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Clin Med III exam III > Complicated Pregnancy > Flashcards

Complicated Pregnancy Flashcards

1
Q

Spontaneous abortion occurs before how many weeks

A

20 weeks

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2
Q

Threatened abortion

A

bleeding with or without cramping with a closed cervix

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3
Q

Inevitable abortion

A

bleeding with or without cramping with dilation of cervix

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4
Q

Complete abortion

A

all products have been expelled

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5
Q

Missed abortion

A

embryo or fetus dies but products of conception are retained

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6
Q

Incomplete abortion

A

some portion of POCs remain in the uterus

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7
Q

Habitual abortion

A

3 or more abortions in succession

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8
Q

Etiology of second trimester abortions

A
  • infection
  • maternal uterine/cervical anatomic defect
  • maternal systemic disease
  • exposure to fetotoxic agents
  • trauma
  • pre term labor/incompetent cervix
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9
Q

What is an incompetent cervix

A

painless dilation and effacement of the cervix

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10
Q

Why is an incompetent cervix bad?

A

fetal membranes are exposed to vaginal flora and there is a increased risk of trauma

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11
Q

Risk factors of incompetent cervix

A
  • cervical surgery or trauma
  • uterine anomalies
  • hx of DES exposure
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12
Q

Treatment of incompetent cervix

A
  • cerclage (suture to close cervix)
  • previable: expectant management and elective termination
  • viable: betamethasone, bed rest, tocolysis if preterm contraction
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13
Q

When is emergent cerclage done

A

management in a previable pregnancy

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14
Q

When is an elective cerclage done

A

if incompetent cervix suspected in previous pregnancy loss (12-14 weeks)

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15
Q

When is a transabdominal cerclage done

A

if both other types of cerclage failed

baby must be delivered via c/s

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16
Q

Risk factors for ectopic pregnancy

A
  • hx of STI/PID
  • prior ectopic preg
  • previous tubal surg
  • adhesions
  • endometriosis
  • exogenous hormone use
  • IVF
  • DES exposed pts
  • IUD use
  • smoking
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17
Q

Ectopic pregnancy on physical exam

A
  • adnexal mass may be tender
  • uterus small for GA
  • bleeding from cervix
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18
Q

Ectopic pregnancy on US

A
  • adnexal mass
  • extrauterine pregnancy
  • ring of fire
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19
Q

Management of rupture ectopic pregnancy

A
  • stabalize (IV fluids, blood products, pressors)
  • exploratory lap
  • rhogam if Rh negative
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20
Q

Management of unruptured ectopic pregnancy

A
  • rhogam if Rh negative
  • surgical
  • methotrexate
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21
Q

What is a heterotopic pregnancy

A

rare co existance of intrauterine with ectopic pregnancy

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22
Q

What is a gestational trophoblastic disease

A

abnormal proliferation of placental tissue

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23
Q

What are the gestational trophoblastic diseases

A
  • molar pregnancy
  • persistent/invasive moles
  • choriocarcinoma
  • placental site trophoblastic tumor
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24
Q

What is the begning GTD

A

molar pregnancy

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25
Q

What are the two types of molar pregnancies

A
  • complete (no fetal abnormality)

- partial (fetal abnormality)

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26
Q

Risk factors for a molar pregnancy

A
  • extremes in age
  • prior hx of GTD
  • nulliparity
  • diets low in beta carotine, folic acid and animal fat
  • smoking
  • infertility
  • OCP use
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27
Q

Molar pregnancy on physical exam

A
  • preeclampsia
  • hyperthyroid
  • absence of fetal heat tones
  • uterine size greater than GA
  • grape like molar clusted extruding from cervix
  • theca lutein cysts
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28
Q

Molar pregnancy on US

A
  • molar tissue id as diffuse mixed echogenic patterns replacing the placent
  • produced by villi and intrauterine blood clots
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29
Q

Hx of a patient with a molar pregnancy

A
  • irregular or heavy vaginal bleeding

- sx attributed to high hCG levels

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30
Q

Management of molar pregnancy

A
  • immediate removal of uterine contents by suction D&C
  • treat other conditions (preeclampsia, hyperthyroid)
  • hysterectomy is patient is done having children
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31
Q

Good prognostic markers for metastatic malignant GTD

A
  • short duration (<4 months)
  • serum hCG <40k
  • no brain or liver mets
  • no hx of chemo
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32
Q

Poor prognostic markers of malignant metastatic GTD

A
  • long duration (>4 months)
  • serum hCG >40,000
  • metastases to brain or liver
  • unsuccessful prior chemo
  • GTD following term pregnancy
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33
Q

When does a persistent/invasive mole commonly occur?

