Pregnancy Complications Flashcards
When do the majority of spontaneous abortions occur?
Why do they occur?
80% occur in the first 12 wks
Most likely d/t chromosomal abnormalities
Threatened abortion
Pt of <20 wks’ gestation who presents with vaginal bleeding and no cervical dilation or effacement
What does an Rh neg mom need with a threatened abortion?
RhoGAM
What is the prognosis of a threatened abortion if cardiac motion is found on u/s?
95% will carry to term
What must be the primary differential for threatened abortion?
Ectopic
Get serum quantitative hCG and transvaginal u/s
Inevitable abortion
Pts with an open cervical os found on pelvic exam but without a hx or evidence of passage of tissue
Prognosis and presentation of inevitable abortion
All pts spontaneously miscarry
Cramping caused by uterine contraction is common and is usually preceded by bleeding
May need D&C to complete the process and RhoGAM if Rh neg
Complete abortion
Complete miscarriage characterized by resolution of sx and the total expulsion of products of conception (POC)
Presentation of complete abortion
On pelvic exam, the cervical os is closed and u/s demonstrates an empty uterus
Plan of care of complete abortion
OB/GYN f/u and counseling, along with RhoGAM if indicated
Incomplete abortion
Dx-ed when only part of the POC has passed through the cervical os
Presentation and tx of incomplete abortion
Pts have a closed cervical os and u/s reveals fetal or placental tissue remaining in the uterus
Needs a D&C within 1-3 days to limit risk of sepsis and RhoGAM if Rh neg
Septic abortion
Refers to an intrauterine infection
Causes of septic abortion
Can occur in elective terminations performed with poor asceptic techniques or inadequate evacuation of the uterus
Can occur in pts using an IUD for contraception, in HIV, and in women who are diabetic
What can be a misdiagnosis of septic abortion?
PID when pregnancy status is not checked
Plan for septic abortion
CBC BCx Cervical cultures Gram stains Triple abx coverage ex: ampicillin, gentamicin, and metronidazole OB consult for urgent D&C
Missed abortion
Occurs when fetus or embryo dies in utero and is not diagnosed
Can happen in women who are using some form of birth control (inconsistently) and don’t realize they are pregnant
Needs OB consult for D&C
RFs for spontaneous abortion
Increased maternal age Smoking Hx of 3 or more miscarriages No previous live birth Environmental toxins Infections Drug and/or alcohol use Maternal diseases Genital tract abnormalities (large fibroids, bicornuate uterus, cervical dysfunction after procedures)
What hx is needed to evaluate for spontaneous abortion?
LMP Gestational hx Amount of time bleeding has occurred Number of pads used Passage of any tissue Presence/absence of cramping Last sexual intercourse Drug/EtOH use General med/surgical hx
PE of spontaneous abortion
Speculum exam to visualize os
Any adnexal tenderness or masses
Work up for spontaneous abortion
TVUS to assess for presence or absence of POC within the uterus, eval of adnexa and presence or absence of fluid in the cul-de-sac
Serum progesterone level
Serum serial quantitative hCG level
Up to what time can a termination of pregnancy be medication-induced?
49th day
Medications that can be used in the termination of a pregnancy
Methotrexate
Prostaglandins
Mifepristone
Statistically less likely to complete the process as compared to surgical termination
Procedure of surgical termination
Vacuum
D&C
D&E
Complications of termination of pregnancy
Infection Uterine perforation Hemorrhage Uterine scarring (Asherman's syndrome) Retained products of conception with hemorrhage Cervical lacerations
Recurrent abortion
Three successive spontaneous abortions
Uterine causes of recurrent abortion
Septum
Leiomyoma
Incompetent cervic
Genetic causes of recurrent abortion
Chromosomal abnormalities with one or both partners resulting in non-viable embryos
Rheumatic causes of recurrent abortion
Endocrine causes of recurrent abortion
Lupus
Thyroid, under-treated DM, PCOS, luteal phase defect
Hematologic causes of recurrent abortion
Other causes of recurrent abortion
Thrombophilias, esp factor V Leiden
Antiphospholipid syndrome
Maternal infections, esp TORCH infections
Incompetent cervix
Cervical length of <2 cm and/or internal cervical os open 1 cm or greater is diagnostic
Causes around 25% of second trimester losses
Many times present with CC of painless increase in vaginal d/c
On spec exam open os may be visible
Funneling of the cervix may be noted on u/s
Risks of incompetent cervix
Congenital uterine or cervical anomaly Previous obstetric trauma Previous mechanical dilation -D&C -TOP -Hysteroscopy Treatments for CIN
Tx of incompetent cervix
Cerclage
Better outcomes if done before membranes are visible
When is an ectopic pregnancy more common?
