Risk factors for Ectopic Pregnancy
- Hx of STIs or PID
- Prior ectopic pregnancy
- Previous tubal surgery
- Prior pelvic or abdominal surgery resulting in adhesions
- Current use of exogenous hormones including progesterone or estrogen
- IVF and other assisted reproduction
- DES-exposed patients with congenital abnormalities
- Congenital abnormalities of the fallopian tubes
- Use of an IUD for birth control
Patients who present with an unrupture ectopic pregnancy can be treated either surgically or medically. Under what conditions is methotrexate prescribed?
- < 4 cm
- serum b-hCG level <5,000
- w/o fetal heartbeat
** and for those pts who will be reliable with follow-up
Pregnancy that ends before 20 weeks' gestation
Spontaneous abortion (estimated to occur in 15% to 25% of all pregnancies)
- Abortus - fetus lost before 20 weeks' gestation or less than 500 g
- Complete abortion - complete expulsion of all POC before 20 weeks' gestation
- Incomplete abortion - partial expulsion of some but not all POC before 20 weeks' gestation
- Inevitable abortion - no expulsion of products, but vaginal bleeding and dilation of the cervix such that a viable pregnancy is unlikely
- Threatened abortion - any vaginal bleeding before 20 weeks, w/o dilation of cervix or expulsion of any POC (i.e., a normal pregnancy w/ bleeding)
- Missed abortion - death of embryo or fetus before 20 weeks with complete retention of all POC
Cause of 60%-80% of all SABs in the first trimester?
Abnormal chromosomes, of which 95% are due to errors in maternal gametogenesis (autosomal trisomy = most common)
Differential Dx of 1st Trimester Bleeding
Vaginal or cervical lesions or lacerations
Extrusion of molar pregnancy
Nonpregnancy causes of bleeding
A pt with a threatened abortion should be followed for continued bleeding and placed on pelvic rest with nothing per vagina. Often, the bleeding will resolve.
However, these pts are at increased risk for ________ & ________.
Preterm labor (PTL) and Preterm Premature Rupture of Membranes (PPROM)
Abortion at 12-20 weeks' GA
- Maternal uterine or cervical anatomic defects,
- Maternal systemic disease
- Exposure to fetotoxic agents
- Advantage: procedure is self-limited and performed faster than an induction of labor
- However, aggressive dilation is necessary prior to procedure with laminaria (small rods of seaweed are placed in the cervix the day prior to the procedure, and these rods expand as they absorb water, thereby dilating the cervix) --> significant risk of uterine perforation and cervical lacerations
In the second trimester, the diagnoses of PTL and incompetent cervix needs to be ruled out. How to tell the difference?
PTL: begins with contractions leading to cervical change --> can be managed with tocolysis
Incompetent cervix: characterized by painless dilation of the cervix often in 2nd trimester --> an emergent cerclage may be offered
Most common cause of cervical incompetence
- Hx of cervical surgery, such as cone biopsy or dilation of cervix
- Hx of cervical lacerations with vaginal delivery
- Uterine anomalies
- Hx of DES exposure
Recurrent pregnancy loss
3 or more consecutive SABs
Less than 1% of population is dx with recurrent pregnancy loss... the risk of an SAB after one prior SAB is 20-25%; after 2 consecutive SABs, 25-30%, after 3 consecutive SABs, 30-35%
15% of pts with recurrent pregnancy loss have _________.
Antiphospholipid antibody (APA) syndrome
Treatment: low dose-aspirin
Also: Luteal phase defects
Ultasound should be able to detect an IUP at b-hCG levels between ____________.
1,500 and 2,000 mIU/mL
What is the most common site of an ectopic pregnancy?
What is the cut-off aka appropriate level for MTX therapy?
Once given, what is the appropriate f/u protocol?
5,000 mIU/mL (must be below this)
b-hCG level commonly rises in the first few days after MTX therapy initiation with a fall of 10%-15% bteween days 4-7 after admin. Pt should be seen sooner than 1 week so that additional MTX may be administered if necessary. 48 hours is too soon.
Ectopic pregnancy: if pt is hemodynamically unstable and has evidence of a rupture ectopic pregnancy on U/S + acute blood loss anemia... next step?
Emergent ex lap to control bleeding and remove ectopic pregnancy