Week 3 Flashcards
Is bleeding in early pregnancy common?
YES, occurs in 20-40% of pregnant women, source is almost always maternal
Name 7 DDXs of bleeding in early pregnancy
- spontaneous abortion/miscarriage
- ectopic pregnancy
- placental bleeding/abruption/hematoma
- trophoblastic dz
- vaginitis, cervicitis, trauma, CA, warts, polyps, fibroids
- cervical ectropion
- physiologic or implantation bleeding
When a pregnant pt presents to your office with bleeding what questions do you need to ask? What do you need to review?
how much blood loss?
cramping or pain?
any tissue present?
review medical hx especially for previous gynecological/obstetrical issues that would increase risk for ectopic pregnancy (LNMP, hx of PID, prior ectopics, adnexal surgery)
on a PE of pregnant women with bleeding what do you need to do?
vitals
abd exam
pelvic exam
auscultate fetal heart tones (after 10-12 wks gestation)
what is quantitative hCG helpful for?
helpful in interpreting U/S findings
serial hCG’s can be helpful in the first 6 weeks of pregnancy
hCG should be doing in a normal intrauterine pregnancy?
doubling every 48-72 hours
what is a falling hCG indicative of? a plateaued or slowly rising hCG
falling hCG–> nonviable pregnancy
plateaued/slow–> ectopic
what 3 blood tests must you do on a newly pregnant mom?
quantitative hCG
ABO-rh
CBC w/diff
what can imaging NOT tell you about bleeding in early pregnancy?
whether it is vaginal or cervical bleeding
definition of spontaneous abortion
pregnancy that ends before fetus has reached 20 weeks
5 subcategories of abortions
- threatened miscarriage
- inevitable miscarriage
- complete miscarriage
- incomplete miscarriage
- missed abortion= confirmed non-viable pregnancy but no sxs yet
7 main risk factors for a spontaneous abortion?
- advancing maternal age
- previous spontaneous abortion
- smoking >10 cigs/day
- cocaine
- NSAIDs, excluding acetominophen
- low or high maternal BMI
- celiac dz
5 inconclusive risk factors for abortion
- EtOH
- gravidity
- fever of >100 deg F
- caffeine
- low folate (MTHFR and MTRR genes)
50% of all miscarriages are from what type of ‘change?’ The other causes of an abortion are what?
chromosomal abnormalities, many are aneuploidies
can also be dt congenital anomalies or trauma or host factors
clinical presentation of a spontaneous abortion?
hx of amennorhea, vaginal bleeding or pelvic pain
definition of an inevitable miscarriage, when does it most likely occur and why?
increasing uterine bleeding and cramping in the presence of a dilated cervix
most often in early pregnancy and usu dt chromosomal abnormalities (empty sac)
what is included in the management of an inevitable miscarriage?
ABO-rh and CBC
can be treated surgically (D&C), medically (misoprostol orally or vaginally) or expectantly
what are the dosages for a missed abortion vs an incomplete abortion?
missed abortion: 800 mcg vaginally or 600 mcg sublingually
incomplete abortion: 600 mcg orally
who is a good candidate for an expectant abortion? majority occur when? risks?
hemodynamically stable
majority occur in women at less then 13 weeks w/no sxs of infxn
risks: unplanned D and C if infxn occurs
can happen w/in 2 weeks of dx but can last up to 4 wks
definition of a threatened miscarriage? quality of bleeding? amount? color?
viable intrauterine pregnancy in the presence of uterine bleeding, bleeding often painless, may be pink, brown or bright red, could be large or small amount
what is the etiology of a threatened miscarriage?
disruption of decidual vessels, will see as a
subchorionic hematoma but usu can’t see b/c bleeding at edge of placenta
what must you always ask if a pt presents w/a threatened miscarriage? labs and imaging? give them what? suggest what?
intercourse in the past 24 hrs
ABO-rh, CBC and U/S
progestins or progesterone
bed rest and pelvic rest
what 4 herbs can help to stop a threatened miscarriage? what vitamins?
