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Questions and Answers
Questions and Answers
What should vaginal bleeding and abdominal pain be considered until proven otherwise?
What should vaginal bleeding and abdominal pain be considered until proven otherwise?
Ectopic
If a patient presents with early pregnancy bleeding, what should exam include?
If a patient presents with early pregnancy bleeding, what should exam include?
Genitalia exam (pelvic exam, quantity & source of bleeding)
What is the first thing that should be assessed for in early pregnancy bleeding?
What is the first thing that should be assessed for in early pregnancy bleeding?
Hemodynamic stability and infection (present = referral)
What quantity of early pregnancy bleeding is considered worrisome?
What quantity of early pregnancy bleeding is considered worrisome?
What are cervical polyps more common in?
What are cervical polyps more common in?
What is a result of separation of the chorion from the uterine lining which results in a collection of blood between the uterine wall and chorionic membrane?
What is a result of separation of the chorion from the uterine lining which results in a collection of blood between the uterine wall and chorionic membrane?
What is the presentation for subchorionic hemorrhage?
What is the presentation for subchorionic hemorrhage?
What will be seen adjacent to the gestational sac for subchorionic hemorrhage?
What will be seen adjacent to the gestational sac for subchorionic hemorrhage?
When does subchorionic hemorrhage typically resolve by?
When does subchorionic hemorrhage typically resolve by?
With subchorionic hemorrhage, the risk of loss is dependent on the size, what size is associated with greater risk?
With subchorionic hemorrhage, the risk of loss is dependent on the size, what size is associated with greater risk?
What results from blastocyst implants and causes HCG levels to rise, but spontaneously aborts before an ultra sound can even detect a fetal heart beat?
What results from blastocyst implants and causes HCG levels to rise, but spontaneously aborts before an ultra sound can even detect a fetal heart beat?
What is the death of an embryo before 10 weeks gestation, before viability is reached often diagnosed on u/s when the embryo is expected to have a heartbeat?
What is the death of an embryo before 10 weeks gestation, before viability is reached often diagnosed on u/s when the embryo is expected to have a heartbeat?
What results from all POC passing, the cervix will be closed, the uterus will be small - associated w. heavy cramping and bleeding, passage of clots/tissue, followed by abrupt decrease in sxs?
What results from all POC passing, the cervix will be closed, the uterus will be small - associated w. heavy cramping and bleeding, passage of clots/tissue, followed by abrupt decrease in sxs?
What results at > 20 weeks gestation with cervical dilation &/or rupture of membranes w. vaginal bleeding and lower abomdinal/back pain but NO passage of tissue?
What results at > 20 weeks gestation with cervical dilation &/or rupture of membranes w. vaginal bleeding and lower abomdinal/back pain but NO passage of tissue?
What will the embryo size be on u/s for an inevitable abortion?
What will the embryo size be on u/s for an inevitable abortion?
What results from the passage of some fetal or placental tissue at < 20 weeks EGA, tissue is still visible in the uterus w.o evidence of viability?
What results from the passage of some fetal or placental tissue at < 20 weeks EGA, tissue is still visible in the uterus w.o evidence of viability?
What type of abortion is often found at a routine visit, the cervix will be closed but there will be retained POC in the uterus w.o FHTs?
What type of abortion is often found at a routine visit, the cervix will be closed but there will be retained POC in the uterus w.o FHTs?
What type of abortion is defined by painless vaginal bleeding w.o cervical dilation or effacement?
What type of abortion is defined by painless vaginal bleeding w.o cervical dilation or effacement?
What results from the development of a gestational sac w.o development of an embryo?
What results from the development of a gestational sac w.o development of an embryo?
What results from loss accompanied by infection and sepsis (rare)?
What results from loss accompanied by infection and sepsis (rare)?
What is the criteria for recurrent abortion?
What is the criteria for recurrent abortion?
Who should a patient be referred to if they meet the criteria for recurrent abortion?
Who should a patient be referred to if they meet the criteria for recurrent abortion?
What are potential pathogenesis for spontaneous abortion?
What are potential pathogenesis for spontaneous abortion?
For spontaneous abortion, when an embryo dies or has failure to develop, where does hemorrhage occur?
For spontaneous abortion, when an embryo dies or has failure to develop, where does hemorrhage occur?
After hemorrhage occurs in teh decidua basalis, what occurs at the implantation site in a spontaneous abortion?
After hemorrhage occurs in teh decidua basalis, what occurs at the implantation site in a spontaneous abortion?
In a spontaneous abortion, what occurs at the site of implantation after necrosis?
In a spontaneous abortion, what occurs at the site of implantation after necrosis?
In a spontaneous abortion, after leukocyte infiltration, what becomes edematous?
