Pregnancy Flashcards
Infertility definition
No pregnancy after trying for 12m w normal sexual activity without conception
Infertility causes- females and males
Female
- anovulation
- endometriosis
- fibroids
- tubal factor
- cervical factor
Male
Unexplained
Infertility labs and imaging
History, PE Semen analysis- sperm concentration, motility, and morphology Chromosomal studies Monitoring of ovulation Hormone analysis Studies of anatomy- hysterosalpingogram Chromosomal studies
Infertility treatment
Assisted reproductive technologies (ART)
- ovulation induction
- insemination w sperm
- in vitro fertilization
First tri bleeding causes
Implantation into the endometrium Abortion Ectopic pregnancy Molar gestation Infection
Abortion definition
termination of pregnancy before 20 wks
Abortion types
Spontaneous abortion (SAB)
Therapeutic abortion (TAB)
Abortion symptoms
Vaginal bleeding (bright red)
Low back pain
Abdominal pain/cramping
Cervical dilation
Passage of products of conception
bHCG levels falling or not adequately rising
Abnormal US findings (empty gestational sac, lack of fetal growth or cardiac activity)
Abortion treatment
Suction curettage- safest and most effective for <12 wks
- dilation of cervix by instruments
- <1% risk for complications such as infection and uterine perforation
Complete abortion definition
All products of conception expelled before 20wks
Complete abortion cervical os
closed
Complete abortion labs and imaging
Serial HCG levels until 0
Products of conception- examined and sent for path lab
Complete abortion treatment
Observe until no further bleeding
If minimal- no further tx necessary
Inevitable abortion definition
Pregnancy cannot be saved
Products of conception not yet passed - poor prognosis
Inevitable abortion cervical os
dilated
Inevitable abortion symptoms
bleeding
mod to severe uterine cramping
Inevitable abortion treatment
D&C
Blood type and crossmatch
Rh status
Threatened abortion definition
Either: Possible pregnancy loss or can continue without problems
- unknown prognosis- better if bleeding and cramping resolved
No products of conception passed
Threatened abortion symptoms
Bleeding before 20 wks
May or may not have abdominal cramping
Uterine size compatible w dates
Threatened abortion cervical os
Cervical os closed
Threatened abortion - treatment
Pelvic rest
Incomplete abortion definition
Only some products of conception passed before 20 wks - prognosis is poor
Incomplete abortion symptoms
Mod to severe cramping
Heavy bleeding
Incomplete abortion cervical os
dilated
Incomplete abortion- treatment
Surgical (D&C)
Medical- ex methotrexate
Expectant management- waiting
Missed abortion definition
Embryo is not viable prior to 20 weeks
Products of conception retained in uterus
Missed abortion cervical os
no dilation
Missed abortion symtoms
Cramping or bleeding
Missed abortion treatment
Surgical (D&C)
Medical- ex methotrexate
Expectant management- waiting
Septic abortion definition
Any embryonic or fetal demis with uterine infection
Retained products of conception or ascending infection- polymicrobial
Septic abortion- symptoms
Uterine bleeding Fever Abdominal pain Cervical motion tenderness Foul smelling discharge
Septic abortion labs and imaging
CBC- Increased leukocytes UA Endocervical cultures Blood cultures Abdominal x-ray to r/o uterine perforation US- to look for retained POCs
Septic abortion - treatment
Hospitalization and IV abx w anaerobic and aerobic coverage
D&C if retained POCs
Elective abortion - medically
- Mifepristone: inhibits progesterone receptors (needed for pregnancy)
- Misoprostol: durg that induces uterine contractions and expulsion of POCs- alone or in combo
- Methotrexate: stops fast growing cells, used in combo w misoprostol
Elective abortion - surgical
- Suction or surgical curettage
- Dilation and evacuation- 2nd tri abortions- up to 18wks
Recurrent pregnancy loss definition
3 or more consecutive SABs before 20 wks
Prognosis is good- 60% have chance of viable pregnancy
Recurrent pregnancy loss- causes
Genetic Auto immune Anatomic Endocrine Thrombophilic
Anembryonic pregnancy
“Blighted ovum” definition
Embryo fails to develop or is resorbed after loss of viability
Anembryonic pregnancy
“Blighted ovum”- symptoms
Similar to missed or threatened:
- mild pain/bleeding
- cervix closed
- retained non-viable pregnancy (still in uterus)
Anembryonic pregnancy
