Pregnancy Flashcards
IDEAS Pregnancy Documentation
Once beta HCG result is back, it is important to add interpretation as “negative” or “positive” this will directly input into the Treatment plan
Beta HCG Results
Human Chorionic Gonadotropin is the hormone produced by the placenta. It is used to confirm pregnancy and to track the progression of the pregnancy in early stages
At Spring we check the first beta HCG level at two weeks from TIC, IUI or Embryo Transfer date
Anything greater than 5 is considered positive however these are the ideal ranges for results:
2 weeks post IUI/TIC = 50+
2 weeks post Day 2/3 Transfer = 50+
2 weeks post Blast Transfer = 300+
At home urine pregnancy tests (UPTs) typically read values of 15-20 or higher as positive
If the result is positive a repeated test will need to be checked 2-4 days later (avoid weekends and holidays). We are looking for the result to increase by 66% every two days
NOTE: if the initial result is >3,000 the expected rise is only 40%
Original Value x 1.66 = Minimum Value 2 days later
Bhcg #1: 568
Bhcg #2 (2 days later): 1,112
Calculate to confirm this is a proper rise:
568 x 1.66 = 942
1,112 > 942, therefore confirmed proper rise
We always need quantitative HCG run that provides actual serum values, not qualitative (positive/negative)
The first bhcg test is included in the patients treatment payment previously collected. However all subsequent tests and ultrasounds are not
Beta HCG Results
If the first bhcg results are greater than 5 but less than the desired value, implantation has occurred and the patient is pregnant. However, the pregnancy is likely abnormal. A repeated check 2-4 days later is still needed.
If the repeated result is about the same value or has decrease this is likely a biochemical pregnancy (early miscarriage)
A biochemical pregnancy is a pregnancy loss before even being seen on ultrasound. Typically this is due to chromosomal abnormalities of the embryo/fetus
Note: High Beta HCG results are not necessarily indicative of multiple gestations
Concerns for ectopic pregnancy or miscarriage (see following slides on abnormal pregnancy)
Negative Beta HCG Results
If negative results for IUI (1st or 2nd): Discuss options for another IUI cycle. If interested the patient will need to call with full flow period to baseline and begin treatment again.
If negative for final IUI (3rd): Discuss options to schedule follow up appointment (F30) with provider to review IVF treatment
If negative for IVF or FET: Stop all medications (if applicable) and need PIV scheduled with provider
Pregnancy Ultrasounds
The first ultrasound is important to confirm intrauterine pregnancy (IUP), number of fetus(s), fetal heart rate (FHR) and crown to rump length (CRL)
The second ultrasound is to confirm proper growth. Once this is confirmed they will “graduate” onto care with their OBGYN
Pregnancy Ultrasounds
CRL length via the Hadlock formula will calculate a corresponding gestation age (GA). It is important that this value is close (within a few days) of the actual (calculated by the transfer/IUI date)For multiples there will be details for each fetus seen
Pregnancy Dating
In the majority of pregnancies, the exact date of ovulation and implantation is not known.
Therefore, the traditional way of dating pregnancy is to calculate based oncycle day one of thelast menstrual period (LMP).
Calculating from LMP is not the most accurate since it doesn’t account for variability in the follicular phase.
If known, it is best to calculate from ovulation day(LD0).
For patients who had an embryo transfer:
you would consider the patient already two weeks + stage of the embryo on the day of embryo transfer:
D3 transfer on 10/18-patient is 2 wks 3 days gestation
D5 transfer on 10/18–the patient is 2 wks 5 days gestation.
We generally schedule the bhcg (pregnancy test) two weeks later.
Add two weeks to the embryo transfer date to determine the current gest.age.
Example:
Gestational age on 11/1:
D3 transfer on 10/18: 2w3d + 2 weeks= 4wks 3 days
D5(Blast) transfer on 10/18: 2w5d+ 2 weeks = 4 wks 5 days
Pregnancy Support Medications - for fresh transfers and FETs, what meds do they take?
(progy is 11)
For Fresh Transfers and Controlled FETs the patients are required to continue Estrogen (Vivelle or Estrace) and Progesterone (IM or PV P4) further into pregnancy.
Eventually the hormone production begins to come for the pregnancy itself (placenta)
Estrogen is continued until 8 weeks and 6 days – this will be their last dose.
Progesterone is continued until 11 weeks and 6 days – this will be their last dose.
