This document discusses vaginal bleeding before 20 weeks of gestation. It covers several topics:
1) Pregnancy loss or miscarriage is the most common cause of bleeding in early pregnancy. Miscarriage can be diagnosed by ultrasound findings such as no cardiac motion or empty gestational sac.
2) Management options for early pregnancy loss include expectant management, medication (mifepristone and misoprostol), and procedural options like uterine aspiration. Clinically stable patients can choose any option.
3) Ectopic pregnancy and molar pregnancy are other potential causes of early pregnancy bleeding that require different procedural management approaches.
This document discusses vaginal birth after cesarean (VBAC) and provides guidelines on when it is appropriate and safe. It defines VBAC and outlines the benefits of reducing morbidity for both mother and baby compared to repeat cesarean sections. Risk factors for uterine rupture are identified such as previous classical or complicated uterine scars. Ultrasound can assess lower uterine segment thickness which may predict rupture risk. Induction or augmentation of labor in VBAC is associated with higher rupture rates. Close monitoring during labor is important to quickly identify signs of rupture. VBAC is generally safe for one previous low transverse incision but risks are higher for two or more prior sections.
This document discusses caesarean section (CS), including its risks, benefits, indications, and surgical technique. It covers topics such as the rising CS rate globally and factors influencing it, contraindications for CS, categories of urgency, optimal timing for elective CS, and techniques to minimize risks like infection and blood loss. Surgical steps are outlined in detail, from skin incision to uterine closure. Overall, the document provides a comprehensive overview of CS for medical professionals.
Some important questions in obstetrics and gynecologyAboubakr Elnashar
1. A retrospective study of 1,242 women found that performing myomectomy during cesarean section was as safe as cesarean section alone and did not result in increased complications. Smaller studies also found caesarean myomectomy to be safe and that it did not affect future fertility or pregnancy outcomes.
2. For infertile women over 35 years old, an initial evaluation including tests like TSH should be done. If no cause is found, ovulation induction with letrozole may be considered.
3. For infertile women whose husband is only present 2-3 months per year, timing intercourse with the fertility cycle and options like IUI or storing semen for future IUI
This document provides guidelines on cervical cerclage from the Royal College of Obstetricians and Gynaecologists. It recommends that women with singleton pregnancies and three or more previous preterm births should be offered a history-indicated cervical cerclage. It also recommends that women with a history of spontaneous second trimester loss or preterm birth may be offered cervical length monitoring and possible ultrasound-indicated cerclage if shortening is detected. For women with no risk factors and an incidentally found short cervix, cerclage insertion is not recommended. Emergency cerclage may delay birth by 34 days on average compared to expectant management.
This study compared outcomes of cesarean scar pregnancies (CSP) implanted on the scar versus in the niche. Of 17 CSP cases, 6 were implanted on the scar and 11 in the niche. Those implanted on the scar had better outcomes: they did not develop morbidly adherent placenta and 5/6 delivered via c-section. Those implanted in the niche all developed morbidly adherent placenta and required hysterectomy, with 10/11 having placenta increta/percreta. CSP implanted in the niche may have worse outcomes than those implanted directly on the scar.
This document discusses breech presentation and external cephalic version (ECV). It provides information on the causes and risks of breech presentation as well as management options. ECV is recommended to attempt to turn breech babies, with success rates around 50% depending on factors like multiparity. ECV carries a low risk of complications when performed by trained practitioners with safety precautions like ultrasound and monitoring. Planned c-section is recommended if ECV fails or is contraindicated due to risks, though some women may opt for planned vaginal delivery.
This document discusses post-term pregnancy, defined as a pregnancy extending beyond 42 weeks from the last menstrual period. It notes that the incidence of post-term pregnancy ranges from 4-14% and can be caused by inaccurate dating, biological variability, or placental aging. Diagnosis involves assessing the patient history, weight, abdominal girth, and fetal size and position. Potential complications for both mother and baby include fetal distress, meconium aspiration, shoulder dystocia, and increased risk of operative delivery. Management of uncomplicated post-term pregnancy involves fetal surveillance and selective induction at 41 weeks, while complicated cases may require cesarean section.
This document discusses vaginal birth after cesarean (VBAC) and provides guidelines on when it is appropriate and safe. It defines VBAC and outlines the benefits of reducing morbidity for both mother and baby compared to repeat cesarean sections. Risk factors for uterine rupture are identified such as previous classical or complicated uterine scars. Ultrasound can assess lower uterine segment thickness which may predict rupture risk. Induction or augmentation of labor in VBAC is associated with higher rupture rates. Close monitoring during labor is important to quickly identify signs of rupture. VBAC is generally safe for one previous low transverse incision but risks are higher for two or more prior sections.
This document discusses caesarean section (CS), including its risks, benefits, indications, and surgical technique. It covers topics such as the rising CS rate globally and factors influencing it, contraindications for CS, categories of urgency, optimal timing for elective CS, and techniques to minimize risks like infection and blood loss. Surgical steps are outlined in detail, from skin incision to uterine closure. Overall, the document provides a comprehensive overview of CS for medical professionals.
Some important questions in obstetrics and gynecologyAboubakr Elnashar
1. A retrospective study of 1,242 women found that performing myomectomy during cesarean section was as safe as cesarean section alone and did not result in increased complications. Smaller studies also found caesarean myomectomy to be safe and that it did not affect future fertility or pregnancy outcomes.
2. For infertile women over 35 years old, an initial evaluation including tests like TSH should be done. If no cause is found, ovulation induction with letrozole may be considered.
3. For infertile women whose husband is only present 2-3 months per year, timing intercourse with the fertility cycle and options like IUI or storing semen for future IUI
This document provides guidelines on cervical cerclage from the Royal College of Obstetricians and Gynaecologists. It recommends that women with singleton pregnancies and three or more previous preterm births should be offered a history-indicated cervical cerclage. It also recommends that women with a history of spontaneous second trimester loss or preterm birth may be offered cervical length monitoring and possible ultrasound-indicated cerclage if shortening is detected. For women with no risk factors and an incidentally found short cervix, cerclage insertion is not recommended. Emergency cerclage may delay birth by 34 days on average compared to expectant management.
This study compared outcomes of cesarean scar pregnancies (CSP) implanted on the scar versus in the niche. Of 17 CSP cases, 6 were implanted on the scar and 11 in the niche. Those implanted on the scar had better outcomes: they did not develop morbidly adherent placenta and 5/6 delivered via c-section. Those implanted in the niche all developed morbidly adherent placenta and required hysterectomy, with 10/11 having placenta increta/percreta. CSP implanted in the niche may have worse outcomes than those implanted directly on the scar.
This document discusses breech presentation and external cephalic version (ECV). It provides information on the causes and risks of breech presentation as well as management options. ECV is recommended to attempt to turn breech babies, with success rates around 50% depending on factors like multiparity. ECV carries a low risk of complications when performed by trained practitioners with safety precautions like ultrasound and monitoring. Planned c-section is recommended if ECV fails or is contraindicated due to risks, though some women may opt for planned vaginal delivery.
This document discusses post-term pregnancy, defined as a pregnancy extending beyond 42 weeks from the last menstrual period. It notes that the incidence of post-term pregnancy ranges from 4-14% and can be caused by inaccurate dating, biological variability, or placental aging. Diagnosis involves assessing the patient history, weight, abdominal girth, and fetal size and position. Potential complications for both mother and baby include fetal distress, meconium aspiration, shoulder dystocia, and increased risk of operative delivery. Management of uncomplicated post-term pregnancy involves fetal surveillance and selective induction at 41 weeks, while complicated cases may require cesarean section.
