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VAGINAL BLEEDING IN VAGINAL BLEEDING IN PREGNANCY PREGNANCY
Craig T Carter DOCraig T Carter DO
Department of Emergency MedicineDepartment of Emergency Medicine
University of KentuckyUniversity of Kentucky
VAGINAL BLEEDING DURING VAGINAL BLEEDING DURING PREGNANCYPREGNANCY
1 DURING PREGNANCY1 DURING PREGNANCY
-FIRST 20 WEEKS-FIRST 20 WEEKS
-SECOND 20 WEEKS-SECOND 20 WEEKS
PREGNANCY AND VAGINAL PREGNANCY AND VAGINAL BLEEDINGBLEEDING
By the NumbersBy the Numbers
40 EXPERIENCE BLEEDING IN THE COURSE 40 EXPERIENCE BLEEDING IN THE COURSE OF PREGNANCYOF PREGNANCY
Up to 20 OF PREGNANCIES TERMINATE IN Up to 20 OF PREGNANCIES TERMINATE IN MISCARRIAGEMISCARRIAGE
2 OF PREGNANCIES ARE ECTOPIC2 OF PREGNANCIES ARE ECTOPIC 9-13 OF FIRST TRIMESTER MATERNAL 9-13 OF FIRST TRIMESTER MATERNAL
DEATHS ARE DUE TO ECTOPIC DEATHS ARE DUE TO ECTOPIC PREGNANCIESPREGNANCIES
BLEEDING AND THE FIRST BLEEDING AND THE FIRST 20 WEEKS20 WEEKS
Three primary causesThree primary causes
SPONTANEOUS MISCARRIAGEABORTIONSPONTANEOUS MISCARRIAGEABORTION
ECTOPIC PREGNANCY (EP)ECTOPIC PREGNANCY (EP)
TROPHOBLASTIC DISORDERSTROPHOBLASTIC DISORDERS
Spontaneous Abortion
Incidence-1 in 5 pregnancies 80 occur in the first trimester Incidence decreases with gestational age
If fetal heart activityviability is noted on ultrasound the loss rate is only 2-3
Loss rate is 20 in those with first trimester bleeding
Risk increases with increasing maternal age paternal age and parity
Spontaneous Abortion
Etiology-
Maternal factors Infectious-Mycoplasma ToxoplasmosisListeria Environmental-Alcohol abuse Smoking Uterine - Septum Fibroids Cervical
Incompetence Systemic Disease-Thyroid Diabetes
1048715 Paternal factors-Chromosomal translocation
Fetal Factors-Chromosomal 50 of 1st trimester abortions caused by
chromosomal anomalies
Spontaneous Abortion-Symptoms
Vaginal bleeding in almost all patients
Cramping and pelvic pain very common
Hemorrhage can lead to syncope from hypovolemiashock
Often discovered when fetal heart activity cannot be detected on exam
SPONTANEOUS SPONTANEOUS MISCARRIAGEMISCARRIAGE
20 OF PREGNANCIES WILL MISCARRY20 OF PREGNANCIES WILL MISCARRY
IS A NATURAL PROCESS THAT IS A NATURAL PROCESS THAT ELIMINATES ALMOST 95 OF ELIMINATES ALMOST 95 OF CYTOGENETIC DEFECTS BEFORE BIRTHCYTOGENETIC DEFECTS BEFORE BIRTH
COMMON CAUSE OF VAGINAL BLEEDING COMMON CAUSE OF VAGINAL BLEEDING DURING PREGNANCYDURING PREGNANCY
Spontaneous Abortion
Differential Diagnosis
Threatened Abortion - bleeding cervix closed
Inevitable Abortion - cervix open ormembranes ruptured
Incomplete Abortion - passed some of the POC Treatment ndash Suction Dilitation and Curettage
or Observation
Complete Abortion - passed all products ofconception (POC)
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
UTERINE BLEEDING IN THE FIRST 20 UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATIONTISSUE OR CERVICAL DILATION
ULTRASOUND MAY DETECT AN IUP ULTRASOUND MAY DETECT AN IUP INDETERMINATE OR EMPTY UTERUS INDETERMINATE OR EMPTY UTERUS CORRELATE WITH BHCG TO RULE CORRELATE WITH BHCG TO RULE OUT EPOUT EP
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOMETREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - THREATENED MISCARRIAGE - TreatmentTreatment
SUCCESS RATES ARE SIMILAR (93) SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
DISCHARGE HOME IS SAFEDISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB MUST INCLUDE MANDATORY OB FOLLOW UPFOLLOW UP
SERIAL BHCG IN 48 HRS SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSSBOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED BOTH PRESENT AND ARE TREATED SIMILARLYSIMILARLY
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN DILATION OPEN CERVIX IS AN IMPORTANT FINDINGIMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE INCOMPLETE INCOMPLETE PASSAGE OF TISSUEOF TISSUE
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
TREATMENT OF CHOICETREATMENT OF CHOICE
UTERINE CURETTAGEUTERINE CURETTAGE
(DampC)(DampC)
COMPLETE MISCARRIAGECOMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPEDVAGINAL BLEEDING HAS STOPPED
Products of ConceptoinProducts of Conceptoin
MISSED MISCARRIAGEMISSED MISCARRIAGE
OCCURS WITH RETENTION OF OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISEDOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND UTERINE INFETION OCCURS AND MAY LEAD TO SEPSISMAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE SPONTANEOUS OR ELECTIVE MISCARRIAGEMISCARRIAGE
LATE COURSE SEPTIC SHOCKLATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIALINFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS TRIPLE ANTIBIOTIC COVERAGE IS
REQUIREDREQUIRED GRAM (+) COVERAGE PENICILLIN GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORINAMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAMAMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLECLINDAMYCIN OR METRONIDAZOLE
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
VAGINAL BLEEDING DURING VAGINAL BLEEDING DURING PREGNANCYPREGNANCY
1 DURING PREGNANCY1 DURING PREGNANCY
-FIRST 20 WEEKS-FIRST 20 WEEKS
-SECOND 20 WEEKS-SECOND 20 WEEKS
PREGNANCY AND VAGINAL PREGNANCY AND VAGINAL BLEEDINGBLEEDING
By the NumbersBy the Numbers
40 EXPERIENCE BLEEDING IN THE COURSE 40 EXPERIENCE BLEEDING IN THE COURSE OF PREGNANCYOF PREGNANCY
Up to 20 OF PREGNANCIES TERMINATE IN Up to 20 OF PREGNANCIES TERMINATE IN MISCARRIAGEMISCARRIAGE
2 OF PREGNANCIES ARE ECTOPIC2 OF PREGNANCIES ARE ECTOPIC 9-13 OF FIRST TRIMESTER MATERNAL 9-13 OF FIRST TRIMESTER MATERNAL
DEATHS ARE DUE TO ECTOPIC DEATHS ARE DUE TO ECTOPIC PREGNANCIESPREGNANCIES
BLEEDING AND THE FIRST BLEEDING AND THE FIRST 20 WEEKS20 WEEKS
Three primary causesThree primary causes
SPONTANEOUS MISCARRIAGEABORTIONSPONTANEOUS MISCARRIAGEABORTION
ECTOPIC PREGNANCY (EP)ECTOPIC PREGNANCY (EP)
TROPHOBLASTIC DISORDERSTROPHOBLASTIC DISORDERS
Spontaneous Abortion
Incidence-1 in 5 pregnancies 80 occur in the first trimester Incidence decreases with gestational age
If fetal heart activityviability is noted on ultrasound the loss rate is only 2-3
Loss rate is 20 in those with first trimester bleeding
Risk increases with increasing maternal age paternal age and parity
Spontaneous Abortion
Etiology-
Maternal factors Infectious-Mycoplasma ToxoplasmosisListeria Environmental-Alcohol abuse Smoking Uterine - Septum Fibroids Cervical
Incompetence Systemic Disease-Thyroid Diabetes
1048715 Paternal factors-Chromosomal translocation
Fetal Factors-Chromosomal 50 of 1st trimester abortions caused by
chromosomal anomalies
Spontaneous Abortion-Symptoms
Vaginal bleeding in almost all patients
Cramping and pelvic pain very common
Hemorrhage can lead to syncope from hypovolemiashock
Often discovered when fetal heart activity cannot be detected on exam
SPONTANEOUS SPONTANEOUS MISCARRIAGEMISCARRIAGE
20 OF PREGNANCIES WILL MISCARRY20 OF PREGNANCIES WILL MISCARRY
IS A NATURAL PROCESS THAT IS A NATURAL PROCESS THAT ELIMINATES ALMOST 95 OF ELIMINATES ALMOST 95 OF CYTOGENETIC DEFECTS BEFORE BIRTHCYTOGENETIC DEFECTS BEFORE BIRTH
COMMON CAUSE OF VAGINAL BLEEDING COMMON CAUSE OF VAGINAL BLEEDING DURING PREGNANCYDURING PREGNANCY
Spontaneous Abortion
Differential Diagnosis
Threatened Abortion - bleeding cervix closed
Inevitable Abortion - cervix open ormembranes ruptured
Incomplete Abortion - passed some of the POC Treatment ndash Suction Dilitation and Curettage
or Observation
Complete Abortion - passed all products ofconception (POC)
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
UTERINE BLEEDING IN THE FIRST 20 UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATIONTISSUE OR CERVICAL DILATION
ULTRASOUND MAY DETECT AN IUP ULTRASOUND MAY DETECT AN IUP INDETERMINATE OR EMPTY UTERUS INDETERMINATE OR EMPTY UTERUS CORRELATE WITH BHCG TO RULE CORRELATE WITH BHCG TO RULE OUT EPOUT EP
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOMETREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - THREATENED MISCARRIAGE - TreatmentTreatment
SUCCESS RATES ARE SIMILAR (93) SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
