Firecracker - Complicated Pregnancies Flashcards
1
Q
What is the teratogenic risk of fluoroquinolones?
A
- Antibiotics that carry teratogenic risks include aminoglycosides, fluoruoquinolones, sulfonamides and tetracyclines.
- Aminoglycosides cause vestibulocochlear damage, skeletal abnormalities and renal defects
- Fluroquinolines cause abnormalities in cartilage development
- Sulfonamides cause kernicterus which is bile infiltration in the brain
- Tetracyclines cause:
- Skeletal abnormalities
- Limb abnormalities
- Teeth discolouration
2
Q
What are the fetal risks of cocaine use during pregnancy?
A
- Cocaine use during pregnancy carries the fetal risks of:
- Abruptio placentae
- Intrauterine growth restriction
- Facial abnormalities
- Delayed intellectual development
- Fetal demise
- Maternal risks of cocaine use during pregnancy include:
- Arrythmia
- Myocardial infarction
- Subarachnoid haemorrhage
- Seizures
- Stroke
3
Q
What are the causes of abruptio placentae?
A
- Abruptio placentae is a premature separation of the placenta caused by a retroplacental clot, which leads to significant maternal haemorrhage.
- Risk factors include:
- Hypertension
- Smoking
- Cocaine use
- Previous amputation
- Older mother
Maternal trauma, especially motor vehicle accidents, can lead to placental abruption as a result of deceleration forces.
4
Q
How can maternal gonorrhea/chlamydia infection be diagnosed during pregnancy?
A
- Gonorrhea/chlamydia infection during pregnancy carries the risk of spontaneous abortion, neonatal sepsis and neonatal conjunctivitis
- Maternal infection can be diagnosed with cervical culture or with enzyme immunoassays, such as nucleic acid amplification tests (NAAT)
5
Q
What is the teratogenic risk of sulfonamides?
A
Sulfonamides cause kernicterus, which is bile infiltration of the brain.
6
Q
When is Rho(D) given in cases of placenta previa?
A
- In cases of minor bleeding, patients with placenta previa can be treated with bed rest.
- However, for active bleeding they require inpatient admission with maternal and fetal monitoring.
- Rho(D) immune globulin is given to any Rh-negative mothers that have bleeding in the third trimester
- Tocolytic agents (agents used to slow contractions) are used to delay delivery in cases of a preterm fetus with immature lungs, if mild maternal bleeding is present
- Patients with placenta previa should deliver by cesarean section.
7
Q
In order of trimester what are the causes of oligohydramnios?
A
- Oligohydramnios is a deficiency of amniotic fluid in the gestational sac (amniotic fluid index <5cm)
- It is associated with:
- Intrauterine growth restriction
- Fetal stress
- Fetal renal abnormalities, such as in potter syndrome
- Poor fetal health
- FIRST TRIMESTER:
- Oligohydramnios frequently results in spontaneous abortion
- SECOND TRIMESTER
- Caused by fetal abnormalities or maternal causes such as:
- Pre-eclampsia
- Renal disease
- Hypertension
- Collagen vascular disease
- Placental thrombosis
- Caused by fetal abnormalities or maternal causes such as:
- THIRD TRIMESTER associated with:
- Premature rupture of the membranes
- Pre-eclampsia
- Abruptio placentae
- Idiopathic causes
8
Q
Outline a brief treatment plan for mothers with pre-eclampsia?
A
- The definitive treatment of preeclampsia and eclampsia is delivery of the baby
- If the symptoms of preeclampsia are mild and the mother is far from term recommend:
- Restrcited activity
- Frequently maternal exams for worsening symptoms
- Growth scans, followed by maternal fetal medicine
- Fetal non-stress tests twice a week
- If symptoms of pre-eclampsia are severe and the mother is far from term:
- Admit the mother and closely monitor
- Maintain blood pressure below 155/105 with diastolic above 90 with antihypertensives like labetalol (do not use ACE-inhibitors anigotensin receptor blockers because of teratogenic effects
- Intravenous magnesium sulfate for seizure prophylaxis and neuroprotection
- Deliver as soon as the fetus is considered viable
- Antihypertensive medication and magnesium sulfate should be continued immediately postpartum while continuing observation for symptoms and lab abnormalities.
- Blood pressure is expected to return to normal within 6 weeks of postpartum
- If mother has pre-existing hypertension, labetalol or methyldopa should be used initially followed by a long acting calcium channel blocker (nifedipine and amlodipine) as a second agent if necessary.
9
Q
What anticoagulants carry teratogenic risks?
A
- Anticoagulants that carry teratogenic risks include heparin and warfarin.
- heparin although safer than warfarin causes:
- Prematurity
- Intrauterine fetal demise
- warfarin causes:
- Spontaneous abortion
- IUGR
- CNS and facial abnormalities
- Dandy-walker malformation
- Mental retardation
- heparin although safer than warfarin causes:
10
Q
What are the teratogenic risks of tetracyclines?
A
Tetracyclines cause:
Skeletal abnormalities
Limb abnormalities
Teeth discoloration
11
Q
What tests should be performed on a pregnant woman to rule out pre-existing complications of hypertension?
A
- Chronic hypertension is defined as hypertension that existed prior to conception, developed before 20 weeks GA or persists 6 weeks postpartum
- A baseline ECG and 24 hour urine output should be obtained to rule out pre-existing complications of hypertension including heart and renal disease
- In woman already on antihypertensives or with blood pressure persistently elevated above 140/90, labetalol and nifedipine are the drugs of choice
- 1/3 of women with chronic hypertension will develop superimposed pre-eclampsia.
12
Q
What steps can be taken to improve amniotic fluid volume?
