Week 8 pt 1

Question 1

List the risks of ectopic pregnancy

Answer 1

Multiple D&Cs, STIs, PID, adhesions, endometriosis, previous ectopic
But 50% have no identifiable risk factors

Question 2

Describe the risks of ectopic pregnancies and how common they are

Answer 2

1) Pregnancies within the tube can rupture and cause hemorrhage = a LEADING cause of maternal deaths in the 1st trimester
2) Numbers are rising
-Factors: increasing infertility (more ART), increasing STIs with associated scarring
3) Currently, ectopic pregnancies account for around 2% of pregnancies in the U.S.
4) They account for 6-16% of ER visits for abdominal pain with bleeding.

Question 3

Describe the symptoms of ectopic pregnancies

Answer 3

1) If early and small, may have no clinical symptoms
2) Most common: Amenorrhea followed by vaginal bleeding and abdominal pain on the affected side
3) If later in pregnancy, may also have breast tenderness, nausea, urinary frequency
4) If rupture occurs, likely will have marked tenderness on abdominal and pelvic exams + increased pain with cervical manipulation

Question 4

Describe how to rule ectopic pregnancy in/out

Answer 4

1) Urine hCG (or serum β-hCG)
2) On TVUS, you may see an empty uterus or there may be a gestational sac outside the uterus (i.e., fallopian tube)
-TVUS should demonstrate an intrauterine pregnancy when hCG 1000-2000 IU/L
4) You may or may not be able to appreciate a mass in the tube
5) If the patient has a positive urine pregnancy test, begin beta subunit hCG testing (serum)
-If level is rising, there’s an embryo somewhere
-If level is falling, keep checking and make sure it goes to 0

Question 5

What is the optimal and most cost-effective strategy for diagnosing ectopic pregnancy?

Answer 5

Transvaginal ultrasonography followed by quantitative beta-hCG testing

Question 6

What are the 2 main tx options for ectopic pregnancy?

Answer 6

Surgical removal of pregnancy +/- tube
OR
Methotrexate (PO or IM— IM more effective)

Question 7

Describe the use of methotrexate for ectopic pregnancy

Answer 7

Only works if tube has not started to rupture
The higher the baseline hCG level is, the less likely methotrexate is to work
Must be done in conjunction with serial beta subunit hCG to verify pregnancy is ending- check Q 2-3 days
*Must have EFFECTIVE contraception and avoid pregnancy for 3 months after use

Question 8

What must your education of ectopic pregnancy pts include?

Answer 8

That a current ectopic increases the risk for future ectopic pregnancies

Question 9

Ectopic pregnancy Tx:
1) What does methotrexate do?
2) What are some other therapeutic agents?

Answer 9

1) disrupts rapidly-dividing trophoblastic cells.
2) Hyperosmolar glucose, prostaglandins, and mifepristone (Mifeprex).
Remember: medical therapy is only an option if tube has not started to rupture

Question 10

What are some absolute contraindications for medical Tx for ectopic pregnancy?

Answer 10

Breastfeeding
Overt or laboratory evidence of immunodeficiency
Known sensitivity to methotrexate
Active pulmonary disease
Peptic ulcer disease
Hepatic, renal, pulmonary, or hematologic dysfunction
Heterotopic pregnancy with viable intrauterine gestation (IUP and ectopic occurring together)
Unable to comply with management protocol

Question 11

Spontaneous abortion:
1) When does it occur?
2) How common is it?

Answer 11

1) Before 20 weeks gestation
2) 15-45% of all pregnancies end in miscarriage
Threatened, missed, inevitable, complete, septic….

Question 12

1) Define threatened abortion
2) Can it be carried to term?

Answer 12

1) Patient of less than 20 weeks’ gestation who presents with vaginal bleeding and no cervical dilation or effacement
+/- pain and cramping.
2) If cardiac motion + by US, 95% will carry to term
*If mom is Rh negative, she needs RhoGAM

Question 13

Define and describe inevitable abortion

Answer 13

1) Patients with an open cervical os found on pelvic examination but without a history or evidence of passage of tissue
2) Cramping caused by uterine contraction is common and is usually preceded by bleeding.
3) May need D&C to complete the process

Question 14

Describe incomplete abortions

Answer 14

1) Only part of the POC has passed through the cervical os
2) On examination, patients may have a closed or open cervical os, and ultrasonography reveals fetal or placental tissue remaining in the uterus
3) Needs a D&C within 1-3 days to limit risk of infection and sepsis

Question 15

Define and describe complete abortion

Answer 15

1) Complete miscarriage is characterized by resolution of symptoms and the total expulsion of products of conception (POC).
2) On pelvic examination the cervical os is closed, and ultrasonography demonstrates an empty uterus.
3) Plan of care consists of OB/GYN follow-up and counseling, along with RhoGAM if indicated

Question 16

What occurs when fetus or embryo is nonviable or “dies” in utero and is retained in the uterus and not expelled spontaneously for more than 2 menstrual cycles?

