3- Abnormal Pregnancy I & II

Question 1

An ectopic pregnancy occurs outside of the uterine cavity. What is the most common location?

Answer 1

Fallopian tube

Question 2

What is the pathophysiology of an ectopic pregnancy?

Answer 2

Disruption of normal tube anatomy or functional impairment that prevents transport of embryo to uterine cavity

Question 3

What factors place a pt at high risk for ectopic pregnancy? (5)

Answer 3

Previous ectopic pregnancy

Previous tubal surgery/ ligation

Tubal pathology

In utero DES exposure

Current IUD use

Question 4

Pt presents with first trimester vaginal bleeding and abdominal pain. VS show hypotension and tachycardia. Abdomen (+) for tenderness, rebound, and guarding. What are you concerned for?

(+/- breast tenderness, dizziness/ fainting, back/ shoulder pain, bleeding/ tenderness on pelvic exam)

Answer 4

Ectopic pregnancy

Question 5

For normal intrauterine pregnancy, when should landmarks be visible on TVUS according to quantitative beta hCG values?

Answer 5

Once discriminatory zone is reached (3500 IU/mL)

Landmarks: “double ring” sign/ fetal pole w/ cardiac activity
(5-6 weeks)

Question 6

Can a single beta hCG measurement diagnose the viability/ location of a gestation?

Answer 6

No

Question 7

If unable to locate a pregnancy on TVUS once discriminatory zone is reached, what is the next step?

Answer 7

Considered “pregnancy of unknown location”

Repeat beta hCG in 48-72 hrs

Question 8

When is expectant management appropriate for an ectopic pregnancy?

Answer 8

Asx + objective evidence of ectopic pregnancy resolution

Pt is reliable for f/u

Question 9

What is included in expectant management of ectopic pregnancy?

Answer 9

Beta hCG q 48-72 hrs w/ US prn

If beta hCG < 200 → resolution of pregnancy

Question 10

What risks are a/w expectant management of ectopic pregnancy? (3)

Answer 10

Tubal rupture, hemorrhage, need for emergency surgery

Question 11

What is used for medical management of ectopic pregnancy (efficacy: 70-95%) and what is the greatest SE?

Answer 11

Methotrexate- affects actively replicating tissue

SE: Abd pain 1-3 days post admin

Question 12

What are the indications for use of medical management of ectopic pregnancy? (4)

Answer 12

Hemodynamically stable

Unruptured mass

No absolute c/i - intrauterine preg, pancytopenia, IMC, active pulmonary disease/PUD/renal dysfunction, breast feeding

Reliable for f/u

Question 13

Aside from methotrexate, what is included in the medical management of ectopic pregnancy?

Answer 13

Serial hCG levels until non-pregnancy level is reached (~2-4 wks)

Question 14

Failure of hCG level to decrease by 15% from day 4-7 is a/w high risk of tx failure and requires what?

Answer 14

Additional methotrexate admin or surgical intervention

Question 15

What pt edu should be provided for medical management of ectopic pregnancy with methotrexate? (5)

Answer 15

Risk of tubal pregnancy rupture/ sxs

Avoid folate containing foods/ drugs/ supplements

Avoid vigorous activity/ sex

Limit sunlight exposure

Avoid pregnancy for 3 mos following admin (teratogenic)

Question 16

In addition to failed medical management, absolute contraindications to medical management and patient request, when is surgical management of ecoptic pregnancy indicated? (3)

Answer 16

Hemodynamically unstable

Sxs of ongoing ruptured ectopic mass

Signs of intraperitoneal bleeding

Question 17

What surgical management of ectopic pregnancy involves removal of the ectopic pregnancy while leaving the affected fallopian tube in situ? What are the associated risks?

Answer 17

Salpingostomy

Risk of repeat ectopic pregnancy

Question 18

What surgical management of ectopic pregnancy involves removal of part of all of the affected fallopian tube? When is this method preferred?

Answer 18

Salpingectomy

Preferred if: severe tubal damage, significant bleeding

Question 19

What must be done following a salpingostomy?