Optimising Delivery Of 1kg Fetus - Special Considerations.pptxNiranjan Chavan
After an uncomplicated vaginal birth in a health facility, healthy mothers and newborns should receive care in the facility for at least 24 hours after birth.
This document discusses evidence-based individual decision making (EBID) in obstetrics and gynecology. It emphasizes that evidence-based medicine (EBM) integrates the best available research evidence, clinical expertise, and patient values and preferences. While randomized controlled trials provide the strongest level of evidence, individual patient circumstances may differ. The document notes gaps between research evidence and clinical practice. It concludes that best research evidence, assessment of maternal risk, and good clinical judgment are needed to prevent adverse pregnancy outcomes through EBID.
This document summarizes information about vaginal birth after cesarean (VBAC) including success rates, benefits, risks of VBAC and repeat cesarean section, predictors of successful VBAC, and recommendations for selecting VBAC candidates. It discusses risks like uterine rupture and how they vary based on factors like number of previous cesareans, induction methods, and single vs double layer uterine closure. Predictors of successful VBAC include previous vaginal delivery while risks increase without prior vaginal delivery, induction, or more than one previous cesarean.
Cervical length for preterm birth prevention Aboubakr ELNASHARAboubakr Elnashar
This document discusses cervical length screening during pregnancy to prevent preterm birth. It begins by explaining that a short cervical length is a strong predictor of preterm birth, especially for women with a prior preterm birth history. Transvaginal ultrasound is described as the gold standard for accurately measuring cervical length. The document then provides steps for proper cervical length measurement and recommends assessing length between 16-24 weeks of gestation. It outlines cervical length screening guidelines for women with a prior preterm birth, which is to screen every 1-2 weeks from 16-24 weeks. The document discusses debate around universal cervical length screening and notes insufficient evidence for screening in some high-risk situations.
Invited lecture by Dr Sujoy dasgupta in the Annual Conference of the "Academy of Clinical Embryologists" (ACE) held in October 2021 in "Hybrid mode" (Kolkata and Webinar)
This document discusses the management of first trimester miscarriage. It defines miscarriage as pregnancy loss before 20 weeks of gestation. For threatened miscarriage of a viable pregnancy, bed rest is not recommended as it does not affect outcomes. Oral progestins may help reduce miscarriage risk but evidence is limited. For non-viable pregnancies, expectant management, medical treatment with misoprostol, or surgical dilation and curettage are options based on patient preference and circumstances. Medical treatment involves administering misoprostol vaginally or orally in single or repeated doses depending on the type of miscarriage.
This document discusses intrauterine fetal death (IUFD), including:
- IUFD affects approximately 4000 families in the UK each year.
- The cause is unknown in about 50% of cases. Known causes include infections, fetal abnormalities, cord accidents, placental insufficiency, and maternal conditions like diabetes.
- Diagnosis is made using ultrasound to check for signs of life. A second opinion is recommended. Discussing the diagnosis and next steps with compassion is important.
At the end of presentation, the participants should be able to understand the following:
Definition of Cerclage
Types of cerclage
Indications
Pre operative Preparations
Removal of Cerclage
This document provides evidence-based recommendations for various aspects of cesarean section (C.S.) procedures based on randomized trials and systematic reviews. It recommends that the operating table should have a 15 degree tilt to reduce hypotension, the Joel Cohen incision be used as it reduces time and morbidity, and blunt extension of the uterine incision to reduce blood loss and hemorrhage. Prophylactic antibiotics should be provided to reduce postoperative infections. External cephalic version should be offered for breech presentations, and C.S. offered if unsuccessful or contraindicated to reduce mortality and morbidity. Early breastfeeding and food/fluid intake should be encouraged for recovery when complications are absent.
O&G PRETERM DELIVERY, Tutorial for 2024 v1getplaye
The document discusses preterm birth, defined as birth occurring between 20 and 37 weeks of gestation. Some key points:
- Globally in 2020, about 13.4 million babies (10% of births) were born preterm. Risks of mortality and morbidity increase with lower gestational ages.
- Ireland's preterm birth rate in 2020 was 7%, up from 6% in 2011. The perinatal mortality rate is much higher for preterm (<37 weeks) births compared to term births.
- Major risk factors for preterm birth include previous preterm delivery, multiple pregnancies, and cervical length less than 25mm on ultrasound between 16-24 weeks.
- Prevention strategies include
The document discusses abnormalities of the fallopian tubes and uterus. It describes various congenital anomalies that can affect the fallopian tubes, including aplasia, atresia, hypoplasia, and accessory horns or ostia, which can cause infertility or ectopic pregnancy. Congenital anomalies of the ovaries are also reviewed, along with paraovarian cysts and other cysts that can develop from embryonic remnants. Abnormalities of the uterus discussed include transverse vaginal septums and double uteri. The learning outcomes focus on explaining these abnormalities of the fallopian tubes and uterus.
1. Preterm prelabour rupture of membranes complicates approximately 3% of pregnancies, causing about one-third of all preterm deliveries. It is associated with high neonatal mortality and both short- and long-term severe morbidity.
2. Expectant management through latency period monitoring remains the standard of care in the absence of infection or other complications, as prematurity confers most of the fetal and neonatal risk.
3. The guideline provides recommendations for diagnosing preterm prelabour rupture of membranes using history, physical exam including sterile speculum exam, and confirmation with multiple conventional tests or commercial tests for equivocal cases.
Management of monochorionic pregnancy PoojaNagappa
1. This document provides definitions and information on the management of monochorionic twin pregnancies. It discusses the types of twin pregnancies, screening and diagnosis of conditions like twin-twin transfusion syndrome (TTTS), selective growth restriction (sGR), and optimal treatment plans.
2. Monitoring of uncomplicated monochorionic twins involves ultrasounds every 2 weeks from 16 weeks to check amniotic fluids and growth. TTTS is diagnosed based on fluid discordance and treated with fetoscopic laser ablation before 26 weeks.
3. sGR is diagnosed when growth discordance is over 20% and referred for specialist care, with delivery planned between 32-36 weeks depending on severity. Out
Cervical incompetence is premature dilation of the cervix during pregnancy before labor begins. It affects 0.1-2% of pregnancies and causes around 15% of preterm births between 16-28 weeks. While the cause is often unknown, it can be due to congenital weaknesses, prior trauma, or connective tissue disorders. Diagnosis relies on history of preterm births and physical findings like dilation of the cervix when not pregnant. Cervical cerclage placement is the standard treatment and involves surgically stitching the cervix closed to prevent premature dilation. The document discusses various cerclage techniques and their appropriate uses.
Induction of labour is performed in over 20% of pregnancies and involves initiating contractions before spontaneous labour begins. It is indicated when delivery is considered safer for the mother or baby than continuing the pregnancy. Common indications include prolonged pregnancy beyond 41 weeks, maternal or fetal medical conditions like diabetes or growth restriction, and prelabour rupture of membranes. The decision requires weighing the potential benefits against risks of a vaginal delivery within 24-48 hours of induction versus continuing the pregnancy. Guidelines make recommendations on the gestational age for induction depending on the indication.
