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This Concept Map, created with IHMC CmapTools, has information related to: SABs, First Trimester Bleeding SAB ងwk Recurrent AB -3+ SABs -ᡏ% risk of future SAB -Usually parental Xome ABNL -balanced translocation, First Trimester Bleeding SAB ងwk SAB -30% pregs end in SAB -70-80% at time of NL menses -15-20% of recognized pregs end Etiology -Chromosomal - mostly trisomy Infx -TORCH, Ureaplama, Mycoplasma, GC/CT, Listeria Uterina ABNL -septate/bicornuate - 25% Endocrine -dec'd progesterone -hypothyroidism -PCOS (too much LH) -DM-uncontrolled Immunologic -APLS -Lupus anticoagulant Env -Tob (ᡆcig/d), EtOH, Irradiation -Caffeine ɱcups/d, First Trimester Bleeding Gestational Trophoblastic Dz -pre-E ងwks -LARGE uterus for wga -painless bleeding ChorioCA -NO villi (unlike moles) -can be during or after preg, First Trimester Bleeding SAB ងwk Threatened AB -No passage of POC -Closed cervix, with blood -20-50% -> Complete AB, Partial Mole-69XXY -has fetal parts -1/50,000 in US -2% malignant -villi vessels -some edema in villi Tx D&C or hysterectomy -r/o invasion -CXR for lungs mets -LFTs for liver mets -hCG qwk until NL x 3wk, then monthly x 6mo, then yearly for 3 yr CTX MTX or Actinomycin D, First Trimester Bleeding SAB ងwk Complete AB -Passage of POC -No more pain -Uterus contracted -Open or closed Cervix -No retained POC -May need D&C if 8-14wga -Observe for fever, bleeding -RhoGAM, r/o ectopic, First Trimester Bleeding SAB ងwk Septic AB -complete or incomplete AB w/ infx -S. aureus, E.coli, gram (-) -pelvic pain, fever, peritoneal Sx Tx: D&E, IV ABX, IVF, Complete Mole-46XX -1/5000 in US -1/200 in Mexico -1/125 in Taiwan -10-15% malignant -no vessels in villi -LOTS OF VILLI EDEMA Tx D&C or hysterectomy -r/o invasion -CXR for lungs mets -LFTs for liver mets -hCG qwk until NL x 3wk, then monthly x 6mo, then yearly for 3 yr CTX MTX or Actinomycin D, First Trimester Bleeding SAB ងwk Inevitable AB -Bleeding, cramps -OPEN CERVIX -Expulsion imminent Tx wks: immed. D&E RhoGAM, First Trimester Bleeding Ectopic Pregnancy Tx: RhoGAM if needed Medical -if (-)Sx, b-hCG,000, f/u, tubal ringɛcm, no FHTs Rx:Methotrexate Surgical -Sx, hemodynamic instability -Laparoscopy w/ salpingostomy, First Trimester Bleeding DDx SAB Ectopic Pregnancy Hydatidaform Mole Benign/Malignant Lesions -cervical, fibroids, First Trimester Bleeding Gestational Trophoblastic Dz -pre-E ងwks -LARGE uterus for wga -painless bleeding Placental Site Trophoblastic Tumor -myometrium invaded by trophoblasts -hPL (+), hCG slightly elevated Tx: TAH + CTX -MTX or MAC or EMACO, First Trimester Bleeding Gestational Trophoblastic Dz -pre-E ងwks -LARGE uterus for wga -painless bleeding Invasive Mole MALIGNANT -invades myometrium Bad Px: -hCG,000 ɰmo from preg -wide mets (brain, liver) -failed with one CTX -after full term delivery, First Trimester Bleeding Gestational Trophoblastic Dz -pre-E ងwks -LARGE uterus for wga -painless bleeding Complete Mole-46XX -1/5000 in US -1/200 in Mexico -1/125 in Taiwan -10-15% malignant -no vessels in villi -LOTS OF VILLI EDEMA, First Trimester Bleeding Gestational Trophoblastic Dz -pre-E ងwks -LARGE uterus for wga -painless bleeding Partial Mole-69XXY -has fetal parts -1/50,000 in US -2% malignant -villi vessels -some edema in villi, First Trimester Bleeding Ectopic Pregnancy Mostly in Tubes (78% ampullary) 2% of pregnancies 7-13-fold recurrence risk More common in AMA Leading cause of preggers death, First Trimester Bleeding SAB ងwk Missed AB -Retained POC after fetal demise -Vaginal d/c-brown/bloody -Closed cervix Px-most will deliver w/in 2wk -DIC can occur Tx-Induce/deliver -Pitocin/Misoprostol -Sched. D&C if 1st trimester -RhoGAM if needed, First Trimester Bleeding Ectopic Pregnancy PE: Vaginal bleeding, adnexal mass/tenderness -peritoneal S/Sx (rupture) Dx: Quant hCG ឲ% increase q48hr -inadequate rise suggests ectopic Progesterone ɝng/mL - ABNL preg (NL ᡑ) TVU/S - should detect IUP at 4-6wga or hCG TAU/S-should detect at hCG ɱ-6000, First Trimester Bleeding SAB ងwk Incomplete AB -Passed some POC -Cramping, bleeding -Enlarged, boggy uterus -Open cervix, POC visible Tx: Stabilize bleeding -Blood Type and cross -RhoGAM if needed -Remove POC, D&C -Methergine + ABX