DISCHARGE HOME IS SAFEDISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB MUST INCLUDE MANDATORY OB FOLLOW UPFOLLOW UP
SERIAL BHCG IN 48 HRS SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSSBOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED BOTH PRESENT AND ARE TREATED SIMILARLYSIMILARLY
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN DILATION OPEN CERVIX IS AN IMPORTANT FINDINGIMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE INCOMPLETE INCOMPLETE PASSAGE OF TISSUEOF TISSUE
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
TREATMENT OF CHOICETREATMENT OF CHOICE
UTERINE CURETTAGEUTERINE CURETTAGE
(DampC)(DampC)
COMPLETE MISCARRIAGECOMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPEDVAGINAL BLEEDING HAS STOPPED
Products of ConceptoinProducts of Conceptoin
MISSED MISCARRIAGEMISSED MISCARRIAGE
OCCURS WITH RETENTION OF OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISEDOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND UTERINE INFETION OCCURS AND MAY LEAD TO SEPSISMAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE SPONTANEOUS OR ELECTIVE MISCARRIAGEMISCARRIAGE
LATE COURSE SEPTIC SHOCKLATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIALINFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS TRIPLE ANTIBIOTIC COVERAGE IS
REQUIREDREQUIRED GRAM (+) COVERAGE PENICILLIN GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORINAMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAMAMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLECLINDAMYCIN OR METRONIDAZOLE
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
PREGNANCY AND VAGINAL PREGNANCY AND VAGINAL BLEEDINGBLEEDING
By the NumbersBy the Numbers
40 EXPERIENCE BLEEDING IN THE COURSE 40 EXPERIENCE BLEEDING IN THE COURSE OF PREGNANCYOF PREGNANCY
Up to 20 OF PREGNANCIES TERMINATE IN Up to 20 OF PREGNANCIES TERMINATE IN MISCARRIAGEMISCARRIAGE
2 OF PREGNANCIES ARE ECTOPIC2 OF PREGNANCIES ARE ECTOPIC 9-13 OF FIRST TRIMESTER MATERNAL 9-13 OF FIRST TRIMESTER MATERNAL
DEATHS ARE DUE TO ECTOPIC DEATHS ARE DUE TO ECTOPIC PREGNANCIESPREGNANCIES
BLEEDING AND THE FIRST BLEEDING AND THE FIRST 20 WEEKS20 WEEKS
Three primary causesThree primary causes
SPONTANEOUS MISCARRIAGEABORTIONSPONTANEOUS MISCARRIAGEABORTION
ECTOPIC PREGNANCY (EP)ECTOPIC PREGNANCY (EP)
TROPHOBLASTIC DISORDERSTROPHOBLASTIC DISORDERS
Spontaneous Abortion
Incidence-1 in 5 pregnancies 80 occur in the first trimester Incidence decreases with gestational age
If fetal heart activityviability is noted on ultrasound the loss rate is only 2-3
Loss rate is 20 in those with first trimester bleeding
Risk increases with increasing maternal age paternal age and parity
Spontaneous Abortion
Etiology-
Maternal factors Infectious-Mycoplasma ToxoplasmosisListeria Environmental-Alcohol abuse Smoking Uterine - Septum Fibroids Cervical
Incompetence Systemic Disease-Thyroid Diabetes
1048715 Paternal factors-Chromosomal translocation
Fetal Factors-Chromosomal 50 of 1st trimester abortions caused by
chromosomal anomalies
Spontaneous Abortion-Symptoms
Vaginal bleeding in almost all patients
Cramping and pelvic pain very common
Hemorrhage can lead to syncope from hypovolemiashock
Often discovered when fetal heart activity cannot be detected on exam
SPONTANEOUS SPONTANEOUS MISCARRIAGEMISCARRIAGE
20 OF PREGNANCIES WILL MISCARRY20 OF PREGNANCIES WILL MISCARRY
IS A NATURAL PROCESS THAT IS A NATURAL PROCESS THAT ELIMINATES ALMOST 95 OF ELIMINATES ALMOST 95 OF CYTOGENETIC DEFECTS BEFORE BIRTHCYTOGENETIC DEFECTS BEFORE BIRTH
COMMON CAUSE OF VAGINAL BLEEDING COMMON CAUSE OF VAGINAL BLEEDING DURING PREGNANCYDURING PREGNANCY
Spontaneous Abortion
Differential Diagnosis
Threatened Abortion - bleeding cervix closed
Inevitable Abortion - cervix open ormembranes ruptured
Incomplete Abortion - passed some of the POC Treatment ndash Suction Dilitation and Curettage
or Observation
Complete Abortion - passed all products ofconception (POC)
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
UTERINE BLEEDING IN THE FIRST 20 UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATIONTISSUE OR CERVICAL DILATION
ULTRASOUND MAY DETECT AN IUP ULTRASOUND MAY DETECT AN IUP INDETERMINATE OR EMPTY UTERUS INDETERMINATE OR EMPTY UTERUS CORRELATE WITH BHCG TO RULE CORRELATE WITH BHCG TO RULE OUT EPOUT EP
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOMETREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - THREATENED MISCARRIAGE - TreatmentTreatment
SUCCESS RATES ARE SIMILAR (93) SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
DISCHARGE HOME IS SAFEDISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB MUST INCLUDE MANDATORY OB FOLLOW UPFOLLOW UP
SERIAL BHCG IN 48 HRS SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSSBOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED BOTH PRESENT AND ARE TREATED SIMILARLYSIMILARLY
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN DILATION OPEN CERVIX IS AN IMPORTANT FINDINGIMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE INCOMPLETE INCOMPLETE PASSAGE OF TISSUEOF TISSUE
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
TREATMENT OF CHOICETREATMENT OF CHOICE
UTERINE CURETTAGEUTERINE CURETTAGE
(DampC)(DampC)
COMPLETE MISCARRIAGECOMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPEDVAGINAL BLEEDING HAS STOPPED
Products of ConceptoinProducts of Conceptoin
MISSED MISCARRIAGEMISSED MISCARRIAGE
OCCURS WITH RETENTION OF OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISEDOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND UTERINE INFETION OCCURS AND MAY LEAD TO SEPSISMAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE SPONTANEOUS OR ELECTIVE MISCARRIAGEMISCARRIAGE
LATE COURSE SEPTIC SHOCKLATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIALINFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS TRIPLE ANTIBIOTIC COVERAGE IS
REQUIREDREQUIRED GRAM (+) COVERAGE PENICILLIN GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORINAMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAMAMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLECLINDAMYCIN OR METRONIDAZOLE
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
BLEEDING AND THE FIRST BLEEDING AND THE FIRST 20 WEEKS20 WEEKS
Three primary causesThree primary causes
SPONTANEOUS MISCARRIAGEABORTIONSPONTANEOUS MISCARRIAGEABORTION
ECTOPIC PREGNANCY (EP)ECTOPIC PREGNANCY (EP)
TROPHOBLASTIC DISORDERSTROPHOBLASTIC DISORDERS
Spontaneous Abortion
Incidence-1 in 5 pregnancies 80 occur in the first trimester Incidence decreases with gestational age
If fetal heart activityviability is noted on ultrasound the loss rate is only 2-3
Loss rate is 20 in those with first trimester bleeding
Risk increases with increasing maternal age paternal age and parity
Spontaneous Abortion
Etiology-
Maternal factors Infectious-Mycoplasma ToxoplasmosisListeria Environmental-Alcohol abuse Smoking Uterine - Septum Fibroids Cervical
Incompetence Systemic Disease-Thyroid Diabetes
1048715 Paternal factors-Chromosomal translocation
Fetal Factors-Chromosomal 50 of 1st trimester abortions caused by
chromosomal anomalies
Spontaneous Abortion-Symptoms
Vaginal bleeding in almost all patients
Cramping and pelvic pain very common
Hemorrhage can lead to syncope from hypovolemiashock
Often discovered when fetal heart activity cannot be detected on exam
SPONTANEOUS SPONTANEOUS MISCARRIAGEMISCARRIAGE
20 OF PREGNANCIES WILL MISCARRY20 OF PREGNANCIES WILL MISCARRY
IS A NATURAL PROCESS THAT IS A NATURAL PROCESS THAT ELIMINATES ALMOST 95 OF ELIMINATES ALMOST 95 OF CYTOGENETIC DEFECTS BEFORE BIRTHCYTOGENETIC DEFECTS BEFORE BIRTH
COMMON CAUSE OF VAGINAL BLEEDING COMMON CAUSE OF VAGINAL BLEEDING DURING PREGNANCYDURING PREGNANCY
Spontaneous Abortion
Differential Diagnosis
Threatened Abortion - bleeding cervix closed
Inevitable Abortion - cervix open ormembranes ruptured
Incomplete Abortion - passed some of the POC Treatment ndash Suction Dilitation and Curettage
or Observation
Complete Abortion - passed all products ofconception (POC)
