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ER Week 5 > Clinical Aspects of Pregnancy > Flashcards

Clinical Aspects of Pregnancy Flashcards

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1
Q

What are the major complications that account for 80% of all maternal death?

A 
severe bleeding (usually HTN - eclampsia
Obstructed labor
Unsafe abortion

remainder are caused by diseases like malaria, anemia and HIV/AIDS

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2
Q

How many pregnancies are complicated by gestational diabetes?

A

7% are complicated by DM and 90% of that is classified as gestational DM

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3
Q

Why do we care about gestational diabetes

A

after 12 weeks, the maternal glucose can cross the placenta and fetal beta cells can produce insulin in response

if maternal glucose is elevated, fetal insulin production will increase, which triggers growth producing macrosomia

also…hyperglycemia in the first 10 weeks of pregnancy while organogensis is taking place is teratogenic and associated with 2-3x increase in congenital malformations and miscarriage (but this isn’t identified by current screening)

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4
Q

What percentage of deliveries of women with GDM are macrosomic?

A

20% - over 8 pounds 13 ounces

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5
Q

WHen do we screen for asymptomatic gestational diabetes?

A

24-28 weeks

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6
Q

What are the risk factors for GDM?

A 
35 yrs and older
BMI over 25
family hx of DM
history of previous GDM
macrosomia in previous pregnancy
high risk ehtnic group: hispanic, asian, native, african, pacific islander)

test using the ADA criteria for nonpregnancy adults

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7
Q

How do we treat GDM?

A

diet
glyburide (micronase0
glucophage (metformin)
intensive insulin therapy

Treatment aims to achiee glucose levels of 130 per dL one hour postprandially

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8
Q

Does early induction for macrosomia help outcomes?

A

it reduces the risk of macrosomia, but doesn’t reduce rates of brachial injuries, hypoglycemia or clavicle fractures

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9
Q

True or false: most women will continue needing insulin after delivery for a few months

A

false - usually can stop right away

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10
Q

What percentage of women with GDM will devlop T2DM within 5-10 years?

A

50%

so continue screening with oral glucose tolerance test at three year intervals

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11
Q

What is the definition of preterm labor?

A

cervical change associated with uterine contractions prior to 37 weeks

in nulliparous women, this is uterine contractions with 2 cm dilation and 80%+ effacement

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12
Q

What is the incidence of preterm labor in the US?

A

11% of pregnancies

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13
Q

What are the risk factors for preterm labor?

A 
premature rupture of membranes (PROM)
multiple gestation
previous preterm birth
hydramnios
uterine anommaly
hx of cervical cone biopsy
cocain abuse
african american
abdominal trauma
pyelonephritis
abdominal surgery in preg
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14
Q

What are some general causes of preterm labor?

A 
UTI
cervical infection
bacterial vaginosis
generalized infection
trauma or abruption
hydramnios
multiple gestation
idiopathic
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15
Q

What are the important questions to ask in the initial assessment of a patient with premature contractions?

A
  1. what is the gestational age
  2. are the membranes ruptured?
  3. is patient in active labor?
  4. is there an infection>
  5. What is the likelihood that the patient will deliver prematurely?
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16
Q

What should you do in the evaluation of premature labor?

A

speculum exam to rule out PROM

culture for GBS, chlamydia and gonorrhdea
check fetal fibronectin
ultrasound for EDD, expected fetal weight, fetal presentation, biophysical profile, cervix length

digital exam to see how far she’s dilated

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17
Q

What is fetal fibronectin and what does it tell us?

A

It’s a large glycoprotein thought to act as an adhesive of fetal membranes to the decidua

A high value is better at predicting imminent delivery than cervical dilation or uterine activity

high negative predictive value -
if it’s normal - they’re not going to be preterm

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18
Q

What should your orders be based on cervical length seen on US?

A

less than 16 mm -
consider cerclage

16-20 - bed rest and remeasure in one week

21-25 mm, reduce physical activity and remeasure in 2 weeks

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19
Q

What can you give antenatal for lung maturation if premature delivery is likely?

