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GYN exam 3 > TEST 3 STUDY GUIDE ECTOPIC PREG & MORALS > Flashcards

TEST 3 STUDY GUIDE ECTOPIC PREG & MORALS Flashcards

1
Q

ectopic pregnancy:

A
  • Location of pregnancy outside uterus
  • 10% maternal deaths related to ectopic pregnancy
  • Effect on future fertility & recurrance
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2
Q

true or false? A woman capable of conceiving is capable of having a pregnancy in a location other than the uterine cavity

A

true

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3
Q

clinical findings ectopic pregnancy:

A
  • Positive pregnancy test
  • Pain 97%
    • Shoulder, generalized abd, lower abd, lower quadrant ipsilateral to ectopic, lower quadrant contralateral to ectopic, back, vaginal
  • Vaginal bleeding
  • Palpable adnexal mass
  • Clinical Triad – Pain, Bleeding, Adnexal mass – 45%
    • Not specific for ectopic pregnancy – 14% confirmed ectopic
    • Ovarian cysts (27%), PID (15%), DUB (4%), Spont Ab (5%)
  • Present at 5-6 weeks
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4
Q

ectopic prenancy occurs in fallopian tubes in almost __ of patients

A

95%

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5
Q

when ectopic pregancy is located in the _____ portion of the ____ ____ near the ___ ___, an increased risk of massive hemorrhage exists, which may lead to hysterectomy or even death.

A

interstitial

fallopian tube

uterine cornua

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6
Q

true or false?

serum beta hCG levels in an ectopic pregancy do not increase as they do in a normal pregnancy

A

true

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7
Q

what is the clinical triad found w/ ectopic pregnancy?

A

Pain, Bleeding, Adnexal mass – 45%

  • Not specific for ectopic pregnancy – 14% confirmed ectopic
  • Ovarian cysts (27%), PID (15%), DUB (4%), Spont Ab (5
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8
Q

when are clinical findings present for ectopic pregnancy?

A

5-6 weeks

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9
Q

Pregnancy Testing w/ hCG: what is 2IS

A

2IS (Second International Reference)

  • Introduced in 1960’s
  • 800 - 1000 IU/L - normal intrauterine gest sac can be seen
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10
Q

slight risk factors for ectopic pregnancy:

A
  • Previous pelvic/abd surgery (.9-3.8),
  • smoker (2.3-2.5),
  • Vaginal douching (1.1-3.1),
  • early age 1st intercourse <18 yrs (1.6)
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11
Q

Moderate Risk factors for Ectopic Pregnancy:

A
  • Infertility (2.5-21),
  • Previous genital infections (2.5-3.7),
  • Multiple sexual partners (2.1)
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12
Q

High risk factors for Ectopic Pregnancy:

A
  • Tubal Surgery (21.0),
  • Sterilization (9.3,
  • Previous ectopic (8.3),
  • DES daughter (5.6),
  • Use of IUD (4.2-45.0),

Documented tubal disease (3.8-21.0)

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13
Q

Pregnancy Testing with hCG: what is 1st IRP

A

(First International Reference Preparation)

  • Purer standard – main standard used today
    • 1000 - 2000 IU/L - normal intrauterine gest sac can be seen
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14
Q

what is the minimum lwvel of hCG in normal pregnancy?

A

2000 mIU/mL, IRP

  • If no gest sac seen ≥ these levels=suspect ectopic
  • Differential dx -> possible early IUP, miscarriage, ectopic
  • As many as 19% may have IUP on followup
  • Guideline only – use clinical indications and f/u if stable
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15
Q

Serial quantitative beta hCG levels

A
  • hCG levels double every 2 days in normal preg
    • & 21% of ectopic
  • 90% ectopic preg nonviable -> beta hCG levels low
  • Falling hCH levels may indicate missed or incomplete abortion
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16
Q

TRUE OR FALSE?

