VAGINAL BLEEDING IN PREGNANCY
Dr Sattam AleneziED Consultant
VAGINAL BLEEDING DURING PREGNANCY
1 DURING PREGNANCY
-FIRST 20 WEEKS
-SECOND 20 WEEKS
PREGNANCY AND VAGINAL BLEEDING
By the Numbers
40 EXPERIENCE BLEEDING IN THE COURSE OF PREGNANCY
Up to 20 OF PREGNANCIES TERMINATE IN MISCARRIAGE
2 OF PREGNANCIES ARE ECTOPIC 9-13 OF FIRST TRIMESTER MATERNAL
DEATHS ARE DUE TO ECTOPIC PREGNANCIES
BLEEDING AND THE FIRST 20 WEEKS
Three primary causes
ABORTION
ECTOPIC PREGNANCY (EP)
TROPHOBLASTIC DISORDERS
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
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
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
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)
Septic Abortion uterine infection during any stage of
abortion
Missed Abortion Embryo larger than 5 mm without
cardiac activity
THREATENED MISCARRIAGE
UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATION
ULTRASOUND MAY DETECT AN IUP INDETERMINATE OR EMPTY UTERUS CORRELATE WITH BHCG TO RULE OUT EP
THREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - Treatment
SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT
THREATENED MISCARRIAGE
DISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB FOLLOW UP
SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED SIMILARLY
INEVITABLE INCOMPLETEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN IMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE OF TISSUE
INEVITABLE INCOMPLETEMISCARRIAGE
TREATMENT OF CHOICE UTERINE CURETTAGE
(DampC)
COMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED
Products of Conceptoin
MISSED MISCARRIAGE
OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE
LATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS
REQUIRED GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLE
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
VAGINAL BLEEDING DURING PREGNANCY
1 DURING PREGNANCY
-FIRST 20 WEEKS
-SECOND 20 WEEKS
PREGNANCY AND VAGINAL BLEEDING
By the Numbers
40 EXPERIENCE BLEEDING IN THE COURSE OF PREGNANCY
Up to 20 OF PREGNANCIES TERMINATE IN MISCARRIAGE
2 OF PREGNANCIES ARE ECTOPIC 9-13 OF FIRST TRIMESTER MATERNAL
DEATHS ARE DUE TO ECTOPIC PREGNANCIES
BLEEDING AND THE FIRST 20 WEEKS
Three primary causes
ABORTION
ECTOPIC PREGNANCY (EP)
TROPHOBLASTIC DISORDERS
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
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
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
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)
Septic Abortion uterine infection during any stage of
abortion
Missed Abortion Embryo larger than 5 mm without
cardiac activity
THREATENED MISCARRIAGE
UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATION
ULTRASOUND MAY DETECT AN IUP INDETERMINATE OR EMPTY UTERUS CORRELATE WITH BHCG TO RULE OUT EP
THREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - Treatment
SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT
THREATENED MISCARRIAGE
DISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB FOLLOW UP
SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED SIMILARLY
INEVITABLE INCOMPLETEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN IMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE OF TISSUE
INEVITABLE INCOMPLETEMISCARRIAGE
TREATMENT OF CHOICE UTERINE CURETTAGE
(DampC)
COMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED
Products of Conceptoin
MISSED MISCARRIAGE
OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE
LATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS
REQUIRED GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLE
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
PREGNANCY AND VAGINAL BLEEDING
By the Numbers
40 EXPERIENCE BLEEDING IN THE COURSE OF PREGNANCY
Up to 20 OF PREGNANCIES TERMINATE IN MISCARRIAGE
2 OF PREGNANCIES ARE ECTOPIC 9-13 OF FIRST TRIMESTER MATERNAL
DEATHS ARE DUE TO ECTOPIC PREGNANCIES
BLEEDING AND THE FIRST 20 WEEKS
Three primary causes
ABORTION
ECTOPIC PREGNANCY (EP)
TROPHOBLASTIC DISORDERS
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
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
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
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)
Septic Abortion uterine infection during any stage of
abortion
Missed Abortion Embryo larger than 5 mm without
cardiac activity
THREATENED MISCARRIAGE
UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATION
ULTRASOUND MAY DETECT AN IUP INDETERMINATE OR EMPTY UTERUS CORRELATE WITH BHCG TO RULE OUT EP
THREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - Treatment
SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT
THREATENED MISCARRIAGE
DISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB FOLLOW UP
SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED SIMILARLY
INEVITABLE INCOMPLETEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN IMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE OF TISSUE
INEVITABLE INCOMPLETEMISCARRIAGE
TREATMENT OF CHOICE UTERINE CURETTAGE
(DampC)
COMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED
Products of Conceptoin
MISSED MISCARRIAGE
OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE
LATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS
REQUIRED GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLE
