Early Pregnancy Complications Flashcards by jaclyn krupsky

incidence of ectopic pregnancy

1 in 100

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why has the incidence of ectopic pregnancy increased over the past 10 years?

increase in assisted fertility, STDs and PID

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RFs for ectopic pg’y

hx of STs or PID
Previous ectopic pg'y
previous tubal surgery
prior pelvic or ab'l surgery (adhesions)
endometriosis
current use of exogenous hrms
IVF/assisted repro
DES-exposed pts w/congenital abnormalities
congenital abnormalities of fallopian tubes
use of an IUD

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presenting sx’s of ectopic pg’y

unilateral pelvic or lower ab’l pain
vag bleeding
may be hypotensive or w/peritoneal signs

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lab findings of ectopic pg’y

b-hCG levels low for GA, does not increase at expected rate (doesn’t double q48h)

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how is ectopic pg’y definitively dx’d?

urine pg’y test is +
u/s shows extrauterine pg’y. If too early to show on u/s, then follow serial b-hCGs and see that it does not double q48h

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at what b-hCG level should you be able to see an intrauterine pg’y

1500-2000

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tx of ruptured ectopic pg’y

stabilize first w/IVF, blood, pressors PRN
ex lap after stabilization to remove pg’y
If they were stable to begin w/, then do ex laparoscopy

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tx of unruptured ectopic pg’y

monitor for signs of rupture
MTX
ex laparoscopy

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what kind of f/u is required if MTX is used to tx unruptured ectopic pg’y?

obtain baseline AST and ALT and Cr, then give IM MTX, then serially follow b-hCG levels. Will at first rise, then will drop by 10-15% by 4-7d. If not, give second MTX dose.

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what is a SAB? Incidence?

pg’y that ends before 20 weeks. 15-25% of all pg’ies end in SAB.

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abortus =

the fetus lost before 20 weeks, or weighing < 500g, or < 25cm long

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complete abortion =

complete expulsion of all POC before 20 weeks

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incomplete abortion =

partial expulsion of POC

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inevitable abortion =

no expulsion of products, but bleeding & dilation of cervix, making a viable pg’y unlikely

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threatened abortion =

any intrauterine bleeding before 20 weeks, w/o cervical dilatation or expulsion of POC

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missed abortion =

death of fetus/embryo but with no expulsion of POC. Usually proceed to complete abortions in 1-3 weeks.

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Most first-trimester SABs are due to what?

chromosomal abnormalities

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DDx of first-tri bleeding:

SAB
postcoital bleeding
ectopic pg'y
vaginal or cervical lesions or lacerations
extrusion of molar pg'y
nonpg'y bleeding

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sx’s of first trimester abortion:

bleeding
cramping
ab’l pain
decreased sx’s of pg’y

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how do you w/u a pt presenting w/vaginal bleeding & cramping in 1st tri?

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Hx of sx’s
Physical - pelvic exam, vitals to r/o infection & shock
labs - b-hCG, CBC, blood type & screen
u/s to assess fetal viability & placentation

tx of 1st-tri complete abortion

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1) stabilize if hypotensive
2) follow for recurrent bleeding and signs of infection
3) send any expelled tissue to pathology

tx of 1st-tri incomplete abortions

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1) stabilize
2) either do expectant mgt or D&C or admin of misoprostol
3) send tissue to pathology

mgt of inevitable abortion & missed abortion

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1) stabilize if hypotensive
2) either do expectant mgt, or D&C
3) send tissue to pathology

mgt of threatened abortion

1) monitor for bleeding 2) bedrest, nothing per vagina 3) give RhoGam if Rh-

what are pts w/threatened abortion at increased risk for?

PTL | PPROM

most common causes of 2nd-tri abortions

maternal systemic dis, infection, fetotoxic agents, trauma, uterine or cervical abnormalities. Chromosomes not a common cause.

tx of 2nd-tri abortion

1) r/o ectopic pg'y, stabilize 2) follow for recurrent bleeding, signs of infection, 3) expectant mgt, or D&E or labor induction if retained POC

D&C vs. D&E

``` D&C = done during 1st tri D&E = done during 2nd tri ```

D&E vs. labor induction

D&E is faster, but aggressive dilation w/laminaria is necessary. Increased risk of uterine perforation & cervical laceration. Labor induction takes longer, uses high doses of oxytocin & PG's. Lower risk of trauma 2/2 instrumentation.

PTL vs. incompetent cervix

PTL = ctr'ns w/cervical dilation | incompetent cervix = painless cervical dilatation

mgt of PTL

tocolytics

mgt of incompetent cervix

emergent cerclage

CP of incompetent cervix:

painless cervical dilation, expsoure of fetal membranes. short-tem cramping or ctr'ns. Maybe infection. Vaginal discharge.

RFs for cervical insufficiency:

surgery/cervical trauma/previous cervical dilation hx of cervical lacerations w/prior vag delivery uterine anomalies hx of DES exposure

dx of cervical insufficiency:

dilated cervix seen on exam or u/s. Level of dilation is more than expected for level of ctr'ns.

tx of cervical insufficiency

``` if < 24 weeks, expectant mgt or elective termination. If viable: 1) betamethasone 2) strict bed rest 3) tocolytics if ctr'ns are occurring - or- immediate cerclage ```

what is cerclage

suture placed around the cervix. McDonald cerclage = suture placed at cervical-vaginal jct Shirodkar cerclage = suture placed at internal os

mgt of a subsequent pg'y in a pt w/hx of cervical insufficiency

elective cerclage offered at 12-14 weeks. Maintained till 36-38 weeks, then rmoved & pt is followed till labor occurs

mgt of subsequent pg'y in a pt in whom previous vaginal cerclage has failed

transabdominal cerclage. Then they'll need C-sections.

cervical insufficiency carries increased risk of:

infection PPROM PTL

what is a recurrent or habitual aborter

a pt who has had 3 or more consecutive SABs

what is the risk of a SAB after one prior? Two prior? Three?

20-25%. 25-30%. 30-35%

causes of recurrent pg'y loss:

``` chromosomal abnormalities maternal systemic dis infection maternal anatomic defects antiphospholipid antibody syndrome luteal phase defect (low progesterone) ```

screening of habitual aborters:

1) karyotype both parents 2) karoytype of POC from previous SABs 3) hysterosalpingogram 4) if HSG is abnormal, then f/u w/hysteroscopy or laparoscopy 5) screen for hypothyroidism, DM, antiphlipid Ig's, hypercoagulability, SLE 6) check serum progesterone level 7) cx's of cervix, vagina, endometrium 8) endometrial bx during luteal phase

labs to check for habitual aborters:

``` TSH, free T3/T4 factor V Leiden mutation prothrombin mutation ANA anticardiolipin antibody Russell viper venom antithrombin III levels protein C and S levels ```

tx of luteal phase defect:

supplemental progesterone

tx of antiphospholipid antibody syndrome

low-dose aspirin

tx of thrombophilia

SQH

pts w/3 prior SABs will have a subsequent normal pg'y how often?

2/3 of the time

cause of recurrent SABs is undiagnosed in how many cases?

1/3

Early Pregnancy Complications Flashcards

(51 cards)