Bonding: helps produce confident infant and child
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25
Q

What are the benefits of breastfeeding for the mother?

A
  • Natural contraception as long as mom is fully breastfeeding, even for months post-partum
    1. Will not ovulate until starts supplementing, & PRL levels go down in intermediary periods
  • Weight loss
  • Some evidence it protects against breast cancer
  • Bonding
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26
Q

What is the physiology of prolactin in lactation/breast devo? Release? Function?

A
  • Pregnancy: level of prolactin INC 10-20x
  • Delivery: progestin, estrogen levels drop, and INH of PRL hormone removed -> milk production begins
  • FUNCTION: promotes casein mRNA transcription
    1. May stimulate syn of alpha-lactalbumin, the regulatory protein of the lactose synthetase enzyme system
    2. INC mammary gland lipoprotein lipase activity
    3. Regulates milk production via osmotic balance at the membrane
  • Levels DEC as nursing becomes established, but nursing itself stimulates episodic production of PRL to keep process of milk production going
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27
Q

What is the physiology of oxytocin in lactation?

A
  • Produced by post pit; contracts smooth mm layer of band-like cells surrounding the alveoli to squeeze the newly produced milk into the duct system (out from the alveoli)
  • INC maternal GI mobility and nutrient absorption so she can make the most of breast feeding (promotes nutrition)
  • Necessary for milk ejection reflex, or let-down, in response to suckling
  • Anti-stress effect: increase bonding (can relax and enjoy nursing)
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28
Q

What is the colostrum? Contents?

A
  • Colostrum from breast in first few days of nursing, NOT breast milk -> low vol, high nutritional content
    1. Perfect for immature gut of newborn b/c simple in construction and low-volume
  • CONTENTS:
    1. Very rich in proteins, Vit A, and NaCl
    2. Lower amts of carbs, lipids, and potassium than mature milk (simpler formulation)
    3. Growth factors (stimulate devo of the gut), anti-microbial factors, Ab’s of passive immunity
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29
Q

What is breast milk composed of? Does maternal diet affect this?

A
  • Glucose is the major substrate for breast milk
  • Glucose, amino acids, and minerals delivered to the milk from maternal circulation
  • Lipid content rises throughout nursing episode: the longer the baby nurses, the higher the lipid content in the breast milk
    1. Protein stays the same
  • Maternal diet variation causes NO variation in milk components (or their concentrations)
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30
Q

How does breast feeding affect mom?

A
  • Nursing itself INC blood flow to the breast by 20-40% so more nutrition can get directly to the breast and into breast milk
  • Maternal cardiac output goes up, and vasodilation occurs from oxytocin
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31
Q

When is breast milk present? What permits its release post-delivery?

A
  • Breast milk is present by mid-pregnancy: women don’t lactate or leak breast milk until baby is born
  • Progesterone drops at delivery, and PRL (from pit gland) increases -> milk production
  • Breast engorgement: 2 days postpartum
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32
Q

How is oxytocin involved in milk let-down?

A
  • Release from post pituitary gland causes breast myoepithelial cells to contract and release milk
    1. Causes uterus muscle cells to contract too, involuting uterus, and reducing bleeding as the mother nurses
  • Released through a somatosensory pathway initiated by neonatal suckling -> breastfeeding begets milk production (when they stop feeding, milk production stops)
  • Remember: pitocin (oxytocin) given to women in labor to help augment their contraction pattern
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33
Q

What has stimulated INC rates of breastfeeding in Memphis?

A
  • Breast feeding coalition -> OB’s now educate the patients that breastfeeding is expected
    1. No longer say, “would you like to breastfeed or bottle feed;” expectation is breastfeeding
  • Educate family members in spite of potential (-) comments or feedback: want mom to feel comfortable breastfeeding
  • Provide support for new moms: teams of lactation consultants -> has worked!
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34
Q

Why is breastfeeding a “hard sell” for some communities? How can we change this?

A
  • BARRIERS: stigma, fear, pressure to bottle feed, esp. with young women that are eager to get back to school or work
  • EDUCATION: baby benefits from improved neonate nutrition, protection against obesity, some infections, allergies and asthma, BONDING
    1. Benefits to mom include convenience, weight loss, protection against breast cancer, and BONDING
    2. Requires support- antepartum by doctors (Not “are you breast or bottle feeding?” like it is an even choice; but. “Breast feeding is best for the baby, so I assume you are breast feeding.”)
    3. Lactation nurses postpartum: in hospital and beyond
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35
Q

What is Sheehan syndrome?

A
  • Postpartum hemorrhage rarely results in hypovolemic shock and necrosis of pituitary (if vascular system not supported, for example)
  • Immediate result will be no prolactin production
    1. First clue to dx is not able to breast feed
  • Very rare phenomenon now because we do so much to prevent and treat post-partum hemorrhage
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36
Q

What can you give to women who do not want to breast feed?

A
  • NO medication to suppress breast milk production
  • Good bra, breast binders, do not stimulate breast, and cycle of stimulation will break and production will cease
  • Bromocriptine was used in the past, but not anymore because terrible side effects, including stroke
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37
Q

What are some of the complications of breastfeeding?

A
  • Mastitis: commonly caused by S aureus, Strep, or H. influenza -> introduced via baby’s mouth (baby giving it to mom)
    1. Treat with antibiotics: Dicloxicillin
    2. Continue breast feeding
    3. Can be painful, so treat with some pain meds (Tylenol, in particular)
  • Occasionally an abscess results that requires surgical drainage (may cause pain)
    1. Patient will feel ill, and have fever
    2. Usually S. aureus via baby’s mouth
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38
Q

Describe fertilization.