For Controlled FET on IM
Normal/Abnormal Symptoms - bleeding - at what date should you schedule a same day ultrasound?
Bleeding
Spotting and even a light flow can be very normal and does not mean anything is wrong with the pregnancy. Bleeding occurs naturally in about 30% of normal pregnancies. It is important to reassure the patient. Encourage the patient to use pads instead of tampons in order to better track the amount of bleeding.
If full flow, like that of a period, then (if 6+ weeks) we can schedule them same day for a PUS.
Some bleeding commonly occurs when stopping progesterone or switching from IM to PV.
The coating on the Prometrium capsule will cause a dark discharge that can be confused with blood.
Vaginal exams and vaginal intercourse can also cause some light spotting after.
Nurse Triage- Vaginal Bleeding
Normal/Abnormal Symptoms
Cramping
Cramps during early pregnancy often feel similar to period cramps, located in the lower abdomen and last only a few minutes at a time. These are normal and a response to the uterus growth and accommodating the pregnancy.
Cramping is not typically a sign of miscarriage unless accompanied with heavy bleeding.
Encourage hydration, rest and light stretching/exercise.
Tylenol ONLY – no Ibuprofen
No heating packs directly applied to the abdomen
If the cramping pains are more severe, intense and persistent, especially if one sided – then the patient should go to urgent care immediately!
Nausea (“Morning Sickness”)
Due to increased hormone levels in early pregnancy (particular estrogen) patients may experience nausea.
Encourage eating small frequent meals and drinking small amounts of water throughout the day to avoid dehydration.
First encourage over the counter options including Vit B6, Unisom, Aromatherapy & Ginger
If necessary can prescribe per MD: Zofran, Diclegis
Miscarriage Risk - just 2 things
Chance of miscarriage depends on:
Age of the egg provider
If the embryo transferred is known to be Euploid.
Below are stats r/t Fresh Embryo transfer (Not tested/Non-donor eggs)
Miscarriage risk (Euploid transfer)
A recentmeta-analysisbySimopoulou et al. (2021)compared miscarriage rates across 7 studies and found an overall reduction inPGT-Atested embryos that was significant (10.1% for PGT-A vs 19.6% for untested,risk ratio0.45, 95% CI [0.25 – 0.80]).
There seems to be a greaterreduction in the >35 group (10.4% forPGT-A vs 27.9% for untested) compared to the <35 group (13.3% forPGT-Avs 16.1% for untested), however neither of these analyses werestatistically significant. According to the authors, the >35 group analysis should be “interpreted with caution” as thesample sizewas small.
Per Dr. Klatsky (6/2023):
Risk of miscarriage is lower than the natural pregnancy risk if pregnancy is from a Euploid embryo.
Less than 10% chance if initial bhcg in desired range.
<5% after 2nd PUS (Pregnancy ultrasound) when +FHT(Fetal heart tones) and Fetal movement is seen.
Abnormal Pregnancy - missed abortion - and how long to track down beta?
Abortions (Spontaneous & Missed)
Often referred to as SAB, a spontaneous abortion is a loss of a pregnancy (miscarriage) without intervention before 20 weeks gestation. This will require tracking of beta HCG levels to negative and potentially a repeated SIS before attempting conception again.
A missed abortion is when the fetus has stopped growing or has died but the embryonic tissue and placenta are still within the uterine cavity. This will require an MUA procedure or Misoprostol administration and then tracking of beta HCG levels to negative and potentially a repeated SIS before attempting conception again.
Symptoms:
bleeding, cramping, abnormal beta HCG results or asymptomatic
Tracking Beta HCG levels down after a loss can take 4-6 weeks. Typically treatment would not be started until the period following this negative (another month later)
Abnormal Pregnancy - ectopic
Ectopic
Occurs when the embryo implants and grows outside the main uterine cavity (most commonly the fallopian tube).
These pregnancies cannot proceed normally and can be life threatening if left untreated.
Diagnosis with include PUS to confirm if in fallopian tube however if too early to see on US may need to complete MUA for diagnosis.
Once confirmed, treatment options include laparoscopic surgery or methotrexate administration
Risk Factors: History of STIs (Chlamydia & Gonorrhea), PID, pelvic/abdominal surgery, elective abortions, endometriosis, tubal ligation or tubal abnormalities/occultations
Symptoms include abnormal beta HCG rise/results, sharp pains, light bleeding, or may be asymptomatic
