Complicated Pregnancy Flashcards
(157 cards)
1
Q
Threatened Abortion
A
Bleeding w or w/o cramping. CLOSED CERVIX
2
Q
Inevitable Abortion
A
Bleeding w or w/o cramping. CERVIX IS DILATED
3
Q
Complete abortion
A
All POC have been expelled
4
Q
Missed Abortion
A
Embryo or fetus dies, but POC are retained. Needs a D&C
5
Q
Incomplete abortion
A
Some portion of POC remains in the uterus. Needs a D&C
6
Q
Habitual Abortion
A
3 or more abortions in succession. Usually spontaneous
7
Q
Spontaneous Abortion
A
Miscarriage. Pregnancy terminating before the 20th week
8
Q
How many pregnancies terminate in a spontaneous abortion?
A
20%. Most of those are before 6 weeks, and before the woman even realizes she’s pregnant. These are usually due to chromosomal abnormalities that are incompatible with life.
9
Q
What is an abortus
A
Fetus lost before 20 weeks
10
Q
Sx of an abortion
A
Bleeding
Cramping
Abd pain
Decreased pregnancy sx
11
Q
PE in an abortion
A
Vitals to R/O shock
Febrile illness
Pelvic exam
12
Q
Txing an Abortion
A
Stabilize if hypotensive Monitor for bleeding/infection Send POC to patho \+/- D&C and misoprostol for dilation Rh -? Rhogam
13
Q
What is an incompetent cervix? When does it usually occur?
A
Painless dilation of the cervix. Usually occurs during the second trimester.
14
Q
RF for having an incompetent cervix
A
Cervical surgery or trauma
Uterine anomalies
Hx of DES exposure
15
Q
Risks of an incompetent cervix
A
Spontaneous abortion
Fetal membranes being exposed to vaginal flora
Inc risk of fetal trauma (ROM)
16
Q
When does a second trimester abortion occur
A
12-20 weeks
17
Q
Options for removing a second tirimester abortion, and what is often the deciding factor
A
D&C, D&E (dilation and evacuation) or IOL (induction of labor)
Very few clinicians can do a D&C at >20 weeks, so if the fetus is 16-24 weeks it’s either D&C or IOL. Later is is, the more likely it will be an IOL
18
Q
Tx for incompetent cervix
A
Cerclage
Then depends on if the fetus is previable or not
19
Q
What is cerclage
A
Putting a suture into the cervix to keep it shut. Can be at the internal or external os. Goes with the risks of ROM, PTL or infection.
20
Q
Previable management of an incompetent cervix
A
Expectant management (we know this is going on and expect it) and elective termination
21
Q
Viable management of an incompetent cervix
A
Betamethasone (in case the kid delivers)
Strict bed rest
Tocolysis if preterm ctx (terbutaline)
22
Q
DIfference between PTL and incompetent cervix
A
PTL will have associated contractions. Sometimes it can be really hard to tell though
23
Q
Three types of cerclage
A
1) Emergent- for managing a previable pregnancy
2) Elective- if there was a prev pregnancy loss and we’re suspicious it was because of an incompetent cervix.
3) Transabdominal- if both other types of cerclage have failed
24
Q
If a woman gets a transabdominal cerclage, how must she deliver the baby?
A
C-section
25
What is an ectopic pregnancy? What is the most common site?
Pregnancy that implants outside the uterus. 99% of these occurs in the fallopian tubes.
26
What two symptoms should automatically make you get an HCG to RO ectopic?
Vaginal bleeding and abdominal pain
27
RF for an ectopic pregnancy
IVF, IUD, PID, tubal surgery, OCP, DES exposure, smoking
28
PE of a ruptured ectopic
Hypotensive, unresponsive, peritoneal irritation secondary to hemoperitoneum
29
HCG levels in ectopic
HCG does not rise appropriately
30
US findings in an ectopic pregnancy
Adnexal mass, extrauterine pregnancy, ring of fire
31
Parameters for giving methotrexate
<4 cm without FH, reliable pt
Baseline CBC, transminases, creatinine, HCG
Repeat HCG after.
If they're not a good methotrexate candidate, go for surgery
32
Management of a ruptured ectopic pregnancy
Stabilize the patient!
IVF, blood products, pressors if necessary
Exploratory lap to control bleeding and remove the ectopic pregnancy
RHogam if RH neg
33
What is a heterotopic pregnancy? What inc the chances of this happen?
Rare! Intrauterine and ectopic pregnancy at the same time.
Most common with IVF ladies
34
What happens to the kiddo if mom never got her rhogam and has anti-D ab?