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
UTERINE BLEEDING IN THE FIRST 20 UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATIONTISSUE OR CERVICAL DILATION
ULTRASOUND MAY DETECT AN IUP ULTRASOUND MAY DETECT AN IUP INDETERMINATE OR EMPTY UTERUS INDETERMINATE OR EMPTY UTERUS CORRELATE WITH BHCG TO RULE CORRELATE WITH BHCG TO RULE OUT EPOUT EP
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOMETREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - THREATENED MISCARRIAGE - TreatmentTreatment
SUCCESS RATES ARE SIMILAR (93) SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
DISCHARGE HOME IS SAFEDISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB MUST INCLUDE MANDATORY OB FOLLOW UPFOLLOW UP
SERIAL BHCG IN 48 HRS SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSSBOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED BOTH PRESENT AND ARE TREATED SIMILARLYSIMILARLY
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN DILATION OPEN CERVIX IS AN IMPORTANT FINDINGIMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE INCOMPLETE INCOMPLETE PASSAGE OF TISSUEOF TISSUE
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
TREATMENT OF CHOICETREATMENT OF CHOICE
UTERINE CURETTAGEUTERINE CURETTAGE
(DampC)(DampC)
COMPLETE MISCARRIAGECOMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPEDVAGINAL BLEEDING HAS STOPPED
Products of ConceptoinProducts of Conceptoin
MISSED MISCARRIAGEMISSED MISCARRIAGE
OCCURS WITH RETENTION OF OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISEDOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND UTERINE INFETION OCCURS AND MAY LEAD TO SEPSISMAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE SPONTANEOUS OR ELECTIVE MISCARRIAGEMISCARRIAGE
LATE COURSE SEPTIC SHOCKLATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIALINFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS TRIPLE ANTIBIOTIC COVERAGE IS
REQUIREDREQUIRED GRAM (+) COVERAGE PENICILLIN GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORINAMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAMAMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLECLINDAMYCIN OR METRONIDAZOLE
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
Spontaneous Abortion
Incidence-1 in 5 pregnancies 80 occur in the first trimester Incidence decreases with gestational age
If fetal heart activityviability is noted on ultrasound the loss rate is only 2-3
Loss rate is 20 in those with first trimester bleeding
Risk increases with increasing maternal age paternal age and parity
Spontaneous Abortion
Etiology-
Maternal factors Infectious-Mycoplasma ToxoplasmosisListeria Environmental-Alcohol abuse Smoking Uterine - Septum Fibroids Cervical
Incompetence Systemic Disease-Thyroid Diabetes
1048715 Paternal factors-Chromosomal translocation
Fetal Factors-Chromosomal 50 of 1st trimester abortions caused by
chromosomal anomalies
Spontaneous Abortion-Symptoms
Vaginal bleeding in almost all patients
Cramping and pelvic pain very common
Hemorrhage can lead to syncope from hypovolemiashock
Often discovered when fetal heart activity cannot be detected on exam
SPONTANEOUS SPONTANEOUS MISCARRIAGEMISCARRIAGE
20 OF PREGNANCIES WILL MISCARRY20 OF PREGNANCIES WILL MISCARRY
IS A NATURAL PROCESS THAT IS A NATURAL PROCESS THAT ELIMINATES ALMOST 95 OF ELIMINATES ALMOST 95 OF CYTOGENETIC DEFECTS BEFORE BIRTHCYTOGENETIC DEFECTS BEFORE BIRTH
COMMON CAUSE OF VAGINAL BLEEDING COMMON CAUSE OF VAGINAL BLEEDING DURING PREGNANCYDURING PREGNANCY
Spontaneous Abortion
Differential Diagnosis
Threatened Abortion - bleeding cervix closed
Inevitable Abortion - cervix open ormembranes ruptured
Incomplete Abortion - passed some of the POC Treatment ndash Suction Dilitation and Curettage
or Observation
Complete Abortion - passed all products ofconception (POC)
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
UTERINE BLEEDING IN THE FIRST 20 UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATIONTISSUE OR CERVICAL DILATION
ULTRASOUND MAY DETECT AN IUP ULTRASOUND MAY DETECT AN IUP INDETERMINATE OR EMPTY UTERUS INDETERMINATE OR EMPTY UTERUS CORRELATE WITH BHCG TO RULE CORRELATE WITH BHCG TO RULE OUT EPOUT EP
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOMETREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - THREATENED MISCARRIAGE - TreatmentTreatment
SUCCESS RATES ARE SIMILAR (93) SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
DISCHARGE HOME IS SAFEDISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB MUST INCLUDE MANDATORY OB FOLLOW UPFOLLOW UP
SERIAL BHCG IN 48 HRS SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSSBOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED BOTH PRESENT AND ARE TREATED SIMILARLYSIMILARLY
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN DILATION OPEN CERVIX IS AN IMPORTANT FINDINGIMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE INCOMPLETE INCOMPLETE PASSAGE OF TISSUEOF TISSUE
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
TREATMENT OF CHOICETREATMENT OF CHOICE
UTERINE CURETTAGEUTERINE CURETTAGE
(DampC)(DampC)
COMPLETE MISCARRIAGECOMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPEDVAGINAL BLEEDING HAS STOPPED
Products of ConceptoinProducts of Conceptoin
MISSED MISCARRIAGEMISSED MISCARRIAGE
OCCURS WITH RETENTION OF OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISEDOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND UTERINE INFETION OCCURS AND MAY LEAD TO SEPSISMAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE SPONTANEOUS OR ELECTIVE MISCARRIAGEMISCARRIAGE
LATE COURSE SEPTIC SHOCKLATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIALINFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS TRIPLE ANTIBIOTIC COVERAGE IS
REQUIREDREQUIRED GRAM (+) COVERAGE PENICILLIN GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORINAMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAMAMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLECLINDAMYCIN OR METRONIDAZOLE
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
Spontaneous Abortion
Etiology-
Maternal factors Infectious-Mycoplasma ToxoplasmosisListeria Environmental-Alcohol abuse Smoking Uterine - Septum Fibroids Cervical
Incompetence Systemic Disease-Thyroid Diabetes
1048715 Paternal factors-Chromosomal translocation
Fetal Factors-Chromosomal 50 of 1st trimester abortions caused by
chromosomal anomalies
Spontaneous Abortion-Symptoms
Vaginal bleeding in almost all patients
Cramping and pelvic pain very common
Hemorrhage can lead to syncope from hypovolemiashock
Often discovered when fetal heart activity cannot be detected on exam
SPONTANEOUS SPONTANEOUS MISCARRIAGEMISCARRIAGE
20 OF PREGNANCIES WILL MISCARRY20 OF PREGNANCIES WILL MISCARRY
IS A NATURAL PROCESS THAT IS A NATURAL PROCESS THAT ELIMINATES ALMOST 95 OF ELIMINATES ALMOST 95 OF CYTOGENETIC DEFECTS BEFORE BIRTHCYTOGENETIC DEFECTS BEFORE BIRTH
COMMON CAUSE OF VAGINAL BLEEDING COMMON CAUSE OF VAGINAL BLEEDING DURING PREGNANCYDURING PREGNANCY
Spontaneous Abortion
Differential Diagnosis
Threatened Abortion - bleeding cervix closed
Inevitable Abortion - cervix open ormembranes ruptured
Incomplete Abortion - passed some of the POC Treatment ndash Suction Dilitation and Curettage
or Observation
Complete Abortion - passed all products ofconception (POC)
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
UTERINE BLEEDING IN THE FIRST 20 UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATIONTISSUE OR CERVICAL DILATION
ULTRASOUND MAY DETECT AN IUP ULTRASOUND MAY DETECT AN IUP INDETERMINATE OR EMPTY UTERUS INDETERMINATE OR EMPTY UTERUS CORRELATE WITH BHCG TO RULE CORRELATE WITH BHCG TO RULE OUT EPOUT EP
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOMETREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - THREATENED MISCARRIAGE - TreatmentTreatment
SUCCESS RATES ARE SIMILAR (93) SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
DISCHARGE HOME IS SAFEDISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB MUST INCLUDE MANDATORY OB FOLLOW UPFOLLOW UP
