Obstretrics: Patient Education, Ectopic Pregnancy/Termination

hyperemesis gravidarum (dehydration/lack of nutrients)
- ketonuria
- loss of >5% pre-pregnancy weight
- persistent vomiting (>3 times/day)

Tx:
- fluids to correct hypovolemia
- IV ondansetron (zofran) -> switch to PO when stable
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hyperemesis gravidarum (dehydration/lack of nutrients)
- ketonuria
- loss of >5% pre-pregnancy weight
- persistent vomiting (>3 times/day)

Tx:
- fluids to correct hypovolemia
- IV ondansetron (zofran) -> switch to PO when stable
A patient states that she has been vomiting 3 times/days for the last 4 weeks. She also says she has lost over 10 lbs since becoming pregnant. After doing a urinanalysis you detect traces of glucose and ketones. What does this patient have? How do you treat this?
hyperemesis gravidarum
- fluids + IV ondansetron (d/c when stable, may need PO zofran)
ondansetron (zofran) is commonly used to treat ___-
pre-pregnancy BMI
recommended weight gain in pregnancy is dependent on _______
Underweight (<18.5 BMI)
- 28-40 lbs

Normal (18.5-24.9 BMI)
- 25-35 lbs

Overweight (25-29.9 BMI)
- 15-25 lbs

Obese (30+ BMI)
- 11-20 lbs
How much weight should someone who is obese gain during pregnancy? underweight patients? normal and overweight patients?
20+ weeks gestation (should be within 3 cm of gestational age, if not do US)


prior to 20 weeks assume fundal ht = gestational age
When should you start measuring fundal height?
do leopold maneuver around 34 weeks pregnant (in T3) to determine fetus presentation

if fetus is breeched presentation, consider doing external cephalic version around 36-38 weeks
When should you do the leopold maneuver during physical exam?
gestational DM: oral glucose tolerance test
- all women: 24-28 weeks
- high risk for DM or obese patients: T1 (usually first appt)

GBS:
- all women tested at 35-37 weeks

antibody screen:
- first prenatal visit and at 28 weeks again in patients that are Rh- to ensure that alloimmunization hasnt already occurred

Rhogam:
- 28 weeks for pts with Rh-
- within 72h after delivery if infant is Rh+ and mom is Rh-
When should you test women for gestational diabetes? GBS? when is antibody screen done and when would rhogam be administered in pregnant patients with Rh-?
18-22 weeks gestation
Most women will get a "standard" structural/anatomic survey around _______ gestation. This type of US will evaluate amniotic fluid, fetal presentation, cardiac activity, placental presentation, and gender of fetus.
Initial Assessment:
1. serum hCG levels via preg test (>2000 HCG should see on TV US)
2. Trans-vaginal US

Diagnosis:
- If not visible on TV US (& > 2000 hCG) = ectopic pregnancy
- if progesterone < 5 ng/ml at 5-10 weeks = ectopic or extrauterine
If a patient comes to the clinic with new onset vaginal bleeding and abdominal pain, what should you do?
dx:
- >2000 hCG but not visible on TV US = ectopic
- <5 ng/ml progesterone at 5-10 weeks = nonviable or ectopic

preferred tx: Monitor hcg at day 1, 4, 7
1. methotrexate (MTX) - single dose
- b-hCG must be less than or equal to 5000
- cannot use if has cardiac activity
- cant have sex until hcg levels undetectable

second line tx: if cant use MTX or MTX fails
2. surgery - salpingostomy or salpingectomy

