3/8/2022

OB Complications

©2022 NPWH
Module 1
Julie S. Gayle DNP, WHNP-BC

Julie S. Gayle DNP, WHNP-BC

• Practicing WHNP for 15 years
• For the last 10 years:
• Associate Faculty
• Coordinator of the Women's Health
Nurse Practitioner Program at
Northwestern State University in
Shreveport, LA
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• Academic Program Leader

Committee for NPWH and served
• Image of presenter on Task Force for NPWH
Guidelines for WHNP Practice &
Education
• Practices in two local community
health clinics providing:
• Women’s Gynecological & Well-
Woman Health Care
• STD Screening & Treatment 2
• HIV PrEP/pEP

Disclosures of the presenter

• No Disclosures
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Copyright 2022
National Association of Nurse Practitioners in
Women’s Health
• All rights reserved. No part of this material may be reproduced, published,
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including but not limited to photocopy, recording on any information
storage and retrieval system, without written permission from National
Association of Nurse Practitioners in Women’s Health (NPWH).
• The authors of each of the modules in this review course have made every
effort to provide accurate information. However, they as well as NPWH, are

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not responsible for errors, omissions, or for any outcomes related to the use
of the contents of the modules and have no responsibility for the use of
drugs, products, or procedures described. Research, clinical practice, and
government regulations often change the accepted standard in the
healthcare field. The individual clinician is responsible for consulting further
sources for the most up-to-date recommendations and regulations and for
determining the appropriate care based on individual patient
circumstances.
• THE AUTHORS AND NPWH DISCLAIM ANY AND ALL LIABILITY TO ANY USER
OF THE MODULES OR TO ANY THIRD PARTY AND SHALL NOT BE HELD LIABLE
FOR DAMAGES OF ANY KIND (INCIDENTAL, CONSEQUENTIAL, INDIRECT,
SPECIAL, OR PUNITIVE), NO MATTER HOW CAUSED (CONTRACT, TORT, 4
NEGLIGENCE, STRICT LIABILITY, BREACH OF WARRANTIES), ARISING OUT OF
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• By participating in this review course, you acknowledge and agree to the
above terms.

Module Objectives
Upon completion of this module the participant should be
able to:
1. Discuss the incidence, risk factors, assessment,
differential diagnoses, and management of bleeding
during pregnancy.
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2. Describe the incidence, risk factors, potential

complications, assessment, and management for
preterm labor and delivery, cervical insufficiency, and
premature (prelabor) rupture of membranes.
3. Describe incidence, risk factors, etiology, potential
complications, assessment, diagnosis, and
management for fetal growth restriction (FGR).
4. Explore pregnancy loss and discuss the assessment
and management of grief following a perinatal loss. 5
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(Image: open source Pixabay)

Normal Physiologic Causes (Implantation Bleeding, Postcoital

Spotting), Spontaneous Abortion (SAB), Subchorionic Hemorrhage ,
Ectopic Pregnancy, Gestational Trophoblastic Disease, Genital Tract
Pathology (Cervical Lesions/Polyps, Cervicitis, Vaginitis)

EARLY PREGNANCY BLEEDING 6

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Early Pregnancy Bleeding

Clinical Case
• 23yo G2P0
• LMP 6 weeks ago
• Positive home urine pregnancy test 2 weeks ago

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• Has initial prenatal visit scheduled in 2 weeks
• Bleeding & cramping for 2 days

Early Pregnancy Bleeding

• Normal Physiologic Causes
• Implantation Bleeding
• Postcoital Spotting
• Spontaneous Abortion (SAB)
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• Subchorionic Hemorrhage
• Ectopic Pregnancy
• Gestational Trophoblastic Disease
• Genital Tract Pathology (Cervical Lesions/Polyps,
Cervicitis, Vaginitis)
8

(Casanova et al, 2019; Kelsey & Nagtalon-Ramos, 2021)

Normal Physiologic Causes:

Implantation Bleeding
• Diagnosis of exclusion
• Usually characterized by small amounts of
spotting or bleeding
• Typically bright red
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• Most commonly 10 to 14 days after fertilization

– resulting from the burrowing of the blastocyst
into the uterine endometrium

(Casanova et al, 2019)

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Normal Physiologic Causes:

Postcoital Spotting
• The cervix is more friable during pregnancy in
general and irritation from sexual intercourse can
cause spotting that may be worrisome to patients in
the first trimester
• Spotting should typically go away within a few hours

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after sex - If not, further evaluation is warranted
• Expectant management for both, provide
reassurance
• Bleeding precautions and when to come in for
evaluation should be given ---- If bleeding becomes
heavy (soaking more than a pad an hour), associated
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pain/cramping, loss of fluid
(Casanova et al, 2019)

Normal Physiologic Causes:

Management
• Expectant management is warranted in most
cases for both implantation bleeding and
postcoital bleeding
• Bleeding precautions and when to come in for
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evaluation should be given

• If bleeding becomes heavy (soaking > 1 pad
per hour), associated pain, cramping, or loss of
fluid
• Approximately 20% of women experience some
cramping & bleeding in early pregnancy
11
• Reassurance is key!
(Casanova et al, 2019; Schadewald et al, 2020)

Spontaneous Abortion (SAB)

• AKA “miscarriage” or “early pregnancy loss”
• Most common complication of early pregnancy
• Nonviable, IUP with either empty gestational sac or
gestational sac containing an embryo or fetus
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without fetal cardiac activity within 12.6 weeks

gestation
• Termination of pregnancy before the point of fetal
viability
• GA < 20 weeks
• Weight < 500 g
• CRL < 16.5cm 12

(ACOG, 2018a; Schadewald et al, 2020)

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Spontaneous Abortion (SAB):

Incidence
• Occurs in 10 to 15% of all clinically recognized
pregnancies
• 80% of all SABs occur in first trimester
• More than half of early SABs due to fetal chromosomal
abnormalities

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• Women at extremes of childbearing age are increased
risk for SAB with women in their 20s being lowest risk
• Increased risk with increasing paternal and maternal age
• Advanced Maternal Age (AMA)
• 9 to 17% at 20 to 30 years of age
• 20% at 35 years of age
• 40% at 40 years of age
• 80% at 45 years of age 13

(ACOG, 2018a)

Spontaneous Abortion (SAB):

Risk Factors
• Endocrinology (thyroid, Cushing’s)
• Genetic (congenital, chromosomal)
• Microbiologic (infections)
• Anatomic Abnormalities (congenital uterine
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abnormalities, adhesions, or fibroids)

• Some Chronic Diseases: diabetes, nutritional
deficiencies, renal diseases, systemic lupus
erythematosus (SLE), Antiphospholipid Syndrome (APS)
• Lifestyle Factors: smoking, substance abuse, and
exposure to environmental hazards
14

(Casanova et al, 2019; Schadewald et al, 2020)

Spontaneous Abortion (SAB):

Subjective Data
• Vaginal bleeding (most common symptom),
abdominal, pelvic, and/or low back pain, fever or
chills, prior symptoms of pregnancy
• Varying degrees of vaginal bleeding, pain, cramping
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• Gush of fluid? Passage of products of conception?

• LMP and/or US for dating
• Previous spontaneous and/or induced abortion
• Menstrual & medical history (ie, thrombophilia)
• Medications
15

(Casanova et al, 2019; Schadewald et al, 2020)

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Spontaneous Abortion (SAB):

Objective Data—Physical Examination
• Temperature, heart rate, blood pressure –to
determine hemodynamic stability
• Speculum exam to determine the source of

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bleeding
• Bimanual exam
• Cervical softening or dilation
• Uterine size, bogginess, or tenderness

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(Casanova et al, 2019; Schadewald et al, 2020)

Spontaneous Abortion (SAB):

Clinical Classification
Threatened Abortion Incomplete Abortion
• Slight bleeding, • Heavy bleeding and
cramping moderate to severe
• Closed cervical os cramping
• Prognosis • Dilated cervical os
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unpredictable • Some POC passed

Inevitable Abortion Complete Abortion

• Moderate bleeding and • Minimal bleeding with
cramping subsiding of cramping
• Dilated cervical os • Closed or dilated
without expulsion of cervical os
POC • All POC expelled 17

Spontaneous Abortion (SAB):

Clinical Classification
• Missed Abortion
• Fetus dies in utero but is not expelled
• Septic Abortion
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• Any type of abortion associated with fever,

chills, pain and purulent uterine discharge
• Habitual Abortion
• Recurrent Pregnancy Loss
• Two or more intrauterine pregnancy (IUP)
losses 18

(Casanova et al, 2019; Schadewald et al, 2020)

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Review:
Human Chorionic Gonadotropin (hCG)
• Βeta-human chorionic gonadotropin (hCG)
doubles every 48 hours in a normal intrauterine
pregnancy (IUP)
• β-hCG increases by only 1/3rd in ectopic

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pregnancy
• Serum β-hCG is positive 8 to 10 days after
fertilization
• Rule of 10: 100 at missed menses & 100,000 at
10 weeks (peak)
19

(Kelsey & Nagtalon-Ramos, 2021; Schadewald et al, 2020)

Spontaneous Abortion (SAB):

Objective Data—Laboratory Evaluation
• Serum Quantitative β-hCG
• Baseline: May be inappropriately low for expected
gestational age
• Repeat in 48 hours
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• Maternal hemoglobin to assess blood loss

• Type & Screen
• Rh negative - Rhogam administration is warranted if SAB
• Blood and cervical cultures if septic abortion suspected
• Tissue passed at home or in hospital should be sent to
pathology if possible
• To assess for chorionic villi and possibly chromosomal 20
analysis
(Kelsey & Nagtalon-Ramos, 2021; Schadewald et al, 2020)

Review:
Sonographic Findings
• Gestational Sac
• Usually seen by 4.5 to 5 weeks gestation
• Caution: may look similar to intrauterine fluid
collections
• Yolk sac
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• Usually appears within 5 to 6 weeks

