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25 Cards in this Set
- Front
- Back
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Semen/Sperm death inside female tract, Attrition Rate, Vaginal Resistance
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Gels immediately after ejactulation, liquefies about half an hour later
Alkaline pH Most sperm die within 2 hrs in vagina, few remaining swim to cervix and gain access to mucus Push through (need to be a certain shape head) and can be "stored" in mucus for up to 72 hours Attrition Rate - 300 million sperm in ejaculate, 1,000 to egg. Vaginal Resistance - muscle contractions during orgasm expel semen, acidity of vagina kills, enzymes in vaginal walls digest sperm |
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Oocye cumulus cells and zona pellucida role
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Cumulus cells - around egg and help ovum attach to uterus
Zona pellucida - contains ligands to help prevent polyspermy |
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Oocyte movement after ovulation
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sticks on top of ovary, fimbrae pull egg into uterine tube. Takes about 2 minutes to get egg to ampulla
fertilization usually occurs in ampulla or isthmus of ovarian tubes |
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ZP3, ZP2, Zona reaction
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ZP3 - most numerous ligands, attract sperm with chemotactic response, help attach sperm and start acrosomal reaction (cortical granules released from egg to allow fusion, membranes fuse to allow nuclear content exchange)
ZP 2 - helps form a hard matrix around egg. Internalizes one sperm and then all receptors disappear Zona reaction - disapearance of ZP2 receptors when one sperm has been internalized |
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Fertilization Timeframe
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Lifespan of egg is 12-24 hours, Sperm last 48-72 hours. Make contact in ampulla
After fertilization, egg stays in ovarian tube for 3-4 days as prostaglandins and progesterone reach high levels to prep uterus for implantation Day 0 - fertilization Day 1-2 - first cleavage Day 4 - zygote in ovarian tube Day 6 - enters uterus Day 7 - begin implantation in uterine wall, placenta formation Day 8 - can have implantation bleed during formation of placenta with slight "spotting) |
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BhCG, levels and role
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Beta Human Chorionic Gonadotropin - made by placenta during pregnancy
hCG doubles every 48 hrs till reaches 10,000 IU/L after implantation Can be used to serologically detect pregnancy. 1000-1500 IU/L on vaginal US means gestational sac, 5000 IU/L see fetal cardiac activity |
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Ultrasonography use at 4 weeks, 5 weeks, 6 weeks
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4 weeks - empty sac = gestational sac, DOES NOT confirm intrauterine pregnancy and can be pseudosac of ectopic pregnancy
5 weeks - yolk sac = bubble; fetal pole and placenta, CONFIRMS intrauterine pregnancy 6 weeks - yolk sac begins disappearing, and there is a little dot which is fetal pole At 8 weeks yolk sac completely regresses to become amnion, chorion and placenta |
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Miscarriage presentation
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HEAVY, painful bleeding, passing tissue
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Pt presenting with vaginal spotting, positive pregnancy test evaluation, H&P, DDx, Imaging, Labs
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History - menstrual history (last period), type of contraception, sexual, OB and STD history, PSH related to tubes, type of bleeding, what is passed, cramping and pain
Physical - cervical dilation or lesions, uterine size in bimanual exam DDx for spotting without menses and positive pregnancy test - abortion, ectopic pregnancy, cervicitis, cervical neoplasm, gestational trophoblastic diseas Imaging - US Labs - BhCG, type and screen (Rh status to determine Rhogam need) , wet prep for any discharge |
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Uterine size in bimanual exam
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Normal (nulliparous) = size of plum
Small female fist - 4-6 weeks gestation Small grapefruit - 8-10 weeks gestation |
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Fetal HR for Threatened Miscarriage/Abortion
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<100 BPM is dangerous. Normal is 120-160
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Diagnosis and Treatment Options for spotting with normal fetal cardiac activity
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Educate about prenatal care
If pt wants termination, counsel Teach signs of miscarriage (heavy, painful bleeding, passing tissue) Consider Rhogam if needed |
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Abortion definition and subtypes
a) Spontaneous (SAB) b) Threatened (TAB) c) Inevitable d) Incomplete/complete e) Missed (MAB) f) Recurrent g) Elective/Induced/therapeutic (EAB or TAB) Evaluation Q's |
Definition - termination of pregnancy by any means before fetus is sufficiently developed to survive. Usually means before 20 weeks. 15-20% known pregnancies end in 1st trimester loss
a) Spontaneous (SAB) - patient actively bleeds and tissue passes on its own (before 20 weeks) b) Threatened (TAB) - spotting, higher risk of miscarriage c) Inevitable - heavy bleeding, products of conception in vagina or cervix d) Incomplete/complete - fetus has come out, but some products of conception remaining e) Missed (MAB) - asymptomatic woman thinks pregnant without viable pregnancy f) Recurrent - more than 3 consecutive g) Elective/Induced/therapeutic (EAB or TAB) - TAB means due to lethal fetal anomaly Ask number of pregnancies, how many children, how many terminations |
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Spontaneous Abortion (SAB), cause, timeframe, Etiology