viburnum prunus, dioscorea villosa, valerian officianalis, hammamelis
vitamin E, C and citrus bioflavinoids
definition of a complete miscarriage? when is it likely to occur before? what will imaging show?
all products of conception have been passed
likely to occur before 12 wks gestation
U/S shows empty uterus
what herbs can help with an incomplete miscarriage? what homeopathics?
caulophylum thalictroides
cimicifuga racemosa
hammamelis virginiana
sabina
viburnum op
ferrum
cimicifuga
definition of an incomplete miscarriage? when is is more likely to happen? ssxs? imaging will show? tx?
miscarriage has occurred but there are still products of conception in the uterus
can happen at any gestation age but more likely >12 wks
variable bleeding, cramping common
U/S confirms retained tissue
medical or surgical tx recommended
definition of a missed abortion? ssxs? imaging shows? at risk of what if prolonged? tx?
in-utero death of fetus, retained products of conception
all ssxs of PG disappear
at risk of infxn
D and C if can’t wait for inevitable, inevitable or medication
definition of an ectopic pregnancy? sites it can occur?
developing blastocyst becomes implanted at site other than endometrium
common sites: fallopian tube (MC), ovar, abd/pelvic region, cervix
risks of an ectopic pregnancy? where does it rank as far as causes of pregnancy related maternal deaths? what %age of all pregnancy related deaths?
risk is rupture of ectopic= hemorrhage, maternal shock and potentially death
leading cause of pregnancy related maternal death in 1st trimester
4-10% of all pregnancy related deaths
untreated, they are often fatal
when do sxs of an ectopic pregnancy usu present? rupture? sxs of an ectopic?
6-8 wks after LNMP, but can be later, majority of rupture occur 6-12 wks gestation
normal pregnancy sxs, abd pain, amenorrhea, vaginal bleeding
PE of a woman with an ectopic PG will reveal what?
low grade fever, adnexal, CM and/or abd tenderness, adnexal mass, PE may be unremarkable
limits of an U/S with a suspected ectopic pregnancy?
difficult to dx intra vs extrauterine pregnancy when [hCG]
tx of an ectopic? who is a good candidate for the rx? indications for 2nd line tx?
methotrexate-folic acid antagonist or surgical
for methotrexate-folic acid antagonist tx need to be hemodynamically stable, will f/u, hCG less than 500
2ndary tx if: Hemodynamic instability, Impending or ongoing rupture of ectopic mass, Failed medical therapy, Women with contraindications to medical treatment
definition of gestational trophoblastic dz? hydatidiform moles are usu benign or malignant? lab? ssxs?
proliferative d/o of trophoblastic cells
hydatidiform moles are usu benign
elevated serum hCG
ssxs: vaginal bleeding, enlarged uterus, pelvic pain/pressure/theca lutein cysts, anemia, hyperemesis gravidarum
definition of a complete mole and partial mole
complete mole: fertilization of an empty ovum by 2 sperm, no fetus
partial mole: fertilization of a haploid ovum by 2 sperm, may result in fetus w/trophoblastic tissue
what 3 types of trophoblastic cells are malignant? when do they generally occur?
invasive moles, choriocarcinoma and placental site trophoblastic tumors
generally occur after a molar pregnancy but can also occur after SAB, TAB, ectopic or normal pregnancy
management of trophoblastic dz? possible complications?
refer to OB/GYN
D&C usu performed
serial hCGs afterwards until reaches zero
localized or metastatic dz can occur
3 other causes of early bleeding in pregnancy?
growths: vaginitis, trauma, CA, warts, polyps, fibroids
ectropion
physiologic or implantation bleeding
bleeding in the 2nd & 3rd trimester DDX (7)
- miscarriage, stillbirth
- cervical, vaginal or uterine pathology
- cervical insufficiency
- placenta previa
- placental abruption
- vasa previa
- uterine rupture
