Womens Health EOR Study Guide Part 1

WOMEN’S HEALTH EOR-Prenatal Care/Normal Pregnancy 16%, Pregnancy Complications 15%, Menstruation 15%, Infections 12%, Neoplasms 10%, Disorders of Breast 8%, Labor and Delivery Complications 8%, Postpartum Care 6%, Structural Abnormalities 5%, Other 5% PRENATAL CARE/NORMAL PREGNACY 16% Prental Prenatal Diagnosis Prenatal Diagnosis Down Syndrome & Trisomy Chromosomal Abnormalities: First Trimester Screening 11-14 weeks •Risk of fetal trisomy increased with •nuchal translucency: max thickness of the maternal age, especially after age 35 subcutaneous translucent area b/w the skin and soft tissue of spine at the back of neck, >3.5 is abnormal targeted sonography, •Women with fhx or personal history of aneuploidy should be referred to chorionic villous sampling, aminocentesis genetic counseling •Biochemical screening: beta-hCG, PAPP-A •Downs: elevated hCG & low PAPP-A •Trisomy 13 & 18: both low •ultrasound: heart tones around 10-12week Neural Tube Defects Birth defects of brain: •anencephaly *failure to close neural tube that becomes cerebrum •spina bifida *incompetent closure of embryonic neural tubule vertebrae •cephalocele •rare spinal fusion abnormalities •elevated AFP in maternal and fetal serum and amniotic fluid •AFP synthesized by fetal yolk sac Pregnancy Signs/Symptoms Second Trimester: 13-27 weeks Triple test •hCG, AFP, & unconjugated estriol •down syndrome: low AFP & estriol, high hCG •trisomy 18: all decreased •spina bifida: high AFP Quad Screen •above + inhibin •Downs: elevated inhibin •Chorionic Villous Sampling: 10-13 weeks women with increased chromosomal abnormalities, prior child with chromosomal abnormalities, materal age >35, abnormal 1st or 2nd T maternal screening tests, abnormal nuchal translucency, prior pregnancy losses Gestational Diabetes: week 24-48 Risk Factors: •family history, MTHFR mutation •aneuploidy, diabetes, hyperthermia •medications *seizure medications Types of Spina Bifida: •myelomeningocele (MC): meninges and spinal cord herniate through gap in vertebrae Screening: mom serum AFP b/w 15-20 wk •occulta: no herniation; overlying skin may be normal or hair; dimling or birth mark AFP can be affected by: •multifetal gestation •pilonidal cyst •chorioangioma of placenta •placental abruption, preeclampsia •oligohydramnios, FGR Aminocentesis: same as chorionic •meningocele: only meninges herniate through gap Diagnostic Tests Combine First & Second Trimester •enhance aneuploidy detection rates •combines results from both trimesters •highest detection of down syndrome •results after both completed Third Trimester: •Gestational Diabetes: 24-28 weeks 1 hour glucola testing •antibody screen in Rh (-): 28wk *give RHOgam if negative •CBC repeat: ~28wk, monitor anemia •UDS repeat if + initial: 28 week •GBS: vaginal/anal culture 36-37wk IV PCN G at labor *alternative: Clindaycin Non-Stress Testing: Baseline fetal HR 120-160bpm Reactive: 2+ accelerations at rate 15+ bpm from baseline for at 15 seconds Nonreactive: no fetal HR accelerations or <15bpm lasting <15 seconds •sleeping, immature, compromised •TX: vibratory stimulation, contraction stress testing Contraction Stress Testing: Negative: no late decelerations Positive: repetive late decelerations hospitalize for fetal monitoring Pregnancy Amenorrhea •cessation of menses in a health •not reliable until 10d + after menses •can have “implantation bleeding” for blastocyst Vaginal/Cervical Changes •Chadwick: mucosa appears dark bluish red & congested •Goodells sign: cervical softening Breast Changes •tenderness & paresthesia •increase in breast & nipple •thick yellowish fluid colostrum •areola becomes deeply pigmented Skin Changes ~16th wk •increased pigmentation, linea nigra •pruritic papules steroids •chloasma “mask” •striae (stretch marks) •cervical mucus: thick due to P •uterine change: •Haegers sign: isthmus soften (6-8) •Ladin sign: uterus softens (6wk) Beta human chorionic gonadotropin (B-hCG) •produced by syncytiotrophoblasts •blood and urine about 8-9d after ovulation •prevents involution of corpus lutem •rare false (-): MCC is herephilic antibodies *urine would be negative •false (+) causes: exogenous hCG, renal failure with failed hCG clearance, pituitary hCG, tumors *home pregnancy tests require value of 12.3 to use 1st urination detect 95% pregnancies Transvaginal US gestational sac: small anechoic fluid within endometrial cavity first evidence ~4-5wk yolk sac: bright echogenic ring with anechoic center confirms location ~56wk fetal pole/embryo: ~6wk crown rump length: used up to 12wk to predict the due date, accurate within 4d Fetal Movement 16-20 weeks •Primigravida ~20wk •Multigravida ~16-18wk Heart Tones: 10-12 weeks Estimate Date of Delivery •Naegele’s Rule -LMP + 7days – 3 months -assumes pregnancy begun 2wk before ovulation •Ultrasound 1st trimester crown rump is MOST ACCURATE Prenatal Visit Lab Tests RhoGam MOA: suppresses immune History First Visit •obstetrical hx: pregnancies, •CBC: WBC, Hgb, Hct, Plt response of Rh negative *monitor anemia & thrombocytopenia complications, infertility individuals to Rh (+) RBCs •menstrual: interval between menses, contraceptives Blood type and Rh Factor: if Rh (-) mother and Rh Dose: 0.3mg eradicates 15ml of (+) fetus then receive RhoGam ~28thwk *RhD •fhx, shx, medical hx fetal RBC •antibody screening Physical Exam Should be given rubella serology: infection in 1st semester can cause •uterine size *bimanual -bleeding or trauma prior to 28wk -small orange ~6wk abortion, malformations -postpartum if infant Rh (+) -large orange ~8wk -invasive diagnostic prenatal test -grapefruit ~12wk •pap smear •cervical dilation, length, consistency •gonococcal & chlamydia, syphilis, HIV, hepatitis Keihauer-Betke *bimanual •urinalysis •tests amount of fetal RBC in •pelvic architecture *bimanual •urine culture & sensitivity maternal circulation Counseling Prenatal Vitamin •400 micrograms of folic acid *4mg if hx neural tube defect Diet: additional 100-300kcal/day - 60-80g protein/day Employment •work until labor Seafood •avoid fish and shellfish contain mercury •High risk: shark, sword, mackerel, tile fish •no more than 6oz of white tuna Weight Gain •Maternal weight gain is correlated with infant weight *obese women who gain <15lb have the lowest complication rate *25-35lbs, underweight: 28-40lbs, obese: gain around 12-20lbs Obesity associated risks: •gestational HTN, DM, preeclampsia •macrosomia •C-section Routine Care •Every 4 weeks until 28 weeks •Every 2 weeks until 36 weeks •Every week unil delivery Prenatal Surveillance At each return visit: •US fetal growth (dating & anatomy) •maternal BP/weight •U/A, protein, glucose •S/S: leak, contractions, N/V, bleed Lead Risk factors: -recent immigrant -living near lead source -using lead glazed pottery -eating nonfood substances -using imported cosmetics -remodeling home with lead -consuming lead water -living w/ someone with elevated lead Common Complaints Nausea/Vomiting “morning sickness” •common in 1st trimester until 16th wk TX: small meals, BRAT diet, ginger, vitamin B6 + Doxylamine, Zofran •Hyperemesis gravidum: vomiting severe that dehydration, electrolyte, and acid-base disturbances and starvation ketosis •hypokalemic, hypochloremic metabolic alkalosis Back Pain *low back pain •increased with gestational age •Reduce By: squatting rather then bending, avoid high heels, use a pillow back support, belly band, PT, Tylenol prn Seat Belt three point restraints with lap belt under abdomen and across upper thigh Smoking: person to person counsel •ask, advise, assess, assist, arrange Alcohol: MC in white; NO ALCOHOL Air Travel can fly up to 36wk, ambulate hourly and wear TED hose Dental: no CI including x-rays Coitus (intercourse): not