SERIAL BHCG IN 48 HRS SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSSBOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED BOTH PRESENT AND ARE TREATED SIMILARLYSIMILARLY
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN DILATION OPEN CERVIX IS AN IMPORTANT FINDINGIMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE INCOMPLETE INCOMPLETE PASSAGE OF TISSUEOF TISSUE
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
TREATMENT OF CHOICETREATMENT OF CHOICE
UTERINE CURETTAGEUTERINE CURETTAGE
(DampC)(DampC)
COMPLETE MISCARRIAGECOMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPEDVAGINAL BLEEDING HAS STOPPED
Products of ConceptoinProducts of Conceptoin
MISSED MISCARRIAGEMISSED MISCARRIAGE
OCCURS WITH RETENTION OF OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISEDOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND UTERINE INFETION OCCURS AND MAY LEAD TO SEPSISMAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE SPONTANEOUS OR ELECTIVE MISCARRIAGEMISCARRIAGE
LATE COURSE SEPTIC SHOCKLATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIALINFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS TRIPLE ANTIBIOTIC COVERAGE IS
REQUIREDREQUIRED GRAM (+) COVERAGE PENICILLIN GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORINAMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAMAMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLECLINDAMYCIN OR METRONIDAZOLE
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
Spontaneous Abortion-Symptoms
Vaginal bleeding in almost all patients
Cramping and pelvic pain very common
Hemorrhage can lead to syncope from hypovolemiashock
Often discovered when fetal heart activity cannot be detected on exam
SPONTANEOUS SPONTANEOUS MISCARRIAGEMISCARRIAGE
20 OF PREGNANCIES WILL MISCARRY20 OF PREGNANCIES WILL MISCARRY
IS A NATURAL PROCESS THAT IS A NATURAL PROCESS THAT ELIMINATES ALMOST 95 OF ELIMINATES ALMOST 95 OF CYTOGENETIC DEFECTS BEFORE BIRTHCYTOGENETIC DEFECTS BEFORE BIRTH
COMMON CAUSE OF VAGINAL BLEEDING COMMON CAUSE OF VAGINAL BLEEDING DURING PREGNANCYDURING PREGNANCY
Spontaneous Abortion
Differential Diagnosis
Threatened Abortion - bleeding cervix closed
Inevitable Abortion - cervix open ormembranes ruptured
Incomplete Abortion - passed some of the POC Treatment ndash Suction Dilitation and Curettage
or Observation
Complete Abortion - passed all products ofconception (POC)
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
UTERINE BLEEDING IN THE FIRST 20 UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATIONTISSUE OR CERVICAL DILATION
ULTRASOUND MAY DETECT AN IUP ULTRASOUND MAY DETECT AN IUP INDETERMINATE OR EMPTY UTERUS INDETERMINATE OR EMPTY UTERUS CORRELATE WITH BHCG TO RULE CORRELATE WITH BHCG TO RULE OUT EPOUT EP
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOMETREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - THREATENED MISCARRIAGE - TreatmentTreatment
SUCCESS RATES ARE SIMILAR (93) SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
DISCHARGE HOME IS SAFEDISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB MUST INCLUDE MANDATORY OB FOLLOW UPFOLLOW UP
SERIAL BHCG IN 48 HRS SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSSBOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED BOTH PRESENT AND ARE TREATED SIMILARLYSIMILARLY
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN DILATION OPEN CERVIX IS AN IMPORTANT FINDINGIMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE INCOMPLETE INCOMPLETE PASSAGE OF TISSUEOF TISSUE
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
TREATMENT OF CHOICETREATMENT OF CHOICE
UTERINE CURETTAGEUTERINE CURETTAGE
(DampC)(DampC)
COMPLETE MISCARRIAGECOMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPEDVAGINAL BLEEDING HAS STOPPED
Products of ConceptoinProducts of Conceptoin
MISSED MISCARRIAGEMISSED MISCARRIAGE
OCCURS WITH RETENTION OF OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISEDOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND UTERINE INFETION OCCURS AND MAY LEAD TO SEPSISMAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE SPONTANEOUS OR ELECTIVE MISCARRIAGEMISCARRIAGE
LATE COURSE SEPTIC SHOCKLATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIALINFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS TRIPLE ANTIBIOTIC COVERAGE IS
REQUIREDREQUIRED GRAM (+) COVERAGE PENICILLIN GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORINAMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAMAMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLECLINDAMYCIN OR METRONIDAZOLE
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
SPONTANEOUS SPONTANEOUS MISCARRIAGEMISCARRIAGE
20 OF PREGNANCIES WILL MISCARRY20 OF PREGNANCIES WILL MISCARRY
IS A NATURAL PROCESS THAT IS A NATURAL PROCESS THAT ELIMINATES ALMOST 95 OF ELIMINATES ALMOST 95 OF CYTOGENETIC DEFECTS BEFORE BIRTHCYTOGENETIC DEFECTS BEFORE BIRTH
COMMON CAUSE OF VAGINAL BLEEDING COMMON CAUSE OF VAGINAL BLEEDING DURING PREGNANCYDURING PREGNANCY
Spontaneous Abortion
Differential Diagnosis
Threatened Abortion - bleeding cervix closed
Inevitable Abortion - cervix open ormembranes ruptured
Incomplete Abortion - passed some of the POC Treatment ndash Suction Dilitation and Curettage
or Observation
Complete Abortion - passed all products ofconception (POC)
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
UTERINE BLEEDING IN THE FIRST 20 UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATIONTISSUE OR CERVICAL DILATION
ULTRASOUND MAY DETECT AN IUP ULTRASOUND MAY DETECT AN IUP INDETERMINATE OR EMPTY UTERUS INDETERMINATE OR EMPTY UTERUS CORRELATE WITH BHCG TO RULE CORRELATE WITH BHCG TO RULE OUT EPOUT EP
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOMETREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - THREATENED MISCARRIAGE - TreatmentTreatment
SUCCESS RATES ARE SIMILAR (93) SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
DISCHARGE HOME IS SAFEDISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB MUST INCLUDE MANDATORY OB FOLLOW UPFOLLOW UP
SERIAL BHCG IN 48 HRS SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSSBOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED BOTH PRESENT AND ARE TREATED SIMILARLYSIMILARLY
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN DILATION OPEN CERVIX IS AN IMPORTANT FINDINGIMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE INCOMPLETE INCOMPLETE PASSAGE OF TISSUEOF TISSUE
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
TREATMENT OF CHOICETREATMENT OF CHOICE
UTERINE CURETTAGEUTERINE CURETTAGE
(DampC)(DampC)
COMPLETE MISCARRIAGECOMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPEDVAGINAL BLEEDING HAS STOPPED
Products of ConceptoinProducts of Conceptoin
MISSED MISCARRIAGEMISSED MISCARRIAGE
OCCURS WITH RETENTION OF OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISEDOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND UTERINE INFETION OCCURS AND MAY LEAD TO SEPSISMAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE SPONTANEOUS OR ELECTIVE MISCARRIAGEMISCARRIAGE
LATE COURSE SEPTIC SHOCKLATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIALINFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS TRIPLE ANTIBIOTIC COVERAGE IS
REQUIREDREQUIRED GRAM (+) COVERAGE PENICILLIN GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORINAMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAMAMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLECLINDAMYCIN OR METRONIDAZOLE
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
Spontaneous Abortion
Differential Diagnosis
Threatened Abortion - bleeding cervix closed
Inevitable Abortion - cervix open ormembranes ruptured
Incomplete Abortion - passed some of the POC Treatment ndash Suction Dilitation and Curettage
or Observation
Complete Abortion - passed all products ofconception (POC)
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
UTERINE BLEEDING IN THE FIRST 20 UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATIONTISSUE OR CERVICAL DILATION
ULTRASOUND MAY DETECT AN IUP ULTRASOUND MAY DETECT AN IUP INDETERMINATE OR EMPTY UTERUS INDETERMINATE OR EMPTY UTERUS CORRELATE WITH BHCG TO RULE CORRELATE WITH BHCG TO RULE OUT EPOUT EP
