(III) Early and late pregnancy pt 1

where do all ectopic pregnancies occur?

outside the uterus (extrauterine)

the MAJORITY of ectopic pregnancies occur where?

what are other less likely but possible sites?

fallopian tubes

- cervix

- intestines

- ovaries

- abdomen

what is the major complication to a raptured ectopic pregnancy?

LIFE THREATENING hemorrhage

when will a tubal ectopic pregnancy be viable

never

what are the 2 big sxs of ectopic preg to look out for around 6-8 weeks after LMP?

- 1st trimester vaginal bleeding

(some may mistake as menses)

- abdominal pain

(lower pelvic or diffuse pain)

T/F an ectopic preg will NOT have pregency sxs

False --> some WILL have preg sxs

pain indicated a ruptured or unruptured ectopic preg?

can indicate either one

what are 2 major signs of a ruptured ectopic preg?

- SEVERE/persistent pain

- ongoing (intraabdominal) blood loss sxs

-ex. feeling faint. LOC

what vital signs would indicate an unstable ectopic preg?

- hypotension

- tachycardia

what abdominal signs would indicate a ruptured/hemorrhaging ectopic preg

distension of the lower abdomen

if a hemorrhage is suspected, a bedside US should be performed quickly.

what is indicative of a hemorrhage on the US

echogenic fluid in the pelvic "cul-de-sac" and surrounding tissue

only if the pt is STABLE can you do a pelvic exam.

what exam is used to assess bleeding?

what exam would indicate enlarged uterus and palpable adnexal masses?

- speculum exam

- bimanual exam (CAREFULLY)

consider an ectopic preg in ANY female pt of reproductive age with vaginal bleeding +/- abdominal pain AND what 4 criteria?

- preg but not confirmed ectopic yet

- preg via IVF

- preg status uncertain

- hemodynamic instability + acute abdomen (not from another cause)

what are 5 r/fs for an ectopic preg?

- previous ectopic preg

- tubal surgery

- tubal pathology

- IUD (current or past)

- IVF

in a pt with no evidence of intrauterine preg on a TVUS, the dx is only SUSPECTED if?

(any of these are +)

- extraovarian adnexal mass or intraperitoneal bleeding on TVUS

- lower hCG than expected

- abdominal pain/vag bleeding in a pt w. risk factors (previous ectopic, IUD, IVF, tubes, etc)

in a pt with no evidence of intrauterine preg on a TVUS, the dx is CONFIRMED if?

(any of these are +)

- TVUS = extrauterine gestation sac with yolk sac or embryo (+/- fetal cardiac activity)

- uterine aspiration = no products of conception

- surgery = visual/histologic confirmation

what is considered an ectopic preg until proven otherwise?

intraperitoneal bleeding in a pt of reproductive age (no other trauma)

what is the preferred pharm treatment in pt with an ectopic preg (if they meet criteria)?

IV or IM Methotrexate (single dose)

what is the criteria to administer methotrexate?

- stable pts

- no kidney, hepatic, or heme disorders

- able/willing to attend post-tx appointment

- have access to emergency care in case of rupture

- pretx hCG = 5,000

= NO fetal cardiac activity (if +, do sx)

post-methotrexate treatment appointment measures what and on what days?

- hCG

- days: 1,4, 7

(in post-methotrexate treatment appointment) if hCG does not decreased after 2 doses, what's the next best step?

refer to surgery

what is the surgical tx for an ectopic preg?

salpingectomy ( - fallopian tubes)

or salpingostomy (- tubal gestation)

Surgery (salpingectomy or salpingostomy) is required in what 4 cases?