harmful Caffeine: >5c can increase abortion, <200mg (10oz) not associated with issues Exercise •do not limit; engage in moderately intense activity for 30min+/day; *don’t lift >25lb •avoid: high risk falling or trauma & scuba Illicit Drugs: less likely to obtain prenatal care Breastfeeding •exclusive BF preferred until 6mo •human milk contains protective immunological substances IgA and GF •protects against rotavirus, decreased atopic dermatitis and resp infections CI: street drugs, uncontrolled alcohol, galactosemia, HIV, TB, medications, breast cancer treatment, active herpes on breast Hemorrhoids •increase in pelvic venous pressure, rectal vein varicositis occur •pain and swelling occur TX: topical applied anestheics, warm soaks, stool softeners Heartburn *very common •GERD in lower esophagus due to upward displacement & compression of stomach TX: antacids, H2 blockers, PPIs Varicosities •femoral venous pressure in pregnant woman increased 8 24mmHg at term •cosmetic blemished to severe discomfort TX: rest with leg elevation, elastic stocking Sleeping & Fatigue: •efficiency declines with gestational age, increase need TX: Benadryl, daytime naps Pica: craving for strange food Leukorrhea: increase discharge iron def. Labor Labor About •The physiologic process by which a fetus is expelled from the uterus Cervical Exam Dilation: 0-10cm (10 is complete) Effacement: length of cervix •difference b/w internal and external os 3 Stages: •Stage 1: onset full dilation •Stage 2: full dilation delivery •Stage 3: delivery placental delivery (0-30min after) Station: degrees of descent of fetus •measure in cm from ischial spines •measure it in thirds -5 +4 Diagnosis of Labor •In order to diagnose labor, THERE MUST BE CERVICAL CHANGE! •contractions without cervical change Braxton Hicks contractions Bishop score: determines how favorable the cervix is for labor Consistency: soft, medium, firm Position: Anterior, mid, posterior 1st Stage Induction of Labor About •Attempt to begin labor in a nonlaboring patient CI: •myomectomy •placenta previa •prolapsed cord •active genital herpes •transverse fetal lie •uterine scar from C-Section incision and cephalopelvic disproportion Pain Spinal Anesthesia •one time dose placed directly into the spinal canal •used for C-section •complication and CI similar to epidural Methods Prostaglandins •Cervidil (PGE2, vaginal) •Cytotec (PGE1, vaginal or oral) •help ripen and dilate cervix (dissolution of collagen & increases water uptake) Status of Membranes: •ferning, nitrazine, pooling, AFI •spontaneous rupture of membrane (during labor), PROM (before labor) •vaginal bleeding Group B Strep: •36-37 weeks with cervical-ano swab (+) treat in labor with Penicillin •allergy, obtain sensitivities: Clindamycin or Erythromycin •no sensitivities: Vancomycin Later Induction-Pitocin (IV) •identical version of oxytocin released from posterior pituitary to lead to uterine contracts SE: tachysystole, fever, V/D, uterine rupture SE: tachysystole (>5 contraction in 10 minutes), uterine rupture, hyponatremia, hypotension, amniotic fluid embolism CI: hx c-section, myomectomy, hysterectomy CI: fetal distress, hypersensitivity Pudendal Block •provides perineal anesthesia •used with operative vaginal deliveries or for extensive perineal repairs after Epidural: catheter placed in L3-L4 space complications: maternal hypotension, maternal respiratory depression, spinal HA (treat with blood path, fluids) CI: bleeding disorder, LMWH w/n 12h, patient refusal Balloon catheter (Cook) Laminaria: use when the mother has had a miscarriage; Artificial rupture of membrane -amnio hook used to puncture sac * risk-umblical cord prolapse General Anesthesia •used for C-section in emergent or urgent setting or when CI to regional anesthesia complications: •maternal aspiration •risk of hypoxia to mother & fetus First Stage of Labor