Fetal heartbeat not audible with hand held doppler after 10-12 weeks
3 Differential Diagnosis Of 1st Trimester Pain or Bleeding
Threatened miscarriage (abortion)
Incomplete abortion with retained products
Missed Ab embryonic demise embryonic absorption
4 Non-Pregnancy Related
Ureteral stone with colic
Cystitis or pyelonephritis
Ruptured ovarian cyst
Corpus luteum cyst
Previous preg. History
Hx of tubal surgery PID IUD
Onset severity duration of pain bleedinggeneralized pain or pain referred to the shoulder may signal a ruptured pregnancy with hemoperitoneum
Any tissue passed
Blood type Rh
7 Physical Exam
Vitals tilt test
Pelvic with rectal!!
Note amount of blood
Posterior fornix bulging
Cervical cultures GC chlamydia
Vag/perineal culture for Gp. B strep.
Ultrasound - Cardiac activity by 6 weeks with the crown rump length 5-8mmdefinitely seen by crown-rump length of 14mm
Heart rate at first is 100b/mindemise likely!!
9 hCG human chorionic gonadotropin
Quantitative level of 1800-2000 mIU/mL should see an embryonic sac!
Quant levels of 5000 should reveal a yolk sac
10 Complications After the First Trimester
Small Large for dates
11 Vaginal Bleeding
Second trimester miscarriage
Cervical or vaginal laceration
Coagulopathy either pre-existing or pregnancy related
12 Vaginal Bleeding
Marginal sinus rupture
13 Diagnostic Approach
May occur after intercourse
May need U/S
Can remain outpatient if no other risks involved!
RTO ASAP for increased bleeding pain decreased fetal movement or labor symptoms!
14 Heavy BleedingOB emergency!! Find that Placenta!!
Placenta Previa occurs when the placenta partially or completely covers the cervical opening
1/20 common on early U/S
1/10 patients cont with previa after 30 wks of pregnancyplacental migration
Common between 27-32 weeks
15 Risk Factors of Placenta Previa
Previous uterine surgery/scar
Previously abnormal placental implantation
Advanced maternal age
16 Complications of Placenta Previa
Velamentous cord insertion
17 (No Transcript) 18 Abruptio Placenta
Premature separation (partial or complete) of the placenta from the uterine wall
2 of pregnancies with 0.2 resulting in fetal demise
Usually present with pain!
May hide the bleeding!
19 Risk Factors for abruption
Sudden decompression of uterine cavity
Prior to 20 weeks may be hard to gage! By 20 weeks should measure to the umbilicus!
20-32 weeks measurements should correlate well with gestational age!
IUGR oligohydramnios or both
5 in general population but higher rates in at risk populations
AIUGR Assymetric head bones grow at a normal rate but the viscera abdomen do not
Associated with long-term problemslearning disablities ADD
23 SIUGR (symmetrical)
Refection of early insult to fetus ie infection or chromosomal abnormality
May want amnio TORCH titers
Both SIUGR AIUGR are associated with all pregnancy complications!
Very short patient
Structural abnormalities of the uterus
Placental insufficiency or abnormalities
Implies a deteriorating pregnancy status!!
Fetal macrosomia without maternal DM
Rh other isoimmunization
GI anomalies usually upper that prevent swallowing
Neural tube defects
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