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOMETREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - THREATENED MISCARRIAGE - TreatmentTreatment
SUCCESS RATES ARE SIMILAR (93) SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
DISCHARGE HOME IS SAFEDISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB MUST INCLUDE MANDATORY OB FOLLOW UPFOLLOW UP
SERIAL BHCG IN 48 HRS SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSSBOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED BOTH PRESENT AND ARE TREATED SIMILARLYSIMILARLY
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN DILATION OPEN CERVIX IS AN IMPORTANT FINDINGIMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE INCOMPLETE INCOMPLETE PASSAGE OF TISSUEOF TISSUE
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
TREATMENT OF CHOICETREATMENT OF CHOICE
UTERINE CURETTAGEUTERINE CURETTAGE
(DampC)(DampC)
COMPLETE MISCARRIAGECOMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPEDVAGINAL BLEEDING HAS STOPPED
Products of ConceptoinProducts of Conceptoin
MISSED MISCARRIAGEMISSED MISCARRIAGE
OCCURS WITH RETENTION OF OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISEDOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND UTERINE INFETION OCCURS AND MAY LEAD TO SEPSISMAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE SPONTANEOUS OR ELECTIVE MISCARRIAGEMISCARRIAGE
LATE COURSE SEPTIC SHOCKLATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIALINFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS TRIPLE ANTIBIOTIC COVERAGE IS
REQUIREDREQUIRED GRAM (+) COVERAGE PENICILLIN GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORINAMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAMAMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLECLINDAMYCIN OR METRONIDAZOLE
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
UTERINE BLEEDING IN THE FIRST 20 UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATIONTISSUE OR CERVICAL DILATION
ULTRASOUND MAY DETECT AN IUP ULTRASOUND MAY DETECT AN IUP INDETERMINATE OR EMPTY UTERUS INDETERMINATE OR EMPTY UTERUS CORRELATE WITH BHCG TO RULE CORRELATE WITH BHCG TO RULE OUT EPOUT EP
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOMETREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - THREATENED MISCARRIAGE - TreatmentTreatment
SUCCESS RATES ARE SIMILAR (93) SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
DISCHARGE HOME IS SAFEDISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB MUST INCLUDE MANDATORY OB FOLLOW UPFOLLOW UP
SERIAL BHCG IN 48 HRS SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSSBOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED BOTH PRESENT AND ARE TREATED SIMILARLYSIMILARLY
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN DILATION OPEN CERVIX IS AN IMPORTANT FINDINGIMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE INCOMPLETE INCOMPLETE PASSAGE OF TISSUEOF TISSUE
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
TREATMENT OF CHOICETREATMENT OF CHOICE
UTERINE CURETTAGEUTERINE CURETTAGE
(DampC)(DampC)
COMPLETE MISCARRIAGECOMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPEDVAGINAL BLEEDING HAS STOPPED
Products of ConceptoinProducts of Conceptoin
MISSED MISCARRIAGEMISSED MISCARRIAGE
OCCURS WITH RETENTION OF OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISEDOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND UTERINE INFETION OCCURS AND MAY LEAD TO SEPSISMAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE SPONTANEOUS OR ELECTIVE MISCARRIAGEMISCARRIAGE
LATE COURSE SEPTIC SHOCKLATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIALINFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS TRIPLE ANTIBIOTIC COVERAGE IS
REQUIREDREQUIRED GRAM (+) COVERAGE PENICILLIN GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORINAMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAMAMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLECLINDAMYCIN OR METRONIDAZOLE
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOMETREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - THREATENED MISCARRIAGE - TreatmentTreatment
SUCCESS RATES ARE SIMILAR (93) SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
DISCHARGE HOME IS SAFEDISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB MUST INCLUDE MANDATORY OB FOLLOW UPFOLLOW UP
SERIAL BHCG IN 48 HRS SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSSBOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED BOTH PRESENT AND ARE TREATED SIMILARLYSIMILARLY
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN DILATION OPEN CERVIX IS AN IMPORTANT FINDINGIMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE INCOMPLETE INCOMPLETE PASSAGE OF TISSUEOF TISSUE
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
TREATMENT OF CHOICETREATMENT OF CHOICE
UTERINE CURETTAGEUTERINE CURETTAGE
(DampC)(DampC)
COMPLETE MISCARRIAGECOMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPEDVAGINAL BLEEDING HAS STOPPED
Products of ConceptoinProducts of Conceptoin
MISSED MISCARRIAGEMISSED MISCARRIAGE
OCCURS WITH RETENTION OF OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISEDOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND UTERINE INFETION OCCURS AND MAY LEAD TO SEPSISMAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE SPONTANEOUS OR ELECTIVE MISCARRIAGEMISCARRIAGE
LATE COURSE SEPTIC SHOCKLATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIALINFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS TRIPLE ANTIBIOTIC COVERAGE IS
REQUIREDREQUIRED GRAM (+) COVERAGE PENICILLIN GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORINAMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAMAMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLECLINDAMYCIN OR METRONIDAZOLE
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
THREATENED MISCARRIAGE - THREATENED MISCARRIAGE - TreatmentTreatment
SUCCESS RATES ARE SIMILAR (93) SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
DISCHARGE HOME IS SAFEDISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB MUST INCLUDE MANDATORY OB FOLLOW UPFOLLOW UP
SERIAL BHCG IN 48 HRS SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSSBOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED BOTH PRESENT AND ARE TREATED SIMILARLYSIMILARLY
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN DILATION OPEN CERVIX IS AN IMPORTANT FINDINGIMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE INCOMPLETE INCOMPLETE PASSAGE OF TISSUEOF TISSUE
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
TREATMENT OF CHOICETREATMENT OF CHOICE
UTERINE CURETTAGEUTERINE CURETTAGE
(DampC)(DampC)
COMPLETE MISCARRIAGECOMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPEDVAGINAL BLEEDING HAS STOPPED
Products of ConceptoinProducts of Conceptoin
MISSED MISCARRIAGEMISSED MISCARRIAGE
OCCURS WITH RETENTION OF OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISEDOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND UTERINE INFETION OCCURS AND MAY LEAD TO SEPSISMAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE SPONTANEOUS OR ELECTIVE MISCARRIAGEMISCARRIAGE
LATE COURSE SEPTIC SHOCKLATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIALINFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS TRIPLE ANTIBIOTIC COVERAGE IS
REQUIREDREQUIRED GRAM (+) COVERAGE PENICILLIN GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORINAMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAMAMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLECLINDAMYCIN OR METRONIDAZOLE
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
THREATENED MISCARRIAGETHREATENED MISCARRIAGE
DISCHARGE HOME IS SAFEDISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB MUST INCLUDE MANDATORY OB FOLLOW UPFOLLOW UP
SERIAL BHCG IN 48 HRS SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSSBOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED BOTH PRESENT AND ARE TREATED SIMILARLYSIMILARLY