• Mean sac diameter > 10mm
• Embryo
• Appears soon after yolk sac
• Approximately 5 to 6 weeks
• Fetal pole with cardiac activity can be seen 5.5 to 21
6 weeks
(Casanova et al, 2019; Cunningham et al, 2018; Kelsey & Nagtalon-Ramos, 2021)

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Spontaneous Abortion (SAB):

Objective Data—Imaging
• Ultrasound to determine presence of embryonic sac and
detect fetal heart tones/motion
• IUP (gestational sac + yolk sac or embryo) should be seen
via (discriminatory value):

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• Transvaginal Ultrasound (TVUS)
• β-hCG > 1000 – 2000 mIU/mL
• Transabdominal Ultrasound (TAUS)
• β-hCG is > 5,000 – 6, 500 mIU/mL
• Absence of an IUP with β-hCG levels above the
discriminatory value suggests an abnormal pregnancy
22

(ACOG, 2018a; Casanova et al, 2019; Kelsey & Nagtalon-Ramos, 2021)

Spontaneous Abortion (SAB):

Objective Data—Imaging
Sonographic Signs Suggestive of Impending Loss:
• Irregularly shaped gestational sac
• Slow fetal heart rate (< 100bpm at 5 to 7wks is
considered slow)
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• No cardiac activity in embryo

• Presence of abnormal hyperechoic material in uterine
cavity
• Subchorionic hematoma is a risk factor (if >25% of
volume of gestational sac or dependent on location (ie,
retroplacental)
23

(ACOG, 2018a)

Spontaneous Abortion (SAB):

Objective Data—Imaging
Sonographic Signs Suggestive of Impending Loss:
• Crown-rump length (CRL) ≥7 mm with no heartbeat
• Mean sac diameter 16-24mm & no embryo
• Absence of embryo with heartbeat 7-13 days after scan
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showing gestational sac without yolk sac

• Absence of embryo with heartbeat 7-10 days after a scan
showing gestational sac with yolk sac
• Absence of embryo for > 6 weeks after LMP
• Empty amnion or enlarged yolk sac > 7mm
24

(ACOG, 2018a)

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Spontaneous Abortion (SAB):

Objective Data—Imaging
Diagnostic Findings of Pregnancy Failure/Loss:
• Crown-rump length (CRL) ≥7 mm with no
heartbeat
• Mean sac diameter ≥25 mm & no embryo

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• Absence of embryo with heartbeat ≥ 2 weeks
after scan showing gestational sac without yolk
sac
• Absence of embryo with heartbeat ≥ 11 days
after a scan showing gestational sac with yolk sac
25

(ACOG, 2018a)

What if ultrasound showed this?

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(Image: “Ultrasound Scan ND 020” by Nevit Dilmen (talk), licensed by CC BY-SA 3.0)

Spontaneous Abortion (SAB):

Differential Diagnoses
• Anembryonic Gestation AKA blighted ovum (suspected if
empty gest sac ≥25mm)
• Ectopic Pregnancy (should ALWAYS be ruled out!)
• Subchorionic hemorrhage
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• Gestational Trophoblastic Disease

• Cervical abnormalities (friability, malignancy, polyps,
trauma)
• Cervicitis/Vaginitis
• Urinary Tract Infection (UTI) in pregnancy
• Idiopathic bleeding in a viable pregnancy 27

(Schadewald et al, 2020)

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Spontaneous Abortion (SAB):

Management
• Expectant
• Widely preferred by women
• Is generally very low risk
• Medical

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• Medical management can be offered if the patient has
a pregnancy loss of <11 weeks’ gestation that is
confirmed by US
• Should not be done if infection, hemorrhage, severe
anemia, or bleeding disorders
• Surgical (D&C or manual vacuum aspiration)
• Women who present with hemorrhage, hemodynamic
instability, or signs of infection 28

(ACOG, 2018a; Casanova et al, 2019)

Spontaneous Abortion (SAB):

Medical Management
• Misoprostol (Cytotec) 800 mcg vaginally with one
repeat dose if needed
• No earlier than 3 hours after the initial dose
• Within 7 days of the initial dose
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• Mifepristone (Mifeprex) 200mg PO can be

administered 24 hours before misoprostol (Cytotec)
to improve efficacy (Level A Evidence)
• Pain Medications and Bleeding Expectations
• For women who are Rh(D) negative & unsensitized
Rh(D)-immune globulin (Rhogam) 50mcg IM within
72 hours of the initial misoprostol (Cytotec) dosage 29

(ACOG, 2018a)

Spontaneous Abortion (SAB):

Medical Management
• In addition to patient-reported symptoms, US
within 7 to 14 days or serial β-hCGs can be used
to assess complete expulsion of tissue
• If complete expulsion has not occurred by Day 8,
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then surgical options should be offered

30

(ACOG, 2018a)

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Spontaneous Abortion (SAB):

Surgical Management
• Dilation and curettage with suction curettage or
manual vacuum aspiration
• Surgical management advised in the following cases:
• Septic abortion
• Unsuccessful medical or expectant management

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• Heavy bleeding / hemodynamic instability
• Patient preference – Some women prefer to have
completed procedure in controlled setting rather
than waiting for the unknown with medical and or
expectant management
• Can be associated with more trauma and infectious
complications than medical or expectant 31
management
(ACOG, 2018a; Kelsey & Nagtalon-Ramos, 2021)

Spontaneous Abortion (SAB):

Follow Up
• Recommend pelvic rest for 1 to 2 weeks after
expulsion
• Monitor for prolonged bleeding
• Monitor for signs of infection
• Prophylactic antibiotics given with surgical
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management
• Assess and monitor psychological state of the
patient and offer resources as needed
• Plans for future conception
• Immunoglobulin to Rh negative, unsensitized
women
• For repeat pregnancy losses, a complete work-up 32
and referral to MFM will be needed
(ACOG, 2018a; Kelsey & Nagtalon-Ramos, 2021)

Subchorionic Hemorrhage
• Sonographic finding of blood between the
chorion & uterine wall – usually in the setting of
bleeding without cramping
• Occurs in 3 to 9% of pregnancies
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• 2 to 3-fold increase in SAB

• Subchorionic hematoma is a risk factor
• If >25% of gestational sac volume
• Dependent on location ie, retroplacental
33

(Cunningham et al, 2018)

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Subchorionic Hemorrhage
• Risk increases with increasing size of the bleed
seen on US and amount of bleeding but majority
of cases the pregnancy continues without
complication

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• If symptomatic – usually late first trimester
bleeding that is not accompanied by pain
• Often times, subchorionic bleeds are incidentally
detected on US and the patient has no bleeding
• Pelvic rest until bleeding has subsided for at least
24 hours
34
• Generally, resolves spontaneously
(Cunningham et al, 2018)

Ectopic Pregnancy
• Ectopic or extrauterine pregnancy is a pregnancy
or implantation of a fertilized ovum somewhere
other than the endometrial lining of the uterus
(cervix, ovary, abdomen)[
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• Fallopian tube (90-95%) most common site for

implantation specifically the ampulla of the tube
• After implantation the embryo grows, but no
decidua is present and rupture is inevitable.

35

(ACOG, 2018b; Casanova et al, 2019; Schadewald et al, 2020)

Ectopic Pregnancy:
Incidence
• About 1 to 2% of reported pregnancies in US
• True incidence difficult to ascertain since most ectopic
pregnancies are treated in outpatient settings
• Prevalence of women with ectopic pregnancy presenting
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to the ED with first trimester bleeding or abdominal pain

or both reported to be as high as 18%
• Despite improvements in prompt diagnosis and
management, ectopic pregnancy remains significant
cause of pregnancy-related morbidity and mortality

36

(ACOG, 2018b)

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Ectopic Pregnancy:
Risk Factors
• Etiology of extrauterine implantation originates
with an interference in normal ovum transport
• One-half of all patients who are diagnosed with
ectopic pregnancy do not have risk factors

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• Prior ectopic pregnancy, history of infertility,
pelvic or tubal surgery or infection (PID)
• Advanced maternal age (AMA), use of ARTs, IUD
or OCPs (alters tubal motility), smoking, DES
exposure, 3 or more SABs
37

(ACOG, 2018b; Casanova et al, 2019; Schadewald et al, 2020)

Ectopic Pregnancy:
Subjective Data
• Wide range of clinical presentations from asymptomatic to
circulatory collapse
• Classic symptoms include amenorrhea followed by vaginal bleeding
& abdominal pain (can be unilateral & sharp)
• Pregnancy signs/symptoms ie, nausea, breast tenderness
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• Malaise, vomiting, dizziness, syncope, fever

• Can experience shoulder as pain as the hemorrhage becomes
extensive (peritoneal hemorrhage) & irritates the diaphragm
• Atypical signs are menstrual irregularities
• SYMPTOMS DO NOT CORRELATE WITH SEVERITY OF CONDITION
• Note that up to 50% of patients with an ectopic pregnancy may be
asymptomatic
38

(ACOG, 2018b; Casanova et al, 2019; Schadewald et al, 2020)

Ectopic Pregnancy:
Objective Data—Physical Examination
• Vital signs: any s/s hypovolemia or shock after hemorrhage (cool,
clammy skin and poor skin turgor, late signs are hypotension &
tachycardia)
• Abdomen: +/- abdominal pain or tenderness, more likely if ruptured,
radiating shoulder pain
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• Pelvic Examination
• Vagina: may be painful vaginal exam and have brick red or brown
blood in vault
• Cervix: may be normal appearing or slightly dilated with blood or
decidual tissue, +CMT
• Uterus: soft, normal or slightly enlarged uterus
• Adnexa: + palpable, unilateral adnexal tenderness and/or mass--
present in approximately one third of cases but absence does not 39
rule out an ectopic pregnancy
(ACOG, 2018b; Casanova et al, 2019; Schadewald et al, 2020)