In a spontaneous abortion, after leukocyte infiltration, what becomes edematous?
In a spontaneous abortion, what results in hormones?
In a spontaneous abortion, what results in hormones?
What results in vaginal bleeding in a spontaneous abortion?
What results in vaginal bleeding in a spontaneous abortion?
In a spontaneous abortion, what does uterine irritability result in?
In a spontaneous abortion, what does uterine irritability result in?
What is the classic sign for a spontaneous abortion?
What is the classic sign for a spontaneous abortion?
What is the primary goal when triaging bleeding in early pregnancy?
What is the primary goal when triaging bleeding in early pregnancy?
For spontaneous abortion management, what has the greatest risk for retained POC?
For spontaneous abortion management, what has the greatest risk for retained POC?
What circumstances do not allow for medical management of a spontaneous abortion?
What circumstances do not allow for medical management of a spontaneous abortion?
What medications are used for medical management of a spontaneous abortion?
What medications are used for medical management of a spontaneous abortion?
How soon should an u/s occur after medical management for a spontaneous abortion?
How soon should an u/s occur after medical management for a spontaneous abortion?
What management for a spontaneous abortion has the lowest risk for retained POC?
What management for a spontaneous abortion has the lowest risk for retained POC?
What circumstances warrant immediate surgical management for a spontaneous abortion?
What circumstances warrant immediate surgical management for a spontaneous abortion?
What is the antibiotic prophylaxis for surgical management of a spontaneous abortion?
What is the antibiotic prophylaxis for surgical management of a spontaneous abortion?
What EGA can MVA/MUA be used for spontaneous abortion management?
What EGA can MVA/MUA be used for spontaneous abortion management?
What EGA will dilation and evacuation be used for the surgical management of a spontaneous abortion?
What EGA will dilation and evacuation be used for the surgical management of a spontaneous abortion?
What is severe pain supicious for after management of a spontaneous abortion?
What is severe pain supicious for after management of a spontaneous abortion?
When should a patient expect menses to return after a spontaneous abortion?
When should a patient expect menses to return after a spontaneous abortion?
When can a patient return to fertility/try to get pregnancy again after a spontaneous abortion?
When can a patient return to fertility/try to get pregnancy again after a spontaneous abortion?
What are findings that are diagnostic of pregnancy failure?
What are findings that are diagnostic of pregnancy failure?
What lab evaluation should occur in recurrent pregnancy loss?
What lab evaluation should occur in recurrent pregnancy loss?
What is recurrent pregnancy loss often a result of?
What is recurrent pregnancy loss often a result of?
What is the only circumstance where anticoagulation should be used for recurrent pregnacy loss?
What is the only circumstance where anticoagulation should be used for recurrent pregnacy loss?
When is hemorrhage higher w. a spontaneous abortion?
When is hemorrhage higher w. a spontaneous abortion?
When is infection a high risk with a spontaneous abortion?
When is infection a high risk with a spontaneous abortion?
What does retained POC after a spontaneous abortion require?
What does retained POC after a spontaneous abortion require?
If a patient has sepsis or a septic abortion post spontaneous abortion, what will it present like?
If a patient has sepsis or a septic abortion post spontaneous abortion, what will it present like?
What is the most common site for an ectopic pregnancy?
What is the most common site for an ectopic pregnancy?
What are risk factors for ectopic pregnancy?
What are risk factors for ectopic pregnancy?
What is the result of hCG production and uptake being decreased in an ectopic pregnancy?
What is the result of hCG production and uptake being decreased in an ectopic pregnancy?
How do pain and bleeding occur in an ectopic pregnancy?
How do pain and bleeding occur in an ectopic pregnancy?
What will be the characteristic of pain and bleeding if an ectopic pregnancy ruptures?
What will be the characteristic of pain and bleeding if an ectopic pregnancy ruptures?
What additional symptoms may occur with an ectopic pregnancy aside from bleeding?
What additional symptoms may occur with an ectopic pregnancy aside from bleeding?
What lab should be obtained to assesss for hemodynamic status in an ectopic pregnancy?
What lab should be obtained to assesss for hemodynamic status in an ectopic pregnancy?
Regarding hCG, what is a concern for ectopic pregnancy or loss?
Regarding hCG, what is a concern for ectopic pregnancy or loss?
What pharm management will be used for an ectopic pregnancy, causes cellular death of trophoblastic tissue and decreases size of ectopic w.o surgery?
What pharm management will be used for an ectopic pregnancy, causes cellular death of trophoblastic tissue and decreases size of ectopic w.o surgery?
What surgical management will be used for an ectopic pregnancy at later EGA?
What surgical management will be used for an ectopic pregnancy at later EGA?
How long should hCG be followed after methotrexate therapy in an ectopic pregnancy?
