Lecture 73, 74 - Disease of Pregnancy

Question 1

Where is the most common location for an ectopic pregnancy

Answer 1

Ampulla of the Fallopian tube (region of first narrowing)

Question 2

Risk Factors for Ectopic Pregnancy

Answer 2

prior PID (salpingitis, endometritis)

Previous Tubal Ligation

Previous ectopic

Smoking

Question 3

what is the classic triad of symptoms for ectopic pregnancy

Answer 3

amenorrhea, vaginal bleeding, sudden abdominal pain

Question 4

Dx of Ectopic Pregnancy:
Requisite labs:

Gold standard Dx Procedure

Other dx procedures

Answer 4

hCG levels usually rise at a much slower rate based on dates

Gold standard: Laproscopy – direct visualization

D&C - absence of chorionic villi

Ultrasound -

Question 5

Treatment of Ectopic Pregnancy:

Medical vs Surgical

who gets which method?

Answer 5

Medical: Methotrexate (anti folic acid), but has lots of side effects and pt must be followed by HCG tracking to make sure the treatment worked

Surgical – Conservatinve mangement (don;t take out anything) vs Salingectomy

Hemodynamically unstable patients need surgery

Question 6

Chronic HTN during Pregnancy

outcomes?

Answer 6

patient has kind of HTN before pregnancy

25% develop chronic HTN or Pre-eclampsia

usually no complications

Question 7

Gestational HTN
what is it?
how is it dx?

Answer 7

BP > 140/90 after 20th week of gestation (no pre-existing HTN). No proteinuria.

BPs measures at least twice, at least 4 hours apart

Blood pressures should be normalized 6 weeks after delivery

Question 8

Pre-eclampsia

Answer 8

new onset HTN after 20th week of gestation + Proteinura and/or end organ damage (TTP, Kidney damage, Liver damage, Pulm Edema, Visual symptoms; cerebral swelling)

Question 9

RF for preeclampsia

Answer 9

Nulliparty, extremities of age, African american, chronic HTN, Chronic renal disease, DM, Multifetal gestation

Question 10

Prevention of progression of pre-eclmapsia to eclampsia

Answer 10

Mg Sulfate

Question 11

Eclampsia

Answer 11

Pre-eclampsia + seizures

Question 12

HELLP Syndrome

Answer 12

Hemolysis, Elevated Liver Enzymes, Low Platelets

Question 13

describe what happens to a woman’s blood pressure normally during pregnancy ?

Answer 13

drops in BP due to increased volume and drop in vascular resistance, and continues to drop until 32 weeks, until it starts to climb back up

Maternal blood volume almost doubles in pregnancy

Question 14

pathophysiology of pre-eclampsia in pregnancy

what is the organ at fault?

what are the meditators of a healthy endothelium ?

what are the mediators which inhibit healthy endothelium?

Answer 14

Placental Dysfunction – not enough syntiotrophoblasts invasion, therefore the vessels of materanal fetal exchange are not compliant enough. Incomplete invasion of the myometrium

TGFB1 and VEGF = healthy endothelial function

sEng and SFLT1 - bind and deactivate TGFB1 and SFLT1

Question 15

what organs can be damaged due to poor endothelial funciton during pre-eclampsia?

what is a fatal complication?

Answer 15

Kidney – Proteinuria, Increased Cr, and BUN

Brain - HA, , Sz, Stroke

Liver - RUQ Pain, increased LFTs, TTP

Liver Rupture = Fatal

Vessels = Vasocontstriction – Microvascular hemolysis
Edema

Question 16

what is the only resolution for pre-eclampsia

Answer 16

i. The only resolution is delivery bc the source of the problem is the placenta

Question 17

Pre-eclampisa –

mother is at term: what is the treatment?

wmother is preterm: what is the treatment protocol ?

Answer 17

If Term –> Mg Sulfate to prevent sz and proceed with delivery

Pre term –>
With severe features: mg sulfate and deliver

Without severe features: expectant management until term or severe

Question 18

PRETERM LABOR –

definition?

Answer 18

uterine contractions between 20 and 36 weeks

Question 19

what normally induces contraction in the uterus? describe the cascade

what is inhibiting this cascade?