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Ectopic Pregnancy:
Objective Data—Laboratory Evaluation
• +UPT – verify the location & viability of the pregnancy
• Serum β-hCG usually low (90% of ectopic pregnancies
have β-hCG < 6500)
• Serial β-hCGs that do not typically follow normal
pregnancy trend suggest an abnormal pregnancy but do

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not inform the location of the pregnancy (IUP, SAB,
Ectopic Pregnancy)
• Serum progesterone levels may be useful but also do not
determine location
• If progesterone level >20ng/dl, there is 98% chance of viable
pregnancy
• If progesterone level < 5 ng/dl, there is a 99% chance nonviable
pregnancy
• In between levels 5 to 20 ng/ml is equivocal 40

(ACOG, 2018b; Casanova et al, 2019; Schadewald et al, 2020)

Ectopic Pregnancy:
Objective Data—Imaging
• TVUS and serial β-hCG measurements are the
most reliable for diagnosis of ectopic pregnancy
• US to determine location, assess size of uterus,
and detect presence of fetal viability
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• f β-hCG > discriminatory zone and IUP not

visualized on TVUS – ectopic pregnancy should
be suspected

41

(ACOG, 2018b; Casanova et al, 2019; Schadewald et al, 2020)

Ectopic Pregnancy:
Differential Diagnoses
• Pelvic Inflammatory Disease
• Ovarian Cyst
• Ovarian Tumor
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• Intrauterine Pregnancy
• Recent Spontaneous Abortion
• Early Hydatididform Degeneration
• Acute Appendicitis
• Bowel-Related Disorders
42

(Schadewald et al, 2020)

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Ectopic Pregnancy:
Management
• Expectant Management
• Surgical Management
• Medical Management

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(ACOG, 2018b)

Ectopic Pregnancy:
Expectant Management
• Candidates
• Willing to accept the potential risks of tubal
rupture and hemorrhage
• Asymptomatic
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• Objective evidence of resolution (declining β-

hCG levels)

44

(ACOG, 2018b)

Ectopic Pregnancy:
Expectant Management
• Success Rates
• The earlier the gestation and the lower the β-hCG
levels, the better the chance the patient can be
managed expectantly
• If initial β-hCG <200 IU/mL, almost 90% will experience
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spontaneous resolution
• If initial β-hCG >2000 IU/mL only 20-25% will resolve
expectantly
• Tubal patency and 1-year fertility rates are equal with
either success or failure of expectant management
• Monitoring
• Serial β-hCG levels until approaching zero
• Prompt evaluation if experiences pain or bleeding 45

(ACOG, 2018b)

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Ectopic Pregnancy:
Surgical Management
• Laparoscopic salpingectomy
• Removal of part or all the affected fallopian tube
• Laparoscopic salpingostomy
• “Tube-sparing” removal of ectopic pregnancy
while leaving the fallopian tube in situ

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• Laparoscopic versus “open” Laparotomy
• Laparoscopy generally preferred because of
shorter operative times, less blood loss, less
analgesic required, shorter hospital stays
• Laparotomy reserved for unstable patients and
patients who have a large amount of peritoneal
bleeding 46

(ACOG, 2018b)

Ectopic Pregnancy:
Surgical Management
• Candidates
• Ruptured ectopic pregnancy
• Hemodynamic instability or signs of
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intraperitoneal bleeding
• Contraindications to or failure of medical
management
• Inability to comply with post-treatment
monitoring, lack of timely access to medical
facility, patient preference
47

(ACOG, 2018b; Casanova et al, 2019; Schadewald et al, 2020)

Ectopic Pregnancy:
Surgical Management
• Success Rates
• Overall success rates for surgical management: 92%
• Similar to medical management
• Monitoring
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• Monitor for signs or symptoms of infection from the

surgery
• Serial β-hCG levels until decrease to non-pregnant
level to ensure absence of trophoblastic disease

48

(ACOG, 2018b)

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Ectopic Pregnancy:
Medical Management
• Intramuscular Methotrexate (MTX): Folate
Antagonist
• Single-dose, two-dose, and fixed multiple-dose
regimens

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• Success (70 to 95%) dependent on treatment
regimen used, GA, and initial hCG level
• Candidates
• Hemodynamically stable with an unruptured
mass < 4 cm
49
• Able to comply with follow up surveillance
(ACOG, 2018b)

Ectopic Pregnancy:
Medical Management
• Absolute contraindications
• Heterotopic pregnancy with viable IUP
• Immunocompromised, breastfeeding, PUD, active
pulmonary disease
• Hepatic, renal, pulmonary, or hematologic dysfunction
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• Hemodynamic instability, inability to remain compliant

with post therapeutic monitoring, & contraindications
to MTX itself
• Relative contraindications
• High initial hCG (>5000)
• Embryonic cardiac motion
• Ectopic pregnancy > 4cm
• Refusal to accept blood and blood products 50

(ACOG, 2018b; Casanova et al, 2019)

Ectopic Pregnancy:
Medical Management
• Vaginal spotting expected
• May have abdominal pain 2 to 3 days after
administration
• GI side effects (nausea, vomiting, stomatitis) most
common after multiple doses
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• Potential severe side effects of MTX: bone marrow

suppression, hepatotoxicity, stomatitis, pulmonary
fibrosis, alopecia, and photosensitivity
• NSAIDs and folic acid-containing foods and supplements
may decrease the efficacy of MTX
• Avoid sunlight during therapy (methotrexate dermatitis)
• Avoid pregnancy for 1 to 3 months after treatment
• No significant impact on future fertility 51

(ACOG, 2018b)

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Ectopic Pregnancy:
Follow Up
• Monitor β-hCG level on Day 4 and Day 7 after
MTX administration
• If β-hCG level fail to decrease by at least 15%
• Can refer for surgical intervention, or

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• Continue treatment until β-hCG levels
decrease by at least 15% in 48 hours or four
doses of methotrexate have been given
• Monitor serum β-hCG weekly until undetected
• Also, monitor blood count, platelet count, and 52
liver enzymes weekly, give Rhogam if RH neg
(ACOG, 2018b)

Gestational Trophoblastic Disease

• A group of neoplastic disorders that originate in
the human placenta
• A vesicular or polycystic placental mass resulting
from the proliferation of the trophoblast & the
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hydropic degeneration & avascularity of the

chorionic villi
• Gestational tissue is present but nonviable
pregnancy (embryo usually absent or dead)
• Hydatidiform mole
• Invasive mole
53
• Choriocarcinoma
(Ngan et al, 2018)

Hydatidiform Mole
• Most common type of gestational trophoblastic
disease
• A benign neoplasm of chorion in which
chrorionic villi degenerate and become
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transparent vesicles containing clear, viscid fluid

• Partial: fetus or evidence of amniotic sac is
present
• Complete: no fetus or amnion present; more
likely to undergo malignant changes
54

(Casanova et al, 2019; Ngan et al, 2018)

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Invasive Mole
• Also known as chorioadenoma destruens
• A complete molar gestation that invaded the
myometrium, metastasized to other tissues
• Karyotyping shows abnormal genetic material

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resulting from an empty egg or diploid sperm

55

(Casanova et al, 2019; Ngan et al, 2018)

Choriocarcinoma
• Rare condition 1 in 20,000–40,000 pregnancies,
approximately
• Chorionic malignancy that may follow any type
of pregnancy: normal, ectopic, abortion, or
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molar pregnancy
• Half follow hydatidiform molar pregnancy

56

(Casanova et al, 2019; Ngan et al, 2018; Schadewald et al, 2020)

Gestational Trophoblastic Disease:

Incidence
• Etiology may be influenced by nutritional factors,
such as protein deficiency
• Varies markedly around the world
• In US, 1 in 1500 pregnancies (molar pregnancy)
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• More prevalent in Hispanic and American Indians

• Advanced maternal age (AMA) is a risk factor

57

(Casanova et al, 2019; Cunningham et al, 2018; Schadewald et al, 2020)

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Gestational Trophoblastic Disease:

Subjective Data
• Amenorrhea, breast tenderness, morning
sickness (hyperemesis) secondary to elevated
levels of β-hCG
• Rapid uterine enlargement

©2022 NPWH
• Vaginal bleeding in first trimester, around the
12th week (starts with brownish spotting)
• Uterine cramping may or may not be present

58

(Casanova et al, 2019; Ngan et al, 2018)

Gestational Trophoblastic Disease:

Objective Data
• Vital Signs
• May have tachycardia due to stimulation of thyroid gland by
high levels of β-HCG or by thyrotropin produced by
trophoblasts
• Elevated BP (as preeclampsia can occur – less common)
• No fetal heart tones or fetal activity is detected
©2022 NPWH

• Expulsion of grapelike vesicles with or without history of

vaginal bleeding (may be first sign)
• Bloody or clear vesicles in the vagina
• Enlarged uterus greater than what is expected for gestational
age, doughy consistency (size/date discrepancy)
• Enlarged tender ovaries secondary to theca lutein cysts
(develop from ovarian hyperstimulation of high hCG levels)
• Elevated levels of β-hCG 59

(Casanova et al, 2019; Ngan et al, 2018)

Gestational Trophoblastic Disease:

Objective Data—Imaging
©2022 NPWH

Molar Pregnancy: “Snowstorm appearance” on ultrasound 60

(Image: “Molar pregnancy,” by Mikael Häggström, 2014, (Image: “Molar pregnancy 0001,” by Mme Mim, CC
DOI:10.15347/wjm/2014.008. ISSN 2002-4436. Public Domain.) BY-SA 4.0)
(Casanova et al, 2019)

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Gestational Trophoblastic Disease:

Differential Diagnoses
• Normal pregnancy
• Threatened Abortion
• Size/Date Discrepancy – Error in dating

©2022 NPWH
• Uterine Myomas
• Polyhydramnios
• Multiple Gestation

61

(Casanova et al, 2019; Ngan et al, 2018; Schadewald et al, 2020)

Gestational Trophoblastic Disease:

Management
• Prompt identification and referral for dilation &
curettage (D&C) or evacuation (D&E)
• Baseline β-hCG within 48 hours of surgical
management
• Weekly levels until 3 consecutive normal values
©2022 NPWH

