Gynecological, Sexual, and Reproductive Health EOR: Prenatal Care & Pregnancy

What is Abortion?

Termination of pregnancy before 20 weeks gestation or loss of a fetus weighing less than 500 g, occurring spontaneously or induced.

What are the features of a threatened abortion?

Vaginal bleeding before 20 weeks with a closed cervical os and a viable intrauterine pregnancy; roughly half progress to miscarriage.

What defines an inevitable abortion?

Vaginal bleeding with a dilated cervical os and/or ruptured membranes, but products of conception have not yet passed.

What defines an incomplete abortion?

Partial passage of products of conception with retained tissue, dilated os, and ongoing bleeding/cramping.

What defines a complete abortion?

Full passage of all products of conception with a closed os, resolving bleeding/cramping, and an empty uterus on ultrasound.

What defines a missed abortion?

Fetal demise before 20 weeks with retained products and a closed os, often without bleeding; absent fetal cardiac activity on ultrasound.

What is a septic abortion and how is it managed?

Abortion complicated by intrauterine infection (fever, uterine tenderness, foul discharge); an emergency treated with broad-spectrum antibiotics and prompt uterine evacuation.

What are the management options for first-trimester miscarriage?

Expectant management, medical management (misoprostol ± mifepristone), or surgical evacuation (suction D&C); give Rh immunoglobulin if the patient is Rh-negative.

What is Cervical Insufficiency?

Painless cervical dilation in the second trimester leading to recurrent pregnancy loss or preterm birth in the absence of contractions.

What is the classic presentation of cervical insufficiency?

Painless cervical dilation with second-trimester loss, often with bulging membranes and a history of recurrent mid-trimester losses.

What are the major risk factors for cervical insufficiency?

Prior cervical surgery (LEEP, cone biopsy), cervical trauma or laceration, congenital uterine/cervical anomalies, and DES exposure.

How is cervical insufficiency diagnosed?

History of recurrent painless second-trimester loss, or a short cervix (

What is the treatment for cervical insufficiency?

Cervical cerclage (typically placed at 12-14 weeks) in appropriate candidates, with vaginal progesterone for a short cervix.

What is Cholestasis of Pregnancy?

Intrahepatic cholestasis of pregnancy is a third-trimester liver disorder marked by pruritus and elevated bile acids from impaired bile flow.

What is the classic presentation of intrahepatic cholestasis of pregnancy?

Intense pruritus (especially palms and soles) that is worse at night and typically without a rash, occurring in the third trimester.

What are the key lab findings in cholestasis of pregnancy?

Elevated serum bile acids (>10 µmol/L), often with mildly elevated transaminases and bilirubin.

What is the major fetal risk in cholestasis of pregnancy?

Increased risk of sudden fetal demise, preterm birth, and meconium-stained fluid; risk rises notably with bile acids >40 µmol/L.

What is the treatment for cholestasis of pregnancy?

Ursodeoxycholic acid (first-line) to reduce pruritus and bile acids, with delivery typically planned at 36-37 weeks.

What is Eclampsia / HELLP Syndrome?

Eclampsia is new-onset seizures in a preeclamptic patient, and HELLP is a severe preeclampsia variant defined by hemolysis, elevated liver enzymes, and low platelets.

What does the HELLP acronym stand for?

Hemolysis, Elevated Liver enzymes, and Low Platelets — a severe form of preeclampsia.

How is an eclamptic seizure managed?

IV magnesium sulfate for seizure control, blood pressure control, airway protection, and ultimately delivery.

What is the typical presentation of HELLP syndrome?

Right upper quadrant or epigastric pain, nausea, and malaise, which may occur even with only mildly elevated blood pressure.

What is the first-line agent for seizure prophylaxis in preeclampsia/eclampsia and its antidote?

Magnesium sulfate; monitor for toxicity (loss of deep tendon reflexes, respiratory depression), and treat toxicity with calcium gluconate.

