Complicated OB Flashcards
1
Q
Ectopic pregnancy
- define
- risk
A
- Developing blastocyst implants at a site other than endometrium
- hemorrhage from ectopic preg is leading cause of preg related maternal death in first trimester
2
Q
Ectopic Pregnancy
- risk factors
A
- *anything that messes with the tube**
- previous ectopic
- tubal pathology/sx
- prev genital infections
- IUD
- infertility
- multiple sex partners
- smoking
- in-vitro fertilization
- vaginal douching
- extremes of age
3
Q
Ectopic Pregnancy
- locations including MC
A
- MC: fallopian tubes (70%)
- cervix
- ovary
- cornea (where fallopian tube enters uterus, doesn’t stretch)
- hysterotomy scar
- abdomen
4
Q
what is a heterotopic pregnancy?
A
rare - ectopic AND viable intrauterine pregnancy at the same time
5
Q
Ectopic Pregnancy
- Dx
A
if pt presents with suspicious history and/or clinical picture:
- quantitative b-hCG
AND
- findings on high resolution TVUS
6
Q
Ectopic Pregnancy
- hCG behavior
A
- rises much slower in most (but not all) ectopic and nonviable IUP than in viable IUP
- falling hCG is sign of failing pregnancy (regardless of its location)
*in 85% of viable IUP, concentrations rise by 66% Q48 hours during first 40 days
7
Q
Sx that indicate ectopic preg until proven otherwise
A
- positive preg test
- abdominal/pelvic pain
- +/- bleeding
8
Q
Ectopic Pregnancy
- sx
A
Classic (ruptured and non-ruptured):
- abd pain (99%)
- amenorrhea (74%) bc pregnant…
- vaginal bleeding (56%)
- If hemodynamically unstable and/or acute abdomen - means lots of blood loss
- may be able to palpate pelvic mass
9
Q
Ectopic Pregnancy
- ddx
A
- UTI
- Kidney stones
- diverticulitis
- appendicitis
- ovarian neoplasm
- endometriosis
- Leiomyomas
- PID/endometriosis
- preg-related: abortion, ruptured corpus luteal cysts, torsed ovary, degenerating fibroids
10
Q
Ectopic Pregnancy
- medical management
A
- Methotrexate
- folic acid antagonist, inhibits DNA synthesis and cell reproduction, especially in proliferating cells
- rapidly cleared by kidneys
- dose based on surface area
11
Q
Ectopic Pregnancy
- indications for sx management
A
- hemodynamically unstable/ruptured
- CI to methotrexate
- Heterotropic pregnancy
- poor medical candidate
- desire for permanent sterilization
- known tubal disease, planned in vitro fert for future pregnancy
- failed medical therpay
12
Q
Ectopic Pregnancy
- sx options
A
Laparoscopic vs. laparotomy
- depends on many factors
- laparoscopic is standard approach
Salpingostomy (open, remove, close) vs. salpingectomy (remove tube with ectopic)
13
Q
Ectopic Pregnancy
- post sx f/u
A
- ensure recover
- follow hCG to ensure complete success (all the way to zero!)
