1st trimesterloss-Table 1 Flashcards
(126 cards)
1
Q
What defines 1st trimester loss?
A
Termination of pregnancy before 20 weeks, loss before viability outside of the womb
2
Q
When do the majority of spontaneous miscarriages happen (SAB)?
A
3
Q
What are the causes of 1st trimester loss?
A
Infectious, immune, environmental, endocrine, structural
4
Q
What is a major endocrine cause of 1st trim loss?
A
Uncontrolled glucose from type I DM
5
Q
When is SAB most commonly caused by ETOH?
A
High doses in the first 8 weeks
6
Q
What might be some concerning hx symptoms that could indicate 1st trimester loss?
A
Cramps, backache, vaginal blood or discharge, and uterine contractions
7
Q
What diagnostics should be run to confirm a viable pregnancy?
A
Serum B-hCG should double q 48 hrs up to 60-80 days post last menstrual cycle
US: should have gestational sac 4-5 weeks and fetal pole at 5-6 weeks
8
Q
Spotting or a light bleed around the time of expected pregnancy is normal or abnormal?
A
Normal if light flow, if heavy like an actual period more likely SAB
Always work them up regardless
9
Q
What are some benign reasons for spotting?
A
Corpus luteum dissolution, implantation
10
Q
What are the types of spontaneous miscarriages?
A
Threatened, inevitable, missed
11
Q
What are emergent conditions associated with spotting?
A
Ectopic or molar
12
Q
What might your pt present with if threatened abortion?
A
Hx of spotting and absence of ab/pelvic issues
All the PE is normal
13
Q
What should you check for if mom is past 12 weeks and threatened abortion?
A
Check for FHT with doppler
14
Q
What should you be checking if pt has threatened?
A
B-hCG, US,
15
Q
How is a threatened abortion managed?
A
Reassurance and precautions
16
Q
What does a threatened abortion mean?
A
May or may not abort… body is deciding
Have them call if bleeding intensifies or ab and pelvic pain…. No sex no tampons maybe stay off her feet (that probs wont help in real life)
17
Q
If threatened progresses to inevitable, what s/s might mom present with?
A
Dilated or open cervix dilted, bleeding, and uterine contractions , low back ache
18
Q
what is incomplete?
A
Partially expelled POC, cervix is dilated and there is bleeding and abdominal pain
19
Q
What is complete?
A
Os closed, canal clear, uterus has expelled all of the POC, +/- adnexal mass, uterus smaller than GA
20
Q
How is an incomplete AB managed?
A
In office… ring forceps to remove visible POC and send to path….monitor B-hCG levels until 0-5.. weekly for about 5 weeks to make sure tissue is gone
KEY: if there is any chorionic villi in sample confirms that POC is out
Hospital: suction curettage to remove POC- monitor B-hCG, will drop quickly
21
Q
What is a missed AB?
A
Embryo fails to develop but POC is retained… no pain or symptoms really
May have brown discharge
22
Q
What do you check in missed AB?
A
US and Doppler…. Verify no heart beats or nothing in sac
23
Q
How is missed AB tx?
A
Need to do hospital outpt suction curettage to remove the POC
24
Q
What are other managements for missed AB?
A
- Monitor bleeding/pain symptoms until B-hCG levels 0-5; analgesia PRN
- Minimize infection risk: monitor temp, pelvic rest
- Rh immunoglobulin (Rh negative mothers)
- Emotional support….. these pts will be angry because they were pregnant and had viable pregnancy past 6-8wks
25
What are the types of induced abortions?
1- Maternal choice: elective termination
| 2- therapeutic termination
26
How long do you have to induce abortions with medical option?
Depends on state…. 63 days
27
What are the medications used in medical abortion?
1st, Oral mifepristone: reverses UC inhibition & causes uterine lining to thin & prevents embryo from remaining implanted
next give misoprostol combo: causes contraction and expulsion, 24-48hrs after mife
28
when should women be rechecked to make sure there has been complete expulsion?
With in 2 weeks
29
What is the surgical procedure for abortion?
Vacuum aspiration 13 wks
30
What are post surgical complications you should have your women come back in for?
```
Severe abdominal or back pain
Heavy bleeding (soaking 2 maxipads per hour x 2 consecutive hours)
Foul-smelling discharge; Temp > 100.4°F
Rh immunoglobulin (Rh negative mothers)
Emotional support
```
31
What defines recurrent loss?