About Onset of labor to complete cervical dilation Freidman’s Labor Curve: •Latent phase: onset of labor 4cm •active phase: 4cm complete dilation (10cm) *faster rate of cervical change nulliparous: 1.2cm, multiparous: 1.5cm Abnormalities Arrest of dilation & descent: •indications for C-section Umbilical Cord Prolapse: •prolapse of umbilical cord in front of fetal head •risks: artificial rupture of membranes, unengaged fetal head •EMERGENCY C-section Passenger Passenger (Fetus): Fetal variables that can affect labor •fetal size (macrosomia) and fetal lie (longitudinal, transverse, oblique) •fetal presentation: vertex, breech, shoulder, compound and cord •attitude: degree of flexion or extension of the fetal head •position: relationship between the fetal part to the R or L side of the birth canal -vertex: occiput is reference -breech: sacrum is reference •station •number of fetuses •presence of fetal anomalies •3 Ps: passenger, pelvis, power Pelvis (Passage) •Bony pelvis & soft tissues of the birth canal (cervix, pelvic floor muscle) •small pelvic outlet can cause cephalopelvic disproportion •bony pelvis can be measured by pelvimetry *not accurate Abnormalities: •cephalopelvic disproportion -passenger is too large, indication for C-section Power Uterine Contractions •force generated by uterine myometrium •contraction force can be measured by direct measurement of intrauterine pressure urince and internal pressure monitor (IUPC) •3-5 contractions in a 10minute period is adequate for labor •adequate labor >200montevideo units in 10 minutes only measure in IUPC Abnormalities: •if labor is not progressing, insert IUPIC; if <200montevideos in 10min Pitocin Labor Augementation •intervening to increase the force of the already present contractions Pitocin, AROM Heart Rate Monitor •Normal fetal HR: 110-160bpm •Bradycardia : FHR <110bpm -causes: heart block maternal hypotension Tachycardia: FHR >160bpm -Causes: infection, Terbutaline •Leopolds maneuver -mother lies supine -can determine: fetal lie, estimate fetal weight, fetal position, fetal presentation *difficult in obese mother, polyhydramnios, multifetus •Vaginal exam: palpation •Ultrasound *MC today Abnormalities: •any position other than vertex usually results in a C-section •macrosomia (>5000g or 4500 in diabetics) should have C-section Decelerations: Early: begin and end approx. at the same time as contractions -result of head compression Baseline: mean bpm over 10 min window Late: peak of contraction, return to baseline after contraction done -uteroplacental insufficiency -require intervention Absent: 0bpm of variation (BAD) Minimal :1-5bpm of variation *sleeping Moderate: 5-25bpm of variation Marked: >25bpm of variation (BAD) Variable: anytime, drop more precipitously cord compression -possible intervention: amniofusion (saline into sac) Accelerations: • >32 weeks: at least three 15bpm above the baseline and lasting for 15 seconds • <32 weeks: at least three 10bpm above the baseline and lasting for 10 seconds Sinusoidal Waveform: sine wave •cause: fetal anemia 2nd Stage Cardinal Movements of Labor About •Changes in the fetal head position during its passage through the canal Seven Movements: -engagement -descent -flexion -internal rotation -extension -external rotation/restitution -expulsion Labor Second , Third, Fourth Stage of Labor About •Interval between full cervical dilation to delivery of the infacnt •characterized by descent of the presenting part through the maternal pelvis and expulsion of the fetus Seven Movements Engagement: •passage of widest diameter fetal presenting part below pelvic inlet •head at level of the ischial spine (zero station) Decent (lightening) •downward passage of the presenting part through the bony pelvis Flexion: •occurs passively as the head descends due to the shape of the bony pelvis •complete flexion allows the fetal head’s