- hemo unstable

- impending tubal rupture (bleeding, pain)

- heterotopic preg with coexisting intrauterine preg (twins: one in uterus, one in tubes)

- failed (or CI) Methotrexate

what is the tx option for very low rupture risk pts with low and declining hCG, no sxs of impending rupture, can follow up after, and has emergency care?

expectant management

preg loss or "miscarriage"

spontaneous abortion

nonviable preg at 20 weeks and UNDER is a what?

spontaneous abortion/preg loss/miscarriage

nonviable preg at 20 weeks and OVER is a what?

stillbirth/fetal death

what is the mc complication of the 1st trimester

spontaneous abortion (early preg loss)

if a loss occurs in the 2nd trimester (up to 20 weeks) it is considered a what?

preg loss

3 most common spontaneous abortion r/fs

other maternal r/fs?

- increasing maternal age (>35)

- genetic anomalies

- prior preg loss

- infx

- DM

- obesity

- thyroid dz

- stress

- anatomic

4 types of spontaneous abortion

- inevitable: open cervix, heavy bleeding, abdominal cramping

- incomplete: tissue in the uterus after dx of preg loss

- complete: empty uterus before 20 weeks (after pervious intrauterine preg)

- missed: nonviable preg retained; no cervical dilation, no passage of products of conception

what type of spontaneous abortion?

closed cervical os, no cardiac activity, no bleeding

missed

what type of spontaneous abortion?

closed but soft cervical os

threatened

what type of spontaneous abortion?

dilated cervical os

inevitable

what type of spontaneous abortion?

dilated cervical os AND some products expelled

incomplete

what type of spontaneous abortion?

closed cervical os, products expelled, bleeding,

complete

sxs of a spontaneous abortion

- vaginal bleeding

- abdominal pain

(similar to ectopic)

sxs of a spontaneous abortion if uncomplicated?

- hemo stable

- no infx

- decreased preg sxs

complicated sxs? Are mostly in the 2nd trimester and can occur spontaneously, esp with a delay in preg loss and expulsion of conception

- severe hemorrhages

- orthostatic vitals (hypotension, tachycardia)

- infx (uterus/cervical tenderness, purulent discharge, fever)

us speculum to see if cervical os is open or closed*

what 2 US dx a spontaneous abortion?

- TVUS

- abdominal US

what will TV or abdominal US show with a spontaneous abortion?

what hCG trend is also helpful

- no or abnormal intrauterine preg on a previously confirmed preg

- declining hCG

what spontaneous abortion management is 70-80% effective if 1st trimester?

- Expectant management: watchful waiting for pregnancy tissue to pass

what is required for pts who are treated with expectant management?

- follow-up every 1-2 weeks until completion

when would switching form expectant management to surgical/medical route be an option?

- complete abortion has not occurred after 4 weeks

- pt has incomplete uterine emptying

- infx develops

- significant bleeding

what is the 1st trimester medical management for spontaneous abortion, given within 24 hours?

mifepristone PO followed by misoprostol vaginally/buccally/SL within 24 hours

what is the 2nd trimester medical management for spontaneous abortion, given Q 3 hours?

mifepristone + misoprostol dose is repeated every 3 hours until expulsion of pregnancy tissue

what is more successful, 1st or 2nd trimester medical management?

1st

(1st trimester can often complete as outpatient - 2nd trimester should be inpatient)

SE of mifepristone + misoprostol

mifepristone: well tolerated

misoprostol: GI side effects (N/V, diarrhea, abdominal pain)

what is the 1st trimester surgical management for spontaneous abortion?

uterine aspiration (manual or electric vacuum)

what is the 2nd trimester surgical management for spontaneous abortion?

D&E +/- misoprostol for cervical ripening

what antimicrobial prophylaxis is needed before surgical management?

when is it geven?

doxycycline PO/IV single dose

1 hr before procedure

recurrent preg loss =______________ OR ____________ (

2 or more failed clinical pregnancies

3 consecutive pregnancy losses

how is a recurrent preg loss documented/confirmed?

US or histology

what are some uterine factors leading to recurrent preg loss? what has the poorest outcome?