A

after a molar pregnancy

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34
Q

How do you diagnose a persistent/invasive mole

A
  • hCG level plateau or rise

- pelvic US may show one or more intrauterine masses with high vascular flow

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35
Q

Rare complications of persistent/invasive mole

A
  • uterine rupture

- hemoperitoneum

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36
Q

Tx of persistent/invasive mole

A

single agent chemo w/ MTX or actinomycin-D

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37
Q

What is chriocarcinoma

A

a malignant necrotizing tumor
-pure epithelial tumor that invades uterine wall and vasculature causing destruction of tissue, necrosis and potentially severe hemorrhage

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38
Q

Patient presentation with choriocarcinoma

A
  • irregular signs of uterine bleeding

- signs on metastatic disease

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39
Q

How do you diagnose choriocarcinoma

A
  • hCG levels
  • pelvic US
  • CXR/CT/MRI of chest, abd/pelvic and brain
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40
Q

Tx of choriocarcinoma

A

either single or multiagent chemo depending on prognosis

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41
Q

Where do placental site trophoblastic tumors arise from

A

the placental implantation site

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42
Q

Diagnosis of PSTT

A
  • irregular bleeding
  • enlarged uterus
  • chronic low hCG
  • pelvic US
  • histology shows absence of villi
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43
Q

Treatment of PSTT

A

-hysterectomy followed by multiagent chemo to prevent recurrence

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44
Q

Four categories of placenta previa

A
  • complete previa
  • partial previa
  • marginal previa
  • low lying placenta
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45
Q

What is placenta previa caused by

A

events that prevent normal progressive development of the lower uterine segment

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46
Q

Risk factors for placenta previa

A
  • prior c/s or uterine surg
  • multiparity/ multiple gestation
  • erythroblastosis
  • hx of previa
  • smoking
  • increasing maternal age
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47
Q

Fetal complications associated with placenta previa

A
  • preterm delivery
  • preterm premature rupture of membranes
  • intrauterine growth restriction
  • malpresentation
  • vasa previa
  • congenital abnormalities
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48
Q

What is placenta accreta

A

abnormal invasion of placenta into the uterine wall

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49
Q

What happen in placenta accreta? What complication does it cause?

A

inability of placenta to properly separate from uterine wall after delivery

-complications: hemorrhage, shock, maternal morbidity and mortality

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50
Q

Three categories of placenta accreta

A
  • accreta: superficial invasion into myometrium
  • increta: placenta invades myometrium
    percreta: invasion through myometrium into uterine serosa
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51
Q

How do you diagnose placenta previa

A

-ultrasound

vaginal exam is contraindicated!

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52
Q

Treatment for placenta previa

A
  • pelvic rest (no sex)
  • modified bed rest
  • cesarean delivery at 36/37 weeks after lung maturity confirmed by amnio
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53
Q

What is a placenta abruption

A

premature separation of normally implanted placenta from uterine wall

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54
Q

When do most placental abruptions occur

A

before labor and after 30 weeks (50%)

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55
Q

What can a large placental abruption result in

A
  • premature delivery
  • uterine tetany
  • DIC
  • hypovolemic shock
56
Q

What factors can predispose a patient for placental abruption

A
  • HTN
  • hx of abruption
  • advance maternal age
  • multiparity/multiple pregnancy
  • uterine distension
  • vascular/collagen deficiency
  • DM
  • cocaine/cigarette/alcohol
  • short umbilical cord
  • circumvallate placenta
57
Q

What is a circumvallate placenta

A

membranes double back over edge of placenta

58
Q

Precipitating factors for placental abruption

A
  • trauma/abdominal trauma
  • MVA
  • sudden uterine volume loss
  • delivery of 1st twin
  • rupture of membranes with polyhydramnios
  • preterm premature rupture of membranes
59
Q

Classic presentation of placental abruption

A

3rd trimester vaginal bleeding associated with severe abd pain and/or frequent, strong contractions

60
Q

What type of contractions would a pt with placental abruption experience? Fetal heart tones?