Massive hemolysis, CHF, hydrops or even death
35
What is Gestational Trophoblastic Disease?
(GTD). Trophoblastic=placental
Diverse group of disease, results in abnormal proliferation of trophoblastic (placental) tissue.
36
Most common form of GTD
Molar pregnancy. Abnormal fetal tissue resulting in a maternal tumor. They'll produce an absurd amount of HCG
37
GTD and chemotherapy
Extremely sensitive. It's the "most curable" or whatever that means
38
Are molar pregnancies (hydatidiform moles) malignant?
No way, super benign GTD
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Two types of molar pregnancies
1) Complete mole- 90%. Totally just molar tissue, no fetus
| 2) Partial- 10%. Molar tissue and some fetal tissue
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Rf for molar pregnancy
```
Extremes in age
Prior hx of GTD
Nullpar
Smoking
Infertility
OCP use
```
41
Sx of a molar pregnancy
Irregular or heavy vaginal bleeding
Insanely high HCG levels, which cause these crazy pregnancy symptoms right off the bat in the first trimester (preeclampsia, hyperemesis, hypoerthyroidism)
42
Pathognomonic for molar pregnancy
Preeclampsia in the first trimester
43
Postmolar malignant sequelae
Post molar D&C, send the tissue down to pathology so they can determine if there's any sequelae. Wicked rare, but these sequelae can turn your benign mole into a proper tumor
44
US Findings of a molar pregnancy
Molar tissue has this mixed echogenic pattern replacing the placenta. Has these villi and intrauterine blood clots.
45
How to manage a molar pregnancy
Immediate removal, suction D&C or hysterectomy. Curative, 95-100%
Also symptomatic relief
a) mole caused PEC? Give antihypertensives to prevent stroke
b) HCG caused hyperthyroidism? BB to prevent thyroid storm
46
Persist disease (malignant GTD) post mole DC is rare, but which type of mole is it more common in? When does it present?
Complete. These patients will develop malignant GTD months to years after a molar pregnancy
47
How do we FU a molar pregnancy?
Serial HCG titers weekly until they're negative. If we see a plateau or a rise >6mo post DC, think persistent disease
48
How long should you wait to get pregnant after a molar pregnancy?
1 yr
49
Two types of malignant GTD (and which is more common)
1) Persistent/invasive moles 75% (months to years post molar pregnancy)
2) Choriocarcinoma (placental carcinoma)- 25%
50
Which type of malignant GTD is more likely to occur right after a normal pregnancy, miscarriage, ectopic or abortion (something with a real fetus)?
Choriocarcinoma
51
Signs of a persistent/invasive mole
HCG level plateau, rise.
Intrauterine masses on US, we'll see this large swollen villi in the myometrium.
These guys rarely rupture and metastasize.
52
Tx of a persistent/invasive mole
Single agent chemo w/ MTX
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FU of a persistent/invasive mole post chemo
Serial HCG and really really good contraceptives
54
What is a choriocarcinoma? How bad is it?
It's a malignant necrotizing tumor. Scary GTD
| Invades uterine wall and vasculature, metastasizing and potentially causing severe hemorrhage.
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Where does choriocarcinoma usually spread
Brain, liver, intestines, lungs, kidneys, liver (VASCULAR HEMATOLOGIC SPREAD)
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Presentation of a choriocarcinoma
Irregular uterine bleeding or signs of metastatic disease
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Leading causes of metastatic cancer in women in africa
Choriocarcinoma. .Wacky right
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Choriocarinoma tx
chemo. The type depends on the prog
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What is a placental site trophoblastic tumor (PSTT)
Wicked rare tumor that arises from placental implantation site.
60
Presentation of a PSTT
Irregular bleeding, enlarged uterus, chronic low HCG
61
Tx of a PSTT
These guys are NOT sensitive to chemo. Hysterectomy is tx of choice, followed up by some "just in case" chemo
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Placenta previa
Low lying placenta, instead of being up by the fundus it's hanging out down low. Graded by how much of it is sitting over the cervix. ***Remember the placenta is that chunk in the back with the "tree of life" appearance
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Complete previa
Placenta completely covers the internal os. Baby is probably breech
64
Partial previa
Placenta covers a portion of the internal os
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Marginal previa
The edge of the placenta covers the margin of the os
66
Low lying placenta
placenta is implanta in close proximity to the os
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Vasa previa
Fetal vessel lies over the cervix -really really scary. Also really rare
68
Placenta accreta? Risks?