>/= 2 consecutive pregnancies or SAB btwn full term IUP
32
What are the different causes depending on timing for recurrent loss?
??????
1st trimester: parent karyotypes - genetics
2nd trimester-Cervical insufficiency: painless effacement & dilation
Common hx: cervical conization
33
How is cervical insufficient tx?
Cervical cerclage
34
Where are the majority of ectopic pregnancies located?
Fallopian tube
35
What are risk factors for ectopic pregnancy?
```
Prior abd’l or pelvic surgery
Tubal scarring 2ndary PID/salpingitis
Prior ectopic or tubal surgery
Hx STD
Hx infertility & ART procedures
```
36
What are the S/S of ectopic pregnancies?
Asymptomatic or vaginal some bleeding or emergent d/t hemodynamic compromise (rare) - might have ab pain
- might have mass
- might have bleeding
- +/- N, V, breast fullness … not really
37
What will be s/sof emergent ectopic preggo?
If shoulder pain… HOSPITAL ASAP will need emergent surgical handling
Ab guarding, hypotension, tachy, dizzy, fever
38
What should be used to diagnose?
TVUS to look for sac
B-hCG
If no sac and beta >2000, diagnostic of ectopic until proven otherwise
39
What is stable and early ectopic and how is it managed?
Asymptomatic, beta
40
If you have expectant management what kind of pts do you have to have??
RELIABLE and have easy access to your clinic
41
If your ectopic mom is not stable, how is it managed?
1- need informed consent
2- give one dose methotrexate
3- follow up to confirm termination
42
What are the CI to methotrexate?
Breastfeeding, immunodef’cy, alcoholism or liver dz d/t EtoH, pre-existent bone marrow/blood dyscrasias, active pulmonary dz, PUD
43
What does mom need to avoid when taking the metho?
Avoid ETOH, NSAIDS, folic acid supplements, sun exposure (photosensitivity), no coitus until beta negative, no strenuous exercise
44
What do you need to get pre-tx for ectopic?
serum creatinine, LFTs, CBC & repeat 1 week s/p methotrexate
45
How is the methotrexate given?
Single IM dose
46
How long do you need to recheck beta quant after methotrexate?
days 4 & 7 post injection (expect 15% drop in level) then weekly until undetectable
47
What are the surgical options for ectopic pregnancy?
```
Laparoscopic linear salpingostomy
-Removes pregnancy – preserves tube
Laparoscopic segmental resection
-Removes portion of tube w/pregnancy
Salpingectomy
-Remove entire tube
```
48
What is gestational trophoblastic neoplasia?
spectrum abnormal placental proliferation (trophoblastic tissue)
49
What are the types of GTN?
Benign: : hydatidiform mole (aka molar pregnancy)
| Persistent or malignant dz
50
What happens to the chorionic villi in benign GTN?
Villi continue to grow & become swollen & visible as “drops of water” - placenta develops into abnormal mass of cysts
51
What is the hydatidiform mole?
Non-malignant, non-metastatic but not compatible w/fetal life
52
What is the complete type of hydatidiform mole?
no embryo just abnormal placenta, more likely to undergo malignant transformation
caused by abnormality of fertilized egg – all chromosomes from dad
53
What is a partial hydatidiform mole?
Some fetal development & abnormal placenta
54
What is the cause of partial?
Maternal chromosomes remain but father provides two sets of chromosomes
Result: embryo has 69 chromosomes instead of 46
55
What might mom come in complaining of if GTN suspected?
Normal IUP initially or dark brown to bright red vaginal bleeding 1st trimester, severe N/V, severe anemia, rarely pelvic pressure or pain
56
What will the PE look like in a women with GTN?
Absent FHT, rapid uterine growth - too large for GA, HTN, preeclampsia, hyperthyroidism
Most likely present at 12-14 weeks can be as early as 8-9
57
What will be the clinical presentation of complete ?
no embryo/fetus; no amniotic fluid; thick & cystic placenta filled uterus (snowstorm appearance), ovarian cysts
58
What will be the clinical presentation of partial?
growth-restricted fetus; low amniotic fluid; a thick cystic placenta
59
What is the tx for GTN?
Stabilize
| Evacuate via D+C
60
What is management following GTN tx?
- -B-hCG w/in 48 hrs s/p evacuation then q 1-2 weeks/while elevated then q 1-2 months for 6 months to 1 year
- --Contraception 1 year
61
What constitutes persistent GNT?