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
BLEEDING AND THE FIRST 20 WEEKS
Three primary causes
ABORTION
ECTOPIC PREGNANCY (EP)
TROPHOBLASTIC DISORDERS
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
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
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
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)
Septic Abortion uterine infection during any stage of
abortion
Missed Abortion Embryo larger than 5 mm without
cardiac activity
THREATENED MISCARRIAGE
UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATION
ULTRASOUND MAY DETECT AN IUP INDETERMINATE OR EMPTY UTERUS CORRELATE WITH BHCG TO RULE OUT EP
THREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - Treatment
SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT
THREATENED MISCARRIAGE
DISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB FOLLOW UP
SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED SIMILARLY
INEVITABLE INCOMPLETEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN IMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE OF TISSUE
INEVITABLE INCOMPLETEMISCARRIAGE
TREATMENT OF CHOICE UTERINE CURETTAGE
(DampC)
COMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED
Products of Conceptoin
MISSED MISCARRIAGE
OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE
LATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS
REQUIRED GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLE
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
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
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
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
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)
Septic Abortion uterine infection during any stage of
abortion
Missed Abortion Embryo larger than 5 mm without
cardiac activity
THREATENED MISCARRIAGE
UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATION
ULTRASOUND MAY DETECT AN IUP INDETERMINATE OR EMPTY UTERUS CORRELATE WITH BHCG TO RULE OUT EP
THREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - Treatment
SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT
THREATENED MISCARRIAGE
DISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB FOLLOW UP
SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED SIMILARLY
INEVITABLE INCOMPLETEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN IMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE OF TISSUE
INEVITABLE INCOMPLETEMISCARRIAGE
TREATMENT OF CHOICE UTERINE CURETTAGE
(DampC)
COMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED
Products of Conceptoin
MISSED MISCARRIAGE
OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE
LATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS
REQUIRED GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLE
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
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
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
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)
Septic Abortion uterine infection during any stage of
abortion
Missed Abortion Embryo larger than 5 mm without
cardiac activity
THREATENED MISCARRIAGE
UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATION
ULTRASOUND MAY DETECT AN IUP INDETERMINATE OR EMPTY UTERUS CORRELATE WITH BHCG TO RULE OUT EP
THREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - Treatment
SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT
THREATENED MISCARRIAGE
DISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB FOLLOW UP
SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED SIMILARLY
INEVITABLE INCOMPLETEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN IMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE OF TISSUE
INEVITABLE INCOMPLETEMISCARRIAGE
TREATMENT OF CHOICE UTERINE CURETTAGE
(DampC)
COMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED
Products of Conceptoin
MISSED MISCARRIAGE
OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE
LATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS
REQUIRED GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLE
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
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
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)
Septic Abortion uterine infection during any stage of
abortion
Missed Abortion Embryo larger than 5 mm without
cardiac activity
THREATENED MISCARRIAGE
UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATION
ULTRASOUND MAY DETECT AN IUP INDETERMINATE OR EMPTY UTERUS CORRELATE WITH BHCG TO RULE OUT EP
THREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - Treatment
SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT
THREATENED MISCARRIAGE
DISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB FOLLOW UP
SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED SIMILARLY
INEVITABLE INCOMPLETEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN IMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE OF TISSUE
INEVITABLE INCOMPLETEMISCARRIAGE
TREATMENT OF CHOICE UTERINE CURETTAGE
(DampC)
COMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED
Products of Conceptoin
MISSED MISCARRIAGE
OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE
LATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS
REQUIRED GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLE
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
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)
Septic Abortion uterine infection during any stage of
abortion
Missed Abortion Embryo larger than 5 mm without
cardiac activity
THREATENED MISCARRIAGE
UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATION
ULTRASOUND MAY DETECT AN IUP INDETERMINATE OR EMPTY UTERUS CORRELATE WITH BHCG TO RULE OUT EP
THREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - Treatment
SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT
THREATENED MISCARRIAGE
DISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB FOLLOW UP
SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED SIMILARLY
INEVITABLE INCOMPLETEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN IMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE OF TISSUE
INEVITABLE INCOMPLETEMISCARRIAGE
TREATMENT OF CHOICE UTERINE CURETTAGE
(DampC)
COMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED
Products of Conceptoin
MISSED MISCARRIAGE
OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE
LATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS
REQUIRED GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLE
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
Septic Abortion uterine infection during any stage of
abortion
Missed Abortion Embryo larger than 5 mm without
cardiac activity
THREATENED MISCARRIAGE
UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATION
ULTRASOUND MAY DETECT AN IUP INDETERMINATE OR EMPTY UTERUS CORRELATE WITH BHCG TO RULE OUT EP
THREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - Treatment
SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT
THREATENED MISCARRIAGE
DISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB FOLLOW UP
SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED SIMILARLY
INEVITABLE INCOMPLETEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN IMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE OF TISSUE
INEVITABLE INCOMPLETEMISCARRIAGE
TREATMENT OF CHOICE UTERINE CURETTAGE
(DampC)
COMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED
Products of Conceptoin
MISSED MISCARRIAGE
OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE
LATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS
REQUIRED GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLE
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
THREATENED MISCARRIAGE
UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATION
ULTRASOUND MAY DETECT AN IUP INDETERMINATE OR EMPTY UTERUS CORRELATE WITH BHCG TO RULE OUT EP
THREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - Treatment
SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT
THREATENED MISCARRIAGE
DISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB FOLLOW UP
SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED SIMILARLY
INEVITABLE INCOMPLETEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN IMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE OF TISSUE
INEVITABLE INCOMPLETEMISCARRIAGE
TREATMENT OF CHOICE UTERINE CURETTAGE
(DampC)
COMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED
Products of Conceptoin
MISSED MISCARRIAGE
OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE
LATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS
REQUIRED GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLE
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
THREATENED MISCARRIAGE
THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - Treatment
SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT
THREATENED MISCARRIAGE
DISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB FOLLOW UP
SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED SIMILARLY
INEVITABLE INCOMPLETEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN IMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE OF TISSUE
INEVITABLE INCOMPLETEMISCARRIAGE
TREATMENT OF CHOICE UTERINE CURETTAGE
(DampC)
COMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED
Products of Conceptoin
MISSED MISCARRIAGE
OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE
LATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS
REQUIRED GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLE
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
THREATENED MISCARRIAGE - Treatment
SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT
THREATENED MISCARRIAGE
DISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB FOLLOW UP
SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED SIMILARLY
INEVITABLE INCOMPLETEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN IMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE OF TISSUE
INEVITABLE INCOMPLETEMISCARRIAGE
TREATMENT OF CHOICE UTERINE CURETTAGE
(DampC)
COMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED
Products of Conceptoin
MISSED MISCARRIAGE
OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE
LATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS
REQUIRED GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLE
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
THREATENED MISCARRIAGE
DISCHARGE HOME IS SAFE
MUST INCLUDE MANDATORY OB FOLLOW UP
