termination of pregnancy Flashcards by Jacqui Joseph

HCG is secreted by the fetus how many days after ovulation?

6-8 days

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at what levels are HCG tests negative and positive

negative: <5 IU/L
positive: >25 IU/L

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HCG doubles every ___ days (in the first 30 days of gestation). how do you know that its destined to abort?

2 days

* pregnancies destined to abort will have levels rise more slowly, plateau or decline

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what is the “fetal pole”?

measure from top to bottom of embryo in US

seen within yoke sac which is within gestational sac

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3 US findings that indicate probably fetal demise (spontaneous abortion). Think in terms of presence/size of sacs, embryo presence, etc.

gestational sac 8mm WITHOUT yoke sac
gestational sac 16mm WITHOUT embryo
absence of fetal cardiac motion in embryo with CRL >5mm

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early pregnancy loss: ___-___% of CLINICALLY recognized pregnancies. what about ALL pregnancies?

10-15%
(as opposed to biochemical pregnancies- aka woman never would have known she was pregnant, came out with next menses)

over 50% of ALL pregnancies (clinically + biochemical) are lost

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80% of spontaneous abortions occur before ___wks gestation

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if there is a normal pregnancy at ___ wks, fetal loss rate is only 3% over the next 20 weeks

8 weeks

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define abortion

expelling of the embryo or fetus prior to being viable (before 20 wks)

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what are the 6 different types of spontaneous abortion?

anembryonic
threatened
inevitable.. leading to complete 
missed
recurrent

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anembryonic pregnancy (leading to spontaneous abortion).

embryo fails to develop or is resorbed after loss of viability

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anembryonic pregnancy on exam

cervix is closed. US: empty gestational sac seen without fetal pole.

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missed, threatened and anembryonic pregnancies all have similar symptoms. what are these?

bleeding maybe

mild pain maybe

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what is a threatened abortion? does it always lead to a complete abortion?

potential cause of spontaneous abortion
- vaginal bleeding before the 20th week

*25% of women get this, only 20-50% of THESE women will progress to complete abortion

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symptoms of threatened abortion

maybe vaginal bleeding and pain. but pain is NOT the prominent symptom

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exam of threatened abortion

cervix is closed, US: normal gestational sac + viable embryo (but irregular sac,fetal pole or heart rate carry poor prognosis)

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what is an inevitable abortion? (symptoms and cervix?)

clinical pregnancy complicated by vaginal bleeding AND crampy lower abdominal bleeding
**cervix partially dilated.

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what is an incomplete abortion?

vaginal bleeding, crampy abd pain, cervical dilation (aka inevitable abortion) AND passage of SOME products of conception (POC)
(some POCs retained and seen US)

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for an incomplete abortion, what do you do with the products of conception that were passed?

send to the lab

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what two types of imaging can be used for incomplete abortion?

US and color doppler

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complete abortion

COMPLETE passage of POC and everything returns to pre-pregnant state

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US for incomplete vs complete abortion?

incomplete: some products of conception visible in cavity
complete: no POCs visible in cavity

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a complete abortion is only Dx with certainty if…

a previous intrauterine gestation was documented on US (if this wasnt done, HCG levels must follow to confirm absence of ectopic)

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missed abortion

fetus died but retained in uterus

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what major problems can occur with a missed abortion? what do you do?

coagulation problems, can be DEADLY for mother - check fibrinogen levels - remove or induce labor of fetus

what must be done in management of threatened abortion ?

Rh testing and administration of immunoglobin Rho-GAM (if mother tests as negative)

3 txt/management options for incomplete or missed abortion

1. surgical D&C - lower rates retained products, quickest solution 2. medical- Misoprostol. increase rate of retained products, lower rates of infection 3. Wait for spontaneous passage- HIGHEST rates retained pregnancy

large hemorrhagic volume loss. what do you do?

large bore IV

if intrauterine pregnancy was NOT previously seen on US and there is NO specimen obtained.. what must be done to confirm there was a spontaneous abortion?

follow HCG levels, they SHOULD decline

what if HCG levels don't decline as expected after supposed abortion?