Rise B-hCG after decline or plateau
62
How is a localized single invasive mole persistent GTN tx?
Single agent chemo
63
How is a choriocarcinoma persistent GTN tx?
Multi agent chemo
64
What defines 1st trimester loss?
Termination of pregnancy before 20 weeks, loss before viability outside of the womb
65
When do the majority of spontaneous miscarriages happen (SAB)?
66
What are the causes of 1st trimester loss?
Infectious, immune, environmental, endocrine, structural
67
What is a major endocrine cause of 1st trim loss?
Uncontrolled glucose from type I DM
68
When is SAB most commonly caused by ETOH?
High doses in the first 8 weeks
69
What might be some concerning hx symptoms that could indicate 1st trimester loss?
Cramps, backache, vaginal blood or discharge, and uterine contractions
70
What diagnostics should be run to confirm a viable pregnancy?
Serum B-hCG should double q 48 hrs up to 60-80 days post last menstrual cycle
US: should have gestational sac 4-5 weeks and fetal pole at 5-6 weeks
71
Spotting or a light bleed around the time of expected pregnancy is normal or abnormal?
Normal if light flow, if heavy like an actual period more likely SAB
Always work them up regardless
72
What are some benign reasons for spotting?
Corpus luteum dissolution, implantation
73
What are the types of spontaneous miscarriages?
Threatened, inevitable, missed
74
What are emergent conditions associated with spotting?
Ectopic or molar
75
What might your pt present with if threatened abortion?
Hx of spotting and absence of ab/pelvic issues
| All the PE is normal
76
What should you check for if mom is past 12 weeks and threatened abortion?
Check for FHT with doppler
77
What should you be checking if pt has threatened?
B-hCG, US,
78
How is a threatened abortion managed?
Reassurance and precautions
79
What does a threatened abortion mean?
May or may not abort… body is deciding
Have them call if bleeding intensifies or ab and pelvic pain…. No sex no tampons maybe stay off her feet (that probs wont help in real life)
80
If threatened progresses to inevitable, what s/s might mom present with?
Dilated or open cervix dilted, bleeding, and uterine contractions , low back ache
81
what is incomplete?
Partially expelled POC, cervix is dilated and there is bleeding and abdominal pain
82
What is complete?
Os closed, canal clear, uterus has expelled all of the POC, +/- adnexal mass, uterus smaller than GA
83
How is an incomplete AB managed?
In office… ring forceps to remove visible POC and send to path….monitor B-hCG levels until 0-5.. weekly for about 5 weeks to make sure tissue is gone
KEY: if there is any chorionic villi in sample confirms that POC is out
Hospital: suction curettage to remove POC- monitor B-hCG, will drop quickly
84
What is a missed AB?
Embryo fails to develop but POC is retained… no pain or symptoms really
May have brown discharge
85
What do you check in missed AB?
US and Doppler…. Verify no heart beats or nothing in sac
86
How is missed AB tx?
Need to do hospital outpt suction curettage to remove the POC
87
What are other managements for missed AB?
- Monitor bleeding/pain symptoms until B-hCG levels 0-5; analgesia PRN
- Minimize infection risk: monitor temp, pelvic rest
- Rh immunoglobulin (Rh negative mothers)
- Emotional support….. these pts will be angry because they were pregnant and had viable pregnancy past 6-8wks
88
What are the types of induced abortions?
1- Maternal choice: elective termination
| 2- therapeutic termination
89
How long do you have to induce abortions with medical option?
Depends on state…. 63 days
90
What are the medications used in medical abortion?
1st, Oral mifepristone: reverses UC inhibition & causes uterine lining to thin & prevents embryo from remaining implanted
next give misoprostol combo: causes contraction and expulsion, 24-48hrs after mife
91
when should women be rechecked to make sure there has been complete expulsion?
With in 2 weeks
92
What is the surgical procedure for abortion?
Vacuum aspiration 13 wks
93
What are post surgical complications you should have your women come back in for?
```
Severe abdominal or back pain
Heavy bleeding (soaking 2 maxipads per hour x 2 consecutive hours)
Foul-smelling discharge; Temp > 100.4°F
Rh immunoglobulin (Rh negative mothers)
Emotional support
```
94
What defines recurrent loss?
>/= 2 consecutive pregnancies or SAB btwn full term IUP
95
What are the different causes depending on timing for recurrent loss?
??????
