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Flashcards in Complications in Pregnancy Deck (65):
1

Size-Date Discrepancy

Exists when woman has reasonably certain LMP & EDD has been determined & size of uterus is either larger or smaller than expected for gestational age.
Can occur at any stage of pregnancy.

2

Most common causes for S/D discrepancy

Big baby (especially in third trimester).
Inaccurate date for LMP.
Congenital anomalies, chronic maternal disease, or viral infection contribute to 1st or 2nd trimester discrepancies – usually size smaller than expected for dates.

3

Size > Dates

Big baby.
Multiple pregnancy.
Diabetes.
Polyhydramnios.
Breech presentation.
Placenta previa
Uterine fibroids

4

Size < Dates

IUGR – intrauterine growth restriction.
Maternal disease – thyroid, hypertension, infectious diseases.
Inadequate nutrition/weight gain
Transverse or oblique fetal lie.
Chemical dependency.
Stress

5

Management of Size/Date Discrepancy

Review dating criteria.
Look at fundal height growth pattern & maternal weight gain pattern.
Evaluate for maternal disease, substance abuse.
Ultrasound.
If problem → refer for perinatalogist management.
Serial ultrasounds to follow fetal growth closely.

6

Bleeding in Pregnancy

Spontaneous abortion
Ectopic pregnancy
Gestational Trophoblastic Disease
Placenta Previa
Placenta Abruptio

7

Placenta Previa

Implantation of placenta over or adjacent to internal cervical os.
Total placenta previa.
Partial placenta previa.
Marginal placenta previa
Estimated incidence 1/200 pregnancies.

8

Risk factors include for Placenta Previa :

↑ maternal age.
↑ parity.
History of lower uterine scar.
History of puerperal endometritis.
Multiple gestation.
Erythroblastosis

9

Signs/Symptoms for placenta previa

Painless vaginal bleeding from second trimester to term.
Initial bleeding may be slight → as pregnancy progresses, greater chance of hemorrhage.
The earlier in the pregnancy that the bleeding occurs → the more serious the previa.
50% with complete placenta previa experience episodic bleeding before 30 weeks’ gestation.

10

Screening/Diagnosis for placenta previa:

Suspect in any pregnant woman with painless vaginal bleeding.
Definitive diagnosis → ultrasound.

11

Safety warning for placenta previa:

Digital examination of the cervix can cause severe hemorrhage → death of mother & baby.

12

Management for placenta previa

Expectant management prior to term:
Hospitalize unstable patient for evaluation.
Stable patient can be managed from home:
Full understanding of her condition.
Good family support.
Quick access to hospital.

13

Management for placenta previa at term

Planned C/section for total or partial previa.
Vaginal birth for marginal previa.
Facility with quick access to operative delivery if needed.
Plan for possible hemorrhage.

14

Placenta Abruption

Premature separation of a normally implanted placenta from the uterus wall.
80% - vaginal bleeding.
20% - bleeding is concealed.
Incidence – 1 in 150-200 pregnancies.

15

Placenta Abruption
can be

Partial – fetus has chance of survival is abruption is less than 50% of placenta surface.
Complete – fetal demise inevitable.

16

Placental Abruption: types

Partial abruption with concealed hemorrhage.
Partial abruption with apparent hemorrhage.
Complete abruption with concealed hemorrhage.

17

Risk factors include:
for placental abruption are

↑ parity.
Previous abruption.
Drug use. (i.e., cocaine)
Hypertensive disorders.
Abdominal trauma.
Short umbilical cord.
Polyhydramnios.
Sudden decompression of the uterus.
Fibroids.
Uterine anomalies.

18

Signs/Symptoms for placental abruption

S/Sx vary depending on extent of abruption.
Classic signs → vaginal bleeding & uterine tetany.
Common findings include → vaginal bleeding, uterine tenderness, back pain, fetal distress, uterine hypertonus, fetal demise.

19

Diagnosis/Screening for placenta abruption

Presumptive dx with classic signs.
Verified by ultrasound.
Made after delivery with discovery of adherent retroplacental clot.

