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Lecture 4: Complications of Pregnancy Flashcards

1
Q

What is an ectopic pregnancy and where is it MC?

A
  • Any pregnancy in which the embryo implants outside the uterine cavity.
  • MC in the ampulla of the fallopian tube.
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2
Q

Risk factors for ectopic pregnancy

A
  • Prior ectopic
  • STD
  • PID
  • Assisted Reproductive Technology (ART)
  • IUD
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3
Q

Dx of Ectopic pregnancy

A
  • Vaginal bleeding
  • Lower Abd Pain
  • Adnexal Mass
  • Tenderness on pelvic exam
  • If ruptured: hypotension, unresponsive, peritoneal irritation up to R shoulder referral
  • b-hCG does not 2x every 48h as it does normally
  • U/S: Empty uterus or donut sign
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4
Q

What is the pathognomonic sign on U/S for an ectopic pregnancy?

A

Donut sign

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5
Q

What risk factor is worrisome for heterotopic pregnancy?

A

ART patients

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6
Q

What is methotrexate’s MOA in regards to pregnancy?

A

Prevents proliferation of tissue such as trophoblasts. It is a folic acid antagonist.

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7
Q

Indications for methotrexate

A
  • Asymptomatic, motivated, compliant
  • Low initial b-hCG (< 5000)
  • Small ectopic size (< 3.5cm)
  • Absent fetal cardiac activity
  • No evidence of intraabdominal bleeding
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8
Q

What should you check prior to administering MTX? During?

A
  • Prior: CMP/CBC
  • During: b-hCG, which should decline starting day 4
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9
Q

What are the SEs associated with MTX use?

A
  • Separation pain (mild and relievable with analgesics)
  • Liver
  • Stomatitis
  • Gastroenteritis
  • Bone Marrow Depression

Immunosuppressant

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10
Q

Tx for ectopic pregnancy

A
  • MTX (first)
  • Surgery: Salpingostomy to salvage tubes
  • Salpingectomy: Tubal resection (MC done)

Surgery used if MTX fails

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11
Q

Define abortion/miscarriage

A

A pregnancy ending prior to 20 weeks gestation

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12
Q

What is a complete abortion?

A

Complete expulsion of all POC (products of conception) prior to week 20.

If no POC found make sure its not ectopic

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13
Q

How does an incomplete abortion present?

A
  • Vaginal bleeding and abd cramping
  • POC protruding thru dilated os or active vag bleeding
  • US shows nonviable intrauterine pregnancy
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14
Q

Management of an incomplete abortion

A
  • Curettage
  • PGE
  • Expectant management
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15
Q

How does an inevitable abortion present?

A
  • No expulsion of POC
  • Vag bleeding and dilation of cervix
  • nonviable pregnancy

Its gunna come out bc cervix is dilated?

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16
Q

Tx of inevitable abortion

A
  • PGE
  • Expectant management

PGE to help dilate and get it out sooner?

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17
Q

How does a missed abortion present?

A
  • Closed cervical os
  • Absence of uterine growth
  • U/S: nonviable pregnancy

Death prior to 20 weeks with complete retnetion of POC

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18
Q

Tx of missed abortion

A
  • Curettage
  • PGE
  • Expectant management

It already died so you gotta scoop it out and keep the cervix open :(

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19
Q

How does a threatened abortion present?

A
  • Vaginal bleeding before 20 weeks without dilation of cervix or expulsion of POC
  • Cervical os closed
  • Vaginal spotting
  • U/S: Viable pregnancy
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20
Q

Tx of threatened abortion

A
  • Pelvic rest
  • Expectant management
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21
Q

What Rh females should always get RhoGAM?

A

RH neg

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22
Q

What is a molar pregnancy?

A
  • Hydatiform mole
  • Excessively edematous immature placentas
  • Villous stromal edema
  • Trophoblast proliferation
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23
Q

Risk factors for molar pregnancy

A
  • Extremes of reproductive age (young or old)
  • Hx of prior
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24
Q

What is a complete mole?

