Pregnancy Loss and Ectopic Pregnancy Flashcards
(22 cards)
Types of pregnancy loss
Threatened Abortion
Spontaneous Abortion
- Inevitable
- complete
- incomplete
- missed
- septic
Induced abortion/pregnancy termination
- therapeutic/elective
Ectopic Pregnancy
Spontaneous abortion RFs
Age - extremes
Previous SAb
Smoking (>10 cigarettes/day)
BMI 25
Maternal disease - heart disease, DM, thyroid disease, hypercoaguable states, anatomic abnormalities
Trauma - contributes more in later term SAb when fetus is larger (trauma can include CVS and amniocentesis)
SAb potential RFs
Alcohol - 3 drinks/week probs ok
NSAIDS - implantation issues, can close PDA early
Caffeine - >10 cups/day
Fever >100 (b/c something else is probably going on
SAb Etiologies
Chromosomal abnormalities MC (50%)
Aneuploides (abnl # of chormosomes)
- autosomal trisomies (trisomy 16 MC, always fatal)
- monosomy X (Turner’s)
- Polyploides - extra set
Anembryomic - normal trophoblasts and yolk sac, but embryo never develops
Congenital anomalies - genetic, chromosomal, extrinsic factors (amniotic bands), exposure to teratogens
Teratogens
- Maternal - DM c poor glycemic control
- drugs - isotretinoin
- physical stress - fever
- environmental chemical - mercury
SAb Presentation (categories to distinguish types)
Vaginal bleeding
pelvic pain/cramping
cervical os open or closed
products or conception passed or retained
uterus - appropriate size, consistency, tenderness
Threatened Abortion
Vaginal bleeding through a closed cervical os, pregnancy may still be viable
Vaginal bleeding
Painless or mild suprapubic pain
** Closed cervical os
Products of conception not visualized (retained)
Uterus appropriate size for gestational age
Reassuring factors: serum hcg, detectable cardiac activity by US or doppler
Supportive management
Inevitable abortion
SAb is imminent
vaginal bleeding (heavier)
Pelvic cramping
cervical os open
gestational products may or may not be visible
uterus may still be appropriate size (tatany)
expectant management
Complete Abortion
A SAb in which the entire contents of the uterus are expelled (Done). Commonly <12weeks.
Minimal vaginal bleeding (heavier bleeding earlier)
mild pelvic cramping
cervical os closed
all products passed
uterus small and contracted (tetany - firm)
Management
- confirm passing of products of conception (US)
- expectant management
Incomplete Abortion
SAb with retained products
Common after 12 weeks
Heavy vaginal bleeding severe cramps cervical os open retained products uterus small for gestational age and not well contracted
Surgical management
Missed abortion
Retention of a failed intrauterine pg
Sxs of pg have abated (n/v, breast tenderness)
mild vaginal bleeding/spotting
cervical os closed
products of conception not visible
uterus small for gestational age
Surgical management
Septic Abortion
SAb complicated by uterine infx
Staph aureus, gram neg bacilli, or some gram positive cocci
RFs: invasive procedures (amnio, CVS), FB’s, incopmlete or illegal induced abortion
Sxs:
- vaginal bleeding
- pelvic tenderness, cramping
- cervical os open
- uterus tender and boggy
- infx: fever, chills, tachycardia, vaginal d/c, peritonitis, septicemia, death
Management (urgent/emergent)
- stabilize the pt
- blood and endometrial cultures
- broad spectrum antibiotics - clinda, gent, +/- amp
- surgical management
SAb evaluation
Confirm pg, dating
ID S&S
Check for infection/sepsis
PE - pelvic and abd exam
hCG, UPT
Transvaginal US
- location of pg, viability via cardiac activity, retained products
Rh incompatibility
Expectant Management
Can do if: tic management - NSAIDS
Risks: incomplete abortion, need for unplanned evacuation, bleeding
Surgical management
Suction curettage (D&C) - suction Dilation and evacuation (D&E) - foreceps + suction
Indications:
- retained products
- septic abortion
- prevent complications (hemorrhage, infx)
- unstable
Risks: anesthesia, uterine perf, cervical trauma, hemorrhage, infx
Other important management considerations
Pregnancy symptoms should abate
Menses to resume by 6 weeks
F/U by phone (24hrs), in clinic in 2-4weeks
Monitor hCG decline
Pelvic rest x 2 weeks
Avoid pg x 6 weeks
Call for heavy bleeding, pelvic pain, discharge, fever
Recurrent Pregnancy Loss (RPL)
3 or more losses before 20 weeks
Possible causes
- early: chromosomal, endocrine
- later: anatomical, immunologic
Hx:
- uterine instrumentation
- inheritable chromosomal abnlties, genetics
- menstrual changes, endocrine changes
- environmental exposures - DES
- venous thrombosis
Work up:
- karyotype, hysteroscopy, hypercoaguability w/u, thyroid ftn, ovarian ftn (FSH or estradiol)
Pregnancy Termination
Elective abortion - termination before viability for any reason; requires parental notification 48hrs before the procedure; Women’s Right to Know Act
Therapeutic Abortion - termination of pregnancy before the time of fetal viability to safeguard mother’s health (ACOG criteria: if mother’s health is at risk or pg is a result of rape or incest)
Medical Abortion
Less than 9 weeks gestation
Methotrexate - progesterone inhibitor; induces contractions, vascular destruction, necrosis and detachment of products of conception
Misoprostol - prostaglandin directly stimulates myometrium
Surgery if not successful
Ectopic Pregnancy
Must r/o in any woman of reproductive age with abdominal/pelvic pain and irregular bleeding
Hemorrhage from ectopic pg is a major cause of maternal death
MC’ly implants in Fallopian tubes, but ovary, abd cavity and cervix also possible
Ectopic pg RFs
PID previous ectopic pg age >35 h/o abd or pelvic surgeries IUD DES exposure
Ectopic pg S&S
Range from asymptomatic to acute abd and hypovolemic shock
abd pain, tenderness abnl uterine bleeding, dizziness amenorrhea peritoneal signs cervical motion tenderness adnexal tenderness
Ectopic pg evaluation
Pg test
Quantitative hCG
transvaginal US
CBC
Note: discriminatory zone - if gestational sac cannot be visualized on TV US, follow hCG changes to tract pg (should double q48hrs)
Tx: Surgical
