Internal Medicine

0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:57

1202 Pregnancy Complications for the Internist

Imaging

■Transvaginal US: more helpful than transabdominal US to assess

intrauterine content and pelvis, adnexal mass or fetal cardiac activity,

fluid or clots in pelvis, placenta previa

differential diagnosis

■Normal intrauterine pregnancy (IUP)

■Abortion: threatened, missed, inevitable (complete/incomplete),

septic

■Gestational trophoblastic neoplasia (GTN): confirmed on US with

characteristic “snowstorm” pattern

■Ectopic pregnancy: potentially life- and fertility-threatening

■Preeclampsia/eclampsia

■Placental abruption

■Membrane rupture

management

What to Do First

■Beta-HCG (+)

■Order US

■Assess stability of patient: if unstable go straight to OR

■Assess risk factors for ectopic pregnancy: higher with history of prior

ectopic, PID, STD, abdominal/pelvic surgery, infertility, poststeril-

ization

■Assess likelihood of IUP vs ectopic pregnancy

General Measures

■Threatened & missed abortion: IUP, cervical os closed and minimal

bleeding

■Inevitable abortion: os open, usually bleeding, assess likelihood of

complete vs incomplete

■Septic abortion: start antibiotics before D&C

■GTN:

➣CXR

➣Assess high or low risk for persistent GTN post D&C: high risk

factors include eclampsia, acute pulmonary insufficiency, theca-

lutein cysts >5 cm, uterus >20 wks, coexistent fetus, uterus large

for dates, beta-HCG >100,000 IU/mL, maternal age >40 y

➣Suspected ectopic pregnancy:

➣If stable with positive beta-HCG and no IUP seen on US, obtain

quantitative beta-HCG and rapid serum progesterone