A

betamethasone (two 12 mg intramusuclar doses 24 hr apart) or dexamethasone ( mg intramuscularly every 12 hours for 4 doses)

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20
Q

You can also give tocolytics to slow down the premature labor. What are some drug options for this?

A

nifedipine
indomethacin
terbutaline

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21
Q

What percent of pregnancies will be affected by UTI?

A

5%

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22
Q

Bacterial vaginosis increases the risk for what?

A

prematur fupture of membranes, preterm delivery and peurperal infections

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23
Q

How do we treat bacterial vaginosis in pregnancy?

A

vaginal metronidazole to decrease nausea

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24
Q

What is chorioamnionitis?

A

infection of the placenta - presents with maternal fevers, elevated maternal white blood count and uterine tenderness
fetal tachycardia

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25
What are the typical infections that can affect the fetus?
``` TORCH Toxoplasmosis Other: Parvovirus, HIV, Niesserie gonorrhea, chlamydia, hepatitis B, syphilis Rubella CMV HSV ```
26
What is the risk with parvovivrus?
fetal hemolytic anemia (fetal hydrops)
27
What is associated with congenital rubella syndrome?
deafness cardiac abnormalities cataracts mental retardation
28
True or false: a woman with HIV should decrease her anti-HIV drugs to avoid teratogenic effects.
false - she should stay on regular triple therapy
29
What issues can be associcated with toxoplasmosis?
severe if transmitted to the fetus during the first trimester - seizures, hydro/microcephaly, hepatosplenomegaly, jaundice, chorioretinitis
30
If someone comes in with vaginal bleeding during pregnancy, what should you do in workup?
abdominal ultrasound FIRST! gentle speculum exam no binary exam
31
What are the two main concerns with antepartum bleeding?
placenta previa | placenta abruption
32
What would be the issue with painless bleeding?
previa
33
What would be the issue with bleeding associated painful contractions?
placenta abruption
34
What is complete placenta previa?
whne the placenta completely covers the internal cervical os
35
WHat is partial placenta previa?
when the placenta partially coveres the internal cervical os
36
What is a low lying placent?
when the edge of the placenta is within 2-3 cm of the internal cervical os
37
What is placental abruption?
premature separation of a normally implanted placenta
38
What is vasa previa?
when the umbilical cord vessels insert into the membranes with the vessels overlying the interal cervical os raises concern for fetal exsanguination upon rupture of the membranes
39
A history of post coital spotting earlier during pregnancy suggests what?
placenta previa
40
What are the risk factors for placetna previa?
``` grand multiparity prior C-section prior uterine curettage previous palcenta previa multiple gestation ```
41
What is the management for placental previa?
delivery by C-section
42
WHat is placenta accreta?
invasion of the placenta into the uterus - which is more common with placenta previa
43
What are the predisposing/precipitating factors for placental abruption?
``` hypertension advanced maternal age multiparity multiple pregnancy diabetes mellitus trauma external/internal version delivery of first twin rupture of membranes with polyhydramnios ```
44
What percentage of pregnancies are affected by abruption? what's the mortality rate?
ocurs in 1-5% of pregnancys ( is the cause of 30% of third trimester bleeding) 15% mortality rate
45
What is the treatment for abruption?
stabilize the patient prepare for the possibility of future hemorrhage prepare for preterm delivery deliver if bleeding is life threatening or fetal testing is non-reassuring
46
What are the variations of the breech presentation?
complete breech incomplete breech frank breech
47
After a breech extraction and delivery, what do you need to check for in the baby?
hip dysplasia
48
What do we attempt if someone is breech? Does it work?
external podalic version usually most successful if you do it and then induce right after because baby will just flip back around because there's usually a reason fro the breech presentation!!
49
What is the biggest concern with all the abnormal presentations?
prolapsed umbilical cord
50