Answer 19

Monitor seial hCG measurements to non-pregnancy level

Question 20

What is defined as a group of conditions that consist of an abnormal proliferation of trophoblastic (placental) tissue?

Answer 20

Gestational trophoblastic disease

Question 21

What is the most common form of gestational trophoblastic disease and is characterized by abns of chorionic villi consisting of varying degrees of trophoblastic proliferation/ edema of villous stroma?

(may be complete, partial, or invasive)

Answer 21

Hydatidiform mole

Question 22

What RFs are a/w hydatidiform mole?

Answer 22

Extremes in age (< 20, > 35)

Hx of previous GTD

Nulliparity

Question 23

Pt presents with irregular/ heavy vaginal bleeding and an enlarged uterus. +/- hyperthyroidism, pre-eclampsia, hyperemesis gravidarum, theca lutein cysts due to high hCG. What type of GTD are you concerned for?

Answer 23

Complete hydatidiform mole

Question 24

Complete hydatidiform mole is derived from where and leads to presence or absence of a fetus?

Answer 24

Paternally derived (46xx)

Absence of a fetus

Question 25

How is a complete hydatidiform mole diagnosed? (3)

Answer 25

Beta hCG: high, \> 100,000 US: "snow storm appearance" Definitive: tissue pathology

Question 26

What is included in the management for complete hydatidiform mole?

Answer 26

Immediate removal of uterine products Measure serial hCG weekly until (-) for 3 consec. weeks OCP until documented resolution

Question 27

What is the protocol for future pregnancies following a complete hydatidiform mole?

Answer 27

Closely monitor w/ early US and hCG levels

Question 28

Pt presents with delayed menses and pregnancy diagnosis or vaginal bleeding from miscarriage/ incomplete abortion. What type of GTD are you concerned for?

Answer 28

Partial hydatidiform mole

Question 29

Partial hydatidiform mole is derived from where and leads to presence or absence of a fetus?

Answer 29

Paternally and maternally derived Presence of a fetus

Question 30

How is a partial hydatidiform mole diagnosed? (2)

Answer 30

Beta hCG: N-high US: "swiss cheese" appearance of intrauterine tissue, fetus w/ anomalies

Question 31

What is included in management of partial hydatidiform mole?

Answer 31

Immediate removal of uterine contents Measure serial hCG weekly until (-) for 3 consec. weeks OCP until documented resolution If coexistent w/ N preg w/o complications → proceed to delivery Low risk of development of persistent malignant disease

Question 32

Pt presents w/ persistent abn uterine bleeding with a plateauing or rising beta hCG following tx of GTD (removal of uterine contents). What are you concerned for?

Answer 32

Invasive molar pregnancy

Question 33

What will US show if invasive molar pregnancy?

Answer 33

Intrauterine mass, increased vascularity w/i myometrium

Question 34

What is included in the management of invasive molar pregnancy aside from serial hCG monitoring and OCP?

Answer 34

Single agent chemotherapy w/ methotrexate or actinomycin-D

Question 35

What GTD is defined as a malignant necrotizing tumor that develops weeks to years after any type of pregnancy and what is the tx? (most common after abn pregnancy)

Answer 35

Choriocarcinoma Tx w/ single agent methotrexate (if good prognostics) vs multi-agent EMACO (if poor prognosis)

Question 36

What GTD is defined as a tumor that arises from the placental implantation site and what is the tx?

Answer 36

Placental site trophoblastic tumor Tx w/ hysterectomy

Question 37

What is defined as persistent N/V that results in dehydration, weight loss, and potential electrolyte abns in pregnancy?

Answer 37

Hyperemesis gravidarum

Question 38

What is included in the general management of hyperemesis gravidarum? (3)

Answer 38

IV hydration Banana bag w/ multivitamins (prevents Wernicke encephalopathy if vit B1 deficient) Anti-emetics

Question 39

What anti-emetics are included in the tx of hyperemesis gravidarum?