Cervical incompetence, or premature cervical dilation, can complicate 0.1-2% of pregnancies and cause 15% of preterm births between 16-28 weeks. While the exact cause is often unknown, it may result from congenital cervical weakness, trauma, or DES exposure. Diagnosis is based on recurrent second trimester miscarriage without other identifiable causes. Treatment options include bed rest or a cervical cerclage procedure to stitch the cervix closed and prolong the pregnancy. Cerclage placement can be elective, urgent based on cervical shortening, or emergency if dilation has already begun. The McDonald and Shirodkar techniques are most common, with choice depending on cervical anatomy and prior trauma. Cer
Asymptomatic short cervix and vaginanal, progesteroneBabak Jebelli
1. Vaginal progesterone reduces preterm birth in women with an asymptomatic sonographic short cervix in the midtrimester. The meta-analysis found vaginal progesterone once daily from identification of a short cervix <25mm until 37 weeks decreases preterm birth <33 weeks by 45% and decreases neonatal morbidity and mortality.
2. Treatment with vaginal progesterone was associated with significant reductions in preterm birth before 28 weeks, 33 weeks, and 35 weeks as well as composite neonatal morbidity and mortality.
3. There were no significant differences in adverse maternal events or congenital anomalies between the vaginal progesterone and placebo groups.
Asymptomatic short cervix and vaginanal, progesteroneBabak Jebelli
1. Vaginal progesterone reduces preterm birth in women with an asymptomatic sonographic short cervix in the midtrimester. The meta-analysis found vaginal progesterone once daily from identification of a short cervix <25mm until 37 weeks decreases preterm birth <33 weeks by 45% and decreases neonatal morbidity and mortality.
2. Treatment with vaginal progesterone was associated with significant reductions in preterm birth before 28 weeks, 33 weeks, and 35 weeks as well as composite neonatal morbidity and mortality.
3. There were no significant differences in adverse maternal events or congenital anomalies between the vaginal progesterone and placebo groups.
Giloy in Ayurveda - Classical Categorization and SynonymsPlanet Ayurveda
Giloy, also known as Guduchi or Amrita in classical Ayurvedic texts, is a revered herb renowned for its myriad health benefits. It is categorized as a Rasayana, meaning it has rejuvenating properties that enhance vitality and longevity. Giloy is celebrated for its ability to boost the immune system, detoxify the body, and promote overall wellness. Its anti-inflammatory, antipyretic, and antioxidant properties make it a staple in managing conditions like fever, diabetes, and stress. The versatility and efficacy of Giloy in supporting health naturally highlight its importance in Ayurveda. At Planet Ayurveda, we provide a comprehensive range of health services and 100% herbal supplements that harness the power of natural ingredients like Giloy. Our products are globally available and affordable, ensuring that everyone can benefit from the ancient wisdom of Ayurveda. If you or your loved ones are dealing with health issues, contact Planet Ayurveda at 01725214040 to book an online video consultation with our professional doctors. Let us help you achieve optimal health and wellness naturally.
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
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Similar to bleeding before 20 weeks of gestation jayaskthi.pptx
Optimising Delivery Of 1kg Fetus - Special Considerations.pptxNiranjan Chavan
After an uncomplicated vaginal birth in a health facility, healthy mothers and newborns should receive care in the facility for at least 24 hours after birth.
This document discusses evidence-based individual decision making (EBID) in obstetrics and gynecology. It emphasizes that evidence-based medicine (EBM) integrates the best available research evidence, clinical expertise, and patient values and preferences. While randomized controlled trials provide the strongest level of evidence, individual patient circumstances may differ. The document notes gaps between research evidence and clinical practice. It concludes that best research evidence, assessment of maternal risk, and good clinical judgment are needed to prevent adverse pregnancy outcomes through EBID.
This document summarizes information about vaginal birth after cesarean (VBAC) including success rates, benefits, risks of VBAC and repeat cesarean section, predictors of successful VBAC, and recommendations for selecting VBAC candidates. It discusses risks like uterine rupture and how they vary based on factors like number of previous cesareans, induction methods, and single vs double layer uterine closure. Predictors of successful VBAC include previous vaginal delivery while risks increase without prior vaginal delivery, induction, or more than one previous cesarean.
Cervical length for preterm birth prevention Aboubakr ELNASHARAboubakr Elnashar
This document discusses cervical length screening during pregnancy to prevent preterm birth. It begins by explaining that a short cervical length is a strong predictor of preterm birth, especially for women with a prior preterm birth history. Transvaginal ultrasound is described as the gold standard for accurately measuring cervical length. The document then provides steps for proper cervical length measurement and recommends assessing length between 16-24 weeks of gestation. It outlines cervical length screening guidelines for women with a prior preterm birth, which is to screen every 1-2 weeks from 16-24 weeks. The document discusses debate around universal cervical length screening and notes insufficient evidence for screening in some high-risk situations.
Invited lecture by Dr Sujoy dasgupta in the Annual Conference of the "Academy of Clinical Embryologists" (ACE) held in October 2021 in "Hybrid mode" (Kolkata and Webinar)
This document discusses the management of first trimester miscarriage. It defines miscarriage as pregnancy loss before 20 weeks of gestation. For threatened miscarriage of a viable pregnancy, bed rest is not recommended as it does not affect outcomes. Oral progestins may help reduce miscarriage risk but evidence is limited. For non-viable pregnancies, expectant management, medical treatment with misoprostol, or surgical dilation and curettage are options based on patient preference and circumstances. Medical treatment involves administering misoprostol vaginally or orally in single or repeated doses depending on the type of miscarriage.
This document discusses intrauterine fetal death (IUFD), including:
- IUFD affects approximately 4000 families in the UK each year.
- The cause is unknown in about 50% of cases. Known causes include infections, fetal abnormalities, cord accidents, placental insufficiency, and maternal conditions like diabetes.
- Diagnosis is made using ultrasound to check for signs of life. A second opinion is recommended. Discussing the diagnosis and next steps with compassion is important.
At the end of presentation, the participants should be able to understand the following:
Definition of Cerclage
Types of cerclage
Indications
Pre operative Preparations
Removal of Cerclage
This document provides evidence-based recommendations for various aspects of cesarean section (C.S.) procedures based on randomized trials and systematic reviews. It recommends that the operating table should have a 15 degree tilt to reduce hypotension, the Joel Cohen incision be used as it reduces time and morbidity, and blunt extension of the uterine incision to reduce blood loss and hemorrhage. Prophylactic antibiotics should be provided to reduce postoperative infections. External cephalic version should be offered for breech presentations, and C.S. offered if unsuccessful or contraindicated to reduce mortality and morbidity. Early breastfeeding and food/fluid intake should be encouraged for recovery when complications are absent.
O&G PRETERM DELIVERY, Tutorial for 2024 v1getplaye
The document discusses preterm birth, defined as birth occurring between 20 and 37 weeks of gestation. Some key points:
- Globally in 2020, about 13.4 million babies (10% of births) were born preterm. Risks of mortality and morbidity increase with lower gestational ages.
- Ireland's preterm birth rate in 2020 was 7%, up from 6% in 2011. The perinatal mortality rate is much higher for preterm (<37 weeks) births compared to term births.
- Major risk factors for preterm birth include previous preterm delivery, multiple pregnancies, and cervical length less than 25mm on ultrasound between 16-24 weeks.