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN DILATION OPEN CERVIX IS AN IMPORTANT FINDINGIMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE INCOMPLETE INCOMPLETE PASSAGE OF TISSUEOF TISSUE
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
TREATMENT OF CHOICETREATMENT OF CHOICE
UTERINE CURETTAGEUTERINE CURETTAGE
(DampC)(DampC)
COMPLETE MISCARRIAGECOMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPEDVAGINAL BLEEDING HAS STOPPED
Products of ConceptoinProducts of Conceptoin
MISSED MISCARRIAGEMISSED MISCARRIAGE
OCCURS WITH RETENTION OF OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISEDOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND UTERINE INFETION OCCURS AND MAY LEAD TO SEPSISMAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE SPONTANEOUS OR ELECTIVE MISCARRIAGEMISCARRIAGE
LATE COURSE SEPTIC SHOCKLATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIALINFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS TRIPLE ANTIBIOTIC COVERAGE IS
REQUIREDREQUIRED GRAM (+) COVERAGE PENICILLIN GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORINAMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAMAMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLECLINDAMYCIN OR METRONIDAZOLE
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSSBOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED BOTH PRESENT AND ARE TREATED SIMILARLYSIMILARLY
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN DILATION OPEN CERVIX IS AN IMPORTANT FINDINGIMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE INCOMPLETE INCOMPLETE PASSAGE OF TISSUEOF TISSUE
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
TREATMENT OF CHOICETREATMENT OF CHOICE
UTERINE CURETTAGEUTERINE CURETTAGE
(DampC)(DampC)
COMPLETE MISCARRIAGECOMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPEDVAGINAL BLEEDING HAS STOPPED
Products of ConceptoinProducts of Conceptoin
MISSED MISCARRIAGEMISSED MISCARRIAGE
OCCURS WITH RETENTION OF OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISEDOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND UTERINE INFETION OCCURS AND MAY LEAD TO SEPSISMAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE SPONTANEOUS OR ELECTIVE MISCARRIAGEMISCARRIAGE
LATE COURSE SEPTIC SHOCKLATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIALINFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS TRIPLE ANTIBIOTIC COVERAGE IS
REQUIREDREQUIRED GRAM (+) COVERAGE PENICILLIN GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORINAMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAMAMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLECLINDAMYCIN OR METRONIDAZOLE
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN DILATION OPEN CERVIX IS AN IMPORTANT FINDINGIMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE INCOMPLETE INCOMPLETE PASSAGE OF TISSUEOF TISSUE
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
TREATMENT OF CHOICETREATMENT OF CHOICE
UTERINE CURETTAGEUTERINE CURETTAGE
(DampC)(DampC)
COMPLETE MISCARRIAGECOMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPEDVAGINAL BLEEDING HAS STOPPED
Products of ConceptoinProducts of Conceptoin
MISSED MISCARRIAGEMISSED MISCARRIAGE
OCCURS WITH RETENTION OF OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISEDOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND UTERINE INFETION OCCURS AND MAY LEAD TO SEPSISMAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE SPONTANEOUS OR ELECTIVE MISCARRIAGEMISCARRIAGE
LATE COURSE SEPTIC SHOCKLATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIALINFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS TRIPLE ANTIBIOTIC COVERAGE IS
REQUIREDREQUIRED GRAM (+) COVERAGE PENICILLIN GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORINAMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAMAMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLECLINDAMYCIN OR METRONIDAZOLE
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
INEVITABLE INCOMPLETEINEVITABLE INCOMPLETEMISCARRIAGEMISCARRIAGE
TREATMENT OF CHOICETREATMENT OF CHOICE
UTERINE CURETTAGEUTERINE CURETTAGE
(DampC)(DampC)
COMPLETE MISCARRIAGECOMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPEDVAGINAL BLEEDING HAS STOPPED
Products of ConceptoinProducts of Conceptoin
MISSED MISCARRIAGEMISSED MISCARRIAGE
OCCURS WITH RETENTION OF OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISEDOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND UTERINE INFETION OCCURS AND MAY LEAD TO SEPSISMAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE SPONTANEOUS OR ELECTIVE MISCARRIAGEMISCARRIAGE
LATE COURSE SEPTIC SHOCKLATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIALINFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS TRIPLE ANTIBIOTIC COVERAGE IS
REQUIREDREQUIRED GRAM (+) COVERAGE PENICILLIN GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORINAMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAMAMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLECLINDAMYCIN OR METRONIDAZOLE
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
COMPLETE MISCARRIAGECOMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPEDVAGINAL BLEEDING HAS STOPPED
Products of ConceptoinProducts of Conceptoin
MISSED MISCARRIAGEMISSED MISCARRIAGE
OCCURS WITH RETENTION OF OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISEDOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND UTERINE INFETION OCCURS AND MAY LEAD TO SEPSISMAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE SPONTANEOUS OR ELECTIVE MISCARRIAGEMISCARRIAGE
LATE COURSE SEPTIC SHOCKLATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIALINFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS TRIPLE ANTIBIOTIC COVERAGE IS
REQUIREDREQUIRED GRAM (+) COVERAGE PENICILLIN GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORINAMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAMAMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLECLINDAMYCIN OR METRONIDAZOLE
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
Products of ConceptoinProducts of Conceptoin
MISSED MISCARRIAGEMISSED MISCARRIAGE
OCCURS WITH RETENTION OF OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISEDOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND UTERINE INFETION OCCURS AND MAY LEAD TO SEPSISMAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE SPONTANEOUS OR ELECTIVE MISCARRIAGEMISCARRIAGE
LATE COURSE SEPTIC SHOCKLATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIALINFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS TRIPLE ANTIBIOTIC COVERAGE IS
REQUIREDREQUIRED GRAM (+) COVERAGE PENICILLIN GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORINAMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAMAMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLECLINDAMYCIN OR METRONIDAZOLE
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
MISSED MISCARRIAGEMISSED MISCARRIAGE
OCCURS WITH RETENTION OF OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISEDOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND UTERINE INFETION OCCURS AND MAY LEAD TO SEPSISMAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE SPONTANEOUS OR ELECTIVE MISCARRIAGEMISCARRIAGE
LATE COURSE SEPTIC SHOCKLATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIALINFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS TRIPLE ANTIBIOTIC COVERAGE IS
REQUIREDREQUIRED GRAM (+) COVERAGE PENICILLIN GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORINAMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAMAMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLECLINDAMYCIN OR METRONIDAZOLE
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND UTERINE INFETION OCCURS AND MAY LEAD TO SEPSISMAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE SPONTANEOUS OR ELECTIVE MISCARRIAGEMISCARRIAGE
LATE COURSE SEPTIC SHOCKLATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIALINFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS TRIPLE ANTIBIOTIC COVERAGE IS
