termination of pregnancy Flashcards
HCG is secreted by the fetus how many days after ovulation?
6-8 days
at what levels are HCG tests negative and positive
negative: <5 IU/L
positive: >25 IU/L
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
what is the “fetal pole”?
measure from top to bottom of embryo in US
seen within yoke sac which is within gestational sac
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
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
80% of spontaneous abortions occur before ___wks gestation
12
if there is a normal pregnancy at ___ wks, fetal loss rate is only 3% over the next 20 weeks
8 weeks
define abortion
expelling of the embryo or fetus prior to being viable (before 20 wks)
what are the 6 different types of spontaneous abortion?
anembryonic threatened inevitable.. leading to complete missed recurrent
anembryonic pregnancy (leading to spontaneous abortion).
embryo fails to develop or is resorbed after loss of viability
anembryonic pregnancy on exam
cervix is closed. US: empty gestational sac seen without fetal pole.
missed, threatened and anembryonic pregnancies all have similar symptoms. what are these?
bleeding maybe
mild pain maybe
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
symptoms of threatened abortion
maybe vaginal bleeding and pain. but pain is NOT the prominent symptom
exam of threatened abortion
cervix is closed, US: normal gestational sac + viable embryo (but irregular sac,fetal pole or heart rate carry poor prognosis)
what is an inevitable abortion? (symptoms and cervix?)
clinical pregnancy complicated by vaginal bleeding AND crampy lower abdominal bleeding
**cervix partially dilated.
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)
for an incomplete abortion, what do you do with the products of conception that were passed?
send to the lab
what two types of imaging can be used for incomplete abortion?
US and color doppler
complete abortion
COMPLETE passage of POC and everything returns to pre-pregnant state
US for incomplete vs complete abortion?
incomplete: some products of conception visible in cavity
complete: no POCs visible in cavity
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)
missed abortion
fetus died but retained in uterus
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
- surgical D&C - lower rates retained products, quickest solution
- medical- Misoprostol. increase rate of retained products, lower rates of infection
- 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)
- cervical incompetence (usually trauma from D&C)
- congenitally abnormal uterus
- 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
9
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
24
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