A
  • Occurs in the ampulla of the fallopian tube
  • Completes meiosis II, & zona pellucida becomes impenetrable so no other sperm can get in
    1. Fails in polyploidy (69 chrom organism)
  • Pro-nuclei of sperm & oocyte fuse: 23 -> 46 chrom
  • Cleavage of cells is rapid to form a morula, or mulberry-shaped embryo (12 or so cells via mitosis)
    1. Blastocyst: morula cavitates -> inner cell mass (fetus) and outer layer (trophoblast and placenta)
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39
Q

What are the steps from morula to implantation?

A
  • Day 4: morula enters the uterus, and cavitates, becoming blastocyst (day 5)
    1. Trophoectoderm becomes the outer cell mass, and is destined to be the placenta
    2. Inner cell mass destined to be the fetus
  • Day 8-9 post-fertilization: blastocyst actually implants
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40
Q

What is this?

A
  • Human blastocyst: can see the blastoceal cavity from the outside (area a little thinner, with mass-like appearance)
    1. Inner cell mass: will become fetus
    2. Outer cell mass: will become trophoblasts
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41
Q

What happens in implantation?

A
  • Embryo travels to the uterine cavity day 5-6, and implantation occurs day 8-9
  • Endometrium glycogen, lipid-rich: decidualization process promoted by progesterone produced by corpus luteum to nourish new embryo
    1. Oftentimes, removal of an ovary will result in miscarriage b/c not enough progesterone
  • Trophoblastic cells invade decidua: act much like cancer cells, attaching embryo to the endometrium
    1. Invades so entire embryo can be nourished; uterine surface folds back over developing embryo
  • hCG produced by trophoblastic cells can be detected via blood testing
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42
Q

How are pregnancies dated?

A
  • Based on first day of last menstrual period (LMP) b/c easier to establish than date of conception
    1. Assumes idealized 28-day menstrual cycle
  • Due date always an estimate (EDD): normal 40 wks +/- 2 wks (or 40 wks gestational age)
    1. Count back 3 mos from LMP and add 7 days: ex., LMP is May 10 -> EDD is February 17
    2. +/- 2 weeks is considered term, or normal
  • This is important for potential EXPOSURES
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43
Q

Ms. L concerned about excessive alcohol use over NYE. First day of her LMP was Dec. 6th. When is her due date? What is your advice?

A
  • Due date is September 13th
  • She should be reassured -> embryo was likely just at an implantation stage where a teratogen would have no effect on organ development
  • You can’t give her any guarantees, but you can certainly give her some advice
  • NOTE: Accutane is the exception to problems with teratogen exposure in very early fetal development because may hang around a bit longer because it is a fat-soluble vitamin (A)
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44
Q

Trimesters (definitions)

A
  • First: 0-14 weeks
  • Second: 14-28
  • Third: 28-40
    1. 40 weeks is due date, but normal +/- 2 wks on either side
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45
Q

Fetus (definitions)

A

Unborn, regardless of gestational age

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46
Q

What is organogenesis?

A
  • When organs forming: 2-8 wks after fertilization (4-10 weeks from LMP)
  • Important for thinking about potential exposures and birth defects, i.e., from meds or environmental exposures
  • Depends on precise ultrasound dating
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47
Q

Abortion (definitions?

A
  • Medical term: by law, <20 wks or < 500 grams (pre-viable pregnancy loss that can be first or second term)
  • Spontaneous: miscarriage
  • Induced: medical/surgical procedure
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48
Q

Viability (definitions)

A
  • Viability: > 23 weeks gestation
  • Variable based on place of delivery
  • Few miracle babies born at 21-22 weeks, but 23 weeks and above considered for possibility of viability
  • No C-section if patient is <23 weeks b/c viability chance is practically 0
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49
Q

Pre-term, late-term, post-term (definitions)

A
  • Preterm: <37 weeks gestation
  • Late term: >41 weeks
  • Post-term: >42 weeks
    1. Start to worry about adverse consequences after this date
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50
Q

What does G3P1011 mean?

A
  • Pregnant now, one term birth, no preterm births, one abortion (not sure if spontaneous or induced), one living child
  • Gravid: pregnant
  • Parity: had a baby (dead or alive at birth)
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51
Q

What does G2P1002 mean?

A
  • Pregnant now, one term birth, no pre-term births or abortions, two children living at home (twins)
  • Gravid: pregnant
  • Parity: had a baby (dead or alive at birth)
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52
Q

Why do we have prenatal care?

A
  • To help achieve as good a maternal and infant outcome as possible
  • Promote good health for mom and baby through the pregnancy
  • Screening for and managing any complications that may develop during pregnancy or immediately post-op
  • Identify needs for care beyond normal OB care: pts may have a number of other medical issues
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53
Q

What are the symptoms of pregnancy?

A
  • Missed menses: the way many young women find out they are pregnant
  • Nausea/vomiting: not sure why this happens; AM sickness generally happens early in pregnancy, but can continue throughout (meds to tx this)
  • Breast tenderness: part of early symptomatology
  • Perceives fetal movement: primigravida 18 weeks; G2 or greater 16 weeks (i.e., if you have had more than one child, and you know what to look for)
    1. NOT possible to feel this @ 8 wks b/c there are specific times when fetal movement is actually perceptible
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54
Q

How do pregnancy tests work?

A
  • URINE detects: >25 mIU/mL -> 5-6 wks gestation (just missed a period); RELIABLE
  • SERUM detects: >5 mIU/ml -> 3 wks LMP -> prior to pt knowing she’s pregnant (b4 missed menses)
    1. Level doubles e/48 hrs in early pregnancy, and peaks at 10-12 weeks
    2. Used to monitor in vitro fertilization
  • This hCG pattern critical for OB b/c they might be trying to determine if the pregnancy is a healthy one (reassuring that pregnancy is a healthy one, even if mom is having lots of cramping, bleeding)
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55
Q

How can the physical exam be used to diagnose pregnancy?

