Week 3

Question 1

Is bleeding in early pregnancy common?

Answer 1

YES, occurs in 20-40% of pregnant women, source is almost always maternal

Question 2

Name 7 DDXs of bleeding in early pregnancy

Answer 2

1. spontaneous abortion/miscarriage
2. ectopic pregnancy
3. placental bleeding/abruption/hematoma
4. trophoblastic dz
5. vaginitis, cervicitis, trauma, CA, warts, polyps, fibroids
6. cervical ectropion
7. physiologic or implantation bleeding

Question 3

When a pregnant pt presents to your office with bleeding what questions do you need to ask? What do you need to review?

Answer 3

how much blood loss?
cramping or pain?
any tissue present?
review medical hx especially for previous gynecological/obstetrical issues that would increase risk for ectopic pregnancy (LNMP, hx of PID, prior ectopics, adnexal surgery)

Question 4

on a PE of pregnant women with bleeding what do you need to do?

Answer 4

vitals
abd exam
pelvic exam
auscultate fetal heart tones (after 10-12 wks gestation)

Question 5

what is quantitative hCG helpful for?

Answer 5

helpful in interpreting U/S findings

serial hCG’s can be helpful in the first 6 weeks of pregnancy

Question 6

hCG should be doing in a normal intrauterine pregnancy?

Answer 6

doubling every 48-72 hours

Question 7

what is a falling hCG indicative of? a plateaued or slowly rising hCG

Answer 7

falling hCG–> nonviable pregnancy

plateaued/slow–> ectopic

Question 8

what 3 blood tests must you do on a newly pregnant mom?

Answer 8

quantitative hCG
ABO-rh
CBC w/diff

Question 9

what can imaging NOT tell you about bleeding in early pregnancy?

Answer 9

whether it is vaginal or cervical bleeding

Question 10

definition of spontaneous abortion

Answer 10

pregnancy that ends before fetus has reached 20 weeks

Question 11

5 subcategories of abortions

Answer 11

1. threatened miscarriage
2. inevitable miscarriage
3. complete miscarriage
4. incomplete miscarriage
5. missed abortion= confirmed non-viable pregnancy but no sxs yet

Question 12

7 main risk factors for a spontaneous abortion?

Answer 12

1. advancing maternal age
2. previous spontaneous abortion
3. smoking >10 cigs/day
4. cocaine
5. NSAIDs, excluding acetominophen
6. low or high maternal BMI
7. celiac dz

Question 13

5 inconclusive risk factors for abortion

Answer 13

1. EtOH
2. gravidity
3. fever of >100 deg F
4. caffeine
5. low folate (MTHFR and MTRR genes)

Question 14

50% of all miscarriages are from what type of ‘change?’ The other causes of an abortion are what?

Answer 14

chromosomal abnormalities, many are aneuploidies

can also be dt congenital anomalies or trauma or host factors

Question 15

clinical presentation of a spontaneous abortion?

Answer 15

hx of amennorhea, vaginal bleeding or pelvic pain

Question 16

definition of an inevitable miscarriage, when does it most likely occur and why?

Answer 16

increasing uterine bleeding and cramping in the presence of a dilated cervix
most often in early pregnancy and usu dt chromosomal abnormalities (empty sac)

Question 17

what is included in the management of an inevitable miscarriage?

Answer 17

ABO-rh and CBC

can be treated surgically (D&C), medically (misoprostol orally or vaginally) or expectantly

Question 18

what are the dosages for a missed abortion vs an incomplete abortion?

Answer 18

missed abortion: 800 mcg vaginally or 600 mcg sublingually

incomplete abortion: 600 mcg orally

Question 19

who is a good candidate for an expectant abortion? majority occur when? risks?

Answer 19

hemodynamically stable
majority occur in women at less then 13 weeks w/no sxs of infxn
risks: unplanned D and C if infxn occurs
can happen w/in 2 weeks of dx but can last up to 4 wks

Question 20

definition of a threatened miscarriage? quality of bleeding? amount? color?

Answer 20

viable intrauterine pregnancy in the presence of uterine bleeding, bleeding often painless, may be pink, brown or bright red, could be large or small amount

Question 21

what is the etiology of a threatened miscarriage?

Answer 21

disruption of decidual vessels, will see as a

subchorionic hematoma but usu can’t see b/c bleeding at edge of placenta

Question 22

what must you always ask if a pt presents w/a threatened miscarriage? labs and imaging? give them what? suggest what?

