Women's Health L22 - Early and Late Pregnancy Complications I

what is an ectopic pregnancy?

an extrauterine pregnancy (occurs outside of the uterus)

in what possible sites might ectopic pregnancies occur?

1. fallopian tubes

2. cervical

3. interstitial

4. ovarian

5. abdomen

where do the majority of ectopic pregnancies occur?

fallopian tube

3 multiple choice options

a rupture of an ectopic pregnancy can lead to life-threatening hemorrhage

true

1 multiple choice option

a tubal ectopic pregnancy will never be viable

true

1 multiple choice option

what is the presentation of an ectopic pregnancy in the first 6-8 weeks following a patient's LMP?

1. 1st trimester vaginal bleeding

2. abdominal pain -- +/- diffuse lower or pelvic pain

3. +/- pregnancy-associated symptoms -- breast tenderness or nausea

what is the clinical presentation of a ruptured ectopic pregnancy?

1. severe or persistent abdominal pain

2. symptoms of ongoing (intra-abdominal) blood loss

what might vitals show that would differentiate unstable vs stable?

1. hypotension

2. tachycardia

what abdominal exam findings might you note if there was a rupture or significant hemorrhage with an ectopic pregnancy?

distention

why might a pelvic exam be performed in a stable patient with an ectopic pregnancy?

to assess the volume of bleeding

what pelvic exams findings might you note in a stable patient with an ectopic pregnancy?

1. enlarged uterus

2. adnexal mass

a bimanual exam in a stable patient with an ectopic pregnancy should be performed carefully

true

1 multiple choice option

when would you suspect an ectopic pregnancy?

1. any female patient of reproductive age with vaginal bleeding and/or abdominal pain AND

2. pregnant but has not been confirmed as intrauterine

3. pregnant and conceived with IVF

4. pregnancy status is uncertain

5. hemodynamic instability and acute abdomen not explained by another diagnosis

what are the risk factors of an ectopic pregnancy?

1. previous ectopic pregnancy

2. previous tubal surgery

3. tubal pathology

4. current or past use of an IUD

5. in vitro fertilization (IVF)

what differentials could explain vaginal bleeding aside from an ectopic pregnancy?

1. physiologic -- implantation bleeding

2. spontaneous abortion

3. cervical/vaginal/uterine pathology

4. gestational trophoblastic disease

what differentials could explain lower abdominal pain aside from an ectopic pregnancy?

1. UTI

2. kidney stones

3. diverticulitis

4. appendicitis

5. ovarian cyst/neoplasm/torsion

in a pregnant patient with no evidence of an intrauterine pregnancy on transvaginal US (TVUS), a diagnosis of ectopic pregnancy is suspected if any of the following are present:

1. an extra-ovarian adnexal mass or intraperitoneal bleeding on TVUS

2. an abnormally rising serum hCG level -- should be lower than expected

3. abdominal pain and/or vaginal bleeding in a patient with risk factors for ectopic pregnancy

in a pregnant patient with no evidence of an intrauterine pregnancy on transvaginal US (TVUS), a diagnosis of ectopic pregnancy is confirmed if any of the following are present:

1. TVUS shows an extrauterine gestational sac with a yolk sac or embryo -- +/- fetal cardiac activity

2. no products of conception are identified on uterine aspiration

3. surgery with visual and histologic confirmation

what is considered a ruptured ectopic pregnancy until proven otherwise?

intraperitoneal bleeding in a patient of reproductive age, in the absence of trauma

what is the preferred treatment option for ectopic pregnancies in those who are candidates?

methotrexate -- IV or IM as a single or multi-dose protocol

what is the criteria for starting methotrexate for ectopic pregnancies?

1. hemodynamically stable

2. no kidney, hepatic, or hematologic disorders

3. able and willing to attend post-treatment appointment -- serum hCG measured on days 1, 4, and 7

4. have access to emergency care in case of a rupture

5. pretreatment serum hCG is ≤ 5000 U/L

6. no fetal cardiac activity on TVUS

what is the next step in management of an ectopic pregnancy if hCG levels do not decrease after 2 doses of methotrexate?

surgery

2 multiple choice options

what are the surgical management options for an ectopic pregnancy?

1. salpingectomy -- removal of fallopian tubes

2. salpingostomy -- incision to remove the tubal gestation

surgical management is required in which cases of ectopic pregnancy?

1. hemodynamic instability

2. suspected or impending tubal rupture -- bleeding/pain

3. heterotopic pregnancy with co-existing viable intrauterine pregnancy

4. contraindication to or failed methotrexate therapy

when is expectant management for ectopic pregnancy used?

1. no symptoms or signs of impeding rupture -- risk is very low

2. serum hCG is low and declining

3. patient can comply with close follow-up and has access to emergency care if needed

what is a spontaneous abortion also referred to as?

pregnancy loss, or miscarriage

what is a spontaneous abortion?

a nonviable intrauterine pregnancy up to 20 weeks of gestation

what is a nonviable intrauterine pregnancy considered after 20 weeks?

