Obstetrics
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| 1st trimester bleed: DDx | implantation; impending SAB; ectopic; cervical polyp/ neoplasia
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| TVS: gestational sac visible at: | 4.5 - 5 wks
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| TVS: fetal pole w/cardiac activity visible at: | 5.5 - 6 wks
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| Any bleeding in the first half of an intrauterine pregnancy = | Threatened Ab
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| Threatened Ab = | bleeding, often painless; 25% of PG (1/2 go to SAB); closed os & EGA; need US
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| Rupture of membranes and/or cervix open, pregnancy loss unavoidable = | Inevitable Ab; cervix is dilated, bleeding increasing, cramping. No expulsion of POC.
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| Complete Ab: when: | Common prior to 12 weeks
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| Incomplete Ab is more likely after what point in time? | After 12 weeks
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| Rupture of membranes, fetus passed, but placental tissue retained; cervix open, gestational tissue seen in cervix, uterus <EGA; bleeding can be severe = | Incomplete Ab
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| 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
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| Missed Ab complication | DIC can occur in 2nd trimester if missed AB >6 weeks
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| SAB: U/S dx | Absence cardiac activity when CRL >5 mm; absent fetal pole when sac >18 mm(TVS) or >25 (AbUS)
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| Ominous sx of SAB | FHR <100; abnormal yolk sac; large subchorionic hematoma
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| Leading PG COD in 1st trimester: | Ectopic PG
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| Ectopic RF | High: tubal surg; IUD. Moderate: infxn; infertility; multiple partners. Low: smoking; hx of abd/pelvic surgery
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| Ectopic PG: most common site | 98% fallopian tube (most often ampulla). Unusual location assoc w/ART
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| ___% of women are asymptomatic with ectopic pregnancy before tubal rupture | 50%
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| Ectopic sx | PG/SAB sx; shoulder pain; if rupture: lightheaded, shock; urge to defecate
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| Ectopic: tx | Salpingostomy. Salpingectomy if ruptured. TxOC: lap surg. Methotrexate only if bHCG <5000, ectopic mass <3.5cm, no fetal Ht tones & no folate supplementation
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| GTN (gestational trophoblastic neoplasia) spectrum | Malignant: invasive mole, choriocarcinoma; PSTT (placental site trophoblastic tumor). Benign: hydatidiform mole (complete/partial molar PG)
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| GTN tx | D&C; methotrexate, other CTx if malignant; follow w/serial hCG
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| Painless cervical changes (dilation) that occur in the second trimester and result in recurrent PTL / pregnancy loss = | Cervical insufficiency
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| Cervical insufficiency: congenital factors | short cervix (PTD risk x10 if 22 mm); mullerian or collagen abnormalities; FH
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| Cervical insufficiency: non-congenital risk factors | Trauma (cervical lac, LEEP, bx); high relaxin; DES exposure; prior Ab
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| Cervical insufficiency: sx | Gradual painless cervical dilatation and effacement. Vaginal fullness, pressure, spotting. Watery/ mucus/ brown discharge. Abd/back pain
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| Cervical insufficiency: tx | Bed rest; 17alpha-hydroxyprogesterone IM weekly; indomethacin; steroids at week 24-34 (prevent PTL comps); cerclage
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| SAB defn | expulsion of all or part of products of conception before week 20 (50% of all PG)
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| Complete Ab defn | expulsion of entire conceptus by 20 weeks. Cervical os is closed. Uterus small & nontender.
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| Incomplete Ab defn | Passage of part of POC. Retained tissue. Profuse continuous bleeding. Boggy uterus & dilated os.
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| Incomplete Ab mgmt | D&E. Pitocin. RhIG PRN. Tissue to pathology.
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| Pelvic US for threatened abortion | Abnormal gestational sac, small embryo with low HR: suggests probable loss of PG
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| Missed abortion mgmt | 1st trimester: suction curettage. 2nd: D&E or induction of labor with PGE2 or misoprostol.
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| 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.
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| Recurrent miscarriage mgmt | LPD (progesterone). Metformin if PCOS. If APS: anticoagulation.
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| Ectopic PG mgmt | Serial HCGs. TVUS. ?laparoscopy.
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| Pregnant + rash, post-auricular or occipital LAD | Rubella; Give vaccine AFTER delivery
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| most common cause of ectopic PG | tubal occlusion 2/2 adhesions
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| Dx of PTL | Pelvic exam (+/- bimanual, if PPROM is ruled out): cervical dilatation >3cm & 80% effacement. TVUS: cervical length <20mm
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| PTL is unlikely diagnosis if exam shows: | Cervical dilatation <3cm & <80% effacement. TVUS: cervical length >30mm
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| Hyperemesis gravidarum workup | Follow weight. UA for ketones. Lytes, LFTs, CBC, TFTs. US.
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| Inevitable abortion definition | vaginal bleeding, open cervical os, no passage of tissue
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