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Miscarriage
Cause: usually disruption between the basalis of placenta and uterine wall leading to subchorionic hemorrhage. Baby succumbs and passes in 1-2 weeks. Ovulation can resume in 2 weeks (so may need contraception) Etiology a) Fetal factors - chromosomal b) Maternal - older age c) Endocrine factors - thyroid disease, DM, HTN d) Immunological - Rh neg mother with Rh+ fetus and no Rhogam All of these contribute but no definitive cause MAIN etiology is chromosomal abnormalities with fetus lost before 8 weeks. Maternal gametogenesis problems 2x more than paternal. Aneuploidy (trisomy or monosomy X) or molar pregnancy (gestational trophoblastic disease) |
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Anembryonic pregnancy, Dx, Tx
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Abnormal zygote is very common, embryo is degenerated or absent ("blighted ovum") but still produces BhCG
Empty gestational sac halks at 4 weeks Dx: TVUS see sac without yolk sac bubble or sac without embryo Tx: usually MAB and must be medically or surgically managed |
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Recurrent/Habitual Abortion Causes
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3 consecutive documented miscarriages with same partner
Causes a) Chromosomal Abnormalities - need karyotype, could have balanced translocation b) Antiphospholipid syndrome - microvascular clots in placenta deplete nutrients to fetus. Check blood for andicardiolipins, prothrombin gene mutation, anti-Lupus Ab. Treat prophylactically c) Metabolic Abnormalities - DM uncontrolled, treat d) Anatomic abnormalities - surgically manage |
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Anatomic Abnormalities that can lead to recurrent/habitual abortion and Treatment
Asherman's syndrome |
Polyps, septum, scarring, Treat with surgical correction
Uterine Septum creating V shaped uterus, check with hysterosalpingogram or colposcopy. Surgically excise Asherman's syndrome - scarring usually after aggressive D&C (done for miscarriage, abnormal bleeding, early stage tumor). Scar tissue prevents implant. Hard to cure, but try to reduce and help restore endometrium |
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P0020 defined
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First number = carried and delivered at term
Second number = carried but delivered pre-term Third number = abortion of some kind (2 in this case) Fourth number = living children |
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Abdominal pain female DDx, Labs, Imaging,
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appendicitis, PID, ectopic pregnancy, ovarian torsion/cyst, GI/GU problems, pregnancy
Labs: urinalysis, pregnancy test, BhCG test, STD screen, CBC, type and screen Imaging - US, may see fetal pole outside uterus = ectopic pregnancy |
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Treatment options for ectopic pregnancy
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Methotrexate - inhibits DNA synthesis, slows growth in a stable, non-hemorrhagic ectopic pregnancy
Surgery, esp if heavily bleeding |
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Ectopic Pregnancy Locations, Most common, Dx, Tx, Complication
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Locations: tube, cornua of uterus, abdomen, ovary, cervix
Most commonly in uterine tube Dx: US to find dilation in tube or location with fetal pole Tx: remove segment (salpingectomy) or take out gestational tissue (salpingotomy). Try to preserve tube but usually scars and increases risk for future ectopic pregnancies. MUST follow BhCG levels to ensure no residual trophoblastic tissue Complications - heavy bleeding so need lots of blood products ready |
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hyperemesis gravidarum, DDx for dehydration, nausea and vomiting in pregnancy, Labs, Imaging
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normal pregnancy with dehydration
DDx: hyperemesis gravidarum, multiple gestation (more BhCG, more nausea), molar pregnancy, infection, gastritis, GERD, pancreatic dysfunction Imaging: US to look at uterine wall Labs: electrolyte panel for dehydration, liver panel, pancreatic panel, urinalysis, BhCG |
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Hydatidiform Mole, Complete vs Partial, Treatment
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Gestational Trophoblastic Disease, 2 Types
Complete Mole - 46 XX, resulting from complete fertilization of a blighted ovum by a sperm that reduplicates. PATERNAL ORIGIN, only has growth of placental parts. VACUOLES ON US "SNOWSTORM" appearance. 20% can become choriocarcinoma Partial Mole - Egg fertilized by two sperm leading to 69XXY karyotype usually. Very abnormal fetal tissue if any. Posses less risk 1% to neoplasia that complete mole Treatment: Must completely evacuate molar pregnancy or perform hysterectomy. NEED BLOOD PRODUCTS ON RESERVE. Follow BhCG weekly to ensure no remnants, then follow 6-12 months, if increases refer to oncology. Prior molar pregnancy predisposes for future |
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Septic abortion presentation, Tx
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Previous abortion a few weeks ago, FEVER, CHILLS, intermittent spotting
Usually due to not clearing all products of conception Tx: Aggressive fluids and IV antibiotic coverage for gram negative (E coli, klebsiella, bacteroides, streptococcus), need to admit to hospital D&C with complete evacuation, careful not to perforate uterus |
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Induced/Elective/Therapeutic Termination
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Medical or Surgical termination of pregnancy
Medical Options a) Ru486 - progesterone antagonist used for early pregnancy termination (less than 7 weeks), disrupts basalis layer and induces miscarriage, 48 hrs later give misoprostol to expel fetus. 15% can be incomplete and at risk for septic abortion b) Methotrexate - NOT OUTPT because need many labs (liver, kidney, etc) to cater treatment. Used in hospital for ectopic pregnancies Surgical - D&C |
