Abortion

Ectopic Pregnancy

Gestation occurring outside the uterine cavity, most commonly in the fallopian tube (98%)

Risk Factors for Ectopic Pregnancy

PID, narrowing of fallopian tube, IUD, assisted reproductive technology, previous ectopic pregnancy

Ectopic Pregnancy Signs and Symptoms

Bleeding/spotting 7-14 days after missed period, unilateral pelvic pain, shoulder pain (with intra-abdominal hemorrhage), shock (first symptom in 20% of cases)

Ectopic Pregnancy Physical Findings

Adnexal mass or tenderness, normal-sized uterus, peritoneal signs, hypotension, tachycardia (shock)

Diagnosis of Ectopic Pregnancy

Pelvic exam, quantitative HCG (should rise 66% every 48 hours), CBC, transvaginal ultrasound (IUP visible when HCG>2000)

Treatment Options for Ectopic Pregnancy

Expectant management, salpingectomy, methotrexate (for unruptured, small ectopics with no cardiac activity and compliant patients)

Prognosis After Ectopic Pregnancy

60% subsequent pregnancy rate (40% infertile), 1/3 of pregnancies after ectopic are another ectopic or spontaneous abortion, only 33% will have subsequent live birth

Threatened Abortion

Vaginal bleeding before 20th week with closed cervix

Inevitable Abortion

Vaginal bleeding with cramping and dilation of the cervix

Incomplete Abortion

Bleeding, cramping, and passage of some products of conception

Complete Abortion

Passage of all products of conception, cervix begins to close, uterus usually firm

Missed Abortion

Fetal death in-utero without expulsion by the uterus

Recurrent Abortion

Three successive spontaneous abortions

Spontaneous Abortion Management

Take history (bleeding, passage of products), ultrasound, determine if cervix is dilating, check fetal heartbeat/hCG levels, offer D&C or natural passage option

First Trimester Abortion Facts

88% of induced abortions performed during 1st trimester, more than half prior to 9th week

First Trimester Abortion Procedures

Surgical/aspiration (check for products after, monitor bleeding) or Medical (mifepristone blocks progesterone, misoprostol produces uterine contractions)

Follow-up After Medical Abortion

Educate patient about seeking attention for severe bleeding or fever, warn about mild cramps and bleeding, re-evaluate in 4-14 days, discuss contraception

Twin Frequency

One out of every 90 births at term

Dizygotic Twins

66% of US twins, fertilization of two ova by two sperm, each twin has own placenta and amniotic sac

Dizygotic Twins Risk Factors

Maternal heredity, race (African>Caucasian>Asian), maternal age >35, fertility drugs (especially gonadotropin induction)

Monozygotic Twins

33% of US twins, division of one egg fertilized by same sperm, timing of division determines placenta/sac configuration

Preterm Labor

Regular contractions every 10 minutes or less between 20-36 weeks gestation (viability at 23 weeks)

Preterm Labor Significance

8-10% of babies born prematurely account for 60-75% of all perinatal morbidity and mortality in the U.S.

Factors Associated with Preterm Labor

Dehydration, excessive uterine enlargement (polyhydramnios, multiple gestation), incompetent cervix, infections, maternal smoking, substance abuse, placental abruption, placenta previa

Signs and Symptoms of Preterm Labor

Abdominal cramping/pressure, diarrhea, pelvic pressure, low back pain, menstrual-like cramps, increased vaginal discharge, early dilation and effacement

Evaluating Preterm Labor

EFM and TOCO monitoring, assess contractions, check cervical change, speculum/digital exam, test for ROM and infections, check fetal fibronectin, ultrasound for cervical length

Managing Preterm Labor

Diagnose and treat underlying cause, IV hydration, tocolysis (terbutaline, magnesium sulfate, nifedipine/indocin), betamethasone for 24-34 weeks

Contraindications to Tocolysis

Mature fetus, advanced labor, intrauterine infection, significant vaginal bleeding, specific maternal contraindications to medications

PPROM

Prolonged Premature Rupture of Membranes before labor onset, occurs in 10-15% of pregnancies, risk doubles in smokers, 75% deliver within 1 week

Diagnosing PPROM

Speculum exam with nitrazine test (turns blue at pH>7.0) and fern test (ferning pattern visible under microscope)

Premature Delivery Considerations

Risk for hypothermia, mother doesn't need to dilate to 10cm, babies usually require resuscitation, viability at 23-24 weeks

