Complications of pregnancy Flashcards
(220 cards)
1
Q
A pregnancy that implants OUTSIDE the uterine cavity
A
ectopic pregnancy
2
Q
MC site for ectopic pregnancy?
other places?
A
ampulla
Can occur in ovary, cervix, abdominal wall
3
Q
RF ectopic pregnancy
A
- Prior ectopic pregnancy – scaring in the tube
- STDs
- PID
- Assisted reproductive technology (ART)
- IUD
4
Q
s/s ectopic pregnancy
A
- Vaginal bleeding
- Lower abdominal pain
- Adnexal mass
- Tenderness on pelvic exam
- When ectopic is ruptured, patient may be hypotensive, unresponsive, signs of peritoneal irritation
5
Q
labs of ectopic pregnancy
A
- β-hCG - Does not double every 48h as it does with a normal IUP
- Discriminatory zone
- Level of β-hCG at which a pregnancy should be seen in the uterus
- 1500-2000mIU/mL (depends on facility) - US - Empty uterus or pseudo-gestational sac (not really a baby)
- heterotopic preg
- adnexal mass/extra uterine preg
6
Q
what is a Heterotopic pregnancy
A
IUP and ectopic pregnancy
Particularly worrisome with ART patients
7
Q
donut sign on US indicates?
A
pathoneumonic
for ectopic
pregnancy
8
Q
what specific medication/non-surgical option is for ectopic pregnancy
A
- methotrexate
9
Q
ectopic pregnancy med
Folic acid antagonist
Highly effective against rapidly proliferating tissue (ie trophoblasts)
A
Methotrexate
10
Q
indications for Methotrexate in ectopic preg tx
A
- Patient should be: asx, Motivated, Compliant
- Low initial β-hCG (< 5000)
- Small ectopic size (< 3.5cm)
- Absent fetal cardiac activity
- No evidence of intraabdominal bleeding
11
Q
CI methotrexate in ectopic preg tx
A
- Sensitivity to MTX
- Evidence of tubal rupture
- Breast feeding
- IUP
- Hepatic, renal or hematologic dysfunction
- Peptic ulcer disease
- Active pulmonary disease
- Evidence of immunodeficiency
12
Q
before giving methotrexate for ectopic preg, what labs do you need beforehand
A
CMP, CBC
13
Q
Monitoring Single Dose Regimen of methotrexate
A
- Check β-hCG on Day 1 then 4 and 7
- May not decline from Day 1-4 but should decrease by 15% from Day 4-7
- Can consider repeating dose of Methotrexate, if first dose is not effective
14
Q
what is “Separation pain” when taking methotrexate for ectopic preg
A
- Increasing abdominal pain beginning a few days after therapy
- Mild and relieved with analgesics
Side Effects: Liver, Stomatitis, Gastroenteritis, Bone Marrow Depression
15
Q
surgicial management for ectopic preg
A
- Laparoscopy = preferred surgical tx
- Salpingectomy = tube resection (done more often)
- Salpinostomy = tubal salvage
16
Q
Salpinostomy or salpingectomy done more often and why?
A
- salpingectomy
- Salpinostomy - Higher rate of subsequent uterine pregnancy; Higher rate of persistently functioning trophoblast
17
Q
complete expulsion of all products of conception (POC) before 20 weeks
A
abortions
18
Q
s/s of abortion
A
- History of vaginal bleeding and passage of tissue
- Cervical os closed
- Ultrasound = nothing inside the uterus
19
Q
tx abortions
A
- If patient brought POC, send to pathology
- No medical treatment necessary
-
Follow up important if no evidence of POC
- CANNOT rule out ectopic!
20
Q
partial expulsion of some but not all POC before 20 weeks
A
incomplete abortion
21
Q
s/s incomplete abortion
A
- Vaginal bleeding and abdominal cramping
- POC protruding thru dilated os or active vaginal bleeding
- Ultrasound = nonviable intrauterine pregnancy
22
Q
tx incomplete abortion
A
- Curettage
- Prostaglandins
- Expectant management
23
Q
no expulsion of products, but vaginal bleeding and dilation of the cervix such that a viable pregnancy is unlikely
A
inevitable abortion
24
Q
s/s inevitable abortion
A
- Cervical dilation
- Rupture of membranes or vaginal bleeding
- Ultrasound = intrauterine pregnancy
25
tx inevitable abortion
* Prostaglandins
* Expectant management
26
death of the embryo or fetus before 20 weeks with complete retention of all POC
missed abortion
27
s/s missed abortion
* Closed cervical os
* Absence of uterine growth
* may still pregnant, but no heart beat
* Ultrasound = nonviable intrauterine pregnancy
28
tx missed abortion
1. Curettage
1. Prostaglandins
1. Expectant Management
29
any vaginal bleeding before 20 weeks without dilation of the cervix or expulsion of any POC
threatened abortion
30
s/s threatened abortion
Cervical os closed
Vaginal spotting
Ultrasound = viable intrauterine pregnancy
31
tx threatened abortion
1. Pelvic Rest
1. Monitor closely
32
RhoGAM mechanism of action
Suppresses the immune response and antibody formation of Rh negative individuals to Rh positive red blood cells
33
Excessively edematous immature placentas
* Villous stromal edema
* Trophoblast proliferation
* Caused by chromosomally abnormal fertilizations
molar pregnancy
34
RF molar pregnancy
1. Age (extremes of reproductive age)- 12-20 or older than 30
1. History of prior mole
35
types of molar pregnancy
1. patial
2. complete
36
what is a complete mole
1. 46, XX or XY (Diploid)
1. Both sets of chromosomes are paternal in origin
- Chromosomes of ovum either absent or inactivated
1. have subsequent Gestational Trophoblastic Neoplasia
37
complete mole presentation
1. Vaginal bleeding
1. Large for date - Soft consistency of uterus
1. hCG >100,000
1. Theca Lutein Cysts present - from overstimulation of lutein elements by hCG
38
pathology of complete mole
1. No fetal parts
1. Edematous villi
39
what is partial mole
* 69 XXX or XXY occasionally XYY (triploid)