A
- Oligohydramnios is treated with expectant management if the fetus responds well to tests of well being
- Induced delivery may be required if the fetus is viable and the risk of fetal demise is significant
- Hydration and best rest may improve amniotic fluid volume.
13
Q
How is polydramnios diagnosed?
A
- The diagnosis of polydramnios is made with sonographic visualization of increased amniotic fluid volume
- The amniotic fluid index will be greater than 25 cm or will show one pocket of at least 8 cm
- The amniotic fluid index is an estimate of amniotic fluid volume.
- The uterus is divided into 4 imaginary quadrants
- The deepest part of these pockets are measured with ultrasound and added up to obtain the amniotic fluid index.
14
Q
What are the drugs of choice for management of pregnant women with chronic hypertension that are already on antihypertensives or with blood pressure persistently above 140/90?
A
- In women already on antihypertensives or with blood pressures persistently elevated above 140/90, labetalol and nifedipiine are the drugs of choice.
15
Q
- Which antihypertensive is teratogenic?
A
- ACE-inhibitors cause renal abnormalities and decreased skull ossification
16
Q
What are some complications of placetnta previa?
A
- Complications from placenta previa include:
- Haemorrhage
- Premature rupture of membranes (PROM)
- IUGR
- Increased risk of hysterectomy with delivery because of catastrophic bleeding
- 1% of causes result in maternal death
17
Q
What are the teratogenic risks of warfarin?
A
- Anticoagulants that carry teratogenic risks include heparin and warfarin
- Warfarin causes:
- Spontaneous abortion
- IUGR
- CNS and facial abnormalities
- Dandy-walker malformation
- Mental retardation
- Warfarin causes:
18
Q
What four major classes of antibiotics carry teratogenic risks?
A
- Aminoglycosides cause vestibulocochlear nerve damage, skeletal abnormalities, and renal defects.
- Fluoroquinolones cause abnormalities in cartilage development.
- Sulfonamides cause kernicterus, which is bile infiltration of the brain.
- Tetracyclines cause:
- Skeletal abnormalities
- Limb abnormalities
- Teeth discoloration
19
Q
What are the maternal risks of stimulant use during pregnancy?
A
Malnutrition from lack of appetite
Arrhythmia
Withdrawal depression
Hypertension
20
Q
Describe rubella infections and how they can be diagnosed and prevented.
A
Rubella infections during pregnancy may result in congenital rubella syndrome, which may include:
Intrauterine growth restriction
Sensorineural deafness
Cardiovascular abnormalities (notably patent ductus arteriosus)
Vision abnormalities (notably cataracts and retinopathy)
CNS abnormalities
Hepatitis
In addition to congenital rubella syndrome, an infection during pregnancy may have the following effects on the fetus/neonate:
Increased risk of spontaneous abortion
A “blueberry muffin” rash due to extramedullary hematopoiesis
Diagnostic tests helpful in preventing congenital rubella syndrome is early prenatal IgG screening to detect immunity to rubella from prior infection or vaccination.
The mother should be immunized 1 month prior to attempting to become pregnant (in order to clear the virus) because there is no proven benefit from rubella immune globulin and there is no treatment if an infection develops during pregnancy. Note: non-immune pregnant patients should not be vaccinated because it is a live-attenuated virus.
21
Q
How can intrauterine fetal demise be managed if the fetus is less than 24 weeks’ gestation?
A
Intrauterine fetal demise is managed by inducing labor and delivery to expel the nonviable fetus. Note: it is not an indication for a cesarean section.
Oxytocin, misoprostol (PGE1 analogue), and PGE2 can be used to induce labor and delivery.
If the fetus is less than 24 weeks’ gestation, dilation and evacuation may be performed to remove the fetus.
22
Q
How is polyhydramnios treated after 32 weeks’ gestation?
A
Treatment of polyhydramnios is only administered if the mother is uncomfortable or if there is a threat of preterm labor.
Pregnancies at <32 weeks’ gestation can be treated with amnioreduction and indomethacin with tapered dosing and weekly amniotic fluid volume measurement.
Pregnancies at >32 weeks’ gestation are only treated with amnioreduction. Indomethacin should be avoided after 32 weeks because of the risk of premature closure of the ductus arteriosus.
23
Q
Describe the different types of multiple gestation.
A
- Multiple gestation pregnancy describes any pregnancy in which more than one fetus develops simultaneously
- Dizygotic twins - ‘fraternal twins’ arise from two zygotes by different sperm and are dichorionic (2 placentas) and diamnionic (2 amniotic sacs)
- Monozygotic twins aka identical twins arise form one zygote and have several presentations
- Dichorionic diamniotic monozygotic twins occur if the clevage of the zygote occurs between 4 and 8 days of fertilization
- Monochorionic, monoamniotic monozygotic twins occur if the cleavage of the zygote occurs between 9-12 days of fertilization
- Conjoined monozygotic twins occur if the cleavage of the zygote occurs after 12 days of fertilization
- an increased incidence of multiple gestation pregnancies are seen in women with a family history and those who have received reproductive assistance with fertility drugs (such as clomiphene citrate).
- Fertility drugs may lead to the growth of more ovarian follices and multiple ovulations and is responsible in part for the increasing number of twin pregnancies.
24
Q
What are some causes of severe polyhydramnios?
A
Polyhydramnios is an excess of amniotic fluid in the gestational sac (amniotic fluid index >25 cm) and is associated with an increased risk of various adverse pregnancy outcomes.