A

tetanic contractions with non reassuring fetal heart tones secondary to hypoxia

61
Q

Classic sign of placental abruption when c/s is done

A

couvelaire uterus (blood from abruption penetrates uterine musculature)

62
Q

How do you treat a placental abruption?

A

STABILIZE

  • hospitalization, prepare for hemorrhage
  • continuous EFM
  • IV access
  • labs (CBC, type and cross_
  • RhoGAM if necessary
63
Q

When do you need to deliver the baby with a placental abruption

A
  • if life threatening bleeding

- fetal testing is non reassuring

64
Q

What type of deliver is preferred with a placental abruption

A

vaginal delivery (if safe)

65
Q

What is “premature rupture of membranes” (PROM)?

A

rupture of membranes before the onset of labor

66
Q

What is “preterm premature rupture of membranes” (PPROM)

A

rupture of the membranes before week 37

67
Q

Prolonged ROM

A

rupture of membranes lasting longer than 18hrs before delivery

68
Q

What is the most common concern with PROM

A

chorioamnionitis

69
Q

If ROM occurs after 36 weeks what is done?

A

labor is induced

70
Q

What is gestational HTN

A

HTN without proteinuria that develops after 20 weeks with return to normal postpartum

71
Q

Diagnosis of gestational HTN?

A

systolic >140 or diastolic >90 occurring after 20 wks in a woman with previously normal BP

72
Q

What is preeclampsia

A

HTN and proteinuria that occurs after 20 weeks

73
Q

What are some maternal complications of preeeclampsia

A
  • seixure
  • cerebral hemorrhage
  • DIC/thrombocytopenia
  • renla fialure
  • hepatic rupture/failure
  • pulmonary edema
  • placental abruption
74
Q

Fetal complications with preeclampsia

A
  • premature birth
  • intrapartum fetal distress
  • stillbirth
  • asymmetric or symmetric SGA fetus
  • IUGR
  • oligohydramnios
75
Q

Ultimate treatment for preeclampsia

A

delivery

76
Q

When is induction of labor treatment of choice for preeclampsia? What type of delivery is preferred?

A
  • term patients
  • unstable preterm
  • pregnancies with evidence of fetal lung maturity

VAGINAL delviery

77
Q

Treatment for stable preterm patients with preeclampsia

A
  • bed rest
  • expectant management
  • betamethasone
78
Q

What is given for prophylaxis in women with preeclampsia? When? Dose?

A

mag sulfate for seizure ppx during labor, delivery and 12 to 24 hrs postparturm

4g loading and 2g/hr after

79
Q

What is superimposed preeclampsia

A

-new onset of proteinuria in a women with CHTN
OR
-a sudden increase in proteinuria if already present in early pregnancy
OR
-a sudden increase in HTN
OR
-development of HELLP syndrome

80
Q

When should you suspect superimposed PEC

A

women with CHTN that develop HA, scotoma or epigastric pain

81
Q

Treatment for superimposed PEC

A

treat like regular PEC

-treat CHTN with labetalol of nifedipine

82
Q

When is preeclampsia considered severe?

