Pregnancy Flashcards
First Trimester Bleeding- pathophysiology
App 25% bleed in 1st trimester
First Trimester Bleeding- cause
Implantation into endometrium Abortion Ectopic Prego Molar gestation Infection
Abortion- pathophysiology
Termination or pregnancy before 20 weeks
Abortion- cause
Spontaneous (SAB)
Therapeutic (TAB)
Abortion- S/S & PE
Vaginal bleeding - bright red Low back pain Abdominal pain/cramping Cervical dilation Passage of products of conception bHCG dec or not rising Abnormal U/S - empty gestational sac, lack of fetal growth, no CV activity
Complete abortion- pathophysiology
All products of conception expelled before 20w
Complete abortion- labs & imaging
HCG levels
Products of conception - sent to path
Complete abortion- treatment
Observe for further bleeding
- if minimal - no further tx needed
Inevitable abortion- pathophysiology
Pregnancy cannot be saved
Inevitable abortion- S/S & PE
Products of conception not yet passed
Bleeding
Mod/severe uterine cramping
Cervical os - dilated
Inevitable abortion- treatment
D&C
Blood type, cross and match
- high risk for bleeding, will need blood products
Rh status
Inevitable abortion- prognosis
Poor
Threatened Abortion- pathophysiology
Possible Pregnancy Loss
- can continue w/out further probs
Threatened Abortion- S/S & PE
No product of conception passed Bleeding before 20w \+/- abdominal cramping/pain Uterine size compatible w/ dates Cervical os - closed
Threatened Abortion- treatment
Pelvic rest
Incomplete Abortion - S/S & PE
Only some products of conception are passed - <20w
Heavy bleeding
Mod/severe cramping
Cervical os - dilated
Incomplete Abortion- treatment
Surgery - D&C
Medical - methrotrexate
Expectant management - watchful waiting
Incomplete Abortion- prognosis
Poor
Missed abortion- pathophysiology
Embryo not viable <20w
Missed abortion- S/S & PE
Product of conception retained in uterus
Cramping or bleeding
No cervical dilation
Missed abortion- treatment
Surgery - D&C
Medical
Expectant management
Septic Abortion- pathophysiology
Embryonic or fetal demis w/ uterine infection
Septic Abortion- cause
Retained products of conception or ascending infection
Polymicrobial
Septic Abortion- S/S & PE
Bleeding Fever Abdominal pain CMT Foul smelling discharge
Septic Abortion- labs & imaging
Inc luekocytes CBC UA Endocerviacl cultures Blood cultures Abdominal xray U/S - retained POC
Septic Abortion- treatment
Hosp and IV abx
- anaerobic and aerobic cover
D&C - POC
Elective Abortion- S/S & PE
Missed period
Elective Abortion- treatment
PO: Mifepristone - RU486 - inhibits progesterone receptors Misoprostol - induces uterine contractions and expulsion of POC - used alone or in combo Methotrexate - stops fast growing cells - combo w/ misoprostol
Surgery: Surgical urrettage Suction Curettage - Safest and most effective - <12w - Dilation of cervix by instruments - low failure rate -<1% risk of complications Dilation and evaculation - more common 2nd tri - <18w output
Anembryonic Pregnancy- pathophysiology
“Blighted Ovum”
Embryo fails to develop or resorbed after loss of viability
Anembryonic Pregnancy- S/S & PE
Mild pain/bleeding
Cervix closed
Retained non-viable pregnancy
Anembryonic Pregnancy- diagnosis
U/S - empty gestational sac seen w/o a fetal pole
Ectopic Pregnancy- pathophysiology
Implantation of fetus in any site other than endometrial vacity
- fallopian tubes - most common
Ectopic Pregnancy- epidemiology
Prior ectopic PID Smoking Anatomic abnormalities IUD
Ectopic Pregnancy- S/S & PE