How long should hCG be followed after methotrexate therapy in an ectopic pregnancy?
What should be avoided until resolution of an ectopic pregnancy is confirmed?
What should be avoided until resolution of an ectopic pregnancy is confirmed?
How long should pregnancy be delayed for an ectopic pregnancy?
How long should pregnancy be delayed for an ectopic pregnancy?
What does gestational trophoblastic disease arise from?
What does gestational trophoblastic disease arise from?
What type of hydatidiform mole has all chorionic villi hyperplastic, edematous and avascular with no embryo, fetus or gestational sac development?
What type of hydatidiform mole has all chorionic villi hyperplastic, edematous and avascular with no embryo, fetus or gestational sac development?
What type of hydatidiform mole has molar changes only in a portion of the chorionic villi, a fetus or embryo will be present?
What type of hydatidiform mole has molar changes only in a portion of the chorionic villi, a fetus or embryo will be present?
What are symptoms assoicated w. a hydatidiform mole?
What are symptoms assoicated w. a hydatidiform mole?
How will typical pregnancy symptoms present for a hydatidiform mole?
How will typical pregnancy symptoms present for a hydatidiform mole?
What will be the characteristics of vessicles passed with a hydatidiform mole?
What will be the characteristics of vessicles passed with a hydatidiform mole?
What will be the characteristic of hCG in the presence of a hydatidiform mole?
What will be the characteristic of hCG in the presence of a hydatidiform mole?
What is the most accurate diagnostic tool for a hydatidiform mole?
What is the most accurate diagnostic tool for a hydatidiform mole?
What will be seen on u/s for a hydatidiform mole?
What will be seen on u/s for a hydatidiform mole?
What will referral be for in a patient with a hydatidiform mole?
What will referral be for in a patient with a hydatidiform mole?
How will hCG be monitored post surgically for a hydatidiform mole?
How will hCG be monitored post surgically for a hydatidiform mole?
What circumstances should an IUD be avoided after a hydatidiform mole?
What circumstances should an IUD be avoided after a hydatidiform mole?
How long should pregnancy be avoided for after the treatment of a hydatidiform mole?
How long should pregnancy be avoided for after the treatment of a hydatidiform mole?
Questions and Answers
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Flashcards
Flashcards
ectopic
ectopic
What should vaginal bleeding and abdominal pain be considered until proven otherwise?
genitalia exam
genitalia exam
What should exam include if a patient presents with early pregnancy bleeding?
hemodynamic stability
hemodynamic stability
What is the first thing that should be assessed for in early pregnancy bleeding?
2 pads/hr for 2 hours
2 pads/hr for 2 hours
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parous indiv
parous indiv
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subchorionic hemorrhage
subchorionic hemorrhage
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painless spotting
painless spotting
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hypoechoic area
hypoechoic area
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20 weeks
20 weeks
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chemical pregnancy
chemical pregnancy
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embryonic demise
embryonic demise
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complete abortion
complete abortion
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inevitable abortion
inevitable abortion
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missed abortion
missed abortion
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threatened abortion
threatened abortion
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septic abortion
septic abortion
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recurrent abortion
recurrent abortion
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endocrinology
endocrinology
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abnormal karyotype
abnormal karyotype
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deciduas basalis
deciduas basalis
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necrosis
necrosis
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Flashcards
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Study Notes
Study Notes
Early Pregnancy Bleeding
- Ectopic Pregnancy: Vaginal bleeding and abdominal pain should be considered ectopic until proven otherwise.
- Initial Assessment: Evaluate hemodynamic stability and signs of infection in patients with early pregnancy bleeding; referral is warranted if present.
- Excessive Bleeding: Bleeding exceeding 2 pads per hour for two consecutive hours is worrisome.
- Pelvic Exam: Includes genital exam (pelvic exam) to assess the quantity and source of bleeding.
- Cervical Polyps: More common in parous individuals; characterized by dark or bright red bleeding.
Types of Spontaneous Abortion
- Chemical Pregnancy: Blastocyst implantation, rising hCG levels followed by spontaneous abortion before fetal heartbeat detected by ultrasound.
- Embryonic Demise: Embryo death before 10 weeks gestation, identified by ultrasound lacking a heartbeat.
- Complete Abortion: All products of conception (POC) have passed; cervix is closed; uterus is small; heavy cramping and bleeding with abrupt decrease.
- Inevitable Abortion: Cervical dilation and/or rupture of membranes; vaginal bleeding and lower abdominal/back pain, but no tissue expulsion.
- Incomplete Abortion: Passage of some POC before 20 weeks; tissue remains in the uterus; fetal viability absent.
- Missed Abortion: Cervix closed; retained POC in uterus; no fetal heart tones (FHTs) detected; often found during a routine visit.
