• Impending abortion
• Ectopic pregnancy
• Severe cervicitis
• Cervical lesions
• Cervical polyp
• Postcoital bleeding
• Spotting during implantation
• Subchorionic bleed
• Demise of a twin
• Hydatiform mole (rare)

• placenta previa
• placental abruption
• vasa previa

abortion is premature birth before a live birth is possible, and in this sense it is synonymous with miscarriage. It also means an induced pregnancy termination to destroy the fetus.

National Center for Health Statistics, the Centers for Disease Control and Prevention, and the World Health Organization define abortion as pregnancy termination prior to 20 weeks' gestation or with a fetus born weighing less than 500 g

• Low back pain or abdominal pain that is dull, sharp, or cramping

• Tissue or clot-like material that passes from the vagina

• Vaginal bleeding, with or without abdominal cramps

  
  

• Dilation and/or effacement of cervix

• Ultrasound - FHT? normal development?  amount of bleeding?

• Tissue or clot-like material may be in the vagina

• Vaginal bleeding

• Blood type (if you have an Rh-negative blood type, you would require a treatment with Rh-immune globulin. See: Rh incompatibility)

• Complete blood count (CBC) to determine how much blood has been lost

• HCG (qualitative) to confirm pregnancy

• HCG (quantitative) done every several days or weeks

• WBC and differential to rule out infection

• Counseling/Education:

• Assess her support system.  Who is at home to support her?  Refer to SW if she is interested.  

• Reassure her that miscarriage is incredibly common - ⅓ of pregnancies and this does not mean that she can’t stay pregnant in the future.  

• Her cycle will return in 4-6 weeks and she can try to get pregnant again or she can take all the time she needs to process this loss.

• Teach s/s infection

• Anticipatory guidance that she may bleed and need to use pads.  If she is farther along or uncomfortable, she can stay in the clinic.  She may pass a large clot/fetal tissue.  Some women don’t expect this.   

• • When a miscarriage occurs, the tissue passed from the vagina should be examined to determine if it was a normal placenta or a hydatidiform mole. It is also important to determine whether any pregnancy tissue remains in the uterus.

  • If the pregnancy tissue does not naturally exit the body, the woman may be closely watched for up to 2 weeks. Surgery (D and C) or medication (such as misoprostol) may be needed to remove the remaining contents from the womb. Monitor for infection.

  • After treatment, the woman usually resumes her normal menstrual cycle within 4 - 6 weeks. Any further vaginal bleeding should be carefully monitored. It is often possible to become pregnant immediately. However, it is recommended that women wait one normal menstrual cycle before trying to become pregnant again.

    
    

• It is often possible to become pregnant immediately. However, it is recommended that women wait one normal menstrual cycle before trying to become pregnant again.

  
  

The timing and extent of evaluation of women with recurrent miscarriage is based on maternal age, coexistent infertility, symptoms, and the level of anxiety.

With otherwise normal findings, we perform tests including parental karyotyping, uterine cavity evaluation, and testing for antiphospholipid antibody syndrome.

60 to 70 percent had a successful subsequent pregnancy with no treatment.

pregnancy test.

depending on the situation. need to r/o ectopic pregnancy, SAB or hydatidiform mole

A. Cervicitis – Infections of the endocervix caused by a variety of organisms including: Chlamydia, trichamonas, gonorrhea. The cervix is reddened with profuse purulent discharge.

B. Erosions – loss of superficial layers of squamous epithelium, may be friable and bleed on contact.

a. Spec Exam: discharge, cervix with erythema/friable, lesions

b. Lab: pap, GC, CT, Wet prep, maybe Hct (if severe bldg)

a. Treat offending organism

b. No organism identified – may treat with clindamycin 2% cream for any non-specific vaginitis

a. uncertain

b. chronic inflammation

c. local vascular congestion

d. hyperestringinism

e. malignancy is rare ~ 1%

a. usually avoid tx until postpartum unless bleeding enough to cause anemia (often resolves with birth)

b. pap

c. Hct (rare: depending on amount of bleeding)

d. Education: draw/show picture etc.

e. MD mgt – hemostat and twist. (CNM can do this) electrosurgical excision if large, send polyp to pathology. D&C if pedicle not visible

Later in the first trimester and early second trimester, the subchorionic hematoma may partially strip the developing placenta away from its attachment site and cause miscarriage.

Pregnancy outcome associated with subchorionic hematoma appears to depend upon location, with worse outcomes for retroplacental than marginal hematomas.

Most hematomas resolve, but they are linked to higher risks of placental abruption and preterm labor so we should provide solid education on danger signs but don’t need to make her overly concerned.  

1. Age >40 or adolescence

2. Residence:

a. US and Europe 1:1500-1:2000

b. Asia, Indonesia, Taiwan, Phillippines have much higher incidence, 1.5-2.5 times greater than American rates (S.E. Asia 1:500)

*per Williams, higher rates in US Hispanic and Native American women

*also mentions higher rates in OCP users

3. Previous molar pregnancy: 1:500

1. Vaginal Bleeding

a. 90-97% experience abnormal uterine bleeding

b. may begin as early as 8 wks after LMP

c. frequently described as being “like prune juice”

d. champagne grape-like vesicles may be passed

2. Pregnancy Symptoms

a. 20-26% have excessive vomiting/hyperemesis

b. no fetal movement

1. VS – B/P may be elevated if preeclampsia develops. 10-27% become preeclamptic. If preeclampsia develops in early pregnancy the diagnosis of exclusion is mole.

