2. Early PG loss, ectopic PG, Rh isoimmunization

Question 1

Which weeks constitute the 1st , 2nd, and 3rd trimesters?

Answer 1

• • 1st = first day of last menstrual period (FDLMP) => 13 weeks + 6 days
• • 2nd = 14 => 27 weeks + 6 days
• • 3rd = 28 => 42 weeks

Question 2

What weeks do the following occur?

1. Estimated date of confinement (EDC)
2. Abortion
3. Preterm delivery
4. Full term delivery
5. Postdates

Answer 2

1. Estimated date of confinement (EDC): due date = 40 weeks after FDLMP
2. Abortion: < 20 weeks
3. Preterm delivery: 20 => 36 weeks + 6 days
4. Full term delivery: 37- 42 weeks
5. Postdates: >42 weeks

Question 3

What is the “discriminatory level” of hCG where a gestational sac be seen with transvaginal US (TVUS)?

Answer 3

1500-2000 mIU/L

***however, these are not always exact

Question 4

What 2 things occur than can confirm a pregnancy?

Answer 4

• 1. Vaginal bleeding (occurs in 40% of W due to implantation bleeding)
• 2. hCG (detected 6-8 days after ovulation)

Question 5

hCG: indicate the levels at the following stages

1. Negative
2. Amount reached when menstruation SHOULD be expected
3. Amount a urine PG test detect
4. How much do we see increase in pregnancy?
5. Peak levels?
6. Abnormal IUP or ectopic pregnancy

Answer 5

hCG

1. Negative: <5
2. Amount reached when period is expected: 100
3. Amount a urine PG test can detect: 25
4. How much do we see increase in PG? Doubles every 2 days
5. Peaks at 10 weeks at 100,000
6. Abnormal rise of less than 53% in 48 hours.

Question 6

What is biochemical pregnancy?

Answer 6

Initial pregnancy test/hCG is (+) 7-10 days after ovulation, but does not progress into a clinical pregnancy because menstruation occurs.

Question 7

Spontaneous abortions occur in 10-15% of clinically recognized cases.

When does the risk of fetal loss decrease to 2%?

Answer 7

If at 8 weeks, US shows a live, appropriately grown fetus with cardiac actvity.

Question 8

What is an abortus?

Answer 8

an aborted fetus specifically : a fetus before 20 weeks, less than 500 grams.

Question 9

80% of spontaneous abortions (SABs) occur during which trimester?

Answer 9

1st trimester

Question 10

What are the most common cause of 1st trimester SAB’s?

Answer 10

Chromosome abnormalities

Question 11

What is the most common single chromosomal abnormality and most common class of chromosomal abnormality responsible for 1st trimester SAB’s?

Answer 11

1. 45 XO (Turner Syndrome) is most common single chromosomal abnormality
2. Most common class is the Trisomy class, with trisomy 16 most common

Question 12

SABs are defined by whether

• All of the products of conception have passed
• Dilation of the cervix.

What is a threatened abortion; how are they managed?

Answer 12

Threatened abortion: Cervix is closed, but vaginal bleeding is occuring.

• Treatment: Expectant management

Question 13

SABs are defined by whether

• All of the products of conception have passed
• Dilation of the cervix.

What is a incomplete abortion; how are they managed?

Answer 13

Incomplete abortion: Cervix is dilated + passage of SOME products ( => vaginal bleeding is occuring) + cramping in lower abdomen.

• Treatment: Suction D&C

Question 14

SABs are defined by whether

• All of the products of conception have passed
• Dilation of the cervix.

What is a inevitable abortion; how are they managed?

Answer 14

Inevitable abortion: Cervix is partially dilated + no passage of tissue + vaginal bleeding is occuring.

• Treatment: Loss is inevitable

Question 15

SABs are defined by whether

• All of the products of conception have passed
• Dilation of the cervix.

What is a missed abortion; how are they managed?

Answer 15

Missed abortion: Fetus has expired and stays in uterus; typically no symptoms/bleeding.

• Coagulation problems may occur so check fibrinogen levels weekly until SAB occurs or perform suction D&C
• Treatment: Expected management vs. misoprostol vs. D&C

.

Question 16

SABs are defined by whether

• All of the products of conception have passed
• Dilation of the cervix.

What is a septic abortion; how are they managed?

Answer 16

Septic abortion: Retain infected products of conception causes => fever, uterine and cervical motion tenderness + purulent discharge + hemorrhage and rarely renal failure

• Treatment: IV ABX (Ampicillin + Gentamycin + Clindamycin), follow with suction D&C.