- can attempt conception once recovered and hCG is zero
14
Q
Gestational Trophoblastic Disease
- overview
A
- Proliferative disorder of trophoblastic cells
- Maternal tumor arises from gestational tissue (not maternal)
- Defined by beta-hCG
15
Q
Gestational Trophoblastic Disease
- list the four types
A
- Hydatidiform mole (complete or partial)
- Persistent/invasive gestational trophoblastic neoplasia (GTN)
- Choriocarcinoma
- Placental site trophoblastic tumors
16
Q
Gestational Trophoblastic Disease
- Risk factors
A
- extremes of age
- Hx of GTD
- smoking >15 cig a day
- Maternal blood AB, A, B (not O)
- Nulliparity
- Hx infertility
- Use of OCP (very small risk)
17
Q
Gestational Trophoblastic Disease
- Clinical sx
A
- vaginal bleeding
- enlarged uterus (rapid proliferation)
- Theca lutein cysts
- anemia
- hyperemesis gravidarum (high level hCG)
- hyperthyroid (hCG mimics TSH)
- preeclampsia before 20 weeks gestation
- vaginal passage of hydronic vesicles
18
Q
Gestational Trophoblastic Disease
- complete vs. partial mole
A
Complete
- complete set of chromosomes. 46XX (MC) or 46XY
- more likely to be persistent and turn into cancer
Incomplete
- triploid set of chromosomes (partially molar)
- more likely to have actual fetus
19
Q
Gestational Trophoblastic Disease
- management of Hydatidiform mole
A
- Preoperative baseline hCG
- Lab to rule out concomitant morbidity
- D&C evacuation, send tissue to pathology to confirm dx
- Serial hCG until 0
- can attempt conception after hCG 0 for 12 months
20
Q
Spontaneous Abortion
- Overview
A
- preg that ends spontaneously before viable gestational age (20 weeks)
- most common complication of early pregnancy
- frequency decreases with increased gestational age
21
Q
Spontaneous Abortion
- Risk Factors
A
- age
- previous SAB
- smoking
- cocaine
- NSAIDs (high dose)
- Caffeine (>200 mg a day)
- Prolonged ovulation to implantation
- prolonged time to pregnancy
- low folate
- BMI >18.5
- Untx celiac dz
22
Q
Spontaneous Abortion
- 5 Etiologies
A
- Chromosomal abnl
- Congenital abnl
- Trauma (CVS and amniocentesis)
- Host factors
- Unexplained
23
Q
Spontaneous Abortion
- Chromosomal abnormalities
A
- 50% SAB
- Most frequent
Autosomal trisomies
polyploidies
Monosomy X - Most arise de novo, rarely d/t inherited karyotypic abnl
24
Q
Spontaneous Abortion
- 5 Host factors
A
- Maternal uterine abnl (uterine septum, submucosal leiomyoma, intrauterine adhesions)
- Acute maternal infection (listeria, toxoplasmosis, CMV, rubella, herpes simplex, parvovirus B19)
- Maternal (uncontrolled) endocrinopathies (Thyroid, Cushings, PCOS, DM, corpus luteum dysfunction)
- Teratogens (drug, physical stress like fever, env chemicals)
- Hypercoagulable state (SLE, antiphospholipid syndrome, thrombophilias)
25
Spontaneous Abortion
| - Sx
- amenorrhea
- vaginal bleeding
- pelvic pain
- loss of fetal cardiac activity on US
- cervix may or may not be dilated
26
Spontaneous Abortion
| - List the 5 categories of
- Missed
- Complete
- Incomplete
- Threatened
- Inevitable
27
Spontaneous Abortion
| - Missed
had no idea, in for routine exam and pregnancy no longer viable
- no vaginal bleeding, cervical dilation, or cardiac activity
28
Spontaneous Abortion
| - Complete
- fetal tissue already gone
- yes vaginal bleeding
- no cervical dilation or cardiac activity
29
Spontaneous Abortion
| - Incomplete
- had sig bleeding, part of tissue still remains in uterus