• Monthly β-hCG monitoring for next 6 to 12

months after surgical management
• Possible treatment with chemotherapeutic agents
if levels do not return to normal (increase or
plateau); MTX for fertility preservation
• Baseline chest x-ray if metastasis is suspected
• Provide support and reassurance especially 62
regarding future pregnancies
(Casanova et al, 2019; Ngan et al, 2018; Schadewald et al, 2020)

Genital Tract Pathology

• Cervicitis
• Cervical lesions
• Cervical polyps
©2022 NPWH

• Vaginitis/vaginosis
• Specific incidences and managements would be
specific to each individual cause
• Management would be directed by the
underlying cause for the bleeding with
consideration for pregnancy (i.e. medications to 63
treat, etc)
(Casanova et al, 2019; Schadewald et al, 2020)

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©2022 NPWH
Placenta problems, cervical insufficiency, uterine rupture, and others

MID TO LATE PREGNANCY BLEEDING 64

Mid to Late Pregnancy Bleeding

Clinical Case

• 40yo G3P2 at 32 weeks gestation

• Painless, moderate vaginal bleeding
©2022 NPWH

• Labetolol 200mg PO BID for CHTN

• Episode of vaginal bleeding at 26wks

65

Mid to Late Pregnancy Bleeding

• Anal • Cervical
• Hemorrhoids • Labor (term/preterm)
• Trauma – tears & • Cervical Insufficiency
lacerations • Cervicitis
• Vulvar
©2022 NPWH

• Polyp
• Varicose veins • Ectropion
• Trauma – tears & • Friable glandular
lacerations tissue
• Vaginal • Trauma – tears &
• Trauma – tears & lacerations
lacerations
66

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Mid to Late Pregnancy Bleeding

• Uterine
• Placenta Previa
• Placenta Accreta

©2022 NPWH
• Placental Abruption
• Vasa Previa
• Uterine Rupture

67

Placenta Previa
• Placental tissue that overlies or is proximate to
the internal cervical os
• Classifications:
• Total or complete previa
©2022 NPWH

• Placenta completely covers the internal os

• Incomplete or partial previa
• Placenta partially covers the internal os
• Marginal or low-lying previa
• Placenta that extends into the lower uterine
segment but does not reach the internal os 68

(Casanova et al, 2019; Cunningham et al, 2018; Schadewald et al, 2020)

Placenta Previa:
Incidence
• Accounts for 20% of third trimester bleeds
• Occurs in 1 of 200 to 300 pregnancies
• Incidence in 2nd trimester = 5% - “placental
©2022 NPWH

migration” occurs in most cases leading to

resolution by term

69

(Casanova et al, 2019; Cunningham et al, 2018; Schadewald et al, 2020)

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Placenta Previa:
Potential Complications
• The placenta is pulled away from the
endometrial wall as the cervix dilates, this causes
bleeding
• Bleeding can lead to hemorrhage which

©2022 NPWH
endangers mother and fetus; can interfere with
uteroplacental sufficiency
• Patients diagnosed with placenta previa have
higher risk of complications after birth
(hysterectomy, intrapartum and postpartum
hemorrhage, and thrombophlebitis) 70

(Casanova et al, 2019; Cunningham et al, 2018; Schadewald et al, 2020)

Placenta Accrete Syndromes

• Potential Complication of Placenta Previa
• Increased bleeding from the lower uterine
segment where placenta was attached at the
time of delivery
©2022 NPWH

• Abnormally implanted placenta: accreta, increta,

percreta
• Incidence of placenta accreta is 1 in 533
pregnancies
• Risk factors include patients with a history of
71
cesarean delivery or previous uterine surgery
(Casanova et al, 2019)

Placenta Accrete Syndromes

• Placenta accrete
• Abnormally adherent to uterine wall
• Placental tissue extends into the superficial
layer of the myometrium
©2022 NPWH

• Placenta increta
• Extends into the myometrium
• Placenta percreta
• Extends completely through the myometrium
to the serosa and sometimes into adjacent
organs such as the bladder 72

(Casanova et al, 2019)

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Placenta Accrete Syndromes

©2022 NPWH
73

(Image: Placenta accreta. Creative

Commons. Public Domain)

Placenta Previa:
Risk Factors
• Previous cesarean delivery
• Increasing parity (grand multiparity)
• Increasing maternal age (AMA)
• Other uterine surgery (uterine scars)
©2022 NPWH

• Previous placenta previa

• Multiple gestations
• Prior curettage
• Cigarette smoking
• Residing in higher elevations
74
• Male fetus
(Casanova et al, 2019; Schadewald et al, 2020)

Placenta Previa:
Subjective Data
• Painless, bright red bleeding during the 3 rd
trimester (characteristic)
• First bleed is usually a small amount
• Bleeding may occur as early as 20 weeks without
©2022 NPWH

precipitating events
• Suspected in any bleeding that occurs after 24
weeks gestation
• May experience symptoms of shock (syncope) if
hemorrhage
75

(Casanova et al, 2019; Cunningham et al, 2018; Schadewald et al, 2020)

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Placenta Previa:
Objective Data
• Avoid pelvic exam
• Abdominal vs transvaginal ultrasound
• Obesity or full bladder may hinder diagnosis

©2022 NPWH
on abdominal ultrasound
• False-positive findings on TVUS if placenta is
located posteriorly
• Low-lying placental: placental edge 1 to 2cm
from cervical os
76

(Casanova et al, 2019; Cunningham et al, 2018; Schadewald et al, 2020)

Placenta Previa:
Differential Diagnoses
• Abruptio Placenta
• Vasa previa
• Uterine Rupture
©2022 NPWH

• Genital Lacerations
• Excessive Bloody Show
• Cervical Lesions and/or Severe Cervicitis
• Nonvaginal Bleeding (rectal or urinary bleed)
• Ectopic Pregnancy
77

(Casanova et al, 2019; Cunningham et al, 2018; Schadewald et al, 2020)

Placenta Previa:
Management
• Management depends on extent of hemorrhage
and gestation
• If diagnosed in second trimester, repeat US in
early third trimester
©2022 NPWH

• Consult OB and MFM

• Bleeding precautions, pelvic rest

78

(Casanova et al, 2019; Cunningham et al, 2018; Schadewald et al, 2020)

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Placenta Previa:
Management
• Outpatient management
• Asymptomatic patients OR
• Patients with history of a small bleed resolved

©2022 NPWH
for more than 7 days
• Must be compliant, aware of risks, live close to
hospital, and have 24-hour emergency
transport access

79

(Casanova et al, 2019; Cunningham et al, 2018; Schadewald et al, 2020)

Placenta Previa:
Management
• Inpatient management
• Continuous EFM, large bore IV, lab studies
• If < 36 weeks gestation, stabilize patient,
©2022 NPWH

administer transfusions as needed, and

maintain the pregnancy
• If stable, bed rest and expectant management
can be done
• Gradual ambulation can be started if bleeding
stopped and hematocrit > 30%
80

(Casanova et al, 2019; Cunningham et al, 2018; Schadewald et al, 2020)

Placenta Previa:
Management
• Antenatal corticosteroids if less than 34 weeks or
before 37 weeks if risk of PTB within 7 days
• If persistent hemorrhage – stabilization of
mother and delivery is indicated regardless of
©2022 NPWH

gestational age

81

(Casanova et al, 2019; Cunningham et al, 2018; Schadewald et al, 2020)

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 3/8/2022

Placenta Previa:
Management
• Delivery
• Once fetal maturity established, cesarean
delivery indicated for all patients with
sonographic evidence of placenta previa

©2022 NPWH
• Asymptomatic patients – delivery 36 to 37
weeks is recommended
• Symptomatic patients with persistent
hemorrhage require delivery at any gestational
age
• There should be preparation for rapid blood
82
loss at the time of delivery
(Casanova et al, 2019; Cunningham et al, 2018; Schadewald et al, 2020)

Placental Abruption
• Abnormal premature separation of a normally
implanted placenta from the uterus at any time
after 20 weeks gestation
• Types:
©2022 NPWH

• Complete abruption
• Entire placenta separates
• Partial abruption
• Part of placenta separates from uterine wall
• Marginal abruption 83
• Separation is limited to the edge of the placenta
(Casanova et al, 2019)

Placental Abruption:
Incidence
• Most common coagulopathy in pregnancy
• One-third of all antepartum bleeds
• Diagnosis made requiring delivery in 1% of
pregnancies
©2022 NPWH

• Most commonly occurring in the third trimester

• Increased risk of perinatal morbidity and
mortality in early abruptions
• Traumatic vs Chronic Abruption
• Classification is based on signs and symptoms of
the abruption in combination with lab findings 84

(Casanova et al, 2019; Cunningham et al, 2018; Schadewald et al, 2020)

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Placental Abruption:
Risk Factors
• Hypertensive Disorders in Pregnancy
• Previous abruption
• Trauma, IPV
• Maternal smoking, cocaine use

©2022 NPWH
• AMA, multiparity, multifetal gestation
• Inherited or acquired thrombophilia
• Placental abnormalities or ischemia
• Uterine anomalies, uterine fibroids
• Poor maternal nutrition, PPROM,
85
chorioamnionitis
(Casanova et al, 2019; Cunningham et al, 2018; Schadewald et al, 2020)

Placental Abruption:
Subjective Data
• Classic presentation: vaginal bleeding and
abdominal pain
• Small or marginal abruption may present with
bleeding only
©2022 NPWH

• Asymptomatic - concealed hemorrhage

• Chronic Abruption
• Intermittent, light vaginal bleeding
• Often evidence of chronic placental inflammation
(oligo, IUGR, PTL, PPROM, PreE)
86
• Presentation often insidious and difficult to diagnose
(Casanova et al, 2019; Cunningham et al, 2018; Schadewald et al, 2020)

