OB pregnancy complications Flashcards
(28 cards)
1
Q
Spontaneous Abortion
- definition
- etiology
- 3 biggest risk factors
- sx
A
Definition
-intrauterine pregnancy (aborted) at less than 20 weeks
Etiology
- 60% result from chromosomal defects
- maternal trauma
- infections
- dietary deficiencies
- DM
- hypothyroidism
- anatomic malformations… incompetent cervix
- 25% cannot be determined
Risk factors
- advanced maternal age
- previous spontaneous abortion
- maternal smoking
Sx
- bleeding (bright red, heavy)
- midline cramping
- low back pain
- open or closed cervical os
- complete or partial expulsion of products of conception
2
Q
What are the subtypes of spontaneous abortion?
A
- Threatened:Os closed, unpredictable outcome (this is the only one that might be ok)
- Inevitable: Os open, products of conception have not passed, pregnancy cannot be saved
- Incomplete: Os open, some products of conception have passed
- Complete: Os may be open or closed, products of conception have passed
- Missed: Pregnancy did not develop
3
Q
Threatened Abortion
- sx
- tx
A
Sx
- slight bleeding
- abd cramping
- cervical os is CLOSED
- uterine size compatible with dates
- no products of conception are passed
- prognosis is unpredictable
Tx
- bed rest from 24-48 hours with gradual resumption of usual activities
- -no work, child care, sex
- -rest in horizontal position
- abx ONLY if there are signs of an infection
- hormonal tx is CI
- hydration
4
Q
Inevitable Abortion
-sx
Incomplete Abortion
-sx
Missed Abortion
-sx
A
Inevitable abortion
- moderate bleeding
- moderate to severe uterine cramping
- low back pain
- Cervical os is dilated
- membranes may or may not be ruptured
- uterine size is compatible with dates
- products of conception are not passed, but passage is inevitable
- prognosis is poor, pregnancy cannot be saved
Incomplete abortion
- heavy bleeding
- moderate to severe abd cramping
- low back pain
- cervical os is dilated
- uterine size is compatible with dates
- some portion of the products of conception (usually the placenta) remain in the uterus
- pregnancy cannot be saved
Missed abortion
- pregnancy ceased to develop, but products of conception have not been expelled
- sx of pregnancy disappear
- brownish vaginal discharge but no free bleeding
- pain does not develop
- cervix is semi-firm and slightly dilated
- uterus becomes smaller and irregularly softened
5
Q
Tx of missed, inevitable, incomplete abortion
A
- counseling
- assess Rh factor and administer IG to Rh negative, unsensitized women
- planning for elective termination
- -empty all products of conception to prevent infection and uterine hemorrhage with D&C
- -insertion of laminaria to dilate the cervix followed by aspiration is the method of choice for missed abortion
- -prostaglandin vaginal suppositories are an effective alternative
6
Q
Complete abortion
-sx
Habitual abortions
-defintion
A
Complete abortion
- bleeding may be heavy or minimal
- moderate to severe abd cramping
- low back pain
- fetus and placenta are completely expelled
- pain the ceases, but spotting may persist
- cervical os may be opened or closed
- uterus is normal pre-pregnancy size
Habitual abortions
-considered recurrent pregnancy loss/habitual abortions if 3 previous pregnancies
7
Q
Spontaneous abortion
- evaluation
- follow up
A
- H and P
- physical exam including pelvic exam and visualization of cervix
- +/- fetal doppler, transvaginal US, lab eval for hCG and Rh
Follow up
- GYN exam in 2-3 weeks after termination
- use contraception for 3 months to allow complete maternal healing and regeneration of endometrial lining
8
Q
Recurrent pregnancy loss
- most useful tests
- others
A
Most useful tests
- assessment of uterine structure
- Anticardiolipin antibody, lupus anticoagulant…lupus
- TSH
Less useful tests
- blood glucose
- genetic (maternal and paternal)
- day 3 FSH levels
- progesterone
9
Q
Ectopic Pregnancy
- definition
- MC site of implantation
