- < 18 years old

- > 35 years old

- Previous obstetrical problems (several abortions, previous toxemia).

- Pre-existing medical problems (hypertension, diabetes, heart problems).

- Lower socioeconomic group (poverty).

- High parity (multi paras).

- Abuse of drugs or alcohol.

- Pregnant before 1 year from previous pregnancy.

1. Ectopic pregnancy.

The word ectopic means it originates from a source other than the original. This is an extrauterine pregnancy. POC are going to implant in a site other than the endometrium.

Sites:

Most common in the Right Fallopian tube.

Ovaries.

Cervix.

Abdominal cavity (peritoneal cavity).

Occurs in 1 out of 200 pregnancies. In inner cities, it is 1 in 80.

Ranks 2nd as cause of bleeding in early pregnancy.

S&S develop by 10 weeks gestation.

By 12 weeks, there are overt signs.

Cell division goes on like it is supposed to but is does not pass thru the Fallopian tube. Fallopian tube will eventually rupture.

Prognosis is good unless mom doesn’t catch it in time.

Fetus does not survive because it does not implant.

The following can predispose a woman to Ectopic pregnancies:

Adhesions (scar tissue) from PID.

IUD increases the incidences.

Adhesions from prior pelvic surgery.

Low levels of estrogen and progesterone (delays transport of zygote).

S&S:

All signs of early pregnancy.

Also can be asymptomatic.

Pelvic discomfort (from zygote growing) to a dull ache.

Sharp, stabbing pain in LQ when it is about to rupture.

When rupture the woman may show S&S of shock.

Abdomen gets rigid because any bleeding into muscle causes it to get hard.

Very little external bleeding.

"Bathroom sign" is blood that collects in the cul-de-sac of Douglas and makes the woman feel like she need to have a BM.

Cullen sign is a bluish tinge around the umbilicus from extensive bleeding.

Vaginal ultrasound.

Hgb and Hct.

HCG test - most levels are lower than in normal pregnancy.

Could be (-).

HCG serum test will show (+).

Culdoscopy - light to look into vagina.

Culdocentesis - needle inserted into the vagina and stuck thru the wall of the cul-de-sac of Douglas the see if blood has accumulated there.

Treatment:

Before surgery, a Foley is put in.

Surgery.

Usually have to remove tube (salpingectomy).

Usually on prophylactic antibiotics. (Old blood is an excellent media for the growth of bacteria).

* Bleeding also causes anemia and lowers the effectiveness of the immune system.

* Bleeding in the abdominal cavity can cause peritonitis. Massive doses of antibiotics have to be used. We are concerned with fever (first day it is normal to have a slight increase in temp) of 102-105. We listen for bowel sounds (a paralytic illeus is common post-op) and we palpate the abdomen to see if it is rigid and tender.

* Rh(-) mom automatically gets RhoGAM.

Interruption of pregnancy before fetus is viable. Weight of fetus is most important to determine viability. 500 grams (20 weeks) to 600 grams (24 weeks) is considered viable. Age of viability is defined by each state. In North Carolina, it is 24 weeks.

A. Stillbirth: intrauterine fetal death of an immature but viable fetus. Born without signs of life.

B. Neonatal death: died before 28 days of life. Shows signs of life at birth, but then dies.

C. Miscarriage: used by lay person to describe a spontaneous abortion occurring at the age of viability.

D. Induced Abortion: elective Ab done before age of viability (or it is considered illegal).

Types of Abortions:

A. Spontaneous: begins from natural causes. Some sort of defect with the embryo. Faulty ovum, ovum rejected by the endometrium, problems with implantation, infection, malnourished, incompetant cervix, hormone imbalence. 75% or more occur between 8-12 weeks. She may not even be aware of the pregnancy.

S&S:

Vaginal bleeding in 1st 20 weeks is most common.

Dark spotting and then frank bleeding.

Lower abdominal cramping.

Classifications:

A. Threatened spontaneous Ab: one that can happen, but has not happened yet. MD will check the cervix (not dilated) and haven't lost POC. Put on bed rest 24-48 hours, no sex, no straining, no laxatives, pad count. Save any tissue passed. Will look at it to see if all POC has passed or is it just clots. Clots are shiney and can pull apart. Tissue looks like chopped liver and cannot be pulled apart.

