Session 1

Assignment: Ectopic Pregnancy– epidemiology, how does it occur, risk factors, signs & symptoms,  PE findings present, and how do you diagnose it?

Epidemiology: Incidence of ectopic pregnancy is about 2/100 diagnosed pregnancies.

Pathophysiology: Typically egg leaves ovary and travels to tube and becomes fertilized by sperm, which implants in endometrium of uterus. In ectopic pregnancy, fertilized egg implants outside uterus, usually fallopian tube (96%). Other sites include abdomen, ovary and cervix.

Risk Factors:

Factor	Odds Ratio (95% CI)
Prior ectopic pregnancy (3-8 fold higher)	12.5 (7.5, 20.9)
Prior tubal surgery	4.0 (2.6, 6.1)
Smoking >20 cigarettes per day	3.5 (1.4, 8.6)
PID confirmed by laparoscopy or positive test for Chlamydia trachomatis	3.4 (2.4, 5.0)
≥3 prior miscarriages	3.0 (1.3, 6.9)
Age ≥40 years	2.9 (1.4, 6.1)
Prior medical or surgical abortion	2.8 (1.1, 7.2)
Infertility >1 year	2.6 (1.6, 4.2)
Lifelong sexual partners >5	1.6 (1.2, 2.1)
Prior IUD use	1.3 (1.0, 1.8)

 

S/Sx:

Clinical presentation: woman of reproductive age, presenting with acute abdominal pain w/ or w/o  vaginal bleeding. In any presentation similar to this, an ectopic pregnancy must be ruled out because it is life threatening.

Clinical Presentation depends on where, symptomatic or asymptomatic, ruptured or not.

Clinical Presentation is often asymptomatic. But symptomatic may include abdominal pain (can be very severe) w/ vaginal bleeding, nausea, shoulder pain indicating ruptured (due to diaphragm irritation so refers pain), and amenorrhea.

Physical exam will also depend on if they’re symptomatic or not and if ectopic pregnancy is ruptured or not. Cervical motion tenderness, unilateral or bilateral adnexal tenderness, or an adnexal mass may be present. The uterus may be slightly enlarged (but often less than anticipated based on date of the last menstrual period). Ruptured ectopic will have tachycardia, hypotension,  and signs of shock and peritonitis (indicating irritation of peritoneum).

Diagnosis:

Source:

1. Ectopic Pregnancy. In: Hoffman BL, Schorge JO, Halvorson LM, Hamid CA, Corton MM, Schaffer JI. eds. Williams Gynecology, 4e New York, NY: McGraw-Hill; . http://accessmedicine.mhmedical.com.york.ezproxy.cuny.edu/content.aspx?bookid=2658&sectionid=220754945.
2. https://www.merckmanuals.com/professional/gynecology-and-obstetrics/abnormalities-of-pregnancy/ectopic-pregnancy#v1074077
3. Pance Prep Pearls

 

 

Session 2

Assignment: Discuss Vasa Previa 

Vasa previa can occur on its own or with placental abnormalities, such as a velamentous cord insertion. In velamentous cord insertion, vessels from the umbilical cord run through part of the chorionic membrane rather than directly into the placenta. Thus, the blood vessels are not protected by Wharton jelly within the cord, making fetal hemorrhage more likely to occur when the fetal membranes rupture.

Prevalence is about 1/2500 to 5000 deliveries. Fetal mortality rate may approach 60% if vasa previa is not diagnosed before birth.

Symptoms and Signs:
The classic presentation of vasa previa is painless vaginal bleeding, rupture of membranes, and fetal bradycardia.

Diagnosis:

• Transvaginal ultrasonography

The diagnosis of vasa previa should be suspected based on presentation or results of routine prenatal ultrasonography. At presentation, the fetal heart rate pattern, commonly sinusoidal, is usually nonreassuring. The diagnosis is typically confirmed by transvaginal ultrasonography. Fetal vessels can be seen within the membranes passing directly over or near the internal cervical os. Doppler color flow mapping can be used as an adjunct.

Vasa previa must be distinguished from funic presentation (prolapse with the umbilical cord between the presenting part and the internal cervical os), in which fetal blood vessels wrapped with Wharton jelly can be seen covering the cervix. In funic presentation, unlike in vasa previa, the umbilical cord moves away from the cervix during ultrasound evaluation; in vasa previa, the cord is fixed in place.

Treatment:

• Prenatal monitoring to detect cord compression
• Cesarean delivery

Prenatal management of vasa previa is controversial, partly because randomized clinical trials are lacking. At most centers, nonstress testing is done twice a week beginning at 28 to 30 weeks. The purpose is to detect compression of the umbilical cord. Admission for continuous monitoring or for nonstress testing every 6 to 8 hours at about 30 to 32 weeks is often offered.

Corticosteroids are used to accelerate fetal lung maturity.

Emergency cesarean delivery is usually indicated if any of the following occurs:

• Premature rupture of the membranes occurs.
• Vaginal bleeding continues.
• Fetal status is non-reassuring

If none of these problems are present and labor has not occurred, clinicians can offer to schedule cesarean delivery. Cesarean delivery between 34 to 37 weeks has been suggested, but the timing of delivery is controversial; some evidence favors delivery at 34 to 35 weeks.

 

Source:

1. https://www.merckmanuals.com/professional/gynecology-and-obstetrics/abnormalities-of-pregnancy/vasa-previa

 

 

Session 3

Assignment: Pick an ObGyn article/study and summarize it

Treatment of Endometriosis-Associated Pain with Elagolix, an Oral GnRH Antagonist

ObGyn Article Summary