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Late Pregnancy Complications Flashcards

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1
Q

Late Pregnancy Complications examples ?

A

Preterm Labor

Premature Rupture of

Membranes

Amniotic Fluid Issues

Oligohydramnios

Polyhydramnios

Post-term Pregnancy

RH Alloimmunization & Blood

Group Incompatibilities

Stillbirth

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2
Q

Preterm Labor: Labor occurring after __ weeks and before __weeks gestation

A

20

37

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3
Q

Preterm Labor: Contractions are ?

A

regular and frequent

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4
Q

Preterm Labor: Cervical effacement ( thinning) or dilation is _______.

A

present

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5
Q

Preterm Labor: Preterm birth occurs in___ of US pregnancies

A

12%

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6
Q

1 cause of neonatal M&M ?

A

Preterm birth

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7
Q

Preterm Labor: Many causes of preterm labor, but 50% are __________.

A

idiopathic

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8
Q

Preterm Labor RF: Obstetric Complications ?

A

In previous or current pregnancy

  • Placental abnormality
  • Amniotic fluid ↓ or ↑
  • Maternal age
  • Socioeconomic status
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9
Q

Preterm Labor RF: Medical Complications ?

A

Pulm, heart or kidney disease

Smoking, alcohol use

Anemia, malnutrition, infection

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10
Q

Preterm Labor RF: Surgical Complications ?

A

Hx of intra-abdominal procedure, cervical conization (LEEP)?, c-section

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11
Q

Preterm Labor RF: Genital Tract Anomalies ?

A

Bicornuate or septate uterus

Cervical incompetence

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12
Q

Preterm Labor prevention ?

A

Not much prevention can be done but prolong as much as possible

For women with a history of prior preterm birth, some evidence that vaginal suppositories or IM injections of progesterone help reduce risk by 30%

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13
Q

Preterm Labor signs and sxs. ?

A

Uterine contractions

Dilation and effacement of cx

+/- bloody mucous vaginal discharge, mucus plug

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14
Q

Preterm Labor evaluation ?

A

Calculate gestational age –by FDLMP or sono estimation

Fetal monitoring
-2 belts around abd.

Tocodynamometry – confirm contractions

PE – check for cervical dilation, ROM, fundal tenderness ( sing of infection - endometritis) , vaginal bleeding, fever

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15
Q

Preterm Labor labs ?

A

CBC with diff

U/A with C&S

US

  • Fetal weight estimation
  • Presenting part – abnormal presentation more common
  • Placenta location
  • -make sure it is not over the oss

Amniocentesis – for fetal lung maturity, if indicated

Speculum exam – cervical culture, wet mount, GBS culture, check any vaginal fluid for amniotic fluid (nitrazine test

  • *blue means amniotic fluid in the vag - rupture of membranes and a sign hat we cant prolong the pregnancy and evacuation is needed!
  • *
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16
Q

about 100% survival rate of a preterm birth ?

A

> 34 weeks

1750-2000g

~100% survival

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17
Q

about 60% survival rate of a preterm birth ?

A

24-25 weeks

500-750 g

60% survival

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18
Q

Fetal Lung Maturity Testing done before ?

A

Elective deliveries

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19
Q

Fetal Lung Maturity Testing by ?

A

Fluorescence polarization

Lecithin/sphingomyelin ration (L/S ratio)

Phosphatidylglycerol (PG)

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20
Q

*Fluorescence polarization ?

A

polarized light in amniotic fluid measured by TDx-FLM analyzer

Moderate cost

Simple to run

Most widely used test

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21
Q

Lecithin/sphingomyelin ration (L/S ratio) ?

A

Large lab variation

Not the test of choice any longer

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22
Q

Phosphatidylglycerol ?

A

part of surfactant

Expensive

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23
Q

Maternal cases in which preterm labor should NOT be suppressed - DELIVER IT!

A

Severe HTN, eclampsia

Pulmonary or cardiac disease

Cervical dilation >4 cms

Maternal hemorrhage

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24
Q

Fetal cases in which preterm labor should NOT be suppressed - DELIVER IT!

A

Fetal death or lethal anomaly

Fetal distress
decelerations on fetal monitoring

Chorioamnionitis

Fetal weight < 2500g - viable - get it out!