B. Complete Ab: all POC are expelled.

C. Incomplete Ab: threatened Ab can lead to this. Not all POC are expelled. Will do a D&C (dilation and currettage). Done on outpatient basis and highly sedated.

Back from recovery:

Pad count = how many and the degree of saturation.

Vitals.

No sex for 4-6 weeks.

No tampons.

Mild analgesic for cramping.

D. Missed or retained Ab: early fetal intrauterine death. POC are not expelled. Cervix is closed. Dark brown vaginal discharge. 2-3 months may go by before fetus is expelled. Will have a leather-like appearance. If spontaneous labor does not occur, it is indiced and may have a D&C.

E. Habitual Ab: have had 3 or more consecutive Ab's. Cheif cause is an incompetant cervix. Usually occurs between 16-20 weeks. Cerclage procedure uses a suture to close the cervix (also called Shirodkar). Will stay in place until person goes in labor. This is usually a good way to prevent abortion.

F. Induced Ab: artificially induced. Can be therapeutic and are legal. Can also be criminal, however. Some people use laxatives, castor oil, coat hangers, and quinine. Can hemorrhage to death or get an infection.

Therapeutic used when mom’s life is in danger or baby has congential anomalies.

In 1973, elective Ab was right of woman. Must be available in all states for women who are not more than 12 weeks. States can decide (Roe vs. Wade) on the specifics. During 1st 12 weeks the state could not barr a woman from an Ab by a MD. Between 12 - 20 weeks states could regualte Ab to protect woman’s health. After 20 weeks, the state could regulate and prohibit Ab except in those cases when Ab is necessary to save mother’s health and life.

Partial birth Ab: suck brains out of head of normal baby at term, then mom delivers rest of baby.

1. D&E: dilation of cervix and evacuation of uterus. After care is same as D&C.

2. D&C: dilation and curetage.

3. Trans abdominal prostiglandin insertion. Injected thru abdominal wall into the amniotic fluid and labor will begin 1-2 hours after.

4. Saline Ab: Go in abdomen, remove amniotic fluid and will inject hypertonic solution of saline and contractions will start in 8-12 hours. May give oxytocin. Not done very much now because a woman can get some of the saline in the bloodstream.

5. Dilate cervix with a rod of absorbant material that swells and one the cervix is open, a prostaglandin suppository is inserted in the vaginal canal. Uterine contractions start. This is the safest and most effective way.

Hemorrhage is the biggest problem after any Ab. Check vitals and may have to have blood replacement.

Infection and Peritonitis are also concerns. For infection, look for fever and foul odor drainage.

** You have to decide how you feel about abortion. You do have a right, the if you do not feel right about Ab, you do not have to participate if there is someone to relieve you.

Gestational trophoblastic neoplasm. Benign growth of the trophoblastic cells. The placental chorionic villi will undergo abnormal degenerative changes. These villi will proliferate (grow rapidly) in the uterus and form grape-like clusters. These vesicles have clear fluid and will eventually fill the entire uterus. A calcified embryo may or may not be found. Because the chorionic villi rapidly produce, a large amount of HCG is produced.

It is not know what causes it.

Possibly caused by malnutrition, genetics, defected ovum.

Will see more in women <18, >40, Asian, Mexican and Indian, and those on fertility drugs. Occurs 1 in 2000 pregnancies.

S&S:

Will present as usual pregnancy.

N/V that is more severe.

Will get sicker earlier in pregnancy and stay sicker longer.

Abnormally rapidly growing uterus.

No FHR.

HCG very high.

Signs of PIH at 20th week.

Diagnosis:

Ultrasound.

HCG levels of blood serum.

Treatment:

Must be evacuated.

1st trimester = D&C.

2nd trimester = Hysterotomy or D&E.

Prone to hemorrhage after procedure because uterus is boggy.

Will be going thru grieving process. Will have fear of malignancy. Benign could go thru malignant changes and can become choriocarcinoma.

These women are advised not to become pregnant for a minimum of 1 year.

Weekly (sometimes twice a week) HCG levels are checked after removal until she has 3 (-) HCG levels in a row. Then she’ll go monthly and if (-), then every 2 months.

If Rh(-) she is given RhoGAM.

Not put on oral contraceptives because they can distort HCG titers.