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Women's Health > Pregnancy Loss and Ectopic Pregnancy > Flashcards

Pregnancy Loss and Ectopic Pregnancy Flashcards

1
Q

Types of pregnancy loss

A

Threatened Abortion

Spontaneous Abortion

  • Inevitable
  • complete
  • incomplete
  • missed
  • septic

Induced abortion/pregnancy termination
- therapeutic/elective

Ectopic Pregnancy

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2
Q

Spontaneous abortion RFs

A

Age - extremes
Previous SAb
Smoking (>10 cigarettes/day)
BMI 25
Maternal disease - heart disease, DM, thyroid disease, hypercoaguable states, anatomic abnormalities
Trauma - contributes more in later term SAb when fetus is larger (trauma can include CVS and amniocentesis)

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3
Q

SAb potential RFs

A

Alcohol - 3 drinks/week probs ok

NSAIDS - implantation issues, can close PDA early

Caffeine - >10 cups/day

Fever >100 (b/c something else is probably going on

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4
Q

SAb Etiologies

A

Chromosomal abnormalities MC (50%)

Aneuploides (abnl # of chormosomes)

  • autosomal trisomies (trisomy 16 MC, always fatal)
  • monosomy X (Turner’s)
  • Polyploides - extra set

Anembryomic - normal trophoblasts and yolk sac, but embryo never develops

Congenital anomalies - genetic, chromosomal, extrinsic factors (amniotic bands), exposure to teratogens

Teratogens

  • Maternal - DM c poor glycemic control
  • drugs - isotretinoin
  • physical stress - fever
  • environmental chemical - mercury
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5
Q

SAb Presentation (categories to distinguish types)

A

Vaginal bleeding
pelvic pain/cramping
cervical os open or closed
products or conception passed or retained
uterus - appropriate size, consistency, tenderness

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6
Q

Threatened Abortion

A

Vaginal bleeding through a closed cervical os, pregnancy may still be viable

Vaginal bleeding
Painless or mild suprapubic pain
** Closed cervical os
Products of conception not visualized (retained)
Uterus appropriate size for gestational age

Reassuring factors: serum hcg, detectable cardiac activity by US or doppler

Supportive management

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7
Q

Inevitable abortion

A

SAb is imminent

vaginal bleeding (heavier)
Pelvic cramping
cervical os open
gestational products may or may not be visible
uterus may still be appropriate size (tatany)

expectant management

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8
Q

Complete Abortion

A

A SAb in which the entire contents of the uterus are expelled (Done). Commonly <12weeks.

Minimal vaginal bleeding (heavier bleeding earlier)
mild pelvic cramping
cervical os closed
all products passed
uterus small and contracted (tetany - firm)

Management

  • confirm passing of products of conception (US)
  • expectant management
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9
Q

Incomplete Abortion

A

SAb with retained products
Common after 12 weeks

Heavy vaginal bleeding 
severe cramps 
cervical os open 
retained products
uterus small for gestational age and not well contracted

Surgical management

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10
Q

Missed abortion

A

Retention of a failed intrauterine pg
Sxs of pg have abated (n/v, breast tenderness)

mild vaginal bleeding/spotting
cervical os closed
products of conception not visible
uterus small for gestational age

Surgical management

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11
Q

Septic Abortion

A

SAb complicated by uterine infx

Staph aureus, gram neg bacilli, or some gram positive cocci

RFs: invasive procedures (amnio, CVS), FB’s, incopmlete or illegal induced abortion

Sxs:

  • vaginal bleeding
  • pelvic tenderness, cramping
  • cervical os open
  • uterus tender and boggy
  • infx: fever, chills, tachycardia, vaginal d/c, peritonitis, septicemia, death

Management (urgent/emergent)

  • stabilize the pt
  • blood and endometrial cultures
  • broad spectrum antibiotics - clinda, gent, +/- amp
  • surgical management
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12
Q

SAb evaluation

A

Confirm pg, dating
ID S&S
Check for infection/sepsis
PE - pelvic and abd exam

hCG, UPT
Transvaginal US
- location of pg, viability via cardiac activity, retained products
Rh incompatibility

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13
Q

Expectant Management

A

Can do if: tic management - NSAIDS

Risks: incomplete abortion, need for unplanned evacuation, bleeding

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14
Q

Surgical management

A 
Suction curettage (D&C) - suction 
Dilation and evacuation (D&E) - foreceps + suction

Indications:

  • retained products
  • septic abortion
  • prevent complications (hemorrhage, infx)
  • unstable

Risks: anesthesia, uterine perf, cervical trauma, hemorrhage, infx

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15
Q

Other important management considerations

A

Pregnancy symptoms should abate
Menses to resume by 6 weeks

F/U by phone (24hrs), in clinic in 2-4weeks

Monitor hCG decline

Pelvic rest x 2 weeks
Avoid pg x 6 weeks

Call for heavy bleeding, pelvic pain, discharge, fever

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16
Q

Recurrent Pregnancy Loss (RPL)

A

3 or more losses before 20 weeks

Possible causes

  • early: chromosomal, endocrine
  • later: anatomical, immunologic

Hx:

  • uterine instrumentation
  • inheritable chromosomal abnlties, genetics
  • menstrual changes, endocrine changes
  • environmental exposures - DES
  • venous thrombosis

Work up:
- karyotype, hysteroscopy, hypercoaguability w/u, thyroid ftn, ovarian ftn (FSH or estradiol)

17
Q

Pregnancy Termination

A

Elective abortion - termination before viability for any reason; requires parental notification 48hrs before the procedure; Women’s Right to Know Act

Therapeutic Abortion - termination of pregnancy before the time of fetal viability to safeguard mother’s health (ACOG criteria: if mother’s health is at risk or pg is a result of rape or incest)

18
Q

Medical Abortion

A

Less than 9 weeks gestation

Methotrexate - progesterone inhibitor; induces contractions, vascular destruction, necrosis and detachment of products of conception

Misoprostol - prostaglandin directly stimulates myometrium

Surgery if not successful

19
Q

Ectopic Pregnancy

A

Must r/o in any woman of reproductive age with abdominal/pelvic pain and irregular bleeding

Hemorrhage from ectopic pg is a major cause of maternal death

MC’ly implants in Fallopian tubes, but ovary, abd cavity and cervix also possible

20
Q

Ectopic pg RFs

A 
PID
previous ectopic pg 
age >35
h/o abd or pelvic surgeries 
IUD 
DES exposure
21
Q

Ectopic pg S&S

A

Range from asymptomatic to acute abd and hypovolemic shock

abd pain, tenderness
abnl uterine bleeding, dizziness
amenorrhea
peritoneal signs
cervical motion tenderness
adnexal tenderness
22
Q

Ectopic pg evaluation

A

Pg test
Quantitative hCG
transvaginal US
CBC

Note: discriminatory zone - if gestational sac cannot be visualized on TV US, follow hCG changes to tract pg (should double q48hrs)

Tx: Surgical

Women's Health (9 decks)

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