* Two paternal haploid sets of chromosomes and one maternal haploid set
40
presentation of partial mole
1. Missed Abortion
1. Small for dates
41
pathology of partial mole
Fetal parts present
42
how to dx molar pregnancy
1. Serum hCG
1. Ultrasound
1. Confirmed on **pathology**!
43
on an US for a suspected molar pregnancy it shows echogenic uterine mass with numerous anechoic cystic spaces but without fetus or amnionic sac
“Snowstorm” appearance
what type of molar pregnancy
complete
44
on an US for a suspected molar pregnancy it shows thickened, multicystic placenta along with a fetus or fetal tissue
what type of molar pregnancy
partial mole
45
common sequelae with molar pregnancy
1. **Thyroid storm**
- Elevated hCG leads to elevated TSH which elevates fT4
- fT4 normalizes after uterine evacuation
2. **Hyperemesis gravidarum**
3. **Preeclampsia/Eclampsia**
- Rarely seen today d/t early diagnosis and evacuation
46
preop eval for molar pregnancy
1. Thyroid studies
1. CBC
1. CMP
1. CXR – if it were to become cancer (arrhythmias)
1. EKG – if it were to become cancer (mets to lung common)
1. Type and screen
47
Suction dilation and curettage management in molar pregnancy
* Pitocin should be given as evacuation is begun – because these patients bleed a lot
* Rhogam given if Rh negative
48
what is Postevacuation Surveillance
| molar pregnancy
**VERY IMPORTANT**
1. _Follow β-hCG levels_
- Check 48h postevacuation then check every 1-2 weeks until undetectable
- Then check monthly for at least _6 mo
--- If remains undetectable thru the 6 mo period, it is ok to allow pregnancy again
--- Should have reliable contraception for this time period
49
Bleeding that occurs with a viable mature fetus (typically considered >24 weeks)
antepartum bleeding
50
where can antepartum bleeding come from?
bladder, rectum, or the vagina
51
MCC of antepartum bleeding
Cervicitis - recent sexual activity
52
considerations with antepartum bleeding
1. where is it coming from
2. have they been sexually active recently
3. has anything else been in their vagina
4. how much bleeding - Clots or active vaginal bleeding Bright red blood or old blood?
53
Separation of the placenta either partially or totally from its implantation site before delivery
placental abruption
54
placental abruption can be caused by?
hemorrhage into the decidua
55
placental abruption can be what 4 types
* complete or partial
* concealed or revealed
56
what is chronic abruption
placental abruption beginnly early in pregnancy
Close monitoring throughout pregnancy
57
RF placental abruption
1. Trauma
1. Increasing maternal age
1. Hypertension/Preeclampsia - Most frequent condition associated with abruption
1. Preterm premature ruptured membranes
1. Cigarette smoking
1. Cocaine
1. Lupus anticoagulant and thrombophilias
1. Uterine fibroids
1. Recurrent abrutpion
58
clinical findings of placental abruption
1. Sudden onset abdominal pain
1. Vaginal bleeding
1. Uterine tenderness
59
dx placental abruption
**Diagnosis of Exclusion**
_US_
* Limited use because negative findings do NOT exclude abruption
60
compliations of placental abruption
1. Hypovolemic shock – will need to be delivered ASAP
1. Consumptive coagulopathy (or DIC)
1. Acute kidney injury
1. Couvelaire Uterus
61
cause and tx for Hypovolemic shock in abruption complication
* Due to maternal blood loss
* Can develop with a concealed or revealed abruption
* Requires prompt tx with crystalloid and blood infusion
* will need to be delivered ASAP
62
____ is the most common obstetric cause of DIC
**Abruption**
Intravascular activation of clotting
63
cause and tx of AKI in placental abruption
* Hypovolemia leads to inadequate renal perfusion and oliguira
* Can be prevented with **tx of hypovolemia**
64
Wide spread extravasation of blood into the uterine musculature and beneath the serosa
gives myometrium a bluish-purple tone
Couvelaire Uterus
placental abruption complication
65
management placental abruption
1. Varies depending on clinical condition, gestational age and associated hemorrhage
1. Cesarean delivery vs Vaginal delivery
- C section - quicker; but risk of consumptive coagulopathy = increased bleeding should be considered
- If deceased fetus = vaginal delivery preferred
1. Expectant management
- Should be considered with premature fetus
66
A placenta that is implanted somewhere in the lower uterine segment, either over or very near the internal cervical os
palcenta previa
67
classifications for placenta previa
**Placenta previa**: Internal os is covered partially or completely by placenta
**Low-lying placenta**: Implantation in lower uterine segment is such that placental edge does not reach internal os and remains outside a 2cm wide perimeter around the os
68
RF placent previa
1. Increasing maternal age
1. Increasing parity
1. Prior cesarean delivery
1. Cigarette smoking
1. Elevated MSAFP
69
clinical feature of placental previa and why does it happen
**Painless vaginal bleeding** - Usually seen after 2nd trimester
* Uterine body is remodeling to form the lower uterine segment
* Internal os dilates and some of the placenta inevitably separates
* Bleeding occurs and myometrium is unable to contract to stop
70
how to dx placenta previa
**Transvaginal ultrasound**
71
Previa should be excluded in any patient who presents with ?