- Prevention strategies include
The document discusses abnormalities of the fallopian tubes and uterus. It describes various congenital anomalies that can affect the fallopian tubes, including aplasia, atresia, hypoplasia, and accessory horns or ostia, which can cause infertility or ectopic pregnancy. Congenital anomalies of the ovaries are also reviewed, along with paraovarian cysts and other cysts that can develop from embryonic remnants. Abnormalities of the uterus discussed include transverse vaginal septums and double uteri. The learning outcomes focus on explaining these abnormalities of the fallopian tubes and uterus.
1. Preterm prelabour rupture of membranes complicates approximately 3% of pregnancies, causing about one-third of all preterm deliveries. It is associated with high neonatal mortality and both short- and long-term severe morbidity.
2. Expectant management through latency period monitoring remains the standard of care in the absence of infection or other complications, as prematurity confers most of the fetal and neonatal risk.
3. The guideline provides recommendations for diagnosing preterm prelabour rupture of membranes using history, physical exam including sterile speculum exam, and confirmation with multiple conventional tests or commercial tests for equivocal cases.
Management of monochorionic pregnancy PoojaNagappa
1. This document provides definitions and information on the management of monochorionic twin pregnancies. It discusses the types of twin pregnancies, screening and diagnosis of conditions like twin-twin transfusion syndrome (TTTS), selective growth restriction (sGR), and optimal treatment plans.
2. Monitoring of uncomplicated monochorionic twins involves ultrasounds every 2 weeks from 16 weeks to check amniotic fluids and growth. TTTS is diagnosed based on fluid discordance and treated with fetoscopic laser ablation before 26 weeks.
3. sGR is diagnosed when growth discordance is over 20% and referred for specialist care, with delivery planned between 32-36 weeks depending on severity. Out
Cervical incompetence is premature dilation of the cervix during pregnancy before labor begins. It affects 0.1-2% of pregnancies and causes around 15% of preterm births between 16-28 weeks. While the cause is often unknown, it can be due to congenital weaknesses, prior trauma, or connective tissue disorders. Diagnosis relies on history of preterm births and physical findings like dilation of the cervix when not pregnant. Cervical cerclage placement is the standard treatment and involves surgically stitching the cervix closed to prevent premature dilation. The document discusses various cerclage techniques and their appropriate uses.
Induction of labour is performed in over 20% of pregnancies and involves initiating contractions before spontaneous labour begins. It is indicated when delivery is considered safer for the mother or baby than continuing the pregnancy. Common indications include prolonged pregnancy beyond 41 weeks, maternal or fetal medical conditions like diabetes or growth restriction, and prelabour rupture of membranes. The decision requires weighing the potential benefits against risks of a vaginal delivery within 24-48 hours of induction versus continuing the pregnancy. Guidelines make recommendations on the gestational age for induction depending on the indication.
Cervical incompetence, or premature cervical dilation, can complicate 0.1-2% of pregnancies and cause 15% of preterm births between 16-28 weeks. While the exact cause is often unknown, it may result from congenital cervical weakness, trauma, or DES exposure. Diagnosis is based on recurrent second trimester miscarriage without other identifiable causes. Treatment options include bed rest or a cervical cerclage procedure to stitch the cervix closed and prolong the pregnancy. Cerclage placement can be elective, urgent based on cervical shortening, or emergency if dilation has already begun. The McDonald and Shirodkar techniques are most common, with choice depending on cervical anatomy and prior trauma. Cer
Asymptomatic short cervix and vaginanal, progesteroneBabak Jebelli
1. Vaginal progesterone reduces preterm birth in women with an asymptomatic sonographic short cervix in the midtrimester. The meta-analysis found vaginal progesterone once daily from identification of a short cervix <25mm until 37 weeks decreases preterm birth <33 weeks by 45% and decreases neonatal morbidity and mortality.
2. Treatment with vaginal progesterone was associated with significant reductions in preterm birth before 28 weeks, 33 weeks, and 35 weeks as well as composite neonatal morbidity and mortality.
3. There were no significant differences in adverse maternal events or congenital anomalies between the vaginal progesterone and placebo groups.
Asymptomatic short cervix and vaginanal, progesteroneBabak Jebelli
1. Vaginal progesterone reduces preterm birth in women with an asymptomatic sonographic short cervix in the midtrimester. The meta-analysis found vaginal progesterone once daily from identification of a short cervix <25mm until 37 weeks decreases preterm birth <33 weeks by 45% and decreases neonatal morbidity and mortality.
2. Treatment with vaginal progesterone was associated with significant reductions in preterm birth before 28 weeks, 33 weeks, and 35 weeks as well as composite neonatal morbidity and mortality.
3. There were no significant differences in adverse maternal events or congenital anomalies between the vaginal progesterone and placebo groups.
Similar to bleeding before 20 weeks of gestation jayaskthi.pptx (20)
Giloy in Ayurveda - Classical Categorization and SynonymsPlanet Ayurveda
Giloy, also known as Guduchi or Amrita in classical Ayurvedic texts, is a revered herb renowned for its myriad health benefits. It is categorized as a Rasayana, meaning it has rejuvenating properties that enhance vitality and longevity. Giloy is celebrated for its ability to boost the immune system, detoxify the body, and promote overall wellness. Its anti-inflammatory, antipyretic, and antioxidant properties make it a staple in managing conditions like fever, diabetes, and stress. The versatility and efficacy of Giloy in supporting health naturally highlight its importance in Ayurveda. At Planet Ayurveda, we provide a comprehensive range of health services and 100% herbal supplements that harness the power of natural ingredients like Giloy. Our products are globally available and affordable, ensuring that everyone can benefit from the ancient wisdom of Ayurveda. If you or your loved ones are dealing with health issues, contact Planet Ayurveda at 01725214040 to book an online video consultation with our professional doctors. Let us help you achieve optimal health and wellness naturally.
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
Dr. Tan's Balance Method.pdf (From Academy of Oriental Medicine at Austin)GeorgeKieling1
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Academy of Oriental Medicine at Austin
Academy of Oriental Medicine at Austin
Academy of Oriental Medicine at Austin
About AOMA: The Academy of Oriental Medicine at Austin offers a masters-level graduate program in acupuncture and Oriental medicine, preparing its students for careers as skilled, professional practitioners. AOMA is known for its internationally recognized faculty, award-winning student clinical internship program, and herbal medicine program. Since its founding in 1993, AOMA has grown rapidly in size and reputation, drawing students from around the nation and faculty from around the world. AOMA also conducts more than 20,000 patient visits annually in its student and professional clinics. AOMA collaborates with Western healthcare institutions including the Seton Family of Hospitals, and gives back to the community through partnerships with nonprofit organizations and by providing free and reduced price treatments to people who cannot afford them. The Academy of Oriental Medicine at Austin is located at 2700 West Anderson Lane. AOMA also serves patients and retail customers at its south Austin location, 4701 West Gate Blvd. For more information see www.aoma.edu or call 512-492-303434.
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7shruti jagirdar
Unit 4: MRA 103T Regulatory affairs
This guideline is directed principally toward new Molecular Entities that are
likely to have significant use in the elderly, either because the disease intended
to be treated is characteristically a disease of aging ( e.g., Alzheimer's disease) or
because the population to be treated is known to include substantial numbers of
geriatric patients (e.g., hypertension).
