complications of pregnancy: ectopic pregnancy, spontaneous abortion, medical and surgical conditions of pregnancy

ectopic pregnancy

in first trimester bleeding rule out _____ until proven otherwise

threatened abortion

vaginal bleeding, closed cervix, viable intrauterine pregnancy

bleeding + cramping, open cervix

define an inevitable abortion

Partial passage of products, bleeding continues

define an incomplete abortion

Passage of all products, closed cervix

define a complete abortion

Fetal demise, no bleeding initially

define a missed abortion

ectopic pregnancy

Bleeding + abdominal pain, no IUP on US

molar pregnancy

Heavy bleeding, very high β-hCG, "snowstorm" US

Cervical polyps

Cervicitis

Trauma

Malignancy

Implantation bleeding (benign, early)

non-pregnancy causes of first trimester bleeding

signs of peritonitis

-positive cough test

-guarding

-rigidity

-rebound tenderness

-percussion tenderness

Rebound tenderness

Rigid abdomen

Severe unilateral pain

Shoulder pain (referred from diaphragm)

Hemodynamic instability

red flags for surgical emergency in acute abdomen

Prior ectopic pregnancy

Pelvic inflammatory disease (Chlamydia/Gonorrhea)

Tubal surgery or ligation

Endometriosis

tubal damages that increase risk of ectopic pregnancy

Assisted reproductive technology (IVF)

Infertility

IUD in place (if pregnancy occurs)

reproductive factors that increase risk of ectopic pregnancy

Cigarette smoking

Advanced maternal age

behavioral/demographic factors that increase risk of ectopic pregnancy

Always check β-hCG

Transvaginal US is diagnostic

1st steps to rule out an ectopic pregnancy

immediate surgery

-don't wait on labs

what is the next step of a suspected ectopic pregnancy in an unstable patient

ruptured ectopic pregnancy

can cause abdominal pain, vaginal bleeding, and hemodynamic instability. Pelvic inflammatory disease is a common cause which itself is commonly caused by infeciton witih N. Gonorrhoeae or Chylamydia trachomatis

yes

do you give rhogam for a Rh- mom with ectopic?

Repeat β-hCG in 48 hours + repeat TVUS

if high suspicion but no definitive diagnosis of ectopic pregnancy....

tranvaginal ultrasound

imaging of choice to dx ectopic pregnancy

adnexal mass

most common ultrasound finding of ectopic

tubal ring sign

This is a hyperechogenci ring surrounding an unruptured ectopic pregnancy

If this looks like a corpus luteum see if it moves with or away from the ovary

discriminatory zone

the level of human chorionic gonadotropin beyond which an intrauterine pregnancy is consistently visible

discriminatory zone: 1500-3500 mIU/mL

hCG in which a IUP should be visible on ultrasound

Could be: very early IUP, ectopic, or failing pregnancy→ repeat β-hCG in 48 hrs + repeat TVUS

if B-hCG is below discriminatory zone and there is an empty uterus, but you expect ectopic

Normal early IUP: rises ~≥35–53% in 48 hrs (varies by starting level)

Ectopic or abnormal IUP: often rises slower, plateaus, or falls

how does B-hCG rise in a normal early IUP vs an ectopic?

methotrexate

-only eligible if pt is hemodynamically stable, able to comply with follow up, no fetal cardiac activity

typical medical management of ectopic pregnancy

β-hCG measured on days 4 & 7; should drop ≥15% from day 4→7, then weekly until zero

required follow up after methotrexate treatment of an ectopic pregnancy

Avoid folate supplements, alcohol, and NSAIDs (often advised), and avoid pregnancy for a period after MTX

meds to avoid due to methotrexate therapy post ectopic

Hemodynamic instability

Suspected rupture / significant hemoperitoneum

Peritoneal signs

Contraindication to MTX

Failed MTX

indications for surigcal management of ectopic

laparoscopic salpingostomy

tube sparing surgery for ectopic pregnancy

salpingectomy

tube removal surgery for ectopic pregnancy

-common if tube is severely damaged or completed family

expectant management of ectopic

This treatment option may be considered if the patient is asymptomatic; ß-hCG is < 200 mIU/mL; the ectopic mass is < 3 cm; and no fetal heartbeat is present.1,2 With this approach, patients must be willing to accept the risk for tubal rupture and agree to close monitoring of ß-hCG levels. The ß-hCG level must be measured every 24 to 48 hours in order to determine if it is declining adequately, plateauing, or increasing.

yes

may pregnancy continue in a threatened abortion?