vaginal bleeding after 2nd trimester
72
what exam should not be performed until previa is r/o?
digital exam - can cause severe hemorrhage
73
what is placenta migration
* Used to describe the apparent movement of the placenta away from the internal os
* Differential growth of the lower and upper uterine segments as pregnancy progresses
* Greater upper uterine blood flow leads to placental growth towards the fundus
74
low lying placenta is MC to persist if pt has h/o?
prior cesarean or hysterotomy scar
75
Until ? weeks, likelihood of previa persistence is low
23
If previa present after 23 weeks, >50% chance will persist
76
management placenta previa
Must consider fetal maturity, labor and amount of bleeding
1. Preterm fetus
- No persistent active vaginal bleeding = Observe; Outpatient vs inpatient management
- Persistent active vaginal bleeding = Delivery
2. Term fetus
- Deliver by C-section
77
* Abnormally implanted, invasive or adhered placenta
* Abnormally firm adherence to myometrium because of partial or total absence of the decidua basalis and imperfect development of the fibrinoid layer
placenta accrete syndromes
78
Villi attached to myometrium
which placenta accrete syndrome
Placenta Accreta
79
Villi invade myometrium
which placenta accrete syndrome
Placenta Increta
80
Villi penetrate through the myometrium and to or through the serosa
which placenta accrete syndrome
Placenta Percreta
81
placenta accrete syndromes increases in incidiences due to ?
increasing number of cesarean deliveries performed
82
RF placenta accrete syndromes
1. Associated Placenta Previa
1. Prior Cesarean Delivery - Decidual formation can be defective over prior scar
83
presentation placenta accrete synromes
asx, picked up on US
84
dx placenta accrete syndromes
* US - specificity using transvaginal US; MRI may be useful adjunct
* Delivery
* **Pathology** - Confirms dx and extent of invasion
85
management placenta accrete syndromes
1. **Planned delivery at tertiary center** - Recommended around 34-36 weeks
- To avoid emergency cesarean delivery
1. Risk of hysterectomy should be discussed with pt
1. **Preop uterine artery embolization** - reduce bleeding
1. **Consider leaving placenta in situ**
- Placenta can reabsorb
- Subsequent hysterectomy can be scheduled when blood loss may be lessened
86
what is cervical insufficiency
* Painless cervical dilatation in the second trimester
* Followed by prolapsing and ballooning of membranes into the vagina and ultimately expulsion of an immature fetus
87
RF cervical insufficiency
1. Prior cervical trauma
- Dilation and curettage
- Conization
- Cauterization of the cervix
2. DES exposure
88
diagnostics for cervical insufficiency
1. Ultrasound - Confirm living fetus
1. Cervical swabs for infection
89
management for cervical insufficiency
**Expectant Management**
1. Trendelenburg position
1. Pelvic rest
1. Delivery?
1. Cerclage? A stitch in the uterus that holds it closed that you keep in until week 36
90
indications for cerclage
1. History of recurrent midtrimester losses and diagnosis of cervical insufficiency
1. Women identified by ultrasound to have a short cervix (< 25mm)
1. Rescue cerclage = done emergently when cervical incompetence identified in a woman with threatened preterm labor
91
what is Rescue cerclage
Performed emergently after the cervix is found to be dilated, effaced or both
92
when is elective cerclage performed
Performed 12-14 weeks gestation with next pregnancy
93
4 reasons for preterm birth
1. Spontaneous unexplained preterm labor with intact membranes
- Includes Cervical Insufficiency
1. Idiopathic preterm premature rupture of membranes (PPROM)
1. Delivery for maternal or fetal indication
- Preeclampsia
1. Twins and higher order multifetal births
94
regular uterine contractions that cause cervical change and ends with delivery of the newborn
labor
95
CC of preterm labor
* Multifetal pregnancy
* Intrauterine infection
* Bleeding
* Placental infarction
* Premature cervical dilation
* Cervical insufficiency
* Hydramnios
* Uterine fundal abnormalities
* Fetal anomalies
96
RF preterm labor
1. Threatened Abortion during this pregnancy
1. Cigarette Smoking
1. Inadequate weight gain during pregnancy
1. Illicit drug use
1. Depression, anxiety, chronic stress
1. Short interval between pregnancies
1. Prior preterm birth
1. Periodontal disease
1. Infection
97
s/s preterm labor
1. Mild, menstrual-like cramps
1. Constant low backache
1. Painless or painful uterine contractions
1. Increase in vaginal discharge
1. Cervical change - Dilation; Effacement (length)
1. Effacement of the cervix
98
work-up for preterm labor
1. Fetal fibronection - Can perform swab between 24-34 weeks
* If negative, < 1% chance will go into labor in next 2 weeks
* If positive, not useful
* Should NOT perform if had sex or anything in the vagina within last 24hours
1. Cervical length - transvaginally; >3cm = not in labor
2. Sterile vaginal exam - evaluate cervix
3. Sterile speculum exam - cx; nitrazine (if suspect rupture of membranes)
4. Check urine analysis and culture