“Blighted ovum” imaging
US- diagnosis- empty gestational sac w/o a fetal pole
Ectopic pregnancy - definition
Implantation of the uterus in any site other than the endometrial cavity- most commonly the fallopian tubes
leading cause of pregnancy related death in 1st tri
Ectopic pregnancy complications
- tubal rupture
- hemorrhagic shock
- death
Ectopic pregnancy risk factors
Prior ectopic PID Smoking Anatomic abnormalities IUD
Ectopic pregnancy symptoms
Pain- pelvic or abdominal Abnormal uterine bleeding Amenorrhea Syncope Adnexal mass Uterine changes Hemodynamic instability- vital signs
Ectopic pregnancy labs and imaging
CBC- hemorrhage concern
B-HCG- high
Blood type/Rh status
Pelvic US- no fetus in uterus
Transvag US- should show intrauterine pregnancy at B-HCG level of 1500-2000 “discriminatory zone”
Progesterone level- <5 not usually a viable pregnancy
Ectopic pregnancy treatment
Methotrexate- #1
- monitor LFTs and Cr
- close follow up until B-HCG= 0
Surgical- laparoscopy
- Salpingostomy- small incision in tube
- Salpingectomy- part of tube removed
Emergency
- sx in ruptured ectopic, transfusion usually required
No intercourse
Gestational trophoblastic disease definition
Group of pregnancy related tumor- rare
Cells are called trophoblasts and come from tissue that is used to form the placenta
Abnormal fertilization
Gestational trophoblastic disease symptoms
Uterine bleeding
Absence of fetal heart tones and structures
Rapid enlargement of uterus or uterine size greater than expected for gestational age
Preeclampsia in 1st tri or early second tri may be pathognomonic for molar pregnancy
Gestational trophoblastic disease - labs
HCG titers greater than expected for gestational age
Hydatidiform mole- molar pregnancy
Molar pregnancy- benign neoplasm derived almost entirely from abnormal placental (trophoblastic) proliferation
- may precede choriocarcinoma
Hydatidiform mole- complete
Contain no fetal tissue, diffuse trophoblastic proliferation, 46xx or 46xy
Hydatidiform mole- partial
Contains some fetal tissue, focal trophoblastic proliferation, 69xxx or 69xxy
Hydatidiform mole- molar mc in ?
early teens (<20yo) or perimenopausal (40)
Hydatidiform mole- molar symptoms
vaginal bleeding
Hydatidiform mole- labs and imaging complete
High BHCG bc trophoblastic neoplasms produce HCG
Complete
- BHCG >50,000, HIGH
US- diagnostic
Complete- hypoechoic areas= ““snowstorm”” pattern, normal gestational sac or fetus is not present, theca lutein cysts may be seen on ovaries
Hydatidiform mole- labs and imaging partial
High BHCG bc trophoblastic neoplasms produce HCG
Partial
- BHCG <50,000, slight elevation
US- diagnostic
Partial- focal areas of trophoblastic changes and fetal tissue may be noted, focal cystic changes in placenta= hallmark finding
Hydatidiform mole- labs and imaging grossly and microscopically
Analysis of tissue obtained from dilation & evacuation for histology and DNA content
Grossly:
- multiple grapelike vesicles filling and distending the uterus
Microscopically:
- edema of villous stroma, avascular villi, and nests of proliferating trophoblastic elements surrounding villi
Hydatidiform mole- molar pregnancy treatment
- Termination of molar pregnancy once confirmed
- Evacuation w suction and curettage under general anesthesia
- Tissue- pathologic evaluation
- Prophylactic chemo- controversial
- Surveillance- risk of malignant gestational trophoblastic disease
- serial HCG titers
- Avoid pregnancy
Invasive mole definition
Invasion and/or perforation of the myometrium
Locally destructive
May have emboli to distant sites (brain, lung, etc)
Invasive mole complications
- uterine rupture from invasion of myometrium
- malignant choriocarcinoma
Invasive mole symptoms
vaginal bleeding
Invasive mole labs
persistent elevated HCG
Choriocarcinoma definition
Malignant tumor- usually of placenta
Capable of widespread metastasis
Choriocarcinoma cause
Pre-existing molar pregnancy
Retained placental cells after abortion
Normal placenta after completion of a nl pregnancy
Abnormal proliferation of cytotrophoblsatic and syncytiotrophoblastic cells (produce B-HCG), no chorionic villi
Choriocarcinoma treatment
Very sensitive to chemotherapy
Choriocarcinoma diagnosis
- rise in HCG of 10% or greater for >/= values over 2 wks
- plateau in >/=4 HCG values over 3 successive wks
- HCG levels elevated for 6m post evacuation or
- tissue dx of choriocarcinoma