The most common cause of severe polyhydramnios are fetal anomalies, which can include:
- anything that decreases the amount of amniotic fluid that the fetus swallows (GI obstruction, neuromuscular disorders, chromosomal abnormalities)
- Fetal anemia
- Maternal diabetes
- Multiple gestation, which can result in twin-twin transfusion syndrome
25
What medications should be continued in patients with eclampsia for 48 hours after delivery and why?
Eclampsia should be managed with magnesium sulfate and intravenous diazepam to control seizures.
The patient should also be stabilized with sufficient oxygen and blood pressure control using labetalol or hydralazine.
Magnesium and antihypertensive medications should be continued for 48 hours after delivery because 25% of seizures occur within 24 hours after delivery.
26
What should not be performed if abruptio placentae is suspected?
Ultrasound inconsistently shows separation of the placenta from the uterus in abruptio placentae (i.e. it does not diagnose it). The diagnosis is clinical.
DO NOT perform pelvic exam.
27
What physical exam finding is suspicious of polyhydramnios?
A physical exam finding of a uterine size that is large for the gestational age is suspicious for polyhydramnios.
28
What is the general management of ectopic pregnancy?
Management:
If the ectopic pregnancy has ruptured, the first goal is to stabilize the patient with IV fluids, blood and pressors as needed before taking her to the operating room for exploratory laparotomy to stop bleeding and resect ectopic pregnancy.
If the woman has an unruptured ectopic and there is no fetal heartbeat, methotrexate is the treatment of choice.
29
What type of delivery is indicated in placenta previa?
Patients with placenta previa should deliver by cesarean section.
30
What two drugs of historical interest carry teratogenic risks?
Drugs of historical interest that carry teratogenic risks include diethylstilbestrol (DES) and thalidomide.
Thalidomide is notorious for causing limb abnormalities.
Diethylstilbestrol (DES) causes vaginal and cervical cancer later in life.
31
What is intrauterine fetal demise?
Intrauterine fetal demise is defined as fetal death after 20 weeks’ gestation and before the onset of labor. Contrast this with miscarriage which is death before 20 weeks.
Associated risk factors include:
Placental or cord abnormalities
Infection
Fetal congenital abnormalities
Maternal hypertension
Poor maternal health
32
What are the teratogenic risks of diazepam?
Sedative-hypnotic drugs that carry teratogenic risks include diazepam and phenobarbital.
Diazepam causes:
Cleft palate
Renal defects
Secondary neoplasms
Phenobarbital causes neonatal withdrawal.
33
What complications are associated with preeclampsia?
Complications of preeclampsia and eclampsia include:
Eclampsia
Stroke
Maternal organ dysfunction
Risk of maternal death
Intrauterine growth restriction, oligohydramnios, preterm delivery, or fetal death
HELLP syndrome (discussed separately)
Risk of preeclampsia and eclampsia in the following pregnancy
34
What is a major fetal risk of ethanol consumption during pregnancy?
Ethanol use during pregnancy carries the risk of fetal alcohol syndrome, which includes:
Mental retardation
Intrauterine growth restriction
Neuropathy
Facial Abnormalities
In addition to fetal alcohol syndrome, fetal effects of maternal alcohol use include spontaneous abortion and intrauterine fetal demise.
Maternal risks of alcohol consumption during pregnancy are minimal.
35
hat must be obtained before performing maternal HIV screening?
In patients with HIV, there is a 5% risk of in-utero infection, but there is a rapid progressionof HIV to AIDS.
Consent is required, but early prenatal blood screening for HIV should be performed.
The use of Zidovudine (AZT) significantly reduces the risk of vertical HIV transmission to the fetus. Note: mothers should continue their antiviral regimens, but sources say the use of efavirenz, didanosine, stavudine, or nevirapine should be avoided.
36
What are the most significant risk factors for an ectopic pregnancy?
Ectopic Pregnancy: Pregnancy occurring outside the uterus. Ectopic embryos will ultimately grow or invade underlying tissues, most commonly causing peritoneal rupture, leading to hemoperitoneum and acute abdomen.
Most often occurs in the ampulla of the fallopian tube. It can also occur in the ovary, peritoneal cavity, and cervix.
Risk factors:
Most common cause: Scarring from chronic salpingitis or PID
Other causes include: History of prior ectopic pregnancy and prior tubal surgery.
Heterotopic pregnancy: A multiple gestation with at least one intrauterine pregnancy and one ectopic pregnancy. The risk of this is small but increases with IVF if multiple embryos were used.
37
How are mothers with severe preeclampsia that are far from term managed?
If symptoms of preeclampsia are severe and the mother is farm from term:
Admit the mother and closely monitor
Maintain blood pressure below 155/105 with diastolic above 90 with antihypertensives like labetalol (do not use ACE-Inhibitors or angiotensin receptor blockers because of teratogenic effects)
Intravenous magnesium sulfate for seizure prophylaxis and neuroprotection
Deliver as soon as the fetus is considered viable
38
What are the teratogenic risks of valproic acid?
Valproic acid causes:
Neural tube defects in 1% of pregnancies
Facial abnormalities
Cardiovascular abnormalities
Skeletal abnormalities
39
How is oligohydramnios diagnosed?
The diagnosis of oligohydramnios is made with ultrasound, which will show amniotic fluid volume \<5 cm with no pockets at least 2 cm in size.
40
What is a heterotopic pregnancy?
Heterotopic pregnancy: A multiple gestation with at least one intrauterine pregnancy and one ectopic pregnancy. The risk of this is small but increases with IVF if multiple embryos were used.
41
What etiologies can cause oligohydramnios?
It is associated with:
Intrauterine growth restriction
Fetal stress
Fetal renal abnormalities, such as in potter syndrome
Poor fetal health
42
How can transmission of HSV from mother to neonate be avoided?