Pain - pelvic or abdominal pain
Bleeding - abnormal uterine bleeding
Amenorrhea
Syncope
PE:
- Adnexal mass
- Uterine changes
- Hemodynamic instability - hypotensive
Ectopic Pregnancy- labs & imaging
CBC
B-HCG
Blood type/Rh
Pelvic U/S
Transvaginal US - intrauterine pregnancy at 1500-2000 bHCG
Progesterone - <5 - not viable pregnancy
Ectopic Pregnancy- treatment
1st line - Methotrexate
- 50mg IM
- monitor LFTs and Cr
- follow bHCG until 0
- SE - abdominal pain, bleeding, N/V
- return to ED if severe pain, dizziness, syncope
Surger - laparoscopy
- salpingostomy - small incision in tube
- salpingectomy - part of tube removed
Emergency - suruger, transfusion
No intercourse
Ectopic Pregnancy- prognosis
Complications
- tubabl rupture
- hemorrhagic shock
- death
Leading cause of pregnancy dead in first trimester
Gestational Trophoblastic Disease- pathophysiology
Group of pregnancy related tumors
Rare
Abnormal fertilization
Gestational Trophoblastic Disease- cause
Trophoblast cells from placenta
Gestational Trophoblastic Disease- epidemiology
Women of child-bearing age
Gestational Trophoblastic Disease- S/S & PE
Uterine bleeding - 1st tri
Absence of fetal heart tones and structure
Rapid enlargement of uterus or uterine size greater than expected age
Preeclampsia in 1st tri or early 2nd tri - pathognomonic
Gestational Trophoblastic Disease- labs & imaging
bHCG - higher than expected for gestational age
Hydatidiform Mole- pathophysiology
Molar Pregnancy
Benign neoplasm - placental trophoblastic proliferation
Hydatidiform Mole- epidemiology
<20 yo
Perimenopausal - 40yo
Hydatidiform Mole- S/S & PE
Vaginal bleeding
Complete - no fetal tissue
- diffuse trophoblastic proliferation
Partial - some fetal tissue
- focal trophoblastic proliferation
Hydatidiform Mole- diagnosis
“U/S:
Complete - snowstorm patter, nl gestation sac or fetus not present, theca lutein cysts
Partial - focal areas of trophoblastic changes and fetal tissues may be noted, focal cystic changes in placenta
Analysis of tissue - histology and DNA contents
- Grossly - multiple grapelike vesicles filling and distending uterus
- microscopy - edema of villous stroma, avascular villi, nests of prelerating trophoblastic elements surroudning villi
Hydatidiform Mole- labs & imaging
Complete
bHCG - >50k
46xx or 46XY
Partial
bHCG <50k
69XX or 69XXY
Hydatidiform Mole- treatment
Termination - evacuation w/ suction and curettage under general anesthesia
Prophylactic chemo - controversial
Surveillance - risk of malignancy - 20-30%
- monitor: bHCG 48hr-> weekly until <5
- if rise noted - monitor for 6m
Avoid pregnancy
Invasive Mole-pathophysiology
Invasion/perf of myometrium
Locally destructive
Invasive Mole- S/S & PE
Vaginal bleeding
Emboli - brain, lungs
Invasive Mole- labs & imaging
bHCG - persistent inc
Invasive Mole- prognosis
Complication - uterine rupture from invasion of myometrium
Go on to become choriocarcinoma
Choriocarcinoma-pathophysiology
Malignant tumor - placenta
Abnormal proliferation of cytotrophoblastic and syncytiotrophoblastic cells
- produce bHCG
- no chorionic villi
Choriocarcinoma- cause
50% - pre-existing molar pregnancy
25% - retained placental cells after abortion
25% - nl placenta after completion of nl pregnancy
Choriocarcinoma- S/S & PE
Possible widespread mets
Choriocarcinoma- diagnosis
- Rise in HCG >10% or >3 from baseline over 2 weeks
- Plateau >4hCG values over 3w
- hCG levels inc at 6m post evacuation
- tissue diagnosis
Choriocarcinoma- treatment
Chemo - very sensitive
- high cure rate