1. stillbirth

2. fetal death

a spontaneous abortion that occurs in the 1st trimester is referred to as an early pregnancy loss

true

1 multiple choice option

what is the most common complication of early pregnancy?

spontaneous abortion

a spontaneous abortion that occurs in the 2nd trimester is referred to as a pregnancy loss

true

1 multiple choice option

what are the risk factors of a spontaneous abortion?

1. increasing maternal age > 35 years

2. genetic anomalies

3. prior pregnancy loss

4. trauma

5. medication/substance us

6. environmental or radiation exposure

7. Black females or other females of color

what are the maternal risk factors for spontaneous abortion?

1. infection

2. diabetes

3. obesity

4. thyroid disease

5. stress

6. anatomic abnormalities

what is the clinical presentation of a spontaneous abortion?

1. vaginal bleeding

2. abdominal cramping

3. uncomplicated vs complicated

what is the clinical presentation of an uncomplicated spontaneous abortion?

1. hemodynamically stable

2. no evidence of infection

3. loss or reduction of pregnancy symptoms

what is the clinical presentation of a complicated spontaneous abortion?

1. severe hemorrhage

2. orthostatic vitals

3. signs of infection -- uterine tenderness, purulent discharge, fever, tachycardia

the severity of symptoms of a spontaneous abortion depend on the gestational age and type of abortion

true

1 multiple choice option

what are the types of spontaneous abortions?

1. inevitable

2. incomplete

3. complete

4. missed

what is an inevitable spontaneous abortion?

miscarriage that cannot be avoided

what is the presentation of an inevitable spontaneous abortion?

1. dilated cervical os

2. heavy or increasing bleeding

3. abdominal cramping

4. products of conception may be seen or felt

what is an incomplete spontaneous abortion?

persistent pregnancy tissue in the uterus after a diagnosis of a pregnancy loss

what is the presentation of an incomplete spontaneous abortion?

1. dilated cervical os

2. vaginal bleeding and cramping

3. some products of conception are expelled

what is a complete spontaneous abortion?

expulsion of all products of conception before the 20th completed week of gestation

what is the presentation of a complete spontaneous abortion?

1. closed cervical os

2. vaginal bleeding

3. empty uterus after documentation of prior intrauterine pregnancy

what is a missed spontaneous abortion?

nonviable pregnancy that has been retained in the uterus

what is the presentation of a missed spontaneous abortion?

1. no cervical dilation and spontaneous passage of products of conception

2. no fetal cardiac activity or empty sac

what is the presentation of a threatened spontaneous abortion?

1. cervix is closed and soft

2. vaginal bleeding and cramping

3. fetal cardiac activity present

how is a spontaneous abortion evaluated?

1. vitals -- stable vs unstable

2. speculum exam -- cervical os open vs closed

3. bimanual exam -- cervical tenderness if infection is present

how is a spontaneous abortion diagnosed?

1. TVUS or transabdominal US

2. serum hCG if diagnosis is unclear

what will a TVUS or transabdominal US show when diagnosing a spontaneous abortion?

1. no or abnormal intrauterine pregnancy

2. loss of previously seen cardiac activity

how can a spontaneous abortion be managed?

1. expectant

2. medical

3. surgical

what is the most effective type of management of a spontaneous abortion in the 1st trimester?

expectant

2 multiple choice options

what is the process of expectant management of a spontaneous abortion?

1. watchful waiting for pregnancy tissue to pass

2. requires a follow-up every 1-2 weeks until completion

3. NSAIDs for pain/abdominal cramping

when might you need to consider switching to medical/surgical management from expectant management of a spontaneous abortion?

1. complete abortion has not occurred after 4 weeks

2. patient has incomplete uterine emptying

3. infection develops

4. significant bleeding occurs

what is the medical management of a spontaneous abortion in the 1st trimester?

1. PO mifepristone 200 mg

2. vaginal/buccal/sublingual misoprostol 800 mcg within 24 hours of mifepristone

what is the medical management of a spontaneous abortion in the 2nd trimester?

1. PO mifepristone 200 mg

2. vaginal/buccal/sublingual misoprostol 800 mcg within 24 hours of mifepristone

3. additional dose of misoprostol every 3 hours until expulsion of pregnancy occurs

a misoprostol-only regimen can be utilized to manage a spontaneous abortion in the 2nd trimester

true

1 multiple choice option

when are NSAIDs advised to be taken for pain management when initiating medical management of a spontaneous abortion?

take ahead of time

what are the side effects of misoprostol?

1. nausea/vomiting

2. diarrhea

3. abdominal pain

what are the potential complications of medical management of a spontaneous abortion?

1. retained pregnancy tissue

2. infection

3. severe hemorrhage

4. uterine rupture

5. death -- rare

what is the surgical management of a spontaneous abortion in the 1st trimester?

uterine aspiration -- manual vs electric vacuum

what is the surgical management of a spontaneous abortion in the 2nd trimester?

1. dilation and evacuation (D&E)

2. +/- misoprostol for cervical ripening

what antimicrobial prophylaxis should be initiated prior to surgical management of a spontaneous abortion?