SERIAL BHCG IN 48 HRS
INEVITABLE INCOMPLETEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED SIMILARLY
INEVITABLE INCOMPLETEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN IMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE OF TISSUE
INEVITABLE INCOMPLETEMISCARRIAGE
TREATMENT OF CHOICE UTERINE CURETTAGE
(DampC)
COMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED
Products of Conceptoin
MISSED MISCARRIAGE
OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE
LATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS
REQUIRED GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLE
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
INEVITABLE INCOMPLETEMISCARRIAGE
BOTH HAVE EARLY PREGNANCY LOSS
BOTH PRESENT AND ARE TREATED SIMILARLY
INEVITABLE INCOMPLETEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN IMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE OF TISSUE
INEVITABLE INCOMPLETEMISCARRIAGE
TREATMENT OF CHOICE UTERINE CURETTAGE
(DampC)
COMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED
Products of Conceptoin
MISSED MISCARRIAGE
OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE
LATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS
REQUIRED GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLE
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
INEVITABLE INCOMPLETEMISCARRIAGE
INEVITABLE VAGINAL BLEEDING OR PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL DILATION OPEN CERVIX IS AN IMPORTANT FINDING
INCOMPLETE INCOMPLETE PASSAGE OF TISSUE
INEVITABLE INCOMPLETEMISCARRIAGE
TREATMENT OF CHOICE UTERINE CURETTAGE
(DampC)
COMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED
Products of Conceptoin
MISSED MISCARRIAGE
OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE
LATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS
REQUIRED GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLE
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
INEVITABLE INCOMPLETEMISCARRIAGE
TREATMENT OF CHOICE UTERINE CURETTAGE
(DampC)
COMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED
Products of Conceptoin
MISSED MISCARRIAGE
OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE
LATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS
REQUIRED GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLE
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
COMPLETE MISCARRIAGE
OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED
Products of Conceptoin
MISSED MISCARRIAGE
OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE
LATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS
REQUIRED GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLE
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
Products of Conceptoin
MISSED MISCARRIAGE
OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE
LATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS
REQUIRED GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLE
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
MISSED MISCARRIAGE
OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE
LATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS
REQUIRED GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLE
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
SEPTIC MISCARRIAGE
UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS
OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE
LATE COURSE SEPTIC SHOCK
SEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS
REQUIRED GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLE
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
SEPTIC MISCARRIAGE
INFECTION IS POLYMICROBIAL TRIPLE ANTIBIOTIC COVERAGE IS
REQUIRED GRAM (+) COVERAGE PENICILLIN
AMPICILILN OR CEPHALOSPORIN
GRAM (-) AREOBIC COVERAGE AMINOGLYCOSIDE OR AZTREONAM
GRAM(-) ANAEROBIC COVERAGE CLINDAMYCIN OR METRONIDAZOLE
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
Ectopic Pregnancy
Pregnancy anywhere outside uterine cavity Fallopian tube most common location
Second leading cause of maternal mortality
COMMON THEME IS SCARRED FALLOPIAN TUBE
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
Ectopic Pregnancy Risk Factors
GREATEST RISK
PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
Ectopic Pregnancy Risk Factors
MODERATE RISK
-PREVIOUS PID -IN VITRO FERTILIZATION
-MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
Ectopic Pregnancy Risk Factors
LESS RISK
PREVIOUS PELVICABDOMINAL SURGERY
CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ECTOPIC PREGNANCY
MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS
UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT
BHCG lt100
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ECTOPIC PREGNANCY
CLINICAL PRESENTATION
CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA
-SYNCOPE +- ( SHOCK)
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ECTOPIC PREGNANCY
ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ECTOPIC PREGNANCY
PHYSICAL FINDINGS
Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one
sided adnexa Uterus-normal size Peritoneal Signs
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66) EVERY 48 HOURS NORMALLY
IN EP BHCG LEVELS FALL PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ECTOPIC PREGNANCY
DIAGNOSTIC MODALITIES ndash LABS
PROGESTERONE