Abnormal invasion of the placenta into the uterine wall. Makes it so the placenta can't separate from the uterine wall properly after delivery. Huge risk for hemorrage, shock, and maternal MM
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Placenta accreta invasion site
Superficial Myometrium
70
Placenta Increta invasion site
invades into the myometrium, deeper than an accreta
71
Placenta Percreta
Invasion through the myometrium and into the uterine serosa. Yikes
72
What happens when you have a previa and an accreta (5% of them present like this!)
You've basically guarenteed yourself a hysterectomy at the time of delivery
73
Sx of a placenta previa
Painless vaginal bleeding in pregnancy. Usually will occur after 28 weeks
74
Tx of placenta previa
Pelvic rest (no intercourse)
Bed red
C section at 36-37 weeks, once lung maturity is confirmed
75
Obstetric causes for antepartum bleeding
1) Placental- previa, abruption, vasa previa
2) Maternal- uterine rupture
3) Fetal- fetal vessel rupture
76
Non-OB causes for antepartum bleeding
1) Cervical- severe cervicitis, polyps, cancer
2) Vaginal/vulvar- lacs, varices, cancer
3) Other- your classic vaginal bleeding causes. Hemorrhoids, trauma, hematuria
77
What is placental abruption? What can it lead to?
Premature separation of the placenta (properly implanted) from the uterine wall. Causes a massive hemorrhage.
Can cause premature delivery, uterine tetany (hypercontract), DIC and hypovolemic shock
78
RF for placental abruption
```
HTN
AMA
Hydraminios
DM
COCAINE- get a tox
DM
EtOH (>14 drinks/week)
Multiple gestation
```
79
Precipitating factors for a placental abruption
```
Trauma
External/internal version (when we're trying to turn the baby)
MVA- inertia can cause it to shear
Delivery of 1st twin
ROM w/ polyhydraminos
PPROM
```
80
Where does the blood go in a placental abruption?
80% of the time it goes outward towards the cervix, it's an external hemorrhage and you know what you're working with.
20% of the time it's occult and is confined/concealed within the uterus. This is scary, but remember that when you feel a rock hard uterus
81
Classic sign of a placental abruption
Couvelaire sign. The blood from the abruption penetrates the uterine muscle, you'll have this rock hard uterus that is purple too. You'll see the purple when you're doing a c section
82
Classic presentation of a placental abruption
3rd trimester vaginal bleeding with severe abdominal pain and frequent/strong cxn
83
Vaginal delivery in a placental abruption?
If the baby looks good and there's not that much blood then go for it. The blood will usually make the uterus hyperactive and you'll have a rapid labor.
84
PROM
Premature ROM. or, ROM before the onset of labor
85
PPROM
Preterm Premature ROM. PROM before 37 weeks
86
Prolonged ROM. What's the risk here
ROM lasting >18 hours w/o deliverying the baby. Risk of chorioamnionitis. Longer the pROM lasts, greater the risk of this.
87
What do we do if ROM occurs but it's after week 36
Roll with it man, let's induce a lady.
88
Gestational HTN
HTN w/on proteinuria. Develops after 20 wks, returns to normal PP.
>140/90. Must have normal BP prior for it to be gestational
89
Difference between preeclampsia and gestational HTN
Proteinuria!!
>0.3g of protein in a 24 hour urine
90
RF for PEC
CHTN, CKI, SLE, DM, AA
91
Ultimate treatment for preeclampsia
Delivery
92
What's the treatment for
a) Term pregnancy w/ PEC
b) Unstable preterm w/ PEC
c) Evidence of fetal lung maturity w/PEC
Induction of labor! Just gotta deliver the kid if the kid's ready or if the mom is unstable. No baby is going to grow in an unstable mom.
If mom is really unstable just run to the OR
93
What's the treatment for PEC in a stable, preterm mom
Bed rest
Expectant management
Betamethasone to beef up the kid's lungs 2 doses within 24 hours
94
When would MgSulfate come into play
also what's Mg's effect on labor
Seizure ppx during labor, delivery and 12-24 hours PP.
4g loading and 2g/hr for maintenance
***If mom is stable, hold off on Mg until active labor. It can make the labor drag on and you'll be more likely to have a csection dt labor failing to progress
95
Superimposed PEC
New onset proteinuria in a woman with CHTN
OR
Sudden increase in proteinuria (that she had prior to gestation) OR
Sudden sharp inc in HTN OR
HELLP Syndrome
96
How do we tx superimposed PEC
just like regular PEC!