REQUIREDREQUIRED GRAM (+) COVERAGE PENICILLIN GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORINAMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAMAMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLECLINDAMYCIN OR METRONIDAZOLE
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
SEPTIC MISCARRIAGESEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIALINFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS TRIPLE ANTIBIOTIC COVERAGE IS
REQUIREDREQUIRED GRAM (+) COVERAGE PENICILLIN GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORINAMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAMAMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLECLINDAMYCIN OR METRONIDAZOLE
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
Induced Abortion
More complicated the further along inpregnancy the procedure is done
Dilitation and Curettage until 12 weeks the Dilitation and Evacuation
1048715 Medical Rx possible until 9 weeks
RU-486 (mifepristone)Misoprostil MethotrexateMisoprostil
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
Induced Abortion Complications
Perforation of uterus Infection Hemorrhage
Septic Abortion -Sepsis shock hemorrhage
-Follows infected complete or incomplete AB
-More common before induced abortion was legalized
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN COMMON THEME IS SCARRED FALLOPIAN TUBETUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
Ectopic Pregnancy Risk Factors
GREATEST RISK GREATEST RISK
PREVIOUS EPPREVIOUS EP PREVIOUS TUBAL SURGERYPREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSUREDIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRINGDOCUMENTED TUBAL SCARRING IUD USEIUD USE
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
Ectopic Pregnancy Risk Factors
MODERATE RISKMODERATE RISK
-PREVIOUS PID-PREVIOUS PID
-IN VITRO FERTILIZATION-IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
Ectopic Pregnancy Risk Factors
LESS RISK LESS RISK
PREVIOUS PELVICABDOMINAL PREVIOUS PELVICABDOMINAL SURGERYSURGERY
CIGARETTE SMOKINGCIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ECTOPIC PREGNANCY -ECTOPIC PREGNANCY -PATHOPHYSIOLOGYPATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZEIS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKSRUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTUREUP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT UP TO 11 OF EP RUPTURED AT
BHCG lt100BHCG lt100
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ECTOPIC PREGNANCY - SITES ECTOPIC PREGNANCY - SITES OF IMPLANTATIONSOF IMPLANTATIONS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ECTOPIC PREGNANCYECTOPIC PREGNANCY
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLASSIC HX CLASSIC HX -UNILATERAL ABDOMINAL PAIN -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING-VAGINAL BLEEDING-AMENORRHEA-AMENORRHEA
-SYNCOPE +- BUThellip-SYNCOPE +- BUThellip
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN ECTOPIC PREGNANCY IN THEIR DIFFERENTIALTHEIR DIFFERENTIAL
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PHYSICAL FINDINGSPHYSICAL FINDINGS
Vaginal bleedingVaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 BHCG DOUBLES(66) EVERY 48 HOURS NORMALLYHOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATIONBEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ECTOPIC PREGNANCYECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABSDIAGNOSTIC MODALITIES ndash LABS
PROGESTERONEPROGESTERONE
-SINGLE LEVEL gt25 CORRELATES -SINGLE LEVEL gt25 CORRELATES TO A TO A VIABLE GESTATIONVIABLE GESTATION
-LEVELlt5 MAY INDICATE A -LEVELlt5 MAY INDICATE A NONVIABLE NONVIABLE GESTATIONGESTATION
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASOUNDULTRASOUNDSINGLE MOST VALUABLE SINGLE MOST VALUABLE
MODALITYMODALITY AVAILABLEAVAILABLE
-BHCG DISCRIMINATORY -BHCG DISCRIMINATORY THRESHOLD THRESHOLD FOR FOR
TVU 1500TVU 1500 FOR TAU 6500FOR TAU 6500
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SACGESTATIONAL SAC YOLK SACYOLK SAC EMBRYONIC POLEEMBRYONIC POLE FETAL CARDIAC ACTIVITYFETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ED ULTRASOUND ED ULTRASOUND
SHOULD BE EMPLOYED TO SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY WITH A BHCG gt THE DISCRIMINATORY THRESHOLDTHRESHOLD
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OTHER DIAGNOSTIC MODALITIESOTHER DIAGNOSTIC MODALITIESCURETTAGE IN PATIENT WITH AN ABNORMAL CURETTAGE IN PATIENT WITH AN ABNORMAL
REPEAT BHCG OR LOW PROGESTERONE REPEAT BHCG OR LOW PROGESTERONE ABSENCE OF VILLI INDICATES A HIGH ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EPSUSPICION OF EP
CULDOCENTESIS CAN BE ACCURATE IN UP CULDOCENTESIS CAN BE ACCURATE IN UP 90 OF RUPTURED EP90 OF RUPTURED EP
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
CULDOCENTESISCULDOCENTESIS
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ECTOPIC PREGNANCYECTOPIC PREGNANCY
PREVENTING MISDIAGNOSISPREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTICULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo studyED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGEMISCARRIAGE
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ECTOPIC PREGNANCYECTOPIC PREGNANCYTreatmentTreatment
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICEMETHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS CONTRAINDICATIONS
-OBVIOUS SIGNS OF RUPTURE-OBVIOUS SIGNS OF RUPTURE
-BHCG gt 2000-BHCG gt 2000
-SUSPECTED HETEROTOPIC -SUSPECTED HETEROTOPIC PREGNANCYPREGNANCY
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ECTOPIC PREGNANCY ECTOPIC PREGNANCY TreatmentTreatment
SURGICAL TREATMENT - MAINSTAY OF SURGICAL TREATMENT - MAINSTAY OF TREATMENTTREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMYLAPARTOMY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ECTOPIC PREGNANCYECTOPIC PREGNANCY
Prognosis for Subsequent Fertility
Overall subsequent pregnancy rate is60 other 40 are infertile
One-third of pregnancies after an ectopic pregnancy are another ectopic
pregnancy
one-sixth are spontaneous abortions
Only 33 of women with ectopic pregnancy will have a subsequent live birth
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 30000 pregnancies
Abdominal Pregnancy-can occur anywherein peritoneal cavity
Cervical Pregnancy (1 in 10000) May need hysterectomy
1048715 Ovarian Pregnancy (1 in 7000)
Oophorectomy usually required
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
TROPOBLASTIC DISORDERSTROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUETROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMACHORIOCARCINOMA
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
TROPHOBLASTIC TROPHOBLASTIC DISORDERSDISORDERS
VAGINAL BLEEDING SEVERE OR VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIADEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS LARGE FOR DATES UTERUS IS PALPATEDPALPATED
BHCG LEVELS ARE MUCH HIGHER BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCYTHAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquoPATTERNrdquo
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
Molar Pregnancy USMolar Pregnancy US
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
CaseCase 23 yo female w vag bleeding23 yo female w vag bleeding LMP 3 months ago(12 WBD)LMP 3 months ago(12 WBD) + suprapubic pain+ suprapubic pain Neg urine Preg tests x 3 over last 2 Neg urine Preg tests x 3 over last 2
weeks including negative at BOH 2 days weeks including negative at BOH 2 days prior to ED visitprior to ED visit
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
The ldquoHook EffectrdquoThe ldquoHook Effectrdquo
ExamExam
+ abd fullnessmass suprapubic area + abd fullnessmass suprapubic area with what appears to be gravid uteruswith what appears to be gravid uterus
Screening US + for ldquosnowyrdquo IU pictureScreening US + for ldquosnowyrdquo IU picture
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
Tze-Kiong ErTze-Kiong Er111 Yuh-Jyh Jong Yuh-Jyh Jong11 Eing-Mei TsaiEing-Mei Tsai221 Chi-Lin Huang Chi-Lin Huang11 Hui-Wen ChouHui-Wen Chou11 Bing-Hong Bing-Hong ZhengZheng11 and Li-Yu Tsai and Li-Yu Tsai13a13a
Clinical Chemistry 52 1616-1618 52 1616-1618 2006 2006 101373clinchem2006068056101373clinchem2006068056
