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Flashcards in complications of pregnancy Deck (70):
1

probs in 1st trimester

Hyperemesis gravidarum
Spontaneous abortion
Recurrent Abortion
Ectopic pregnancy
Gestational trophoblastic disease

2

Hyperemesis Gravidarum

Extreme end of nausea/vomiting of pregnancy
Diagnosis of exclusion
0.3-3% of pregnancies
Weight loss of more than 5%:
Ketonuria
Electrolyte abnormalities
Liver abnormalities
Thyroid
Unknown cause:
?Psychogenic
?hCG
?Estrogen

3

Hyperemesis Gravidarum

Maternal Effects
Fetal Effects

Treatment: *Pyridoxine (vit B6), Doxylamine*, (Diclegis is combo of those 2) anti emetics: Ondansetron, Metoclopramide, Promethazine
Corticosteroids
IV fluids, parenteral nutrition, enteral tube feeding

4

Spontaneous abortion

less than 20 weeks gestation
Common – 20% of pregnancies
60% due to chromosomal defects
*table slide 7*

5

Spontaneous Abortion

Work up: Vitals, hCG, CBC, Blood type, Ultrasound
Treatment:
-Hemodynamically stable: Expectant
Medical: misoprostone +/- mifepristone
-Hemodynamically unstable: D&C
-more than 12 weeks: D&E

6

recurrent abortions

3+ spontaneous abortion: Abnormalities can be found in more than 50%
-check for Karyotype
-Uterine assessment (septums)
-Anticardiolipin antibody, lupus anticoagulant
-Thombophilia assessment: (Factor V Leiden, Prothrombin gene mutaation, Antithrombin III, homocystine, protein S and C)
-Thyroid function

7

ectopic preg

Pregnancy outside the uterine cavity
98% tubal
RF: infertility, PID, prior tubal surgery
10% risk of recurrence
more slide 12, 13

8

ectopic preg

?

9

ectopic preg

?

10

Gestational Trophoblastic Disease

Hydatidiform mole: partial or complete
Invasive mole
Choriocarcinoma
Placental site trophoblastic tumor

11

Hydatidiform mole

1/1500 pregnancies
20%  malignant sequelae
Aberrant fertilization
chart slide 15

12

hydatidiform mole dx

Bleeding
Large uterus
Hyperemesis
HTN
Extremely elevated hCG
can cause hyperthyroidism
Placental vesicles on ultrasound ("snow storm pattern")
biopsy: “grape-like clusters”

13

hydatidiform mole tx

D&C
CXR

14

hydatitiform mole follow up

Birth control!! (don't want them to get pregnant again and raise HCG)
Weekly hCG until 3 negatives
hCG q1-3 months x 6 months
(should decrease after D/C)



15

Post molar gestational trophoblastic disease:

hCG plateau x4 over 3 weeks
hCG increase more than 10% x3 over 2 weeks
Persistence of hCG after 6 moths
-methotrexate

16

Choriocarcinoma

1/20,000-40,000 pregnancies
50% after term pregnancies, 25% after molar pregnancies, 25% other
-Persistent bleeding or hCG after delivery/D&C
Metastasis – vagina, lung, liver, brain
-Chemotherapy: MTX or actinomycin

17

Second and Third Trimesters

Pre-eclampsia/eclampsia
Acute fatty liver of pregnancy
Gestational diabetes
Preterm labor/Preterm rupture of membranes
Oligo- or Poly-hydramnios
Bleeding: Placental abruption, Placenta previa, Vasa previa
Cholestasis of Pregnancy

18

Pre-eclampsia/eclampsia

Pre-eclampsia: Elevated blood pressure + proteinuria (if no proteinuria just gestational HTN)
Eclampsia: + seizures (5%)
-more than 20 weeks gestation to less than 6 weeks postpartum
-Treatment: delivery
-Incidence: 7%
Risk Factors: multiple gestations, CHTN, DM, kidney disease, collagen-vascular disorders, autoimmune disorders, GTN

19

Pre-eclampsia/Eclampsia: mild vs. severe

mild:
BP: 140-160/90-110
proteinuria: 0.3-5g/24hrs
severe:
BP: more than 160/110
proteinuria: more than 5g/24hrs

Other indications of severe disease:
S/S: (ha, scotomas, hyperreflexia, clonus, low urine output)
Labs (listen)
Fetal findings

20

Pre-eclampsia/Eclampsia tx

Treatment:
** Delivery
Allow fetal lung maturity
Mild: 37 weeks at the LATEST
Severe: 34 weeks at the LATEST (Corticosteroids, aggressive fetal monitoring, serial labs and evaluation)
Prevent eclampsia: Mg sulfate (calcium gluconate if toxicity)
Treat blood pressure

Eclampsia: obstetric emergency!