- decline rate is slow: ectopic or retained products possible - plateau or rise: molar gestation

what is a molar gestation?

tumor-like thing that produces HCG

complications post-abortion: more advanced gestation = more risk for what?

greater likelihood of excessive blood loss

what is "asherman's syndrome"?

intrauterine adhesions following abortion

complications post abortion (4)

- excessive blood loss (more with advanced gestation) - infection - asherman's syndrome - infertility

complications from D&C

- perf of uterus - injury to bowel / bladder - hemorrhage - infection - cervical trauma and/or insufficiency

what defines "recurrent abortion"?

more than three spontaneous abortions in a row | squishy definition

evaluation of recurrent abortion: general factors: 5 possibly causes to consider

- infrequent event (random) - infection - exposures (i.e. smoke and alcohol) - medical disorders - age

what factor increases the incidence of chromosomally NORMAL abortions?

smoking and alcohol

eval for recurrent abortions: local factors (4)

1. cervical incompetence (usually trauma from D&C) 2. congenitally abnormal uterus 3. acquired abnormalities (i.e. fibroids, asherman's)

sudden loss and painless expulsion of POC is likely an abortion from what?

cervical incompetence

ectopic pregnancies are more common in what type of pregnancies?

if in vitro or other assisted technologies used

ectopic pregnancy surgery

- tube ressected or tied | * if you just take out the ectopic, it can scar down the tube and happen again

in what part of the tube are most ectopic pregnancies?

ampulla of the fallopian tube

what is the most common cause of maternal death in the 1st trimester?

ectopic pregnancy

there has been an ____ incidence in ectopic pregnancies but a _____ mortality in the past 10 years

increasing incidence | decreasing mortality

are chromosomal problems a reason for ectopic pregnancy?

NO!

3 possible clinical presentations of ectopic

- acutely ruptured - probable ectopic in symptomatic women - possible ectopic

symptoms of ectopic

amenorrhea, vaginal bleeding, lower abd pain

acutely ruptured ectopic: presentation and Txt

intraperitoneal hemorrhage severe abd pain and dizzy positive HCG *surgical emergency, large bore IV

ectopic pregnancy can result in what possible fates?

- tubal rupture and hemorrhage - pregnancy resorption - tubal abortion into peritoneal cavity - abd pregnancy (very rare)

probable ectopic Dx

US: no intrauterine pregnancy BUT they have significant HCG txt: surgical eval and therapy

what is the discriminatory zone of HCG?

quantitative HCG level above which viable IUPs are visible by ultrasound (about 2000 mIU/mL)

possible ectopic

pt is seen multiple times before anyone realizes what it is!

txt/management of ectopic: unstable vs stable

unstable: laparotomy (large incision to view) stable: laparoscopy (small incision with camera) - salpingectomy - salpingotomy/salpingostomy

salpingectomy

txt for ectopic: removal of fallopian tube if damaged, will be <6cm of tube left

salpingotomy/salpingostomy

txt for ectopic: incision along axis, POC removed

medical management of ectopic

methotrexate and monitor HCG (follow to zero)

when would you do expectant management for ectopic pregnancy?

``` stable undiagnosed (as ectopic) pts - reliable hCG levels less than 200 and declining ```

two types of induced abortion: surgical

D&C : earlier in pregnancy (<12 wks) | Dilation and evacuation: 13+ wks (vacuum & forceps use)

induced medical abortions can be done up to __ wks

3 types of medication used for induced abortion

misoprostol- dilates cervix and triggers contractions mifepristone- blocks progesterone methotrexate (with misoprostol) - interferes with placenta growth

90% of medical-abortions are complete within __ hrs

induced abortion: hypertonic saline or urea

later in pregnancy (16-24 wks ) injected directly into amniotic cavity (* not really done anymore, risk injecting Vascular system)

induced abortion complications

retained tissue- can cause thrombotic events

what is acute hematometra?

complication of induced abortion: collection of blood in uterine cavity