Answer 39

**1st line- vit B6 + doxylamine** **2nd line- diphenhydramine/ prochlorperazine/ promethazine** 3rd line- ondansetron, metoclopramide 4th line- clorpromazine/ methylprednisolone

Question 40

When does Rh incompatibility and alloimmunization occur?

Answer 40

Mother Rh (-), fetus Rh (+) → mixing of maternal/ fetal blood → development of maternal antibodies to Rh antigen Does not affect *current* pregnancy, only *future* pregnancies

Question 41

What are the complications of Rh incompatibility and alloimmunization once the maternal antibodies to the Rh antigen cross the placenta?

Answer 41

Destruction of fetal RBCs → fetal hemolytic anemia → erythroblastosis fetalis (HF, diffuse edema, ascites, pericardial effusion)

Question 42

What is the primary goal of management for an unsensitized Rh (-) pt and how is this done?

Answer 42

Keep from being sensitized * Type/ screen @ prenatal visit * Type/ screen @ 28 wks + RhoGAM * If neonate is Rh (+) → RhoGAM postpartum * Exposure to fetal blood cells → RhoGAM

Question 43

What is RhoGAM?

Answer 43

Anti-D immunoglobulin

Question 44

What is the protocol for a sensitized Rh (-) pt? (6 steps) (sensitized: antibody screen (+) for Rh (D) antigen)

Answer 44

Collect titers ↓ Titer followed q 4 weeks ↓ \< 1:16 = expectant management \> 1:16 = amniocentesis ↓ Fetal blood type (-) = expectant management Fetal blood type (+) = screen for fetal anemia (MCA doppler) ↓ Anemia suspected = percutaneous umbilical blood sampling (PUBS) ↓ Anemia detected = intrauterine transfusion | (≥ 1:16 = risk of fetal hydrops)

Question 45

What is the leading cause of maternal morbidity and mortality in developed nations?

Answer 45

HTN

Question 46

What is defined as chronic HTN diagnosed/ present before pregnancy or diagnosed _prior to 20 weeks gestation_?

Answer 46

Chronic HTN

Question 47

What is defined as HTN diagnosed _after 20 weeks gestation_ in a woman w/ previously normal BP?

Answer 47

Gestational HTN 140 SBP +/- 90 DBP on 2 occasions at least 4 hrs apart

Question 48

What BP is determined severe gestational HTN?

Answer 48

\> 160/ 110 Tx w/ IV antihypertensives

Question 49

How can you differentiate between pre-eclampsia and superimposed pre-eclampsia?

Answer 49

Pre-eclampsia: gestational HTN + proteinuria \> 300mg Superimposed pre-eclampsia: chronic HTN + pre-eclampsia

Question 50

Pt presents with HTN after 20 weeks gestation plus 1+ of the following: - thrombocytopenia - renal insufficiency - impaired LFTs - pulm edema - new onset HA unresponsive to meds What are you concerned for?

Answer 50

Pre-eclampsia

Question 51

What is defined as pre-eclampsia + new onset of generalized, tonic-clonic seizures?

Answer 51

Eclampsia

Question 52

What is the general pathophysiology of pre-eclampsia?

Answer 52

Failure to establish adequate uteroplacental BF

Question 53

How is presence of proteinuria confirmed when diagnosing pre-eclampsia?

Answer 53

SPOT (+) if \> 300mg

Question 54

What is included in the management of pre-eclampsia _without_ severe features?

Answer 54

Out-pt management Delivery at 37 0/7 weeks

Question 55

What is included in the management of pre-eclampsia _with_ severe features? (5)

Answer 55

In-pt management Delivery @ 34 0/7 weeks Tx severe HTN- IV labetalol, IV hydralazine, PO nifedipine Mg sulfate for seizure prophylaxis Glucocorticoids

Question 56

What is included in the management of eclampsia? (4)

Answer 56

Prevent maternal hypoxia/ trauma Prompt delivery (usually C-section) Tx severe HTN- IV labetalol, IV hydralazine, PO nifedipine Mg sulfate for seizure prophylaxis

Question 57

What is HELLP sydrome a/w (severe form of pre-eclampsia)?