Question 17

What is anembryonic gestation (blighted ovum); what do we see on US, how is it managed?

Answer 17

• Fertilized egg develops a placenta, but no embryo.
• US shows empty gestational sac >25 mm (too big to not have embryo)
• Tx: expected management vs. misoprostol vs. D&C

Question 18

How are induced or elective abortions most often performed in the 1st semester?

Answer 18

Suction D&C;

*More successful 1st therapy then medical or expectant managment.

Question 19

Recurrent abortions occur in 1% of women and often have no cause.

Recurrent abortions are defined as what?

Answer 19

3 successive SAB, excluding ectopic and molar pregnancies.

Question 20

What general maternal factors increase risk of recurrent abortions?

Answer 20

1. Infection (Mycoplasma, Chlamydia, Listeria or Toxoplasma) is rare. Tx = ABX
2. Smoking and alcohol (4x risk is smoke 20 ciggs/day and 7 drinks/week)
3. Medical disorders: antiphospholipid syndrome *** (main), DB, hypothyroidism, SLE.
4. Age of mom

Question 21

How does the % rate of spontaneous abortion change from women <30 yo to women >40?

Answer 21

• W <30: 11.2%
• W >40: 56%

Question 22

What is usually seen with 2nd trimester pregnancy loss, causing “painless dilation” and delivery?

Answer 22

Incompetent cervix

Question 23

RF and treatment for incompetent cervix as a cause of recurrent SAB’s?

Answer 23

• RF:
  
  • Utermine anomalies
  • Previous trauma
  • Hx of conization
• Treatment: cervical cerclage.

Question 24

What is recommended for both parents whom are trying to get pregnant?

Answer 24

Karyotyping to detect balanced reciprocal and Robertsonian translocations that could be passed onto the fetus unbalanced. There is a 3% chance one is a asyx carrier.

Question 25

What is the most common immunologic abnormality contributing to **recurrent** and **SAB's**?

Answer 25

**Antiphospholipid Syndrome**

Question 26

What is the treatment of **antiphospholipid syndrome** for patient trying to conceive?

Answer 26

**Prophylactic dose of heparin** and **low dose aspirin**

Question 27

Tests for what 3 serum markers can be done for antiphospholipid syndrome?

Answer 27

1. **- Lupus anticoagulant** 2. **- Anticardiolipin antibodies** (IgG and IgM) 3. **- Anti-B2-glycoprotein 1 antibodies (**IgG and IgM)

Question 28

What is the leading cause of maternal death in the first trimester?

Answer 28

**Ectopic pregnancy, a** gestation that implants outside of the uterus, most often in the fallopian tube (98%)

Question 29

What occurs during an **ectopic pregnancy**?

Answer 29

Trophoblasts implant into the mucosa of the fallopian tube and rapidly erods through the underlying BV. Too much bleeding can cause pressure necrosis of the overlying tubal serosa =\> acute rupture and hemoperitoneum.

Question 30

Who's at greater risk of ectopic pregnancy: woman **with IUD or without**?

Answer 30

- Women without an IUD are at greatest risk - But IF **woman with IUD** gets pregnant they are at an ↑ risk of having an ectopic pregnancy

Question 31

**Classic triad** symptoms of ectopic pregnancy

Answer 31

1. **Prior missed menses** 2. **Vaginal bleeding** 3. **Lower abdominal pain**

Question 32

What is the **most common clinical presentation** of ectopic pregnancy?

Answer 32

**_Possible ectopic_** * Often, we see pt more than once before diagnosis is confirmed: follow serial B-hCG quants and TVUS accordingly * **Mild non-specific sx's**

Question 33

What is seen on **ultrasound** of pt with **possible ectopic pregnancy?**

Answer 33

**- Thickening of the endometrium/endometrial stripe (Arias-Stella rxn),** however, you RARELY see the ectopic pregnancy.

Question 34

What are the symptoms, PE and US of the **_probable_** **ectopic pregnancy.**

Answer 34

* **Symptoms**: Lower abdominal/pelvic pain and vaginal spotting/bleeding * **PE**: Abdominal/adnexal tenderness and cervical motion tenderness. * **US**: Fluid in the abdomen (cul de sac) and you may the ectopic pregnancy.