≥2 consecutive spontaneous pregnancy losses

define recurrent pregnancy loss

-genetic (balanced translocations)

-anatomic (uterine septum, fibroids)

-endocrine (thyroid disease, diabetes)

-antiphospholipid syndrome

common causes of recurrent pregnancy loss

Antiphospholipid syndrome

Venous or arterial thrombosis

Persistent & unexplained thrombocytopenia

Recurrent fetal loss

Detected by:

Lupus anticoagulant test

Anticardiolipin antibody ELISA

Anti-B2 glycoprotein-I ELISA

chromosomal abnormalities

most first-trimester losses are due to

cervical bleeding, closed cervix , fetal cardiac activity

define a threatened abortion

Hemorrhage

Infection

Retained products of conception

immediate complications associated with spontaneous abortion

Asherman syndrome (intrauterine adhesions)

Infertility (rare)

Isoimmunization (Rh sensitization)

primary long term complications associated with spontaneous abortion

Asherman syndrome

a syndrome characterized by endometrial adhesions that typically occur as a result of scar formation after some types of uterine surgery

retained products or infection

persistent bleeding or fever after abortion=

Polymicrobial:

Anaerobes

Gram-negative rods

Group A Strep

common organisms of septic abortion

septic abortion

foul smelling vaginal discharge after abortion raises flags for

Retained products of conception

Non-sterile abortion (instrumentation or medications)

Inadequate antibiotic prophylaxis

causes of septic abortion

Septic shock

Disseminated intravascular coagulation (DIC)

death

primary complications associated with septic abortion

Immediate IV broad-spectrum antibiotics

e.g., clindamycin + gentamicin ± ampicillin

Prompt uterine evacuation

IV fluids, vasopressors if needed

immediate management of a septic abortion

clindamycin + gentamicin ± ampicillin

best broad spectrum Abx for a septic abortion

Bleeding/cramping expected for days-weeks

symptoms of spontaneous abortion

Prognosis is excellent

Most patients can conceive again

No required waiting period once emotionally ready

Recurrent loss → further evaluation

future fertility associated with spontaneous abortion

iron deficiency

most common anemia of pregnancy

Preterm birth

Low birth weight

Intrauterine growth restriction (IUGR)

impact of maternal anemia on newborn

physiological dilutional anemia

plasma volume expansion during pregnancy results in

Asymptomatic bacteriuria

Cystitis

Pyelonephritis

how do urinary tract disorders present in pregnancy

Preterm labor

Low birth weight

how do maternal urinary tract disorders impact fetus?

Progesterone → ureteral dilation & urinary stasis

Enlarged uterus compresses ureters

why does pregnancy increase risk for urinary tract infections?

reflux urine culture

UAs in pregnant patients should always have

Stroke

Placental abruption

HELLP syndrome

Renal failure

maternal hypertension impact on pregnancy

IUGR

Placental insufficiency

Preterm birth

Stillbirth

maternal hypertension impact on fetus

↑ cardiovascular demand

Can unmask chronic HTN

why is hypertension more prevalent in pregnancy?

Asthma

Pulmonary hypertension

Pneumonia

respiratory disorders that are worse in pregnancy

appendicitis

most common non-OB surgical emergency

Appendicitis (most common non-OB surgical emergency)

Cholecystitis

Ovarian torsion

Bowel obstruction

most common causes of surgical abdomen in pregnancy

ultrasound

first step in evaluation of surgical abdomen of pregnancy

fetal growth restriction

preeclampsia affects placenta-->

pain may migrate upward as uterus enlarges

pain distribution of appendicitis in pregnancy

BP ≥ 140/90 before pregnancy, before 20 weeks, or persists >12 weeks postpartum

define chronic hypertension in pregnancy

New-onset BP ≥ 140/90 after 20 weeks

NO proteinuria or end-organ dysfunction

BP normalizes postpartum

define gestational hypertension

BP ≥ 140/90 after 20 weeks PLUS:

Proteinuria (≥300 mg/24 hr or protein/Cr ≥0.3) OR

End-organ dysfunction

clinical definition of preeclampsia

Thrombocytopenia (<100k)

Elevated liver enzymes

Renal insufficiency (Cr >1.1 or doubling)

Pulmonary edema

New-onset headache or visual changes

end-organ criteria of preeclampsia

BP ≥ 160/110

Platelets <100,000

Severe RUQ/epigastric pain

Pulmonary edema

Severe renal dysfunction

Persistent neurologic symptoms

'severe features' of preeclampsia with severe features

Requires hospitalization + magnesium sulfate

Often indication for delivery

management of preeclampsia with severe features

Preeclampsia + seizures not attributable to another cause

clinical definition of eclampsia

Labetalol (oral)

Nifedipine (extended-release)

Methyldopa (older, less used)

first line blood pressure meds in pregnancy

Typically 37 weeks

Earlier if progression to preeclampsia

typical delivery in gestational hypertension

Close BP monitoring

No routine antihypertensives unless severe

Labs to rule out preeclampsia

Fetal surveillance

management of gestational hypertension

if BP persistently ≥140/90

when do you give antihypertensives in HTN of pregnancy

≥34 weeks → deliver

<34 weeks → stabilize, give steroids, consider expectant management in select cases

delivery timing in preeclampsia with severe features

asthma, heart block

contraindications to IV labetalol

reflex tachycardia

adverse effect of IV hydralazine

≥160/110

define severe hypertension

Lower BP to <160/<110 (not normal BP—avoid placental hypoperfusion)

-oral nifedipine has the most rapid onset

how fast should you manage severe HTN?

Preeclampsia with severe features

Eclampsia

Sometimes intrapartum/postpartum

indications for magnesium sulfate

Calcium Gluconate

antidote for magnesium sulfate

enalapril

BP med safe in breastfeeding only