99
what is detected vaginally in labor
Reflects stromal remodeling of the cervix before labor
| preterm labor
glycoprotein
100
what vaginal cx are you checking for preterm labor work-up
Gonorrhea, Chlamydia, Candidiasis, Group B Streptococcus, etc
101
nitrazine results with preterm labor work-up
* Normal vaginal pH 4.5-5.5
* Amniotic fluid pH 7.0-7.5
* Evaluates pH of vaginal fluid, typically turns blue if amniotic fluid is present
102
med tx preterm labor
Tocolysis – stopping the contractions; May delay delivery 48hours
* Magnesium Sulfate
* Calcium channel blockers - Nifedipine
* Prostaglandin synthetase inhibitors - Indomethacin
* β-agonists - Terbutaline
Neuroprotection - Prevention of neonatal intracranial hemorrhage
* Magnesium sulfate given from 24-32 weeks gestation for at least 12 hours
103
tocolysis
Maintenance therapy for longer than ? is ineffective and not recommended by ACOG
48 hours
104
which Tocolysis med is not used past the 2nd trimester because it can close the ductus arteriosis
Indomethacin
105
general management preterm labor
1. Bed Rest - No research supporting or refuting
1. **Betamethasone** for Fetal Lung Maturation - effective in lowering the incidence of respiratory distress syndrome and neonatal mortality rates if birth delayed for 24hours
106
when to give Corticosteroids for Fetal Lung Maturation
between 24-34 weeks gestation
Can consider to 36 weeks
107
prevention preterm labor
1. Cervical Cerclage
- Rescue Cerclage
2. Progesterone Therapy
- Intramuscular - Weekly injections beginning at 16 weeks till 36 weeks
- Vaginal
107
indication for cervical cerclage in preterm labor prevention
for women identified to have a cervical length <25mm who are at high risk for Preterm Birth
108
indications for intramusclar progesterone therapy for preterm labor
history of prior preterm birth
109
which type of progesterone therapy is indicated for women with a shortened cervix
vaginal
110
Membrane rupture before the onset of contractions and before 37 weeks gestation
preterm premature rupture of membranes (PPROM)
111
RF for PPROM
1. Genital tract infection
1. History of PPROM
1. Antepartum bleeding
1. Cigarette smoking
112
dx for PPROM
1. Speculum exam
- Pooling: pooling of amniotic fluid within the vagina
- Nitrazine swab: detects alkaline pH of amniotic fluid
- Ferning: Fluid from posterior fornix is swabbed; dried fluid - amniotic fluid causes a ferning pattern
2. Ultrasound = low amniotic fluid index
113
False positive results in nitrazine swab
| PPROM
1. Blood
1. Semen
1. Antiseptics
1. Bacterial vaginosis
114
management PPROM
1. **admit** for remainder of pregnancy
2. **Corticosteroids** for Fetal Lung Maturity
3. **Tocolysis**: Utilized to administer corticosteroids and transport patient
4. Abx for Latency: Extends the time period before delivery
- **Amipicillin** IV, then **Amoxicillin** PO
- **Erythromycin** IV, then PO
--- alt: **Azithromycin** PO
115
PPROM - Expectant management for delivery until 34 weeks
1. Average latent period - 1 week
1. Proceed to delivery (either vaginal or cesarean) at 34 weeks
1. If develops clinical chorioamnionitis = delivery
- sx: F, Uterine tenderness, Malodorous vaginal discharge, Fetal or maternal tachycardia
116
complications PPROM
1. Placental Abruption
1. Chorioamnionitis
1. Sepsis
1. Cord Prolapse – this is why they stay in the hospital
- The cord gets compressed between the babies head or butt and the wall of the uterus
- THIS IS BAD BAD!
117
Impairment of fetal growth, preventing the fetus from achieving its individual growth potential
intrauterine growth restriction (IUGR)
118
maternal RF IUGR
1. Smoking
1. Alcohol
1. Low pre-pregnancy weight
1. Poor weight gain
1. Malnutrition
1. DM
1. Systemic lupus erythematous
1. Chronic hypertension
1. Preeclampsia
1. Meds: corticosteroids, methotrexate, antiseizures
1. Low maternal socioeconomic status
119
fetal RF IUGR
1. Multiple gestation
1. Anomalies
1. Infections TORCH
120
placental RF IUGR
1. Abruption
1. Previa
121
IUGR - Fetal Morbidity and Mortality
1. Stillbirth
1. Neonatal encephalopathy
1. Cerebral palsy
122
management IUGR
Antepartum
1. Amniotic Fluid Volume measurement
- Monitor weekly after 34 weeks
- Association between IUGR and oligohydramnios
2. Umbilical Artery Doppler velocimetry
- Begin around 28 wks and repeat q 1-wks
- Absent or reverse end diastolic flow can indicate fetal compromise and the need for delivery
3. Growth US
- Repeat growth measurements q 3-4 wks after 18 wks gestation
4. Fetal surveillance
- Biophysical profile
- NST
Plan for delivery at 38 weeks - Unless fetal compromise
122
how to dx IUGR
1. Abdominal palpation - Not very sensitive
1. **US**
- **abd circumference & estimated fetal wt** - most accurate US biometrical parameters for IUGR
- **< 10th percentile** overall growth / **< 10th percentile** Abdominal circumference - indicates IUGR
123
The intrauterine death of a fetus at any gestational age
fetal death
124
Reporting of fetal death differs by state but typically required at ? weeks or with birthweight of ?