- yes vaginal bleeding and cervical dilation
- no cardiac activity
30
Spontaneous Abortion
| - Threatened
- any vaginal bleeding in first trimester of pregnancy
- yes vaginal bleeding and cardiac activity
- no cervical dilation
31
Spontaneous Abortion
| - Inevitable
- hasn't occurred yet but def will happen
- Yes vaginal bleeding, cervical dilation
- Yes/No cardiac activity
32
Spontaneous Abortion
| - septic
- fever, chills, other signs of infection
- lower abd tenderness
- boggy, tender uterus w/ dilated cervix
33
Spontaneous Abortion
| - organisms that cause septic
- staph aureus
- gram neg bacilli
- gram pos cocci
- mixed
- anaerobic orgs
- fungi
34
Spontaneous Abortion
| - management
- Expectant: let it pass on its own, usually within first 2 weeks
- Medical: expedite or control over when will occur. U
- Surgical: suction D&C (dilation and curettage) or D&E (dilation and evacuation)
35
Spontaneous Abortion
| - medical management uses what med
Misoprostol
| - prostaglandins E1 analog
36
Spontaneous Abortion
| - What must not forget to assess
RH status - will affect future pregnancies
37
Recurrent pregnancy loss (RPL)
| - definition
- three or more consecutive losses of clinically recognized pregnancies prior to 20 weeks gestation
- Excludes ectopic, molar, biochemical pregnancies
- can be primary (never have had live birth) or secondary (had normal first preg and now this)
38
Recurrent pregnancy loss (RPL)
| - risk factors (6)
- previous preg loss
- uterine factors
- immunologic factors
- Endocrine factors
- Genetic
- Thrombophilia and fibrinolytic factors
39
Recurrent pregnancy loss (RPL)
| - Uterine factors
- impaired uterine distention or abnl implantation d/t decreased vascularity, increased inflammation, reduction in sensitivity to steroid hormones
- fibroids (leiomyomas)
- endometrial polyps
- intrauterine adhesions (prior curettage)
- uterine septum
40
Recurrent pregnancy loss (RPL)
| - endocrine factors
- poorly controlled DM
- PCOS
- Hyper- or hypothyroidism
- HyperPRL
41
Recurrent pregnancy loss (RPL)
| - evaluation first step
- Extensive history and PE is paramount
42
Recurrent pregnancy loss (RPL)
| - useful tests
- karyotyping
- uterine assessment
- anticardiolipin abs and lupus anticoagulant
- thyroid tests
- PRL levels
- hgb A1C
43
Placental Infections
| - Two vulnerable portals
- fetal membranes overlying cervix: direct access to pathogens ascending from vagina and cervix
- Placental intervillous space and fetal villi - hematogenous access
44
Placenal Infections
| - Chorioamnionitis overview
- inflammation of chorion and or amnion
| - can be sx or silent
45
Placenal Infections
| - Chorioamnionitis sx
- preterm labor
- preterm premature rupture of membranes
- prolonged labor
- neonatal infection
46
Placenal Infections
| - Chorioamnionitis microbiology
Often polymicrobial
- GBS
- E. coli
- Ureaplasma
- Fusobacterium
- Mycoplasma
- anaerobes
47
Placenal Infections
| - Chorioamnionitis dx
Maternal fever (38C) AND 2 of the following:
- maternal leukocytosis (>15k)
- maternal tachycardia (>100)
- fetal tachycardia (>160)
- uterine tenderness
- amniotic fluid has foul odor
48
Placenal Infections
| - Chorioamnionitis risk factors (7)
- nulliparity
- spontaneous labor
- longer length of labor, esp if membranes are ruptured (rate doubles after 24 hours)
- meconium-stained amniotic fluid
- internal fetal/uterine monitoring
- presence of genital tract pathogens (GC...)