Placental Abruption:
Diagnostic Data
• Primarily a clinical diagnosis with support from
US, labs, and pathology
• Any patient with vaginal bleeding, preterm labor,
abdominal pain or trauma should prompt
©2022 NPWH

investigation of abruption
• May occur in the absence of US findings

87

(Casanova et al, 2019; Cunningham et al, 2018; Schadewald et al, 2020)

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Placental Abruption:
Potential Complications
• Maternal-fetal compromise, hemorrhage or
death (Couvelaire uterus)
• Shock, DIC, HELLP
• Monitor VS

©2022 NPWH
• CBC (H/H, platelets may be decreased)
• Clotting Studies (PT/PTT, fibrinogen may be
decreased)

88

(Casanova et al, 2019; Cunningham et al, 2018; Schadewald et al, 2020)

Placental Abruption:
Differential Diagnosis
• Placenta Previa
• Placenta Accreta
• Hematoma of Rectus Muscle
©2022 NPWH

• Ovarian Cysts
• Appendicitis
• Degeneration of Fibroids

89

(Schadewald et al, 2020)

Placental Abruption:
Management
• Management depends on the severity of
bleeding, GA, and maternal-fetal status
• Expectant management if small abruption occurs
remote from term with minimal bleeding, and
©2022 NPWH

mother/baby stable
• Monitor for potential maternal-fetal
complications
• Antenatal steroids
• If condition of mother or baby worsens then
90
delivery at any gestation
(Casanova et al, 2019; Cunningham et al, 2018; Schadewald et al, 2020)

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Placental Abruption:
Management
• Patients at or near term should undergo
delivery; mode determined by mother/baby
status
• Cesarean delivery indicated when signs of fetal

©2022 NPWH
distress, maternal hemorrhage, maternal
coagulopathy, or poor progress of labor

91

(Casanova et al, 2019; Cunningham et al, 2018; Schadewald et al, 2020)

Vasa Previa
• The passage of fetal vessels over the internal
cervical os below the presenting part of the fetus
• Can occur when there is an accessory
(succenturiate) placental lobe across the os from
©2022 NPWH

the main disk of the placenta, or

• A velamentous insertion of the umbilical cord
• Fetal blood vessels insert into the membranes
between the amnion and chorion instead of the
placenta
• Fetal blood vessels not protected by Wharton jelly 92

(Casanova et al, 2019)

Vasa Previa:
Incidence
• Rare but associated with high rate of fetal death
• Occurs 1 in 2000 to 5000 pregnancies
• Rupture of a fetal vessel occurs rarely in
©2022 NPWH

pregnancy, but the risk is greatest with vasa

previa
• Rupture of a vessel can quickly lead to fetal
death because of the small fetal blood volume
• If undetected before delivery, 60% risk of fetal
mortality
93

(Casanova et al, 2019)

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Vasa Previa:
Risk Factors
• Multiple gestation
• IVF
• Velamentous insertion of the umbilical cord

©2022 NPWH
• Accessory placental lobes

94

(Casanova et al, 2019)

Vasa Previa:
Diagnosis and Management
• Classic Triad
• ROM
• Painless vaginal bleeding
©2022 NPWH

• Fetal bradycardia
• Often not diagnosed until after delivery
• Occasionally detected in the second or third
trimester via US
• Immediate caesarean section is necessary
95

(Casanova et al, 2019)

Uterine Rupture
• Breach in the myometrial wall
• Spontaneous complete transection of the uterus
from the endometrium to the serosa
• Can potentially be life-threatening
©2022 NPWH

• Incomplete or partial rupture – peritoneum

remains intact
• Complete rupture – contents of the uterus
may spill into the peritoneal cavity or the
broad ligament
96

(Casanova et al, 2019)

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Uterine Rupture:
Incidence
• Uterine rupture is rare
• Uterine scar dehiscence (partial rupture) is more
common
• Involves the disruption and separation of a

©2022 NPWH
preexisting uterine scar
• Seldom results in major maternal or fetal
complications

97

(Casanova et al, 2019)

Uterine Rupture:
Risk Factors
• Previous cesarean section scar or other uterine
surgery, VBAC or TOLAC, labor augmentation by
oxytocin and prostaglandins, and high parity
©2022 NPWH

98

(Casanova et al, 2019)

Uterine Rupture:
Assessment & Management
• Assessment
• Abdominal pain
• Chest pain
©2022 NPWH

• Hypovolemic shock
• Non-reassuring fetal heart tones
Management
• Emergency cesarean section
• IV fluids, blood transfusion
99

(Casanova et al, 2019)

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©2022 NPWH
(Image: open source Pixabay)

PRETERM LABOR AND BIRTH 100

Preterm Birth
• Preterm birth (PTB) occurs between 20
weeks and 37 weeks gestation
• May be spontaneous following PTL (50%),
©2022 NPWH

PPROM (25%), or cervical insufficiency, or

• May be indicated for maternal-fetal
complication (25%)
• Early preterm birth: before 34 weeks gestation
• Late preterm birth: 34 weeks to 36 weeks and
101
6 days gestation
(ACOG, 2021a)

Preterm Birth: Incidence

• Increasing PTB rates (late preterm birth)
• In US, PTB rate is approximately 10.2%
• Racial disparity in PTBs (2019)
©2022 NPWH

• White: 9.3%
• Hispanic: 10%
• American Indian and Alaskan Native: 11.5%
• Native Hawaiian and other Pacific Islander: 11.8%
• Non-Hispanic Black: 14.2%
• Socioeconomic disparity in PTBs 102

(ACOG, 2021a)

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Preterm Birth: Incidence

• 1 in 10 newborns are born prematurely
• PTBs account 75% of perinatal mortality
• More than one-half of long-term neonatal
morbidity

©2022 NPWH
• Significant social and economic costs
• Increased risks of morbidity and mortality
• Especially in the first year of life
• Risk inversely related to decreasing GA
• Risks of CP, seizure disorder, neurological
impairment (vision, hearing loss), intellectual
103
impairment
(ACOG, 2020a, 2021a; Cunningham et al, 2018; Schadewald et al, 2020)

Preterm Birth: Fetal Complications

• Threshold of fetal viability: 20 to 26 weeks
gestation
• PTB less than 25 weeks gestation higher risk of
brain injury
©2022 NPWH

• Responsible for approximately 25 to 50% of cases

of neurological impairment in children
• High survival rate (95%)
• Birthweight ≥ 1000g, or
• Gestational age of 28 weeks in females; 30 weeks
104
in males or greater
(Cunningham et al., 2018)

Preterm Birth: Complications

• Conditions common in the premature infant:
• Respiratory Distress Syndrome (RDS)
• Intraventricular hemorrhage
©2022 NPWH

• Bronchopulmonary dysplasia (BPD)

• Patent ductus arteriosus (PDA)
• Necrotizing enterocolitis (NEC)
• Sepsis
• Apnea
105
• Retinopathy
(Schadewald et al, 2020)

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Preterm Labor
• Preterm labor (PTL) is the onset of regular
contraction patterns causing cervical change and
or change in effacement, or
• Presentation with regular contractions and

©2022 NPWH
dilation of 2 cm or more
• Approximately one-half of PTBs followed by PTL
• 30% of PTL cases spontaneously resolve
• Less than 10% of PTL go on to deliver within 7
days
• One-half of patients hospitalized for PTL go on to 106
deliver at term
(ACOG 2020a, 2021a; Schadewald et al., 2020)

Preterm Labor: Pathophysiology

• Most cases etiology unknown but a number of
inciting events have been implicated in PTL
• Decidual hemorrhage (abruption)
• Mechanical factors (overdistention of uterus,
©2022 NPWH

cervical incompetence)
• Hormonal factors (maternal or fetal stress)
• Subclinical or clinical infection (which occur in
one-third of PTBs, most commonly in early
pregnancy)
107

(ACOG 2021a; Casanova et, 2019; Schadewald et al., 2020)

Preterm Labor: Risk Factors

• Demographic risk factors:
• Lower socioeconomic factors
• Non-whites
• Potentially-modifiable risk factors:
• Low maternal pre-pregnancy weight (BMI < 18.5cm)
©2022 NPWH

• Substance use, cigarette smoking

• Short interpregnancy interval (< 18 months)
• Unplanned pregnancy
• Fetal risk factors:
• PROM
• Fetal anomalies
• Placental insufficiency 108

(ACOG 2021a; Casanova et al, 2019)

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Preterm Labor: Risk Factors

• Maternal risk factors:
• Prior history of PTB
• Multifetal gestation
• Systemic diseases

©2022 NPWH
• Cervical insufficiency, shortened cervical length
< 25mm: 16 to 24 weeks gestation
• Vaginal bleeding
• Structural uterine abnormalities
• Overdistended uterus
• Periodontal disease 109
• Urinary or genital tract infection
(ACOG, 2021a)

Preterm Labor: Subjective Data

• Menstrual like cramping (with/without diarrhea)
• Low, dull backache
• Abdominal or pelvic pressure
©2022 NPWH

• Increase in vaginal discharge

• Bloody show or spotting
• Progressive dilation

110

(Casanova et al, 2019; Schadewald et al., 2020)

Preterm Labor: Objective Data

• Cervical change occurring with regular uterine
contraction pattern
• Electronic fetal monitor with tocodynamometer to
assess fetal well-being and quantify the frequency
©2022 NPWH

and duration of contractions

• Cervical examination – visualization with sterile
speculum or digital exam
• Length (cm)
• Dilation (cm)
• Consistency (soft, firm)
• Position (anterior, posterior)
111
• Fetal station (-1, 0, +1)
(Schadewald et al., 2020)

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Preterm Labor: Objective Data

• Tests for suspected infections  urinalysis, urine
culture with sensitivity, chlamydia/gonorrhea (if
suspected), wet prep
• If suspect ROM (see PPROM)

©2022 NPWH
• Fern testing (positive)
• Nitrazine test (pH = 7.1 to 7.3)
• False positives if blood or semen present
• Fetal fibronectin – collect prior to digital exam
112