Answer 57

**H**emolysis **E**levated **l**iver enzymes **L**ow **p**latelet count

Question 58

What is included in the management of HELLP syndrome?

Answer 58

Maternal stabilization- platelet transfusion if \< 50 for c-section, \< 20 for vaginal Prompt delivery Tx severe HTN- IV labetalol, IV hydralazine, PO nifedipine Mg sulfate for seizure prophylaxis

Question 59

What is often seen with lab values of a pt with HELLP syndrome?

Answer 59

Continue to worsen following delivery for 24-48 hrs May require ICU

Question 60

What is defined as an estimated fetal weight (EFW) below the 10th percentile for gestational age in the 2nd half of pregnancy?

Answer 60

Intrauterine growth restriction

Question 61

EFW is determined by which 4 measurements?

Answer 61

Biparietal diameter Head circumference Abd circumference Femur length

Question 62

What infections can be a/w intrauterine growth restriction?

Answer 62

TORCH Toxoplasmosis Other (Syphilis, Varicella) Rubella Cytomegalovirus HSV

Question 63

Intrauterine growth restriction is a/w with increased risk of what?

Answer 63

Perinatal/ neonatal morbidity and mortality

Question 64

How do you screen for intrauterine growth restriction?

Answer 64

Fundal height measurements starting at 16 weeks gestation If \> 3cm off → consider LGA/ SGA → US

Question 65

In screening for intrauterine growth restriction, what test is used to eval EFW, amniotic fluid volume, and umbilical artery BF?

Answer 65

US

Question 66

In screening for intrauterine growth restriction, what test is used to identify fetus at risk for uteroplacental insufficiency (may require early delivery)?

Answer 66

Uterine artery dopplers

Question 67

What is the goal of management for intrauterine growth restriction?

Answer 67

Provide fetal surveillance until risk of intrauterine demise \> than risk of early delivery (fetal surveillance via US q 3 weeks, BPP 2x weekly w/ umbilical artery dopplers, NST, fetal kick counts)

Question 68

When is delivery indicated for IUGR if no complications?

Answer 68

38 0/7 to 39 6/7

Question 69

When is delivery indicated for IUGR if abnormal uterine dopplers?

Answer 69

32 0/7 to 37 0/7

Question 70

When is delivery indicated for IUGR w/ other conditions? (GDM, HTN, oligohydraminos)

Answer 70

34 0/7 to 37 6/7

Question 71

GDM is a/w what maternal/ infant risks?

Answer 71

Maternal- pre-eclampsia, c-section, T2DM later in life Infant- T2DM, adult-onset obesity

Question 72

What is the pathophysiology of GDM?

Answer 72

Pregnant state = insulin resistance (provides for ample nutrients) Pancreatic function insufficient to overcome insulin resistance

Question 73

When is screening performed for GDM if RFs vs routine?

Answer 73

If RFs = 1st trimester Routine = 24-28 weeks

Question 74

What is the protocol for screening of GDM?

Answer 74

1 hr glucose tolerance test * If ≥ 135 → 3 hr tolerance test + A1c * If ≥ 200 → GDM 3 hr glucose tolerance test: * 8 hrs fasting * 2+ elevated values → GDM * fasting- 95 * 1 hr- 180 * 2 hr- 155 * 3 hr- 140

Question 75

What is included in the initial management of GDM?

Answer 75

Diabetic educator (ADA diet, fasting 1-2 hrs prior to meals) * Fasting \< 95 * 1 hr post-prandial \< 140 * 2 hr post-prandial \< 120 Increase activity

Question 76

What is included in the management of GDM if refractory to lifestyle changes?

Answer 76

Insulin initiation (1st line) Metformin

Question 77

If pt requires meds to control GDM, what is required?

Answer 77

Monitoring w/ growth US, BPP, delivery by 39 0/7 weeks or sooner