- Multiple vaginal examinations
49
Placenal Infections
| - Chorioamnionitis tx
- initiate abx
| - expedite delivery
50
Vaginal bleeding during pregnancy
| - overview
- common event at all stages of pregnancy
- almost always maternal, not fetal
- disruption of decidual blood vessels or discrete cervical/vaginal lesions
51
Vaginal bleeding during pregnancy
| - 1st Trimester
- 20-40% all women
- light, heavy, intermittent, constant, painless, painful
Four major causes:
- ectopic pregnancy
- miscarriage
- Implantation of pregnancy
- cervical/vaginal/uterine pathology
52
Vaginal bleeding during pregnancy
| - 2nd and 3rd trimester
```
- less common
major causes:
- bloody show assoc. with cervical insufficiency
- placenta previa
- abrupt placenta
- uterine rupture
- vasa previa
- cervical/vaginal/uterine pathology
```
53
Placenta previa
- placent covers the cervix
- can be complete or partial
- ok as long as 2 cm away from edge
- not painful, just locate of placenta
54
Abruptio placenta
- painful
| - blood gets in between placenta and uterus
55
Vasa previa
- blood vessels are over cervix
| - very bad
56
Vaginal bleeding during pregnancy
| - evaluation
- complete hx and PE
| - AVOID DIGITAL VAGINAL EXAM if you don't know where the placenta is
57
Vaginal bleeding during pregnancy
| - prognosis
depends on gestational age
58
Vaginal bleeding during pregnancy
| - management
Depends on
- gestational age
- cause of bleeding
- severity of bleeding
- fetal status
59
Vaginal bleeding postpartum
| - post partum hemorrhage (PPH) overview
- true emergency
- major cause of morbidity
- leading cause of admission to ICU in OB
- Most preventable cause of maternal mortality
- 1-5% deliveries
- 10% recurrent in subsequent pregnancies
60
Vaginal bleeding postpartum
| - Post partum hemorrhage definitions
- excessive bleeding that makes the pt sx or hypovolemic
- >500 cc vaginal
- >1000 cc C-section
- >1500 cc cesarean hysterectomy
61
Vaginal bleeding postpartum
| - postpartum hemorrhage: what is very helpful vital sign
- pulse: tachycardia will occur before falling BP
- >120 is a problem
- >140 is a major problem
62
Vaginal bleeding postpartum
| - What controls uterine bleeding post delivery
- contraction of myometrium constricts blood flow
| - local decidual hemostatic factors aid in hemostasis
63
Vaginal bleeding postpartum
| - 4 causes of postpartum hemorrhage
1. Uterine atony (MC, 80%)
2. Trauma
3. Coagulation defects
4. Retained products of conception
64
postpartum hemorrhage
| - uterine atony
Uterus is tired:
- overdistention (twins, big baby)
- Uterine infection
- Drugs (mg relaxes muscle)
- Uterine fatigue dt prolonged labor
- Uterine inversion
65
postpartum hemorrhage
| - complications
- Morbidity: shock, renal failure, ARDS
| - Sheehan's syndrome
66
postpartum hemorrhage
| - management
- Tx like any other trauma/hemorrhage
- Non-operative and operative combos:
- restore circulator volume
- restore tissue O2
- Reverse/prevent coagulopathy
67
Hypertensive disorders
| - Intro
- MC med complication of pregnancy
- 2nd MC cause of maternal mortality
- 5-10% incidence
68
Hypertensive disorders
| - variation of presentation (4)
1. Gestational hypertension
2. Preeclampsia
3. Chronic hypertension (preexisting)
4. chronic HTN and preeclampsia
69
Hypertensive disorders
| - pathophys
- do NOT know cause
- likely involves both maternal and fetal factors
- abnl in placental vasculature early in preg
- circulating antiangiogenic factors that cause maternal endothelial dysfunction
- environmental factors
- paternal (more likely if paternal mother had preeclampsia!)
70
Hypertensive disorders
| - mild preeclampsia bp and proteinuria
- BP >140/90 mmHG
| - Proteinuria >300 mg/dL/24 hours
71
Hypertensive disorders
| - severe preeclampsia bp and proteinuria
- BP > 160/110
| - Proteinuria >5000
72
Hypertensive disorders
| - gestational HTN
elevated BP without proteinuria
73
Hypertensive disorders
| - severe preeclampsia sx
- Oliguria (<500 cc/24 hours)
- Cerebral/visual disturbances (blindness or scotomota)
- pulmonary edema