PO/IV doxycycline 200 mg an hour before

what are the potential complications of surgical management of a spontaneous abortion?

1. retained pregnancy tissue

2. need for repeat procedure

3. bleeding

4. cervical trauma

5. perforation

6. infection

7. intrauterine adhesion(s)

8. death -- rare

how is recurrent pregnancy loss defined?

1. 2+ failed clinical pregnancies as documented by US or histology

2. 3 consecutive pregnancy losses -- do not have to be intrauterine

what are the uterine factors that cause recurrent pregnancy loss?

1. congenital uterine anomalies -- septate uterus has the poorest outcome

2. leiomyomas

3. endometrial polyps

4. adhesions

5. cervical insufficiency

what are the immunologic factors that cause recurrent pregnancy loss?

1. antiphospholipid syndrome

2. allogenic factors

what are the endocrine factors that cause recurrent pregnancy loss?

1. diabetes

2. PCOS

3. thyroid disease

4. hyperprolactinemia

what are the genetic factors that cause recurrent pregnancy loss?

1. chromosome number/structure abnormalities -- most common!

what are some other causes that cause recurrent pregnancy loss?

1. thrombophilia

2. infection

3. untreated Celiac disease

what are TORCH infections?

1. infections acquired in utero or during birth, making them a significant cause of fetal/neonatal morbidity and mortality

2. well-known acronym of infectious diseases that can be passed from mother to baby

what does TORCH stand for?

1. T -- toxoplasmosis

2. O -- others (syphilis, Zika, or VZV)

3. R -- rubella

4. C -- cytomegalovirus (CMV)

5. H -- herpes simplex (HSV)

what is the etiology of toxoplasmosis?

1. toxoplasma gondii

2. present in raw/undercooked/cured meats or contaminated water/soil

3. cats (domestic and wild) can be hosts

what is the clinical presentation of mothers with toxoplasmosis?

1. fever, myalgias

2. non-tender cervical lymphadenopathy

what is the clinical presentation of newborns with toxoplasmosis?

1. chorioretinitis

2. hydrocephalus

3. seizures

4. anemia

how is a fetus diagnosed with toxoplasmosis?

amniocentesis

what is the treatment of toxoplasmosis in the 1st trimester?

spiramycin

what is the treatment of toxoplasmosis in the 2nd and 3rd trimesters and in postnatal patients?

pryimethamine-sulfadiazine

how can toxoplasmosis be prevented?

1. encourage handwashing

2. if there is a cat at home, avoid cleaning the litter box

what is group B streptococcus and what is a potential fetal complication?

1. asymptomatic lower genital tract colonization

2. septicemia in an early-onset infection

how and when is group B streptococcus screened for?

1. rectovaginal culture

2. collect at 35-37 weeks of gestation

how is group B streptococcus prevented?

penicillin G at delivery

how is hepatitis B prevented/treated?

1. vaccination during pregnancy in HBsAg-negative women with HBV risk factors

2. HBlg, followed by vaccination for maternal HBV exposure

3. all infants receive a hepatitis B vaccination within 2 days to 2 months of delivery

what lab values are mildly elevated in newborn infants with hepatitis C?

AST and ALT

antiviral therapy for hepatitis C is not an option during pregnancy

true

1 multiple choice option

HIV and pregnancy can enhance the presentation and treatment of other infections which could cause pregnancy complications or perinatal infections

true

1 multiple choice option

antiretroviral therapy (ART) can be initiated for HIV-positive patients during pregnancy and has been shown to reduce transmission rates

true

1 multiple choice option

laryngeal papillomatosis can be a manifestation of which virus in pregnancy?

maternal-fetal transmission of HPV

what is the treatment for condyloma acuminata in pregnancy?

1. cryotherapy

2. laser therapy

3. trichloroacetic acid (TCA)

treponema pallidum (syphilis) can cross the placenta after 16 weeks of gestation, but can occur at any stage of maternal infection

true

1 multiple choice option

what is the clinical presentation of congenital syphilis?

1. "snuffles"

2. Hutchinson teeth

3. saddle nose

4. saber shins

what is the treatment for syphilis in pregnancy?

penicillin G

what can neonatal transmission of gonorrhea cause?

gonococcal ophthalmia

when should high-risk pregnant patients be screened for gonorrhea?

1. initial prenatal visit

2. screen again in the 3rd trimester

what is the treatment for gonorrhea in pregnancy?

1. ceftriaxone + empiric azithromycin for chlamydia

2. neonates should receive prophylactic topical ophthalmic erythromycin

what can neonates develop if exposed to chlamydia?

1. purulent conjunctivitis

2. pneumonia

what is the treatment for chlamydia in pregnancy?

1. azithromycin

2. perform test of cure (TOC) in 4 weeks

what is the treatment of varicella in a pregnant patient with a rash?

PO acyclovir

what is the treatment for varicella in a neonate whose mother is infected and within days of labor?

varicella zoster Ig to infant

what are the fetal effects of Zika?

1. microcephaly

2. IUGR

3. stillbirth