20

Management
for placenta abruption

Depends on condition of mother & fetus.
If bleeding mild & no fetal distress → observation
Facility with quick access to operative delivery.
Preparation for immediate intervention if maternal and/or fetal status worsen quickly.
Continuous fetal monitoring.
Unstable mother/fetus
Immediate C/Section if vaginal birth not imminent

21

Iron Deficiency Anemia

Significant iron requirements in pregnancy as a result of maternal & fetal needs → all women at risk.
Exceeds maternal iron stores.
Increased intake through dietary sources & supplementation is necessary to meet demands.

22

Iron deficiency has been associated with

urinary tract infections, preterm delivery, low birth weight, preeclampsia, perinatal mortality.

23

Signs/Symptoms
of iron deficiency

Most women asymptomatic.
Sx can include → fatigue, lack of energy, light-headedness.
Severe anemia → dyspnea, palpitations.
Physical exam may reveal → pale mucous membranes, cracking of the lips, brittle nails.

24

Screening/Diagnosis
for iron deficiency

Hgb & Hct → most common tests used to screen for iron deficiency anemia.
Peripheral blood smear → characteristic microcytic, hypochromatic RBCs.
Serum ferritin → more definitive test.
<15 μg/L – diagnostic of iron deficiency anemia

25

Management for iron deficiency

Screen at 1st prenatal visit.
Nutritional education & counseling.
Correct pica if present.
Iron supplementation if Hgb < 11μg/L
30 mg elemental iron/day for women at risk of developing iron deficiency anemia.
60-120 mg elemental iron/day for women with dx of iron deficiency anemia.

26

response to iron supplements

Response to supplementation is rapid, especially in women with severe deficiency.
↑ in reticulocyte count > 2% can be seen after 10-14 days of tx.
Once production of RBCs occurs, HCT ↑ 1-2 % points per week until iron stores are no longer depleted.
If no improvement seen:
Be certain patient is taking supplementation.
If she is, evaluate for other types of anemia.

27

Gestational Diabetes Mellitus (GDM)

Definition → “carbohydrate intolerance of variable severity with onset or recognition in pregnancy”.

Incidence → 0.15% – 12.3% pregnant women dx with GDM

28

GDM risk factors include:

Maternal age > 35.
Previous GDM.
Previous infant > 4000gm.
Previous unexplained fetal losses.
Family history of diabetes in first-degree relatives.
Obesity.
Previous birth of child with a congenital anomaly.

29

GDM associated with:

Increased maternal & neonatal morbidity.
Macrosomia & associated complications of prolonged or arrested labor, forceps or vacuum delivery, shoulder dystocia, & cesarean birth.

30

Physiology of GDM

Insulin resistance occurs during 2nd half of pregnancy → result of placental lactogen.
Most women able to maintain blood glucose in normal range.
Some women unable to meet the demands created by increased insulin resistance & are identified as having GDM.

31

Screening/Diagnosis of GDM

Most sites use 2 step approach:
One hour after 50 gm glucose load.
Abnormal → ≥ 130 mg/dL
If 1 hour test abnormal → 3 hour GTT with 100 gm glucose load.
Early screening recommended for women at high risk for GDM.
Screen asap in pregnancy.
If normoglycemic, should be rescreened at 24-28 weeks gestation.

32

Screening/Diagnosis of GDM

Random blood glucose > 200 mg/dl or fasting blood glucose > 126 mg/dl → highly suggestive of diabetes & precludes need for full GTT.

Women with normal second trimester screen and/or normal 3 hour GTT who exhibit persistent glucosuria unrelated to recent intake, suspected macrosomia, or polyhyramnios → rescreen in third trimester

33

Management of GSM

Dietary management & monitoring blood glucose levels.
ADA 2000-2400 kcal/day diet.
No standard for frequency of glucose monitoring.
Recommended → test 4 times/day – fasting & 1-2 hour postprandials.
Maintain fasting glucose < 105 mg/dl; 1 hour postprandial < 140 mg/dl; 2 hour postprandial < 120 mg/dl.