2. General Exam – S/Sx of dehydration and weight loss if excessive vomiting present.

3. Abdominal Exam

a. uterus larger than expected for dates in 40-50%

b. uterus is enlarged from proliferating trophoblastic tissue and clotted blood

c. S=D in 30% S<D in 15-20%

d. FHT’s absent

4. Pelvic Exam

a. Speculum – blood or grape-like vesicles in vagina or cervix

b. Bimanual

i. S>D *may feel “softness” of uterus

ii. 15-25% develop enlarged, tender ovaries/thecalutein cysts

1. Anemia is common

2. UA with proteinuria suggests preeclampsia

3. Beta HCG-quantitative, is dramatically elevated. It is also elevated with multiple gestations so it does not discriminate

1. diagnosis is usually made around 10-12 wks into pregnancy

2. Ultrasound scan 98% accurate in making diagnosis

3. Consult with MD if suspicious, when diagnosis established REFER for immediate termination *usually uterine evacuation/curettage, with f/u to detect persistent trophoblastic disease

Patient should not get pregnant for 1 year

Depending on when the pt presents, may be abdominal/pelvic pain (usually more on one side than the other, not bilateral/midline) generally persistent and worsening with time and not improving with rest or medication, bleeding/spotting, cervical motion tenderness, pooling in posterior fornix, “decidual cast,” pain on vag exam.  

Sx of a ruptured ectopic are shoulder pain radiating down the arm, shock-y (low BP, tachy, dizzy), may appear pale/diaphoretic, diarrhea possible d/t peritoneal irritation from hemorrhage.

unknown;

risk factors include hx PID, smoking, previous ectopic, surgery (e.g., oophorectomy), fertility issues/tx, TL/IUD

• maternal HTN disorders, 
• AMA or parity, 
• maternal smoking, 
• poor maternal nutrition, 
• chorioamnionitis, 
• blunt abdominal trauma, 
• hx of previous abruption, 
• sudden decrease in uterine volume or size- ROM in polyhydraminos or between delivery of twins or multiples, 
• ECV, 
• cocaine (crack cocaine in particular) usage

• generalized back pain, colicky, discoordinate UCs, can be mistaken for PTL or false labor. 
• painful localized or generalized uterine tenderness, 
• FM may be decreased or absent or have violent FM with large bleeds.

• Classic hypertonic, boardlike uterus and uterine rigidity occur with a large abruptions. (I have had pt get an epidural with a partial abruption and that one spot on their uterus is still painful and firm in between CTXs even with the epidural). 
• FHR may be normal or variables, late decels or sinusoidal rhythm.
• SXS of shock
• enlarging uterus d/t concealed bleed.

PTL

Early labor

Previa 

• MD consult and immediate delivery- if small bleed vaginal delivery may be feasible. If Preterm with small bleed consider tocolytics and Mag to get BMZ on board. 
• Send: CBC, PT, PTT and INR, fibrinogen, Type and screen for possible transfusion.

Can you do a speculum exam if you suspect a placental abruption?

What about a digital exam?

Speculum exam, especially if she is late to care and you have not r/o previa

Digital exam, after confirmation of no previa with small bleed check for dilation if vaginal birth is feasible.

What is placenta previa?

What are the three categories of previa?

Malposition of the placenta in the lower uterine segment, either anteriorly or posteriorly, so that the fully developed placenta extends into the cervical os.

1. Complete or central means the body of the placenta completely covers the cervical os.

2. Partial means partially covered os.

3. Marginal means near the os but not actually covering it.

multips

AMA

previous preg with placenta previa

previous uterine surgery (incl C/S)

multiple gestations

and/or smoking.

cardinal sign is painless vaginal bleeding w a sudden onset.

Occurs during 3rd tri, may be accompanied by uterine irritability. Malpresentation is a common finding.

- Duration of treatment

- People with latent TB don't want to be treated for a disease with no symptoms

- Access to care

- Language and cultural barriers

- Other underlying medical conditions or substance abuse

- Delayed detection

1. Immediate clearance

2. Rapid progression to active disease (primary disease)

3. Latent infection w/reactivation

4. Latent infection w/o reactivation

Pregnant women with tuberculosis have been noted to have an increased incidence of preeclampsia, vaginal bleeding, early fetal death, prematurity, small for date, low birth weight, and low APGAR scores and perinatal death compared with pregnant women without tuberculosis.

Statistically significant increases in the neonatal morbidity rate and number of adverse obstetric outcomes have been demonstrated in pregnant woman with tuberculosis compared with a matched control group of nontuberculous pregnant women.

Risk of passing TB to fetus and newborn.

Women diagnosed with active TB will need treatment during pregnancy and will need to be isolated from others until the TB is no longer contagious.

Isoniazid + Rifampin for 9 months

OR

pyrazinamide+Isoniazid + Rifampin for 6 months