Abortion, Infertility, Preconception, Ectopic Pregnancy

Spontaneous abortion

Unplanned pregnancy loss; most often caused by fetal abnormalities

Other spontaneous abortion causes

Systemic disease, hormonal imbalance, anatomic abnormalities

Most common spontaneous abortion timing

2nd–3rd month of gestation

Threatened abortion

Cervix remains closed

Incomplete abortion

Only some pregnancy tissue passes; remaining tissue requires removal

Incomplete abortion treatment

D&C/D&E or oral misoprostol

Complete abortion

Fetus and all related tissue are spontaneously evacuated

Habitual/recurrent abortion

Repeated spontaneous abortions of unknown cause

Procedural abortion methods

Uterine aspiration or D&E

Procedural abortion process

Dilate cervix and remove products of conception by suction; curettage may confirm empty uterus

First-trimester abortion risks

Infection, retained products, hemorrhage, uterine perforation, pelvic pain, low-grade fever, cervical tear

Rh-negative abortion care

Rh-negative patients require RhoGAM before medical or surgical termination

Medical abortion

Medication-induced termination of pregnancy

Misoprostol role

Causes uterine cramping/bleeding and helps empty the uterus

Medical abortion complications

Incomplete expulsion, failed abortion, infection, hemorrhage

Insemination timing

Usually optimized around days 10–17 based on ultrasound/hormone levels

Insemination attempts

Up to 3 attempts per cycle

IVF sequence

Ovarian stimulation → egg retrieval → fertilization → embryo transfer

IVF fertilization

Sperm and eggs are coincubated for up to 36 hours

IVF embryo transfer

Embryos transferred approximately 48 hours after retrieval

IVF implantation

Implantation should occur within 3–5 days

IVF/GIFT indications

Irreparable tubal damage, endometriosis, unexplained infertility, inadequate sperm, DES exposure

ICSI

Single sperm injected through zona pellucida and egg membrane into oocyte cytoplasm

TET

Tubal embryo transfer; fertilized eggs/embryos placed in fallopian tube via laparoscopy

Infertility program priorities

Diet, exercise, stress reduction, folic acid, health maintenance, disease prevention

Infertility study focus

Infertility risk factors and clomiphene/clomafine

Preconception care goal

Identify and modify biomedical, behavioral, and social risks before pregnancy

Preconception priorities

Pregnancy intention, STI absence, access to care, healthy weight, glycemic control, folic acid, avoiding teratogens/tobacco

Pregestational diabetes goal

Optimize glycemic control before pregnancy

Preconception vitamin

Prenatal multivitamin containing folic acid

Ectopic pregnancy

Implantation of fertilized ovum/blastocyst outside uterine lining

Most common ectopic location

Fallopian tube

Ectopic pregnancy emergency

Rupture can cause fatal hemorrhage; immediate care is critical

Early ectopic symptoms

Vague unilateral soreness progressing to sharp/colicky pain, spotting/bleeding, GI symptoms, dizziness

Ruptured ectopic symptoms

Severe pain, dizziness/faintness, nausea/vomiting, dyspnea, shock

Peritoneal blood effect

Nausea/vomiting may occur from irritation caused by intraperitoneal blood

Ectopic hemorrhage signs

Rapid/thready pulse, decreased BP, low temperature, restlessness, pallor, sweating

Ectopic pelvic findings

Blood mass behind uterus or tender adnexal mass may be palpable

Normal early pregnancy hCG

Normally approximately doubles every 3 days early in pregnancy

Ectopic hCG

Abnormally low/reduced rate of rise compared with normal pregnancy

Ectopic diagnosis

Transvaginal ultrasound; laparoscopy may be required

Ectopic treatment

Pharmacologic or surgical depending on size and tubal damage

Preferred ectopic medication

Methotrexate

Amenorrhea

Absence of menstruation

Amenorrhea treatment

Correct underlying cause, achieve fertility if desired, prevent complications

Amenorrhea testing

Karyotype, pelvic/vaginal ultrasound, hCG, thyroid studies, prolactin, FSH, LH, 17-ketosteroids

Karyotype in amenorrhea

May identify Turner syndrome

hCG in amenorrhea

Rules out pregnancy