TEST BANK For Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 14...Donc Test
TEST BANK For Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition (Hinkle, 2017) Verified Chapter's 1 - 73 Complete.pdf
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TEST BANK For Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition (Hinkle, 2017) Verified Chapter's 1 - 73 Complete.pdf
bleeding before 20 weeks of gestation jayaskthi.pptx
1. VAGINAL BLEEDING
BEFORE 20 WEEKS GESTATION
SEMINAR
Department of DNB-Obg
DISTRICT HOSPITAL - BALLARI
29-09-2023 DNB-OBG District Hospital- BALLARI 1
2. Vaginal Bleeding
Before 20 Weeks Gestation
Presenter: Dr Jayasakathi
Dr Mrunal
Moderator: Dr Ashraf Ali
Guide: Dr Joshi Suyajna D.
29-09-2023 DNB-OBG District Hospital- BALLARI 2
3. Introduction
• Bleeding in the first 20 weeks of pregnancy can be a sign of
anything from benign implantation bleeding to life-threating
conditions.
• This article aims to provide connections between and resources
for the most common early pregnancy complications that often
present with bleeding in the first half of pregnancy: pregnancy
loss, ectopic pregnancy, and molar pregnancy.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 3
4. First and Second Trimester
Pregnancy Loss
• Pregnancy loss or miscarriage is an intrauterine
embryonic or fetal demine before 20 weeks gestation.
• Early pregnancy loss (EPL) is the most common type
of pregnancy loss .
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 4
5. • ACOG : EPL is defined as a nonviable intrauterine pregnancy before
13 weeks gestation with ultrasound showing an empty gestational sac
or a gestational sac containing an embryo without fetal cardiac
activity.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 5
7. • Pregnancy loss can present at different stages.
• When the pregnancy tissue is still inside the uterus, the cervix can be
closed (missed abortion) or open (inevitable abortion).
• When the pregnancy tissue has all passed (complete abortion), the
cervix may be open or closed.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 7
8. • When some tissue has passed (incomplete abortion), the
cervix is generally still open. The patient may or may not
present with bleeding.
• Concerning bleeding is often considered saturating more
than two pads per hour for 2 hours in a row or bleeding at a
rate anticipated to exceed this volume.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 8
9. • Concerning bleeding, signs or symptoms of infection,
abnormal vital signs, and/or abnormal laboratory values
indicate clinical instability and require urgent procedural
management.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 9
10. Epidemiology
• Approximately 10% of clinically identified pregnancies and one-third of all
pregnancies end in pregnancy loss.
• Increasing age and prior pregnancy loss are common risk factors for EPL.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 10
11. • Disparities exist in pregnancy loss: Black patients experience higher
rates of miscarriage compared with White patients and Black and
Hispanic patients are more likely to present to emergency
departments (ED) for vaginal bleeding in early pregnancy than non-
early pregnancy issues.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 11
12. Evaluation
• Pregnancy loss is diagnosed primarily by ultrasound.
• According to the Society of Radiologists’ guidelines, EPL can be
definitively diagnosed by any of four specific ultrasound findings:
(1) crown-rump (CRL) length of 7 mm or greater and no cardiac
motion,
(2) mean sac diameter (MSD) of 25 mm or greater and no embryo,
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 12
13. (Absence of embryonic cardiac motion 2 weeks or more after a scan
showing a gestational sac without a yolk sac, or
(4) The absence of embryonic cardiac motion 11 days or more after a
scan showing a gestational sac with a yolk sac
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 13
15. • The guidelines also stipulate findings suspicious for, but not
diagnostic of, pregnancy loss:
(1) CRL <7 mm and no cardiac motion,
(2) MSD 16 to 24 mm and no embryo,
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 15
16. (3) absence of embryonic cardiac motion 7 to 13 days after a scan
that showed a gestational sac without a yolk sac,
(4) absence of embryonic cardiac motion 7 to 10 days after a scan
that showed a gestational sac with a yolk sac,
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 16
17. (5) absence of an embryo ≥6 weeks after last menstrual period,
(6) empty amnion,
(7) enlarged yolk sac (>7 mm),
(8) small gestational sac in relation to the size of the embryo (<5 mm
difference between MSD and CRL). 1
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 17
19. • Some patients prefer to start management after meeting
“suspicious for” pregnancy loss criteria rather than waiting
for an additional ultrasound to meet definitive criteria;
• Patient-centered counseling allows providers to provide
care according to the patient’s preferred timeline.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 19
20. • Patient history, laboratory confirmation of recent pregnancy, or
available products of conception can help diagnose a complete
abortion when ultrasound shows no gestational sac and low concern
for ectopic pregnancy.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 20
21. Management
Early pregnancy loss
There are three management options for EPL:
(1) expectant
(2) medication
(3) procedural.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 21
22. • Clinically stable patients can choose any of the three options; those who receive
their preferred options report higher satisfaction with care.
See Table 1 for management overview.
Unstable patients require prompt procedural management via uterine aspiration.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 22
24. Early
Pregnancy
Condition
Management Options
Expectant Medication Procedural
Pregnancyloss
<13 weeks
(EPL)
Can wait until
8 weeks but
likely
diminishing
returns with
increasing time
Mifepristone
200 mg PO
+
Misoprostol
800 mcg PV
Uterine
aspiration
At home In clinic → at
home At
home
a
In clinic In
operating
room,In ED or
L&D
Antibiotics not
recommended
Antibiotics
recommended
29-09-2023 DNB-OBG District Hospital- BALLARI 24
25. Early
Pregnancy
Condition
Management Options
Expectant Medication Procedural
Pregnancy
loss 13–
20 weeks
n/a Mifepristone
200 mg PO
+
Serial
misoprostol
800 mcg PV
Uterine
aspiration or
Dilation &
evacuation
On Labor &
Delivery
In clinicIn
operating
roomIn ED
or L&D
29-09-2023 DNB-OBG District Hospital- BALLARI 25
26. Early
Pregnancy
Condition
Management Options
Expectant Medication Procedural
Ectopic
pregnancy
Limited
circumstances
Methotrexate Salpingectomy
or
salpingostomy
In operating
room
Molar
pregnancy
n/a Rarely used Uterine aspiration
or hysterectomy
Antibiotics
In operating
room
Antibiotics
recommended
29-09-2023 DNB-OBG District Hospital- BALLARI 26
27. Early
Pregnancy
Condition
Management Options
Expectant Medication Procedural
Septic abortion n/a n/a Uterine aspiration
or Dilation &
Evacuation
Intravenous fluids
In operating roomIn
ED or L&D
Intravenous
followed by
po antibiotics
recommended
29-09-2023 DNB-OBG District Hospital- BALLARI 27
28. • Expectant management involves the patient waiting for the
pregnancy tissue to pass without intervention.
• Expectant management was successful within 14 days for 84% of
patients with incomplete abortion and approximately half of the
patients with missed abortion and anembryonic pregnancies.
• Waiting 7 weeks resulted in 91%, 76%, and 66% success for
incomplete abortions, missed abortions, and anembryonic
pregnancies,respectively.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 28
29. • Complications are rare at ∼1% for patients opting for expectant
management, with no major differences in pelvic infection by
8 weeks and higher, but still rare, risk of the need for transfusion
compared with patients choosing procedural management.
• Expectant management is less expensive than procedural
management.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 29
30. • Medication management expedites EPL resolution for patients who
wish to avoid a procedure.