Erythroblastosis fetalis

Severe IUGR

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25
Preterm Labor: If no contraindication to suppress labor: ___________ management versus __________________.
Expectant Intervention to induce
26
Expectant Management: If ________ weeks or fetal weight _____ – generally not viable
20-23 <550g
27
Expectant Management: Once _______ weeks, nearly same survival rate as __ weeks NO steroids needed
34-37 37
28
Suppression of Preterm Labor-
24-34 weeks examples ?
Bedrest- controversial Corticosteroids ABS Tocolytics
29
Corticosteroids for labor supression ?
for fetal lung maturation Peak effect at 48 hours, lasts 7 days 2nd course of IM injections if still pregnant after two weeks
30
ABS for labor supression ?
Does not delay birth but for prevention of GBS
31
Tocolytics for labor supression ?
If cervix <5 cms Short term goal is 48 hours, so steroids can reach peak effect Long term goal is to get to 34-36 weeks Many agents, each with contraindications and SE’s
32
Tocolytics examples ?
**Magnesium sulfate Beta-mimetic adrenergics (Sub cut) - Terbutaline Calcium channel blockers - Nifedipine Prostaglandin synthase inhibitors (indomethacin) Mutliple agents – better effect, but ↑ SE’s
33
**Magnesium sulfate ?
Reduces uterine contractility Better tolerated, watch for resp and card depression Plus, neuroprotective - reduces risk of cerebral palsy ** calcium glutinate is the antidote to mag sulfate - if fetus becomes under distress **
34
Terbutaline ?
Beta-mimetic adrenergics Relaxes uterus, but CV side effects Used only initially until other therapy started * *T and N used in triage in early labor but ideally it is mag sulfate to stop the contractions nd it is better tolerated and had neuroprotective effects on the baby * *
35
Nifedipine ?
CCB Reduces uterine contractility Oral admin, less side effects * *T and N used in triage in early labor but ideally it is mag sulfate to stop the contractions nd it is better tolerated and had neuroprotective effects on the baby * *
36
indomethacin ?
Prostaglandin synthase inhibitors Serious fetal effects
37
Tocolytics – when to stop ?
Adverse maternal or fetal response Cervix reaches 5 cms dilation Intrauterine infection esp. if membranes has ruptured Placental abruption (separation)
38
PROm can occur when and what is it ?
Can occur at any point in pregnancy Rupture before onset of labor
39
Preterm PROM – ?
fetus is preterm
40
Prolonged PROM – ?
term fetus, but delay of contractions by >24 hours * *risk for infections , open bag with bacterial being able to ascend into the U * *
41
Is PROM common ?
Common – 10% of all pregnancies, usually at term
42
PROM RF ?
Decidual hemorrhage Hx of spontaneous preterm birth Intrauterine bacterial infection Amniocentesis Cervical insufficiency Multiple gestation
43
PROM prevention ?
for women with hx of preterm birth, weekly progesterone (vaginally or IM) may help
44
PROM signs and sxs. ?
Sudden gush of fluid or continued leaking Possible flecks of vernix (white cheesy stuff on the baby) or meconium in the fluid Reduced uterine size Increased prominence of fetus
45
PROM PE ?
STERILE SPECULUM Pooling of amniotic fluid in posterior fornix Nitrazine test - paper turns blue (alkaline) Ferning – air-dried slide
46
PROM PE inspect cervix exams ?
Sterile speculum Dilation and effacement Cord prolapse Observe for leakage of amniotic fluid with valsalva If enough fluid Send for tests of fetal lung maturity and infection NO digital cervical ?
47
PROM - Labs ?
CBC with diff U/A with C&S US – fetal size and amniotic fluid index (Biophysical Profile)
48
PROM - Treatment depends on ?
gestational age presence or absence of chorioamnionitis **meconium staining in the right - deliver it - baby is turing blue
49
PROM and Chorioamnionitis pathology and S&S ?
Infection, usually due to bacteria ascending from vagina ecoli, GBS, bacteriodes Fever Maternal leukocytosis Uterine tenderness Tachycardia Foul-smelling amniotic fluid
50
PROM and Chorioamnionitis In all cases ?
Safer for fetus to be delivered than to stay in utero. Delivery ASAP, regardless of gestational age
51
PROM in Term Pregnancy Without Chorioamnionitis (infection) What management is better ?
