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OB: Complications
OB: Early and Mid-Trimester Complications
| Question | Answer |
|---|---|
| Most common complication of early pregnancy | Spontaneous abortion. Estimated 50% of all pregnancies. Diagnosed SAB probably less than 1/2 of women |
| Risk factors for SAB | Maternal and Paternal age, increasing parity, smoking, ETOH, NSAIDs, ASA, caffeine, submucous fibroid(s), uterine abnormality, Asherman's (uterine synechiae), DM, thyroid, PCOS, hx of SAB |
| Usual presentations of SAB | Amenorrhea, Vaginal Bleeding, Abdominal pain |
| Bleeding in the first trimester | Physiologic (implantation), Ectopic Pregnancy, Impending SAB, Cervical polyp, Cervical infection, neoplasia |
| hCG | Can be qualitative (+/-) usually on urine. Quantitative on serum |
| TVS | transvaginal ultrasonography. Can see a lot better and sooner than abdominal. Gestational sac usually visible at 4.5-5 weeks. Fetal pole with cardiac activity: 5.5-6 wks |
| Any bleeding in the first half of an intrauterine pregnancy | Threatened Abortion (so, within the first 20 wks). May not result in an abortion |
| EGA | estimated gestational age |
| OOM | onset of menses |
| Threatened AB | bleeding, often painless, closed os, 25% of pregnancies have TAB, 50% of these proceed to SAB. US needed. Uterine size is EGA |
| Rupture of membranes and/or cervix open, pregnancy loss unavoidable | Inevitable AB. Cervix is dilated, bleeding increasing, cramping |
| All Products of Conception passed, common prior to 12 weeks | Complete AB |
| Partial expulsion of gestational tissue, after 12wks, incomplete AB more likely. placental tissue retained. ROM, cervix open, bleeding can be severe | Incomplete AB |
| ROM | rupture of membranes |
| Uterus<EGA, loss of pregnancy sx. Retention of a failed intrauterine pregnancy for an extended period. Also called blighted ovum, anembryonic pregnancy | Missed AB. DIC (disseminated intravascular cogaulopathy) can occur in 2nd trimester if missed AB>6 weeks |
| More than 2 consecutive or 3 total SAB | Recurrent AB. Extensive work up |
| Induced AB | Elective: legal, but not medically necessary. Therapeutics: necessary for the health of the mother |
| Miscarriage should be documented as | SAB: spontaneous abortion |
| SAB evaluation | Definite US dx |
| Threatened abortion | painless bleeding |
| Treatment SAB | Threatened: reassurance, pelvic rest (no sex, no tampons). Follow hCG quantitatively to make sure it returns to nl (placenta not remaining). D&E. Medical tx: misoprostol, mifepristone. Expected Pregnancy <13 wks: stable vital signs, no evidence of infxn |
| Post-abortion care | Rhogam, Methylergonovine maleate, Doxy for prophylaxis w/ D&C, Grief counseling, pelvic rest 2 weeks, custom is to advise no pregnancy for 2-3 cycles, contraception if desired |
| Leading cause of pregnancy-related death in the first trimester | Ectopic pregnancy |
| Why is the rate of ectopic pregnancy increasing | STDs, reverse tubal, assisted fertilization, PID rates increasing |
| Location most common for ectopic pregnancies | tubes 98%. Other locations: cornual (interstitial), cervical, fimbrial, ovarian, abdominal, heterotopic (two pregnancies at 2 diff. places). Unusual location more common with Assisted Reproductive Technologies |
| High Risks for ectopic pregnancies | high: tubal pathology, previous ectopic, DES, exposure, Tubal surgery. |
| Moderate Risks for ectopic pregnancies | previous infxn (PID, chlamydia, GC) especially recurrent, Infertility, Multiple sexual partners (STDs) |
| Low Risks for ectopic pregnancies | smoking, vaginal douching, Age (early sexual debut, older age groups from cumulative risk factors over time) |