Precipitous Delivery

Occurs in less than 3 hours of labor, usually in grand multipara patients (>5 births), more intense contractions, risk of fetal trauma or cord tearing

Meconium Staining

Green or brown amniotic fluid, can suggest fetal distress, thick meconium requires suctioning hypopharynx and trachea using endotracheal tube

Amniotic Fluid Embolism

Amniotic fluid enters maternal pulmonary/circulatory system, causes allergic reaction with respiratory distress, hypotension, possible seizures, high mortality

Antepartum Bleeding

Obstetric emergency in 3rd trimester, most common causes are placenta previa and abruptio placentae, ultrasound is most accurate diagnostic tool

Placenta Previa

Placenta implanted in lower uterine segment instead of fundus, causes painless bright red vaginal bleeding, diagnosed by ultrasound

Clinical Presentation of Placenta Previa

Painless onset of vaginal bleeding, placenta partially or totally covering cervical os, mean gestational age is 30 weeks

Management of Placenta Previa

Cesarean section regardless of gestational age if bleeding excessive

Abruptio Placentae

Normally implanted placenta prematurely separates from uterus before delivery, can cause vaginal or concealed hemorrhage, occurs in 1 in 120 pregnancies

Risk Factors for Abruptio Placentae

Maternal hypertension, previous abruptio, trauma, polyhydramnios that rapidly decompresses, PROM, short umbilical cord, tobacco use, folate deficiency

Clinical Presentation of Abruptio Placentae

Painful (severe abdominal/pelvic/back pain), hard and rigid uterus, hypercontractility, increased uterine tone, fetal distress common, vaginal bleeding may be absent

Management of Abruptio Placentae

Start large bore IV, monitor vital signs and fetal distress, highly deadly condition (35% fetal mortality), complications include hypovolemia, shock, DIC, acute renal failure

Postpartum Hemorrhage

Loss of more than 500cc blood after vaginal delivery, causes include prolonged labor, multiple gestation, retained products, placenta previa, full bladder

Dystocia

Difficult childbirth due to ineffective uterine expulsion, abnormal lie/presentation, fetal structure issues, or disproportion between fetal head and pelvis

Cephalopelvic Disproportion

Insufficient pelvic outlet for fetal head, assess maternal pelvis and fetal head, prolonged dilation may cause dystocia, true insufficiency requires Caesarean

Operative Delivery

35-40% of all deliveries, includes forceps (5%) and vacuum (5-10%)

Forceps Delivery

Provides traction/rotation of fetal head, higher maternal morbidity, used for prolonged 2nd stage, suspected fetal compromise, stabilizing head during breech

Vacuum Extraction

Suction-cup device, more common due to provider ease of use, higher rate of fetal morbidity

Cesarean Delivery

Most common operation in US (25% of births), hospitals must perform emergent C-section within 30 minutes, mortality rate 5x greater than vaginal delivery

Indications for Cesarean Delivery

Dystocia, repeat C-section, breech presentation, fetal distress, cord prolapse, placenta previa, previous incision through myometrium

Types of Cesarean Delivery

Low transverse, classic, low vertical (women with classic C-sections should always have repeat C-sections)

External Cephalic Version

For breech position around 36-39 weeks, 50-75% success rate, C-section rate half of those who don't undergo version

Uterine Rupture

Tearing of uterus, causes severe abdominal pain and shock, abdomen tender and rigid, more common with previous C-section, treat with fluids, oxygen, IVs, surgery

Uterine Inversion

Uterus turns inside out after delivery and extends through cervix, blood loss 800-1800cc, causes weakness, dizziness, lessened contractions, shock

Post Partum Infections

UTI (distention/delayed emptying, catheterization/trauma), wound infections (C-section scars, episiotomy, lacerations)

Risk Factors for Post Partum Infections

PROM >24hrs, multiple vaginal exams in labor, endometritis, intrauterine monitor, intercourse after ROM

Mastitis

Infection of breast tissue causing pain, swelling, warmth, redness, fever and chills, usually within first 6-12 weeks postpartum

Causes of Mastitis

Blocked milk duct (incomplete emptying), bacteria entering breast through skin break or milk duct opening

Mastitis Treatment

Dicloxicillin 250mg QID x 10-14 days, pain relievers, proper breastfeeding technique, rest, continued breastfeeding, increased fluids