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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
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)!
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
Criteria for selecting surgery for ectopic
- -unstable vitals or hemoperitoneum
- -uncertain Dx
- -advanced ectopic pregnancy
- -unreliable follow-up
- -C/I to expectant or MTX
Criteria for medical mgmt of ectopic
- -stable vitals, few Sx
- -no C/I to drug
- -absence of embryonic heart activity
- -ectopic mass ≤ 4 cm
- -starting B-hCG levels < 5,000 - 10,000 mIU/ml
Rh dose for miscarriage in 1st trimester
50mcg Rhogam for negative women
What should B-hCG do in normal IUP over 48h?
double in normal IUP
What should B-hCG do in ectopic pregnancy over 48h?
Stay same or small increase/decrease in ectopic
What should B-hCG do in Spontaneous abortion over 48h?
Decrease more than 25% in SA
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
What should TVUS show @ 3-4 weeks?
TVUS @ 4-5 wks?
If B-hCG level > 1500-2000, then must see a gestational sac
TVUS @ 5-6 wks?
see fetal cardiac activity
How do you determine GA (menstrual age) by TVUS in 1st term?
CRL (cm) + 6.5 = age in weeks (menstrual age)
What is float test?
If passing clots, put then in normal saline - look for float/folliage = chorionic villi
What is a subchorionic hemorrhage?
A bleed between placenta and uterus (if in 1st trimester)
What is a subchorionic hemorrhage in term 2 and 3 called?
What is the chance of pregnancy loss with PV bleeding?
50%, but if FHR present then reassuring
What is a heterotropic pregnancy?
Ectopic + IUP
3 management choices for incomplete abortion?
- Surgical (D&C or manual vacuum aspiration)
- Medical (misoprostol)
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
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
When to choose surgical mgmt for ectopic?
Unstable, uncertain Dx, advanced GA, unreliable to follow up, C/I to meds/expectant
When to choose medical mgmt for ectopic?
- stable, few Sx
- No contraindications to meds
- Unruptured, no FHR, ≤4cm, BhCG ≤4cm
What is medical mgmt of Ectopic?
- MTX 1mg/kg or 50mg/m2 IM
- then serum BhCG @ 4, 7days until < 5
Criteria for expectant mgmt of ectopic?
- no bleeding/pain
- no rupture
- <3cm or not found on US
- NO FHR
Incidence of Ectopics
>1% of pregnancies
What is a complete hydatidiform mole?
46XX - no fetus, placenta proliferates
What is a partial hydatidiform mole?
What is recurrent hydatidiform mole?
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
What is an important mgmt consideration for T1 bleeding?
Rh status - if -ive, give 50mcg Rhogam
When to Rx blood pressure actuely?
If bp > 160/ >105-110
What to use to Rx acute bp in pregnancy?
Labetolol, Nifedipine XL, Hydralazine
- Labetolol - 20mg IV bolus, then if still high after 10 min
- 20-80mg IV q 30min
- 300mg max
5-10mg IV q20min, 20mg max
Nifedipine XL dose?
5-10mg PO q30min
Preferred dose of anti-convulsant in severe preeclampsia?
MgSO4 4-6g IV over 15-20min, then 2g/h IV
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
Antidote if MgSO4 toxicity?
Calcium gluconate 1g IV over 3min