1st trimester: parent karyotypes - genetics
2nd trimester-Cervical insufficiency: painless effacement & dilation
Common hx: cervical conization
96
How is cervical insufficient tx?
Cervical cerclage
97
Where are the majority of ectopic pregnancies located?
Fallopian tube
98
What are risk factors for ectopic pregnancy?
```
Prior abd’l or pelvic surgery
Tubal scarring 2ndary PID/salpingitis
Prior ectopic or tubal surgery
Hx STD
Hx infertility & ART procedures
```
99
What are the S/S of ectopic pregnancies?
Asymptomatic or vaginal some bleeding or emergent d/t hemodynamic compromise (rare) - might have ab pain
- might have mass
- might have bleeding
- +/- N, V, breast fullness … not really
100
What will be s/sof emergent ectopic preggo?
If shoulder pain… HOSPITAL ASAP will need emergent surgical handling
Ab guarding, hypotension, tachy, dizzy, fever
101
What should be used to diagnose?
TVUS to look for sac
B-hCG
If no sac and beta >2000, diagnostic of ectopic until proven otherwise
102
What is stable and early ectopic and how is it managed?
Asymptomatic, beta
103
If you have expectant management what kind of pts do you have to have??
RELIABLE and have easy access to your clinic
104
If your ectopic mom is not stable, how is it managed?
1- need informed consent
2- give one dose methotrexate
3- follow up to confirm termination
105
What are the CI to methotrexate?
Breastfeeding, immunodef’cy, alcoholism or liver dz d/t EtoH, pre-existent bone marrow/blood dyscrasias, active pulmonary dz, PUD
106
What does mom need to avoid when taking the metho?
Avoid ETOH, NSAIDS, folic acid supplements, sun exposure (photosensitivity), no coitus until beta negative, no strenuous exercise
107
What do you need to get pre-tx for ectopic?
serum creatinine, LFTs, CBC & repeat 1 week s/p methotrexate
108
How is the methotrexate given?
Single IM dose
109
How long do you need to recheck beta quant after methotrexate?
days 4 & 7 post injection (expect 15% drop in level) then weekly until undetectable
110
What are the surgical options for ectopic pregnancy?
```
Laparoscopic linear salpingostomy
-Removes pregnancy – preserves tube
Laparoscopic segmental resection
-Removes portion of tube w/pregnancy
Salpingectomy
-Remove entire tube
```
111
What is gestational trophoblastic neoplasia?
spectrum abnormal placental proliferation (trophoblastic tissue)
112
What are the types of GTN?
Benign: : hydatidiform mole (aka molar pregnancy)
| Persistent or malignant dz
113
What happens to the chorionic villi in benign GTN?
Villi continue to grow & become swollen & visible as “drops of water” - placenta develops into abnormal mass of cysts
114
What is the hydatidiform mole?
Non-malignant, non-metastatic but not compatible w/fetal life
115
What is the complete type of hydatidiform mole?
no embryo just abnormal placenta, more likely to undergo malignant transformation
caused by abnormality of fertilized egg – all chromosomes from dad
116
What is a partial hydatidiform mole?
Some fetal development & abnormal placenta
117
What is the cause of partial?
Maternal chromosomes remain but father provides two sets of chromosomes
Result: embryo has 69 chromosomes instead of 46
118
What might mom come in complaining of if GTN suspected?
Normal IUP initially or dark brown to bright red vaginal bleeding 1st trimester, severe N/V, severe anemia, rarely pelvic pressure or pain
119
What will the PE look like in a women with GTN?
Absent FHT, rapid uterine growth - too large for GA, HTN, preeclampsia, hyperthyroidism
Most likely present at 12-14 weeks can be as early as 8-9
120
What will be the clinical presentation of complete ?
no embryo/fetus; no amniotic fluid; thick & cystic placenta filled uterus (snowstorm appearance), ovarian cysts
121
What will be the clinical presentation of partial?
growth-restricted fetus; low amniotic fluid; a thick cystic placenta
122
What is the tx for GTN?
Stabilize
| Evacuate via D+C
123
What is management following GTN tx?
- -B-hCG w/in 48 hrs s/p evacuation then q 1-2 weeks/while elevated then q 1-2 months for 6 months to 1 year
- --Contraception 1 year
124
What constitutes persistent GNT?
Rise B-hCG after decline or plateau
125
How is a localized single invasive mole persistent GTN tx?
Single agent chemo
126
How is a choriocarcinoma persistent GTN tx?
Multi agent chemo