HSV infection can be confirmed with viral culture or enzyme immunoassays. Mothers with active HSV lesions or a primary outbreak should deliver the baby via cesarean section to avoid transmission.
43
Describe HSV infection.
Herpes simplex virus (HSV) infection carries a high risk of neonatal death in addition to the following fetal/neonatal effects:
Intrauterine growth restriction
Microcephaly
Spontaneous abortion
Increased risk of prematurity
Mental retardation
Rather than transplacentally, HSV is more commonly transmitted as the neonate passes through the birth canal.
HSV infection can be confirmed with viral culture or enzyme immunoassays. Mothers with active HSV lesions or a primary outbreak should deliver the baby via cesarean section to avoid transmission.
Acyclovir may be beneficial in the neonate if transmission has occurred.
44
What are the teratogenic risks of heparin?
Heparin, although safer than warfarin, causes:
Prematurity
Intrauterine fetal demise
45
What are the maternal risks of opioid use during pregnancy?
Opioid use during pregnancy carries the fetal risks of:
Narcotic withdrawal
Prematurity
Intrauterine growth restriction
Meconium aspiration
Neonatal infections
Maternal risks of opioid use in pregnancy include:
Infection
Narcotic withdrawal
Premature rupture of membranes
46
What is an ectopic pregnancy?
Ectopic Pregnancy: Pregnancy occurring outside the uterus. Ectopic embryos will ultimately grow or invade underlying tissues, most commonly causing peritoneal rupture, leading to hemoperitoneum and acute abdomen.
47
What is the fetal and maternal risks of hallucinogen use during pregnancy?
Hallucinogen use during pregnancy carries the fetal risk of possible developmental delays. Maternal risks of hallucinogen use includes personal endangerment, which means putting herself in a position that causes a substantial risk of serious injury or death due to hallucinations.
48
Describe CMV infection.
CMV is the most common fetal infection. Signs and symptoms of congenital CMV that can be permanent and devastating can be remembered with the mnemonic “MR DICS”:
Microcephaly vs. the macrocephaly secondary to hydrocephalus in congenital toxoplasmosis
Mental Retardation
Deafness (sensorineural), which is also seen in congenital rubella
Intracranial Calcifications (periventricular) vs. the intracranial calcifications distributed throughout the cortex and basal ganglia in congential toxoplasmosis
Seizures (likely due to the intracranial calcifications)
Congenital CMV may also present with the following signs and symptoms that may be present at birth but resolve within the first few weeks of life:
```
Thrombocytopenic purpura (“blueberry muffin” rash), which is similar to the rash of congenital rubella
Hepatosplenomegaly and jaundice
```
Maternal CMV infections present with a mononucleosis-like illness (fever, pharyngitis, lymphadenopathy), similar to that of Toxoplasma gondii infection. Congenital CMV can be screened using neonatal IgM levels, but it should be confirmed with PCR of viral DNA in the first few weeks of life of the neonate.
Good hygiene, such as hand-washing, can reduce the risk of CMV transmission, but there is no treatment if an infection occurs during pregnancy. In the neonate, ganciclovir and valganciclovir can reduce the effects of the disease.
49
What complications are associated with polyhydramnios?
Complications associated with polyhydramnios include:
Maternal respiratory compromise
Preterm labor and premature rupture of membranes
Fetal malpresentation
Umbilical cord prolapse
Postpartum uterine atony
50
When should a mother be tested for listeriosis?
Listeria monocytogenes infection during pregnancy (listeriosis) can occur with consumption of soft cheeses/unpasteurized milk, which can be contaminated with Listeria monocytogenes. This can lead to the fetal/neonatal effects of:
Amnionitis
Neonatal sepsis and meningitis
Spontaneous abortion
Blood cultures should be taken and tested for Listeria monocytogenes in any mother that is febrile during pregnancy.
Mothers should avoid soft cheese/unpasteurized milk during pregnancy, but an infection can be treated with ampicillin or penicillin G.
51
What is gestational hypertension?
Gestational Hypertension is defined as the onset of BPs over 140/90 beyond 20 weeks GA that returns to baseline after delivery. Compare this to preeclampsia, in which hypertension also develops after 20 weeks gestational age, but is also accompanied by evidence of end-organ dysfunction such as proteinuria or elevated liver enzymes. In gestational hypertension, there are no accompanying symptoms of end-organ dysfunction.
These patients can be managed expectantly, but are at an increased risk for developing preeclampsia.
52
What complications can occur if the developing fetuses survive twin-twin transfusion syndrome?
Twin-twin transfusion syndrome (TTTS) is one of the most serious complications of monochorionic multiple gestation pregnancies. It is the result of disproportionate blood supply between the developing fetuses.
The donor twin has decreased blood volume, is small, and has low urine output (due to hypovolemia), resulting in oligohydramnios.
The recipient twin has increased blood volume, becomes occasionally hydropic, and has increased urine output resulting in polyhydramnios.
The mortality rate is high and if the fetuses survive, they are at a higher risk for cardiac, neurological, and developmental disorders.
53
What can be done to prevent a congenital hepatitis B infection?
Hepatitis B infection carries an increased risk of neonatal death if an acute disease develops. Other fetal effects include intrauterine growth restriction, and an increased risk of prematurity.
Prenatal surface antigen screening is used to diagnose an infection. (Note: Testing is for surface antigen, not surface antibody, which is induced by vaccination or prior infection.)
Maternal vaccination should be performed prior to pregnancy to prevent a congenital hepatitis B infection.
If congenital hepatitis B infection has occurred, the neonate should receive both the hepatitis B vaccine and immune-globulin shortly after birth. More information can be found in the pediatrics topic
54
What fetal/neonatal risks are associated with listeriosis during pregnancy?