A

one of more of the following

  • systolic >160 or diasolitc >110 on 2 or more occasions 6 hrs apart while on bed rest
  • proteinuria of >5g in 24hr or >3+ on 2 random 4 hrs apart
  • oliguria less than 500ml in 24hrs
  • cerebral/visual disturbances
  • pulmonary edema or cyanosis
  • epigastric of RUG pain
  • impaired liver function
  • thrombocytopenia
  • fetal growth restrication
83
Q

When do you deliver immediately in a patient with severe PEC

A
  • greater than 32 weeks
  • signs of renal or liver failure
  • pulmonary edema
  • HELLP
  • DIC
84
Q

What is eclampsia

A

new onset grand mal seizure in a women with preeclampsia

85
Q

What is the treatment for eclampsia

A
  • BP control
  • seizure management/PPX

MgSO4 from tiem of diagnosis through 12-23 hrs postpartum

86
Q

When should delivery be initiated in a patient with eclampsia

A

after pt has been stabilized and convulsions have been controlled

87
Q

What is a common complication of eclampsia? How do you treat it?

A

-fetal heart rate decelerations, tx my stabilizing mother

88
Q

What is HELLP syndrome

A
  • hemolytic anemia
  • elevated liver enzymes (AST/ALT)
  • low platelets (thrombocytopenia)
  • hepatic rupture or DIC
89
Q

Hemolytic anemia with HELLP syndrome

A
  • schistocytes
  • elevated LDH
  • elevated total bilirubin
90
Q

How do you diagnose acute fatty liver of pregnancy

A

differentiate from HELLP

  • elevated ammonia
  • blood sugar <50
  • reduced fibroginogen
  • reduced antithrobin III
91
Q

When does gestational diabetes typically manifest?

Why?

A

late 2nd trimester or early 3rd trimester because hormones increase in volume with size and function of placenta

92
Q

Gestational diabetes leads to an increased risk for what things

A
  • fetal macrosomia
  • birth injuries
  • neonatal hypoglycemia, hypocalcemia, hyperbillirubinemia, polycythemia
93
Q

What are some risk factors for developing gestational diabetes

A
  • hispanic/latina
  • asian
  • native american
  • advanced maternal age
  • obesity
  • family hx of DM
  • previous infant weighting >4000g
  • previous stillborn
94
Q

When are women screened for gestational diabetes

A

between 24 and 28 weeks

95
Q

Screening for gestational diabetes

A
  • glucose loading test

- glucose tolerance test

96
Q

What is the glucose loading test

A

50g of oral glucose, check serum glucose 1hr later

if >140 do GTT

97
Q

How is a glucose tolerance test done

A

check fasting serum glucose, 100g oral glucose, check serum glucose 1/2/3 hours after dose

98
Q

Elevation of __ of more values indicates GDM. What are the values

A

2 or more

fasting >95
1hr >180
2hr >155
3hr >140

99
Q

Treatment for GDM

A
  • 2,200 calories a day
  • 200 to 220g of carbs
  • QID blood sugar testing
  • exercise
  • insulin or oral hypoglycemic agent
100
Q

When do you do fetal monitoring with GDM?What do you do?

A

GDMA2 on insulin or oral hypoglycemic agent

NST or BPP weekly or biweekly starting between 32 and 36 weeks

101
Q

if GDMA2 how do you handle delivery

A

induction of labor at 39 weeks

102
Q

Fetal weight of over 4,000 grams–> increased risk of ___. What do you avoid

A

increased risk of shoulder dystocia

avoid forceps and vacuum

103
Q

When should you consider a cesarean with GDM

A

fetal weight >4,500g

104
Q

Infants of pts with GDM are at an increased risk of what

A
  • childhood obesity

- type 2 DM

105
Q

Maternal complications with pregestatinal diabetes

A
  • obstetric: polyhydraminos, preeclampsia, miscarriage, infection, PPH
  • diabetic emergencies: hypoglycemia, ketoacidosis, diabetic coma
  • vascular neurologic, end organ involvement
106
Q

Fetal complications with pregestational diabets

A
  • macrosomia
  • delayed organ maturity
  • congential malformations
  • IUFD
107
Q

What is shoulder dystocia

A

difficulty delivering shoulders after the head of the fetus is delivered (anterior shouldder gets stuck behind pubic symphysis)

108
Q

What are risk factors for shoulder dystocia

A
  • macrosomia
  • diabetes of any kind
  • hx
  • maternal obesity
  • postterm pregnancy
  • prolonged second stage of labor
  • operative vaginal delivery
109
Q