A
  • Uterus soft (a little enlarged) at 6-7 wks gestation
  • Cervix is bluish (blood engorgement)
  • Can tell is enlarged at 7-8 weeks, and sometimes earlier, depending on the habitus
  • Hear fetal heart tones w/battery operated Doppler at 10 weeks from LMP (depending on pt habitus)
  • Used to rely on physical exam to diagnose early pregnancy before HCG levels and US to help
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56
Q

What are the PE landmarks for fundal height?

A
  • Pelvic brim: 12 weeks -> should be able to feel the uterus abdominally
    1. Umbilicus: 20 weeks
    2. Beyond 20 wks: +1cm from pubic bone to fundus each week of gestation
  • In general, in spite of patient’s habitus, uterus for the most part grows in a predictable fashion
  • Msmt in cm should be approx to wk of gestation -> important to be able to document normal growth
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57
Q

When should you be able to feel the uterus abdominally?

A

12 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

What is ultrasound dating?

A
  • TRANSVAGINAL: 3-4 wks gestation, hCG 1000-2000 mIU/mL (much earlier than abdominal)
    1. If < this, won’t see anything on transvaginal US, but this doesn’t mean she’s not pregnant
  • ABDOMINAL: 5-6 wks post-LMP, cardiac activity
    1. HcG is 4000-5000 mIU/mL
  • Earlier these are performed, the more accurate they are for dating
  • IMAGE: fetal pole at 7 o’clock, normal gestational sac surrounded by thickened endometrium (7 wks, so would be able to see fetal heart beat at this gestation as well)
59
Q

What do you see here?

A
  • Ultrasound: could be transvaginal or transabdominal
  • Yolk sac = YS
  • Fetal pole = FP -> inner and outer cell mass sitting at lining of uterus
60
Q

Woman with vaginal spotting. Last day of menstrual period was 5 weeks ago. hCG 938. Can’t see any gestational sac on US. What do you tell her?

A
  • She is too early to detect pregnancy on US
  • Look again when hCG is over 2000
61
Q

What screening should be done in the prenatal visit?

A
  • Screen for adverse history that predisposes to problems for maternal and fetal outcome
  • Questionnaire or face to face: usually both
  • LMP and contraception use
  • Meds, esp. any that may cause birth defects
  • Previous pregnancy hx: if she has had pregnancy losses -> spontaneous abortions or pre-term deliveries may put patient at-risk for more of these
  • Medical: diabetes, HTN, heart disease AND sx hx
  • Hx of infectious diseases: may have adverse fetal outcome if during pregnancy
  • Genetic history: previous child with birth defects or family history of cystic fibrosis or sickle cell
  • PE, labs, US (dating, # of fetuses; assess for birth defects at later date)
  • Referrals if indications, or to high-risk OB
62
Q

What are the routine prenatal labs? What are you looking for?

A
  • CBC: anemia, thrombocytopenia
  • Urine culture: look for asymptomatic bacteriuria to prevent pyelonephritis during pregnancy
    1. Culture >105 of identifiable organism tx with AB; test cure later in pregnancy to ensure pt adherence to regimen and infection is gone
  • Blood group: Rh and Ab screen
  • Infectious disease profile -> test for infections that put fetus/neonate at risk:
    1. Syphilis
    2. Hepatitis B and C
    3. Chlamydia and Gonorrhea
    4. HIV is an opt-in
  • NOTE: make pt aware of the tests you are doing
63
Q

What are some optional tests that can be offered at a prenatal screening?

A
  • Genetic screening via questionnaire + might offer screenings for the following depending on pt answers:
    1. Chromosome abnormalities: trisomy 21
    2. Carriership of single gene disorders, incl. sickle cell disease
    3. Cystic fibrosis, hemoglobinopathies (sickle cell, thalassemia), spinal muscular atrophy (SMA) type 1 should be offered to all patients
  • HIV: can opt out
  • PAP smear: guideline dependent
64
Q

Why is blood typing/antibody screening important at the prenatal visit?

A
  • Typing and matching blood critical because some fetal blood may make it into maternal circulation in pregnancy -> want to prevent antibody response
  • Rh factor is most common type of Ag/Ab rxn in pregnancy -> anti-D Ab can be made by Rh- mom to Rh+ fetal RBCs (ALLO-IMMUNIZATION)
    1. 85% of pop Rh+: D/D or D/d (auto dom)
    2. 15% Rh-: d/d
  • Ab to Rh factor is IgG, and can pass freely to the placenta, and into fetal circulation
    1. Ab-Ag complexes form on fetal RBCs, and they are lysed in liver, spleen, bone marrow, and macros -> fetus at risk for anemia and high output heart failure
65
Q

28-y/o G3P1011 at 16 wks for new OB visit. Blood type O-. Ab screen +; anti-D titer 1;4. She thinks she had Rhogam with a previous pregnancy.

What are your next steps? How did she get sensitized?

A
  • If this is a new partner and he is Rh-, there is nothing to be concerned about
  • If he is Rh+, repeat the titer in one month. If >1;32, fetus may be at risk -> 8x original value, meaning mom mounting an immune response to fetal blood
    1. If amnestic (remembered) response like this, ultrasound + fetal cord sampling so we can know how severely the baby is being affected
    2. Intrauterine transfusions can be performed if fetus is pre-viable or baby can be delivered early if pregnancy is further along (transfused after birth, in this case)
  • She may have been sensitized when she had her miscarriage, or maybe she didn’t get enough Rhogam
66
Q

What can US and fetal cord sampling show in a mom with a high anti-D titer?

A
  • Ultrasound: will eventually show signs of heart failure
    1. Edema
    2. Hydrops: can have swelling of entire fetus
    3. Fetal tachycardia, impending demise
  • Fetal cord sampling: can be used to diagnose fetal anemia
67
Q

Why can’t you give Rhogam to a mom with an anti-D titer?

A
  • It is too late
  • Mom has already mounted an immune response, and the whole point of Rhogam is to prevent this
68
Q

What do you do with Rh- moms in whom you do not know the fetal Rh status?