Answer 19

CRH – activates fetal pituitary and adrenal glands –> ACHT and Cortisol —> estrogen and prostaglandins —> Positive feedback with CRH –> other substances that lead to contractions of the myometrium

Inhibitng the cascade;
Progesterone inhibits CRH
CRH BP decreases free CRH

Question 20

what else can induce the contraction process?

Answer 20

Inflammation, Over distention (twins), Hemorrhage

Question 21

Risk factors for pre-term delivery:

what is #1

Answer 21

1) H/o prior pre term delivery

other: Infection, Placental abn, Smoking, Multiple gestastion, Bleeding during pregnancy

Question 22

Dx of pre term delivery –

what visualization/recording modalitites?

What ultrasound finding?

what is a good serum marker and why?

Answer 22

Tocogram - record contractions

Cervical Change – advance in dilation

US; Shorter cervical length

Fetal Fibronectin – Found in the ECM of the amniotic sac; will be present in vaginal secretions in delivery and PTL

If negative == Powerful predictor of not being in pre-term labor

Question 23

what three drugs are administered in the management of PTL,

what are the reasons for each?

Answer 23

Steroids – promote lung maturity

Tocolysis – stop contractions long enough to administer steroids

Antibiotics: Prophylaxis for GBS

Question 24

what drugs are used for tocolysis:

mechanisms for each

Answer 24

MG Sulfate – competes with calcium

Nifedipien – ca channel blocker

Indomethacin – indomethacin

Question 25

Preterm Premature Rupture of Membranes (PPROM) what is it Risks

Answer 25

rupture of amniotic membranes prior to onset of labor at < 37weeks Infection Cord Prolapse -- Placental abruption -- loss of fluid around the baby; Pulmonary Hypoplasia

Question 26

how is the dx made? what three things are found

Answer 26

pooling - of amniotic fluid in the vagina Nitrazine positive -- alkaline fluid (indicates amniotic fluid) ferning -- NaCl crystals indicating amniotic fluid

Question 27

mangment of PPROM contraindciations

Answer 27

managment: - watchful waitng - Abx for GBS - STeroids for lung maturity - Tocolysis until completion of steroids Contraindications - - infection already present - pregnancy > 34 weeks

Question 28

Placenta previa common presenting symptom: management:

Answer 28

placenta attachement over or in close proximity to the internal cervical os painless bleeding in the third trimester management: watchful waiting until term Then proceed with C -section

Question 29

Placental Abruption common prsenting symptom what can cause it? (classically, what behavior causes it in baltimore) management:

Answer 29

Placenta Separates prematurely from the uterine wall before delivery of the infant Abrupt Painful vaginal bleeding + abdominal discomfort and uterine contracttions in the third trimester Abrupt Painful vaginal bleeding + abdominal discomfort and uterine contracttions in the third trimester management: IV Fluids, blood products C -section

Question 30

Morbidly Adherent Placenta: what is it? what are three subtypes? most common RF:

Answer 30

Defective decidual layer -- abnormal attachment and separation after delivery Placenta Accreta, Increta, Percreta RF: Previous C section; placenta previa, HTN, Smoking,

Question 31

Placenta Accreta, Increta, Percreta differences between the three

Answer 31

accreta -- placenta attaches to myometrium but not penetrating Increta -- placenta penetrates into myometrium Percreta -- placenta penetrates through myometrium and into serosa

Question 32

why is the incidnce of Morbidly Adherent Placenta increasing?

Answer 32

Increasing Rate due to increasing rate of C section deliveries

Question 33

MULTIFETAL GESTATION complications:

Answer 33

``` PTL -- (due to over distention) Spontaenous Abortion Gestational DM Preeclampsia Maternal Hemorrhage ```

Question 34

time line for the following: Monochorionic and monoamniotic Dichorionic diamniotic Conjoined twins Monochorionic diamniotic which is at risk for twin twin transufion syndrome which is at risk for cord entaglement

Answer 34

4 day split: Dichorionic + Diamniotic 4-8 day split: Mono chorionic + Diamniotic - Twin twin infusion 8-13 day split: Monochroic + Monoamniotic - Cord entanglement >13 day split = Conjoined twins

Question 35

Twin-Twin Transfusion Syndrome what is it how is it managed?

Answer 35

Monochorionic Diamniotioc twins Vascular anastomoses between the two twins; Donor: impaired growth, hypovolemia, anemia, etc recipient: Hypervolemia, CHF, HTN, Treat: laser separation of the anastamosis