- RUQ/epigastric pain
- impaired liver fn
- thrombocytopenia
- fetal growth restriction
74
scotomota
spots of blindness
75
Hypertensive disorders
| - HELLP syndrome
- severe subset of severe preeclampsia
- Dx requires three:
Hemolysis (LDH >600)
Elevated LFTs (2x nl)
Low platelets (<100K)
76
Hypertensive disorders
| - preeclampsia risk factors
SO MANY
- nulliparity
- hx preeclampsia
- extremes of age
- fam hx
- chronic HTN
- chronic renal dz
- thrombophilia
- vascular/CT disease
- DM
- multiple gestation
- high BMI
** Smoking is NOT a risk factor
77
Hypertensive disorders
| - Preeclampsia dx
- have a high index of suspicion
- Lab (CBC, CMP, Uric acid, LDH, quantitative urine protein)
- Increased antepartum fetal surveillance (US, amniotic fluid index, non-stress testing)
78
Hypertensive disorders
| - preeclampsia managment
- variable, depends on situation
- assess maternal status for end-organ damage
- Control blood pressure (<160/105)
79
Hypertensive disorders
| - preeclampsia antihypertensive meds
- Alpha-methyl dopa (aldomet)
- Hydralazine (Apresoline)
- Labetalol
- Nifedipine (Procardia, Adatta) 1st line
80
Hypertensive disorders
| - preeclampsia seizure prophylaxis
- IV Mg (can be toxic so monitor)
| - Phenytoin is alt option, requires continuous heart monitoring
81
Hypertensive disorders
| - eclampsia
- Have had a seizure
- Administer Mg
- for persistent convulsions: diazepam or lorazepam, sodium amobarbital
- fetal resuscitation is via maternal resuscitation
- delivery is only treatment
82
Diabetes in Pregnancy
| - types
- Pregestational DM (T1 or T2 before preg)
| - Gestational DM
83
Diabetes in Pregnancy
| - overview
- Pregnancy is a state of insulin resistant and hyperinsulinemia
- maternal insulin resistant is nl. Starts in the second trimester and peaks in third.
- Results from increased placental secretion of diabetogenic hormones (GH, CRH, hCS/human placental lactose, progesterone)
- HCS plays major role in maternal insulin resistance, peaking at 30 weeks gestation
84
Diabetes in Pregnancy
| - Diagnosis of overt DM
- Fasting glucose >125
- A1C >6.4%
- Random glucose >199
85
Diabetes in Pregnancy
| - Dx of Gestational DM
- test at 24-28 weeks
- 1 hour OGTT >135
- confirm with 3 hour OGTT
86
Diabetes in Pregnancy
| - complications of gDM
- preeclampsia
- hydramnios (big with gDM and small with T1DM)
- fetal macrosomia (big baby)
- fetal organomegaly
- birth trauma (bc big baby)
- operative delivery
- perinatal mortality (stillbirth)
- Neonatal respiratory problems and metabolic complications
87
Diabetes in Pregnancy
| - fetal/neonatal complications of pre-gestational DM
- congenital malformations
- spontaneous abortion
- macrosomnia (big baby)
- polyhydramnios
- preterm baby
- perinatal mortality (stillbirth)
- neurodevelopment outcomes
88
Diabetes in Pregnancy
| - maternal complications of pre-gestational DM
same issues as DM in general
| - retinopathy, nephropathy, etc.
89
Diabetes in Pregnancy
| - general management
- nutrition
- exercise (increases sensitivity to insulin)
- Glucose monitoring (A1C pre-preg 6-7%)
- Antenatal fetal testing
- Assessment of fetal growth
- Timing of delivery (early if poor glycemic control, 37-39 weeks)
- Intrapartum glycemic control
90
Diabetes in Pregnancy
| - glycemic control
- via diet and exercise
- A1C 6-7%
- Oral meds: sulfonylurea is standard, metformin is an option
- Insulin: studies show better outcomes vs. oral meds.
91
Diabetes in Pregnancy
| - postpartum management
- avoid hypoglycemia!
- F/u 4-6 weeks for 2 hour OGTT to r/o undiagnosed DM
- Pregestational DM return to primary care or endocrinologist for continued management
92
PTL and PPROM
| - define
- PTL: preterm labor
| - PPROM: preterm premature rupture of the membranes
93
PTL and PPROM
| - overview
- leading cause of infant mortality in US
- relationship between neonatal mortality and gestational age is nonlinear
- <37 weeks is preterm
- 12% of births preterm in 2009
94
PTL and PPROM
| - Risk factors
- stress
- occupational fatigue
- excessive/impaired uterine distention (twins!)
