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Misoprostol (off-label) dose for incomplete or missed abortion
- 600 mcg PO or 600-800 mcg PV x 1
- fewer GI Sx with PV dose
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RF's for Ectopic
- Hx previous ectopic
- Hx tubal surgery
- Hx tubal infections
- Progestin-only contraception
- Contraceptive IUD
- In utero DES exposure
- *may occur in women with no risk factors (obviously)!
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Dx of Ectopic
- Failure of B-hCG to double in 48-72 hours
- Low serum progesterone
- TVUS - IUP rules out ectopic
- No gestational sac + B-hCG > 1800 = highly suggestive of ectopic
- Gestational sac outside ousters confirms ectopic
- Gold standard = laparoscopy
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Criteria for selecting surgery for ectopic
- -unstable vitals or hemoperitoneum
- -uncertain Dx
- -advanced ectopic pregnancy
- -unreliable follow-up
- -C/I to expectant or MTX
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Criteria for medical mgmt of ectopic
- -stable vitals, few Sx
- -no C/I to drug
- -unruptured
- -absence of embryonic heart activity
- -ectopic mass ≤ 4 cm
- -starting B-hCG levels < 5,000 - 10,000 mIU/ml
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Rh dose for miscarriage in 1st trimester
50mcg Rhogam for negative women
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What should B-hCG do in normal IUP over 48h?
double in normal IUP
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What should B-hCG do in ectopic pregnancy over 48h?
Stay same or small increase/decrease in ectopic
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What should B-hCG do in Spontaneous abortion over 48h?
Decrease more than 25% in SA
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What does progesterone level tell you in 1st term bleeding?
- < 5 ng/mL = strongly suggestive of SA/Ectopic
- > 5 ng/mL = strongly associated with live IUP
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What should TVUS show @ 3-4 weeks?
decidual thickening
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TVUS @ 4-5 wks?
If B-hCG level > 1500-2000, then must see a gestational sac
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TVUS @ 5-6 wks?
see fetal cardiac activity
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How do you determine GA (menstrual age) by TVUS in 1st term?
CRL (cm) + 6.5 = age in weeks (menstrual age)
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What is float test?
If passing clots, put then in normal saline - look for float/folliage = chorionic villi
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What is a subchorionic hemorrhage?
A bleed between placenta and uterus (if in 1st trimester)
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What is a subchorionic hemorrhage in term 2 and 3 called?
Abruption
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What is the chance of pregnancy loss with PV bleeding?
50%, but if FHR present then reassuring
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What is a heterotropic pregnancy?
Ectopic + IUP
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3 management choices for incomplete abortion?
- Surgical (D&C or manual vacuum aspiration)
- Medical (misoprostol)
- Expectant
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What are considerations for management of incomplete/missed abortions?
- Incomplete - med and expectant
- Missed - med is better than expectant
- Misoprostol - increases bleeding but less pain than surgery
- Expectant - more outpatient visits
- Surgery - more trauma, more infection than misoprostol
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What is the mechanism of injury in ectopic?
ECtopic outgrows its blood supply, low blood flow, fetus dies, erodes through tube, intraperitoneal bleed, sepsis/death
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When to choose surgical mgmt for ectopic?
Unstable, uncertain Dx, advanced GA, unreliable to follow up, C/I to meds/expectant
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When to choose medical mgmt for ectopic?
- stable, few Sx
- No contraindications to meds
- Unruptured, no FHR, ≤4cm, BhCG ≤4cm
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What is medical mgmt of Ectopic?
- MTX 1mg/kg or 50mg/m2 IM
- then serum BhCG @ 4, 7days until < 5
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Criteria for expectant mgmt of ectopic?
- no bleeding/pain
- reliable
- no rupture
- <3cm or not found on US
- NO FHR
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Incidence of Ectopics
>1% of pregnancies
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What is a complete hydatidiform mole?
46XX - no fetus, placenta proliferates
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What is a partial hydatidiform mole?
69XXY
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What is recurrent hydatidiform mole?
Metastatic choriocarcinoma
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MGMT of GTD?
- Prompt removal (D&C)
- Serial B-hCG's
- Contraception x 1yr (to allow you to follow B-hCG)
- Recurrs in 20% - then need MTX
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What is an important mgmt consideration for T1 bleeding?
Rh status - if -ive, give 50mcg Rhogam
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When to Rx blood pressure actuely?
If bp > 160/ >105-110
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What to use to Rx acute bp in pregnancy?
Labetolol, Nifedipine XL, Hydralazine
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Labetolol dose?
- Labetolol - 20mg IV bolus, then if still high after 10 min
- 20-80mg IV q 30min
- 300mg max
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Hydralazine dose?
5-10mg IV q20min, 20mg max
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Nifedipine XL dose?
5-10mg PO q30min
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Preferred dose of anti-convulsant in severe preeclampsia?
MgSO4 4-6g IV over 15-20min, then 2g/h IV
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Main concern with MgSO4?
May affect renal fxn. Don't send Mg level as will be panic high, unless Pt has oliguria or high Cr
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Antidote if MgSO4 toxicity?
Calcium gluconate 1g IV over 3min
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