21

HELLP

hemolysis, elevated liver enzymes, low platelets
tx: delivery

22

Acute Fatty Liver of Pregnancy (rare, but high mort. rate)

Acute hepatic failure
7-23% mortality
Poor placental mitochonrial function
Flu-like symptoms-->abd pain, jaundice, encephalopathy, DIC, death
-Elevated Alk Phos, PT, Bilirubin, mild elevation of AST/ALT
**Hypoglycemia
Treatment: immediate delivery, supportive care

23

Cholestasis of Pregnancy

Incomplete clearance of bile acids
Generalized pruritis – especially hands and feet
Elevated bile acids
Treatment: ursodeoxycholic acid
*Increased risk of stillbirth: Increased surveillance, early delivery

24

Gestational Diabetes*

*Abnormal glucose tolerance*
Human placental lactogen (HPL, chorionic somatomammotropin):
-Increase in # of pancreatic beta cells
-Natural “insulin resistant” state
-Glucose and amino acids-->fetus
-Increases between *24-30 weeks gestation* (when screen)
When pancreatic function not sufficient-->Gestational Diabetes

*50% of women with GDM will develop overt DM* may change DM screening

25

Gestational diabetes: Pregnancy implications

Excessive fetal growth
Shoulder dystocia
Cesarean section
Pre-eclampsia
Fetal hypoglycemia

26

Gestational diabetes Testing – 2 steps

Screening – 50g glucose tolerance test (1 hour)
-between 24-48 weeks
-if greater than 140 do dx test

Diagnostic – 100g glucose tolerance test (3 hours)
normal glucose levels:
fasting: 95 or less
1 hr: 180
2 hr: 155
3 hr: 140

*if 2 abnormal, dx with GDM


27

Gestational diabetes Types:
Testing

A1: controlled with diet
A2: controlled with medication: *Insulin, glyburide, metformin

28

preterm labor

Labor before 37 weeks
RF: prior PTD, PPROM, multiple gestation, intrauterine infection, mullerian anomalies, smoking, substance abuse, BV (bac bag), low socioeconomic status
Testing: Tocometer (see if contracting), FHTs, Cervical exams, Fetal fibronectin

29

preterm labor: Interventions to improve neonatal outcome

-Between 24-34 weeks: corticosteroids
-less than 32 weeks: magnesium sulfate (prevent CP)
Antibiotics
Tocolysis (stop labor): Terbutaline, Nifedipine, Indomethacin (stops contractions only use for about 48 hrs, dec. fluid around baby)

Prevention: IM progesterone?

30

Cervical insufficiency

-Cervical dilation without contractions
-Short cervical length
-Treatment:
Cervical cerclage
Vaginal progesterone

31

oligohydramnios

Too little amniotic fluid (less than 0.5L)
Measured by Amniotic Fluid Index: less than 5, DVP (deep pouch): less than 2
Fetal complications:
POTTER sequence: Pulmonary hypoplasia, Oligohydramnios (trigger), Twisted face, Twisted skin, Extremity defects, Renal failure (in utero)
NRFS

Causes:
Placental insufficiency
Bilateral renal agenesis
Posterior urethral valves
PPROM

32

Polyhydramnios

Too much amniotic fluid (more than 1.5-2L)
By AFI: greater than 24, DVP more than 8
Causes:
Fetal malformations:
Esophageal/duodenal atresia (can't swallow it), Anencephaly
Maternal DM, Fetal anemia, Multiple gestation

Risk of: maternal respiratory issues, malpresentation, PTD/PPROM, cord prolapse, abruption, stretch of uterus, uterine atony (doesn't contract down like it should-->bleeding-->hemorrhage)

33

Oligo- or Polyhydramnios Treatment

Oligohydramnios:
Amnioinfusion
Hydration

Polyhydramnios:
Indomethacin
Amnioreduction

34

Bleeding: placental causes

Placental abruption
Placenta previa
Placenta accreta
Vasa previa

35

Bleeding: non-placental causes

Labor/PTL/CI
Infection
Disorder of lower genital tract
Cervical trauma
Systemic disease

36

placenta abruption

Premature separation of the placenta
RF: *HTN, *cocaine, multiparity, smoking, prior abruption, thrombophilias
Symptoms:
PAINFUL bleeding, frequent contractions
Non-reassuring fetal status
Severe hemorrhage
slide 41: too many contractions?

