Gestational conditions Flashcards
highest rate of pregnancy related hypertension
first pregnancy over 40
maternal death associated with severe hypertension result of?
hepatic rupture, placental abruption and eclampsia (characterized by seizures)
classification of hypertensive disorders in pregnancy
pre-existing hypertension (with or without combined conditions and with or without evidence of pre-eclampsia) - appears before 20 wks
gestational hypertension (with or without combined conditions and with or without evidence of pre-eclampsia) - appears after 20 wks
transient hypertension - elevated BP due to external stimuli
white coat hypertension - BP elevated in clinicians office but normal outside
masked hypertension - BP normal in clinicians office but elevated outside
pre-existing hypertension with superimposed pre-eclampsia
associated with severe maternal and fetal complications
presence of the following:
hypertension before 20 wks with new or worsening proteinuria
hypertension and proteinuria before 20 wks
sudden increase in BP in women whose hypertension was previously well controlled
thrombocytopenia
elevated liver enzymes
pre-eclampsia
hypertensive disorder most commonly defined by onset of proteinuria and other end organ dysfunction and may result in maternal complications or intrauterine fetal morbidity and mortality due to uteroplacental insufficiency and placental abruption
HELLP syndrome
lab diagnosis for variant of severe pre-eclampsia characterized by (H) hemolysis, (EL) elevated liver enzyme, (LP) and low platelets
GESTATIONAL DIABETES MELLITUS (GDM)
defined as elevated glucose levels that are first recognized
during pregnancy. In the first trimester of pregnancy, uncontrolled hyperglycemia can impact fetal development resulting in
malformations. women with GDM have twice the risk of developing pre-eclampsia, particularly if they have chronic hypertension already
Risk factors for GDM
Age ≥35 years • Previous GDM • Prediabetes • High-risk population among Indigenous, Latin American, South Asian, Asian, African • Body mass index (BMI) ≥30 kg/m2 • Polycystic ovarian syndrome • Acanthosis nigricans • Corticosteroid use • History of macrosomic infant • Current fetal macrosomia or polyhydramnios
early pregnancy bleeding
common bleeding of early pregnancy include miscarriage, premature dilation of the pregnancy, ectopic pregnancy, hydatidiform mole (molar pregnancy)
pregnancy loss
early pregnancy loss - before 12 weeks
late pregnancy loss - between 12 and 20 weeks
threatened abortion: management
bleeding in early pregnancy with no loss of placenta or fetus
slight bleeding, mild cramping. bedrest ordered but not proven to prevent progression to miscarriage. repeated testing done to determine if fetus is still viable
inevitable abortion: management
cervix dilated but conception products not expelled
moderate bleeding, mild to severe cramping, cervical dilation. bedrest for no pain, fever, or bleeding. If ROM, bleeding, pain, or fever present, uterus emptied properly by dilation and curettage (removal of leftover placenta/fetus)
incomplete abortion: management
partial loss of fetus/placenta
heavy bleeding, severe cramping, cervical dilation with tissue in cervix and passage of tissue. may or may not require additional cervical dilation for curettage
complete abortion: management
slight bleeding, mild cramping, passage of tissue. no further intervention needed if uterine cramping adequate to prevent hemorrhage. suction curettage sometimes done to remove leftover tissue
missed abortion: management
fetus not viable but does not get expelled by uterus
spotting, no cramping. if spontaneous evacuation of the uterus does not occur within 1 month, pregnancy terminated in method appropriate for gestational age. coagulation monitored for hemorrhage
septic abortion: management
uterus infected by microorganism
malodorous bleeding, varied cramping, varied tissue passage, cervical dilation. immediate termination of pregnancy by appropriate method. treatment for sepsis
recurrent abortion: management
3 consecutive pregnancy losses prior to 20 weeks gestation.
varied bleeding, varied cramping, passage of tissue and cervical dilation. tx varies depending on type but prophylactic cerclage (using a ring or loop to bind the opening of the cervix) performed if cause if early cervical dilation
dilation and curettage (D&C)
surgical management in which the cervix is dilated and a curette inserted to remove uterine contents. Commonly used for inevitable and incomplete miscarriage.
dilation and evacuation is performed after 16 weeks and is a wide cervical dilation with instrumental removal of uterine contents
Misoprostol
for late, incomplete, inevitable, or missed pregnancy loss (16 to 20 weeks) given orally or vaginally to induce labour and deliver the fetus.
premature dilation of cervix
passive and painless dilation of the cervical os without labour or contractions of the uterus (cervical insufficiency or incompetent cervix). miscarriage or preterm birth may occur. tx: restricted activity and hydration, cervical cerclage such as Shirodkar or McDonald procedure,
shirodkar procedure
maternal fascia lata (muscle from thigh) is threaded submucosally in the cervix anteriorly and posteriorly and tied
mcdonald procedure
nonabsorbable ribbon is placed around the cervix beneath the mucosa to constrict the internal os of the cervix
ectopic pregnancy
fertilized ovum is implanted outside the uterine cavity. increased incidence in women with reproductive therapy. majority occur in the fallopian tube on the ampullar (largest portion of the tube). 3 clinical signs of ectopic tubal pregnancy are abdominal pain, delayed menses, and abnormal vaginal bleeding approx 6 to 8 weeks after last period. in ruptured ectopic pregnancy, shoulder pain is evident.