| Other factors for ectopic pregnancies | IVF (in vitro fertilization) previously, tubal sterilization (higher in BTL before age 30, bipolar coagulation more associated w/ ectopic, Copper IUD and Mirena lowest rate) |
| Ectopic Sx | Abdominal pain, amenorrhea, vaginal bleeding. BUT 50% of women are asx with ectopic pregnancy before tubal rupture |
| Other Ectopic SX | Usual pregnancy sx (N/V), Shoulder pain (blood under diaphragm), rupture: lightheadedness, shock. Urge to defectate (blood in cul-de-sac; blood pools down behind uterus and puts pressure on rectum) |
| Ectopic Evaluation | Exam often unremarkable. PE: orthostatic vitals if ruptured, occasionally fever, CMT, Adnexal pain, Pain to abdominal palpation, rebound |
| Ectopic Evulation labs and imaging | Quantitative hCG, TVUS |
| Natural hx of ectopic | Tubal rupture, tubal abortion (expulsion of POC through the fimbrae, resulting in tissue regression or reimplantation), spontaneous resolution |
| Ectopic Tx: Surgical Indications | Ruptured ectopic, especially if hemodynamically unstable. not-compliant with rx tx, problems with access to care, Laparoscopic surgery is the approach of choice. Salpingostomy with healing by secondary intention best outcomes. |
| Ectopic Tx: Rx | Methotrexate |
| Gestational Trophoblastic Neoplasia (GTN) AKA molar pregnancies | A rare variant of pregnancy. No actual embryo or fetus; just placenta tissue. Etiology unknown. Hydatidform mole, invasive, choriocarcinoma, placental-site trophoblastic tumor (PSTT) |
| GTN clinical presentations | often exaggerated pregnancy sx, hCG much higher than it should be in a nl pregnancy (tumor marker). Highly curable with chemotherapy |
| GTN Evaluation | hCG, U/S, Work up metastatic dz |
| GTN Tx | D&C, Methotrexate, chemotherapeutic agents, follow with serial hCGs |
| Cervical Insufficiency | Painless cervical changes that occur in the second trimester and result in recurrent pregnancy loss |
| Congenital factors for Cervical Insufficiency | short cervix (mean is 35mm, preterm birth risk 10x higher if cervix is 22mm), Mullerian abnormalities (bicornuate), collagen abnormalities, familial clustering, Trauma, elevated serum relaxin, 'other factors" |
| Trauma of cervix | cervical laceration, instrument dilation, cone biopsy, LEEP |
| Elevated serum relaxin | connective tissue remodeling, higher in twin pregnancies and pregnancies induced by menotropins |
| Clinical Manifestations of Cervical Insufficiency | Vaginal fullness or pressure, vaginal spotting or bleeding, watery, mucousy, or brown vaginal discharge, vague abdominal or back discomfort |
| Dx of Cervical Insufficiency | Hx of acute, painless 2nd trimester pregnancy loss, premature cervical effacement &/or dilatation (>2cm), serial digital exams. TVS (shortening endocervical canal, "funneling" fetal membraines into endocervix |
| Effacement | thinning of cervix. Normal near due date, but don't want cervix to efface too early. |
| Tx of cervical insufficiency | Pelvic rest, progesterone, indomethacin, Prophylactic cerclage ("purse string suture") |
| Two placentas, two amnions, two chorions | from either dizygotic twins or monozygotic twins with cleavage of zygote during first 3 days after fertilization |
| One placenta, one chorion, two amnions | monozygotic twins with cleavage of zygote from the fourth to the eighth day after fertilization |
| One placenta, one chorion, one amnion | monozygotic twins with cleavage of zygote from the eighth to the twelfth day after fertilization |
| Risks in multifetal gestation | Preterm labor and delivery, IUGR, Polyhydramnios, Preeclampsia, Congenital anomalies, postpartum hemorrhage, placental/umbilical cord accidents, increased risk of SAB |
Created by:
ltm12