Listeria monocytogenes infection during pregnancy (listeriosis) can occur with consumption of soft cheeses/unpasteurized milk, which can be contaminated with Listeria monocytogenes. This can lead to the fetal/neonatal effects of:
Amnionitis
Neonatal sepsis and meningitis
Spontaneous abortion
55
How is intrauterine fetal demise managed?
Intrauterine fetal demise is managed by inducing labor and delivery to expel the nonviable fetus. Note: it is not an indication for a cesarean section.
Oxytocin, misoprostol (PGE1 analogue), and PGE2 can be used to induce labor and delivery.
If the fetus is less than 24 weeks’ gestation, dilation and evacuation may be performed to remove the fetus.
56
What complications are associated with HELLP syndrome?
Preeclampsia and eclampsia can be associated with HELLP syndrome (Hemolysis, Elevated Liver function tests, Low Platelets).
HELLP may present with nausea, vomiting and right upper quadrant pain secondary to distention of the liver capsule.
Untreated, HELLP syndrome is fatal. The fetus must be delivered, regardless of viability, in order to prevent maternal death. Maternal corticosteroids may help with liver function and thrombocytopenia.
Complications include:
Abruptio placentae
Encephalopathy
Renal insufficiency
DIC
57
What is the amniotic fluid index and how is it determined?
The diagnosis of polyhydramnios is made with sonographic visualization of increased amniotic fluid volume. The amniotic fluid index will be \>25cm or will show one pocket of at least 8 cm.
The amniotic fluid index is an estimate of amniotic fluid volume. The uterus is divided into 4 imaginary quadrants. The deepest part of these pockets are measured with ultrasound and added up to obtain the amniotic fluid index.
58
What are the fetal/neonatal effects of a congenital herpes simplex infection?
Herpes simplex virus (HSV) infection carries a high risk of neonatal death in addition to the following fetal/neonatal effects:
Intrauterine growth restriction
Microcephaly
Spontaneous abortion
Increased risk of prematurity
Mental retardation
59
What are the teratogenic risks of carbamazepine?
Carbamazepine causes:
Facial abnormalities
Intrauterine growth restriction
Mental retardation
Cardiovascular abnormalities
Neural tube defects
60
What are the teratogenic risks of phenytoin
Phenytoin causes:
Facial abnormalities
Intrauterine growth restrictions
Mental retardation
61
What are the teratogenic risks of oral contraceptive pills?
OCPs cause spontaneous abortion and ectopic pregnancy.
62
Describe and outline pre-eclampsia
Preeclampsia is defined clinically as hypertension which develops after 20 weeks' gestation, with evidence of end-organ dysfunction.
Specifically, the patient must have BP \>140/90 on at least two occasions at least 4 hours apart, as well as at least one of the following:
Proteinuria
Renal insufficiency
Elevated liver enzymes
Thrombocytopenia
Pulmonary edema
Visual disturbance
Note that the American College of Obstetricians and Gynecologists no longer requires proteinuria to diagnose pre-eclampsia if there is other evidence of end-organ dysfunction as described above. For example, hypertension that develops after 20 weeks plus thrombocytopenia is diagnostic of pre-eclampsia. The "classic triad" of hypertension, edema and proteinuria is no longer required.
Preeclampsia develops in up to 5% of pregnancies.
Risk factors associated with preeclampsia include:
Pre-existing conditions (hypertension, diabetes mellitus, obesity, renal disease)
Genetics (African American ancestry)
Obstetric history (nulliparity, previous history of preeclampsia, multiple gestation)
Advanced maternal age
63
What are tocolytics used for in placenta previa?
Tocolytics (agents used to slow contractions) are used to delay delivery in cases of a preterm fetus with immature lungs, if mild maternal bleeding is present.
64
What are some risk factors for abruptio placentae?
Risk factors include:
Hypertension
Smoking
Cocaine use
Previous abruption
Older mother
65
What is the classic clinical presentation of ectopic pregnancy?
Clinical presentation
Sudden lower abdominal pain and/or vomiting (often mistaken for appendicitis)
Adnexal tenderness
Uterine bleeding \> 6 weeks beyond LMP
Urine pregnancy test MUST be ordered, however, + result does NOT exclude appendici
66
Describe varicella infection during pregnancy and its treatment?
Varicella infection during pregnancy carries a high risk of neonatal death if the birth occurs during an active infection.
Other fetal/neonatal effects associated with congenital varicella include:
Encephalitis
Pneumonia
CNS abnormalities
Blindness
Prematurity
Limb abnormalities
Diagnosis of a cogenital infection can be made with a maternal IgG screening if there is no known history of disease and can be confirmed with neonatal IgM and IgG titers.
If the mother is infected during pregnancy, varicella immune-globulin should be administered within 96 hours of exposure and to the neonate if born during an active infection. Note: the varicella vaccine is contraindicated during pregnancy as it uses a live-attenuated virus.
67
What are some risk factors for the development of placenta previa?
Risk factors for placenta previa include:
Prior placenta previa
Prior cesarean section
Multiparity
Advanced maternal age
Smoking
Multiple gestations
68
Describe rubeola infection during pregnancy and its management?
Rubeola (measles) infection during pregnancy carries a high risk of neonatal death in addition to:
Increased risk of prematurity
Intrauterine growth restriction
Spontaneous abortion
A clinical diagnosis of rubeola in the mother can be confirmed by measuring serum IgM and IgG after the development of the rash associated with the infection.
Like with rubella, the mother should be immunized for rubeola 1 month prior to becoming pregnant. Note: the rubeola vaccine is a live-attenuated vaccine and is contraindicated to administer during pregnancy.