Answer 22

intercourse in the past 24 hrs
ABO-rh, CBC and U/S
progestins or progesterone
bed rest and pelvic rest

Question 23

what 4 herbs can help to stop a threatened miscarriage? what vitamins?

Answer 23

viburnum prunus, dioscorea villosa, valerian officianalis, hammamelis
vitamin E, C and citrus bioflavinoids

Question 24

definition of a complete miscarriage? when is it likely to occur before? what will imaging show?

Answer 24

all products of conception have been passed
likely to occur before 12 wks gestation
U/S shows empty uterus

Question 25

what herbs can help with an incomplete miscarriage? what homeopathics?

Answer 25

caulophylum thalictroides cimicifuga racemosa hammamelis virginiana sabina viburnum op ferrum cimicifuga

Question 26

definition of an incomplete miscarriage? when is is more likely to happen? ssxs? imaging will show? tx?

Answer 26

miscarriage has occurred but there are still products of conception in the uterus can happen at any gestation age but more likely >12 wks variable bleeding, cramping common U/S confirms retained tissue medical or surgical tx recommended

Question 27

definition of a missed abortion? ssxs? imaging shows? at risk of what if prolonged? tx?

Answer 27

in-utero death of fetus, retained products of conception all ssxs of PG disappear at risk of infxn D and C if can't wait for inevitable, inevitable or medication

Question 28

definition of an ectopic pregnancy? sites it can occur?

Answer 28

developing blastocyst becomes implanted at site other than endometrium common sites: fallopian tube (MC), ovar, abd/pelvic region, cervix

Question 29

risks of an ectopic pregnancy? where does it rank as far as causes of pregnancy related maternal deaths? what %age of all pregnancy related deaths?

Answer 29

risk is rupture of ectopic= hemorrhage, maternal shock and potentially death leading cause of pregnancy related maternal death in 1st trimester 4-10% of all pregnancy related deaths untreated, they are often fatal

Question 30

when do sxs of an ectopic pregnancy usu present? rupture? sxs of an ectopic?

Answer 30

6-8 wks after LNMP, but can be later, majority of rupture occur 6-12 wks gestation normal pregnancy sxs, abd pain, amenorrhea, vaginal bleeding

Question 31

PE of a woman with an ectopic PG will reveal what?

Answer 31

low grade fever, adnexal, CM and/or abd tenderness, adnexal mass, PE may be unremarkable

Question 32

limits of an U/S with a suspected ectopic pregnancy?

Answer 32

difficult to dx intra vs extrauterine pregnancy when [hCG]

Question 33

tx of an ectopic? who is a good candidate for the rx? indications for 2nd line tx?

Answer 33

methotrexate-folic acid antagonist or surgical for methotrexate-folic acid antagonist tx need to be hemodynamically stable, will f/u, hCG less than 500 2ndary tx if: Hemodynamic instability, Impending or ongoing rupture of ectopic mass, Failed medical therapy, Women with contraindications to medical treatment

Question 34

definition of gestational trophoblastic dz? hydatidiform moles are usu benign or malignant? lab? ssxs?

Answer 34

proliferative d/o of trophoblastic cells hydatidiform moles are usu benign elevated serum hCG ssxs: vaginal bleeding, enlarged uterus, pelvic pain/pressure/theca lutein cysts, anemia, hyperemesis gravidarum

Question 35

definition of a complete mole and partial mole

Answer 35

complete mole: fertilization of an empty ovum by 2 sperm, no fetus partial mole: fertilization of a haploid ovum by 2 sperm, may result in fetus w/trophoblastic tissue

Question 36

what 3 types of trophoblastic cells are malignant? when do they generally occur?

Answer 36

invasive moles, choriocarcinoma and placental site trophoblastic tumors generally occur after a molar pregnancy but can also occur after SAB, TAB, ectopic or normal pregnancy

Question 37

management of trophoblastic dz? possible complications?

Answer 37

refer to OB/GYN D&C usu performed serial hCGs afterwards until reaches zero localized or metastatic dz can occur

Question 38

3 other causes of early bleeding in pregnancy?

Answer 38

growths: vaginitis, trauma, CA, warts, polyps, fibroids ectropion physiologic or implantation bleeding

Question 39

bleeding in the 2nd & 3rd trimester DDX (7)

Answer 39

1. miscarriage, stillbirth 2. cervical, vaginal or uterine pathology 3. cervical insufficiency 4. placenta previa 5. placental abruption 6. vasa previa 7. uterine rupture