37

Placenta previa

Placenta covers internal cervical os:
-Placenta accreta: Placental tissue invades through the endometrium
-Placenta increta: invasion to myometrium
-Placenta percreta: invasion through uterine serosa ("higher percentage", may invade bladder)

RF: prior c-section**
Symptoms: PAINLESS vaginal bleeding
Delivery: C-section
Appropriate planning, can result in massive hemorrhage-->hysterectomy
(can only consider vaginal delivery with low lying

38

Uterine rupture

Uncommon
Prior uterine scar (0.3-1%)
C-section
Myomectomy
PAINFUL bleeding
Non-reassuring fetal heart tones
Management: immediate delivery

39

Vasa Previa

Portion of membranes cover the internal cervical os with fetal blood vessels:
-Velamentous umbilical cord
-Placental lobes with connection

40

Stillbirth/IUFD

Loss of pregnancy >20 weeks
Similar work up as recurrent abortion
Add syphilis testing, parvovirus B19 and maternal-fetal hemorrhage screen
Possible fetal autopsy
Delivery:
Induction of labor
Prior c-section not a contraindication
Increased surveillance in subsequent pregnancies

41

Peripartum

Mastitis
Chorioamnionitis
Endometritis

42

Mastitis

Staph aureus
more than 3 months after delivery
Engourged breast
Cellulitis
Fever/chills
Eval for abscess (esp with MRSA)

Tx: dicloxacillin or cephalosporin
Continue nursing
Abscess drainage

43

Uterine infections: Chorioamnionitis

Uterine infection diagnosed during pregnancy
Polymicrobial
RF: prolonged labor, c-section, internal monitors, mutliple exams, prolonged ROM, lower genital infection
Maternal sequelae: abnormal labor, hemorrhage
Fetal sequelae: sepsis, pneumonia, IVH, CP

44

Uterine infections: Endometritis

Uterine infection diagnosed after pregnancy

45

uterine infection dx and tx

dx:
Fever
One of the following:
Maternal tachycardia
Fetal tachycardia
Foul smelling lochia
Uterine tenderness
+/- amniocentesis
-screen at 35 wks for GBS
tx: Broad spectrum antibiotics: (during labor)
Ampicillin/Gentamycin
Ertapenem


46

Pre-Existing Medical Problems

Anemia
Antiphospholipid Antibody Syndrome
Thyroid disease
Diabetes Mellitus
Chronic Hypertension
Heart DiseaseAsthma
Seizure disorders

47

Antiphospholipid Antibody Syndrome

Arterial/venous thrombosis and adverse pregnancy outcomes + lab evidence of antiphospholipid antibodies

Treatment in pregnancy:
Heparin (LMWH) and low dose aspirin

48

APS

Diagnosis: Sydney crideria (Sapporo classification criteria)
Diagnosis = 1 clinical + 1 lab criteria
Clinical:
-1+ episode of venous, arterial, small vessel thrombosis
-Pregnancy morbidity:
Unexplained fetal death more than 10 wks gestation, 1+ PTD less than 34 wks 2/2 eclampsia, preeclampsia, placental insufficiency, 3+ fetal losses less than 10 wks gestation
-Lab: 2+ occasions, 12 wks apart: IgG or IgM anticardiolipin abs, Abs to beta2-glycoprotein I, Lupus anticoaculant activity

49

Hypothyroidism:

SAB, PTD, preeclampsia, placental abruption, impaired neuropyschological development
Treat with levothyroxine
Serial labs

50

Hyperthyroidism:

SAB, PTD, preeclampsia, maternal heart failure
Thyroid storm: life threatening
Propylthiouracil: hepatotoxicity, agranulocytosis
First trimester
Methimazole: congenital aplasia cutis, choanal/esophageal atresia
Second/third trimester
Beta blocker
NO radioiodine ablation