A
  • Give Rhogam at 28 weeks gestation to help protect against fetal-maternal exchange that may happen at delivery
  • These moms would have a (-) titer at prenatal screening; if they had a titer, it would be too late to admin Rhogam
69
Q

What tx can you offer a mom who has a (+) anti-D titer, and wants to get pregnant again with the same partner?

A
  • One option may be donor sperm because there will be fetal risk with every pregnancy in which baby is Rh+
  • Happens earlier and earlier with subsequent pregnancies at risk
  • NOTE: ABO incompatibility can also cause fetal anemia and jaundice (O- moms), but this is much more mild than the anti-D rxn
70
Q

What diet/vitamin recommendations should be given at prenatal visit?

A
  • Folic acid prior to, and throughout pregnancy to prevent fetal birth defects
  • Multivitamin: this may not be as important for some affluent populations; chewable forms okay
  • Diet: INC fluids b/c blood volume expanded by 40-50%, avoid sushi, and improve diet
71
Q

When should US be performed during a pregnancy?

A
  • Early for dating: more accurate LMP the earlier you do this
  • 18-20 wks: to detect birth defects -> best time to do this b/c should be able to see 4 chambers of the heart, determine septal/vessel defects, look at limbs/digits pretty, facial structures, intracranial findings and sex
  • Add’l US only for indications: uterus small, large, and other concerns, i.e., may need another US to rule out restriction or too large a baby
72
Q

What routines should be done at 28 and 36 weeks?

A
  • 28 wks: 1-hr post glucola (50gm load) serum glu screen for gestational diabetes
    1. Rhogam if Rh(-): MAb to Rh (D) Ag; prevents mom’s immune response by “tagging” fetal RBCs that get into mom’s bloodstream
  • 36 wks: repeat STI screen (CDC recommends for high-risk pops) -> HIV, Hep B/C, RPR (syphilis), GC + chlamydia (if previously + and tx, and high-risk)
    1. Culture for group B streptococcus: if (+), tx during labor w/penicillin to prevent neonatal disease (baby could die soon after birth from sepsis, meningitis, pneumonia if no tx)
    a. >50% of Memphis pts + for GBS
73
Q

Woman found to be Hep B carrier b/c surface Ag+ on third trimester labs (if Ab+, then she had Hep B, or got vaccine). She was not tested earlier. What is the next step?

A
  • Discuss with the neonatal team -> baby will get Ig at birth
  • RARELY trans-placental transmission
  • Baby will also get vaccinated early
74
Q

Pt resents in early labor. Not been in clinic for 6 months. Don’t know 3rd trimester HIV status. Next step?

A
  • Rapid HIV is drawn, and if (+), AZT is begun
    1. If HIV rapid is (+) and pt refuses AZT intrapartum, her wishes must be respected
  • REMEMBER: if in high risk population, re-screen for HIV, Hep B, syphilis at 36 weeks
75
Q

How often should pts have OB visits? What should happen at these routine visits?

A
  • Every 4 weeks from first visit to 28 weeks
  • Every 2 weeks from 28-36 weeks
  • Every week from 36 weeks until delivery
  • Monitoring: BP, complaints, FHTs (fetal heart tones), fundal height
  • Education: preterm labor signs/symptoms, diet, exercise, breast feeding benefits, contraceptive plans, delivery plan
76
Q

What are the signs of labor?

A
  • Contractions: get closer together, more regular, and more painful as time goes on
    1. If this happens far from labor, patient needs to come in to be evaluated for pre-term labor
    2. Aches, pains normal in pregnancy; labor = regular ontractions + cervical changes
  • Ruptured membranes, or bleeding: should prompt presentation for care
77
Q

What causes labor?

A
  • We don’t really know:
    1. Fetal cortisol rises, but fetuses that don’t have this rise are still born
    2. INC in plasma PG’s + changes in estrogen:progesterone ratio (both fall) near due date, but no consistent swings/sways
  • Iatrogenic PG’s will induce labor, but how they work is still kind of a mystery
78
Q

What are the two phases of labor?

A

Latent and active

79
Q

What is the latent phase of labor?

A
  • From “not in labor” to 4 cm from contractions (but there is debate about this; can be up to 5-6 cm)
  • Contractions become regular, painful, and cervical dilation picks up
    1. Contractions don’t always mean labor: Braxton-Hicks contractions
  • May be 18 hrs in primigravida, or very rapid in multigravidas
80
Q

What is the active phase of labor?

A
  • Rapid cervical change because contractions much more regular, intense (>4cm)
  • From this moment (4-5cm) to delivery of infant
    1. 0.8 cm/hr in a primigravida or 1.3cm/hr in a multiparous patient (much more rapid)
81
Q

What is cervical effacement?

A
  • Thinning of the surface of the cervix during dilatation
  • IMAGE: may be able to get one finger in at stage 2
    1. Bit of guess work for stage 4: helpful to have same OB monitor pregnancy b/c they can see the change in cervical dilation/initiation of the labor process
82
Q

What is Freidman’s curve?

A
  • Idealized labor curve
  • Some things have to be evaluated and treated during labor in some cases
83
Q

21-y/o G1P0 presents at 39 weeks with ruptured membranes. She is having contractions every 6 minutes, and is 3cm, 100% effaced and vertex presentation. Next step?

A
  • She is admitted
  • Pitocin for labor augmentation, if necessary
84
Q

What are the 3 stages of labor during the active phase?