What is the definitive treatment for eclampsia/HELLP?

Delivery of the fetus and placenta regardless of gestational age, once the mother is stabilized.

What is Ectopic Pregnancy?

Implantation of a fertilized ovum outside the uterine cavity, most commonly in the ampulla of the fallopian tube.

What is the classic triad of ectopic pregnancy?

Amenorrhea, vaginal bleeding, and unilateral lower abdominal/pelvic pain.

What are the major risk factors for ectopic pregnancy?

Prior ectopic, prior PID/salpingitis, tubal surgery, IUD in place, assisted reproduction, and smoking.

How is ectopic pregnancy diagnosed?

Quantitative β-hCG with transvaginal ultrasound; absence of an intrauterine pregnancy when β-hCG exceeds the discriminatory zone (~1500-2000 mIU/mL) suggests ectopic.

When is medical management with methotrexate appropriate for ectopic pregnancy?

In hemodynamically stable patients with a small unruptured ectopic, no fetal cardiac activity, low β-hCG, and reliable follow-up.

What is the surgical treatment for ectopic pregnancy?

Laparoscopic salpingostomy or salpingectomy for rupture, hemodynamic instability, or methotrexate contraindication/failure.

What are the signs of a ruptured ectopic pregnancy?

Acute severe pain, hypotension and tachycardia, peritoneal signs, and shoulder pain from diaphragmatic irritation — a surgical emergency.

What is Gestational Diabetes Mellitus (GDM)?

Glucose intolerance with onset or first recognition during pregnancy, typically driven by placental hormone-induced insulin resistance.

When is GDM screening performed?

Universal screening at 24-28 weeks with a 50-g 1-hour glucose challenge, performed earlier if the patient is high risk.

How is GDM diagnosed?

An abnormal 1-hour screen (≥130-140 mg/dL) confirmed by a 3-hour 100-g oral glucose tolerance test (two-step), or a one-step 75-g 2-hour OGTT.

What is the first-line management of GDM?

Dietary modification and exercise, with insulin as the preferred pharmacologic agent if glucose targets are not met.

What are the fetal complications of GDM?

Macrosomia, shoulder dystocia, neonatal hypoglycemia, polyhydramnios, and increased risk of birth injury.

What postpartum follow-up is needed after GDM?

A 75-g 2-hour OGTT at 4-12 weeks postpartum to screen for persistent diabetes, given the lifelong increased risk of type 2 DM.

What is Gestational Trophoblastic Disease?

A spectrum of tumors arising from abnormal proliferation of placental trophoblastic tissue, including hydatidiform mole and choriocarcinoma.

How do complete and partial hydatidiform moles differ?

Complete mole is typically 46,XX with no fetal tissue, grape-like vesicles, and very high β-hCG; partial mole is triploid (69) with some fetal tissue and lower β-hCG.

What is the classic presentation of a molar pregnancy?

First-trimester bleeding, a uterus large for dates, hyperemesis, markedly elevated β-hCG, and sometimes early preeclampsia or hyperthyroidism.

What is the classic ultrasound finding in a complete mole?

A "snowstorm" or "cluster of grapes" appearance with no fetal heart tones.

What is the treatment for a hydatidiform mole?

Suction dilation and curettage to evacuate the uterus, followed by serial β-hCG monitoring.

Why is β-hCG follow-up critical after molar evacuation?

Serial β-hCG detects persistent GTD or choriocarcinoma; reliable contraception is needed during monitoring, and a rising β-hCG suggests malignant transformation.

What is Hyperemesis Gravidarum?

Severe, persistent nausea and vomiting in pregnancy causing dehydration, weight loss (>5%), electrolyte imbalance, and ketosis.

What are the key features of hyperemesis gravidarum?

Intractable vomiting, >5% pre-pregnancy weight loss, ketonuria, dehydration, and electrolyte disturbances such as hypokalemia and hypochloremic alkalosis.