Answer 16

Missed abortion

(need D&C)

Question 17

Describe septic abortions & who they may occur in

Answer 17

An intrauterine infection
Can occur in elective terminations performed with poor aseptic techniques or inadequate evacuation of the uterus
Can occur in spontaneous abortions
Can occur in patients using an IUD for contraception, in HIV, and in women who are diabetic

Question 18

When _____________________________, patients who have septic miscarriage are commonly misdiagnosed as having pelvic inflammatory disease.

Answer 18

pregnancy status is not checked

Question 19

Summarize the types of miscarriages/ spontaneous abortions

Answer 19

Question 20

List the risk factors for spontaneous abortions

Answer 20

1) Increasing maternal age
2) Smoking
3) History of 3 or more miscarriages
4) No previous live birth
5) Environmental toxins
6) Infections
7) Drug and/or alcohol use
8) Maternal diseases (DM)
9) Genital tract abnormalities (large fibroids, bicornuate uterus, cervical dysfunction after procedures)

Question 21

List 3 reasons for 1st trimester losses

Answer 21

Genetics
Antiphospholipid antibodies
Asherman syndrome

Question 22

List 3 reasons for 2nd trimester losses

Answer 22

Anatomic abnormalities (septate uteri or fibroids)
Cervical insufficiency
Cervical cerclage

Question 23

Describe a PE for spontaneous abortion

Answer 23

1) Speculum exam to visualize os; must be visualized as this dictates the management.
2) If external os is slightly open (not widely open), is internal os open or closed?
3) Any adnexal tenderness or masses (ectopic??)

Question 24

Name 3 lab tests/ imaging that should be done for spontaneous abortion pts

Answer 24

1) TVUS
2) Serum progesterone level
3) Serum quantitative hCG level

Question 25

Why is TVUS needed for spontaneous abortion?

Answer 25

To assess for presence or absence of POC within the uterus, evaluation of adnexa and presence or absence of fluid in the cul-de-sac (to rule out ectopic)

Question 26

Why is serum progesterone needed for spontaneous abortion?

Answer 26

Levels below 45 nmol/L predict pregnancy failure with a sensitivity of 87%

Question 27

Serum quantitative hCG level: Why is this a part of spontaneous abortion workup?

Answer 27

Can be performed serially Healthy pregnancy levels double every 48 hrs

Question 28

Spontaneous abortion: What should you do if the cervical OS is open?

Answer 28

If so, inevitable miscarriage. OB consult or out-pt follow-up if patient stable

Question 29

Spontaneous abortion: What should you do if the cervical OS is closed?

Answer 29

1) If not ectopic, are there POC within the uterus? 2) If no, dx is complete miscarriage or an ectopic was MISSED If yes, is there heart motion (7 weeks)? If yes, it is a threatened miscarriage (cervix closed, + POC, +FHR) If no, then inevitable or incomplete miscarriage (cervix closed, +POC, -FHR) molar pregnancy (cervix closed, SOMETHING in uterus, -FHR), or very early pregnancy (less than 7 weeks) compare with hCG

Question 30

Describe the prevalence of induced abortions in the US

Answer 30

1 million abortions each year in the U.S. alone Half are performed on women under the age of 25 90% are done in the first trimester (before 12 weeks) 10% are done in the second trimester (before 24 weeks unless medically “necessary”) About 50% of babies born at 24 weeks survive

Question 31

Describe medical abortions

Answer 31

1) Medication-induced; alone or in combination 2) Appropriate up until the 49th day of pregnancy -Methotrexate -Prostaglandins (Misoprostol) -Mifepristone 3) Statistically less likely to complete the process as compared to surgical abortion (96% effective) -Suction curettage if not complete 4) * Many (if not most) medical abortions do not get included in the statistics that go to the CDC

Question 32

Describe surgical abortions in the first trimester

Answer 32

1) Vacuum, D&C, D&E 2) 99% effective 3) Low rate of complications but can include: Infection, uterine perforation, hemorrhage, uterine scarring (Asherman’s Syndrome), retained products of conception with hemorrhage, cervical lacerations

Question 33

Describe abortion in TN

Answer 33

1) Total ban as of August 25, 2022 2) Exceptions: To save the pregnant person’s life To preserve the pregnant person’s physical health If the fetus is not expected to survive the pregnancy 3) Class C felony