• Although misoprostol had been the standard medication regimen for
years, in 2018, a randomized controlled trial of patients 5 weeks to
12 weeks 6 days with a closed cervix demonstrated a large
improvement in treatment success
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 30
31. • When mifepristone—a steroid that competitively antagonizes
progesterone and glucocorticoid receptors and is approved by the
Food and Drug Administration for induced abortion and treatment of
Cushing’s Syndrome—was administered before misoprostol.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 31
32. • Eight-four percent of patients who received mifepristone 200 mg
orally followed by misoprostol 800 mcg vaginally had successful
treatment of their miscarriage within 2 days compared to 67% of
patients who received misoprostol alone.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 32
33. • Thirty days after treatment, only 9% of patients in the mifepristone
group needed procedural management compared with 24% in the
misoprostol-only group.
• Side effects were similar between groups.
• The optimal timing between mifepristone and misoprostol is likely 6
to 20 hours, but still effective through 48 hours.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 33
34. • Mifepristone and misoprostol are cost-effective compared with
procedural management.
• American College of Obstetricians & Gynecologists (ACOG)
recommends mifepristone before misoprostol, but if mifepristone is
not available, then misoprostol 800 mcg be administered vaginally
with one repeat dose between 3 hours and 7 days later if needed.
• For incomplete abortion, misoprostol is not clearly superior to
expectant management.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 34
35. • Patients choosing expectant or medication management can be
counseled about managing symptoms at home, reasons to present for
urgent care, and how to ensure their miscarriage is complete.
• Vaginal bleeding that is heavier than menses and intense cramping
are normal.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 35
36. • There have not been studies about pain management during expectant
management of miscarriage, however, literature for medication
induced abortion reports decrease in pain with administration of
ibuprofen after cramping begins.
• An easy reference for patients regarding when to seek medical
attention for bleeding is soaking two maxi pads per hour for two
consecutive hours or bleeding at a rate that will likely exceed that
amount.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 36
37. • The Reproductive Health Access Project and University of
Washington’s Training, Education, & Advocacy in Miscarriage
Management (TEAMM) have helpful patient handouts for counseling
and home management (see Resources section).
• Follow-up ultrasound showing lack of a gestational sac confirms
successful treatment.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 37
38. • The thickness of the endometrial stripe does not determine treatment
success.
• Where ultrasound is not available, follow-up calls, urine pregnancy
tests, and serial quantitative serum β-hCG measurements may be
used to confirm completion, although most of the data on these
follow-up options are extrapolated from medication-induced
abortion.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 38
39. • Uterine aspiration is the preferred procedural management and is
used for patients who prefer to have a procedure or who are not
candidates for expectant or medication management.
• Uterine aspiration is also known as suction dilation and curettage.
• ACOG and the World Health Organization recommend against sharp
curettage based on studies showing its associated adverse effects.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 39
40. • Uterine aspiration can be completed in clinic or in an operating room
with manual vacuum aspiration or electric vacuum aspiration.
• Clinic aspiration is cost- and time-saving compared with aspiration
in the operating room, and patients report high satisfaction with both
options.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 40
41. • Unlike expectant or medication management, antibiotic prophylaxis
is recommended, although data are less conclusive for pregnancy loss
than for induced abortion.
• Common regimens are a single pre-procedural dose of doxycycline
200 mg, metronidazole 500 mg, or azithromycin 500 mg
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 41
42. Second trimester pregnancy loss until 20 weeks
• Because second trimester pregnancy loss is less common and less frequently
studied, its management is based on the existing literature on second trimester
induced abortion.
• Given the risk of hemorrhage for second trimester pregnancy loss, expectant
management is not recommended.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 42
43. • Medication management with labor induction is 97% effective within 24 hours
when mifepristone 200 mg oral is administered 36 to 48 hours before a loading dose
of misoprostol 800 mcg vaginal and then 400 mcg every 3 hours.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 43
44. • Different regimens that alter the mifepristone pretreatment interval
and misoprostol dosing and route are also highly effective.
• Mifepristone and misoprostol are cost-effective compared to
misoprostol alone.
• Misoprostol alone results in longer induction times, but is faster than
high-dose oxytocin, which can be used in the absence of
misoprostol.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 44
45. • The risk of rupture is estimated to be 0.04% for unscarred uteri and
0.28% for one prior cesarean delivery.
• Patients can receive the same analgesic options as for term labor
inductions as well as also patient-controlled analgesia.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 45
46. • Procedural management of second trimester loss includes uterine
aspiration through 14 to 16 weeks and dilation and evacuation (D&E)
thereafter, similar to how induced abortion is performed.
• Cervical preparation with misoprostol, osmotic dilators, and/or
mifepristone reduces the risk of cervical laceration and uterine
perforation in the late first and throughout the second trimester.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 46
47. • The same pre-procedural antibiotic prophylaxis can be used in the
first or second trimester.
• Although prevalence data are limited, potential complications such as
disseminated intravascular coagulation, amniotic fluid embolism,
hemorrhage, and infection may make the operating room an
appropriate setting when available for second trimester loss D&E.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
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48. Potential Complications
• Pregnancy loss is associated with psychological and physical complications.
• Pregnancy loss can be a significantly distressing event with almost half of the
people experiencing persistent and enduring psychological morbidity including
depression, anxiety, and grief.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
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49. • Depressive disorders after miscarriage have the same incidence and
prevalence as postpartum depression, but often are not screened for
or treated.
• Patients’ partners may also suffer depression, anxiety, or post-
traumatic stress disorder symptoms after pregnancy loss.
• Again, disparities exist: Black patients have twice the risk of major
depression after EPL compared with White patients.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
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50. • Minor physical complications include side effects of medication
management—nausea, vomiting, diarrhea, and cramping pain.
• Retained products of conception can occur with any management
option and can be treated with misoprostol or uterine aspiration.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 50
51. • Cervical laceration after a procedure can be managed with pressure
or suturing.
• Hemorrhage that requires hospitalization or blood transfusion occurs
no more than 1% of the time with any treatment options and can
often be managed with immediate uterine aspiration, uterotonics, and
blood transfusion as needed.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 51
52. • Maternal sepsis is responsible for 10% of maternal deaths worldwide.
• Septic abortion is infected products of conception, endometritis, or
parametritis during a current or following a recent pregnancy before
20 weeks gestation.
• Importantly, septic abortion accounts for two-thirds of deaths from
miscarriage.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 52
53. • Septic abortion presents with numerous different symptoms,
however, most likely are uterine tenderness and foul smelling
discharge and mild fever.
• Patients with septic abortions require immediate uterine evacuation,
broad-spectrum intravenous antibiotics, intravenous fluids, and,
depending indicated depending on the severity, intensive care unit
admission.
• Expectant and medication management are contraindicated.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 53
54. Counseling Patients After Pregnancy Loss
• Many patients have historically felt as though they had a lack of information
or support; we do not yet know if the recent media attention from celebrities
sharing their personal stories will change this.
• It may be helpful to share that more than half of miscarriages are due to
genetic causes that are unlikely to happen again, rather than something the
patient felt they did wrong.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 54
55. • First-time miscarriages usually do not require evaluation for a cause and
most patients will have a baby in their next pregnancy.
• Patients who want to conceive again should continue folic acid
supplementation.
• Waiting beyond 1 to 2 weeks, when theoretically the cervix should be closed
and infection risk decreased, does not improve the likelihood of having a
baby in their next pregnancy.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 55
56. • Patients who wish to avoid pregnancy can start any method of
contraception after pregnancy loss, except that intrauterine
contraception is contraindicated after septic abortion.
• Please see additional considerations for psychological care after all
conditions below.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
29-09-2023 DNB-OBG District Hospital- BALLARI 56
57. Rh(D) Immunoglobulin for Allo-
Immunization Prophylaxis
• ACOG recommends administering Rh(D) immunoglobulin (RhIG)
for EPL (evidence level C).