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What's a funky way superimposed PEC might present
Women with CHTN who suddenly develop HA, scotoma, or epigastric pain
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Severe PEC "deliver immediately" signs
```
>32 weeks
Signs of LF or RF
Pulmonary edema
HELLP
DIC
```
99
Signs of severe PEC (more of a read and understand)
One of more of the following:
>160/110 on two occasions 6 hrs apart when pt is in bed
Proteinuria >5g on 24 or >3g on 2 random spots
Oliguria (<500ml)
Cerebral/visual disturbances (scotoma)
Pulmonary edema- vessels get leaky. Flash E happens fast
Epigastric pain
Impaired LF
Thrombocytopenia
Fetal growth restriction
100
What is fetal growth restriction considered in severe PEC
End organ damage. It's a sign that the BP is affecting the baby
101
Difference between Severe PEC and EC
Grand mal serizures!
102
Giving Mg in an EC pt
Give mg from the time they're diagnosed until they're 12-24hrs PP
103
Tx the mom:
| Tx the baby?
Mom: Stop the seizures and book it to an OR
Baby: Fix mom. Decels are going on because mom is seizing. Fix mom, you fix the baby
104
What does HELLP stand for?
What might HELLP patients develop
Hemolytic Anemia (LDH, Bili, schistocytes)
Elevated Liver enzymes (inc AST/ALT)
Low platelets. (LIKE REAL LOW, plt 9?)
They might develop DIC or hepatic rupture
105
Acute Fatty Liver of Pregnancy- these patients will commonly have what two symptoms normally associated with PEC
HTN and proteinuria.
106
How can we differentiate acute fatty liver of pregnancy from HELLP
Labs will show ammonia, reduced fibrinogen and antithrombin II (liver labs)
107
What is true GDM caused by
anti-insulin agents produced by the placenta. Increases with size/function of the placenta, so we don't usually see this until the 2nd/3rd trimester
108
When do we screen for GDM
28 weeks, unless they're high risk
109
What makes someone high risk for GDM
```
Not white
AMA
Obese
Fhx of DM
Biggo kiddo previously
```
110
What is a GLT? Screening or diagnositic?
Glucode loading test. Screening test done at 28wks for GDM.
Give 50g of glucose as a loading dose and check serum glucose 1 hr later. If >140, go ahead and do the GTT
111
What is the GTT? Screening or diagnostic?
Diagnostic test for GDM. We take a fasting serum glu, then give 100g of PO glucose as a loading dose. Then we take a serum glucose 1,2 and 3 hours after that loading dose. If two or more of these values are elevated, that's diagnostic for GDM
112
GTT Glucose levels
Fasting >95
1hr >180
2hr> 155
3 hr>140
113
Mainstay of tx for GDM
Diet! True GDM is an issue of CHO digestion. Limit calories, carbs to 220g a day. Promote walking and exercise
114
When to consider insulin for GDM
When >25-30% of BG are elevated.
115
Hard to ask this in a question. "True" GDM will have _ fasting glucose and _ PP glucode
Normal fasting and elevated PP, since the issue is with glucose digestion
116
White classification for GDM
It's how we classify GDM.
Class A is when you just have GDM, and you're in category 1 or 2 depending on whether or not you're medicated. The other classes are all based on if you have preexisting DM, looks at things like age of onset, end organ damage, stuff like that
117
When do we US GDM mom's for macrosomia
Weeks 34-37. We might base the delivery plan around this
118
What do we do if a GDMA1 mom comes in for delivery?
Take a random BG. If it's normal, we just deliver the babe as per usual
119
How do we manage GDMA2 when mom comes in for IOL
Laboring women don't exactly eat regular meals, so we keep them on a dextrose/insulin drip to keep the BS <120
120
GDM, baby weighs >4,000g
Inc risk of shoulder dystocia. Avoid forceps/vacuum, be quicker to go for a cesarean
121
GDM, baby weights >4,500g
Offer elective cesarean. This weight is a guarenteed birth injury
122
Why is diet education so important for PP GDM mom;s
Because they have SUCH a high risk of developing DM later on in life/in future pregnancies
123
RF for shoulder dystocia
Macrosomia, diabetes of all kinds, maternal obesity, postterm pregnancy (biggo kiddo), prolonged 2nd stage of labor
124
Fetal complications of shoulder dystocia
```
Fx of humerus or clavicle
Brachial plexus nerve injuries dt hyperflexion of the neck (Erb's palsy)
Other palsies
Brain injury (hypoxia)
Death
```
125
Hallmark sign for shoulder dystocia
Turtle sign. Incomplete delivery of head, or the chin tucking up against maternal perineum. Kid will bob in and out
126
Why might we do an episiotomy for a shoulder dystocia
If we can't fit our hands in there to rotate the baby. This is a bone issue, an episiotomy will not get the baby out on its own
127
How much time do you have to deliver the kid in a shoulder dystocia
5 min before brain death
128
Is a shoulder dystocia an emergency
Heck yeah it is
129
Three main maneuvers for shoulder dystocia
1) McRoberts- sharp flexion of maternal hips to decrease pelvis inclincation and just max out the diameter. Always done w/ #2 as the primary maneuver.
