Complicated pregnancy

Ectopic pregnancy

  • Fertilized egg attaches outside of uterus (MC ampulla of fallopian tubes)

  • Risk factors: HX of ectopics (highest RF), PID, smoking

  • SSX ~4-6wks after LMP

    • Interstitial pregnancy (rare) presents ~8-12wks after LMP

    • ABD pain, guarding, nausea

    • Tenderness at site, ± CMT

    • Amenorrhea OR vaginal bleeding

  • SSX of rupture

    • Acute ABD with ssx of shock

    • Blood in peritoneal cavity ➔ diaphragmatic irritation ➔ shoulder pain

  • DX

    • Transvaginal US is best test, bedside US is first test if rupture suspected

    • HCG and call an adult (OB/GYN) and get US even if HCG negative

    • HCG discriminatory level: Intrauterine pregnancy typically seen on US when HCG > 1,500-2,000

      • If IUP not seen and HCG > discriminatory level ➔ likely ectopic

      • Serial HCG: After 48hrs HCG should raise in IUP

        • Ectopic or spontaneous abortion may ➔ falling HCG

    • If unstable - GET AN ADULT for exploratory laparoscopy and don't wait for imaging

      • Laparotomy if critically unstable

  • TX

    • Hemodynamically stable

      • AND HCG < 5,000

      • AND able to return for f/u HCG

      • Methotrexate (CI in renal insufficiency, avoid in PUD, immunodeficient, pulmonary disease)

        • ↓ effectiveness of MTX if HCG >5k, fetal cardiac activity is present, ectopic > 3.5cm

      • Expectant management only for small population (asx, HCG <200 and declining, no findings on US)

    • Hemodynamically unstable

    • OR SSX of rupture

    • OR HCG > 5,000/8wks since LMP

      • Surgery - salpingectomy (does not preserve function)

Spontaneous Abortion (<20wks)

  • CLOSED OS

    • Threatened - bleeding with fetal activity (no passage of POC)

    • Complete - complete passage of POC

    • Missed - in utero death

  • OPEN OS

    • Inevitable - POC present ± activity

    • Incomplete - POC in cervical canal

  • DX

    • US

  • TX

    • < 14 wks - expectant (within 4 wks)

    • Or Mifepristone then Misoprostol

      • Same for termination of pregnancy (elective)

    • ABX if septic

Gestational trophoblastic disease

Hydatidiform mole (molar pregnancy)

  • Abnormal fertilization of ovum ➔ benign tumor of uterus

  • Partial: Fertilization of normal egg with two sperms ➔ 69xxx or 69 xxy or 69 xyy

    • Can contain fetal or embryonic parts

    • Vaginal bleeding, normal size uterus

  • Complete: Fertilization of empty egg ➔ 46xx or 46xy (sperm haploid duplicates)

    • No fetal or embryonic parts

    • ↑ risk of choriocarcinoma

    • Vaginal bleeding (1st trimester), large uterus for gestational age, ↑ N/V

  • DX

    • ↑ ↑ HCG and confirmed with US

      • Elevated HCG is present in multiple gestations (twins)

  • TX

    • D&C and monitor HCG for 3mos

    • Methotrexate if HCG doesn't come down

Choriocarcinoma

  • Highly aggressive, malignant tumor of trophoblastic tissue (MC preceded by complete hydatidiform mole)

    • Mets to lungs ➔ hemoptysis, dyspnea

    • Postpartum vaginal bleeding with poor uterine regression s/p delivery

    • Theca lutein cysts

  • DX

    • ↑ ↑ HCG and confirmed with US (hypervascular on doppler)

  • TX

    • Methotrexate and monitor HCG for 1yr

    • Surgical hysterectomy may be needed

Placental site trophoblastic tumor

  • Rare malignant gestational trophoblastic disease

  • Persistent HCG but lower levels compared to other gestational throphoblastic disease

  • Resistant to chemo