34

Management of GDM with insulin therapy

patients unable to maintain blood glucose control with dietary measures

35

Monitoring for fetal well being

No evidence based guidelines for monitoring baby.
Daily fetal kick counts advisable from 32 weeks.
Some recommend weekly NSTs from 32 weeks gestation until delivery.

36

Hypertensive Disorders in Pregnancy Four Categories - US National High Blood Pressure Education Program (NHBPEP)

Chronic hypertension.
Preeclampsia-eclampsia.
Preeclampsia superimposed on chronic hypertension.
Gestational (transient/chronic) hypertension.

37

Chronic Hypertension

Known hypertension before pregnancy with or without use of antihypertensive drugs.
Increase in B/P before 20 weeks of pregnancy

38

Preeclampsia/Eclampsia S/SX

B/P increase:
> 15 mmHg diastolic or > 30 mmHg systolic – compared to average B/P values before 20 weeks.
Or
> 140/90 in late pregnancy if no early reading is available.
Proteinuria:
> 1+ on random voiding – measured by dipstick.
> 300mg in a 24 hour urine collection.

39

Preeclampsia/Eclampsia

May be diagnosed without proteinuria – if there are other systemic symptoms:
Headache – usually frontal, throbbing, similar to migraine.
Visual changes – scintillations & scotomata.
Epigastric pain – hepatic swelling & inflammation.
Brisk reflexes common in pregnancy → clonus is sign of neuromuscular irritability.
Abnormal lab values.

40

Eclampsia:

Occurrence of seizures precipitated by hypertension disorder of pregnancy.
20% women with eclampsia – B/P < 140/90.
Premonitory signs – headache, visual disturbances, epigastric, or upper right quadrant pain.

41

Chronic Hypertension with Superimposed Preeclampsia

Disorder most often associated with severe maternal & fetal complications.
Consider this disorder when:
Hypertension before 20 weeks & new onset of proteinuria.
Both hypertension & proteinuria before 20 weeks.
Previously controlled hypertension with sudden ↑ B/P.
Thrombocytopenia & elevated hepatic enzymes.

42

Gestational Hypertension

Relatively benign disorder → good pregnancy outcomes.

43

Transient hypertension of pregnancy

Elevated B/P without proteinuria occurring late in pregnancy or early puerperium.
B/P returns to normal levels by 12 weeks postpartum.

44

Chronic gestational hypertension

No evidence of preeclampsia but B/P remains elevated beyond 12 weeks postpartum.

45

HELLP Syndrome

Variant of preeclampsia.
Components:
H – Hemolysis.
EL – Elevated liver enzymes.
LP – Low platelets.
May present initially as small rise in B/P & findings of HELLP components.

46

Preeclampsia
Risk Factors

Nulliparity
Age - Women ↓ 20 and ↑ 35.
Race - Afro-American & Hispanic women in clinic populations.
Family History
Multiple Gestation
Trophoblastic Disease
Hydropic Fetus
History of diabetes, hypertension, vascular, renal or collagen disease.
Obesity
Multiparous with history of preeclampsia.

47

Etiology of Preeclampsia

1916 – Preeclampsia - a disease of theories.
2008 – still an accurate characterization.

48

Preeclampsia:

Pregnancy-specific syndrome.
Clinical continuum ranges from mild to severe.
Not just a hypertensive problem – systemic disorder with both maternal & fetal manifestations.
May involve multiple organs – maternal kidneys, liver, cardiovascular system, hematologic system, neurologic system.
Many of its nonhypertensive complications can be life-threatening even when blood pressure elevations are mild.

49

Placenta problems

↓ perfusion  inadequate oxygenation of fetal-placental unit.
Clinically:
Fetal growth impairment.
Fetal hypoxia.
Fetal death.
Risk of placenta abruption ↑ with severity of disease.