A
  • 46 XX or XY
  • Paternal in origin for both sets
  • Vag bleeding
  • Large for date
  • hCG > 100k
  • Theca lutein cyst
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25
Pathology of a complete mole
* **No fetal parts** * Edematous villi
26
What is a partial mole?
* 69 XXX or XXY or XYY * **Two paternal haploid and 1 maternal** * Missed abortion + small for date * **Fetal parts present**
27
Dx of molar pregnancy
* Serum hCG * **U/S for complete**: echogenic uterine mass with numerous anechoic cystic spaces without fetus or sac **snowstorm appearance** * U/S for partial: Thickened, multicystic placenta along with fetus or tissue * **Pathology confirms**
28
Common sequelae of molar pregnancies
* Thyroid storm * Hyperemesis gravidarum * Preeclampsia/eclampsia
29
Management of molar pregnancy
* Preop eval: thyroid, CBC, CMP, CXR, EKG, Type and screen * Suction dilation and curettage (pitocin) * RhoGAM if needed
30
What needs to be continuously monitored post evacuation of a molar pregnancy?
1. b-hCG every 1-2wks until undetectable. 2. Check monthly for 6 months afterwards
31
What is antepartum bleeding?
Bleeding occurring with a viable mature fetus (> 24 wks)
32
What is placental abruption?
Separation of placenta prior to delivery due to hemorrhage into decidua
33
How does placental abruption present early?
* Considered chronic abruption if early * May be **associated with elevated AFP**
34
Risk factors for placental abruption
* Trauma * Increasing age * HTN/preeclampsia (**MC condition associated**) * Preemie ruptured membranes * smoking * cocaine * Lupus * Thrombophilias * Uterine fibroids * Recurrent abruption
35
What are the clinical findings and dx of placental abruption?
* Sudden onset abd pain * Vaginal bleeding * Uterine tenderness * **DX of exclusion** * U/S: generally limited in use.
36
Complications of placental abruption
* Hypovolemic shock * Consumptive coagulopathy/DIC * AKI * **Couvelaire Uterus** (makes myometrium bluish purple)
37
Management of placental abruption
* C-section for quicker sx but risk of DIC is higher * **If fetus is dead already, do vaginal**
38
What is placental previa?
* Placenta implanted in lower uterine segment * Over/near internal cervical os | Blocking the cervix
39
What are the two types of placenta previa?
* Placenta previa: internal os covered partially or fully by placenta * Low-lying placenta: Implantation in lower uterine segment but **not reaching internal os; 2cm outside of os**
40
Risk factors for placental previa
* Increased age * Increased parity * Prior C-section * Smoking * **Elevated MSAFP**(same as AFP)
41
Clinical presentation of placenta previa
**Painless** vaginal bleeding occurring **past 2nd trimester**
42
Dx of placenta previa
TVUS is most accurate | **DO NOT DO DIGITAL EXAM UNTI PREVIA IS RULED OUT** ## Footnote you might puncture the placenta doing a digital exam
43
What factors make a low-lying placenta likely to persist?
Hx of prior C-section or hysterotomy scar | Low chance up until 23 weeks, at which time it goes up in persistence.
44
Management of placenta previa
* If persistent bleeding: Delivery for preemie * If non-persistent bleeding: watch if its preemie * If Term: Delivery via C-section
45
What are the placenta accrete syndromes?
* Abnormally implanted, invasive, or adhered placenta * Abnormally firm **adherence** to **myometrium** due to lack/thin decidua basalis and imperfect fibrinoid layer. * Placenta **A**ccreta: **A**ttached to myometrium * Placenta **I**ncreta: **I**nvading myometrium * Placenta **P**ercreta: **P**enetrating myometrium and serosa
46
Risk factors for placenta accrete syndromes
* Associated placenta previa * Prior C-section
47
Dx of placental accrete syndromes
* TVUS * MRI can be adjunct * **Pathology to confirm**
48
Management of placenta accrete syndromes
* Planned delivery at 34-36 to avoid C-section * **Consider pre-op uterine artery embolization** * **Consider leaving placenta in situ** and do hysterectomy later
49
What is cervical insufficiency?
* **Painless cervical dilatation in 2nd trimester** * Followed by prolapsing and ballooning of membranes into vagina, leading to **expulsion of immature fetus** | your cervix cant keep it in
50
Risk factors for cervical insufficiency?