(Schadewald et al., 2020)

Preterm Labor: Objective Data –

Imaging
• Ultrasound
• Fetal well-being including GA, AFI, fetal
presentation, and placental location
• Endovaginal US for cervical length
©2022 NPWH

• Singleton with prior PTB: 16 to 24 weeks gestation,

assess every 1 to 4 weeks
• Single or multifetal gestation with no risk factors:
18 to 20 weeks gestation

113

(ACOG 2021a; Cunningham et al, 2018; Schadewald et al, 2020)

Preterm Labor: Differential

Diagnoses
• False labor or Braxton Hicks contractions
• Urinary tract infection
• Pyelonephritis
©2022 NPWH

• Low back pain

114

(Schadewald et al., 2020)

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Preterm Labor: Prevention

• Bed rest and hydration have not shown to be
effective in preventing PTL
• Refer to cervical insufficiency management for
prevention of preterm delivery

©2022 NPWH
• Progesterone Supplementation (vaginal, IM)
• Cervical length measurements
• Cervical cerclage, pessary

115

(ACOG 2020a, 2021a; Casanova et al, 2019)

Preterm Labor: Management

• Goal of management is to delay delivery, if
possible, until fetal maturity obtained
• Management should be done in collaboration or
consultation with OB
©2022 NPWH

• Non-pharmacological management (minimal

evidence to support prevention of PTB):
• Hydration
• Left lateral bed rest
• Pelvic rest 116

(ACOG 2020a, 2021a; Casanova et al, 2019)

Preterm Labor: Medical Management

– Tocolytics
• From age of viability to 34 weeks gestation
• First-line tocolytic therapy options for short-term
prolongation of pregnancy (48 hours) to allow
for administration of antenatal corticosteroids
©2022 NPWH

• Calcium Channel Blockers: Nifedipine (Procardia)

• NSAIDs: Indomethacin (Indocin)
• Β-adrenergic agonists: Terbutaline (Brethine)
• No evidence to support maintenance tocolytic
therapy in prevention of PTB and improvement
in neonatal outcomes 117

(ACOG 2020a, 2021a; Casanova et al, 2019; Schadewald et al, 2020)

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 3/8/2022

Preterm Labor: Medical Management

– Tocolytics
• Magnesium Sulfate
• Exact mechanism of action is unknown, but
appears to inhibit calcium uptake into smooth
muscle therefore reducing uterine contractility

©2022 NPWH
• Routinely used in practice as tocolytic therapy and
anti-seizure therapy secondary to preelampsia
• Evaluation in inpatient setting with electronic fetal
monitoring
• Magnesium Sulfate 6 gm bolus then 2mg/hour
maintenance for 24 hours for fetal 118
neuroprotection
(ACOG 2020a, 2021a; Casanova et al, 2019)

Preterm Labor: Medical Management

– Tocolytics
• Patients should be monitored closely for signs of
magnesium sulfate toxicity
• Deep tendon reflexes, pulmonary exams, and
fluid balance
©2022 NPWH

• Increased risk of maternal pulmonary edema

with use in multifetal gestation
• No tocolytics if less than 2 cm and contractions
with no cervical change, IUFD, fetal anomaly,
PPROM, chorioamnionitis, maternal bleeding
with hemodynamic instability, severe
preeclampsia, eclampsia 119

(ACOG 2020a, 2021a; Casanova et al, 2019; Schadewald et al, 2020)

Preterm Labor: Medical Management

– Corticosteroids
• Single course of corticosteroids
• 12 mg betamethasone IM q 24h for two doses, or
• 6 mg dexamethasone IM q 12h for four doses
• Predicted delivery within 7 days
• Between 24 weeks and 37 weeks gestation
©2022 NPWH

• Between 24 weeks and 34 weeks gestation for

patients with ROM or multifetal gestation
• In periviable setting, antenatal corticosteroids can be
considered between 22 weeks and 24 weeks
gestation after counseling and plans for neonatal
resuscitation
• Rescue dose may be given 7 to 14 days from last 120
dose
(ACOG 2020a, 2021a, 2021b; Schadewald et al, 2020)

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 3/8/2022

Preterm Labor:
Medical Management – Antibiotics
• Antibiotics should not be prescribed to prolong
pregnancy or improve neonatal outcomes in
patients with PTL and intact membranes
• Prophylactic antibiotics for preterm labor with

©2022 NPWH
ROM and/or +GBS carrier or unknown GBS

121

(ACOG, 2020a; 2021a)

Preterm Labor:
Education and Counseling
• Risks associated with preterm labor/birth
• Signs and symptoms of PTL
• Palpate uterine contractions
©2022 NPWH

• Minimal proven preventative interventions

• Management options and associated outcomes
• Risk of PTL with subsequent pregnancies
• Frequent assessments and follow up

122

(ACOG 2020a, 2021a; Schadewald et al., 2020)

Preterm Labor:
Follow up and Referral
• Collaborate with OB and/or MFM
• Return if contractions continue or worsen or
decreased fetal movement or vaginal bleeding
are noted
©2022 NPWH

• If contractions cease and no further cervical

changes, then likely labor has currently stopped
or slowed but observation is still warranted

123

(ACOG 2021a; Schadewald et al., 2020)

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Cervical Insufficiency
• Dilation or inability of the cervix to remain
closed in absence of contractions in second
trimester

©2022 NPWH
124

(Schuiling & Likis, 2022)

Cervical Insufficiency:
Risk Factors
• Trauma following cervical conization, loop
electrosurgical excision procedures (LEEP),
mechanical dilation during pregnancy
termination, trauma from cervical lacerations
©2022 NPWH

• History of fetal loss ≥ 14 weeks gestation

• History of multiple pregnancy terminations

125

(Schuiling & Likis, 2022)

Cervical Insufficiency:
Assessment
• Subjective complaints of backache, uterine
contractions, vaginal bleeding, pelvic pressure,
vaginal discharge
• Decreased cervical length or cervical dilation
©2022 NPWH

• Cervical length less than or equal to 25 mm or

funneling with possible bulging bag

126

(Schuiling & Likis, 2022)

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Cervical Insufficiency:
Management
• Refer to MFM
• Serial endovaginal sonography from 16 weeks to
24 weeks gestation
• Vaginal pessary, cerclage

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• Progesterone therapy
• Indicated for asymptomatic pregnant patients
with no history of preterm delivery but cervical
length ≤ 20mm at ≤ 24 weeks gestation
• Vaginal suppository: 90 to 200 mg Q HS until 127
36 weeks gestation
(ACOG, 2020a)

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(Image: open source Pixabay)

Prelabor rupture of membranes

RUPTURE OF MEMBRANES 128

Rupture of Membranes (ROM)

• Prelabor rupture of membranes (PROM)
• Rupture of membranes prior to onset of labor
• Preterm premature rupture of membranes
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(PPROM)
• Rupture of membranes before 37 weeks and
prior to onset of labor

129

(ACOG, 2020b)

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PROM:
Etiology
• Exact cause of rupture is unknown
• Disease and disorders associated with PROM
• Maternal infection

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• Intrauterine infection
• Cervical insufficiency
• Multiple previous pregnancies
• Polyhydramnios
• Decreased tensile strength of membranes
130
• Family history
(ACOG, 2020b)

PROM:
Risk Factors
• Short Cervical Length
• Prior PTB
• Polyhydramnios
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• Multifetal gestations
• Bleeding in early pregnancy
• Smoking

131

(ACOG, 2020b)

PROM:
Subjective Data
• History of a gush of fluid from the vagina or
watery vaginal discharge
• Amount of fluid loss
• Urinary incontinence
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• Time of rupture
• Color of fluid
• Odor of fluid
• Last sexual intercourse
132

(ACOG, 2020b)

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PROM:
Objective Data
• Demonstration of amniotic fluid leakage from
the cervix
• Speculum exam
• Fern test

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• Nitrazine paper test
• Amnisure
• Ultrasound
• Tampon test
133

(ACOG, 2020b)

PROM: Objective Data

– Sterile Speculum Exam
• Inspect external genitalia for signs of fluid
• Visualize cervix for flow of fluid from os, prolapsed cord,
or fetal extremities
• Diagnosis occurs from visualization of amniotic fluid
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• Pooling of fluid in vagina

• If no fluid visualized have patient bear down
• Assess cervical dilation and length
• Do not perform digital exam on patient with PROM or
PPROM unless patient appears to be in active labor;
increases risk for infection
• Obtain cervical cultures and /or amniotic fluid sample
134
• FFN is sensitive but not specific for PPROM
(ACOG, 2020b)

PROM: Objective Data

– Fern Test
• Obtain specimen with sterile cotton tipped swab
from fluid exuding from cervical os or posterior
vaginal fornix
• Do not touch cervix; cervical mucous can cause
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false positive
• Smear specimen on slide, allow to dry, inspect
slide for fern pattern
• More reliable than nitrazine paper test
135

(ACOG, 2020b)

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PROM: Objective Data

– Nitrazine Testing
• Mustard colored pH- sensitive paper
• Turns dark blue in presence of alkaline material
• Normal vaginal pH is < 4.5

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• Amniotic fluid pH is 7.0 to 7.5
• False-positive Nitrazine Testing
• Alkaline urine
• Cervical mucous, blood, or semen
• Glove powder
136
• Vaginal discharge caused by BV or trichomonas
(ACOG, 2020b)

PROM: Objective Data

– Amnisure
• Commercial tests that assess for amniotic proteins
• Does not require speculum exam and detects
minuscule amounts of amniotic fluid in vaginal
discharge
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• Test functions properly when trace amounts of blood

are present, but new sample must be collected if
considerable amounts of blood are seen
• False negative is sample collected more than 12
hours after ROM
• 19 to 30% false positives
• Should be used as ancillary to other diagnostic tests 137
and not alone to make diagnosis
(ACOG, 2020b)