- Threatened Abortion: Painless vaginal bleeding; no cervical dilation or effacement.
- Anembryonic Pregnancy (Blighted Ovum): Gestational sac forms without embryo development.
- Septic Abortion: Loss of pregnancy accompanied by infection and sepsis (rare).
- Recurrent Abortion: Two or more clinical pregnancy losses.
- Referrals: Patients with recurrent loss should be referred to endocrinology specialists.
Spontaneous Abortion Pathogenesis
- Pathogenesis: Potential causes include abnormal karyotypes (50%), infection, anatomic defects, endocrine factors, exposure to toxic substances, and unknown factors.
- Hemorrhage/Necrosis: Hemorrhage occurs in the decidua basalis; the implantation site undergoes necrosis.
- Leukocyte Infiltration: Leukocyte infiltration follows necrosis.
- Chorionic Villus Edema: Chorionic villi become edematous.
- Hormonal Changes: Estrogen and progesterone levels drop.
- Decidual Sloughing: Results in vaginal bleeding.
- Uterine Contractions: Uterine irritability leads to contractions.
- Classic Sign: Bright red vaginal bleeding (like a period).
Spontaneous Abortion Management
- Primary Goal: Prevent/assess for life-threatening blood loss.
- Management Options: Expectant, Medical, or Surgical management.
- Expectant: Highest risk for retained POC.
- Medical: Contraindicated for infection, hemorrhage, or bleeding disorders.
- Medical Management: Misoprostol (800 mcg vaginal) or mifepristone (200mg 24 hours prior to misoprostol) followed by 800 mcg misoprostol.
- Follow-up: Ultrasound within 7-14 days after medical management.
- Surgical Management: Lowest risk for retained POC.
- Surgical Indications: Hemorrhage, hemodynamic instability, or infection.
- Antibiotic Prophylaxis: 200 mg Doxycycline 1 hour prior.
- Management Considerations: MVA/MUA (<10 weeks) and D&E (>14 weeks) for surgical management.
- Complication: Retained POC; severe pain.
- Post-Abortion Recovery: Menses return in 4-6 weeks (hormone levels ordered if not occurred at this point).
- Fertility Return: Patients can return to fertility/try to get pregnant anytime.
- Pregnancy Failure Diagnosis: Ultrasound findings indicating pregnancy failure (e.g., CRL 7mm+, no heartbeat).
Ectopic Pregnancy
- Site: Most common site is the ampulla.
- Risk Factors: Pelvic inflammatory disease (PID), smoking (dose-related), prior tubal/pelvic surgery, contraceptive failure, assisted reproductive technology (ART), and unknown factors.
- Symptoms: Minimal pregnancy symptoms initially; then pain followed by bleeding; a rupture causes pain to cease, continued bleeding. Additional symptoms may include abdominal pain/tenderness, delayed menses, absence of common pregnancy signs, palpable mass, and hemodynamic instability.
- Lab Assessment: Complete Blood Count (CBC) to assess for hemodynamic status.
- hCG Concerns: Absence of hCG doubling every 48 hours.
- Pharmaceutical Management: Methotrexate to cause cellular death of trophoblastic tissue; decreases ectopic size without surgery.
- Surgical Management: Laparoscopy or laparotomy.
- Post-Treatment: Monitor hCG until no longer detectable (non-pregnancy level); avoid intercourse, excessive exercise, excessive pelvic exams.
- Post-Treatment Return to Fertility: 1-3 months post-methotrexate treatment; pregnancy delayed for this period.
Gestational Trophoblastic Disease (Hydatidiform Mole)
- Types: Complete Mole (46,XX, all paternal origin) and Partial Mole (69,XXX or 69,XXY).
- Symptoms: First-trimester bleeding, variable uterine size (small or large), ovarian enlargement (multiple theca lutein cysts), and exaggerated pregnancy symptoms.
- Ultrasound Findings: Grape-like structures; snowstorm appearance.
- Diagnosis: Ultrasound.
- Referral: D&C or hysterectomy.
- Monitoring: Weekly hCG until undetectable; then every 1-3 months.
- Pregnancy Avoidance: Avoid pregnancy until monitoring is complete.
General Considerations
- High Risk for Hemorrhage: Expectant or medical management.
- High Risk for Infection: Retained POC or genital tract infection.
- Retained POC: Surgical treatment required.
- Endometritis: Presentation in sepsis or septic abortion.
- Lab Evaluation in Recurrent Pregnancy Loss: Endocrine, coagulation, and autoimmune disorders testing.
- Recurrent Pregnancy Loss Etiology: 50% due to aneuploidy.
- Anticoagulation: Only indicated in recurrent pregnancy loss with antiphospholipid antibodies.
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