medical conditions in pregnancy Flashcards
(27 cards)
placenta previa
Pathology
-placenta extends over and covers cervix
Risk
- prior C section
- prior previa
- multiple gestation
- advanced maternal age
Clinical features
-asymptomatic, diagnosed on 2nd trimester US
Management
- pelvic rest
- most resolve due to lower uterine segment lengthening or placental growth toward fundus
- persistent undergo C section at 36-37 weeks
complications
- early cervical changes
- partial detachment
- massive maternal hemorrhage
Complete hydatidiform mole
pathology
- abnormal fertilization of an empty ovum
- one sperm duplicates genome
- or two sperms
Clinical
- uterine size greater than gestational age
- first trimester vaginal bleeding
- markedly elevated beta hCG
US
- swiss cheese
- snowstorm
- no fetus
- no amniotic fluid
- theca lutein cysts –> ovarian hyperstimulation
Treatment
- suction curettage
- risk of malignant transformation
- serial monitoring of hCG levels
Second stage arrest of labor
Second stage: cervix is 10cm dilated
definition
-insufficient descent after pushing more than 3 hours in nulliparous or 2 hours in multiparous
risk factors
- maternal obesity
- excessive pregnancy weight gain
- DM
Etiology
- cephalopelvic disproportion
- malposition (anything other than occiput anterior)
- inadequat contractions
- maternal exhaustion
management
- operative vaginal delivery
- C section
late decelerations
- sign of uteroplacental insufficiency
- impending fetal hypoxemia and acidemia
uterine tachysystole
- more than 5 contractions in 10 mins
- can occur spontaneously
- increased risk with induced or augmented labor (uterotonic agents like oxytocin)
management
- supportive
- discontinue uterotonic agents
intraamniotic infection (chorioamnionitis)
Risk
- prolonged rupture of membranes
- preterm premature rupture of membranes
- prolonged labor
- internal fetal/uterine monitoring devices
- repetitive vaginal examinations
- presence of genital tract pathogens
Diagnosis
- maternal fever plus one of the following
- fetal tachycardia (over 160)
- maternal leukocytosis
- purulent amniotic fluid
Management
- broad spectrum antibiotics
- delivery
complications
- maternal: postpartum hemorrhage, endometritis
- neonatal: preterm birth, pneumonia, encephalopathy
preeclampsia
DEFINITION
- new onset HTN at over 20 weeks gestation
- proteinuria and or end organ damage
SEVERE FEATURES
- thrombocytopenia
- increased creatinine
- increased transaminases
- pulmonary edema
- visual or cerebral symptoms
MANAGE
- without severe features: delivery at over 37 weeks
- with severe features delivery at over 34 weeks
- mg sulfate
- antihypertensives
NEONATES
-fetal growth restriction
Wernicke encephalopathy
ASSOCIATED CONDITIONS
- chronic alcholism
- malnutrition
- hyperemesis gravidarum
PATHOPHYS
-thiamine deficiency
CLINICAL
- encephalopathy – AMS
- oculomotor dysfunction
- postural and gait ataxia
- absent reflexes
TREATMENT
-IV thiamine then glucose
hyperemesis gravidarum
RISK
- hydadidiform mole
- multifetal gestation
- hx of hyperemesis
CLINICAL
- sever, persistent vomiting,
- > 5% weight loss in pregnancy
- dehydration
- orthostatic hypotension
LABS
- hypochloremic metabolic acidosis
- hypokalemia
- elevated serum aminotransferases
- ketonuria
- hemoconcentration
MANAGE
- antiemetics
- fluids
- thiamine supplementation
COMPLICATIONS
-spontaneous abortion
eclampsia
Definition
-severe preeclampsia plus seizures
CLINICAL
- hypertension
- proteinuria
- severe headaches
- visual disturbances
- RUQ or epigastric pain
- 3-4 mins of tonic clonic seizure
MANAGE
- administer mg sulfate
- administer antihypertensives
- deliver the fetus
chronic hypertension
- systolic over 140
- diastolic over 90
- prior to conception or 20 weeks gestation
gestational hypertension
- new onset after 20 weeks gestation
- no proteinuria or end organ damage
chronic hypertension with superimposed preeclampsia
-chronic hypertension and one of the following
