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Clin Med - Repro > Lecture 6 - Complications of Pregnancy > Flashcards

Lecture 6 - Complications of Pregnancy Flashcards

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1
Q

What is the frequency of ectopic pregnancy?

A

1:100

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2
Q

Where are ectopic pregnancies MC?

A

in the tubes
70% in the ampullary

why? because this is where the sperm meets the egg

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3
Q

What are the risk factors of ectopic pregnancy?

A

H/o ectopic pregnancy
H/o tubal surgery
Endometriosis
H/o pelvic infection (Chlamydia is MC reason of tubal disorders and thus ectopic pregnancies)
H/o infertiity
IUD (if you are in the 1% that get pregnant while on IUD)
Smoking

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4
Q

What are the sxs of ectopic pregnancy?

A

Pelvic pain
Missed LMP
vaginal bleeding

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5
Q

What labs should you order for a pt who you suspect of ectopic pregnancy?

A

Bhcg
CBC (r/o anemia and possible internal bleed)
Type and Screen (Rh status –remember that even those this pt won’t be pregnant for long or deliver, we still don’t ever want the mom to produce antibodies to Rh+)
Pelvic US

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6
Q

Discriminatory Zone

A

when the Bhcg is 1500-2000 mIU/mL –you should be able to see something on US in the uterus

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7
Q

Does the Bhcg tell you anything about the gestational age of the fetus?

A

no
it tells you (when 1500-200) that you should see something on US and it should be doubling every 48 hours
but that is all it tells you

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8
Q

When should you expect to see fetal pole?

A

6 weeks

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9
Q

When should you expect to see FMH?

A

FMH - fetal heart motion

6.5 weeks

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10
Q

What do you need to be able to say the pregnancy is “viable”?

A

fetal pole and FMH

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11
Q

Heterotopic pregnancy

A

when you have both an ectopic pregnancy and a uterine pregnancy

these pts are NOT candidates for methotrexate for ectopic management since you would be harming the uterine fetus

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12
Q

How do you dx ectopic pregnancy?

A

adnexal mass c/w ectopic
free fluid in pelvis (ruptured ectopic)
hemodynamically unstable (HTN, tachy, diaphoretic)
Bhcg >1500-2000 with no intrauterine gestational sac
inappropriately rising Bhcg and no intrauterine gestation sac

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13
Q

What is the dx of ectopic pregnancy is unclear, what should you do?

A

have the pt come back in 2 days to retest the Bhcg and pelvic US

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14
Q

What is the treatment for ectopic pregnancy?

A

Surgery or medication

Methotrexate (MTX)

  • IM injection
  • check Bhcg on day 1, 4 and 7

if you see a 15% decrease between day 4 and 7 = SUCCESS

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15
Q

Who is not a candidate for methotrexate tx for ectopic pregnancy?

A

Evidence of rupture
Hemodynamically unstable
Absolute or relative contraindications to MTX
Heterotopic

These pts need to have surgery —salpingectomy/salpingostomy

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16
Q

Besides methotrexate, what other medication do you need to give pts with ectopic pregnancy?

A

Rhogam if they are Rh negative

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17
Q

What do you need to tell pts who were given Methotrexate to avoid?

A

Avoid the sun and NSAIDs and stop taking prenatal meds

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18
Q

What are the relative contraindications for methotrexate?

A

Showing that the pregnancy is “further along”:
-Bhcg >5000
-Gestational sac >35mm
-Fetal heart tones
Pt unwilling/unable to comply with follow up
Pt unwilling to accept blood transfusion

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19
Q

What are the absolute contraindications of methotrexate?

A 
Hemodynamically unstable or clinical evidence of ruptured ectopic 
Liver disease or EtOHism
Blood dyscrasias
Renal dysfunction 
Immunodeficiency 
Active pulmonary disease 
Peptic ulcer disease 
Breastfeeding
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20
Q

Salpingectomy

A

Remove entire fallopian tube

Surgery for ectopic

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21
Q

Salpingostomy

A

Remove pregnancy only from fallopian tube

You have to follow up with these pts to make sure their Bhcg is below 5 d/t risk of pregnancy tissue being left in the tube

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22
Q

Why chose salpingectomy over salpingostomy?