- cervical factors
- infection
- placental pathology
- fetal congenital anomalies
95
PTL
| - preterm labor definition
painful uterine contractions that lead to cervical dilation
| contraction WITHOUT cervical change is NOT preterm labor
96
PTL
| - evaluation
- History (characterize the sx)
- PE (cervical exam)
- Determine gestational age
- Labs: urine culture, GBS, gonorrhea/chlamydia, fetal fibronectin (not used much anymore), drug screen?
- US
- +/- cervical length
97
PTL
| - management
- Give steroids, even if not sure if in labor!! Reduces morbidity and mortality related to preterm birth
- Abx for GBS prophylaxis
- Tocolytic drugs for up to 48 hours to delay delivery, allow glucocorticoids to achieve max benefit
- Abx if positive gonorrhea/chlamydia
98
GBS prophylaxis
- Ampicillin or penicillin
- if PCN allergic, do culture
if GBS unknown, treat if there are risk factors:
- Rupture > 18 hours
- preterm <37 weeks
- GBS bacturia
- previous GBS sepsis in another infant
99
PTL
| - Antenatal glucocorticoid administration
- Administer between 24 and 33 completed weeks of gestation
| - Betamethasone and dexamethasone
100
PTL
| - Benefits of antenatal glucocorticoid administration
Reduces:
- neonatal respiratory distress**
- intraventricular hemorrhage
- retinopathy of pregnancy
- necrotizing enterocolitis
101
PTL
| - tocolytics
- Magnesium sulfate: decreases rates of cerebral palsy
- Procardia (CCB)
- Indomethacin (cyclooxygenase inhibitor, <32 weeks only to avoid fetal kidney damage)
- Terbutaline (beta-adrenergic receptor agonist): not used much anymore
102
PPROM
- overview
- definition
- treat just like PTL except also give abx
- PROM is membrane rupture prior to onset of uterine contractions
- PPROM is PROM <37th week
- management of PPROM is controversial!
103
PPROM
| - evaluation
- Hx
- PE (cervical exam)
- Determine gestational age
- Labs: urine culture, GBS, gonorrhea/chlamydia, fetal fibronectin, drug screen?
- US +/- cervical length
- Sterile speculum exam: nitrazine, ferning test (looks like snowflake bc salty), pooling of fluid coming out cervix
104
PPROM
| - management overview
- similar to PTL +/- tocolytics AND admin of latency abx (latent refers to period btwn breaking of membrane and delivery)
- expedite delivery in cases of overt infection
- Vaginal or cesarean route of delivery
105
PPROM
| - latency abx
- ampicillin and erythromycin IV X 2D
| - amoxicillin and erythromycin PO X 5D
106
Postpartum blues
| - overview
- transient condition characterized by mild, often rapid, mood swings from elation to sadness, irritability, anxiety, decreased concentration, insomnia, tearfulness, crying spells
- 40-80% of women within 2-3 days of delivery
- resolves in 2 weeks
MAKE THIS NORMAL
107
Postpartum blues and depression
| - Risk factors
- Hx of depression
- depressive sx during pregnancy
- Fam hx of depression
- Stress around child care
- Psychosocial impairment at work, relationships, leisure
- Postpartum blues = increased risk of postpartum depression
108
Postpartum blues
| - treatment
- usually resolves over time with support and reassurance
| - seek med attn if persist >2 weeks
109
Postpartum depression
| - overview
- often unrecognized bc similar to dx of normal puerperium changes (time 6 weeks after delivery)
- 5% prevalence (maybe way higher)
110
Postpartum depression
| - diagnosis
SIG E CAPS
- sleep
- interest
- guilt
- energy
- concentration
- appetite
- psychomotor retardation
- suicidal
- 5+ sx, present most of the day nearly every day for min 2 consecutive weeks.
- One sx must be either depressed mood or loss in interest or pleasure
111
Postpartum depression
| - management
- address psychosocial and biologic factors
- Psychosocial therapy (mild to mod sx)
- light therapy
- Pharm for severe sx. Sertraline (least in breastmilk) or paroxetine, or anything that has worked in the past :)
- avoid bentos
- Severe: electroconvulsive therapy
- Hormone therapy
