11/4- Complications of Early Pregnancy

Question 1

How is gestational age determined?

Answer 1

• Full-term human pregnancy lasts 37-42 weeks (average is 40 weeks)
• Calculated from first day of last menstrual period (LMP)
• Developmental (conceptional) age is 2 weeks less than menstrual age

Question 2

What are the time ranges for each trimester?

Answer 2

• First TM = 0-12 wks
• Second TM = 13-27 wks
• Third TM = 28-40 wks

Question 3

What are the terms for pregnancy loss in terms of time frame?

Answer 3

• 0-20 wks = Abortion
• 20-36+6 wks = Preterm delivery

Question 4

Case 1)

• Mrs. Adams comes to your office for her initial prenatal visit. - Her last menstrual period was 6 weeks ago, and she had a positive home pregnancy test 3 days ago.
• She has had one previous pregnancy which resulted in spontaneous miscarriage at approximately 7 weeks gestation.
• What is the likelihood of her current pregnancy resulting in a liveborn infant?

Answer 4

?

Question 5

Define the following:

• Spontaneous abortion:
• Incomplete abortion:
• Threatened abortion:
• Missed abortion:
• Induced abortion (elective ab):
• Recurrent abortion:

Answer 5

- Incomplete abortion: retention of parts of products of conception

- Threatened abortion: patient presents with some vaginal bleeding, and the cervix is not dilated; abortion may or may not occur

• Vaginal bleeding in the 1st trimester is never considered normal but it does not necessarily mean morbidity

- Missed abortion: retention in the uterus of an abortus that had been dead for at least eight weeks

- Induced (elective) abortion: abortion brought on by medications or instruments

• Recurrent abortion: >3 spontaneous abortions

Question 6

Fetal viability is only achieved in __% of all conceptions

• __-__% clinically diagnosed are lost in the 1st and 2nd TM

Answer 6

Fetal viability is only achieved in 30% of all conceptions

- 15-20% clinically diagnosed are lost in the 1st and 2nd TM

Question 7

T/F: a spontaneous abortion may present with or without physical symptoms

Answer 7

True

Question 8

When is the likelihood of spontaneous abortion lower?

Answer 8

Once fetal heart activity is visualized on USG

Question 9

What are the recurrence risks of abortion if the woman has had prior abortions?

• With/without other liveborn children?

Answer 9

Question 10

Another risk chart for spontaneous abortion

Answer 10

Question 11

What are etiologies of spontaneous abortion?

Answer 11

• Chromosome abnormalities
• Abnormal morphology
• Placental mosaicism
• Luteal phase defects
• Metabolic disease
• Uterine anomalies
• Infection
• Other

Question 12

What is the most common genotype involved in spontaneous abortion?

Answer 12

46,XX or 46, XY

Question 13

What are the common chromosomal abnormalities responsible for spontaneous abortion?

Answer 13

- Normal 46,XX or 46, XY (54%)

• Monosomy X (45x) (9%)
• Tripoloidy (68, XXX or 69, XXY) (8%)
• Tetraploidy (3%)
• Structural abnormalities (2%)

- Autosomal trisomy (22%)

• Mosaic trisomy (1%)

Question 14

What is the most common group of aneuploidy in spontaneous abortion?

Answer 14

Autosomal trisomies

Question 15

Describe autosomal trisomies in terms of spontaneous abortion

• Prognosis
• Beneficial factors
• Most common one
• Caused by

Answer 15

• Most common group of aneuploidy in spontaneous abortion
• Most are lethal in early pregnancy
• Mosaics may have higher survival
• Single most common trisomy in spontaneous abortion: Trisomy 16
• 90-95% result of maternal non-disjunction

Question 16

What is the single most common aneuploidy in abortuses?

Answer 16

45X

Question 17

What causes 45X genotype (mostly)?

Answer 17

>80% are due to loss of paternal sex chromosome (no maternal effect!)

Question 18

Look at this picture for confined placental mosaicism.

Answer 18

Question 19

What are maternal diseases that may contribute to spontaneous abortion?

Answer 19

• Thyroid disease
• Diabetes (insulin-dependent)
• Chronic HTN (later losses)
• Collagen vascular diseases (e.g. Lupus)

Question 20

What are uterine factors that may contribute to spontaneous abortion?

Answer 20

• Intrauterine synechiae (adhesions)
• Mullerian anomalies
• Bicornate or T shaped uterus, etc.
• Fibroids (benign, large masses within the uterus
• Incompetent cervix

Question 21

What are common exposures that may contribute to spontaneous abortion?

Answer 21

• Radiation (way higher SAb if > 10 rads)
• Smoking (increased SAb if moderate/more)
• Alcohol ( but teratogenic)
• Caffeine ( if moderate)
• Trauma (unlikely)

Question 22

What are the different management methods of spontaneous abortion?