A
  • Stage 1: 4 cm (5 or 6 cm) to completely dilated
    1. Contractions drive this process: not much the pt can do to affect an INC/DEC in this time
  • Stage 2: completely dilated to delivery of baby
    1. Requires maternal effort: pushing (valsalva maneuvers)
  • Stage 3: delivery of baby to delivery of placenta
  • NOTE: she mentioned a fourth stage in podcast in which the uterus involutes, but said it is a bit of an afterthought people don’t really talk about
85
Q

Androgen insensitivity syndrome

A
  • X-linked mutation in androgen receptor; 46 XY
    1. May be complete or partial
    2. Prenatal diagnosis possible
  • Present at puberty with amenorrhea (older brother could not be affected, but younger sister could be)
    1. No pubic or axillary hair
  • HIGH testosterone level -> aromatase converts to estrogen, so female habitus
  • No uterus (AMH), cervix, tubes, or upper vagina on US
  • 40-50% risk for gonadoblastoma -> testes
86
Q

5-alpha reductase deficiency

A
  • 46 XY; autosomal recessive
  • Female or ambiguous external genitalia and male internal genitalia
    1. No chest hair and male chest devo + fused labial folds
    2. No uterus -> testes produced AMH, and now have risk of gonadoblastoma (seminoma)
87
Q

Mixed gonadal dysgenesis

A
  • Mosaic karyotype: 45X, 46 XY
  • Presents with ambiguous genitalia: level of ambiguity depends on level of functioning testis
    1. No F pubertal devo, and may have virilization at puberty
    2. Usually raised as female
  • Short stature, web-necked, wide-spaced nipples: like Turner + male pseudohermaphroditism
  • Streak gonad on one side; testis on the other (needs to be removed bc gonadoblastoma risk)
    1. Unicornuate uterus and fallopian tube
88
Q

How common is pregnancy loss? When is it most likely?

A
  • Very common: 25% of all pregnancies end in loss
    1. Most sporadic, with NO recurrence risk -> after first one, couple should be reassured they will have live birth on next pregnancy
  • Earlier in pregnancy = higher risk for loss
    1. Once a heart beat is seen on ultrasound, the chance of a successful pregnancy is >90%
89
Q

What are the common causes of sporadic pregnancy loss? When do these occur?

A
  • Most chromosomal abnormalities -> earlier miscarriages
    1. 50-60% in first trimester
    2. 15-20% in second
    3. 5-6% in third (or stillbirths)
  • 1/500 in alive-born
  • Most common type of chromosome abnormality is aneuploidy: trisomy 16 (NOT born alive), trisomy 21
  • Single most common abnormality: 45,X -> can be born alive, but a common cause of sporadic losses
90
Q

What are 4 causes of recurrent pregnancy loss?

A
  • Usually caused by the same event:
    1. Insufficient cervix
    2. Uterine anomalies: T-shaped (DES) or other birth defects of uterus itself (treated w/surgery, but C-section needed if uterine scarring)
    3. Ab syndromes: Ab recognizes placenta as foreign, and attacks it, leading to scarring and vasculitis
    4. Parent a carrier of a balanced translocation, and passes unbalanced complement to fetus
91
Q

What is insufficient cervix? Tx?

A
  • Cervical integrity compromised, usually causing 2nd trimester losses (may cause recurrent losses)
    1. Can be dx’d during early pregnancy if, on US or digital exam, cervix noted to be opening up
  • Hallmark is painless: no associated contractions
    1. Pressure in vagina, presents for care, then spontaneously delivers fetus
  • Tx: cerclage placed during 1st trimester -> stitch around cervix to hold it closed, hold up pregnancy (see attached image)
  • This is a pretty common phenomenon
92
Q

How can phospholipid Ab syndrome be treated?

A
  • TX with heparin subcu throughout pregnancy to prevent clot formation, and produce successful pregnancy
93
Q

How can fetal unbalanced translocations be prevented?

A
  • Prenatal diagnosis
  • Pre-implantation genetic diagnosis (PGD): allows only healthy, chromosomally normal embryos to be implanted in an IVF procedure
94
Q

What % of women experience bleeding in 1st trimester?

A
  • 25%
  • Bleeding and cramping during this time is worrisome
95
Q

What tests can you do when you are concerned mom is presenting with a spontaneous abortion?

A
  • Ultrasound: best way to reassure mom everything is normal
    1. Trans-abdominal can detect gestational sac when hCG level is 2000 mIu
    2. Transvaginal can detect gestational sac when hCG level is 1000 mIu
  • Hormone levels: progesterone >5 is reassuring for a normal early IUP (intrauterine pregnancy)
    1. HcG levels should double every 48 hours in a normal IUP
  • Oftentimes bring pts back to check hCG levels, and then to look for sac on US
96
Q

What things can cause 2nd trimester losses?

A
  • Chromosome abnormalities: less likely than first trimester losses
  • MDA: mullerian duct abnormalities
  • Insufficient cervix (incompetent cervix): painless dilation, no contractions (image attached)
    1. May deliver at home or come to the hospital with spotting or feeling pressure
    2. Cervix found to be advanced dilation
97
Q

G2P1011 presents after her most recent pregnancy (karyotype 47, +16) ended in a loss at 9 weeks. Her first pregnancy was a full term, vaginal birth. She has questions about the loss. Which of the following is true?

A
  • This is a sporadic loss: no reason to evaluate for recurrent losses
98
Q

Loss at 20 weeks. Fully dilated at hospital with fetus and bag in the vagina. Delivered soon after that. What do you think happened?

A
  • Sounds like insufficient cervix, and a CERCLAGE should be considered with next pregnancy
99
Q

Name some common congenital anomalies, and their associations.

A
  • Chromosomal: associated with INC maternal age
    1. Trisomy 21, 18, 13
    2. Down’s screen option in 1st, 2nd trimester
  • Single gene: sickle cell, CF, spinomuscular atrophy -> part of routine care to offer screening
  • Structural: usually sporadic or assoc w/a teratogen (i.e., alcohol or Dilantin) -> picked up on US
    1. All women should have US at 18-20 wks to confirm dates and look for birth defects
100
Q

What do you see here?

A
  • Normal US in first trimester
  • Some birth defects can be detected this early
101
Q

What is going on here?

A
  • Anencephaly: large orbits on right side, and no fetal head
  • Can also see INC thickening in a line down the back of the fetus
    1. Cystic nuchal translucency: an abnormality indicating that birth defects might be present
102
Q

What are these arrows pointing at?