salpingostomy = remove fetus but leave tube intact
salpingectomy = remove fetus and uterine tube (if ectopic pregnancy was > 3 cm, tube was damaged, or uncontrolled bleeding)
If you diagnose a patient with extrauterine or ectopic pregnancy, what is the next steps in treatment?
serum hCG pregnancy test and find that the progesterone levels are less than 5 ng/ml (at 5-10 weeks gestation) = ectopic/extrauterine also if hCG > 2000 but not visible on TV US = ectopicif you do a serum hCG pregnancy test and find that the progesterone levels are less than ______ and the patient is between _____ and ____ weeks gestation, this means the fetus is non-viable (ectopic/extrauterine pregnancy).Salpingostomy - use this because cant use MTX (due to cardiac activity) - wouldnt do salpingectomy because bleeding controlled and tubal pregnancy is less than 3 cm. First Line (MTX) Contraindications: - cant use if HCG > 5000, cardiac activity present, or patient has renal/hepatic issues, or is breastfeedingA 32 yo patient that is 14 weeks gestation has serum hCG levels that are 3200 and you diagnose an ectopic pregnancy due to inability to visualize sac on TV US. You detect a fetal heartbeat that is equal to 90 bpm. The bleeding is controlled and the tubal pregnancy was found to be ~2 cm. What is the treatment? Why?if ectopic/extrauterine pregnancy: 1. MTX - single dose (+ hcg on day 1, 4, and 7) - cant use if cardiac activity present, hCG >5000, breast feeding, renal/hepatic dysfunction 2. Salpingostomy - do if MTX fails or cant be used (ex. if hCG > 5000 or cardiac activity) - tubal pregnancy must be <3 cm and bleeding cant be uncontrolled 3. salpingectomy - do if uncontrolled bleeding, > 3 cm tubal pregnancy, damage to tubesWhat is treatment for ectopic and extrauterine pregnancy? When is each treatment indicated/contraindicated?spontaneous abortion/early pregnancy loss - loss of pregnancy prior to 20 weekspregnancy that is lost before 20 weeks and after implantation is calledComplete EPL: - complete spontaneous passage of fetal tissue (no intervention) before 20 weeks gestatation Incomplete EPL (w/o complication): - history of ongoing vaginal bleeding, cervical os is opened, no HR, evidence of POC - before 20 weeks gestation Missed Abortion: (type of incomplete EPL) - little or no vaginal bleeding, no HR, evidence of POC - before 20 weeks gestation Threatened abortion: - vaginal bleeding with evidence of fetal viability (such as HR) IUFD or Stillbirth: - loss of pregnancy after 20 weeks gestationWhat is the difference between complete EPL, incomplete EPL w/o complication, missed abortion, threatened abortion, and intrauterine fetal demise/stillbirth?incomplete EPL - hx of bleeding - open cervical os - no cardiac activity Ways to confirm EPL diagnosis if US available: 1. TV US shows embryo w/ crown rump length > 7 mm w/o HR 1. gestational sac 25 MM+ and no embryo visible on US 2. NO fetal heart tones at > 12 weeks (still need to confirm w US) Ways to confirm EPL diagnosis if no US available: 1. serum hCG and progesterone - hcg drops by > 25% in 48 hrs or progesterone less than 5 at 5-10 weeks pregnant = EPL, may be ectopic only way to definitely diagnose EPL is in pinkPhysical exam findings of an open cervical os with visible tissue and bleeding is ______. How do you diagnose this for sure?Definitive Diagnosis: 1. TV US shows embryo w/ crown rump length >= 7 mm w/o HR - prefer trans-vaginal US to dx 2. 25 MM gestational sac w/ no embryo on US Suggestive Diagnosis: 1. NO fetal heart tones at > 12 weeks (still need to confirm w US) 2. serum hCG and progesterone (if no US available) - if hCG drops by > 25% in 48 hours = likely EPL - if progesterone <5 (at 5-10 weeks) = likely EPL if hCG > 2000 and no gestational sac on US = ectopicWhat is the only way to definitely diagnose EPL/spontaneous abortion? What are suggestive findings?T1 Abortions: 1. expectant (<14 wks, stable, no infection) - expulsion w/in 2 wks 2. Mifepristone/Misoprostol (10wks or less, no infx, stable) 3. D&C/uterine aspiration (<14 wks, signs of infx or hemorhage) - D&C, & prophylactic doxycycline Signs of infection: - abdominal/pelvic pain, uterine tenderness, purulent discharge, fever, etc. Signs of hemorrhage: - heavy bleeding - tachycardia, anemia, orthostatic vitals,How do you treat/manage a missed abortion or incomplete EPLs in T1?Patient must be less than 14 weeks (up to 13 