1. Reviewed x1
2. Ectopic Pregnancy
   1. Location
      1. Fallopian tube: 99%
      2. Others
         1. ovary
         2. outside fallopian tube
         3. cervix
         4. abdominal wall
         5. bowel
   2. Risk factors
      1. surgery
      2. PID
      3. becoming pregnant with IUD in place
      4. endometriosis
      5. prior ectopic pregnancy
      6. assisted reproductive technologies
   3. Diagnosis
      1. beta-hCG
         1. normal pregnancy: beta-hCG doubles every 48 hrs
         2. ectopic beta-hCG low for gestational age
      2. US may show ectopic pregnancy
   4. Treatment
      1. medical: methotrexate
         1. follow beta-hCG
            1. rise first few days
            2. fall days 4-7
            3. second dosage in no fall
         2. monitor for signs of rupture
            1. inc abd pain
            2. bleeding
            3. signs of shock
         3. indication
            1. patient stable
            2. small ectopic (< 4 cm)
            3. no fetal hearbeat
      2. surgical
         1. stabilize
         2. ex-lap
            1. salpingostomy
            2. salpingectomy
3. Spontaneous Abortion (Miscarriage)
   1. Definition
      1. pregnancy that ends before 20 weeks gestation (stillbirth after 20 wks)
      2. terminology
         1. abortus: fetus lost before 20 weeks; < 500 g or < 25 cm
         2. complete abortion: expulsion of all POC from uterus
         3. incomplete abortion: partial expulsion of some but not all POC
         4. inevitable abortion: no expulsion of products, but bleeding and cervical dilation make viable pregnancy unlikely
         5. threatened abortion: normal pregnancy with bleeding
         6. missed abortion: death of fetus, complete retention of all POC
   2. First trimester (1-12 wks)
      1. Causes
         1. chromosome abnormalities (60-80%)
         2. other factors
            1. infx
            2. maternal anatomical defects
            3. immunologic
            4. endocrine
      2. Diagnosis
         1. presentation
            1. most women: vaginal bleeding
            2. other findings
            3. cramping
            4. abd pain
            5. dec sx of pregnancy
         2. physical exam
            1. vital signs: r/o shock and fever
            2. pelvic exam
            3. other sources of bleeding
            4. changes in cervix leading to inevitable abortion
         3. labs
            1. beta hCG
            2. blood count, blood type, antibody screen
         4. ultrasound
      3. Treatment
         1. complete abortion
            1. follow
            2. passed tissue sent to pathology
            3. chromosome analysis
            4. look for all POC
         2. partial, missed, inevitable abortions
            1. expectant management
            2. D&C
            3. administration of prostaglandins (misprostol)
         3. threatened abortion
            1. follow with pelvic rest
            2. inc risk of
            3. preterm labor (PTL)
            4. preterm premature rupture of membranes (PPROM)
         4. RhoGAM for all Rh(-) women who experience vaginal bleeding during pregnancy
   3. Second trimester (12-20 wks)
      1. Causes
         1. maternal anatomic defects
         2. maternal systemic disease
         3. infection
         4. exposure to fetotoxic agents
         5. trauma
         6. Rule out causes of cervical dilation
            1. incompetent cervix: painless dilation
            2. treatment
            3. ceclage
            4. preterm labor: contraction + dilation
            5. treatment
            6. tocolysis
         7. NOT chromosomal abnormalities
      2. Treatment Depends on Scenario
         1. finish on their own
         2. D&C or D&E
         3. induction of labor
            1. high dose prostaglandins
            2. high dose oxytocin
   4. Recurrent pregnancy loss
      1. Definition
         1. 3 consecutive SABs
         2. probabilities
            1. P(SAB | 1 prior SAB) = 20-25%
            2. P(SAB | 2 prior SABs) = 25-30%
            3. P(SAB | 3 prior SABs) = 30-35%
      2. Pathogenesis
         1. Antiphospholipid Antibody Syndrome (15%)
         2. Luteal Phase Defect
         3. same as SABs
            1. chromosome abnormalities
            2. maternal anatomic defects
            3. maternal systemic illness
            4. infection
      3. Diagnosis
         1. Karyotype
            1. both parents
            2. POC from previous SABs
         2. Hysterosalpingogram
            1. if abn or nondiagnostic:
            2. laparoscopic exam or
            3. hysteroscopic exam
         3. Maternal screening tests
            1. hypothyroidism
            2. diabetes
            3. APA
            4. lupus anticoagulant
            5. anticardiolipin antibody
            6. Russell viper venom time (dRVVT)
            7. hypercoagulability
            8. SLE
            9. other labs
            10. factor V leiden
            11. prothrombin G20210A mutation
            12. antinuclear antibody
            13. antithrombin III
            14. protein S and protein C
         4. Progesterone level in luteal phase
         5. Cultures of vagina, cervix, endometrium to r/o infx
      4. Treatment
         1. chromosome abn: IVF w/ donor sperm or ova
         2. APA: low dose aspirin
         3. hypercoagulability: SQ heparin
         4. cervical insufficiency: cerclage
4. Incompetent Cervix
   1. Risk Factors
      1. cervical trauma, surgery
      2. congenital abnormality due to DES exposure
   2. Diagnosis
      1. rule out preterm labor (PTL)
      2. presentation
         1. cervix more dilated than expected with amount of contractions present on routine exam
         2. may have discharge, bleeding
   3. Treatment
      1. previable (<24 wks)
         1. expectant management
         2. elective termination
         3. emergent cerclage
            1. types
            2. McDonald: cervical-vaginal junction
            3. Shirodkar: internal os
            4. transabdominal ceclage
            5. complications
            6. PTL
            7. rupture of membranes
            8. infection
            9. offer elective cerclage if previous cervical incompetence
5. Differential Diagnosis of 1st trimester bleeding
   1. ectopic pregnancy
   2. spontaneous abortion
   3. postcoital bleeding
   4. vaginal or cervical lesions / lacerations
   5. extrusion of molar pregnancy
   6. nonpregnancy causes of bleeding