new onset proteinuria or worsening proteinuria at more than 20 weeks gestation
sudden worsening hypertension
signs of end organ damage
Intrahepatic cholestasis of pregnancy
PATHOPHYS
-increased estrogen and progesterone causing stasis and decreased bile excretion
CLINICAL
- develops in 3rd trimester
- generalized pruritis worse on palms and soles
- no associated rash
- RUQ pain
LAB
- elevated total bile acids
- elevated transaminases
- elevated total and indirect bilirubin
OBSTETRIC RISK
- intrauterine fetal demise
- preterm delivery
- meconium-stained amniotic fluid
- neonatal RDS
MANAGEMENT
- ursodeoxycholic acid (first line)
- delivery at 37 weeks gestation
- antihistamines
Complications of inappropriate weight gain in pregnancy
GAIN
- gestational DM
- fetal macrosomnia
- c section
LOSS
- fetal growth restriction
- preterm delivery
Uterine inversion
-potentially fatal cause of PPH
RISK
- nulliparity
- fetal macrosomnia
- placenta accreta
- rapid labor and delivery
PATHOGEN
-excessive fundal pressure and traction on umbilical cord before separation
CLINICAL
- smooth round mass protruding through cervix or vagina
- unterine fundus in no longer palpable
- hemorrhagic shock
- lower abdominal pain
MANAGEMENT
- agressive fluid replacement
- manual replacement of uterus
- placental removal and uterotonic drugs after replacement
PPROM
Defintion
-membrane rupture at less than 37 weeks
RISK
- prior PPROM
- genitourinary infection
- antepartum bleeding
DIAGNOSIS
- vaginal pooling or fluid from cervix
- nitrazine positive fluid
- ferning on microscopy
MANAGE
- less than 34 weeks with reassuring fetal–> latency antibiotics, corticosteroids
- less than 34 weeks non reassuring –> deliverys
- over 34 weeks –> delivery
COMPLICATIONS
- preterm labor
- intraamniotic infection
- placental abruption
- umbilical cord prolapse
gestational DM
Target levels
- fasting less than 95
- 1 hour less than 140
- 2 hour less than 120
treatment
- diet first
- insulin, metformin
SLE nephritis in pregnancy
CLINICAL
- edema
- malar rash
- arthritis
- hematuria
LAB
- nephritic range proteinuria
- urinalysis with RBC and WBC casts
- low complement levels
- increased ANA titers
DIAGNOSIS
-renal biopsy
OBSTETRIC COMPLICATIONS
- preterm birth
- c section
- preeclampsia
- fetal growth restriction
- fetal demise
Neonatal thyrotoxicosis
PATHOPHYS
- transplacental passage of maternal anti-TSH receptor antibodies
- antibodies bind to infant’s TSH receptors and cause excessive thyroid hormone release
CLINCAL
- warm, moist, skin
- tachycardia
- poor feeding, irritability, poor weight gain
- low birth weight or preterm birth
DIAGNOSIS
-maternal anti TSH receptor antibodies (500% of normal)
TREAT
- self resolves in 3 months
- ethimazole plus beta blockr if symptomatic
Antiphospholipid syndrome
DIAGNOSIS -vascular thrombosis and or -pregnancy complication PLUS -anti-cadriolipin antibody -lupus anticoagulant -anti beta 2 glycoprotein antibody
CLINICAL
- recurrent pregnancy loss
- prior TIA
MANAGE
-anticoagulation with heparin or warfarin
Diabetic nephropathy
- significant proteinuria prior to 20 weeks gestation
- glomerular hyperfiltration
- acceleration of renal disease during pregnancy
- HTN is a common complication due to excess sodium retention and activation of RAAS
acute cholangitis
ETI
-ascending infection due to biliary obstruction
CLINICAL
- fever
- jaundice
- RUQ pain
- +/- hypotension, AMS
DIAGNOSIS
- increased direct bili, alk phos
- mildly increased aminotransferases
- biliary dilation on abdominal us or ct scan
TREAT
- antibiotic coverage of enteric bacteria
- biliary drainage by ERCP within 24-48 hours
acute appendicitis in pregnancy
CLINICAL
- atypical due to cephalad displacement by gravid uterus
- right mid-to-upper quadrant or right flank pain
- fever, nausea, vomiting
- rebound and guarding
obstetric symptoms
- uterine irritability and contractions
- fetal tachy (secondary to maternal fever)
RISK
- delayed diagnosis
- increased risk of complications
MANAGE
-immediate surgery