Unlike rubella, rubeola (measles) immune globulin is helpful and may be given to the mother if an infection develops during pregnancy.
69
What is ultrasound used for in placenta previa?
Ultrasound is used to determine the location of the placenta in placenta previa.
70
How should maternal HIV be managed in order to reduce the risk of vertical transmission?
The use of Zidovudine (AZT) significantly reduces the risk of vertical HIV transmission to the fetus. Note: mothers should continue their antiviral regimens, but sources say the use of efavirenz, didanosine, stavudine, or nevirapine should be avoided.
71
How is maternal syphilis diagnosed during pregnancy?
A congenital syphilis infection carries a 25% mortality rate in addition to the following fetal/neonatal effects:
Hepatomegaly in almost all infants, which may include splenomegaly
Rhinitis, which usually develops during the first week of life
Cutaneous lesions, appearing 1-2 weeks after rhinitis
Chorioretinitis or uveitis
Osteodystrophy, commonly affecting the tibia (“saber shins”), femur, and humerus
Neonatal anemia
Maternal syphilis can be diagnosed with early prenatal rapid plasma reagin (RPR) or venereal drug research laboratory (VDRL) screening followed by a confirmation with FTA-ABS.
Maternal/congenital syphilis can be treated with maternal or neonatal penicillin.
72
How does placenta previa present?
Placenta previa presents as painless vaginal bleeding in the third trimester (most often the 30th week). Note: abruptio placentae presents as painful bleeding in the third trimester.
73
How is maternal parvovirus B19 infection diagnosed?
Parvovirus B19 infection during pregnancy carries the risk of causing decreased RBC production, hemolytic anemia, and hydrops fetalis in the neonate.
Maternal parvovirus B19 infection can be confirmed with IgM antibody screening or PCR of viral DNA.
Management of maternal parvovirus B19 infections should consist of fetal hemoglobin monitoring by percutaneous umbilical cord blood sampling and intrauterine transfusion in cases of severe anemia.
74
What symptoms are associated with HELLP syndrome?
Preeclampsia and eclampsia can be associated with HELLP syndrome (Hemolysis, Elevated Liver function tests, Low Platelets).
HELLP may present with nausea, vomiting and right upper quadrant pain secondary to distention of the liver capsule.
Untreated, HELLP syndrome is fatal. The fetus must be delivered, regardless of viability, in order to prevent maternal death. Maternal corticosteroids may help with liver function and thrombocytopenia.
Complications include:
Abruptio placentae
Encephalopathy
Renal insufficiency
DIC
75
How should a multiple gestation pregnancy be managed initially?
Multiple gestation pregnancies should be followed closely starting at 24-weeks’ gestation.
Beginning at 36 weeks’ gestation, activity should be restricted, fetal growth should be assessed frequently with ultrasound, and weekly nonstress tests should be performed.
Vaginal delivery is possible if both twins are in the vertex position, otherwise cesarean section is indicated.
76
How are pregnant women with gestational hypertension managed?
Gestational Hypertension is defined as the onset of BPs over 140/90 beyond 20 weeks GA that returns to baseline after delivery. Compare this to preeclampsia, in which hypertension also develops after 20 weeks gestational age, but is also accompanied by evidence of end-organ dysfunction such as proteinuria or elevated liver enzymes. In gestational hypertension, there are no accompanying symptoms of end-organ dysfunction.
These patients can be managed expectantly, but are at an increased risk for developing preeclampsia.
77
What risk factors are associated with intrauterine fetal demise?
Intrauterine fetal demise is defined as fetal death after 20 weeks’ gestation and before the onset of labor. Contrast this with miscarriage which is death before 20 weeks.
Associated risk factors include:
Placental or cord abnormalities
Infection
Fetal congenital abnormalities
Maternal hypertension
Poor maternal health
78
How does placental abruption present?
Placental abruption presents with painful uterine bleeding and tetanic contractions in the third trimester. Note painless bleeding in the third trimester is associated with placenta previa.
Additional symptoms of abruptio placentae include:
Abdominal and back pain
Pelvic and abdominal tenderness
Hypotension if there is severe hemorrhage
79
How are serial hCG levels used to screen for ectopic pregnancy?
Serial hCG is used to screen for suspected ectopic pregnancy:
hCG levels generally rise at a slower rate than a normal pregnancy.
Because of this, serum hCG levels can be compared to the normal if ectopic pregnancy is suspected.
Inappropriately low hCG levels → likely ectopic
Note: Inappropriately high hCG levels → molar pregnancy
Diagnosis confirmed with ultrasound → lack of intrauterine pregnancy
The "ring of fire" is the classic finding on ultrasound, and describes the increased vascular flow to the adnexa when color Doppler is applied.
80
What physical exam finding is suspicious for oligohydramnios?
A physical exam finding of a fundal height that is small for gestational age is suspicious of oligohydramnios, but it can also be asymptomatic. Remember that a uterus that is small for gestational age could also indicate intrauterine growth restriction (IUGR) or intrauterine fetal demise (IUFD)!
81
What complications are associated with oligohydramnios?
Complications associated with oligohydramnios include:
Spontaneous abortion
Intrauterine fetal demise
Developmental abnormalities due to fetal compression (i.e. limb, facial, lung, and abdominal abnormalities)
82
What are the teratogenic risks of phenobarbital?
Sedative-hypnotic drugs that carry teratogenic risks include diazepam and phenobarbital.
Diazepam causes:
Cleft palate
Renal defects
Secondary neoplasms
Phenobarbital causes neonatal withdrawal.
83
What maternal complications are associated with multiple gestation pregnancies?