A
  • Cystic nuchal translucency: lg space b/t skin and remainder of tissue indicative of possible birth defects, including:
    1. Aneuploidy: abnormal # of chromosomes in a cell
    2. Cardiac defects
    3. Neural tube defects (NTD)
  • Unsure what this actually is: may be lymphatics
103
Q

Why do we do a second trimester US?

A
  • Routine care at 18-20 wks
  • Dating by msmts of biparietal diameter, femur length, humerus length, head circumference, and abdominal circumference
    1. Create a composite to allow us to best date the pregnancy
  • Scan for birth defects
  • Could be done at OB, radiology, or perinatology
104
Q

What is this?

A
  • Normal anatomy of fetal head at 18 wks in biparietal diameter view (BPD)
  • Cerebral falx going left to right down midline, and evidence of ventricles on either side
  • Line measures the cerebellum, and shows normal size -> banana, crescent-shaped organ in the back of the head, where the calipers are making their measurements
105
Q

What is going on here?

A
  • Ventriculomegaly: hydrocephalus
  • Abnormal BPD: can still see the falx, but don’t get the integrity of white and grey matter
    1. Huge ventricle; choroid plexus dangling in it
  • Size of skull may not be big, but intracranial findings abnormal, and brain tissue pushed and compressed against fetal skull
106
Q

What happened here?

A
  • Gastroschisis: ventral wall hernia (1/10,000)
  • Allows gut to exteriorize: happens prematurely, and can be detected prenatally via US
107
Q

What is this? Is this guy going to be okay?

A
  • Gastroschisis on US at 20 wks
  • Something sitting out from the fetus: lumen with fluid spaces in it -> bright spaces probably ischemic areas in the gut after it has been compressed
  • Usually, these kids do very well, but may have to have some gut resected if it was strangulated in utero
108
Q

What do you see here?

A
  • Cleft palate: easier to pick-up on 3D US
  • In general, 2D the best for routine evaluation
    1. The exception is cleft lip and palate because you can see 3D structures so well, particularly in the face
109
Q

Why are multiple gestations becoming more common?

A
  • Advanced reproductive technologies like IVF, or gonadotropin-induced pregnancies
    1. Can result in many more than 2 babies, and is a serious issue for the repro endocrinology community
  • Associated with advanced maternal age, and we’re seeing more older mothers
110
Q

How common are twins? Types?

A
  • 1/30 pregnancies start out as twin gestation
    1. 1 will then not survive in some, so rate turns out to be 1/76 live gestations
  • 1/3 are monozygotic (identical) and 2/3 are dizygotic (fraternal): separate eggs fertilized by separate sperm
111
Q

What are the risk factors for dizygotic and monozygotic twins?

A
  • DIZYGOTIC: black race
    1. Maternal family history
    2. Very young maternal age, or advanced maternal age
  • MONOZYGOTIC: sporadic!!!
    1. Only risk factor is IVF -> occasionally, a single gestation will divide after being implanted as an IVF
112
Q

What is the difference b/t mono- and dizygotic twins?

A
  • Monozygotic: one egg and sperm, but conception splits in early development
    1. One, shared placenta
  • Dizygotic: two eggs (superovulation), and both are fertilized
    1. Always are dichorionic/diamniotic
    2. Separate placentas
113
Q

What are the variations in chorionicity of monozygotic twins?

A
  • Chorionicity depends on when the split happened
  • Di/Di: separate chorionic and amniotic sacs, but share one placenta -> still some communication (never totally separate)
    1. Cleavage days 1-3
  • Mono/Di: one, large chorionic sac, but two smaller amniotic sacs, sharing same placenta
    1. Cleavage days 4-8 (implantation typically occurs during this time)
  • Mono/Mono: chorionic and amniotic sacs shared
    1. Cleavage days 8-13
    2. Must be DELIVERED EARLY to prevent cord entrapment
  • Conjoined: often times not compatible with life, but sometimes one or both can survive
    1. Cleavage days 13-15
114
Q

What is this arrowhead pointing at? What does this mean?

A
  • Lambda sign: V and very thick membrane, which suggests this is a Di/Di gestation
  • US helps diagnose chorionicity: most likely would be diagnosed as dizygotic twins
115
Q

What are the complications with all twins?

A
  • Prematurity: most common complication; average age of delivery is 36 wks
    1. Some very premature and have problems as a result: CP (cerebral palsy), blindness, MR (mental retardation)
  • Birth defects: more common in twins, especially limb abnormalities and NTD’s
  • Need for C-section: oftentimes, but not always -> depends on the presentation
    1. Depends on presenting fetus; if 1st is coming headfirst, then vaginal is fine, but if coming legs or butt first, then C-section is better
  • Maternal diabetes: more risk with twin gestations
  • Maternal hemorrhage: more likely with twins
116
Q

What is a common complication in Mono/Mono twins?

A
  • Cord entanglement and death are common
  • These patients are hospitalized at viability (at UT), and monitored in hospital to ensure code entanglement isn’t occurring
  • Can pick up signs of distress via fetal heart tones
  • Delivery at 32-34 weeks gestation
117
Q

What is a common complication in Mono/Di twins?

A
  • Twin-to-twin transfusion: one twin often dies in utero or after delivery
  • Timing crucial bc risk of death with either twin due to shifts of blood from one fetus to the other via placental circulation
    1. Recipient is likely to survive, even though s/he has more problems (e.g., polycythemia)
  • Effort made to treat this with laser (laparoscope inside the uterus) by ablating communicating vessels -> high risk of miscarriage/fetal death, but can be used in extreme circumstances
118
Q

How does the fetus usually present at delivery? Variations?