wks 6 days), stable, and have no signs of infection Signs of infection: - abdominal/pelvic pain, uterine tenderness, purulent discharge, fever, etc. Signs of hemorrhage: - heavy bleeding - tachycardia, anemia, orthostatic vitals,If a EPL was diagnosed, when would you do natural expulsion of embryo?13 weeks + infection/hemorrhage: - D&C, doxycycline, no sex for 2 weeks infection - abdominal/pelvic pain, uterine tenderness, purulent discharge, fever, etc. hemorrhage - heavy bleeding, tachycardia, anemia, orthostatic vitals ---------------------------- Expectant - if patient is < 14 weeks (+ stable/no infx) M&M - if patient is 10 weeks or less (no infx, stable) D&C - < 14 weeks + signs of infection or hemorrhageA 25 yo patient had no vaginal bleeding with no signs of fetal HR and an incomplete EPL at 13 weeks gestation was diagnosed. Pt denies N/V but states that she has abdominal pain. Upon examination, you note that the uterus is tender and their is presence of purulent discharge. what is the treatment?9 + 5/7 weeks (NO infection, stable): - Expectant (<14 weeks) - or can do mifepristone/misoprostol (10 weeks/70days or lesss)If a patient had very little vaginal bleeding with no signs of fetal HR and an incomplete EPL at 9 weeks + 5 days gestation was diagnosed w/o uterine tenderness, fever, abdominal pain, or purulent discharge what is the treatment?D&C, doxycycline, no sex for 2 weeks - due to heavy vaginal bleeding (hemorrhage) and tachycardia if patient was not hemorrhaging/not tachy: - then you could potentially do expectant (since less than 14 weeks), but couldnt do M&M because have to be 10 weeks or less (70d) D&C if: - heavy bleeding (hemorrhage), tachy, anemia, orthostatic vital signs - infection: purulent discharge, abdom/pelvic pain, tender uterus - must be less than 14 weeksIf a patient had heavy vaginal bleeding, no fetal HR was detected and an incomplete EPL at 13 weeks 2/7 days gestation was diagnosed. The patient denies uterine tenderness, and fever. The patient has a HR of 122 and a BP of 118/78. what is the treatment?if D&C, mifepristone/misopristol, or even expectant (ANY EPL) - must wait 2 weeks to use tampons or have sex if MTX therapy: - no sex OR new contraception until HCG is undetectable - check hcg at day 1, 4, and 7How long must a patient wait to have sex or use tampons following an incomplete EPL? what if the patient had MTX therapy for ectopic pregnancy?Pre-Procedure: - CBC + Rh(D) (check H&H bc if anemic cant do M&M) - US (ensure correct gestational date and check fetal viability) - Antibiotic Prophylaxis (Doxycycline) before any surgical procedures T1 Procedures: - Mifepristone/Misoprostol (10 weeks or less) - D&C/Uterine Aspiration (<14 weeks) T2 Procedures: - dilation & evacuation (D&E) - evacuate the uterus with suction, forcepts, and curettage - medical induction (M&M prior)Prior to inducing pregnancy termination what do you do as a provider?True - also if you take mifepristone you can change your mind about abortion as long as you havent taken misoprostolT/F: If a patient vomits after taking mifepristone for T1 abortion, you should administer a second dose. Then 24-48 hours later you should administer misoprostol.1. Dilation & Evacuation (T2) +/- inject to stop heart, evacuate uterus w/ suction, forcep, curettage 2. Medication Induction Abortion (T2) - mifeprostone (24h prior to induction) & misoprostol (also for cervical prep), +/- injection to stop heart, then similar to natural birth D&E - faster, cheaper - increased maternal mortality/morbidity (both T2 abortions) Medication Induction Abortion - desire for intact fetus - long duration, inpatient, risk of hemorrhage/retained placentaWhat are the ways that you can terminate a pregnancy during T2 (14 weeks+)? What are the pros and cons of each?