* Prior cervical trauma * DES exposure
51
Dx of cervical insufficiency
* TVUS to confirm fetus * Swab for infection
52
Expectant management for cervical insufficiency
* Trendelenberg position (tr = toes raised) * Pelvic rest * Cerclage? (stitch of uterus until 36wk)
53
Tx of cervical insufficiency
* Done for the subsequent pregnancy * Cerclage
54
4 primary reasons to deliver a preterm baby
1. Spontaneous unexplained preterm labor with intact membranes (including cervical insufficiency) 2. Idiopathic preterm premature rupture of membranes (PPROM) 3. Delivery for maternal or fetal indication (Pre-eclampsia) 4. Twins and higher order births
55
W/u for preterm labor
* Fetal fibronectin (good negative predictive value) * Cervical length (check transvaginally, > 3cm = not in labor * Sterile vag exam * Sterile spec exam (cultures and nitrazine) * UA/UC
56
Tx of preterm labor
* Tocolysis (stopping contractions) for 48h or less * Mg sulfate (neuroprotection) * Nifedipine * PGE synthetase inhibitor prior to 2nd trimester (indomethacin) * Terbutaline (B-agonist) * Bedrest * Corticosteroids for lung maturation (beta/dexamethasone for 24-34 wks) | all the drugs are tocolytics
57
Prevention of Preterm labor
* Cervical cerclage (length < 25mm at high risk) * IM progesterone for hx of prior preemie birth * Vaginal progesterone for shortened cervix
58
What is PPROM?
Membrane rupture **before contraction onset** and **before 37 wks**
59
PPROM risk factors
* Genital tract infection * History of PPROM * Antepartum bleeding * Smoking
60
Dx of PPROM
* **Speculum exam** showing pooling or nitrazine weirdness or ferning pattern * US showing **low AFI**
61
Management of PPROM
* **Hospitalize for rest of pregnancy** * Corticosteroids * Tocolysis * **ABX for latency** (**ampicillin** then amoxicillin/erythro IV then PO or azithro)
62
Management of PPROM
* Expectant management for delivery until 34wks * If clinical chorioamnionitis: deliver
63
Most dangerous complication of PPROM
Cord prolapse
64
What is IUGR?
Intrauterine growth restriction
65
Dx of IUGR
* Abd palpation (eh) * U/S: abd circumference + estimated fetal wt | < 10th percentile
66
Management of IUGR
* Antepartum: AF volume measurement * Umbilical artery doppler velocimetry * Growth U/S * Plan for 38wk delivery
67
When do most fetal deaths occur?
Prior to week 20
68
MCC of fetal death
Obstretical complications: abruption, multifetal gestation, PPROM
69
What is HTN in pregnancy?
BP >= 140 and/or 90 on 2 occasions at least 6 hours apart
70
What is pre-existing HTN?
> 140/90 prior to week 20 or longer than week 12 postpartum
71
What anti-HTNs cant be used in pregnancy?
ACEis and ARBs
72
Prenatal labs for chronic HTN
* EKG * Echo if long-term * Baselines of CBC, BMP, LFTs, Coags, Urine dipstick
73
Tx of chronic HTN
* Taper/D/C if BP < 120/80 in 1st trimester, restart if 150 or 95 * **Primarily ASA** to reduce risk of superimposed preeclampsia * Labetalol * CCBs
74
Management of chronic HTN
1. Observational management 2. NSTs, BPPs, Growth US 2. Without complications: 37-39 wk delivery
75
What is gestational HTN?
* BP > 140/90 **after 20 wks** in normotensive women * Develops late and usually resolves 12 weeks postpartum | Tx same as chronic HTN
76
What is preeclampsia?
**New onset HTN + proteinuria** after 20 wks ## Footnote > 140/90 > 0.3g (**2+**) on urine dipstick
77
Risk factors for Preeclampsia
* First preg * Young * Multifetal gestation * DM, SLE, renal disease * Obesity * African-American * Chronic HTN
78
What other conditions can occur in place of proteinuria to qualify for preeclampsia?
* Thrombocytopenia * Renal insufficiency * Impaired liver function * Pulmonary edema * New onset HA unresponsive to therapy
79
What is eclampsia?
**Seizure/coma** with preeclampsia with **no other neurological condition**
80
When is pre-existing HTN superimposed by pre-eclampsia?
* New onset proteinuria * Sudden increase in BP * Development of HELLP or symptoms of severe preeclampsia
81
What is HELLP?
Hemolysis, Elevated Liver enzymes and Low Platelets | RUQ pain ## Footnote Indicates severe preeclampsia
82
Tx of preeclampsia
* Definitive: Deliver * AntiHTN therapy to prevent CV hemorrhage or HTN encephalopathy (IV labetalol, hydralazine, PO nifedipine) * MgSO4: Prevent CNS depression * Corticosteroids for fetal lung maturation