treatment of ectopic pregnancy
can resolve spontaneously with tubal abortion or regression of the pregnancy from the tube. Medical management is methotrexate to dissolve the tubal pregnancy (it is a antimetabolite and folic acid antagonist that destroys rapidly dividing cells). surgical management depends on cause of pregnancy, extent of tissue involvement, and women’s desire to get pregnant again. Could be salpingectomy (removal of entire tube) or if women would like to get pregnant again, salpingostomy (incision in tube and removal of conception products - not sutured but left to close to reduce scarring)
magnesium sulfate
used to prevent seizures in preeclampsia, slow or stop preterm labour, and prevent injury to preterm baby brain
molar pregnancy
benign proliferative growth of the placental trophoblast in which the chorionic villi develop into edematous, cystic, avascular transparent vesicles that hang in a grape like cluster. hydatidiform mole is a gestational trophoblastic disease (GTD) which is a group of pregnancy related trophoblastic proliferative disorders without a viable fetus that are caused by abnormal fertilization.
molar pregnancy types and risk factor
at risk if in teens or older than 40 or had molar pregnancy before
complete molar: fertilization of an egg in which the nucleus has been lost or inactivated. contains no fetus, placenta, amniotic membranes, or fluids, just grape like cluster of hydropic vesicles. Maternal blood has no placenta to receive it, therefore, hemorrhage in uterine cavity and vaginal bleeding occur.
partial molar: two sperms fertilizing an apparently normal ovum. partial molar have embryonic or fetal parts and an amniotic sac. congenital anomalies present
molar pregnancy management
most moles pass spontaneously, suction curettage offers safe, rapid, and effective method of evacuating the mole. another option is hysterectomy. admin of Rh immune globulin recommended in Rh negative women
placenta previa
placenta is implanted in the lower uterine segment so that it completely or partially covers the cervix or is close enough to the cervix to cause bleeding when the cervix dilates or the lower uterine segment effaces. placenta previa during second trimester is risk factor for vasa previa (fetal vessels in placenta are near cervical opening). complete placenta previa - total cervical covering, Marginal placenta previa - edge of placenta seen in vaginal ultrasound to be 2.5cm or closer to internal cervical os. Low lying placenta - exact relationship of placenta and interval os not determined or apparent placenta previa in second trimester. dx: painless bright red vaginal bleeding after 20 weeks gestation
expectant management of placenta previa
less than 36 weeks of gestations and not in labour, bleeding is mild or has stop, expectant management - reduced activity and close observation - is treatment of choice. ultrasound done every 2 weeks, fetal surveillance (NST or BPP) one or twice weekly. venous access with heparin lock in case of blood therapy. antepartum steroids (betamethasone) for lung maturation if fetus under 34 weeks. vaginal rest ordered (nothing in vagina)
active management of placenta previa
at or beyond 36 weeks or bleeding is excessive or persistent, immediate C section indicated. in women with partial or marginal placenta previa vaginal birth may be attempted. Natural mechanism to control bleeding after pregnancy not present in lower uterine segment so bleeding may continue after fetal birth and hemorrhage may occur even if fundus contracted firmly
placental abruption (premature separation of placenta)
detachment of part of all of the placenta from its implantation site. maternal hypertension most common risk leading to placenta abruption.
3 types of placenta abruption
mild abruption: minimal, dark red bleeding, no pain. normal FHR
moderate abruption: moderate dark red blood, mild shock, occasional DIC, increased uterine tone, atypical FHR, moderate pain
severe abruption: heavy dark red blood, sudden and profound shock, frequent DIC, tetanic uterine tone, agonizing pain, abnormal FHR
couvelaire uterus
blood accumulates between uterine wall and separated placenta due to placental abruption resulting in uterus appearing purplish and copper coloured, ecchymotic, and contractility is lose
diagnosis of placental abruption
strongly suspected in the women with sudden onset of intense, usually localized uterine pain, with or without vaginal bleeding.
treatment of placental abruption
tx depends on severity of blood loss, fetal maturity and status. If mild abruption, fetus not in distress, and less than 36 weeks, expectant management implemented at hospital. fetal status closely monitored until fetal maturity is achieved. deteriorating condition indicates immediate birth - use of betamethasone for fetal lung maturation. if fetal to maternal hemorrhage occurs Rh negative mother treated w/ Rh immunoglobulin if fetus Rh positive. vaginal birth attempted if fetus is dead or fetus is alive in no distress and mother is hemodynamically stable - otherwise C section. blood and fluid volume replacement most likely ordered. Note: c section not attempted if mother has severe or uncorrected coagulopathy as may result in uncontrolled bleeding.
placenta accreta
serious complication of placenta previa. trophoblastic invasion extends beyond the normal endometrial barrier. if extended into myometrium called placenta increta. if extends beyond uterus serosa called placenta percreta. massive hemorrhage can occur with any of these conditions. tx: c section with fundal incision, followed by total abdominal hysterectomy.
velamentous insertion of the cord
occurs when the umbilical vessels begin to branch at the membranes and then course onto the placenta.