A
  • Vertex: 95% of the time (normal)
  • Malpresentation (something other than the head presenting): 5%
    1. In general, all require C-section: breech, foot, face, arm
  • Cord prolapse: obstetrical emergency, and need to deliver ASAP via cesarean because cord can be compressed with presenting part, leading to fetal anoxia or death
  • Placenta previa
119
Q

How are small for gestational age (SGA) fetal growth disturbances dx’d and monitored? Aka? 2 types?

A
  • Intrauterine growth restriction (IUGR): high morbidity and mortality
    1. Dx w/serial ultrasound when fetal growth <10th percentile (fundal height)
    2. Early delivery or extensive monitoring with US and listening to fetal heart tones
  • Symmetrical: all msmts equally small, and have been since the beginning; usually chromosomal abnormalities
  • Asymmetrical: “head sparing” -> apparent as the pregnancy progresses b/c some vascular accident or insufficiency occurring, and all fetal efforts being made to spare brain and head
    1. Smoking, sickle cell, diabetes with vascular disease: not enough O2/nutrition is getting to the fetus (placental insufficiency)
    3. Head may measure more or less normal for gestational age, but everything else small
120
Q

Fetus dx’d with IUGR at 34 weeks. Asymmetric growth (head 32 weeks and abdomen 28 wks). What may have caused this?

A
  • Smoking, sickle cell, diabetes w/vascular disease: not enough O2/nutrition is getting to the fetus (placental insufficiency)
  • “Head sparing” -> all fetal efforts being made to spare brain and head
121
Q

What is the most common cause of large for gestational age (LGA) babies? Other causes?

A
  • Maternal diabetes: glu moves freely across the placenta, and babies become macrosomic (>4500)
    1. >4500 gms (macrosomic) delivered via C-section if mom diabetic
    2. At-risk for birth injury: shoulder dystocia (OB emergency: head out, rest of baby too big to deliver), stuck in birth canal, death in delivery
    3. Neonatal complications: hypoglycemia, polycythemia, hypoCa2+, hyperbilirubinemia in nursery when mom has uncontrolled diabetes (every effort to keep this in control with insulin during pregnancy, IV insulin drips in delivery)
  • Other causes: some birth defects, like Beckwith-Weideman syndrome -> 10-11 lbs, and C-section indicated, auto dom, and often predicted based on mom or dad having it
  • Weights can be estimated by US and a delivery plan (vaginal delivery versus CD) can be made
122
Q

What are 5 causes of 3rd trimester bleeding?

A
  • These are OB emergencies:
    1. Placenta previa
    2. Placental abruption
    3. Labor
    4. Vaso previa
    5. Trauma
  • Have to think of these things when mom presents with bleeding in 3rd trimester
123
Q

What is going on here? Risk factors? Presentation? Tx?

A
  • Placenta previa: placenta overlying cervical os, and in the way of baby coming through cervix (3rd trimester bleeding)
    1. Usually, a zygote embryo will implant on ant or post surface high in the endometrial fundus
    2. If drops lower in uterine cavity, may implant lower, closer to cervix -> placenta previa
    3. When cervix opens naturally, in preparation for labor, little rip in plate defining vessels from uterus to placental surface for oxygenation can tear and bleed -> maternal blood
  • Risk factors: previous previa
    1. Multiparous: uterine cavity might be quite big, and egg will search for awhile, then nearly drop out of cervix before implanting low
    2. Previous cesarean: can cause scarring and mixed signals, making mom more prone
  • Presentation: painless bleeding -> wake up in pool of blood, or bleed in toilet
    1. May be hemorrhage: telltale signs of great deal of bleeding -> may require transfusion
    2. Not having contractions
    3. Can be quite serious
  • Tx: requires C-section; rarely, fetal anemia
124
Q

What is placental abruption? Risk factors? Presentation?

A
  • Placental separation from uterine wall in 3rd trimester that prevents oxygenation of fetus, and presents as bleeding (can be severe)
    1. Severity of abruption: % of detachment
  • Risk factors: previous abruption, smoking
    1. Hypertensive disorders: vasculopathy can cause fragile vessels, & spike in HTN episode may cause hemorrhage and abruption
    2. Cocaine use: BP goes up very high, and pt will have essentially what looks like a stroke -> hemorrhagic bleed causing separation
  • Presentation: PAIN, tetanic contractions (one right after the other, and can feel on uterine palpation), bleeding (unless concealed)
    1. Fetal distress: late decelerations after freq contractions, indicating fetus getting poorly oxygenated during contractions (attached image; also flat HR instead of variation)
    2. DIC in mom: clot consumptive, and chews up clotting factors in maternal system -> need to deliver (and get out products of conception) and replace clotting factors with blood (pt would receive fibrinogen, cryoprecipitate, platelets, and blood, as needed)
125
Q

What is vaso previa?

A
  • OB cx in which fetal blood vessels cross or run near external orifice of the uterus (os; lengthened across and through the membranes)
    1. Placenta on ant surface of uterus
  • Vessels at-risk of rupture when the supporting membranes rupture during contractions b/c they are unsupported by the umbilical cord or placental tissue -> fetus can exsanguinate (blood is fetal)
  • Very rare; presents with 3rd trimester bleeding
  • C-section immediately due to fetal distress
  • Do NOT perform physical exam until you have done imaging
126
Q

Pt presents to ER w/complaints of vaginal bleeding at 33 weeks gestation. No pain. Few drops of blood on pad now. What do you do next?

A
  • US for localization of the placenta
  • Do NOT do physical exam until you have done imaging
127
Q

Pt comes in with suspected abruption. 38-y/o at 37 wks with no prenatal care who presents to ED with painful contractions. BP 170/90. What do you do?

A

You should ask and screen for drug use

128
Q

How common are ectopic pregnancies?

A

About 2% of reported pregnancies

129
Q

How common are ectopic pregnancy-related deaths?

A
  • 9% of all pregnancy-related deaths
  • Most common cause of death in first trimester
  • Hemorrhage
130
Q

Name 6 risk factors for ectopic pregnancy.