Maternal complications associated with multiple gestation pregnancies include:
Hypertension
Diabetes mellitus
Preeclampsia
Preterm Labor
Fetal complications associated with multiple gestation pregnancies include:
Malpresentation
Placenta previa, abruptio placentae, and premature rupture of membranes
Intrauterine growth restriction
Birth trauma
Respiratory distress syndrome
Twin-twin transfusion syndrome
84
How are maternal and congenital syphilis treated?
A congenital syphilis infection carries a 25% mortality rate in addition to the following fetal/neonatal effects:
Hepatomegaly in almost all infants, which may include splenomegaly
Rhinitis, which usually develops during the first week of life
Cutaneous lesions, appearing 1-2 weeks after rhinitis
Chorioretinitis or uveitis
Osteodystrophy, commonly affecting the tibia (“saber shins”), femur, and humerus
Neonatal anemia
Maternal syphilis can be diagnosed with early prenatal rapid plasma reagin (RPR) or venereal drug research laboratory (VDRL) screening followed by a confirmation with FTA-ABS.
Maternal/congenital syphilis can be treated with maternal or neonatal penicillin.
85
How should eclampsia be managed?
Eclampsia should be managed with magnesium sulfate and intravenous diazepam to control seizures.
The patient should also be stabilized with sufficient oxygen and blood pressure control using labetalol or hydralazine.
Magnesium and antihypertensive medications should be continued for 48 hours after delivery because 25% of seizures occur within 24 hours after delivery.
86
What are the common complications of ectopic pregnancy?
Complications
Hypovolemic shock from intraperitoneal bleed (most common cause of hematosalpinx)
Fetus almost NEVER survives
87
How are multiple gestation pregnancies diagnosed?
The diagnosis is made with ultrasound, which will show 2 or more gestational sacs.
88
What are the neonatal effects of a maternal Group B Strep infection during pregnancy?
Group B streptococcus (GBS) colonizes 30% of women, so there is a significant risk of neonatal transmission, which can cause:
Respiratory distress and/or pneumonia if early onset infection (more common) and occurs within hours to days
Meningitis and/or sepsis if late onset infection, usually 7 or more days after birth.
Women are screened for GBS after week 34 with a vaginal/rectal swab that is then screened for antigen.
Neonatal GBS can be treated with penicillin or clindamycin during labor or in infected neonates. Note: If the mother is not treated, 1/500 infants will develop an early or late onset infection or sepsis.
89
How is polyhydramnios treated prior to 32 weeks’ gestation?
Pregnancies at \<32 weeks’ gestation can be treated with amnioreduction and indomethacin with tapered dosing and weekly amniotic fluid volume measurement.
90
What are the fetal risks of stimulant use during pregnancy?
Stimulant use (such as amphetamines) during pregnancy carries the fetal risks of:
Congenital heart defects
Intrauterine growth restriction
Cleft palate
91
What is eclampsia?
Eclampsia is defined similarly to preeclampsia, but with the addition of grand mal seizures.
There is an increased incidence in patients with preexisting diabetes mellitus, hypertension, chronic renal disease, and autoimmune disorders.
The etiology of preeclampsia and eclampsia involves placental ischemia secondary to lack of trophoblastic invasion of the spiral arteries in the myometrium.
92
What symptoms are associated with intrauterine fetal demise?
Symptoms of intrauterine fetal demise include:
Uterus size inconsistent with gestational age
No fetal movement
No fetal heart tones
93
What are some potential complications of abruptio placentae?
Complications of abruptio placentae include:
```
Disseminated intravascular coagulation
Severe hemorrhage (increases risk of maternal death)
Fetal demise in 20% of cases
Increased risk of future abruption
```
94
What is the definitive treatment of preeclampsia and eclampsia?
The definitive treatment of preeclampsia and eclampsia is delivery of the baby.
If the symptoms of preeclampsia are mild and the mother is far from term, recommend:
Restricted activity
Frequent maternal exams for worsening symptoms
Growth scans, followed by maternal fetal medicine
Fetal non-stress tests twice a week
If symptoms of preeclampsia are severe and the mother is farm from term:
Admit the mother and closely monitor
Maintain blood pressure below 155/105 with diastolic above 90 with antihypertensives like labetalol (do not use ACE-Inhibitors or angiotensin receptor blockers because of teratogenic effects)
Intravenous magnesium sulfate for seizure prophylaxis and neuroprotection
Deliver as soon as the fetus is considered viable
Antihypertensive medication and magnesium sulfate should be continued immediately postpartum while continuing observation for symptoms and lab abnormalities. Blood pressure is expected to return to normal within 6 weeks postpartum.
If the mother has preexisting hypertension, labetalol or methyldopa should be used initially followed by a long-acting calcium channel blocker (nifedipine and amlodipine) as a second agent if necessary.
95
What is the teratogenic risk of lithium?
Lithium causes Ebstein’s anomaly, which is atrialization of the right ventricle (the tricuspid valve is displaced towards the right ventricle). Note that carbamazepine and valproic acid, also indicated for bipolar disorder, are also teratogenic and are often considered more dangerous than lithium, particularly beyond the first trimester.
96
What are the three different types of placenta previa?
Placenta previa is an improper plantation of the placenta near the cervical os, which is frequently associated with vaginal bleeding.
Different types of placenta previa are based on the location of placental implantation, including:
Low implantation - the placenta is in the lower uterus, but does not cover cervical os until dilation occurs.
Partial placenta previa - the placenta partially covers the cervical os.
Complete placenta previa - the placenta completely covers the cervical os.
97
What are the fetal risks of opioid use during pregnancy?