2) Suprapubic pressure- Pressure directed at an oblique angle to dislodge that anterior shoulder out from the pubic symphysis
3 )If the two above fail, we do the Rubin maneuver where we stick our hands all the way in and push the shoulder towards the anterior chest wall to dislodge it.
130
What are some other things we can do for a shoulder!
1) Wood's corkscrew- apply pressure to the posterior shoulder and try and rotate the infant
2) Deliver the posterior arm/shoulder, free up space
3) Fx fetal clavicle
4) Cut maternal pubic symphysis
5) ZavanellI!
131
ml of blood loss to define a PPH
>500ml for vag and >1,000 for c section
132
Early vs late PPH
<24 hours after delivery =early
| >24 hours after delivery = late
133
>___L we get worried about DIC. What do we give?
2-3L
| Give coag factors and platelets. Which is a normal part of a massive transfusion protocol
134
What is Sheehan syndrome? When would we see it? Manifestations?
Sheehan syndrome is a pit infarct that can happen during a PPH because of the hypotensive/hypovolemic state.
Manifests as a lack of lactation dt lack of prolactin or amenorrhea dt lack of GnRH. Bc the pit is totally blown out
135
RF for PPH
abnormal placenta
trauma during LD
Uterine atony
Coagulation defects
136
Causes of a PPH-vag
```
Vaginal lacs
Cervical lacs
Uterine atony
Placenta accreta
Retained POC
Uterine inversion
Uterine rupture (yikes)
```
137
Causes of a PPH- csection
Uterine atony
Surgical blood loss
Placenta accreta
Uterine rupture (also yikes)
138
Four T's of a PPH
1) Tone- Give uterotonic agents if the contractions are crummy
2) Trauma- suture any lacs. General or inversion of uterus
3) Tissue: Is the placenta retained? D&C?
4) Thrombin- are they clotting? Do they need plt/cofactor?
139
Prolonged Decel
FHR <110 for >2min
140
Fetal brachycardia
prolonged decel for >10min
141
3 Etiologies of FHR decel
1) Preuterine- Any event that leads to maternal hypotension or hypoxia
2) Uteroplacental- Abruption, infarction, hemorrhaging previa
3) Postplacental- cord prolapse, compression, rupture of fetal vessel
142
Managing FHR decel
Conservative at first!
- Move position
- Nasal O2 for mom
- Did mom get an epidural and this is probably caused by a drop in BP? Consider giving a pressor
- Stop pitocin drip if baby is deceling
143
Most common reason for a c-section
Labor failing to progress. 2 hrs in active phase of labor without cervical change. This is when the uterine cxn are more than adequate
144
3 P's of failure to progress
Power: Strength of contractions
Passenger: Is the baby okay
Passage: if the pelvis/vagina big enough to support this kiddo
145
Maternal indications for a CS
Maternal dx (genital herpes, HIV, cervical cancer)
Prior uterine surgery
Prior uterine rupture
Obstruction of birth canal (fibroids, ovarian tumor)
146
Fetal indications for a CS
```
Nonreassuring FHT (brady, asbsence of variability, acidodic)
Cord prolapse
Malpresentation (breech, brow)
Multiple gestations
Fetal anomalies (hydrocephalus)
```
147
What direction should the incisions go in?
Horizontal if you can! OK to do vertical on the skin, but never on the uterus
148
When would we do a single layer uterine closure?
If we're going to go back and do a tubal ligation. Otherwise do a double
149
Monozygotic twins
1 Fertilized ovum divides into two separate ova
150
Dizygotic twins
Ovulation produces two eggs which are both fertilized
151
TTS- Twin to Twin Transfusion Syndrome
One twin "eats" the other. Most common with Monochorionic (one placenta), diamnionic twins (two sacs)
152
Mono/di-chorionic
of placenta
153
Mono/di-amnionic
of amniotic saccs
154
Monochorionic/monoamnionic twins MM
Crazy high due to risk of entangling cords
155
What determines amnionicity/chorionicity?
```
When the monozygotic twin cleaves!
Cleavage between...
1-3 days? Di/Di
4-8 days? Mono/Di
8-13? Mono/Mono
13-15? Conjoined
```
156
What is mastitis? What causes it?
Regional infection of the breast. Caused by pts skin flora or infants mouth flora
157
Tx for mastitis
Dicloxacillin. Keep pumping. If unresponsive to PO abx give IV abx until 48hrs afebrile