50

Prenatal Care:

Screen for signs & symptoms of hypertensive disorders.
Identify early.
Treat promptly.
Usually involves long-term monitoring of women who are high risk.

51

Objective Data

Evaluate for :
Blood pressure.
Proteinuria.
Generalized edema – legs, hands, face.
Rapid weight gain - >5lbs/week due to edema.
Increased B/P & hyperreflexia / +clonus.

52


Fetal well-being studies

fetal movement counts, nonstress test, BPP, Doppler studies of umbilical arteries.

53

PIH Labs:

CBC with platelet count
 Hgb & HCT – hemoconcentration.
 platelets – platelet consumption – thrombocytopenia.
PT/PTT & fibrinogen – abnormal values usually not observed unless there is thrombocytopenia.
Liver Enzymes - SGOT or SGPT (or both)
Elevation indicates liver involvement.
Serum uric acid, creatinine, & blood urea nitrogen (BUN)
Indicates degree of renal involvement.
24 hour urine collection for protein & creatinine
Indicates degree of renal function.

54

Management of PIH/Preeclampsia

Most effective treatment - delivery of infant & placenta:
Pregnancies at or close to term with a favorable cervix – induction of labor.
Pregnancies remote from term – more difficult problem.

55

Management of PIH/Preeclampsia Goal of Care

prevent development of severe disease & eclampsia:
Recognizing early signs & symptoms of the disease.
Initiating appropriate surveillance & interventions.

56

Management of Mild Preeclampsia

Remain at home.
Modified bedrest.
Must be able to rest – cannot be primarily responsible for child care & care of home environment.
Home assessment of urine protein.
Frequent office visits:
Assessment of B/P & other symptomatology.
Serial PIH labs.
Ongoing evaluation of fetal well-being.
Educate in signs & symptoms of worsening preeclampsia.
Must be able to access medical attention 24 hours a day.

57

Preterm Labor

Definition – cervical effacement & dilatation between 20-37 weeks gestation.
Incidence:
4% - 16% of pregnancies in the US.
Identification of causative factor in preterm labor continues to elude researchers.
Success in preventing preterm birth rests in identifying preterm labor before significant cervical change occurs.

58


Risk factors for preterm birth include:

Hx previous preterm birth.
Hx hypertension, renal disease, diabetes mellitus.
Generalized infections, especially viral.
Uterine abnormalities.
Bleeding in pregnancy.
UTIs
Genital infections → particularly, bacterial vaginosis, chlamydia, & Group B Strep

59

Risk factors for preterm birth include:

Multiple pregnancy.
Polyhydramnios.
Fetal anomalies.
Rh disease.
Intrauterine fetal demise.
Substance abuse, particularly, cocaine.
High social stress.

60

Signs/Symptoms
for preterm birth

Rhythmic contractions (with or without pain).
Backache.
Pelvic pressure.
Intestinal cramping and/or diarrhea.
Increased vaginal discharge.
Signs that may be picked up by clinician:
Palpable uterine contractions.
Change in cervical position, effacement, dilation.

61

Diagnosis of preterm birth

identification of contractions occurring more frequently than 6-8/hour & cervical change.

62

Screening of preterm birth

Thorough history to identify known risk factors.
Frequent cervical evaluations.
Softening of cervix & effacement more predictive of preterm birth than dilation.
Serial ultrasounds → evaluate cervical length.
Cervical length > 30mm by transvaginal ultrasound suggests that significant effacement has not occurred

63

Screening of preterm birth

Identification of fetal fibronectin in cervical and vaginal secretions has been used to identify impending preterm labor.
Use is limited by high false positive rates.

64

Management
Prevention of preterm birth

Identify risk factors.
Frequent surveillance for women at risk.
Education about s/sx preterm labor for all women.

65

Management treatment of preterm birth

Hospitalization & tx with tocolytic agents → MgSO4, Brethine, Indomethacin.
None of these agents has been proven to be effective in stopping true preterm labor.
Close follow-up care of patients with successful stopping of preterm contractions.