83
Dx of pregestational DM
* High plasma glucose, glucosuria, ketoacidosis * Random plasma glucose > 200 mg/dL + polydipsia/polyuria/unexplained wt loss * Fasting glucose > 125
84
Pregestational diabetes thresholds
* FBG > 125 * HbA1c > 6.5% * Random BG > 200 + confirmation
85
What HbA1c level or FBG is bad juju for pregnancy?
* HbA1c > 12 * FBG > 120
86
Complications of neonates born to pregestational DM
* RDS * Hypoglycemia (glucose crosses placenta, insulin does not) * Hypocalcemia * Hyperbilirubinemia and polycythemia * Cardiomyopathy * Long term cognitive defects | Infant overproduces insulin
87
Fetal effects due to pregestational DM
* Spontaneous abortion * Preterm delivery * Malformations (esp with T1) * IUGR or macrosomia * Fetal demise * Hydramnios
88
What supplement needs to be increased in pregestational DM?
Folic acid
89
1st trimester management for pregestational DM
1. Glucose monitoring 2. **Insulin preferred over orals** 2. **Baby ASA** 3. EKG, Echo 3. 24 hour urine
90
How do insulin needs vary throughout pregnancy?
Increased as it progresses
91
Risk factors for gestational DM
* Hispanic/African American/Native American/AAPI * Obesity * Increased age * Sedentary * Hx of gestational
92
2 step method for screening gestational DM
1. 50g 1 hour oral glucose at 24-28wk 2. If positive, 100g 3hour oral glucose 2x
93
Ideal FBG and 2h PPBG for gestational DM
* FBG < 95 * 2h PPBG < 120
94
Ideal nutrition balance for gestational DM
* 40% carbs * 40% fat * 20% protein
95
Pharm Management for gestational DM
* **Insulin (does not cross placenta)** * Oral hypoglycemics: glyburide/metformin (outcome data eh)
96
When is elective C-section recommended in gestational DM?
Baby heavier than 4500g is at risk for shoulder dystocia
97
What postpartum test should all gestational DM get?
75g 2h glucose tolerance test 6-12 wks postpartum
98
What is most closely associated with the rise of multifetal births?
Infertility tx
99
MC type of twin gestation
Fertilization of 2 ova => dizygotic (non-identical)
100
What are vanishing twins?
1 twin vanishes before 2nd trimester | incidence of a twin is higher in 1st trimester
101
Dx of multifetal gestation
* Uterine size larger than expected during 2nd trimester * U/S to check for multiple placentas and twin peak sign/lambda/delta sign * T sign suggests shared placenta
102
U/S images of T sign and twin peak sign
103
Complications of multifetal gestations
* SPontaneous abortion * Congenital malformations * Low birthwt: often preterm delivery * HTN (baby asa at 12 wk) * Preterm birth * Size discordance (if baby A is smaller than B, vaginal delivery is likely to fail) | A = first to come out
104
What complications are unique to monochorionic monoamnionic twins?
* Cord entanglement * Twin twin transfusion syndrome (in monochorionic)
105
What is twin twin transfusion syndrome?
* One twin donates to the other * Recipient twin develops HF, polycythemia, and severe hypervolemia * Donor twin develops anemia and IUGR * Need laser ablation of anastomosis | **In any monochorionic twins there is a risk of this occurring**
106
Usage of what mechanical thingie can help with preterm birth in multifetal gestations?
Pessaries
107
What twin type needs earliest delivery?
Monochorionic monoamniotic ## Footnote High risk of TTTS?
108
When does the fetus make its own thyroid hormone?
12 wks
109
How does pregnancy affect thyroid hormone?
* Increases in TBG * Stimulation of TSH by hCG
110
MCC of hypothyroidism in pregnancy
Hashimoto's thyroiditis, tx with levothyroxine | Increase levothyroxine during pregnancy
111
What is subclinical hypothyroidism?
* Elevated TSH * Normal FT4 * Consider levothyroxine
112
When should we screen pregnant women for depression?
Initial prenatal visit
113
What is Zuranolone?
* GABA A receptor + modulator * Adjunct to SSRI/SNRI for 14d daily
114
What opioid crosses the placenta? What does not?
* Subutex does not cross readily. * Methadone **crosses the placenta**
115
When should UTI screening with a UC be performed?
Initial prenatal visit
116
Tx of UTI in pregnant women
Macrobid or keflex | Will also suppress with macrobid BID if 2+ tx still persistent

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