>20
>350g
125
causes of fetal death
1. **_Obstetrical complications_** – 29%
- Abruption, multifetal gestation, PPROM at 20-24 weeks
2. **Placental abnormalities** – 24%
- Uteroplacental insufficiency, maternal vascular disorders
1. Fetal malformations – 14%
1. Infection – 13 %
1. Umbilical cord abnormalities – 10%
- Prolapse, stricture, thrombosis
1. Hypertensive disorders – 9%
1. Medical complications – 8%
1. **Undetermined** - 24%
126
RF fetal death
1. AMA
1. African american race
1. Smoking
1. Illicit drug use
1. Maternal medical diseases
1. ART
1. Nulliparity
1. Obesity
1. Previous adverse pregnancy outcomes
127
dx fetal death
1. incidental
1. Found during fetal assessment
128
management fetal death
1. Plan for delivery - Based on gestational age, prior deliveries,etc
1. Evaluate fetus after delivery –optional for parents, recommend this
- Neonatal autopsy
- Karyotyping
- Examination of placenta, cord and membranes
- Cultures to test for infection
129
management after fetal death
1. psychological considerations
2. management with future pregnancies
- Control modifiable risk factors (ie Hypertension, etc)
- Offer routine genetic testing
- Obtain anatomy scan at 18 weeks and then serial growth ultrasounds beginning at 28 weeks
- Begin antepartum surveillance at 32 weeks or 1-2 weeks prior to stillbirth
- Elective induction or cesarean at 39 weeks
130
what is HTN in pregnancy
Elevation of BP ≥140 mmHg systolic and/or ≥90 mmHg diastolic, on two occasions at least 6 hours apart.
131
HTN pregnancy classifications
1. Chronic Hypertension
1. Gestational Hypertension
1. Preeclampsia
1. Preeclampsia superimposed on Chronic Hypertension
1. HELLP
132
what is preexisting HTN
1. Systolic pressure ≥ 140 mmHg, diastolic pressure ≥90 mmHg, or both.
1. Present before 20 weeks gestation or persists longer then 12 weeks postpartum.
133
effects of pregnancy on chronic HTN
1. BP falls in early pregnancy
1. BP rises again in third trimester
1. Elevated vascular resistance and reduced intravascular volume
134
CI antiHTN drugs
* ACE inhibitors
* Angiotensin receptor antagonists
135
chronic HTN maternal effects
* Superimposed preeclampsia
* HELLP
* Stoke
* Acute kidney injury
* Heart failure
* Hypertensive cardiomyopathy
* Myocardial infarction
* Placental abruption
* Maternal death
136
fetal effects from chronic HTN
1. Fetal death
1. Growth restriction
1. Preterm delivery
1. Neonatal death
1. Neonatal morbidity
137
prenatal care for chronic HTN
1. ECG in long-standing hypertension.
1. Consider echocardiogram-if they have had it long enough
1. Baseline laboratory tests
* CBC (Hgb, Plts)
* Renal Function (Cr, UA, Albumin)
* Liver Function (AST, ALT, ALP, LD)
* Coagulation (PT, PTT, INR, Fibrinogen)
* Urine Protein (Dipstick, 24 hour)
138
med tx chronic HTN
1. May taper or DC meds for women with blood pressures < 120/80 in 1st trimester.
- Reinstitute or initiate therapy for persistent diastolic pressures >95 mmHg, systolic pressures >150 mmHg, or signs of hypertensive end-organ damage.
2. 81-162mg **Aspirin** - can reduce risk of superimposed preeclampsia
3. Medication choices - **Labetalol, CCB**
139
general management for chronic HTN
1. Depends on severity of hypertension and gestational age
1. Observational Management
- Restricted activity
- Close Maternal and Fetal Monitoring
--- BP Monitoring
--- s/s of preeclampsia
--- Antepartum assessment: NSTs, BPPs, Growth US
1. Delivery - w/o complications = 37-39 weeks
140
definition of gestational HTN
BP > 140/90 after 20 weeks in previously normotensive women
Develops in late pregnancy, after 20 weeks gestation
Resolves by 12 weeks postpartum.