smallest diameter to fit through (suboccipitobregmantic diameter) Examining Fetal Head Molding: alteration of fetal cranial bones as a result of compressive forces of pelvis Internal Rotation: •rotation of the fetal head from occiput transverse to occiput anterior to posterior position •occurs passively Extension: •occurs when the fetus has descended to the level of the vaginal introitus •when the occiput is past the level of symphysis, the angle of the birth canal changes to upward position Laceration Perineal Lacerations: 1st degree: perineal skin and vaginal mucosa 2nd degree: injury to perineal body 3rd degree: through external anal sphincter th Caput: localized edematous area 4 degree: injury through rectal mucosa *3rd and 4th degree require surgery on the fetal scalp caused by pressure by the cevrix Indications: •pelvic/rectal pressure “need to push” •mother has active role of pushing to aid in fetal descent Lightening: fetal head descending into pelvis changes abdomens shape and sensation that baby has “become lighter” Bloody Show: passage of bloodtinged cervical mucus late in pregnancy when cervix thinning External Rotation/Restitution: •As the head is delivered, it rotates back to its original position •head aligns anatomically with the fetal torso •release of the passive forces on the fetal head allow it to return Expulsion •delivery of fetus •downward traction allows released of the anterior shoulder Third and Fourth Stage Third Stage • fetal delivery to placenta delivery (0-30 min) Episiotomy: •surgical incision of female perineum •increases diameter of soft tissue pelvic outlet to allow delivery •rationale: reduce 3rd and 4th degree lacerations, •indications: fetal distress •complications: vaginal bleeding, increase potpartum pain, unsatisfactory anatomic results, sexual dysfunction, infections •types: midline, mediolateral (MC) Three signs of placental separation: 1. lengthening of umbilical cord 2. gush of blood 3. fundus becomes globular and more anteverted against abdominal hand •Placenta is delivered using one hand on umbilical cord with gentle downward traction other hand on abdomen supporting fundus •Risks for traction-EMERGENCY -immediate replacement of fundus Fourth Stage •Time from delivery of the placenta to ONE hour immediately postpartum Monitor: blood pressure, uterine blood loss, pulse rate q15minutes for 2 hours Fundal Height: 12 weeks (above pubic symphysis), 16 weeks (midway between pubis & umbilicus), 20 weeks (umbilicus), 38 weeks (2-3cm below xiphoid APGAR Score: 7+: normal, 4-6: fairly low, < 4: critically low A: appearance: blue grey (0), body pink/blue extremities (acrocyanosis) (1), pink (2) P: pulse: none (0), <100 (1), 100+ (2) G: grimace: no response to stimulation (0), grimaces freebly (1), pulls away/sneeze/cough (2) A: activity: no muscle tone (0), some flexion (1), flexes arms and legs (2) R: respiration: absent (0), weak & irregular (1), stron crying (2) OBGYN Multiple Gestations About •gestational trophoblastic disease •rapid maternal weight gain and growth of uterus Clinical Presentation Dizygotic (fraternal): fertilization of 2 ova by 2 different sperm Monozygotic (identical): fertilization of 1 ovum that splits Care and Disposition Ultrasound: visualize fetuses B-HCG: elevated AFP: elevated Gravida: number of times a woman have been pregnant Parity: Number of pregnancies that led to a birth either at or after 20 weeks - T (term) number born at 37 weeks or older - P (preterm) born after 20 weeks but before 37 weeks - A (abortion) all pregnancy losses prior to 20 weeks - L (living) infant who lives beyond 30 days Nulligravida: woman who currently is not pregnant and never has been pregnant Primigravida: woman who currently is pregnant and has never been pregnant before Multigravida: woman who currently is pregnant and who has been pregnant before Nullipara: woman