Expectant vs Active Management – active is preferred
52
PROM in Term Pregnancy Without Chorioamnionitis (infection) Tx. ?
Induce labor Reduces amount of time between PROM and delivery Reduces risk of chorioamnionitis
53
PROM -Preterm Pregnancy Without Chorioamnionitis Tx if 34 weeks ?
induce labor
54
PROM -Preterm Pregnancy Without Chorioamnionitis Tx. if 22-24 weeks ?
terminate pregnancy or expectant management
55
PROM -Preterm Pregnancy Without Chorioamnionitis Tx. 24-34 weeks /
Amniotic sample to check lung maturity Antibiotics – prolong delivery after PROM and ↓ infection Corticosteroids – before 32 weeks and IF no infection. Magnesium sulfate – neuroprotective ** NO tocolytics, or for 48 hours only, to allow for steroids and ATB’s**
56
Amniotic Fluid Issues is measured by ?
amniotic fluid index (AFI) on ultrasound Measure fluid pockets, correlate with gestational age **measure 4 pockets of A fluid to see if it is to much or to little **
57
Amniotic Fluid Issues: Oligohydramnios inhibits ?
NL fetal movement
58
Amniotic Fluid Issues: Oligohydramnios can lead to ?
fetal deformation. umbilical cord compression, death
59
Amniotic Fluid Issues: Oligohydramnios can be caused by ?
fetal renal dz, post-term status, maternal disorder, PROM or idiopathic
60
Amniotic Fluid Issues: Oligohydramnios results in fetal death when ?
In 1st and 2nd trimester not enough A fluid to support it
61
Amniotic Fluid Issues: Oligohydramnios what helps evaluate the fetus ?
Saline infusion
62
Amniotic Fluid Issues: Oligohydramnios Tx. ?
No long term treatment available Trying maternal hydration and desmopressin (DDAVP
63
Amniotic Fluid Issues: Polyhydramnios caused by ?
decreased fetal swallowing or increased fetal urination
64
Amniotic Fluid Issues MC etiologies ?
Fetal malformations/genetic disorders Maternal DM, multiple gestation, fetal anemia
65
Amniotic Fluid Issues Tx. ?
Dependent on age, degree Amnioreduction - remove fluid Indomethacin, plus steroids - Not given after 34 weeks as may cause premature closure of ductus arteriosus
66
Postterm Pregnancy patho ?
+42 weeks from FDLMP
67
Postterm Pregnancy risks of what ?
dysmaturity from impaired nutritional supply Weight loss, ↓subcut tissue, parchment-like skin
68
Postterm Pregnancy maternal risks ?
large fetal size (CPD) * *CEPHALOPELVIC DISPROPORTION * *
69
Postterm Pregnancy fetal risks ?
birthing injury, aging placenta
70
Postterm Pregnancy: Oligohydramnios risk ?
cord compression
71
Postterm Pregnancy offer induction at ?
41 weeks If declined, careful fetal monitoring
72
Rh Alloimmunization 1 ?
Fetus gets half of genes from mom, half from dad So, fetus may have RBC antigens different from mom If enough fetal cells cross into maternal blood, can provoke an antibody response If maternal antibodies cross the placenta, they can destroy fetal erythrocytes – hemolytic anemia ( in the next baby) Fetus response – erythroblastosis fetalis (fetal hydrops). Death can result Rh group causes the majority of cases -Mom is Rh-negative, fetus is Rh-positive
73
Rh Alloimmunization 2 ?
Rh-negative mothers need prophylaxis to prevent sensitization Screen pregnant woman at first prenatal visit -ABO and Rh(D), also known as (Rh-negative) ``` Administer RhIgG (RhoGAM) -Prenatally, IM to mom at 28 weeks and again within 72 hours of delivery if infant is Rh-positive ```
74
Other times to administer RhoGAM ?
Abortion Amniocentesis, Chorionic Villus Sampling Antepartum bleeding Any time fetal blood mixes with maternal blood
75
Stillbirth definition ?
Intrauterine fetal death at or beyond 20 weeks <1% of pregnancies 50% of cases – difficult to identify cause
76
Stillbirth RF ?
similar to risks for infertility and abortion
77
Stillbirth is determined by ?
absence of cardiac activity on US
78
Stillbirth sxs. ?
pain, bleeding or asymptomatic
79
Stillbirth evaluation ?
Thrombophilia Maternal toxicology Testing for diabetes Placental pathology Karyotyping (best done through amniotic fluid)
80
Stillbirth Tx. ?
Induction of labor D&E – intact delivery up to 26-28 weeks with cervical dilation
81
Stillbirth prognosis ?
If no etiology found, risk for repeat stillbirth is 1-2%

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