51

Pre-existing Diabetes Mellitus

SAB and IUFD
Fetal malformations:
Cardiac, skeletal and neural tube defects; caudal regression syndrome
Slow fetal growth
Inverse relationship with glucose control

52

chronic HTN

ddx from preeclampsia!
Superimposed preeclampsia: 20-50%

Antihypertensives when BP over 150/100 or end organ damage
*No ACE-I or ARB
Diuretics: don’t start in pregnancy, but may continue

53

asthma

Treat similarly in pregnancy
Pulmonary function tests
Beta 2 agonists
Inhaled corticosteroids
Systemic corticosteroids

**Minimize hypoxic episodes to fetus

54

seizure disorders

Discontinuation of meds if seizure free 2-5 years
Consider teratogenicity of medications: D/C valproic acid
-Newer antiepileptic drugs:Lamotrigine, Topiramate, Oxcarbazepine, Levetiracetam
-Folic acid

55

Infectious complications

UTI
GBS
Varicella
Tuberculosis
HIV/AIDS
Hepatitis B/C
Herpes Genitalis
Syphilis, Gonorrhea, Chlamydia

56

UTI of preg

Very common in pregnancy
Predisposition to urinary stasis
2-8% have asymptomatic bacteriuria  TREAT
Risk of PTD
20-40% develop pyelonephritis

57

how to tx UTI

Nitrofurantoin, ampicillin, cephalexin
No sulfonamides in 3rd trimester
Neonatal hyperilirubinemia
No flouroquinolones
Fetal carilage and bone defects
Always do test of cure

58

GBS

Carriage rate 10-30%
30% spontaneous clearing
10% recolonization

Neonatal sepsis:
20-30% mortality in premature infants (2-3% in term)
Mental retardation
Neurologic disability

59

GBS tx

Anyone with + vaginal/rectal culture
Anyone with + urine culture
Prior infant with invasive GBS disease
Unknown culture with
Elevated temperature
Ruptured membranes more than 18 hours
Preterm (less than 37 weeks)

60

VZV

-Congential VZV syndrome:
Skin lesions
Limb/digit abnormalities
Limb abnormalities: hypoplasia
Microcephaly
Ocular defects: cataracts, microphthalmos

-2nd, 3rd trimesters:
Protected by maternal IgG
Risk: maternal infection 5 days before – 2 days after delivery
-VZIG within 96 hrs of exposure (up to 10 days)

Maternal risk of pneumonia

61

TB

Latent disease: treatment postpartum
Active disease:
Isoniazid and ethambutol
Isoniazid and rifampin
Vitamin B6

Good prognosis if appropriately treated

62

HIV/AIDS

High neonatal transmission rate (66%) in the past
Now 2%

CD4 count, viral load
Continue current antiretroviral regimen
3 drug therapy regardless of viral load and CD4 count
Second trimester
*IV zidovudine before delivery when viral load greater than 400*
*Cesarean delivery if viral load more than 1000*

63

Hep B/C

Vertical transmission blocked by hep B IG and hep B vaccine
Repeat vaccine 1 month and 6 month

Hep C: 5-6% transmission rate
14% when also HIV+

64

Herpes Genitalis

Primary infection late in pregnancy
High risk of transmission
Acyclovir 400mg TID

Recurrent infection:
-Lower neonatal attack rate
-Asymptomatic shedding is common
-Cesarean if active lesion or prodromal symptoms
-Acyclovir prophylaxis at 36 weeks

-Neonatal infection: SEM, CNS, Disseminated disease

65

Herpes Genitalis

Neonatal infection
Skin, eye mouth
Central nervous system
Disseminated disease

66

Syphilis transmission

Abortion, IUFD, transplacental infection, congenital syphilis

67

early syphilis signs

Hepatomegaly, rhinitis, rash, nonimmune fetal hydrops, myocarditis, pneumonia, etc.

68

late syphilis signs

frontal bossing, saddle nose, hutchinson teeth, mulberry molars, saber shins, etc.

69

G/C

Gonorrhea:
Large joint arthritis, ophthalmia neonatorum (Ulceration, scarring, visual impairment)
Chlamydia:
inclusion conjunctivitis, pneumonia

70

Zika virus

-transmitted by mosquitos
-if pregnant: baby-->microencephaly, neurologic deficits
-may get late abortions