Which conditions are associated with hyperemesis gravidarum?

High β-hCG states such as multiple gestation and molar pregnancy.

What is the first-line treatment for hyperemesis gravidarum?

IV fluids and electrolyte correction with antiemetics — pyridoxine (B6) ± doxylamine first-line, adding ondansetron or promethazine as needed.

What supplementation is important before giving dextrose fluids in prolonged vomiting?

Thiamine, to prevent Wernicke encephalopathy.

What is Hypertensive Disorders of Pregnancy?

A group of conditions including chronic hypertension, gestational hypertension, preeclampsia/eclampsia, and chronic hypertension with superimposed preeclampsia.

How is chronic hypertension defined in pregnancy?

Hypertension that predates pregnancy or is diagnosed before 20 weeks and persists beyond 12 weeks postpartum.

How is gestational hypertension defined?

New hypertension (≥140/90) after 20 weeks without proteinuria or end-organ dysfunction.

What are the diagnostic criteria for preeclampsia?

Hypertension after 20 weeks plus proteinuria OR end-organ dysfunction (thrombocytopenia, renal or liver involvement, pulmonary edema, or cerebral/visual symptoms).

What are the severe features of preeclampsia?

SBP ≥160 or DBP ≥110, thrombocytopenia, elevated liver enzymes, renal insufficiency, pulmonary edema, and cerebral or visual symptoms.

How is preeclampsia prevented in high-risk women?

Low-dose aspirin started between 12-28 weeks (ideally before 16 weeks).

What is Multiple Gestations?

A pregnancy with more than one fetus, arising from one fertilized ovum (monozygotic) or multiple fertilized ova (dizygotic).

Why is chorionicity important in multiple gestations?

Monochorionic twins share a placenta and carry higher risk (TTTS, IUGR); chorionicity is best determined by first-trimester ultrasound.

What is twin-twin transfusion syndrome?

A monochorionic complication from unequal placental sharing, producing a donor twin (anemic, oligohydramnios) and a recipient twin (polycythemic, polyhydramnios).

What maternal complications are increased in multiple gestations?

Higher risk of preeclampsia, gestational diabetes, anemia, preterm labor, postpartum hemorrhage, and hyperemesis.

What fetal complications are increased in multiple gestations?

Preterm birth, IUGR, congenital anomalies, cord entanglement (monoamniotic), and increased perinatal mortality.

What is Placenta Previa?

Implantation of the placenta over or near the internal cervical os, causing painless third-trimester bleeding.

What is the classic presentation of placenta previa?

Painless, bright red vaginal bleeding in the second half of pregnancy.

What is a key clinical rule when placenta previa is suspected?

Avoid digital vaginal examination until previa is excluded by ultrasound, as the exam may provoke hemorrhage.

How is placenta previa diagnosed?

Transvaginal ultrasound (safe and most accurate) showing the placenta covering or near the internal os.

What are the risk factors for placenta previa?

Prior cesarean or uterine surgery, prior previa, multiparity, advanced maternal age, multiple gestation, and smoking.

How is placenta previa managed?

Stable patients are managed expectantly with pelvic rest; cesarean is the route of delivery, with resuscitation for hemorrhage.

What is Placenta Accreta Spectrum?

Abnormal invasion of the placenta into or through the uterine wall due to defective decidua, preventing normal separation after delivery.

How are accreta, increta, and percreta distinguished?

Accreta attaches to the myometrium, increta invades into the myometrium, and percreta penetrates through the serosa into adjacent organs.

What are the major risk factors for placenta accreta spectrum?

Prior cesarean delivery and placenta previa, with risk multiplying as the number of prior cesareans increases.

What is the main clinical danger of placenta accreta spectrum?

Massive postpartum hemorrhage due to failure of placental separation.

How is placenta accreta spectrum managed?