who has never completed a pregnancy beyond 20 weeks Primipara: woman who has delivered a fetus or fetuses born alive or dead with an estimate length of gestation of >20weeks Multipara: woman who completed 2+ pregnancies to 20 weeks gestation or mo PREGNANCY COMPLICATIONS Management Maternal Complications: preterm labor, spontaneous abortion, preeclampsia, anemia Fetal Complications: IUGR, placental abnormalities, breech, umbilical cord prolapse, preeclampsia OBGYN Incompetent Cervix (Cervical Insufficiency ) OBGYN Placental Abruption About •premature cervical shortening or dilation in the second or early third trimenters (up to 28wk) Risks: •hx cervical insufficiency •hx injury, surgery, conization •DES exposure in utero •anatomic abnormalities Clinical Presentation Diagnostics Management •significant cervical dilation (>2cm) TVUS: most accurate & predicitive Cerclage (purse string suturing of os) & •minimal contractions until 4cm •done at 14-16 weeks o earlier bed rest *confirm vitable intrauterine pregnancy •bleeding or vaginal discharge •wide internal os, shortening of canal, nd (especially in the 2 trimester) before placing hourglass, bulging of fetal membrane *culture of G/C and GBS before place •cervical length <25mm before 24wk Exam: PAINLESS dilation & effacement CI: infection, ROM •weekly 17 alpha-hydroxyprogesterone injection in some women About/Rsiks Separation of the placenta either partially or totally from its implantation site before delivery Cause: hemorrhage into decidua basalis Placenta Previa Presentation •Sudden onset of abdominal PAIN •vaginal bleeding •uterine tenderness Risks: •materal HTN •trauma, uterine fibroids, lupus •increasing maternal age, past aborption •Preeclampsia, smoking, cocaine MCC bleeding in THIRD TRIMESTER Placenta that is implanted either over or near internal cervical os •PAINLESS vaginal bleeding usually after the second trimester (28 wks) Classifications: •Placental previa: os covered partial or complete •Low-lying: implantation in lower uterine segment •partial: partial coverage •marginal: adjacent to internal os (<2cm away) Exam: •tender, rigid hypertonic uterus •NO PELVIC EXAM Diagnostics •DIAGNOSIS OF EXCLUSION •CBC, CMP, PT/PTT/INR, blood type •transabdominal US TVUS •May be associated with elevated AFP Speculum and digital pelvic exam CI unltil US r/o placenta previa Management •fluids and blood if needed •emergenct OBGYN consult -possibly emergent C-section Complications: •hypovolemic shock •DIC •AKI (hypovolemia) •Couvelair uterus: extravasation of blood into uterine musculature & beneath serosa -myometrium “blue-purple” tone C-Section performed in complete, major degrees, and fetal distress *uterine body is remodeling to form the lower uterine segment internal os dilates bleeding occurs Risks: maternal age, mult. gestations, C-section, smoking, high MSAFP, preveious previa OBGYN About Clinical Presentation Care and Disposition Management Ectopic Pregnanc y •leading cause of maternal pregnancy-related death in 1st trimester •pregnancy outside uterine cavity •MC in ampulla of fallopian tube Risk Factors •previous ectopic pregnancy *strongest risk factor •PID, STDs •surgery on fallopian tubes •IUD, infertility treatments Clinical Presentation TRIAD: unilateral pelvic pain, vaginal bleeding, amenorrhea •light or heavy vaginal bleeding •diffuse pain peritonitis after rupture • referred shoulder pain or upper abdomen Physical Exam •hypotension, hypovolemia, or shock •localized or generalized tenderness •cervical motion tenderness, adnexal tenderness with or without mass Diagnostics •b-HCG >1500 *serum is best *does NOT double q48h like normal •vaginal US -transvaginal is best *beta level of 1500 & empty uterus Transvaginal US: •empty uterus with adnexal mass w/ or w/o free fluid in the abdomen •empty uterus without adnexa mass or free fluid with a (+) pregnancy