• SFP recommends against RhIG before 12 weeks gestation for uterine
aspiration, 100 mcg/500 IU for 13 to 17 completed weeks gestation,
and 300 mcg/1500 IU dose starting at 18 weeks.
• If sharp curettage is the only option available, then 50 mcg/250 IU
should be given before 12 weeks.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
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60. Ectopic pregnancy
• Ectopic pregnancy occurs when an embryo implants outside the
endometrial cavity.
• The fallopian tube is the most common ectopic site. Other locations
include the abdomen, cervix, ovary, or cesarean scar.
• Cesarean scar ectopics may be increasing in frequency along with
the increasing incidence of cesarean delivery and can appear similar
to EPL or low viable pregnancies, leading to delayed diagnosis.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
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61. Epidemiology
• At least 2% of all reported pregnancies are likely ectopic.
• Hemorrhage from ruptured ectopics is the main cause of first
trimester pregnancy-related mortality.
• The most common risk factors are a history of prior ectopic(s),
fallopian tube injury, and having an intrauterine device in place when
pregnant; however, half of the patients lack risk factors.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
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62. • Again, disparities exist that are likely related to social and structural
determinants of health.
• The mortality rate from ectopic complications is a disturbing 6.8
times higher in Black patients compared with White patients in the
United States and is 3.5 times higher for people over the age of
35 years. 1
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
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63. Evaluation
• Any reproductive-age patient with female sex reproductive organs and vaginal
bleeding should be evaluated for ectopic pregnancy.
• Suspected ectopic pregnancy requires confirmation of pregnancy with urine or
serum hCG.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
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64. • Ultrasound evaluation of the endometrial cavity, cervix,
and adnexa can establish any concerning masses,
particularly an ectopic gestational sac with yolk sac.
• Significant free fluid in the posterior cul-de-sac deserves
evaluation of intraperitoneal bleeding from rupture.
• Clinically unstable patients with high suspicion of
ectopic pregnancy need immediate surgical
evaluation. 14
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
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65. • However, patients with early vaginal bleeding do not
always have obvious intrauterine or ectopic pregnancies
on ultrasound.
• Therefore these pregnancies of unknown location
require clinical judgment regarding whether to proceed
with diagnostic laparoscopy or to follow closely by
trending hCG values and ultrasound.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
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66. • If hCG levels are used, clinical judgment still needs to be
applied because the discriminatory zone—the hCG level at
which an intrauterine pregnancy should be seen—may
misclassify multiple gestations and overlap exists in the hCG
trends between viable intrauterine pregnancies, EPL, and
ectopics.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
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67. • Additionally, a patient’s pregnancy desires should guide
treatment. For example, management can be expedited
for clinically stable patients with undesired pregnancies
via uterine aspiration and/or methotrexate, but a highly
desired pregnancy in a stable patient may follow a
longer hCG trend. 94 A helpful algorithm for this patient-
centered approach exists
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
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68. Management
• Once ectopic pregnancy is diagnosed, three management options can
be offered:
• (1) expectant,
• (2) medication,
• (3) surgical.
• Similar to pregnancy loss, unstable patients require urgent surgical
management.
Obstretrics and Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
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69. • • INDICATIONS FOR EXPECTANT
MANAGEMENT-
• -Gestational sac <4cm
• Beta hCG <1500
• No fetal cardiac activity
• -Hemodynamically stable
• INDICATIONS FOR MEDICAL MANAGEMEN
-Beta hCG levels >3000
-No fetal cardiac activity
-Hemodynamically stable
29-09-2023 DNB-OBG District Hospital- BALLARI 69
70. • Expectant management of ectopic pregnancies is rare.
This management option may be considered for
asymptomatic patients whose ectopic pregnancies are
likely resolving spontaneously.
• Indications of resolving ectopic pregnancy include low
and decreasing hCG levels, no evidence or concerning
findings for ectopic on ultrasound, and the ability to
follow-up.
Obstretrics snd Gynecology Clinics, 2023-09-01,Volume 50, Issue 3
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72. • Intramuscular methotrexate—
• a folate antagonist—is currently the only recommended medical
treatment of ectopic pregnancy.
• Before administering methotrexate, patients should have blood
count, liver function, and renal function evaluated to determine any
contraindications.
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73. ABSOLUTE CONTRAINDICATIONS TO
METHOTREXATE-
• Intrauterine pregnancy
• Evidence of immunodeficiency
• Moderate to severe anemia, leukopenia or
thrombocytopenia
• Sensitivity to methotrexate
• Active pulmonary disease
• Active peptic ulcer disease
29-09-2023 DNB-OBG District Hospital- BALLARI 73
74. • Clinically important hepatic dysfunction
• Clinically important renal dysfunction
• Breastfeeding
• Ruptured ectopic pregnancy
• Hemodynamically unstable patient
• Inability to participate in follow-up
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75. RELATIVE CONTRAINDICATIONS TO
METHOTREXATE-
• Embryonic cardiac activity detected by transvaginal ultrasonography
• High initial hCG concentration
• Ectopic pregnancy greater than 4 cm in size as imaged by transvaginal
utrasonography
• Refusal to accept blood transfusion.
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76. METHOTREXATE
• Mechanism of action-
Methotrexate is a chemothrerapeutic drug that competitively inhibits dihydrofolate
reductase,an enzyme that participates in folate pathway. This inhibits the DNA
synthesis in rapidly dividing cells, such as cells in developing pregnancy tissue
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77. Single- dose regimen
• Administer a single dose of methotrexate at a dose of 50mg/m2
• Measure hCG levels on day 4 and day 7
-if decreases >15%,measure hCG levels weekly till it reaches non-
pregnant levels
-if decrease <15% , readminister methotrexate at dose of 50mg/m2
intramuscularly and repeat hCG levels
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78. TWO-DOSE REGIMEN
• Administer methotrexate at a dose of 50mg/m2
intramuscularly on D1
• Administer second dose of methotrexate at a dose of 50mg/m2
intramuscularly on day4
• Measure hCG level on post-treatment day 4 and day 7
-if decrease >15 % measure hCG levels weekly until non-
pregnant levels
-if decrease <15% readminister methotrexate 50mg/m2
intramuscularly on day 7 and check hCG levels on day 11
-if hCG levels decrease 15% between D7 and D11, continue to
monitor weekly until reaches non-pregnant levels
-if hCG decrease is <15%,between D7 and D11,readminister
methotrexate dose 50mg/m2 intramuscularly on D11 and check
hCG levels on D14
If hCG dose not decrease after 4 doses consider surgical
treatment
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79. • For example, the two-dose regimens may be more effective when hCG
levels are higher. 98 Alternative management should be considered for non-
tubal ectopics, including intra-sac injection of methotrexate or potassium
chloride with or without adjunctive systemic methotrexate, uterine aspiration,
or surgical excision, depending on the location.
• During management with methotrexate, hCG follow-up is necessary to
monitor the treatment effect.
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80. • Patients treated with methotrexate should be
educated about symptoms of tubal rupture versus
tubal abortion, and the need for immediate medical
attention if symptoms of rupture occur.
• Patients should also be advised to avoid folic acid
supplements, foods that contain folic acid,
nonsteroidal anti-inflammatory drugs, sexual
intercourse, and sun exposure during therapy
because these products may decrease the efficacy
of methotrexate, increase side effects, or cause
tubal rupture.