90% ectopic preg nonviable -> beta hCG levels low

A

true

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17
Q

Falling hCH levels may indicate:

A

missed or incomplete abortion

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18
Q

common sites of ectopic pregnancy

A
  • Tubal 95-97%
    • Ampullary – most common
    • Isthmus – second most common
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19
Q

Uncommon Sites of Ectopic Pregnancy

A
  • Interstitial (Cornual) – rare 2-5%
  • Ovary – rare 0.5 – 1.0% (text states <3%)
  • Fimbria – very rare
  • Cervix – very rare 0.1%
  • Abdominal – very rare
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20
Q

image: sites of ectopic preg

A
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21
Q

A

A

Interstitial (cornual)

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22
Q

B

A

isthmus

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23
Q

C

A

abdominal

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24
Q

***D

A

ampullary

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25
Q

**E

A

fimbrial

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26
Q

**F

A

Ovary

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27
Q

**G

A

cornual (interstitial)

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28
Q

**H

A

fornix

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29
Q

**I

A

cervical

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30
Q

**J

A

body of uterus

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31
Q

**K

A

abdominal peritoneum

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32
Q

true or false? a increased risk of a complete hysterectomyexists when an ectopic pregnany is located in the uterine cervix.

A
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33
Q

a combination of ___ ___ and an ___ ___ is the best correlation in dagnosis of an ectopic pregnancy.

A

free fluid; adnexal mass

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34
Q

echogenic free fluid is related to a __% risk of ectopic pregnancy.

A

92% (86%-93%)

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35
Q

what are the Sonographic Findings: Ectopic

A
  • Determine if normal early intrauterine pregnancy
    • Intrauterine gestational sac preferably with heart beat
  • Extra-ovarian Adnexal mass
  • Fluid in cul-de-sac
    • Echogenic fluid (86-93% for ectopic)
    • Check kidneys for hemoperitoneum
  • Pseudogestaional sac
    • Differentiate betwn normal IUP & pseudo
    • 20% ectopic preg demonstrate pseudo gest sac
  • Finding of live embryo within adnexa (specific)
  • Extrauterine gestational sac or ring in adnexa - 71%
  • 26.3% ectopic preg with a normal sonogram
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36
Q

what is a pseudogestational sac?

A

located in middle of endometrium, does not have a yolk sac, has internal echoes, and a high resistive spectral waveform

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37
Q

EARLY IUP: shape, location, margins, decidual reaction, sac

A

round

eccentric location in endometrium

well defined margins

well defined decidual reaction

possible double decidual sac sign

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38
Q

Pseudosac: shape, location, margins, decidual reaction, sac

A

ovoid shape

cebtral location in endometrium

poorly defined margins

absent decidual reaction

single decidual layer

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39
Q

pseudogestational sac characteristics

A
  1. No living embryo
  2. No yolk sac
  3. Sac central endometrium
  4. Low level echos
  5. Best seen endovaginal
  6. High resistance pattern
    * (low diastolic flow) with low peak velocities
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40
Q

decidual cast - pseudosac

A
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41
Q

gestational sac

A

echogenic ring - classic chorionic ring

Double decidual sac sign

–Inner ring – echogenic chorionic vili

–Outer ring- deeper layer of decidua vera (D)

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42
Q

gestational sac

A

Double decidual sac sign plus yolk sac

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43
Q

Adnexal Masses with Ectopic

A

Complex adnexal mass

  • Extrauterine gest sac
  • Hematoma within peritoneal cavity
    • Within fallopian tube or broad ligament
  • Ovarian Cyst: Corpus luteum cyst
    • Differentiate with surrounding ovarian tissue
    • Quantitative beta-hCG levels
  • 80% with ectopic have @25 ml blood pooling in peritoneum
  • 60% Intraperitoneal fluid - moderate to large quantities
    • Check abd gutters to eval extent of fluid present
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44
Q

what is the most frequent sonographic finding in an ectopic pregancy?

