Ob 4

Front 1

What is "implantation bleeding?"

Back 1

Implantation bleeding is vaginal discharge which usually contains a small amount of pinkish or brownish blood.
- Only about a third of pregnant women experience implantation
- Painless bleeding
- Typically 6-12 days post ovulation
Rx:
- Restrict heavy activity
- Avoid sex
- Modified bedrest to increase the chances of a better implantation.

Front 2

What is placental implantation?

Back 2

- Vaginal spotting, 6-12 wks after ovulation, lighter, cramps, light backache, bloating
- Trophoblast tissue is highly specialized, forms from fertilized egg & surrounds egg
- Placenta makes contact with maternal circulation, small amounts of blood may leak

Front 3

First trimester bleeding:

Back 3

- Clinical evaluation of women with first trimester bleeding involves looking for evidence of other conditions such as:

- Infection (Cervicitis), polyps, cervical/vaginal trauma
-Vaginal candidiasis, Bacterial vaginitis, GC, Chlamydia
- Threatened abortion
- Inevitable abortion
- Incomplete abortion
- Ectopic pregnancy
- Gestational trophoblastic disease (molar pregnancy)

Front 4

Why is cervicitis common in pregnancy?

Back 4

With the hormonal changes of pregnancy, the fragile internal cells peek out a bit onto the external portion of the cervix, which is a harsher environment for them. Normally nestled more deeply away from sexual activity, now they can be battered. They're easily damaged, causing bleeding

Front 5

What is spontaneous abortion?

Back 5

- Termination of pregnancy
- Expulsion of an immature, nonviable fetus
- < 20 weeks gestation
- < 500 gm
- Occurs in 15% of all pregnancies
- Many women abort, nonclinical recognition
- Usually occurs during the first 12 weeks of pregnancy.

Front 6

What is the most common etiology for spontaneous abortion?

Back 6

- Chromosome abnormalities incompatible w/ life

- Trisomy (especially 18 and 13) are the most common.

Front 7

What is a threatened abortion?

Back 7

- Bleeding first 20 wks w/o Rupture Of Membrane or tissue.
- Cramping, low abdominal pain
- 25 % of pregnancies
- Sxs: N/V, fatigue, breast tenderness, urinary frequency
- PE: blood from cervical os w/o amniotic fluid or tissue
- Internal os closed
- Uterus soft, enlarged appropriate for gestational age

Front 8

What is a complete abortion?

Back 8

- All products of conception (fetal tissue & placenta) passed through cervix.
- Expected outcome for a pregnancy not viable from outset.
- Often, a fetus never forms (blighted ovum). The bleeding and cramping steadily increases, leading up to an hour or two of fairly intense cramps. Then the pregnancy tissue is passed into the vagina.
- Women seeking another pregnancy
- Wait 1-2 mo’s, re-establish a normal uterine lining.

Front 9

What is the medical treatment in someone who has had a complete abortion?

Back 9

Uterotonic drug (such a Methergine 0.2 mg PO TID x 2 days)
- Minimize bleeding
- Encourage expelling of any remaining fragments of tissue
- Doxycycline or Amoxicillin
- Vaginal rest (no tampons, douches, intercourse)
- Analgesics
- RhoGAM if Rh-
- B hCG levels until zero, incomplete Ab if levels fail to reach zero w/in 4 wks

Febrile, uterus tender
- Septic Abortion: IV broad-spectrum antibiotics, D&C to remove any POC

Front 10

What is an incomplete abortion?

Back 10

- Retained Products Of Conception
- Cramping, continued bleeding, passage of tissue, dilated os w/tissue in vagina or endocx canal
- Profuse bleeding, orthostatic dizziness, syncope, orthostatic BP
- Ultrasound may reveal the presence of identifiable tissue within the uterus.
- Serial quantitative HCG levels can be measured if there is doubt about the completeness of a miscarriage

Front 11

What is the treatment of Incomplete abortions?

Back 11

Rh typing, RhoGAM if -
Blood typing and cross-matching
Karyotyping of POC if loss is recurrent.
CBC post curettage
Re-assess VS, if stable, discharge:
Vaginal rest (no coitus, douching, tampons)

Front 12

What is a missed abortion?

Back 12

- POC retained after fetal demise
- Results in severe coagulopathy with bleeding
- Signs: pregnant uterus fails to grow as expected, or, FHT disappear
- Amenorrhea may persist, intermittent vaginal bleeding, spotting, or brown discharge
- Ultrasonography confirms diagnosis
- Management:
- CBC w/plt, fibrinogen, PTT, ABO blood typing, Ab screen
- Evacuation of uterus is completed after fetal death confirmed (D&C vs medical therapy with Misoprostol)
- RhoGAM if unsensitized (-)

Front 13

What is the treatment of septic abortion?

Back 13

- Bedrest, IV antibiotics, uterotonic agents, and complete evacuation of the uterus.
- Evacuation of the uterus can be initiated with oxytoxin, 20 units (1 amp) in 1 Liter of any crystalloid IV fluid at 125 cc/hour or ergonovine 0.2 mg P.O. or IM three times daily. If the patient response: D&C

Options of pharmacotherapy include:
- Ampicillin 2 gm IV Q6 hours, plus
- Gentamicin 1-1.5 mg/kg IV Q8 hours, plus
- Clindamycin 900 mg IV Q8 hours
- Flagyl 1 gm IV loading dose, then 500 gm IV maintenance dose

Front 14

Spontaneous Abortion summary:

Back 14

- The cardinal clinical sign of SAB is vaginal bleeding. Bleeding in the first trimester may be light, heavy, intermittent, or constant and it may be painless or painful.

- The four major causes of bleeding early in pregnancy are:
- Physiologic (ie, believed to be related to implantation)
- Ectopic pregnancy
- Impending miscarriage
- Cervical, vaginal, or uterine pathology

Front 15

What are some risk factors for ectopic pregnancy?

Back 15

- PID or history of genital infections
- previous ectopic pregnancy
- Hx of tubal surgery and conception after tubal ligation
- use of fertility drugs or assissted reproductive technology
- use of IUD
- increasing age
- smoking

Front 16

How does ectopic pregnancy usually present?

Back 16

- Classic clinical triad of ectopic pregnancy is abdominal pain, amenorrhea, and vaginal bleeding. Unfortunately, only 50% of patients present typically.

- Other complaints:
Nausea, breast fullness, fatigue, low abdominal pain, heavy cramping, shoulder pain, and recent dyspareunia
- Abdominal pain, 80-100%
- Amenorrhea, 75-95%
- Vaginal bleeding, 50-80%
- Dizziness, fainting, 20-35%
- Urge to defecate, 5-15%
- Pregnancy sxs, 10-25%
- Passage of tissue, 5-10%

Front 17

What is the treatment for ectopic pregnancy?

Back 17

- medical therapy: MTX
- Rhogam if indicated
- operative management: Laparoscopy or laparotomy

Front 18

What is an incompetent cervix and how is it treated?

Back 18

In pregnancy, cervix is softer and weaker than normal, and as a result, might open prematurely during pregnancy.
Dx: Ultrasound, most often, not discovered until a woman has lost a pregnancy, usually in her second or third trimester. "It is estimated that incompetent cervix is responsible for 25 percent of all second trimester miscarriages .
Treatment:
- Cerclage (stitching the cervix closed) can be performed prophylactically at approximately 14-16 weeks

- can't have cerclage if:
- Hyperirritability of the cervix
- Your baby has already died
- You are more than 4 cm dilated
- Your water is broken