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
False-Negative False-Negative Pregnancy Test in Pregnancy Test in Hydatidiform MoleHydatidiform Mole
According to the manufacturerrsquos information of the According to the manufacturerrsquos information of the BeckmanBeckman Access 2 analyzer a hook effect will occur when Access 2 analyzer a hook effect will occur when the serum szlig-hCGthe serum szlig-hCG concentration exceeds 1 000 000 IULconcentration exceeds 1 000 000 IUL
We diluted the urine sample to various concentrationsWe diluted the urine sample to various concentrations (12 (12 14 16 18 and 110 dilutions) and performed qualitative14 16 18 and 110 dilutions) and performed qualitative
analysis of urinary hCG on each (Table 1analysis of urinary hCG on each (Table 1 ) The results ) The results showedshowed no hook effect in the qualitative urine hCG test at no hook effect in the qualitative urine hCG test at 487 000487 000 IUL but a hook effect was evident at IUL but a hook effect was evident at concentrations of 609concentrations of 609 000 to 2 000 000 IUL There was 000 to 2 000 000 IUL There was complete signal eliminationcomplete signal elimination at a concentration of 4 000 000 at a concentration of 4 000 000 IULIUL
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
RHESUS FACTORRHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) ARE AT RISK FOR CARRYING A RH (+) CHILDCHILD
SENSITIZATION OCCURS AT 8 WEEKS OF SENSITIZATION OCCURS AT 8 WEEKS OF GESTATIONGESTATION
lt12 WEEKS OF GESTATION ADMINISTER lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCGRHOGAM 50 MCG
gt12 WEEKS OF GESTATIONgt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCGADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
Bleeding in First 20 weeks Bleeding in First 20 weeks EvaluationEvaluation
Hx (specific OB Hx) and Px (w pelvic Hx (specific OB Hx) and Px (w pelvic exam) VITALSexam) VITALS
IVIV May need 2 large bore IV if hypotensive etcMay need 2 large bore IV if hypotensive etc
LabsLabs BHCG quantBHCG quant Type and RhType and Rh CBC +-CBC +- Coags +- Type and CrossCoags +- Type and Cross UAUA
Rad Pelvic USRad Pelvic US
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
BLEEDING AND SECOND 20 BLEEDING AND SECOND 20 WEEKS OF GESTATIONWEEKS OF GESTATION
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PLACENTA PREVIAPLACENTA PREVIA
VASA PREVIAVASA PREVIA
UTERINE RUPTUREUTERINE RUPTURE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PREMATURE SEPARATION OF PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTAABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISEINTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY MOST COMMONLY OCCURS SHORTLY BEFORE LABORBEFORE LABOR
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ABRUPTIO PLACENTAABRUPTIO PLACENTA
PATHOPHYSIOLOGY PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUATHE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE MAY BE CONCEALED ENTIRELY INSIDE THE UTERUSTHE UTERUS
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ABRUPTIO PLACENTAABRUPTIO PLACENTA RISK FACTORSRISK FACTORS
MATERNAL HYPERTENSIONMATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIAECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTIONHISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTIONUTERINE DISTENTION VASCUALR DISEASEVASCUALR DISEASE TOBACCO SMOKINGTOBACCO SMOKING COCAINE USECOCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIAMICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANEPREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMABLUNT UTERINE TRAUMA SHORT UMBILICAL CORDSHORT UMBILICAL CORD
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ABRUPTIO PLACENTAABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDINGPAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMALNORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWEREDFIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMONFIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ABRUPTIO PLACENTAABRUPTIO PLACENTA
DIAGNOSIS IS CLINICALDIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONSTOWARDS THE COMPLICATIONS DIC WORK UP INCLUDING DIC WORK UP INCLUDING
FIBRINOGEN LEVELS CORRELATE FIBRINOGEN LEVELS CORRELATE WITH SEVERITY OF DISEASEWITH SEVERITY OF DISEASE
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ABRUPTIO PLACENTAABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONSOF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL RETORPLACENTAL OR PRELACENTAL HEMATOMASHEMATOMAS
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
ABRUPTIO PLACENTAABRUPTIO PLACENTA TREATMENTTREATMENT
2 LARGE BORE IV2 LARGE BORE IV CARDIAC MONITORINGCARDIAC MONITORING FETAL MONITORINGFETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOODTYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATESHEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATIONOBSTETRICAL CONSULTATION RHOGAM IF NECESSARYRHOGAM IF NECESSARY
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
PLACENTA PREVIAPLACENTA PREVIA
IMPROPER IMPLANTATION OF IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE IMPAIRING THE DESCENT OF THE FETUSFETUS
HEMORRHAGE OCCURS WITH HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA SEPARATION OF THE PLACENTA FROM THE UTERUSFROM THE UTERUS
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
PLACENTA PREVIAPLACENTA PREVIA
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
PLACENTA PREVIAPLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS)RISK FACTORS(SCARRED UTERUS) MULTIPARITYMULTIPARITY PRIOR C-SECTIONPRIOR C-SECTION PRIOR PLACENTA PREVIAPRIOR PLACENTA PREVIA MULTIPLE GESTATIONSMULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGEPRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
PLACENTA PREVIAPLACENTA PREVIA
CLINICAL PRESENTATIONCLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO PAINLESS VAGINAL BLEEDING (UP TO
70)70) DEFER ALL VAGINAL EXAM UNTIL DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETEDULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
PLACENTA PREVIAPLACENTA PREVIA
IMAGING STUDIESIMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELYADDRESSED AGGRESIVELY
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
PLACENTA PREVIAPLACENTA PREVIA
TREATMENTTREATMENT
PREFFERED METHOD OF MANAGEMENT PREFFERED METHOD OF MANAGEMENT IS IS C-SECTIONC-SECTION
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
VASA PREVIAVASA PREVIA
UMBILICAL CORD TRAVELS ACROSS UMBILICAL CORD TRAVELS ACROSS THE CERVIX AND RESULTS IN THE CERVIX AND RESULTS IN BLEEDING WHEN THE PRESENTING BLEEDING WHEN THE PRESENTING FETAL ANATOMY DESCENDSFETAL ANATOMY DESCENDS
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
VASA PREVIAVASA PREVIA
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
VASA PREVIAVASA PREVIA
THE MOTHER IS NOT IN ANY THE MOTHER IS NOT IN ANY PHYSICAL DANGERPHYSICAL DANGER
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
VASA PREVIAVASA PREVIA
FETAL BLOOD VOLUME IS SMALL (-500 CC) FETAL BLOOD VOLUME IS SMALL (-500 CC) AND SMALL AMOUNT OF VAGINAL AND SMALL AMOUNT OF VAGINAL BLEEDING MAY INDICATE FETAL BLEEDING MAY INDICATE FETAL EXSANGUINATIONEXSANGUINATION
CONSIDER THE DIAGNOSIS IF SMALL CONSIDER THE DIAGNOSIS IF SMALL AMOUNT OF BLEEDING IS COUPLED WITH AMOUNT OF BLEEDING IS COUPLED WITH ABSENCE OF MATERNAL SYMPTOMS AND ABSENCE OF MATERNAL SYMPTOMS AND FETAL DISTRESS PATTERNSFETAL DISTRESS PATTERNS
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
VASA PREVIAVASA PREVIA
TREATMENT IS EMERGENT TREATMENT IS EMERGENT
C-SECTIONC-SECTION
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
UTERINE RUPTUREUTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABORDURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY` UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE EMERGENCT C-SECTION IS THE TREATMENTTREATMENT
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
BLEEDING IN PREGNANCY BLEEDING IN PREGNANCY
QuestionsQuestions