- course
A
Definition
-implantation of fertilized ovum outside of the uterine cavity
Implantation
- MC (98%) is fallopian tube
- cervix
- ovary
- abd cavity
Course
- rupture is inevitable (could also spontaneously resolve or abortion)
- major cause of maternal death in the first trimester**
10
Q
Ectopic Pregnancy
- risk factors
- presentation
A
Risk factors
- hx of genital infections
- hx of infertility
- hx of tubal pregnancy (ligation or reconstruction)
- hx of any ectopic pregnancy
- IUDs
- intrauterine exposure to DES (synthetic estrogen…bad)
Classic Presentation
- 1-2 months amenorrhea
- morning sickness
- breast tenderness
- diarrhea, urge to defecate
- malaise and syncope
- lower abd pain/pelvic pain (sudden and severe, especially adnexal)
- referral of pain to shoulder
Atypical presentation
- vague or subacute sx
- menstrual irregularity
11
Q
Ectopic Pregnancy
- PE
- Dx
- Tx
A
PE
- tachycardia, hypotension
- adenexal, cervical motion, and/or abd tenderness on pelvic exam
- normal appearing cervix, marked tenderness
- vaginal vault may be blood, usually brick red to brown in color
- tender adnexal mass may be palpated
Dx
- hCG (will be lower than expected for normal pregnancies for the same duration
- CBC (anemia or slight leukocytosis)
- Rh factor
- transvaginal US (will should empty uterine cavity)
- **an hCG level of 6500mU/ml with an empty uterine cavity by US is diagnostic of ectopic pregnancy
- Laparoscopy is definitive
Tx
- remember, this may kill your pt! be vigilant about vital signs and maintaining IV access
- emergency surgery*** is the only thing that can save them once rupture with hemorrhage has occurred
- pt with tachycardia, hypotension, and a positive pregnancy test needs surgery before they bleed out*
- medical management
12
Q
Ectopic Pregnancy
- indications for surgery
- medical management
- follow up
A
Indications for surgery
- hemodynamic instability
- impending or ongoing ectopic mass rupture
- not able or willing to comply with medical therapy post treatment follow up
- lack of timely access for medical care in case of tube rupture
- failed medical therapy
Medical management
- Methotrexate
- -acceptable for EARLY ectopic pregnancy who are:
- hemodynamically stable
- are willing and able to comply with post tx follow up
- have hCG less than 5000mIU/ml
- have no fetal cardiac activity
- size of ectopic is less than 3.5 cm with no active bleeding
Follow up
- Rh immunoglobulin for Rh-negative women
- contraception for at least 2 months to allow for adequate tissue healing and repair
- pelvic rest until b-hCG is negative (no sex)
- F/U appt within 2 weeks of surgery
13
Q
Gestational Trophoblastic Disease
- types
- MC type
A
Types
- Hydatiform mole (MC)
- Choricarcinoma
14
Q
Hydatiform mole
- what is this
- occurs when
- describe partial vs complete
- risk factors
- presentation
A
What
-BENIGN neoplasm of the chorion in which chorionic villi degenerate and become transparent vesicles containing clear, viscous fluid
Occurs when a single sperm fertilizes an egg without a nucleus
Partial-a fetus or evidence of an amniotic sac is present
Complete- no fetus or amnion is found. have tendency ro become choricarcinoma
Risk factors
-low SES
-hx of mole
age below 18 or over 40
Presentation
- vaginal bleeding
- enlarged uterus
- pelvic pressure or pain
- theca lutein cysts
- anemia
- hyperemesis gravidarum
- hyperthyroidism
- preeclampsia before 20 weeks gestation
- vaginal passable of hyfropic vesicles
- no fetal hear tones or activity
15
Q
Hydatiform Mole
- Dx
- Tx
A
Dx
- hCG (will be extremely high for gestational age)
- US (absence of gestational sac, characteristic multiple echogenic region “snowy” within the uterus)
- CXR to rule out pulmonary mets of trophoblast
Tx
- D&C immediately
- effective birth control
- weekly quantitative hCG
- no pregnancy until hCG levels remain normal for a minimum of 1 year***
16
Q
Choricarcinoma
- what is this?