A

Either way you are at the same risk of recurring ectopic and change in fertility is the same

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23
Q

GTD

A

Gestational trophoblastic disease
Lesions characterized by abnormal proliferation of placenta tophoblast

Molar pregnancy

This can progress to GTN which is cancer

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24
Q

What are the sxs of GTD?

A

Bhcg >100,000
Abnormal vaginal bleeding
Hyperthyroidism

Dx: pathology is definitive
US

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25
How do you dx GTD?
Bhcg >100,000 US - “snowstorm” Pathology (definitive)
26
What do you see on US for GTD?
Snowstorm appearance Complete mole - no fetal parts Partial mole - +/- fetal parts, enlarged cystic placenta
27
What are the differences between partial and complete mole?
``` Complete mole - 46XX, XY P57 - negative (all paternal) No fetal tissue Bhcg >100,000 Uterus is large for date 6-32% risk of GTN ``` ``` Partial mole - 69 XXX, XXY P57 - positive (positive when maternal is present) Fetal tissue present <100,000 mIU/mL Uterus is small for date <5% risk of GTN ```
28
What is the management of GTD?
Surgical evacuation (D and C) Follow up - serial Bhcg Weekly until <5 Can’t get pregnant for 6 months —> contraception
29
GTN
Progression from GTD (molar pregnancy) This is cancer Bhcg positive at 6 months Tx: Chemotherapy Single or multi agent based on risk factors MTX (methotrexate) or actinomycin - D WHO score <6 High risk disease WHO score >6 EMA-CO (etoposide, methotrexate, actinomycin - D, cyclophasphasmide, vincristine)
30
What is the treatment for GTN?
Tx: Chemotherapy Single or multi agent based on risk factors MTX (methotrexate) or actinomycin - D WHO score <6 High risk disease WHO score >6 EMA-CO (etoposide, methotrexate, actinomycin - D, cyclophasphasmide, vincristine)
31
Monozygotic vs dizygotic
Mono is 1 sperm, 1 egg Splits to identical twins Dizygotic is 2 eggs and 2 sperms
32
Dichorionic diamniotic
2 placentas, 2 sacs This occurs if the split happens 0 - 4 days Monozygotic or dizygotic
33
Monochorinoic diamniotic
1 placenta 2 sacs This occurs if the split happens 4-8 days Monozygotic
34
Monochorionic monoamniotic
1 placenta 1 sac This happens if the split occurs 8-12 days Monozygotic
35
Conjoined twins
This occurs if the slit happens >12 days Monozygotic
36
How do dizygotic twin pregnancies show in regards to sac and placenta?
Dichorionic diamniotic | 2 placentas, 2 sacs
37
Lambda sign
Seen on US with Dichorionic —2 placentas
38
T sign
Sign on US for monochorionic
39
What are the risks of pregnancy for a women having twins?
``` Abortion Hyperemesis Preterm labor (PTL) Preterm rupture of membranes (PROM) Preterm birth (PTB) Placenta previa Placental abruption Pre-eclampsia Gestational DM (GDM) Postpartum hemorrhage (PPH) ```
40
What are the risks for the baby with a twin birth?
``` Growth restriction Prematurity Still birth (5X) Neonatal death (7X) ```
41
Monochorionic twins are at greater risk of what?
Increased risk of congenital anomalies (ex. Heart defects)
42
Monochrionic diamniotic twins are at increased risk of what?
Twin twin transfusion syndrome (TTTS) Twin anemia polycythemia sequence (TAPS) Twin reversed arterial perfusion (TRAP)
43
Monochorionic monamniotic twins are at an increased risk of what?
Cord entanglement/accident
44
Do multiple gestation (twins) make it to full term?
No
45
Dichorionic/Diamniotic (DCDA) go to delivery when?
38 weeks Growth scan every 4 weeks
46
When do monochorionic/diamniotic (MC/DA) deliver?
34-37 weeks Growth scan every 4 weeks Fluid/bladder scan every 2 weeks starting at 16 weeks to screen for TTTS MCA dopplers every 2 weeks starting at 20 weeks, screening for TAPS Non-stress tests weekly starting at 32 weeks
47
When do monochorionic/monoacmniotic (MC/MA) delivery?
32-34 weeks Inpt management at 24 weeks d/t risk of sudden cord entanglement
48
Vertex
When the babies head is down (ready for vaginal delivery)
49
What determines the mode of delivery for twin births?