Question 35

Which type of ectopic pregnancy is a **surgical emergency?**

Answer 35

Acutely **ruptured** ectopic pregnancy

Question 36

What will an **U/S** of an acutely **ruptured** ectopic pregnancy show?

Answer 36

**Empty uterus** w/ significant amount of **free fluid**

Question 37

**Symptoms** and **PE** of an acutely ruptured ectopic pregnancy.

Answer 37

* **Symptoms**: severve abdominal pain and dizziness due to intraperitoneal hemorrhage) * **PE**: * Abdomen is distended and tender (guarding and rebound) * Cervical motion tenderness * Hemodynamic instability =\> diaphoresis, tachycardia, loss of consciousness.

Question 38

**Diagnostic tests** for ectopic pregnancies.

Answer 38

1. Abnormal rise in hCG of \<53% in 48 hrs 2. Transvaginal US

Question 39

**Transvaginal US** can sshow what

Answer 39

1. **IUP** or **extrauterine pregnancy** 2. **Non-diagnostic** (nothing in or outside the uterus): wait until hCG is in 1500-2000 IU/L discriminatory zone and then repeat U/S to see if there is a gestational sac

Question 40

**Medical management** for ectopic pregnancy

Answer 40

1. Compliant women who are hemodynamically stable with an unruptured ectopic PG: **Medical management with methotrexate (MTX),** a folic acid ANT; DNA synthesis and cell wall inhibitor 1. Check hCG levels on day 4 and 7 --\> compare at both days and if levels ↓ 15%, continue to follow weekly; if levels plateau or fall slowly give another dose of MTX.

Question 41

Avoid ________ when taking **methotrexate (MTX)**

Answer 41

**Vitamins with folate**

Question 42

What are some of the **absolute contraindications** for using **methotrexate** in medical management of ectopic pregnancy?

Answer 42

1. **- Non-compliant pt** 2. - Intrauterine pregnancy 3. **- Breastfeeding** 4. **- Active pulmonary disease or PUD** 5. **- Hepatic, renal, or hematologic dysf.** 6. - Alcoholic 7. - Ruptured ectopic or hemodynamically unstable

Question 43

What are some of the **relative contraindications** for using **methotrexate** in medical management of ectopic pregnancy?

Answer 43

1. Gestational sac is greater than or equal to 3.5 cm. 2. Embryonic cardiac motion 3. hCG levels \> 6000 mIU/ml

Question 44

Which patients may qualify for **expected managment** of an ectopic pregnancy?

Answer 44

1. If they are **stable** and **sx's are spontaneously resolving =\>** follow closely w/ serial hCG testing and give strong ectopic precautions

Question 45

What is the **surgery** do we do for an **ectopic pregnancy** in **hemodynamically stable** vs. **unstable pt?**

Answer 45

* - ****_S_**table** = laparo****_s_**copy** * - **Unstable** = laparo**tomy**

Question 46

Which surgical approach to ectopic pregnancies has been associatd with **better long-term tubal function (wants to still be fertile)**

Answer 46

**Salpingostomy**

Question 47

Which surgery is best for ectopic pregnancies when there has been **significant damage to the tube?**

Answer 47

**Salpingectomy** - removal of the entire fallopian tube

Question 48

After surgery for an **ectopic pregnancy,** what should be done?

Answer 48

1. **Repeat hCG titers** 3-7 days later

Question 49

What is **Rhesus Isoimmunization?**

Answer 49

1. Immunologic disorder that occurs when **Rh (-) women** is carrying an **Rh (+) fetus =\>** 2. **Rh (+) antigens** cross the placenta into mom (perhaps through *fetomaternal hemorrhage*), causing **mom to make Ab to Rh (+) antigen:** 1. IgM abs first, but do not cross placenta =\> IgG abs cross placenta and enter fetal circulation. 3. **Destroy fetal RBC's** ---\> 1. Mild hemolysis =\> fetus can compensate by increasing erythropoiesis 2. Severe hemolytic disease in the fetus/newborn =\> anemia =\> hydrops fetalis from CHF and intrauterine fetal death

Question 50

* **Rh complex** is made up of ___________ antigens. * _________ =\> **Rh (+)** * _________ =\> **Rh (-)**

Answer 50

* Rh complex = **C, D, E, c, d, e antigens** * **Rh D antigen** =\> Rh (+) * **No Rh D antigen** =\> Rh (-)

Question 51

**Rh (-) W** is most common in \_\_\_\_\_\_.

Answer 51

* **Caucasions** (15% of whites have it) **\>** AA (8%)

Question 52

Which **prophylactic treatment** is used to prevent mom from making **antibodies** to **Rh antigen?**

Answer 52

**300 mcg** of **Rh immune globulin (RhoGAM)** - Prevent isoimmunization after exposure of up to 30mL of RhD (+) whole blood or 15mL of fetal RBC -

Question 53

Who should **RhoGAM** be administered to and when is it given?