- tx
A
What
- highly malignant GTTD
- malignant tumor cells enter the circulation through open blood vessels in the endometrial cavity and are transported to lungs, brain, or other sites
- causes ulcerating surfaces into the endometrial cavity
Tx
- Chemo (DOC)
- surgery only if tumor is resistant to chemo and single mets persisting despite chemo
17
Q
4 major causes of bleeding in the first timester
A
- Physiologic (implantation)
- ectopic pregnancy
- impending of complete abortion
- cervical, vaginal, uterine pathology
- polyps, inflammation, infection, trophoblastic disease
18
Q
Placenta Previa
- what is this
- types
- risk factors
A
What
-placenta implanted in lower segment of the uterus and extends over or lies proximal to the internal cervical os
Types
- total or complete:entire os is covered
- partial: internal os partially covered
- Marginal or low-lying: edge of placenta at os but does not cause obstruction
Risk Factors
- previous placenta previa
- multiparity
- multiple gestation
- previous c section
- trauma
- smoking
- advanced maternal age
- infertility tx
19
Q
Placenta Previa
- presentation
- dx
- tx
A
Presentation
- painless bleeding in 3rd trimester
- bright red blood
- may have shick sx if bleeding severe
- VS stable
- FHT(fetal heart tones) normal
- fetal activity present
Dx
- US***
- NO VAGINAL OR SPECULUM EXAM SHOULD BE DONE
Tx
- acute bleeding episode
- -supportive care to maintain hemodynamic stability
- -FHT monitor
- -IV NS or LR
- -Mag sulfate and corticosteriods if in labor and less than 34 weeks
- Indications for delivery
- -nonreassuring FHT
- -LTB(life threatening maternal hemorrhage)
- -significant vaginal bleeding after 34 weeks
20
Q
Abruptio Placentae
- What
- common in what trimester
- Outcome
- risk factors
A
What
-partial or complete detachemnt of a normally implanted placenta at any time prior ro delivery
More frequent during 3rd trimester, but may occur anytime after 20 weeks gestation
Outcome
-significant cause of maternal and fetal morbidity and mortality
Risk Factors
- previous abruption
- abd trauma
- cocaine
- smoking
- eclampsia
- pregnancy induced HTN
21
Q
Abruptio Placentae
- Presentation
- maternal complications
- fetal complications
- Dx
- Tx
A
Presentation
- Vaginal bleeding (mild to severe, amount does not correlate with degree of separation
- abd or back pain
- uterine contractions
- uterine tenderness
- nonreassuring fetal heart rate pattern
Maternal complications
- hemorrhagic shock
- coagulopathy/DIC
- uterine rupture
- renal failure
- ischemic necrosis of distant organs
Fetal complications
- hypoxia, anemia, growth retardation
- CNS abnormalities, fetal death
Dx
- elevated AFP with no other explanation and elevated hCG
- fibrinogen to evaluate for DIC
- **ultrasound (classic finding is retroplacental hematoma)
Tx
- these pts can have sudden worsening of abruption at any time so be prepared for the worst
- continuous fetal monitoring
- IV access, maintain maternal O2 sats
- CBC, blood typing, coag studies
- Tx of DIC as indicated
- may require delivery of baby (if over 36 weeks or severe abruption, deliver regardless)
22
Q
Placenta Accreta
- definition
- associated with a hx of what (3)
- risks associated
- Tx
A
Definition
-the placenta attaches too deeply into the wall of the uterus
Associated with a hx of prior c section, uterine surgery, or placenta previa
Risks
- preterm delivery
- severe postpartum hemorrhage
Tx
- try to get them as far along in the pregnancy as you can
- little can be done for tx once placenta accreta has been dx