-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION
-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ECTOPIC PREGNANCY
ULTRASOUNDSINGLE MOST VALUABLE
MODALITY AVAILABLE
-BHCG DISCRIMINATORY THRESHOLD FOR
TVU 1500 FOR TAU 5000
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ECTOPIC PREGNANCY
ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ECTOPIC PREGNANCY
ED ULTRASOUND
SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ED ULTRASOUND
Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ECTOPIC PREGNANCY
PREVENTING MISDIAGNOSIS EP CAN RUPTURE AT BHCG AS LOW AS 100 UP TO 40 OF EP WERE MISDIAGNOSED AT
1ST ED VISIT ABOUT 50 OF TRANSABDOMINAL
ULTRASOUND WERE NONDIAGNOSTIC ED US ndash If non diagnostic ndash need ldquoofficialrdquo study
PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ECTOPIC PREGNANCYTreatment
MEDICAL MANAGEMENT
METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity
compliant patient
CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC
PREGNANCY
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ECTOPIC PREGNANCY Treatment
SURGICAL TREATMENT - MAINSTAY OF TREATMENT
Laparoscopy Salpingostomy Salpingectomy
Laparotomy
LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
Ectopic Pregnancy-Unusual Variants
Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies
More in women on fertility drugs
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
TROPOBLASTIC DISORDERS
ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
TROPHOBLASTIC DISORDERS
VAGINAL BLEEDING SEVERE OR PERSISTENT HYPERMESIS EARLY DEVELPOMENT OF PREECLAMPSIA
LARGE FOR DATES UTERUS IS PALPATED
BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
ULTRASOUND WILL SHOW A ldquoSNOWY PATTERNrdquo
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
Molar Pregnancy US
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
RHESUS FACTOR
UP TO 15 OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG
gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
Bleeding in First 20 weeks Evaluation
Hx (specific OB Hx) and Px (w pelvic exam) VITALS
IV May need 2 large bore IV if hypotensive
etc Labs
BHCG quant Type and Rh CBC +- Coags +- Type and Cross UA
Rad Pelvic US
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
BLEEDING AND SECOND 20 WEEKS OF GESTATION
ABRUPTIO PLACENTA
PLACENTA PREVIA
UTERINE RUPTURE
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
Abrutio Placentae
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ABRUPTIO PLACENTA
PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ABRUPTIO PLACENTA
PATHOPHYSIOLOGY
ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ABRUPTIO PLACENTA RISK FACTORS
MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA HISTORY OF PREVIOUS ABRUPTION UTERINE DISTENTION VASCUALR DISEASE TOBACCO SMOKING COCAINE USE MICROANGIOPATHIC HEMOLYTIC ANEMIA PREMATURE RUPTURE OF MEMBRANE BLUNT UTERINE TRAUMA SHORT UMBILICAL CORD
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ABRUPTIO PLACENTA PAINFUL VAGINAL BLEEDING
GRADE I SLIGHT OR MINIMAL BLEEDING LIMITED UTERINE IRRITABILITY NORMAL BP FHT ARE NORMAL FIBRINOGEN IS NORMAL
GRADE II EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD) UTERINE IRRITABILITY COMPROMISED FHT PATTERNS FIBRINOGEN IS LOWERED
GRADE III BLEEDING IS MODERATE TO SEVER HEMODYNAMIC INSTABILITY REDUCED FIBRINOGEN LEVEL FETAL DEATH IS COMMON
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ABRUPTIO PLACENTA
DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED
TOWARDS THE COMPLICATIONS
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ABRUPTIO PLACENTA
ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS
ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
ABRUPTIO PLACENTA TREATMENT
2 LARGE BORE IV CARDIAC MONITORING FETAL MONITORING TYPE AND CROSS 2-4 UNITS OF BLOOD COAGULATION PROFILE CBC PT PTT
FIBRINOGEN D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
OBSTETRICAL CONSULTATION RHOGAM IF NECESSARY
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
Placenta Previa
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
PLACENTA PREVIA
IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
PLACENTA PREVIA
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
PLACENTA PREVIA
RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
PLACENTA PREVIA
CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO
70) DEFER ALL VAGINAL EXAM UNTIL
ULTRASONOGRAPY IS COMPLETED
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
PLACENTA PREVIA
IMAGING STUDIES TRANSABDOMINAL ULTRASOUND IS THE
MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93
EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
PLACENTA PREVIA
TREATMENT No PV exam at ED OBGY consultation
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
Postpartum hemorrhage
Early within 24hrs from delivery
Late up to 1-2 weeks PP
More 500 cc blood loss after PVD
More 1000cc blood loss after CS
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
CAUSES
Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
UTERINE RUPTURE
SUDDEN DETERIORATION IN VITAL SIGNS
DURING LABOR RISK FACTORS INCLUDE PREVIOIUS C-
SECTIO FIBROIDREMOVAL PLACENTAL ABRUPTION BLUNT ABDOMINAL TRAUMA UTERINE PAIN OR IRRITABILITY`
EMERGENCT C-SECTION IS THE TREATMENT
Late Endometritis RPOC
Late Endometritis RPOC