tx and management similar to chronic HTN
141
gestational HTN can progress onto what condition in ~50% of cases
preeclampsia
142
New onset of hypertension and proteinuria after 20 weeks gestation
preeclampsia
143
criteria for preeclampsia
* Systolic blood pressure ≥140 mmHg OR diastolic blood pressure ≥90 mmHg
* Proteinuria of 0.3 g or greater in a 24-hour urine specimen (+2 on a urine dipstick)
144
preeclampsia can be present with these other conditions
1. Thrombocytopenia
1. Renal insufficiency
1. Liver involvement
1. Cerebral symptoms
1. Pulmonary edema
145
pathophys of preeclampsia
1. Abnormal trophoblastic invasion
1. Endothelial cell activation
1. Genetic factors
146
RF preeclampisa
1. First pregnancy
1. Young women
1. Multifetal gestations
1. Presence of certain vascular disorders - DM, SLE, renal disease, etc
1. Obesity
1. African American race
1. Chronic hypertension
147
Occurrence of generalized convulsion and/or coma in the setting of preeclampsia, with no other neurological condition
Eclampsia
May occur before, during or after labor
148
Preexisting HTN with the following additional signs/symptoms:
| preclampsia superimposed on chronic HTN
1. New onset proteinuria
1. A sudden increase in blood pressure.
1. Development of any component of HELLP Syndrome or symptoms of Severe Preeclampsia
149
what is HELLP
Hemolysis, Elevated Liver enzymes and Low Platelet Count
Patients have RUQ pain because the liver bleeds and it distends the capsule
150
HELLP increases risk for?
hepatic hematoma and hepatic rupture
151
HELLP is an indicator of ?
Indicator of severe preeclampsia
Associated with a worse outcome
152
definitive tx preeclampsia
delivery
153
management for Mild preeclampsia
should be monitored closely
Consider hospitalization
Expectant management
154
Major indication for antihypertensive therapy in preeclampsia tx is
1. prevention of cerebrovascular hemorrhage and hypertensive encephalopathy
1. Diastolic pressure ≥110 mmHg or systolic pressure ≥160 mmHg
1. Choice of drug therapy: Acute – IV labetalol, IV hydralazine, PO nifedipine
155
Effective anticonvulsant that avoids producing central nervous system depression in preeclampsia
NOT given to treat hypertension! More to treat the ecclampsia
Magnesium Sulfate
156
Diagnosis of Diabetes before pregnancy
Pregestational Diabetes
157
Diagnosis of Diabetes during pregnancy that is not clearly Type or Type 2 Diabetes
Gestational Diabetes
158
pregestational DM - Increasing number of affected pregnancies due to increasing number of ?
**younger patients with Diabetes** (particularly Type 2)
Many women with gestational diabetes actually have Type 2 Diabetes and were not previously diagnosed
159
dx pregestational DM
* High plasma glucose levels, glucosuria, ketoacidosis
* Random plasma glucose >200 mg/dL plus classic symptoms such as polydipsia, polyuria and unexplained weight loss
* Fasting glucose >125 mg/dL
160
International Association of Diabetes and Pregnancy Study Group (IADPSG) recommends using these thresholds at prenatal care initiation:
* Fasting plasma glucose >125 mg/dL
* Hemoglobin A1c >6.5%
* Random plasma glucose >200 plus confirmation
161
Hemoglobin A1c of ? or preprandial glucose of ? are at increased risk in impacting pregnancy
| pregestational DM
* >12
* >120 mg/dL
162
Outcomes of prestational dM are worsened by what other conditions
cardiovascular or renal disease
163
fetal complications of pregestational DM
1. Spontaneous Abortion
1. Preterm Delivery
1. Malformations
- Fourfold higher risk of cardiac defects
- Caudal regression sequence associated with poorly controlled diabetes
1. Altered Fetal Growth (IUGR and macrosomia)
- Blood glucose >130mg/dL increases risk of macrosomia
1. Unexplained Fetal Demise
- Risk of death 3-4x > normoglycemic women
1. Hydramnios
164
neonatal complications in pregestation DM
1. Respiratory distress syndrome
1. Hypoglycemia – insulin does not cross the placenta
- Rapid drop in plasma glucose after delivery
- Glucose crosses placenta, Insulin does not
- Infant is overproducing insulin and there is no longer overproduction of glucose from the mother
1. Hypocalcemia – no explanation
1. Hyperbilirubinemia and Polycythemia
1. Cardiomyopathy
1. Long term cognitive defects
165
maternal complication in pregestational DM
1. Preeclampsia
1. Preterm Delivery
1. Diabetic Nephropathy
1. Diabetic Retinopathy
1. Diabetic Neuropathy
1. Diabetic Ketoacidosis
- Affects 1% of pregnancies
- Most often in Type 1 DM
- Associated with Hyperemesis gravidarum, β-mimetic drugs for tocolysis, infection and corticosteroids
166
preconceptional care in pregestational DM
1. Optimal glucose control!
- Preprandial 70-100mg/dL
- Peak Postprandial 100-129mg/dL
- Mean daily glucose concentrations < 110mg/dL
- A1c < 7
1. Should be evaluated for retinopathy and nephropathy
1. Folic Acid 400µg/day orally
167
1st trimester tx pregestational DM
1. **Careful glucose monitoring**!