- hemorrhage - hemometra (right after D&C, T1 abortion procedure) - endometritis infection (risk reduced if given prophylactic ATB) - ongoing pregnancyThe earlier the termination, the lower the risk of complications. However, what are some potential complications of having an abortion?hemometra -dull, lower abdominal pain + uterine tenderness/pain within 1 hour of procedure (usually D&C) tx: - must immediately evacuate the uterus45 minutes after doing a dilation & curettage (uterine aspirations) to terminate a 12 week gestation pregnancy, the patient began to have dull, aching lower abdominal pain. upon palpation, you notice the uterus is tense and painful. What does the patient have, how do you know, and how do you treat this?Partial Molar - vaginal bleeding - lack of fetal heart tones - unusually high hCG for gestational age TX: - uterine evacuation (D&E) - hysterectomy (if signs of malignancy or doesnt want more kids)A 17-year-old G1 P0 patient presents to your office with vaginal bleeding at approximately 8 weeks gestation by her last menstrual period. Her examination is benign with a 10-week-sized uterus, a closed cervical os, and a small amount of blood within the vaginal vault. A pelvic ultrasound that shows an intrauterine gestational sac containing a fetus measuring approximately 6 weeks gestation without a fetal heartbeat. The placenta demonstrates marked thickening and increased echogenicity with scattered cystic spaces within the placenta. A serum β-hCG is 52,000 mIU/mL. What is the most likely diagnosis?endometritis infection remember: - D&E = T2 abortions (14 weeks +) - D&C = T1 abortions (less than 14 weeks)Prior to doing a surgical termination of pregnancy, such as D&C (uterine aspiration) or D&E, a patient is given prophylactic antibiotics. What does this lower the risk of by 50%?Complete Mole: - US - hCG > 100,000 - S/S: vaginal bleeding, hCG > 100K Partial Mole: - difficult to dx on US (but if visible will have cysts) - S/S: vaginal bleeding, hCG very elevated ****partial molars sometimes have hCG levels that are less than 100K (technically cant diagnose if less than 100K?)How do you diagnose molar pregnancies (both complete and partial)? What signs/symptoms will the patient have?Complete: - no embryo/fetus (only placental tissue) - no amniotic fluid - no fetal HR - mass with anechoic spaces (mass with black spots) Partial: - fetus may be identified/viable (may have HR) - abnormal placenta (scattered cysts) - reduced volume of amniotic fluid suspect molar pregnancy if appears like this on US + vaginal bleeding + very high hCG levelsA 24 yo patient comes in due to experiencing vaginal bleeding. She is 22 weeks pregnant. Her hCG levels are extremely elevated, and you suspect molar pregnancy. How would a complete and partial molar pregnancy appear on US?Dx: partial molar pregnancy Tx: - uterine evacuation (D&E) - hysterectomy (signs of trophoblastic proliferation or if dont want more kids) Follow up: - serial hCG monitoring (weekly until undetectable then monthly for 6 months) - contraception STRONGLY recommended unntil serial monitoring is complete (NO IUD) This treatment is the same for both types of molar pregnancies (complete and partial)A patient is 22 weeks gestation and comes in with vaginal bleeding. Her hCG levels were found to be 101,000 and her US shows cystic spaces within the placenta and a fetus was identified with no heart rate. What is this and how do you treat this?Follow up: - serial hCG monitoring (weekly until undetectable + 3 more weeks then monthly for 6 months) - contraception STRONGLY recommended unntil serial monitoring is complete (NO IUD) GTN recurrence is highest in first yearAfter doing a uterine evacuation to remove a molar pregnancy, what is the follow up care?Gestational Trophoblastic Neoplasia (GTN) two types: - invasive mole (growth that invades myometrium) - choriocarcinoma (malignant tumor spreading to dif areas, can occur after normal pregnancy, abortion, or ectopic as well but highest risk with molar) Most GTN (even malignant) respond well to chemoWhat is a potential complication for molar pregnancies? How is it treated?False - could follow molar preg, normal preg, abortion, or ectopic preg expect molar pregnancy if abnormal bleeding for 6+ weeks + severely elevated hCG (ex. 300,000)T/F: Choriocarcinoma, a type of gestational trophoblastic neoplasia, is a potential complication for molar pregnancies onlyFalseT/F: hysterectomy due to molar pregnancy will eliminate the risk of metastatic diseaseask about differences between termination procedures are complete and partial molar treated the same?False - contraception recommended BUT IUD is strongly contraindicated after molar pregnancyT/F: following a molar pregnancy termination, you should recommend patients to be on contraception. This could be oral, IUD, depo, or others.TrueT/F: partial and complete molar pregnancies are considered pre-malignant. Therefore, both complete and partial should be sent for pathologic evaluation.