Notes

With a heterotopic pregnancy, there should be a visible pregnancy in the uterus. With a missed abortion there should also be some visible tissue or a fetal pole within the uterus.
Certain conditions must be met prior to initiating methotrexate therapy for treatment of an ectopic pregnancy. These include: hemodynamic stability; non-ruptured ectopic pregnancy; size of ectopic mass <4 cm without a fetal heart rate or <3.5 cm in the presence of a fetal heart rate; normal liver enzymes and renal function; normal white cell count; and the ability of the patient to follow up rapidly (reliable transportation, etc.) if her condition changes.
This scenario is consistent with the patient having a ruptured ectopic pregnancy. Signs of hypovolemia (tachycardia, hypotension) with peritoneal signs (rebound, guarding and severe abdominal tenderness) and a positive pregnancy test lead to the diagnosis of ruptured ectopic pregnancy. - perform laparoscopy
Hematometra can develop after an abortion, but the patient would complain of cyclic midline abdominal cramping pain. Retained products of conception would cause profuse vaginal bleeding and if not removed may lead to a septic abortion.
Systemic diseases such as diabetes mellitus, chronic renal disease and lupus are associated with early pregnancy loss. The patient’s history of mild chronic hypertension and one prior termination of pregnancy do not increase her risk of a first trimester loss. Environmental factors, such as smoking, alcohol and radiation are causes of spontaneous abortion.
This patient is actively bleeding and is anemic. She, therefore, requires immediate surgical treatment consisting of dilation and suction curettage
antiphospholipid antibody syndrome - 2nd trimester abortion
incompetent cervix - cervical cerclage
It is important to rule out systemic disease in a patient with recurrent abortion (three successive first trimester losses). Testing for lupus anticoagulant, diabetes mellitus and thyroid disease are commonly performed. Maternal and paternal karyotypes should also be obtained. Infectious causes should also be considered. Uterine imaging to exclude a septum or other anomaly is routinely done using hysteroscopy or hysterography and not CT or MRI scanning.
Neither controlled trials nor surveillance data support the contention that a single, prior first trimester surgical abortion increases the risk of subsequent first trimester pregnancy loss.
The baseline transmission rate of HIV to newborns can be reduced from about 25% to 2% with the HAART (highly active antiretroviral therapy) protocol antepartum and continuing through delivery with intravenous zidovudine in labor and zidovudine treatment for the neonate.
Gestational Diabetes screening: Patients at low risk are not routinely screened. For those patients of average risk screening is performed at 24-28 weeks while those at high risk (severe obesity and strong family history) screening should be done as soon as feasible.
Among women with cardiac disease, patients with pulmonary hypertension are among the highest risk for mortality during pregnancy, a 25-50% risk for death.
Mitral valve prolapse - asymptomatic then can watch, symptomatic with chest pain/palpatations then treat with beta blocker
Hemoglobin H disease and beta thalassemia are characterized by moderate to severe anemia. Beta-thalassemia would have hemoglobin F as well as hemoglobin A2 on hemoglobin electrophoresis.
This patient has classic depression. The most commonly used antidepressants are the selective serotonin reuptake inhibitors (SSRIs). One SSRI, paroxetine (Paxil) has been changed to a category D drug because of the increased risk of fetal cardiac malformations and persistent pulmonary hypertension
pruritus gravidarum - mild variant of intrahepatic cholestasis of pregnancy - Antihistamines and topical emollients may provide some relief and should be used initially. Ursodeoxycholic acid relieves pruritus and lowers serum enzyme levels.
This patient has met criteria for the diagnosis of mild preeclampsia based on her persistent elevation of blood pressure and 24-hour urine results. The amount of protein excreted in the urine varies throughout the day, therefore a sample is collected over a 24-hour time period. Twenty-four hour urine protein values greater that 300 mg are required for the diagnosis of mild preeclampsia. Values greater than 5000 mg (or 5 g) are required for the diagnosis of severe preeclampsia (assuming no other defining criteria are present such as SBP >160 or DBP >110). This patient has not had a seizure which is the hallmark of eclampsia syndrome.