- Fasting < 95
- 1h postprandial < 140
- A1c < 6 = Associated with lowest risk for LGA
1. Optimal management with **Insulin**
1. Nutritional Counseling, Opthamologist, Dietician, etc
1. Consider maternal echocardiogram, EKG
1. 81mg **ASA**
- Pregestational DM - high RFfor development of preeclampsia
1. May require more frequent visits throughout pregnancy- High risk consultation should be obtained
1. **24 hour urine**
168
2nd trimester pregestational DM tx
1. Targeted Ultrasound between 18-20 weeks
1. Fetal Echocardiogram between 20-24 weeks
1. Continued glycemic control
- If on oral agents and not euglycemic, consider insulin
- If on insulin and not euglycemic, consider insulin pump
169
3rd trimester pregestational DM tx
1. **Antepartum testing at 32-34 wks**
- Earlier if uncontrolled or nephropathy
- NSTs with AFIs done weekly
- Growth should be monitored q 4 wks
2. **Delivery at 36-40 weeks**
- Delivery timing based on _glucose control, associated maternal vasulopathy, nephropathy or prior stillbirth_
3. **Delivery**
- **Insulin drip** may be needed during delivery
- **Vaginal or Cesarean Delivery** as indicated - **>4500g, = cesarean**
170
postpartum pregestational DM tx
1. Remember insulin requirements increase throughout pregnancy
1. Insulin may need to be decreased by half and monitored closely in the subsequent weeks
1. Risk of infection is increased!
171
RF gestational DM
1. Ethnicity - in Hispanic, African American, Native American, Asian or Pacific Islander women
1. Obesity
1. Increasing age
1. Sedentary lifestyle
172
screening and dx for gestational DM
1. 2 step method
1. **50g 1 hr oral glucose challenge test 24-28 wks**
- Not affected by fasting
- Could consider testing women with RF asap
2. **If positive 1 hour glucose challenge test proceed to _100g 3 hour glucose tolerance test_**
- Must be fasting for this test
2. 3 hour glucose tolerance test - Must have 2 abnormal results to receive diagnosis of gestational diabetes
173
management gestational DM
1. Monitor blood glucose
- Fasting < 95 and 2h postprandial < 120 is optimal
- Should test at least fasting and postprandial to achieve optimal management of blood sugars
2. diet modification
- Nutritional counseling
--- 40% of total calories should be carbohydrates
--- 20% protein
--- 40% fat
- Exercise - moderate activity
3. meds
- insulin - standard therapy; Does not cross placenta; Allows tight glycemic control
- Glyburide, metformin
174
If do NOT require insulin or medication then what is not required
| gestational DM
early intervention not required
175
postpartum - All women should receive ?
| gestational DM
75g 2 hr glucose tolerance test at 6-12 wks postpartum
176
maternal and fetal effects of gestational DM
1. Increase rate of stillbirth - esp in women with elevated fasting glucose levels
2. Fetal macrosomia
- Increase risk of shoulder dystocia and difficult delivery
- Fetus has excessive shoulder and trunk fat
1. Neonatal hypoglycemia
1. Maternal Obesity
177
lifelong effects on fetus - increased risk of
Childhood obesity
Adults onset obesity
178
multifetal gestations was associated with rise in
infertility therapy
179
Usually result from fertilization of two ova = Dizygotic
MC
twins
180
Twins of the opposite sex are most often ____
dizygotic
181
monozygotic - increased frequency d/t ?
ART (assisted reproductive technology)
182
Incidence of twin is higher in which trimester
first
183
One twin vanishes or is lost before which trimester
second
184
dx multifetal gestations
US - Determines chorionicity – 1st TRIMESTER!
- Dichorionic
- Monochorionic
185
* Two separate placentas suggests
* Identification of a thick dividing membrane (>2mm) suggests
* **Twin peak sign** = triangular projection of placental tissue extending a short distance between the layers of the dividing membrane
* Also referred to as Lambda or Delta sign
Dichorionic on US
186
* Thin dividing membrane (< 2mm)
* **T sign** = right angle relationship between the membranes and placenta and no apparent extension of placenta between the dividing membrane
Monochorionic on US
187
multifetal gestation complications
1. Spontaneous abortion
1. Congenital malformations
1. Low birthweight - Related to PTL = avg gestational age at delivery is 36 wks
1. HTN (Recommend 81mg ASA at 12 weeks)
1. Preterm Birth
1. Size discordance
- Wt discordance >20% most accurately predicts adverse outcomes
- More likely to fail a vaginal delivery if baby A is smaller than baby B
188
Monochorionic Monoamnionic twins associated with high fetal death rate d/t these causes: (4)
* Cord entanglement
* Congenital anomalies
* Preterm birth
* Twin twin transfusion syndrome
189
Monochorionic Monoamnionic twins have an increased risk of congenital cardiac disease, therefore need this imaging
fetal echo
190
management for Monochorionic Monoamnionic twins
* Begin antepartum testing at 24-28 weeks
* Give corticosteroids around 24-28 weeks
* C-section at 32-34 weeks - Unless fetal testing not reassuring before this time
191
Unique Fetal Complications
1. Monochorionic Monoamnionic twins
1. Conjoined twins
1. Twin Twin Transfusion Syndrome
192
what is and the cause of Twin Twin Transfusion Syndrome
* Due to placental vascular anastomotic connections
* Blood transfused from a donor twin to its recipient sibling
* Donor becomes anemic and growth restricted
* Recipient twin can develop heart failure, polycythemia and severe hypervolemia
193