The presentation of the presenting twin (twin A) Both vertex? —> vaginal delivery one vertex, one breech? —> vaginal or cesarean Non-vertex twin a? —> cesarean section ALL MC/MA get delivered by C section (probably d/t cord entanglement problems)
50
Who gets screened for GDM?
``` BMI >30 First degree relative with DM Hx GDM in prior pregnancy Hx macroscomic infant (>4000mg) Physical inactivity (subjective) HgbA1c >7.5% ```
51
How do you screen and dx GDM?
Start with the GCT (Glucose challenge test) This is when give them 50gms of sugar and wait an hour to test their BG which should be below 140 If they fail the GCT then you move on to the 3 hour GTT Give them 100 gm of sugar and test their blood sugar every hour on the hour
52
GCT
50 gm 1 hour wait BG should be below 140 Used as first test for GDM
53
GTT
Used if the GCT test is failed 100gm sugar ``` Positive result if: Fasting BG >95 1hr >180 2hr > 155 3hr > 140 ``` Fail if greater than 2 from those marks
54
What is the treatment for GDM?
Diet Exercise - 3-5x/week 30 min Blood sugar monitoring 4-5 times per day In the morning before food (fasting), 2 hour post prandial, +/- night Goals: Fasting <95 1hr post prandial <140 2hr post prandial <120
55
What are the goals of blood glucose with GDM?
Fasting <95 1hr post prandial <140 2hr post prandial <120
56
A1 GDM vs A2 GDM
A1 - abnormal OGTT but normal fasting and post prandial blood glucose —diet control is enough to manage A2 - abnormal OGTT with abnormal fasting and post prandial blood glucose - medication required
57
What is the preferred medication for GDM?
Insulin
58
What pregnancy risks are present with GDM?
``` PreEclampsia C section Indicated PTB Still birth Macrosomia Shoulder dystocia Neonatal: hypoglycemia, hyperbilirubinemia ```
59
What is the screening and delivery schedule for A1 GDM?
Growth scan every 4 weeks | Delivery by 41 weeks
60
What is the screening and delivery schedule for A2 GDM?
Growth scan every 4 weeks NST (non-stress test) weekly between 28 and 32 weeks Delivery depends on how well controlled the DM is Well controlled - 40 weeks Poorly controlled - 37-39 weeks
61
What is the postpartum GDM management?
Basically nothing Just do a 75g OGTT at 6-12 weeks postpartum since 50% of women with GDM go on to develop DM during their lifetime Then monitor their HgA1c every 3-5 years Their OGTT should be <110 fasting and <140 2hr post prandial
62
What timing during pregnancy differentiates between chronic HTN and gestational HTN?
If HTN <20 weeks —chronic HTN If HTN >20 weeks —Gestational HTN
63
What criteria needs to be met to be dx with gestational HTN?
BP >140/90 x2 >4hr apart >20 weeks GA
64
What is the HTN spectrum with gestation?
``` Gestational HTN | | PreEclampsia without severe features | | PreEclampsia with severe features | | Eclampsia ```
65
How does gestational HTN differ from preeclampsia?
No proteinuria with gestational HTN
66
What are the severe features than can be seen with preeclampsia?
``` HELLP Crt >1.1 Plt <100K Pulmonary edema HA Vision changes Oliguria (<500cc/day) Liver hematoma ```
67
What is the difference between preeclampsia and eclampsia?
Eclampsia has seizures d/t the increase in cerebral edema
68
What is the treatment of preeclampsia?
Delivery
69
What are the risk factors of preeclampsia?
``` Hx of preeclampsia First pregnancy Family hx of preeclampsia T1DM/T2DM Chronic HTN Lupus Antiphospholipid antibody syndrome CKD Multifetal pregnancy Advanced maternal age (>/=35) ```
70
HELLP
Might be seen with severe features of PreEclampsia Hemolysis Elevated Liver Enzymes Low Platelets
71
What is the most common type of HA seen with preeclampsia?
Occipital HA
72
Why don’t gestational HTN pts make it to full term?
Increased risk of still birth
73
What are the common BP meds used in pregnancy?
Labetalol Hydralazine Nifedipine Methyldopa (less common)
74
What additional meds are you giving for HTN for preeclampsia with severe features and eclampisa?
Magnesium sulfate to decrease seizure risk
75
How do you treat seizures from eclampsia?
Lorazepam Immediate delivery
76
ABO vs Rh D?