Opioid use during pregnancy carries the fetal risks of:
Narcotic withdrawal
Prematurity
Intrauterine growth restriction
Meconium aspiration
Neonatal infections
98
What are the maternal risks of cocaine use during pregnancy?
Maternal risks of cocaine use during pregnancy include:
Arrhythmia
Myocardial infarction
Subarachnoid hemorrhage
Seizures
Stroke
99
How is placental abruption treated?
The treatment of abruptio placentae is delivery of the baby by emergency c-section if there is hemodynamic instability.
Transfusion is frequently required because of massive blood loss.
Remember to give Rh immune globulin (Rhogam) if the mother is Rh negative. Multiple doses may be required.
100
Besides magnesium sulfate and intravenous diazepam, what else should be used to stabilize a patient with eclampsia?
Eclampsia should be managed with magnesium sulfate and intravenous diazepam to control seizures.
The patient should also be stabilized with sufficient oxygen and blood pressure control using labetalol or hydralazine.
Magnesium and antihypertensive medications should be continued for 48 hours after delivery because 25% of seizures occur within 24 hours after delivery.
101
In addition to painful bleeding, what are some other symptoms of abruptio placentae?
Placental abruption presents with painful uterine bleeding and tetanic contractions in the third trimester. Note painless bleeding in the third trimester is associated with placenta previa.
Additional symptoms of abruptio placentae include:
Abdominal and back pain
Pelvic and abdominal tenderness
Hypotension if there is severe hemorrhage
102
What are the teratogenic risks of chemotherapeutics?
Chemotherapeutics cause:
Intrauterine demise in 30% of pregnancies
Severe intrauterine growth restriction
Multiple anatomic abnormalities (palate, bones, limbs, genitals)
Mental retardation
Spontaneous abortion
103
What risk factors are associated with eclampsia?
Eclampsia is defined similarly to preeclampsia, but with the addition of grand mal seizures.
There is an increased incidence in patients with preexisting diabetes mellitus, hypertension, chronic renal disease, and autoimmune disorders.
The etiology of preeclampsia and eclampsia involves placental ischemia secondary to lack of trophoblastic invasion of the spiral arteries in the myometrium.
104
What sedative-hypnotic drugs carry teratogenic risks?
Sedative-hypnotic drugs that carry teratogenic risks include diazepam and phenobarbital.
Diazepam causes:
Cleft palate
Renal defects
Secondary neoplasms
Phenobarbital causes neonatal withdrawal.
105
How are patients with active bleeding due to placenta previa treated differently than those with minor bleeding?
In cases of minor bleeding, patients with placenta previa can be treated with bed rest. However, for active bleeding they require inpatient admission with maternal and fetal monitoring.
Rho(D) immune globulin is given to any Rh-negative mothers that have bleeding in the third trimester.
Tocolytics (agents used to slow contractions) are used to delay delivery in cases of a preterm fetus with immature lungs, if mild maternal bleeding is present.
Patients with placenta previa should deliver by cesarean section.
106
What is the most concerning complication of intrauterine fetal demise?
A major complication associated with intrauterine fetal demise is DIC, which can occur if the fetus is retained for a prolonged period of time.
107
What is the clinical presentation of preeclampsia? What makes the diagnosis eclampsia?
Clinical symptoms associated with preeclampsia include:
Headache
Blurred vision
Abdominal pain
Edema of the face and extremities
Altered mentation
Hyperreflexia
Decreased urine output
The presence of seizures makes the diagnosis eclampsia.
108
What is the etiology of eclampsia?
The etiology of preeclampsia and eclampsia involves placental ischemia secondary to lack of trophoblastic invasion of the spiral arteries in the myometrium.
109
What are some effects of congenital syphilis on the fetus/neonate?
A congenital syphilis infection carries a 25% mortality rate in addition to the following fetal/neonatal effects:
Hepatomegaly in almost all infants, which may include splenomegaly
Rhinitis, which usually develops during the first week of life
Cutaneous lesions, appearing 1-2 weeks after rhinitis
Chorioretinitis or uveitis
Osteodystrophy, commonly affecting the tibia (“saber shins”), femur, and humerus
Neonatal anemia
Maternal syphilis can be diagnosed with early prenatal rapid plasma reagin (RPR) or venereal drug research laboratory (VDRL) screening followed by a confirmation with FTA-ABS.
Maternal/congenital syphilis can be treated with maternal or neonatal penicillin.
110
What are the maternal risks of tobacco use during pregnancy?
Tobacco use during pregnancy carries the fetal risks of:
Intrauterine growth restriction
Intrauterine fetal demise
Spontaneous abortion
Prematurity
Increased risk of neonatal respiratory distress syndrome
Maternal risks of tobacco use in pregnancy include:
Abruptio placentae
Placenta previa
Premature rupture of membranes
111
What are the fetal and maternal risks of marijuana use during pregnancy?
Marijuana use during pregnancy carries the fetal risks of intrauterine growth restriction and prematurity. There is minimal maternal risks of marijuana use during pregnancy.
112
What are the teratogenic risks of retinoids?
Retinoids cause:
CNS abnormalities
Cardiovascular abnormalities
Facial abnormalities
Spontaneous abortion
113
How is HELLP syndrome managed?
Preeclampsia and eclampsia can be associated with HELLP syndrome (Hemolysis, Elevated Liver function tests, Low Platelets).
HELLP may present with nausea, vomiting and right upper quadrant pain secondary to distention of the liver capsule.
Untreated, HELLP syndrome is fatal. The fetus must be delivered, regardless of viability, in order to prevent maternal death. Maternal corticosteroids may help with liver function and thrombocytopenia.
Complications include:
Abruptio placentae
Encephalopathy
Renal insufficiency
DIC
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