Fetal complication of shoulder dystocia

A
  • fracture of humerus or clavicle
  • brachial plexus nerve injury
  • phrenic nerve palsy
  • hypoxic brain injury
  • death
110
Q

How do you prepare a patient for delivery if shoulder dystocia is suspected

A
  • pt in dorsal lithotomy position
  • adequate anesthesia
  • experienced staff
  • episiotomy prn
111
Q

Increased suspicion of shoulder dystocia with ___. What is it

A

“turtle sign”

incomplete delivery of head or chin tucking up against maternal perineum

112
Q

What should be done if fetus has shoulder dystocia during delivery

A

EMERGENCY

  • designated someone to track time (delivery in less than 5 minutes)
  • two people hold legs
  • one person provides suprapubic pressure
  • pediatric team should be called to delivery room
113
Q

3 maneuvers for shoulder dystocia

A
  • McRoberts
  • Suprapubic
  • Rubin
114
Q

McRobert maneuver

A

sharp flexion of maternal hips to decrease inclination of pelvis and increased AP diameter

115
Q

Suprapubic pressure

A

pressure directed at an oblique angle to dislodge anterior shoulder from behind pubis symphysis

116
Q

Rubin maneuver

A

place pressure on shoulder and push toward anterior chest wall to decrease bisacromial diameter and free impacted shoulder

117
Q

What classifies postpartum hemorrhage

A

> 500mL blood loss for vaginal delivery and >1,000mL for cesarean

118
Q

Treatment for postpartum hemorrhage

A
  • investigate cause
  • start fluid resuscitation
  • prepare for blood transfusion
119
Q

If blood loss >2-3L pt may develop ___ give __ and ___

A

pt may develop DIC, give coagulation factors and platelets

120
Q

Rare complication of postpartum hemorrhage

A

Sheehan syndrome (pituitary infarct)

121
Q

Risk factors for PPH

A
  • abnormal placentation
  • trauma during labor and delivery
  • uterine atony
  • coagulation defects
122
Q

Fetal heart rate deceleration

A

fetal heart rate <110 for loner than 2 minutes=prolonged

longer than 10 minutes= bradycardia

123
Q

Etiology of fetal heart rate decelerations

A
  • preuterine: anything leading to maternal hypotension of hypoxia
  • uteroplacental: abruption, infarction, hemorrhage, uterine hyperstimulation
  • postplacental: cord prolapse, cord compression, rupture of fetal vessel
124
Q

Most common indication for primary cesarean section

A

failure to progress (2hrs without cervical change in the setting of adequate uterine ctxs in active phase of labor)

125
Q

What are the 3 P’s of labor

A

Powers: contractions
Passage: pelvis and soft tissue
Passenger: the baby

126
Q

Preparation for cesarean section

A
  • IV fluids
  • 1 to 2 grms of IV cefazolin
  • spinal or epidural anesthesia
  • foley to empty bladder
  • local prep
127
Q

Monozygotic twins

A

fertilized ovum divided into two separate ova, identical twins

128
Q

Dizygotic twins

A

ovulation produces 2 ova and both are fertilized, fraternal twins

129
Q

Obstetric complications of multiple gestation

A
  • preterm labor
  • placenta previa
  • cord prolapse
  • postpartum hemorrhage
  • cervical incompetence
  • gestation diabetes
  • preeclampsia
130
Q

Fetal complications of multiple gestation

A
  • preterm delivery
  • congenital abnormalities
  • small for gestational age
  • malpresentation
131
Q

Average age of delivery of twins. Triplets.

A

twins: 36-37 weeks
triplets: 33-34 weeks

132
Q

Galactorrhea

A

spontaneous flow of milk from the breast

133
Q

What causes galactorrhea

A

production of prolactin by pituitary gland

134
Q

What is mastitis

A

regional infection of the breast commonly causes by pt’s skin flora or oral flora from breastfeeding infants

135
Q

Treatment of mastitis

A

dicloxacillin

Clin Med III exam III (10 decks)

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