What are the 5 general itiologies for hypertension in pregnancy?
``` chronic hypertension (just continuing on) pregnancy-induced HTN pre-eclampsia Eclampsia HELLP syndrome ```
51
WHen do we call it chronic hypertension?
BP 140/90 before pregnancy or at less than 20 weeks gestation
52
Treatment of chornic hypertension in pregnancy is controbersion, but what are some options?
beta blockers calcium channel blockers methyldopa diuretics
53
What hypertension drug do you NOT give in pregnancy
ACE inhibitors - associated with neonatal renal failure
54
When do we call it pregnancy-induced hypertension?
hypertension without proteinuria at greater than 20 weeks gestation usually mild to moderate. maternal risks are small
55
When do we call it pre-eclampsia?
over 140/90 after 20 weeks of gestation in a woman whos BOP was previously normal WITH proteinuria non-dependent edema is usually present, but not a criterion
56
What percentage of pregnancies are effected by pre-eclampsia?
5-8%
57
What do we think pre-eclapsia is caused by?
probably some sort of placental vasospasm
58
True or false: pre-eclampsia is more common in a woman's first pregnancy.
true - but this may be because women who have pre-eclampsia are more likely to chose not to get pregnant a second time.
59
What are the risk factors for pre-eclapsia?
previous pre-eclampsia in other pregnancies chronic hypertension low dietary calcium
60
How can you reduce the risk for pre-eclampsia?
calcium supplementation low dose aspirin if they have a history of Pre-ec, chronic hypertension, diabetes, autoimmune disease, renal disease or gestational hypertension
61
What are the complications of pre-eclampsia?
``` eclampsia (seizures) placenta abruption coagulopathies renal failure hepatic subcapsular hematoma hepatic rupture uteroplacental insufficiency ```
62
At what BP do we consider the pre-ec severe?
160/110
63
At what level of proteinuria do we consider it severe?
over 5 g in 24 hours
64
What are some other signs of severe pre-eclampsia?
``` oliguria pulmonary edema or cyanosis impariment of liver funtion visual or cerebral disturbnances pain in epigastric or RUQ decreased platelets intrauterine growth restriction ```
65
What is the treatment for pre-ec?
delivery! control BP wth hydralazine or labetolol Magnesium sulfate to prevent seizures
66
What is hELLP syndome?
Hemolysis (DIC) Elevated Liver enzymes Low Platelet counc
67
What fetal monitoring would you do in pre-ec or other hypertension?
you try to buy time before having to deliver... 1. obtain nonstress test twice weekly 2. biophysical profile weekly 3. ultrasonogrphay every 3-4 weeks
68
True or false: If you are concerned, yo can tell the woman to count fetal movements
false - doesn't improve outcomes and increases anxiety leading ot more triage evaluations
69
How do we do non-stree testint?
patient is connected to the montiro to measure baby's heart rate, which hsould go up when baby moves
70
When do you do an oxytocin stress test?
WHen the non-stress test was concerning
71
How do you do a oxytocin stress test?
give IV oxytocin to induce contractions the FHT should show VARIABILITY without decelerations with the contractions
72
What is assessed in the biophysical profile/
five categories with 0-2 score ``` amniotic fluid volume fetal tone fetal activity fetal breathing movements fetal heart rate reactivity (nonstress0 ```
73
What is considered a normal biophysical profile score?
8-10
74
BIshop's score for induction is used for what?
guides us about whether we can successfully attempt induction
75
What are the 5 things that go into a bishops score?
``` position of the cervix consistency of the cervix effacement dilation fetal station ``` each one goes from 0-3
76
A score of ___ would suggest favorable induction?
10
77
What are the methods to ripen the cervix?
mechanical with balloon catheter oxytocin prostaglandins (Dinoprostone - Cervidil or Misoprosol - Cytotec)
78
What drugs can you use during pregnancy to treat depression?
you can use TCAs, but prefer SSRIs Save buproprion for smoking cessation typically, but can use if nothing else worked
79
Can you use these during breast feeding as well?
yes there will be byproducts in the milk, but this doesn't seem to affect the infant
80
What are the three screening tools for postpartum depression?
Edinburgh Postnatal Depression Scale PHQ-9 Beck Depression Inventory

ER Week 5 (6 decks)

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