ABO - IgM - does NOT cross placenta Rh D - IgG - crosses placenta
77
What are the fetal consequences of Rh Incompatibility?
Anemia Hydrops fetalis (skin edema, ascites, pericardial effusion, pleural effusion) Death
78
What is the prevention for Rh incompatibility?
Rhogam (AntiD immunoglobulin) Prevents Rh D alloimmunization Given prophylactically to Rh negative mothers at 28 weeks, within 72 hours of delivery if Rh + fetus, and after any sensitizing event like CVS or ECV
79
What is the mom has antibodies against Rh -?
``` Check titers every 4 weeks If: >1:16 Then: Fetal MCA doppler every 2 weeks ``` PUBS - peri umbilical cord blood sample and fetal RBC transfusion
80
What is considered preterm labor?
<37 weeks 30% spontaneously resolve 50% deliver at term
81
What are the risk factors of preterm labor?
``` Hx of PTL Hx of cervical surgery Uterine malformations Multiple gestation Infection Substance abuse Smoking ```
82
What labs do you need to draw for a mom in preterm labor?
``` Gonorrhea Chlamydia Urinalysis Urine culture Group B strep ``` Inpt admission
83
When are preterm infants considered “viable”?
24 weeks
84
What medications should a preterm infant get?
Bethamethason - for fetal lung maturity - STOP @ 37 weeks Magnesium Sulfate - for cerebral palsy prevention - STOP @ 32 weeks GBS prophylaxis - PCN
85
PROM vs PPROM
Premature rupture of membranes -ROM before onset of labor (contractions) Preterm premature rupture of membranes -ROM <37 weeks AND before onset of labor
86
What do you need to dx premature rupture of membrane?
Sterile speculum exam should show: - Nitrazine - Ferning - Pooling - Amniotic fluid index (AFI)
87
Latency period
Time between rupture (PROM) and delivery 40-50% deliver within 1 week 70-80% deliver within 2-5 weeks
88
Tocolysis
Short term drug given in preterm labor to suppress preterm labor Only given if preterm by 24-32 weeks +/- 32-34 weeks
89
A women is coming in 30 weeks gestation for preterm labor, what do you do?
For all preterm labors 24-32 weeks Bethamethsone for fetal lung maturity Mag sulfate for cerebral palsy prevention Tocolysis to suppress labor GBS prophylaxis - PCN
90
A women is in preterm labor at 33 weeks, what do you do?
For all preterm 32-34 weeks Betamethasone +/- tocolysis GBS prophylaxis (PCN)
91
What drugs can be used for tocolysis?
To suppress pre term labor Nifedipine Indomethacin Terbutaline Mag sulfate (weak)
92
A women comes in for premature rupture of membrane at 30 weeks, what do you do?
``` For all premature ruptures 24-32 weeks: Betamethasone Mag sulfate Tocolysis Latency ABX -IV ampicilin + erythromycin for 2 days -PO amoxicillin + erythromycin for 5 days ``` Delivery at 34 weeks
93
How does the management for a premature rupture of membrane differ between 33 weeks and 30 weeks?
``` 24-32 weeks: Betamethasone Mag sulfate Tocolysis Latency ABX Delivery by 34 weeks ``` ``` 32-34 weeks: Betamethasone Tocolysis Latency ABX Delivery by 34 weeks ```
94
What is the management for rupture of membrane between 34 and 37 weeks?
Betamethasone GBS prophylaxis (PCN) Deliver!
95
For premature rupture of membrane, the goal is to deliver at 34 weeks, under what circumstances would you deliver sooner?
Fetal distress Placental abruption Infection
96
Molar pregnancy put you at risk of GTN, which cancers are these pts most at risk for?
Complete molar pts are more at risk of GTN than partial molar ``` Gestational trophoblastic neoplasia (GTN): Choriocarcinoma PSTT- placental site trophoblastic timor ETT - epitheloid trophoblastic tumor Invasive mole ```
97
If a pt had been treated for molar pregnancy with a D and C, and the BhCG had not gone down, what is your next move?
Remember that with molar pregnancy these BhCGs are super duper high After a D and C we check their BhCG weekly until its less than 5 and then continue to check it monthly for 6 months (these pts need to go on contraception because they can not get pregnant for 6 months) If the BhCG is not going down with the weekly checks, we should start on Methotrexate

Clin Med - Repro (18 decks)

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