When there is scarring of the internal genital tract such as with multiple D&Cs, STIs, PID, ahesions, endometriosis
Infertility pts
PREVIOUS ectopic is a HUGE risk factor
Which type of ectopic pregnancy is a leading cause of maternal deaths in the 1st trimester?
Tubal pregnancy
PE of ectopic pregnancy
On TVUS, you may see an empty uterus or there may be an empty gestational sac within the uterus
You may or may not be able to appreciate a mass in the tube
Dx of ectopic pregnancy
TVUS followed by quantitative beta-hCG testing
Heterotopic pregnancy
Where there is an IUP and ectopic at the same time
DDx of ectopic pregnancy
Acute appendicitis Miscarriage Ovarian torsion PID Ruptured corpus luteum cyst or follicle Tubo-ovarian abscess Urinary calculi
Tx of ectopic pregnancy
Surgical removal of pregnancy and tube
Methotrexate (PO or IM-IM more effective)
Details about using methotrexate for ectopic pregnancy
Only works if the tube hasn’t started to rupture
The higher the baseline hCG level is, the less likely methotrexate is to work
Must be done in conjunction with serial beta subunit hCG to verify pregnancy is ending-check q2-3 days
NOT an option if heterotopic and parents want the IUP
Other therapeutic agents for an ectopic pregnancy
Hyperosmolar glucose
Prostaglandins
Mifepristone
Who is a good candidate for expectant management of ectopic pregnancy
Has a beta-hCG level <1,000 mIU per mL and declining
Ectopic mass <3 cm
No fetal heartbeat
AND
Has agreed to comply with f/u requirements
Isoimmunization
Affects babies of Rh neg mothers
Only occurs if the baby is Rh pos
Fetal cells enter maternal circulation and antibodies to those cells are created
With future pregnancies, those antibodies attack the blood cells of future Rh pos babies
Pathogenesis of Rh isoimmunization
Initial response to D antigen is slow sometimes taking as long as 6 mos to develop
Re-exposure to the antigen produces a rapid immunological response
The sensitized mother produces IgG anti-D that crosses the placenta and coats D-pos fetal red cells which are then destroyed in the fetal spleen
Severe hemolysis leads to RBC production by the spleen and liver leading to portal HTN with placental edema and ascites, eventually leading to hydrops (fetal heart failure)
Prevention of isoimmunization
All mothers should be blood typed and screened at first antenatal visit
All mothers with no prenatal care should be blood typed at the hospital
RhoGAM should be given to prevent future problems: at 28 wks, postpartum, after any miscarriage or termination, after any occurrence that could cause fetal cells to enter maternal circulation
Tx of isoimmunization
Best tx is still prevention
Tx of the fetus with tranfusion in utero is standard of care for severely affected fetuses
What are the two types of hydatidiform mole?
Complete
Partial
Complete mole
Develops when a sperm fertilizes an empty egg (contains no nucleus or DNA)
All the genetic material comes from the father’s sperm. Therefore, there is no fetal tissue
A small percentage of complete moles may develop into choriocarcinoma
Tx of complete mole
Up to 20% of pts will need additional surgery or chemo after their initial surgery