tx for TTTS
* Laser ablation of anastomosis is preferred
* Selective reduction can be considered
194
multifetal gestation prenatal care
1. Wt gain
- Recommend 37-54lb weight gain for women with normal BMI
2. Antepartum testing is indicated
- Should follow growth for discordance
- Monoamniotic twins watched more cautiously
195
management for preterm birth in multifetal gestation
1. No evidence that bed rest or prophylactic tocolysis prolong multifetal pregnancies
1. No evidence that IM progesterone, vaginal progesterone or cervical cerclage are effective in multifetal pregnancies
1. **Pessary use**
- little donuts that can be put into vagina behind the pubic symphysis in order to help support the area and keep the babies in for longer
196
labor management in multifetal gestation
1. **Delivery**
- Dichorionic Diamniotic twins at 38 weeks
- Monochorionic Diamniotic twins at 34-37 weeks
- Monochorionic Monoamniotic twin at 32-34 weeks
2. **Vaginal delivery**
- Should be prepared to deal with any change in fetal position
- Cephalic-cephalic presentation ideal; controversial
3. **Cesarean delivery**
- Recommended for breech presentation of first twin and esp breech-vertex presentation
- Monoamniotic twins delivered by cesarean
--- Avoids umbilical cord complication
197
Fetal thyroid gland begins concentrating iodine and synthesizing thyroid hormone after ? weeks gestation
12 wks
Any thyroid need before 12 weeks is provided by the mom
198
how does pregnancy affects on thyroid hormone
1. Increase thyroid binding globulin
- Estrogen increased thyroid binding globulin
- Causes an increase in T3/T4 production = Affects the Total T3 and Total T4 amount
2. Stimulation of TSH by hCG
- hCG causes increase in Total T3 and T4 = decrease in TSH production
- Pregnant women may appear to have subclinical hyperthyroidism which is normal
199
hypothyroidism s/s
Vague nonspecific sx
Cold intolerance
Muscle cramps
Constipation
Fatigue
Weight gain
Insomnia
Hair loss
200
testing for hypothyroidism
If sx, should test at initial prenatal visit
Obtain TSH level, if abnormal then check Free T4
201
MCC of hypothyroidism
Hashimoto’s thyroiditis: Painless inflammation with progressive enlargement of the thyroid gland
202
dx and tx for Hashimoto’s thyroiditis
1. Dx - elevated TSH/ Low Free T4
1. Tx - **Levothyroxine**
- will need an increase in dose during pregnancy
- Should follow thyroid levels about every 6 weeks – because they may need more Levo during pregnancy
203
Elevated TSH/ Normal Free T4 is what type of hypothyroidism
Subclinical Hypothyroidism
Studies suggest treating with **Levothyroxine** decreases risk of neurodevelopmental complications in offspring
204
One of the most common treatable causes of mental retardation
Congenital Hypothyroidism
205
2 hallmarks of MDD
1. Depressed mood
1. Anhedonia
206
RF MDD
1. History of depressive disorders
1. Low social support
1. Financial disadvantage
1. Adolescence
1. Unmarried
1. Recent adverse life events
1. History of abuse
Every patient should be screened for depression at their initial prenatal visit - If at risk, should screen at every visit
207
tx MDD
Counseling
Medication
- **SSRIs and SNRIs** are first line treatment
- If mother is stable on her current medication and there is so no CI = continue tx
- There are no risk-free treatment options
208
Untreated maternal depression has been associated with
1. Low birth weight
1. Long term neurobehavioral issues with the infant
209
* GABA A receptor positive modulator
* **First oral medication indicated for PPD**
* Utilized for severe PPD with onset in the third trimester or within 4 weeks postpartum
* adjunct with SSRI or SNRI
zuranolone
210
substance abuse - Pattern of abuse characterized by:
1. tolerance
1. craving
1. inability to control use
1. continued use despite adverse consequences
Treatable disease with combining medication with behavioral therapy and recovery support
211
affects of substance abuse on pregnancy
1. Preterm Labor
1. Placental Abruption (cocaine)
1. Intrauterine growth restriction
1. Fetal Alcohol Syndrome
1. Prolonged hospital stay for infant - Secondary to Neonatal abstinence syndrome
212
opioid substitutions?
which ones can cross the placenta?
1. Methadone, Suboxone, Subutex (Buprenorphine)
2. Associated with Neonatal Withdrawal
- Methadone crosses the placenta
-Subutex does not cross as readily
213
pregnancy changes that favors UTI
1. Immunosuppression of pregnancy
1. Dilation of ureters
1. Compression of bladder by enlarging uterus – this can cause some stasis
214
what is Asymptomatic Bacteruria? affects on pregnancy?
1. Positive urine cx in asx pt
1. Pregnancy affects:
- Preterm Birth
- Low birth weight
- Perinatal morbidity
1. Screening with a urine culture should occur at initial prenatal visit
215
management for asx bacteruria
1. **Macrobid, Keflex**
- Should evaluate cx sensitivities
- Urine cx repeated a week after completion of tx to ensure resolution
2. **Suppressive** therapy
- considered for a persistent infection after 2 courses of tx
- **Macrobid** 100 PO daily
216
CVA tenderness
Fever
Nausea and vomiting
Flank pain
what UTI complication
Pyelonephritis
217
20% of pregnant women develop what severe complications from pyelonephritis
1. Acute respiratory distress syndrome
1. Septic shock
218
management for pyelonephritis
1. Tx - Hospitalization, IV abx
1. Supression - Recommended for duration of pregnancy to prevent recurrence
