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Early OB Comps


1st trimester bleed: DDx implantation; impending SAB; ectopic; cervical polyp/ neoplasia
TVS: gestational sac visible at: 4.5 - 5 wks
TVS: fetal pole w/cardiac activity visible at: 5.5 - 6 wks
Any bleeding in the first half of an intrauterine pregnancy = Threatened Ab
Threatened Ab = bleeding, often painless; 25% of PG (1/2 go to SAB); closed os & EGA; need US
Rupture of membranes and/or cervix open, pregnancy loss unavoidable = Inevitable Ab; cervix is dilated, bleeding increasing, cramping. No expulsion of POC.
Complete Ab: when: Common prior to 12 weeks
Incomplete Ab more likely when? After 12 weeks
ROM, fetus passed, but placental tissue retained; cervix open, gestational tissue seen in cervix, uterus <EGA; bleeding can be severe Incomplete Ab
Retention of a failed IUP for an extended period = Missed Ab; AKA blighted ovum, anembryonic pregnancy; uterus < EGA, loss of PG sx. Cervix is firm & closed
Missed Ab complication DIC can occur in 2nd trimester if missed AB >6 weeks
SAB: U/S dx Absence cardiac activity when CRL >5 mm; absent fetal pole when sac >18 mm(TVS) or >25 (AbUS)
Ominous sx of SAB FHR <100; abnormal yolk sac; large subchorionic hematoma
Leading PG COD in 1st trimester: Ectopic PG
Ectopic RF High: tubal surg; IUD. Moderate: infxn; infertility; multiple partners. Low: smoking; hx of abd/pelvic surgery
Ectopics: where 98% fallopian tube; unusual location assoc w/ART
___% of women are asymptomatic with ectopic pregnancy before tubal rupture 50%
Ectopic sx PG/SAB sx; shoulder pain; if rupture: lightheaded, shock; urge to defecate
Ectopic: tx If ruptured, TOC: lap surg; salpingostomy; methotrexate
GTN (gestational trophoblastic neoplasia) spectrum Malignant: invasive mole, choriocarcinoma; PSTT (placental site trophoblastic tumor). Benign: hydatidiform mole (complete/partial molar PG)
GTN tx D&C; methotrexate, other CTx if malignant; follow w/serial hCG
Painless cervical changes (dilation) that occur in the second trimester and result in recurrent PTL / pregnancy loss = Cervical insufficiency
Cervical insufficiency: congenital factors short cervix (PTD risk x10 if 22 mm); mullerian or collagen abnormalities; FH
Cervical insufficiency: non-congenital risk factors Trauma (cervical lac, LEEP, bx); high relaxin; DES exposure; prior Ab
Cervical insufficiency: sx Gradual painless cervical dilatation and effacement. Vaginal fullness, pressure, spotting. Watery/ mucus/ brown discharge. Abd/back pain
Cervical insufficiency: tx Bed rest; 17alpha-hydroxyprogesterone IM weekly; indomethacin; steroids at week 24-34 (prevent PTL comps); cerclage
SAB defn expulsion of all or part of products of conception before week 20 (50% of all PG)
Complete Ab defn expulsion of entire conceptus by 20 weeks. Cervical os is closed. Uterus small & nontender.
Incomplete Ab defn Passage of part of POC. Retained tissue. Profuse continuous bleeding. Boggy uterus & dilated os.
Incomplete Ab mgmt D&E. Pitocin. RhIG PRN. Tissue to pathology.
Pelvic US for threatened abortion Abnormal gestational sac, small embryo with low HR: suggests probable loss of PG
Missed abortion mgmt 1st trimester: suction curettage. 2nd: D&E or induction of labor with PGE2 or misoprostol.
Workup for recurrent miscarriage (3+ consecutive spontaneous PG losses) Imaging for structural defects. Endometrial bx. Luteal phase progesterone (check for luteal phase defects). PCOS eval. Labs for antiphospholipid syndrome.
Recurrent miscarriage mgmt LPD (progesterone). Metformin if PCOS. If APS: anticoagulation.
Ectopic PG mgmt Serial HCGs. TVUS. ?laparoscopy.
Pregnant + rash, post-auricular or occipital LAD Rubella; Give vaccine AFTER delivery
most common cause of ectopic PG tubal occlusion 2/2 adhesions
Dx of PTL Pelvic exam (+/- bimanual, if PPROM is ruled out): cervical dilatation >3cm & 80% effacement. TVUS: cervical length <20mm
PTL is unlikely diagnosis if exam shows: Cervical dilatation <3cm & <80% effacement. TVUS: cervical length >30mm
Hyperemesis gravidarum workup Follow weight. UA for ketones. Lytes, LFTs, CBC, TFTs. US.
Created by: Adam Barnard Adam Barnard