Planned cesarean hysterectomy at a tertiary center (often late preterm) with blood products and a multidisciplinary team available.

What is Pregnancy Physiology?

The normal adaptive changes across the cardiovascular, hematologic, renal, respiratory, and metabolic systems that support pregnancy.

What are the key cardiovascular changes in pregnancy?

Increased cardiac output (~30-50%) and plasma volume, decreased systemic vascular resistance, and a physiologic BP drop in the second trimester.

What are the hematologic changes of pregnancy?

Plasma volume rises more than red cell mass, causing dilutional anemia, along with a hypercoagulable state that increases VTE risk.

What are the respiratory changes of pregnancy?

Increased tidal volume and minute ventilation produce a mild compensated respiratory alkalosis, while functional residual capacity decreases.

What are the renal changes of pregnancy?

Increased GFR and renal plasma flow, decreased serum creatinine and BUN, and sometimes mild physiologic glucosuria.

What are the GI changes of pregnancy?

Progesterone lowers lower esophageal sphincter tone (reflux) and slows motility (constipation).

What is Pregnancy-Induced Hypertension (PIH)?

An older term for new-onset hypertension after 20 weeks of gestation, now classified as gestational hypertension.

What are the diagnostic criteria for PIH/gestational hypertension?

BP ≥140/90 on two occasions at least 4 hours apart after 20 weeks in a previously normotensive woman, without proteinuria.

What is the main progression risk of PIH?

A portion of cases progress to preeclampsia, requiring ongoing monitoring of BP, proteinuria, and symptoms.

How is PIH managed?

Serial monitoring of BP and labs, antihypertensives for severe-range pressures, and delivery timing based on severity (often by 37 weeks).

Which antihypertensives are safe in pregnancy and which should be avoided?

Labetalol, nifedipine, and methyldopa are safe; ACE inhibitors and ARBs are teratogenic and must be avoided.

What is Prenatal Management?

The schedule of routine visits, screening, counseling, and interventions that optimize maternal and fetal health throughout pregnancy.

What are the standard first-trimester prenatal labs?

Blood type/Rh and antibody screen, CBC, rubella, HIV, hepatitis B, syphilis (RPR), urinalysis/culture, and a Pap if due.

What supplementation is recommended for all pregnancies and why?

Folic acid 400-800 µg daily started preconception to reduce neural tube defects, with a higher dose for high-risk patients.

What are the options for aneuploidy screening in pregnancy?

First-trimester combined screen (nuchal translucency + PAPP-A + β-hCG) or cell-free DNA, with a quad screen available in the second trimester.

What is the routine prenatal visit schedule?

Every 4 weeks until 28 weeks, every 2 weeks from 28-36 weeks, then weekly until delivery.

What are the key third-trimester screening tests?

Glucose challenge at 24-28 weeks, group B strep culture at 36-37 weeks, and a repeat antibody screen for Rh-negative women.

What is Rh Incompatibility?

A condition in which an Rh-negative mother is exposed to Rh-positive fetal blood, prompting maternal antibody formation that can attack fetal red cells.

What is the pathophysiology of Rh incompatibility?

In a sensitized mother, anti-D antibodies cross the placenta and cause fetal hemolysis (hemolytic disease of the newborn).

What events can sensitize an Rh-negative mother?

Delivery, miscarriage or abortion, ectopic pregnancy, amniocentesis, trauma, external cephalic version, and antepartum bleeding.

How is Rh sensitization prevented?

Anti-D immunoglobulin (RhoGAM) at 28 weeks, within 72 hours of delivering an Rh-positive infant, and after any sensitizing event.

How is Rh status and fetal anemia monitored?

Indirect Coombs (antibody screen) in the mother, with MCA Doppler used to assess fetal anemia in sensitized pregnancies.

What is the purpose of the Kleihauer-Betke test?

It quantifies fetomaternal hemorrhage to determine whether additional anti-D immunoglobulin dosing is needed.