test Suspect in any female of childbearing age with abdominal/pelvic pain or bleeding Molar Pregnanc y •neoplasm due to abnormal placental development with trophoblastic tissue proliferation •painless vaginal bleeding •preeclampsia before 20wk •hyperemesis gravidarum *elevated b-hCG Complete: Diploid 46XX: empty egg with no DNA, all paternal chromosome absence of fetal tissue Exam: •uterine size and date discrepencies •discharge if beta <1000 •laporoscopcie exam or medical management with MTX Methotrexate: Must be: •aymptomatic, motivated, compliant •low b-hcg (<5000), small (<3.5cm) •absent fetal heart activitity •no intrabaomdinal bleding Surgery •Laparoscopy (PREFERRED!) -salpinostomy: tubal salvage -salpingectomy: tube resection Labs: •b-hCG: super high >10,000 •surgical uterine evacuation •follow weekly until b-hCG drop Pelvic Ultrasound •complete: central heterogenous mass w/ multiple discrete anechoic spaces “snowstorm” or “grape cluster” *obtain CXR to look for mets (choriocarcinoma) •partial: gestational sac and fetal heart tones + abnormal tissue Partial/Incomplete: Triploid 69XXX or XXY: egg fertilized by 2 sperm, fetal tissue may be seen but abnormal *confirm with biopsy Risks: prior molar, extreme ages (<20, >35), Asians Choriocarcinoma Cancer of gestational contents •elevated B-hCG •Resect by suction curettage Pelvic Ultrasound: •uterine size much larger than expected for dates •Methotrexate, Actinomycin *confirm with biopsy OBGYN About Work-Up Care and Disposition Spontaneous Abortion Pregnancy that ends <20 WEEKS gestation Threatened: *only one potentially viable •products of conception intact •cervical os closed Inevitable: •products of conception intact •bleding, cramps, os dialted Incomplete: •some products expelled •bleeding, cramping, os dilated Complete: •products of conception expelled •cervical os closed Missed: fetal death <20 wks, brownish discharge, no fetal tissue is passed •US should sac with no heart beat Pelvic Exam •caution in patients beyond 20 weeks because risk of placentia previa hemodynamically unstable: -emergent consult -fluid and blood -Rhogam if RH (-) Labs: •CBC •blood typing and crossmatch •Rh factor •B-hcg •Urinalysis Types Threatened Abortion: •pelvic rest •may be discharge home with close follow up with OB •return to ED if significant pain, fever, vaginal bleeding, passage of tissue Ultrasound transabdominal or transvaginal •may confirm fetal death by noting evidence of fetus with no heartbeat or movement Complete Abortion: •may be discharged home if stable and vaginal bleeding is decreasing or absent •pelvic rest •close follow up with OB •Rhogam if indicated Setpic abortion •obtain CBC, blood and uterin cx, LFTs, BMP, PT/PTT •OB/GYN consult and asmiddion •Ampicilling/Sulbactam •Clindamycin + Gent Inevitable: •surgical evacuation (D&C) •Misoprostol •expectant management Incomplete/Missed: •surgical evacuation (D&C) •Misoprostol •expectant management low: repeat in 2-3 weeks medium: repeat in 1-2 weeks high: percutaneous umbilical blood sample, low htc intrauterine umbilical vein infusion Prevention: •anti-D Rh immunoglobulin 3x: 1. 28 weeks 2. w/n 72h delivery of Rh (+) baby 3. after potential blood mixing (spontaneous abortion, ectopic pregnancy, aminocentesis) Septic Abortion MCC incomplete evacuation •some products of conception retained •cervical os closed; cervical tenderness •brown, foul discharge; fever, chills RH Alloimmunizatio n •when Rh(D) negative women carry a Rh(D) positive fetus Pathophysiology: •in subsequent pregnancy, the antibodies will cross palcenta and attack fetal RBC hemolysis of fetal RBC At-Risk: (-) mother, (+) father or unknown Antibody Screen: •initial prenatal visit •repeat at 28 weeks if (-) Antibody Titers: (-) women •unsensitized: no antibodies •sensitized: titers performed via indirect antiglobulin test *1:16+, aminocentesis 16-20 wk