A

adnexal mass

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45
Q

Pregnancy Testing w/ hCG: what is 1st IRP

A

1st IRP (First International Reference Preparation)

  • Purer standard – main standard used today
  • 1000 - 2000 IU/L - normal intrauterine gest sac can be seen
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46
Q

___ ___ cysts usually regress and are not seen beyond 16 to 18 weeks, but are commonly seen with ectopic pregnancy

A

corpus luteum

47
Q

most common mass in 1st trimester

A

corpus luteum

48
Q

**ectopic preg

A

Rt adnexal ectopic pregnancy

Note: echogenic ring between Right ovary and Uterus - Double white arrows

Note: embryo within ring (E)

49
Q

**extraovarian adnexal ring

A
  • Left tubal ring adjacent to left ovary
  • Lt ovarian corpus luteum cyst
  • No intrauterine preg seen
  • Small amount free fluid adjacent to ovary (f)
50
Q

adnexal echogenic ring

A

Rt adnexa mass with echogenic ring consistent with ectopic gestational sac

Ring represents trophobastic Tissue or chorionic villi

51
Q

**Ectopic Pregnancy

A

corpus luteum cyst on left ovary

52
Q

adnexal mass

A

ectopic pregnancy with blood around it (found during surgery)

53
Q

ectopic scenario

A
54
Q

**definitive ectopic

A

90% do not show heart beat

55
Q

true or false? blood + positive hCG results has 86-93% positive perdictive value for ectopic pregnancy

A

true

56
Q

assessment of cul-de-sac

A
  • Cul-de-sac should be examined for free fluid
    • Characterize as simple or complex
    • Complex (echogenic) is suggestive of blood
    • Blood + positive hCG results has 86-93% positive predictive value for ectopic pregnancy
    • May be only TV sonographic finding
  • Check kidneys to evaluate for hemoperitoneum
57
Q

free fluid in pelvis

A

intraabdominal blood

58
Q

types of ectopic pregnancy

A

heterotopic

interstitial

cervical

ovarian

abdominal

59
Q

heterotopic pregnancy:

A
  • Increased incidence with ovulation induction
  • Increased incidence with IVF & embryo transfer
    • Increased risk bilateral ectopic pregnancy
60
Q

interstitial pregnancy (cornual)

A
  • Most life threatening with parauterine & myometrial vasculature
    • life threatening hemorrhage
    • 2% occurance in ectopic pregnancies
    • Eccentrically placed gest sac with incomplete myometrial mantel surrounding sac.
61
Q

interstital pregnancy

A
62
Q

cervical pregnancy

A
  • Gestational sac within cervix
    • May contain spontaneous abortion in progress
    • Color doppler: eritrophoblastic flow in cervical preg
  • Increased risk of complete hysterectomy
    • Uncontrolled bleeding w/ increased vascularity of the cervix
    • Risk factors: multiparity, prior abortion or instrumentation of cx or endometrial cavity
63
Q

cervical ectopic pregnancy

  • In past, led to hysterectomy
    • Result of life-threatening hemorrhage
  • Current treatment conservative
    • US guided local potassium chloride injection
    • Systemic or local methotrexate
    • Preoperative uterine artery embolization before D&C
A
  • TV scan of sagittal uterus showing cervical ectopic pregnancy
  • No GS present in endometrial cavity.
  • Intact GS containing YS present in cervix
  • Magnified view of GS shows embryonic pole with cardiac activity documented with M-mode tracing
64
Q

ovarian ectopic pregnancy

A
  • Very rare - less than 0.5-1% all ectopic
  • Textbook states <3%
  • Complex adnexal masses may involve or contain ovary - making it difficult to distinguish from other ovarian process
65
Q

true or false? if gestational sac is moving it is a spontaneous abortion in progress.

A

true

color is also an easy way to tell if spontaneous abortion or ectopic

66
Q

true or false?

the embryo is attracted to c section scars?