- congenital uterine anomalies

- septate uterus

- leiomyomas, endometrial polyps, adhesions, cervical insufficiency

septate uterus has the poorest outcome

what are some Immunologic factors leading to recurrent preg loss?

- antiphospholipid syndrome (RPL is part of the clinical diagnostic criteria for this condition)

- Allogeneic factors

what are some endocrine factors leading to recurrent preg loss?

- DM

- PCOS

- Thyroid dz

- hyperprolactinemia

what are some genetic factors leading to recurrent preg loss?

Chromosome number/structure abnormalities (MOST COMMON cause of early pregnancy loss)

what is the MCC of early preg loss?

Chromosome number/structure abnormalities

TORCH infx:

- T = toxoplasmosis

- O = others (syphilis, Zika, VZV)

- R = rubella

- C = cytomegalovirus (CMV)

- H = herpes simplex (HSV)

caused by: raw meats, water/soil, cats

Maternal symptoms - fever, myalgias, nontender cervical lymphadenopathy (can last weeks)

Newborn symptoms - chorioretinitis, hydrocephalus, seizures, HSM, anemia

Screening/Prevention: no standard screening, handwashing, avoid cleaning litter box

TOXOPLASMOSIS

Management for toxoplasmosis in 1st trimester?

2-3rd trimester/post natal?

1st trimester - spiramycin

2nd/3rd trimester and postnatal- pyrimethamine-sulfadiazine

what are the others in TORCH?

Group B Streptococcus

Hep B

Hep C

HIV

HPV

Syphilis

Gonorrhea

Chlamydia

Varicella

Zika

Parvovirus B19

how to screen for GBS?

how to prevent GBS?

fetal complications ?

rectovaginal culture at 35-37 weeks

- abx prophylaxis at delivery

- Pen G

septicemia

HBV prevention?

HBV tx?

vaccines during preg

if mother HBV exposure: HBig then vaccinate

ALL infants should receive Hep B vax in 2 day - 2 months of delivery

HCV sxs on labs for infant?

HCV prevention/tx

- mildly elevated aminotransferases

- routine screening

- no prevention btwn mother and infant

- ART is not an option during preg

HIV/AIDS treatment

ART

HPV treatment for condyloma acuminata

cryotherapy, laser therapy, trichloroacetic acid

Syphilis (Treponema pallidum) tx?

congenital syphilis sxs

pen G

"suffles", maculopapular rash, Hutchinson teeth, saddle nose, saber shins

gonorrhea tx for mother vs infant

Ceftriaxone = mother

all infants get prophylactic topical ophthalmic erythromycin

Tx for chlamydia

when to do test of cure?

what can neonates develop from chlamydia?

azithromycin

4 weeks after finishing therapy

conjunctivitis or pneumonia

varicella tx if preg w/rash

varicella tx if preg and infxed within days of labor/what is given to infant?

- oral acyclovir

- varicella zoster to infant

zika virus tx

none

and no screening

parovirus b19 tx

what s the complication if preg and positive? what do you do?

IgM/igG

- hydrops fetalis

- US every 1-2 weeks to monitor for hydrops fetalis

- Aka German measles/nasopharyngeal secretions

- Newborn symptoms - hearing loss, cataracts, heart defects

- Fetal tx - none available

- antibodies checked as part of standard prenatal eval

- Encourage vaccination in all patients PRIOR to pregnancy

rubella

- Most common congenital viral infection

- Those immunosuppressed should be checked at first prenatal visit

- no screening, wash hands

CMV

how to treat fetal CMV if in 1st trimester

maternal high-dose valacyclovir if in 1st trimester

- Typically transmitted to the neonate due to direct contact during labor and delivery

- Newborn symptoms: may be localized to skin/eyes/mouth, seizures, sepsis

- no screening, safe sex

HSV

maternal HSV tx

- acyclovir x 7-10 days for new lesion AND daily suppressive acyclovir at 36 weeks gestation until delivery