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81. • If hCG levels are used, clinical judgment still needs to be applied because the
discriminatory zone—the hCG level at which an intrauterine pregnancy should be
seen—may misclassify multiple gestations and overlap exists in the hCG trends
between viable intrauterine pregnancies, EPL, and ectopics.
• Additionally, a patient’s pregnancy desires should guide treatment.
• For example, management can be expedited for clinically stable patients with
undesired pregnancies via uterine aspiration and/or methotrexate, but a highly
desired pregnancy in a stable patient may follow a longer hCG trend.
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82. • Surgical management is indicated for clinically unstable patients, patients with
absolute contraindication to methotrexate or failed medical management, concerns
about follow-up, or patient preference.
• Surgical management of ectopic pregnancy is usually performed using laparoscopic
salpingectomy or salpingostomy.
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83. • Salpingostomy allows for future fertility in patients with an absent or badly
damaged contralateral tube.
• Consider trending hCGs after salpingostomy and potentially giving a dose of
methotrexate if a complete resection was not achieved.
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84. Rh(D) Immunoglobulin for Allo-
Immunization Prophylaxis
• ACOG and SFP recommend administering Rh(D)
immunoglobulin (RhIG) for ectopic pregnancy.
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87. Molar pregnancy
• Molar pregnancies, or hydatidiform moles, are caused by abnormal
growth of pre-placental cells. Complete molar pregnancies have a
diploid karyotype, no fetal tissue, and a 15% to 20% risk of
progression to gestational trophoblastic neoplasia (GTN).
• Partial moles are triploid, may have fetal tissue, and have a 1% to 5%
risk of progression to GTN.
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88. Epidemiology
• The incidence of molar pregnancy is difficult to know because it is
rare.
• Recent data are limited, but older studies reveal North American and
European countries report rates of 66 to 121 per 100,000 pregnancies,
compared to Latin American, Asian, and Middle Eastern countries
reporting rates as high as 1299 per 100,000 pregnancies.
• Older and younger patients have higher risks of molar pregnancy.
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89. Evaluation
• Molar pregnancy often initially presents with signs and symptoms of
early pregnancy complications, including vaginal bleeding, pelvic or
abdominal pain, uterus enlargement greater than expected for
gestational age, hyperthyroid, pre-eclampsia, and hyperemesis
gravidarum.
• Quantitative serum hCG should be measured, as molar pregnancy
usually has higher than expected levels than viable intrauterine
pregnancy or ectopic pregnancy.
• Initial hCG level can be higher than 100,000 mIU/mL and should be
followed with a transvaginal ultrasound to exclude twin pregnancy or
coexistence of singleton pregnancy and molar pregnancy
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90. Initial hCG level can be higher than 100,000 mIU/mL
and should be followed with a transvaginal ultrasound to
exclude twin pregnancy or coexistence of singleton
pregnancy and molar pregnancy
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91. • Transvaginal ultrasound findings suggestive of complete mole
include absence of an embryo or fetus, absence of amniotic fluid,
central heterogeneous mass with numerous discrete anechoic spaces
or what has been described as a “snowstorm pattern”, which indicates
hydropic villi, and theca lutein cysts.
• Ultrasound findings for partial mole may include identification of a
growth-restricted fetus, oligohydramnios, placental enlargement and
cysts, chorionic villi echogenicity, sac diameter, and absence of theca
lutein cysts.
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92. • Partial mole ultrasound findings can be more difficult to interpret and
are often misdiagnosed as EPL in up to 60% of cases.
• When concerned about potential molar pregnancy, ask for pathology
to perform p57 staining and ploidy.
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93. Management
• Surgical removal of molar pregnancy is the mainstay of treatment.
• Uterine evacuation in the operating room is the preferred method, as
it is effective and preserves childbearing capacity.
• Hysterectomy may be appropriate for patients who do not wish to
have any more children or have signs of trophoblastic proliferation
and GTN.
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94. Complications
• As diagnosis and management are occurring earlier in pregnancy,
complications associated with molar pregnancy are less, however,
there is still risks of hemorrhage or cardiopulmonary compromise.
• Additionally, there is a risk of development of GTN.
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95. • This is less common due to earlier detection and intervention,
however, even after uterine aspiration or hysterectomy, there is still a
risk of development of GTN so it is recommended to follow hCG for
3 months after complete moles and 1 month after partial moles.
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96. Rh(D) Immunoglobulin for Allo-
Immunization Prophylaxis
• The Society of Gynecologic Oncology recommends administering
Rh(D) immunoglobulin (RhIG) for molar pregnancy.
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97. Psychological care
• Along with those experiencing miscarriage, patients with ectopic or
molar pregnancies may also grieve.
• In a recent opinion editorial, a mother describes seeking care for
ectopic pregnancy and the importance of her surgeon listening to her,
taking her desire to bury her baby seriously, and caring for both her
and her lost baby.
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98. Early pregnancy assessment centers
• Early pregnancy assessment centers (EPAC) or Early Pregnancy Units are clinics
where patients can seek care for first trimester complications.
• Early pregnancy assessment services or units were started in the United Kingdom in
the 1990s to improve care quality and to divert patients with first trimester bleeding
and pain away from EDs.
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99. • In the United States, approximately 900,000 ED visits annually are
for vaginal bleeding in early pregnancy, of which roughly 250,000
likely carry a diagnosis of EPL.
• This represents a substantial burden on EDs and hundreds of
thousands of patients who might prefer to receive care in a clinic.
Hundreds of Early Pregnancy Units and clinics exist in the United
Kingdom, Australia, New Zealand, and Canada
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100. • Though not always called by the same name, similar clinics exist in
the United States.
• EPACs can provide a range of services or referrals before most
patients typically initiate prenatal care, including ultrasound;
diagnosis and management of EPL, ectopic pregnancy, molar
pregnancy, and induced abortion; and contraceptive services.
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101. • Protocols drive evidence-based care, and clinicians and staff are
trained in the emotional aspect of early pregnancy care.
• In the United States, EPACs have been proposed as an opportunity to
improve health equity by providing high-value, efficient, and patient-
centered care to historically marginalized groups that often
disproportionately present to EDs with vaginal bleeding in early
pregnancy.
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102. Potential Consequences of Restrictive Abortion
Bans on Early Pregnancy Conditions
• Managing these early pregnancy conditions overlaps with induced
abortion care.
• Ectopic and molar pregnancies, septic abortions, and inevitable
miscarriages may have cardiac activity and yet need prompt
termination of the pregnancy to avoid maternal morbidity and
mortality.
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103. • Uterine aspiration is the procedure used for induced abortion as well
as EPL and molar pregnancies; it can be used in the diagnosis of
ectopic pregnancy.
• D&E and labor induction are used for second trimester pregnancy
loss and for induced abortion.
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104. Clinics care points
• The most common early pregnancy conditions that present with vaginal bleeding and
are associated with morbidity and mortality before 20 weeks gestation are pregnancy
loss, ectopic pregnancy, and molar pregnancy.
• Determine if a bleeding patient is stable while establishing a diagnosis.
• Clinically unstable patients require prompt procedural management.
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105. • Mifepristone pretreatment to misoprostol is more effective than
misoprostol alone for EPL up to 12 weeks 6 days gestation.
• Evidence around the necessity for prophylaxis against Rh(D) allo-
immunization and remote follow-up is evolving for EPL.
• The table shows management options for each early pregnancy
condition included in this article.
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