A

true

67
Q

abdominal pregnancy

A
  • Pregnancy develops outside tubes within peritoneal cavity
  • Sonographic Findings
    • Fetus, placenta, amniontic fluid outside the uterus
    • Membrane around abdomnal pregnancy very thin - no myometrium
    • Pregnancy lies close to abdominal wall
  • Abdominal pregnancies often fail before term
  • C-section delivery with placenta left in place
    • Methotrexate to help reabsorption
68
Q

c section scar pregnancy

A
69
Q

treatment of ectopic pregnancy

A
  • Microsurgery through laparoscope to maintain function of unruptured tube
    • Linear salpingostomy with milking pregnancy out of distal ampulla
      • Possible resection of segment of fallopian tube w/ gestation w/ or w/o reanastomosis
  • Methotrexate injection - antimetabolite chemotherapeutic agent that interferes with DNA synthesis & disrupts cell multiplication.
    • Eliminates morbidity from surgery & general anesthesia
    • less tubal damage, less cost & need for hospitalization
    • Patient must return for follow up
    • Lower success rate w/ ectopic with cardiac activity
  • Surgery
    • Live ectopic
    • Large adnexal mass > 4cm
70
Q

indications for 1st trimester exam

A
  • confirm IUP vs. EUP
  • define cause of bleeding
  • pelvic pain
  • viability
  • # of embryos
  • gestational age
  • detect anomalies
  • r/o hydatidform mole
  • adjunct to CVS, amnio, embryo transfer, IUD removal
  • 1st trimester exam done only when deemed necessary
71
Q

gravidity:

A

of pregnancies including this one

72
Q

parity:

A

all pregnancies

fullterm, premature&stillborn, early loss or abortion, living children.

In US P+A= G

73
Q

1st trimester

A

till 14 weeks (0-14 weeks)

74
Q

**2nd trimester

A

till 27 weeks (14-27 weeks)

75
Q

**3rd trimester

A

27 weeks-term

76
Q

2nd and 3rd trimester indications

A
  • gestational age
  • fetal growth
  • vag. bleeding
  • abd/pelvic pain
  • incompetent cervix
  • # fetuses
  • determine fetal presentation
  • size descrepancies to dates
  • pelvic mass
  • r/o ectopic
  • suspect hydatidform mole
  • cervical cerclage placement
  • fetal viability
  • uterine abnormality
  • amniotic fluid
  • evaluate fetal well being
  • placental abruption
  • external cephalic version
  • premature rupture of membranes
  • abnormal chemical markers -lab values
  • f/u fetal anomaly
  • hx prev congenital anomaly
  • eval for late to prenatal care (cant see bones block view
77
Q

maternal risk factors

A
  • Maternal Age
  • Abnormal triple screen biochemistry values
  • Maternal disease
  • Uterus measures large or small for dates
  • Previous child with chromosomal disorder
  • Exposure to teratogenic drug or infectious agent
  • Maternal environment
    • Nutrition
    • Genetic
78
Q

patient history

A
  • LMP - first day of last menstrual period
  • EDC determined by earliest ultrasound
  • Current medications
  • Clinical problems with pregnancy
  • Problems with previous pregnancies
    • Incompetent cervix, fibroids, fetal anomalies
    • C-section delivery, hypertension
79
Q

safety of ultrasound

A
  • Used in pregnancy since 1950’s - no side effects
  • exisiting studies not large enough to document small increases in normally occurring anomalies
  • Studies in animals have suggested:
    • Growth differences
    • Increase in left handedness
    • Delayed speech
80
Q

Obstetrical US factors

A
  • Theoretical effects of US energy on fetus has potential biological effects not yet documented
  • Energy produced by US equipment today is higher than that produced by earlier units
  • Doppler imaging produces higher energy
  • Study of US bioeffects are not definitive- continued research is essential
  • Sonographers have responsibility to be knowledgeable about US bioeffects and use the least amount of energy necessary to produce clinical information needed.
81
Q

biologic effects

A
  • Thermal - a rise in temperature
    • Minimize thermal effects
      • Don’t stay in one spot for long period of time over bone
      • Extend focus of beam deep for adequate image
  • Cavitation - production and collapse of gas filled bubbles
    • Dependent on the presence of gas preexisting within tissue
      • Neonatal lung
82
Q

guidelines for US exam

A
  • Examination protocol
    • AIUM guidelines
  • Qualification of personnel
    • National board certification
  • Documentation standards
    • Patient name, date, image orientation
    • Written report in patient records
  • Equipment
    • Transducer frequency selection
      • ALARA- (as low as reasonably achievable) principle
  • Safety
    • HIPAA, Infection control, Quality control,
    • Musculoskeletal injury - ergonomic protection
83
Q

informed consent is an ____ based right

A

autonomy

84
Q

what did thomas percival do?