PROM: Objective Data

– Imaging/Other
• Ultrasound
• AFI measurement
• Normal amount of fluid may still be present in
ROM
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• Tampon test
• Used when physical exam findings and
ultrasonography are inconclusive
• 1ml of indigo carmine dye mixed with 9ml normal
saline injected into amnion via amniocentesis
• The blue dye will pass onto the tampon with 30
minutes of instillation if membranes are ruptured 138

(ACOG, 2020b)

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PROM: Potential Complication

– Chorioamnionitis
• Acute inflammation of the membranes and
chorion on the placenta, typically due to
bacterial infection from rupture of membranes
• Most commonly caused by retrograde or

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ascending infection from the lower genital tract
• Can occur with intact membranes
• Complicates 1 to 4% of all births in the US
• 40 to 70% of preterm births with PPROM
139

(ACOG, 2020b)

PROM: Potential Complication

– Chorioamnionitis
• Fetus should be delivered regardless of GA
• Treat with broad spectrum antibiotics
• Reliable signs of infection
• Fever – temp checked every 4 hours
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• Maternal leukocytosis – daily leukocyte count

with differential
• Uterine tenderness – check every 4 hours
• Tachycardia – maternal pulse >100 bpm or
fetal heart rate >160 bpm
• Foul smelling amniotic fluid 140

(ACOG, 2020b)

PROM:
Differential Diagnoses
• Urinary incontinence
• Urinary tract infection
• Vaginal or cervical discharge
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• Pregnancy
• Infection

141

(ACOG, 2020b)

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PROM:
Management
• Once diagnosed, assure gestational age, fetal
presentation, and fetal well-being
• Assess for intrauterine infection, abruptio placentae, and
fetal compromise
• Expectant management in < 34 weeks gestation if no

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maternal or fetal contraindications
• Refer to physician for inpatient management
• IOL in PROM in > 34 weeks gestation
• Determine/document FLM before IOL in 32 to 34
weeks
• Obtain GBS culture and administer antibiotics
• 7-day course of IV Ampicillin and Erythromycin
followed by PO amoxicillin and erythromycin 142

(ACOG, 2020b)

PROM:
Management
• Tocolysis is not recommended
• Benefits of tocolysis are limited in PPROM and are
only recommended to allow for completion of first
course of antenatal corticosteroids
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• Single course of corticosteroids

• Predicted delivery within 7 days
• Between 24 weeks and 34 weeks gestation
• 12 mg betamethasone IM q 24h for two doses, or
• 6 mg dexamethasone IM q 12h for four doses
• Rescue dose may be given 7 days from last dose 143

(ACOG, 2020b)

PROM:
Management
• Administer magnesium sulfate if birth seems
imminent in next 24 to 48 hours for fetal
neuroprotection, particularly if PROM < 32
weeks gestation
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• Some form of fetal surveillance should be done

for PROM but there is no clear consensus on
type and frequency

144

(ACOG, 2020b)

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(Image: open source Pixabay)

FETAL GROWTH RESTRICTION 145

Fetal Growth Restriction (FGR)

• AKA intrauterine fetal growth restriction (IUGR)
• Estimated fetal weight (EFW), or
• Abdominal circumference < 10th percentile
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• Small for Gestational Age (SGA)

• Estimated fetal weight < 10th percentile

146

(ACOG, 2021c; Cunningham et al, 2018; Schadewald et al, 2020)

Review – Fetal Growth

• Characterized by sequential patterns of tissue
and organ growth, differentiation, and
maturation
• 3 Phases:
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• Cellular hyperplasia
• 1st 16 weeks gestation
• Cellular hyperplasia and hypertrophy
• 17 to 32 weeks gestation
• Cellular hypertrophy
• Fetal mass (most fetal fat & glycogen) greater than 147
32 weeks gestation
(ACOG, 2021c; Schadewald et al, 2020)

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Symmetrical FGR
• Occurs earlier in pregnancy - most commonly in
first trimester
• Decrease in both cell size (hypertrophy) and cell
number (hyperplasia)

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• Inadequate growth of both head and body but
organs are proportionate
• Proportionately small; below average
measurements for length, weight, HC, AC
• Potential Causes: teratogen exposure, maternal
viral infections, substance abuse, and
148
congenital/chromosomal abnormalities
(ACOG, 2021c)

Asymmetrical FGR
• Occurs later in pregnancy - most commonly in 3rd trimester
• Diminished glucose transfer and hepatic storage affects cell
size (hypertrophy) but not cell number (hyperplasia)
• HC > AC
• Musculoskeletal & head dimensions (head sparing) are
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unaltered
• Lagging abdominal growth in comparison to the rest of the
body
• Abdominal dimensions are diminished due to decrease in liver
size and decreased amount of subcutaneous fat present
• At birth, an infant with asymmetrical FGR will have a brain
weight to liver weight ration of 5:1 (normal = 3:1)
• Often caused by decreased placental perfusion and maternal
vascular disease (ex. HTN)
149

(ACOG, 2021c)

FGR: Pathophysiology
• Although etiological conditions vary, each
condition often leads to a common pathway:
suboptimal uterine-placental perfusion and fetal
nutrition
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• Abnormal placentation that results in poor

placental perfusion is the most common
pathology associated with FGR
• Insufficient transfer of oxygen and nutrients
from mother to fetus resulting in decreased
fetal growth 150

(ACOG, 2021c)

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FGR: Risk Factors

• Pregestational DM
• Renal insufficiency
• Autoimmune Disease (SLE)

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• Cyanotic cardiac disease
• Hypertensive Disorders in Pregnancy
• CHTN, gestational HTN, preeclampsia
• Antiphospholipid Antibody Syndrome (APS)
• Substance use and abuse
151
• Tobacco, alcohol, cocaine, or narcotics
(ACOG, 2021c)

FGR: Risk Factors

• Multiple Gestation
• Teratogen exposure
• Valproic acid, antithrombotic medications
• Infectious diseases
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• Malaria, CMV, rubella, toxoplasmosis, syphilis

• Genetic and structural disorders
• Trisomy 13, trisomy 18, congenital heart
disease, gastroschisis
• Placental disorders and umbilical cord
abnormalities 152

(ACOG, 2021c)

FGR: Potential Complications

• Risk depends on etiology, gestational age,
and severity of the maternal condition
• Increased risk for morbidity and mortality
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• Smaller size
• Male more than female deaths
• Symmetrical more than asymmetrical
• FGR infants with congenital anomalies
• 30 to 60% chance of perinatal death 153

(ACOG, 2021c)

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FGR: Potential Complications

• GOAL of recognizing growth abnormalities is to
identify infants at risk for increased short-term and
long-term morbidity and mortality
• Short-term Complications

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• Fetus vulnerable to death, asphyxia, ischemia, and
labor intolerance
• Neonatal complications include low Apgar scores,
hypoglycemia, hypothermia, polycythemia,
hyperbilirubinemia, RDS, seizures, sepsis,
meconium aspiration syndrome (MAS), and 154
neonatal death
(ACOG, 2021c; Cunningham et al, 2018)

FGR: Potential Complications

• Long-term Complications
• Associations between birth weight and adult
obesity, CV disease, insulin resistance, and
dyslipidemia
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• Numerous studies have shown accelerated

FLM in complicated pregnancies associated
with FGR
• SGA infants may have hypoglycemia,
hyperbilirubinemia, hypothermia, IVH, NEC,
155
seizures, sepsis, RDS & death
(ACOG, 2021c; Cunningham et al, 2018)

FGR: Subjective Data

• OB/GYN History
• Establish dates
• Any previous pregnancies with FGR
• Placental or uterine abnormalities
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• PMH, PSH, Medications

• Family history (genetic abnormalities/conditions)
• Social history
• Alcohol intake, smoking, illicit drug use
• Nutritional status and exercise routine
• Environmental safety and occupation
156
• Any exposure to teratogens/chemicals/pollutants
(ACOG, 2021c)

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FGR: Objective Data

– Physical Examination
• Vital Signs: Monitor BP for preeclampsia
• High blood pressure could be FGR cause
• Should be monitored routinely in order to

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make an early diagnosis
• Fundal Height (FH) should be measured in cm
between 24 to 38 weeks gestation
• Should increase 1cm per week consistent with
gestational age in weeks
• > 3cm discrepancy warrants evaluation 157

(ACOG, 2021c)

FGR: Objective Data

– Ultrasound
• Preferred screening tool
• Measuring for Estimated Fetal Weight (EFW):
• Biparietal diameter (BPD)
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• Head Circumference (HC)

• Abdominal Circumference (AC)
• A normal AC excludes FGR
• Femur length (FL)
• Must be seen on two separate US 2 to 4 weeks
apart to confirm IUGR diagnosis 158

(ACOG, 2021c)

FGR: Objective Data

– Ultrasound
• Further evaluation needed if:
• AC < 10%, or
• Combined measurement yields an estimated
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fetal weight (EFW) < 10% percentile for GA

• Should measure AFI
• Scan for fetal anatomy
• IUGR will have higher incidence of structural
and genetic abnormalities
159

(ACOG, 2021c)

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FGR: Objective Data –

Doppler Velocimetry
• Absent or reversed end-diastolic flow in the
umbilical artery increases risk of perinatal
mortality
• Abnormal flow in the ductus venosus and fetal

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aortic and pulmonary outflow tracts
• Increased impedance in the umbilical artery
could suggest placental insufficiency causing
fetal growth restriction
• Use in conjunction with BPP and NST for
160
standard surveillance of IUGR
(ACOG, 2021c)

FGR: Differential Diagnoses

• Small for gestational age (SGA)
• Asymmetrical vs symmetrical FGR
• Oligohydramnios
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161

(ACOG, 2021c; Schadewald et al, 2020)

FGR: Management
• GOAL is to deliver healthiest possible infant at
optimal time
• Refer to MFM
• Treat any underlying conditions such as,
hypertension, infections
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• Antenatal corticosteroids for FLM