Answer 22

• Expectant
• Medical
• Surgical

Question 23

Case 2)

• Miss Burke, a 22 year old college student, presents to the ER with severe LLQ pain. The pain has been getting steadily worse over the past 10 days.
• She thinks she started her period a couple days ago.
• She states she “likes to party”, is sexually active, and not using contraception. Her pregnancy test is positive.
• During the evaluation, she becomes tachycardic and hypotensive.
• What is the most likely diagnosis?

Answer 23

Ectopic pregnancy

Question 24

What is an ectopic pregnancy?

Answer 24

Any pregnancy implanted outside of endometrial cavity

Question 25

What are common sites of ectopic pregnancy?

Answer 25

**- Tubal (96%)** * Ampullary (most common) * Isthmus (2nd most common) * Interstitial, cornual (rare, 2-5%) - Ovary (0.5-1%) - Fimbria (very rare) - Cervix (0.1%): very rare but very dangerous

Question 26

Look at this picture of a tubal pregnancy.

Answer 26

This camera is coming from the anterior abdominal wall

Question 27

T/F: the incidence of ectopic pregnancies is increasing?

Answer 27

True

Question 28

What are contributing factors to ectopic pregnancies?

Answer 28

- More conservative PID therapies (rather than surgical excision) - Successful tubal surgeries - Increased use of assisted reproduction, such as IVF

Question 29

What are risk factors for ectopic pregnancy?

Answer 29

- Previous pelvic infection - Previous tubal surgery - Intrauterine device in place - Previous tubal pregnancy

Question 30

What is the clinical presentation of an ectopic pregnancy?

Answer 30

- Abdominal pain (90-100%) - Amenorrhea (75-85%) - Vaginal bleeding (50-80%) - Dizziness - Pregnancy symptoms - Tissue passed

Question 31

What are physical findings with an ectopic pregnancy?

Answer 31

- Adnexal tenderness (75-90%) - Abdominal tenderness (80-95%) - Adnexal mass (50%) - Uterine enlargement - Orthostatic bp changes - Fever

Question 32

How is an ectopic pregnancy diagnosed?

Answer 32

- Monitor hCG levels (normally doubles every 48 hrs in the 1st TM) - High-resolution ultrasonography

Question 33

How should an ectopic pregnancy be managed?

Answer 33

- Vaginal ultrasonography to look for intrauterine gestational sac * If intrauterine gestation sac visualized: routine follow up (repeat US in 1 wk) * If no intrauterine gestational sac seen: look for tubal pregnancy * When looking for tubal pregnancy, if none visualized, do quantitative hCG (if \> 2000 than treat for ectopic pregnancy, otherwise follow up) * If tubal pregnancy visualized, treat for ectopic pregnancy

Question 34

What are treatment options for ectopic pregnancy?

Answer 34

Surgical - Laparoscopy with salpingectomy or salpingotomy Medical - Methotrexate (single or mutliple dose); recall, this inhibits DHFR (stop prenatal vitamins with folate)

Question 35

Case 3) - Mrs. Chang, a 42 year old librarian, presents to the Emergency Room with heavy vaginal bleeding and passage of tissue she describes as “lots of tiny sacs”. - Her menstrual periods are irregular, and the last one was 4 months ago. - On physical exam, her uterus reaches to the level of her umbilicus. - What is your next step in her evaluation and treatment?

Answer 35

Molar pregnancy (hydatidiform mole)

Question 36

What is a molar pregnancy (hydatidiform mole)?

Answer 36

- Definition: abnormal development of chorionic villi in pregnancy (with or without fetal tissue) - Can persist and develop into gestational trophoblastic disease (GTD)

Question 37

What are features of molar pregnancy?

Answer 37

Features of complete mole: - Trophoblastic proliferation - Cystic villi - No fetal tissue

Question 38

What is a partial mole?

Answer 38

- Fetus or fetal tissue present - Non-viable: multiple structural anomalies of fetus with major growth lag

Question 39

What is the clinical presentation for a molar pregnancy?

Answer 39

- Vaginal bleeding - Uterine size discrepant from dates - Hypertension - Hyperemesis - Thyroid dysfunction - Theca lutein cysts of ovaries

Question 40

What is seen here?

Answer 40

Ultrasonographic findings of a molar pregnancy: - Left: 11 wk fetus - Right: hydatidiform mole

Question 41

What groups are most affected by molar pregnancies?

Answer 41

Asian - Vietnamese - Japanese American...

Question 42

What are risk factors for molar pregnancy?

Answer 42

- Maternal age \< 20 or \> 40 yo - Asian ethnicity - Prior molar pregnancy - Low SES (possible nutritional factors)

Question 43

Look at this flowchart for therapy of molar pregnancies

Answer 43