A
  • History of Chlamydia, GC, or PID: can lead to sub-acute scarring (patient may not even know she had this, but still have tubal disease as a result)
  • Tubal ligation: possible one sperm could get through and fertilize egg distal to ligation site
  • Previous ectopic pregnancy: this means you have tubal disease
  • IVF pregnancy: eggs introduced into uterus with catheter -> may travel retrograde to tube or corneal portion of the uterus
  • Endometriosis
  • Previous tubal re-anastomosis: scarring can prevent egg fertilized in ampulla from traveling to the uterus
131
Q

What is ectopic pregnancy? Most common locations?

A
  • Any one that is not in the uterine cavity: ovary, tube, cervix, abdomen
  • Ampullary and interstitial portions of tubes most common
132
Q

When and how does ectopic pregnancy usually present?

A
  • Pt usually presents w/irregular bleeding and some pain -> pregnancy test (even urine) will be positive
    1. May not be acute abdomen, but rather just spotting
    2. 7-8 wks gestation (LMP)
  • Ultrasound will reveal an empty uterus
  • Ectopic in interstitial or corneal segment of tube may be diagnosed later b/c more room to grow before causing symptoms (more dangerous)
    1. May present at 12 weeks; if it should rupture at this stage, in this portion of the uterus, pt may bleed out very rapidly
133
Q

What is the DDx for a (+) pregnancy test and no confirmed IUP?

A
  • Ectopic pregnancy
  • Early IUP
  • Spontaneous or complete abortion
134
Q

How can you diagnose ectopic pregnancy in an unstable patient?

A
  • Type & cross for blood products, and to the OR if:
    1. Blood in abdomen + positive pregnancy test
    2. Acute abdomen
    3. Tachycardia, hypotension: signs, symptoms of blood loss (hemodynamically unstable)
    4. Anemia
  • This is very rare these days
135
Q

How can you diagnose ectopic pregnancy in a stable patient?

A
  • Be patient, but counsel pt about signs of rupture: can be rapid; pt should return for pain, dizziness
  • Draw quantitative hCG levels and progesterone
    1. Progesterone <5 likely a failed pregnancy, ectopic, or spontaneous abortion (SAB)
    2. Progesterone >5, but nothing on US, may be early pregnancy
  • Quantitative hcg levels should double in 48 hrs: can do serial levels if no dx on first visit (stable, progesterone >5), and need to monitor
    1. hCG based on LMP, last US, evidence of IUP
136
Q

What is the dx if hCG levels fo up a little, but not 2x in 48 hrs, progesterone <5, no IUP on US? What next?

A
  • Dx: failed pregnancy (may or may not be in uterus)
  • Curette the uterus, and send to pathology
    1. If products of conception (membranes, placental tissue): SAB
    2. If no products: ectopic
  • If no evidence of pregnancy in uterus, and still have hCG levels that are slightly rising, even without finding of mass on US, you can make the diagnosis this is likely ectopic pregnancy
137
Q

What do you see here? What next?

A
  • Ectopic pregnancy in isthmic portion of fallopian tube
  • Can easily be removed with ligatures or cautery via laparoscopy
  • US also attached here showing mass with fluid-filled areas (darker) on left + some placental/tubal tissue (imaging can be hard to see)
138
Q

Pt presents to ED with lower abdominal pain. LMP 7 weeks ago. Urine pregnancy test is positive. What is next step?

A

Ultrasound

  • If US shows empty uterus, and hCG is 3100, further evaluation is necessary
  • If 48 hrs later, her hCG is 2900 and bleeding has decreased, this is possibly an ectopic pregnancy and we should still follow her
    1. Rule out failed IUP: evacuate uterus to look for villi
139
Q

How is ectopic pregnancy typically managed? Stable vs. unstable?

A
  • Surgical treatment is the standard
    1. Stable patient: laparoscopy
    2. Unstable patient: may need laparotomy to get in, find bleeding, stop it, and remove pregnancy and all of the blood inside the abdomen
  • Patients may need a transfusion
  • Post-resection in attached image: cautery, ligatures, tube removal to isthmus via laparoscope
140
Q

What is an alternative mgmt plan for ectopic pregnancy?

A
  • Medical mgmt: if mass <5 cm, including hematoma that sometimes surrounds ectopic pregnancy
    1. If no cardiac activity: sometimes fetus thrives in this envo and heartbeat is detectable on US in the tube
  • Methotrexate: capacity to kill rapidly growing cells, i.e., trophoblastic cells (dose to kill cells, and stop growth)
    1. Needs f/u with HCG levels to see if effective
  • Patient must be reliable, and return if any pain or concerns occur
  • Also depends on what the patient may want
  • Becoming more and more popular as we pick these up earlier, prior to rupture
141
Q

Do ectopic pregnancies recur?

A
  • Advise pt of recurrence risk: 7%
  • Almost invariably, other tube is damaged, which can lead to infertility -> may need to move towards IVF as a method, rather than via natural pregnancy
  • MTX may have advantage over removing tube to help promote healthy pregnancy next time around
  • If tube greatly damaged, and the other one is normal, may be advantage to removing damaged tube and hoping healthy tube works just fine
142
Q

How can IVF cause ectopic pregnancy?

A
  • Usually 1 or 2 embryos are transferred to uterine cavity at the 4-8 cell stage
  • Can result in embryo being pushed into the tube
143
Q

What is heterotopic pregnancy?

A
  • 1 IUP and 1 ectopic possible 1/10,000 (VERY rare)
  • When naturally occurring
144
Q

What are the 3 requirements for medical mgmt of ectopic pregnancy?

A
  • Mass <5 cm, including hematoma that sometimes surrounds ectopic pregnancy
  • No cardiac activity: sometimes fetus thrives in this environment and heartbeat is detectable on US in the tube
  • Pt must be reliable: need f/u hCG levels to determine if effective, and pt should return if any pain or concerns
  • Depends on what the patient may want

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