- monitor pregnancy with the intent of scheduling a delivery and using a surgery that may spare the uterus
- hysterectomy may be needed
23
Q
Hyperemesis Gravidarium
- definition
- evaluation
- tx
A
Definition
- persistent, severe, intractable vomiting during pregnancy
- wt loss of 5% or more of pre-pregnancy weight
- Ketonuria not from other causes in the 1st trimester
Evaluation
- weight
- orthostatic vital signs
- urinalysis (looking for ketones)
- Electrolytes
- US to rule out gestational trophoblastic disease or multiple gestation
Tx
- hospitalization with bed rest
- NPO x 48hrs
- maintain hydration and electrolyte balance and vitamins
- asap, place pt on a dry diet consisting of 6 small feedings daily plus clear liquids
- !st line: vitamin B6 (25mg po TID or QID) + Doxylamine (Unisom) OTC 25-50 mg po Q4-6 hrs
- 2nd line: DC doxylamine and try compazine (prochlorperazine) or Reglan (metaclopramide)
- 3rd line: zofran
- IV fluids with thiamine if dehydration is noted
- glucocorticoids after the 1st trimester
- TPN is unable to keep anything down
24
Q
Preterm Premature Rupture of the Membranes (PPROM)
- dx
- tx
A
Dx
- can be clinical: visualization of fluid in the vagina of a pregnant woman who presents with a hx of leaking fluid
- pH paper (nitrazine test): amniotic fluid will be around 7, vaginal wall fluid will be around 4
- Ferning
- US
- Instillation of indigo carmine into amniotic fluid
- placental alpha microglobulin-1 protein assay (amnisure) $$$
- placental fibronectin
Tx
- if unstable, deliver
- if stable, kepp in the hospital until delivery
- -administer abx, steroids, and monitor for stability of mother and baby
- -deliver at 34 weeks
25
Describe ferning
- fluid from posterior vagina swabbed onto a glass slide and allowed to dryfor 10 min
- amniotic fluid=delicate fern pattern
- cervical mucous=dense and thick fern pattern
26
Diabetes
- carries a risk of congenital abnormalities if HgA1C is greater than what
- mothers at an increased risk for what
- risks to the fetus
- management
-carries a risk of congenital abnormalities if HgA1C is greater than 9.5%
- mothers at an increased risk for DKA
- 2x risk of pregnancy induced HTN or pre-eclampsia
Risks to the fetus
- congenital abnormalities
- increased risk of spontaneous abortion
- Macrosomia
- uteroplacental insufficiency and IUGR (intrauterine growth retardation)
- polyhydramnios (amniotic fluid greater than 2L)
- sjoulder dystocia
Management
- Frequent BG monitoring
- Aim for optimal glucose control through diet, exercise, and insulin therapy
- insulin requirements increase throughout pregnancy, most markedly at 28-32 weeks
- requires follow up every 1-2 weeks for the first 2 trimesters and then weekly during third
27
Gestation DM
- when is screening done? What test is done?
- Tx
- Screening 24-28 weeks with a 50g one hour oral glucose challenge
- -if BG greater than 140, they need a 3 hour glucose tolerance test
Tx
- mainstay is diet and maintain 30kcal/kg of IBW/day
- blood sugar goals
- -fasting: less than 95
- -1 hr post prandial: 130-140
- -2 hr post prandial: less than 120
- if unable to attain goals, move to insulin therapy and start metformin
28
Thyroid disease
- tx of hypothyroidism
- how long might this last?
- why does this occur?
Tx of hypothyroidism is levothyroxine
Post partum thyroiditis can occur for up to a year post delivery
Why
-thyroid binding globulins increase during pregnancy
*if hyperthyroid pre-pregnancy, likely will need to adjust meds during pregnancy
