OB: Early and Mid-Trimester Complications
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| Most common complication of early pregnancy | Spontaneous abortion. Estimated 50% of all pregnancies. Diagnosed SAB probably less than 1/2 of women
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| 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
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| Usual presentations of SAB | Amenorrhea, Vaginal Bleeding, Abdominal pain
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| Bleeding in the first trimester | Physiologic (implantation), Ectopic Pregnancy, Impending SAB, Cervical polyp, Cervical infection, neoplasia
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| hCG | Can be qualitative (+/-) usually on urine. Quantitative on serum
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| 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
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| Any bleeding in the first half of an intrauterine pregnancy | Threatened Abortion (so, within the first 20 wks). May not result in an abortion
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| EGA | estimated gestational age
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| OOM | onset of menses
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| Threatened AB | bleeding, often painless, closed os, 25% of pregnancies have TAB, 50% of these proceed to SAB. US needed. Uterine size is EGA
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| Rupture of membranes and/or cervix open, pregnancy loss unavoidable | Inevitable AB. Cervix is dilated, bleeding increasing, cramping
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| All Products of Conception passed, common prior to 12 weeks | Complete AB
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| Partial expulsion of gestational tissue, after 12wks, incomplete AB more likely. placental tissue retained. ROM, cervix open, bleeding can be severe | Incomplete AB
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| ROM | rupture of membranes
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| 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
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| More than 2 consecutive or 3 total SAB | Recurrent AB. Extensive work up
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| Induced AB | Elective: legal, but not medically necessary. Therapeutics: necessary for the health of the mother
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| Miscarriage should be documented as | SAB: spontaneous abortion
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| SAB evaluation | Definite US dx
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| Threatened abortion | painless bleeding
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| 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
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| 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
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| Leading cause of pregnancy-related death in the first trimester | Ectopic pregnancy
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| Why is the rate of ectopic pregnancy increasing | STDs, reverse tubal, assisted fertilization, PID rates increasing
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| 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
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| High Risks for ectopic pregnancies | high: tubal pathology, previous ectopic, DES, exposure, Tubal surgery.
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| Moderate Risks for ectopic pregnancies | previous infxn (PID, chlamydia, GC) especially recurrent, Infertility, Multiple sexual partners (STDs)
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| Low Risks for ectopic pregnancies | smoking, vaginal douching, Age (early sexual debut, older age groups from cumulative risk factors over time)
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| 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)
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| Ectopic Sx | Abdominal pain, amenorrhea, vaginal bleeding. BUT 50% of women are asx with ectopic pregnancy before tubal rupture
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| 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)
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| Ectopic Evaluation | Exam often unremarkable. PE: orthostatic vitals if ruptured, occasionally fever, CMT, Adnexal pain, Pain to abdominal palpation, rebound
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| Ectopic Evulation labs and imaging | Quantitative hCG, TVUS
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| Natural hx of ectopic | Tubal rupture, tubal abortion (expulsion of POC through the fimbrae, resulting in tissue regression or reimplantation), spontaneous resolution
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| 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.
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| Ectopic Tx: Rx | Methotrexate
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| 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)
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| GTN clinical presentations | often exaggerated pregnancy sx, hCG much higher than it should be in a nl pregnancy (tumor marker). Highly curable with chemotherapy
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| GTN Evaluation | hCG, U/S, Work up metastatic dz
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| GTN Tx | D&C, Methotrexate, chemotherapeutic agents, follow with serial hCGs
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| Cervical Insufficiency | Painless cervical changes that occur in the second trimester and result in recurrent pregnancy loss
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| 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"
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| Trauma of cervix | cervical laceration, instrument dilation, cone biopsy, LEEP
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| Elevated serum relaxin | connective tissue remodeling, higher in twin pregnancies and pregnancies induced by menotropins
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| Clinical Manifestations of Cervical Insufficiency | Vaginal fullness or pressure, vaginal spotting or bleeding, watery, mucousy, or brown vaginal discharge, vague abdominal or back discomfort
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| 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
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| Effacement | thinning of cervix. Normal near due date, but don't want cervix to efface too early.
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| Tx of cervical insufficiency | Pelvic rest, progesterone, indomethacin, Prophylactic cerclage ("purse string suture")
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| Two placentas, two amnions, two chorions | from either dizygotic twins or monozygotic twins with cleavage of zygote during first 3 days after fertilization
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| One placenta, one chorion, two amnions | monozygotic twins with cleavage of zygote from the fourth to the eighth day after fertilization
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| One placenta, one chorion, one amnion | monozygotic twins with cleavage of zygote from the eighth to the twelfth day after fertilization
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| Risks in multifetal gestation | Preterm labor and delivery, IUGR, Polyhydramnios, Preeclampsia, Congenital anomalies, postpartum hemorrhage, placental/umbilical cord accidents, increased risk of SAB
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Created by:
ltm12