Answer 53

- **Rh (-) woman** who is not Rh D-alloimmunized @ at **28 weeks** and **within 72 hrs** after delivery of a Rh D (+) infant

Question 54

How can we prevent **Rh isoimmunization,** which can occur in high risk situations that cause a larger volume of fetomaternal hemorrhage.

Answer 54

* **Kleinhauer-Betke test:** ID's fetal RBC in maternal blood and determines if more RhoGAM is needed.

Question 55

**3 things** to get at **1st prenatal visit** to **prevent Rh isoimmunization:**

Answer 55

1. **ABO blood group** 2. **Rh D type** 3. **Antibody screen**

Question 56

If pregnant women is **Rh (-)** and has **(+) anti-D antibody titers**, what does this mean; what should be done next?

Answer 56

1. **She is Rh D sensitized** 2. Next test the father of baby for the Antigen status in question 1. If he is **Rh-D (-)** =\> **no further workup** or tx is necessary 2. If he is **Rh-D (+)** =\> 1. **homo- (all fetuses will be Rh +)** 2. **heterozygous for D antigen (50% will be Rh +/-)**

Question 57

If father of the baby is **heterozygous** for RhD antigen, what must be done?

Answer 57

1. **Determine fetal RhD status** 1. Non-invasively with cell-free fetal DNA in maternal plasma 2. Invasively with fetal antigen testing via amniocentesis

Question 58

Which titers are used as a screening tool to estimate the **severeity** of fetal hemolysis in Rh disease?

Answer 58

**Maternal Rh-antibody titers**

Question 59

What do **maternal Rh-antibody titers** of **\< 1:8** and **\> 1:16** indicate; what is management for each of these situations?

Answer 59

* **\< 1:8** = fetus not in serious jeopardy; recheck titers q 4 wks * **\> 1:16 =** require further eval: * **US** to detect fetal hydrops * **Doppler studies** of the Middle Cerebral Artery (**MCA**)

Question 60

**US** can detect **fetal hydrops.** What would we see on US that would indicate it?

Answer 60

1. **Ascites** 2. **Pleural effusion** 3. **Pericardial effusion** 4. **Skin or scalp edema** 5. **Polyhydramnios**

Question 61

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ most valuable tool for **detecting fetal anemia** and should be performed \_\_\_\_\_\_\_\_\_\_\_\_\_.

Answer 61

* **Doppler** of the **peak systolic velocity** in the fetal *MCA* in cm/sec * **every 1-2 wks from 18-35 wks**

Question 62

\_\_\_\_\_\_\_\_\_\_ fetal MCA value peak systolic velocity for gestational age = moderate to severe fetal anemia.

Answer 62

**\> 1.5 MOM**

Question 63

It fetal MCA peak systolic velocity **\> 1.5 MOM,** what should be done?

Answer 63

1. **Percutaneous umbilical blood sampling** to assess the true concentration of Hb 2. If indicated, perform a **intrauterine tranfusion.**

Question 64

Which Hct level is considered **_SEVERE fetal anemia_**; when are intrauterine transfusions done and with what?

Answer 64

* **Severe fetal anemia:** Hct is \< 30% or 2 standard deviations below the mean Hct for the gestational age. * Intrauterine transfusions using fresh group O, Rh (-) packed RBC's performed between 18-35 weeks.

Question 65

What type of **_transfusions_** for **_severe fetal anemia_** are preferrd due to more rapid and reliable therapeutic benefits?

Answer 65

**_Intravascular transfusions_** into **_umbilical vein_**

Question 66

What is the management of Rh-isoimmunization **after 35 weeks gestation**?

Answer 66

Consider **delivery** and **transfuse** the neonate

Question 67

What is the **risk of hydrops** with **subsequent pregnancies** after the 1st affected pregnancy?

Answer 67

**90%**

Question 68

In addition to **serial** **US w/ MCA dopplers,** what other 2 tests should be used to manage Rh-isoimmunization?

Answer 68

1. **Antepartum testing:** 2x weekly non-stress test or biophysical profiles 2. **Serial growth scans q 3-4 weeks**