A

changed medical ethics

  • Redefined patient as anyone needing care.
  • Team approach in health care and public health
  • Needs of patient came over competition or professional interests
85
Q

Hippocrates said what and what does it mean?

A

“First do no harm”

  • ethical principle of nonmaleficence
  • emphasized tmts based on best benefit to patient
  • treat pt like you would your own family
86
Q

what emphasizes individual rights and autonomy, which has beecome a key element in modern day ethics

A

Nuremberg Code

-came from experimenting on prisoners

basic principles put into research , professional codes and clinical practice throughout the world

87
Q

basic principles of ethics

A
  • autonomy
  • justice
  • beneficence
  • nonmaleficence
  • integrity
  • respect for persons
88
Q

___ethics serve as a foundation for ___ ethics

A

philosophic

medical

89
Q

ethics

A
  • systematic reflection on and analysis of morality
  • stuy seeks to articulate clear, constant, coherent, and practical guidelines for conduct and character
90
Q

nonmaleficence

A

cause no harm

education, competency, skill, impressions are appropriate

91
Q

which principle directs the sonographer not to cause harm

A

nonmaleficence principle

92
Q

beneficence:

A

seeks greatest benefit from exam

the goal seeking a greater balance of clinical goods over clinical harms

93
Q

integrity:

A

ino difference exists in what a person says and what he or she does

94
Q

primum non-nocere (first do no harm)

A

stresses choosing a treatment based on the best benefit to the patient

95
Q

pain

A

physiologic phenomenon involving the central nervous system processing tissue damage

96
Q

morality

A

reflects duties and values &

matters concerning right and wrog conduct and good and bad character

97
Q

confidentiality:

A

of HIPPA

from principle of beneficence

pateint spouse and familes are third parties

no info given w/out pt explicit permission

the job of the healthcare professional to protect and respect a patients privacy

98
Q

**HIPPA practices conform to what principle of medical ethics?

A

confidentiality of findings

99
Q

**continuing ed is an ex. of what principle of ethics?

A

non-maleficience

100
Q

true or false? SDMS has adopted a code of ethics for medical sonographers?

A

true

101
Q

what type of issue is family tradition?

A

moral issue

102
Q

providing a detailed explanantion of the exam is an ex. of what principle of ethics?

A

autonomy

103
Q

integrity

A

adhering to moral and ethical principles

104
Q

reading current medical literatures, and being aware of new developments is an ex. of what principle of ethics?

A

nonmaleficience

105
Q

the principle of ______requires sonographers to preform only medically indicated examinations and to perfor all examinations in keeping with ALARA to get desired results

A

nonmaleficience

106
Q

veracity:

A

truthfulness

107
Q

justice:

A

fair ditribution of benefits and burdens

sonographers must thrive to treat all pateints equally

108
Q

____ encourages sonographer to go beyond the minimum standard protocol and to seek additional images and info if achievable and in the best interest of the patient

A

beneficence

109
Q

principle of ____ obligates the sonographer to seek the greates benefit for the pt

A

beneficience

110
Q

autonomy:

A

key ethical principle is the right to self-determination, patient right to refuse, right to information (1st trimester scan for abortion)

self governing or self directing freedom to choose and have their decision respected

111
Q

an obligation to the fetal patient going to term to protect and promote both fetal interests and those of the child it will become as understood from a rigorous clinical perspective ai what principle of medical ethics?

A

beneficence

112
Q

which ethics principle requires sonographers to perform all examinations with ALARA

A

nonmaleficence

113
Q

true or false? info receivewd from a sonogram enhances a woman’s choice or autonomy, and failure to provide these choicesw to some women and not others is an example of injustice.

A

true

114
Q

truthfullness w/ respect to abilites and limits is an example of ____

A

veracity

GYN exam 3 (7 decks)

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