• Less than 34 weeks gestation
• 34 to 36 weeks gestation
• Risk of PTB within 7 days
• No previous administration of corticosteroids
• Magnesium sulfate for fetal neuroprotection
• Less than 32 weeks gestation 162

(ACOG, 2021c; Cunningham et al, 2018)

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FGR: Management
• Fetal Monitoring
• Fetal Kick Counts
• NSTs, BPPs

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• Doppler studies of fetal vessels
• Serial evaluations of fetal biometry every 3 to
4 weeks to follow extent of growth restriction

163

(ACOG, 2021c; Cunningham et al, 2018)

FGR: Management
• Optimal timing of delivery depends on the
underlying etiology of FGR, GA, and antepartum
fetal surveillance findings
• Individualized and multidisciplinary approach
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• Delivery if risk of fetal death exceeds that of

neonatal death (often difficult to assess)
• Anticipate delivery in facility with higher level
NICU
• FGR is not indication for cesarean delivery
• Route of delivery should be based on other 164
clinical circumstances
(ACOG, 2021c)

FGR: Education and Counseling

• Possible causes of FGR, manifestations, risk
factors, and possible outcomes
• Various disease processes, infections, and
chromosomal abnormalities that could be
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present
• Discuss preterm delivery & possible NICU
admission
• Dietary changes that include increased protein
intake, smoking cessation
165

(ACOG, 2021c)

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FGR: Education and Counseling

• Risks of using alcohol or illicit drugs during
pregnancy and ways to stop
• Possible long term developmental effects on the
child

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• Proper medication administration if prescribed
• Future appointments, follow up, and reason for
close monitoring of both mother and baby
• Bedrest, if applicable
166

(ACOG, 2021c)

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(Image: open source Pixabay)

Pregnancy loss and coping with pregnancy loss

PREGNANCY LOSS 167

Pregnancy Loss
• Encompasses SABs, ectopic pregnancy, perinatal
mortality, stillborn, and neonatal death (within
the first 28 days of life)
• May be a perceived or actual loss
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• Loss of an expectation
• Negative birthing experience
• Viable infant born prematurely and/or with
congenital anomalies
• Giving up baby for adoption
• Miscarriage, induced AB
168
• Loss often involves the mother and the family
(Schadewald et al, 2020)

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Pregnancy Loss:
Incidence
• Infant mortality rate
• Includes any infant death before the first
birthday
• 5.6 deaths per 1,000 live births in the US

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• In 2018, the five leading causes of infant
mortality (X = 21,000)
• Congenital Malformation
• PTB
• Injuries (ie, suffocation)
• SIDS
169
• Maternal pregnancy complications
(Kochanek, 2020; Schadewald et al, 2020)

Pregnancy Loss:
Incidence
• Infant mortality rates by race and ethnicity were
as follows in 2018:
• Non-Hispanic black: 10.8
• Native Hawaiian or other Pacific Islander: 9.4
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• American Indian/Alaska Native: 8.2

• Hispanic: 4.9
• Non-Hispanic white: 4.6
• Asian: 3.6
• Lower rates in western part of US, higher rates in
south, southeast
170

(Kochanek, 2020; Schadewald et al, 2020)

Pregnancy Loss:
Subjective Data
• May report hopelessness, sadness, loss of
appetite, inability to sleep, increased irritability
or hostility towards others, preoccupation with
lost of infant, social isolation, inability to return
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to normal activities, somatic distress

• May hold feelings of guilt and preoccupation
with blame, negligence, or minor omissions
• Also experience by siblings and grandparents

171

(Schadewald et al, 2020)

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Pregnancy Loss:
Objective Data
• Observation and Counseling
• Assess grieving of patient and family member
• Each member may express grief differently

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• Progression (and sometimes regression)
through the stages of grief will vary

172

(Schadewald et al, 2020)

Pregnancy Loss: Management

• Psychosocial interventions aimed at helping
parents/family work through loss and make loss real
• Assess coping abilities
• Communicate and allow for contact with patient and
family to evaluate coping and readjustment
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• Provide anticipatory guidance regarding the grief

process and acute grief (emotional roller coaster,
good/bad days) which often occurs during first 2 to 4
months
• Equip parents to deal with reactions from others,
especially well-intended but insensitive comments
• Refer to support groups 173
• Facilitate communication and expression of grief
(Schadewald et al, 2020)

Pregnancy Loss:
Grief
• Perinatal grieving involves acute grief which is most
intense during the first 4 to 6 weeks
• Normal grief reaction may last 6 months to 2 years, never
resolve, or be reactivated by anniversary, birthdates, etc
• Course of grief does not always proceed through a
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predictable series of stages, course varies, depending

upon the circumstances and consequences
• 5 Stages of the Grief Process
• Shock
• Anger
• Bargaining
• Depression
174
• Resolution
(Schadewald et al, 2020)

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Pregnancy Loss:
Grief
• Communicate with family/friends about the infant or
child who died
• Well-balanced diet, adequate hydration, rest, and
exercise
• Avoid tobacco, caffeine, alcohol

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• Clarify values and don’t be persuaded to act or think as
you think you “should”
• Ease marital stress by communicating, offering affection,
and recognizing and respecting need for solitary time
• Keep diary of thoughts, memories, and mementos
• Write letter to the infant
• Accept help from others and request help when needed
• Avoid making any big life decisions or changes in 24 175
months
(Schadewald et al, 2020)

Pregnancy Loss:
Follow Up
• Follow-up visit generally scheduled for 2 to 6
weeks after a pregnancy loss
• Evaluate uterine involution
• Assess the return of menses
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• Discuss reproductive plans

• Assess for positive resolution of grief:
• Functioning at home and/or work
• Individual can turn outward, think/help others
• Place the loss in perspective with this life
176
• Making future plans
(Schadewald et al, 2020)

Pregnancy Loss:
Follow Up
• Unresolved grief behaviors suggest need for
skilled professional counselor
• Persistent yearning for recovery of lost objects
• Overidentification with the deceased
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• Inability to cry or rage despite the desire to do so

• Misdirected anger or ambivalence towards infant
• Lack of support group, network, or persons
• Presence of secondary gain (ie, increased attention
to mother)
177

(Schadewald et al, 2020)

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Module Objectives
Upon completion of this module the participant should be
able to:
1. Discuss the incidence, risk factors, assessment,
differential diagnoses, and management of bleeding
during pregnancy.

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2. Describe the incidence, risk factors, potential
complications, assessment, and management for
preterm labor and delivery, cervical insufficiency, and
premature (prelabor) rupture of membranes.
3. Describe incidence, risk factors, etiology, potential
complications, assessment, diagnosis, and
management for fetal growth restriction (FGR).
4. Explore pregnancy loss and discuss the assessment
and management of grief following a perinatal loss. 178

References
• American College of Obstetricians & Gynecologists (ACOG). (2018a). Early
Pregnancy Loss. Practice Bulletin No. 200. Obstetrics & Gynecology, 132(5), e197-
207.
• American College of Obstetricians & Gynecologists (ACOG). (2018b). Ectopic
Pregnancy. Practice Bulletin Number 193. Obstetrics & Gynecology, 131(3), e91-
103.
• American College of Obstetricians & Gynecologists (ACOG). (2020a). Management
of Preterm Labor. Practice Bulletin No. 171. Obstetrics & Gynecology 2016, 128,
e155-64.
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• American College of Obstetricians & Gynecologists (ACOG). (2020b). Prelabor

Rupture of Membranes (PROM). PB Number 217. Obstetrics & Gynecology, 135(3),
e80-97.
• American College of Obstetricians & Gynecologists (ACOG). (2021a). Prediction &
Prevention of Spontaneous Preterm Birth. Practice Bulletin No. 234. Obstetrics &
Gynecology, 138(2), e65-90.
• American College of Obstetricians & Gynecologists (ACOG). (2021b). Use of
Antenatal Corticosteroids at 22 Weeks of Gestation. Practice Advisory, September
2021. Retrieved from [Link]
advisory/articles/2021/09/use-of-antenatal-corticosteroids-at-22-weeks-of-
gestation
• American College of Obstetricians & Gynecologists (ACOG). (2021c). Fetal Growth 179
Restriction. Practice Bulletin No. 227. Obstetrics & Gynecology, 137(2), e16-28.

References
• Casanova, R., Chuang, A., Goepfert, A. R., Hueppchen, N. A., Weiss, P. M. (2019).
Beckmann & Ling’s Obstetrics & Gynecology. (8th ed.). Philadelphia: Wolters- Kluwer.
ISBN: 9781496353092.
• Cunningham, F., Leveno, K., Bloom, S. et al (2018). Williams Obstetrics. (25th ed.).
McGrawHill Education/Medical. ISBN: 9781259644320.
• Kelsey, B.M. & Nagtalon-Ramos, J. (2021). Midwifery & Women’s Health Nurse
Practitioner Certification Review Guide. (5th ed.). Jones & Bartlett.
• Kochanek, KD, Xu, JQ, & Arias E. (2020). Mortality in the United States, 2019. NCHS
©2022 NPWH

Data Brief, no 395. Hyattsville, MD: National Center for Health Statistics. Retrieved
from [Link]
• Ngan, H.Y.S., Seckl, M.J., Berkowitz, R.S., & Xiang, Y., Golfier, F., Sekharan, P.K., Lurain,
J.R., Massuger, L. (2018). FIGO Cancer Report 2018: Update on the diagnosis and
management of gestational trophoblastic disease. International Journal of Gynecology
& Obstetrics, 143(2), 79-85. DOI: 10.1002/ijgo.12615
• Schedewald, D., Pritham, U. A., Youngkin, E. Q., Davis, S.M., & Juve, C. (2020).
Women's Health: A Primary Care Clinical Guide. (5th ed). Pearson. (ISBN: 978-
0135659663)
• Schuiling, K. D., & Likis, F. E. (2022). Gynecologic Health Care: With an introduction to
prenatal and postpartum care. (4th ed.). Boston: Jones & Bartlett. (ISBN:
1284182347).
180

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