Pregnancy complications

Question 1

What is a spontaneous abortion? How many occur in first semester? Risk after 15 wks?

Answer 1

• intrauterine preg at less than 20 wks - after 20 wks considered a still birth
• about 80% occur in first trimester
• after 15 wks risk is 0.6%
• overally almost 20% of all cinincally recognized pregnancies terminate in spontaneous abortion

Question 2

Etiology of spontaneous abortion?

Answer 2

• 60% result from x’somal defects
• 15% assoc with:
  maternal trauma
  infections
  dietary deficiencies
  DM
  hypothyroidism
  anatomic malformations- incompetent cervix
• 25% can’t be determined

Question 3

What are the biggest RFs for spontaneous abortion?

Answer 3

• advanced maternal age
• previous spontaneous abortion
• maternal smoking

Question 4

Sxs of a spontaneous abortion?

Answer 4

• bleeding: bright red mostly, heavy - saturating pads
• midline cramping
• low back pain
• open or closed cervical os
• complete or partial expulsion of products of conception

Question 5

Subtypes of spontaneous abortion?

Answer 5

1. threatened: Os closed, unpredictable outcome (pregnancy may still be viable)
2. inevitable: Os opened, products of conception have not passed, pregnancy can’t be saved
3. incomplete: os open, some products of conception have passed
4. complete: os may be open or closed, products of conception have passed
5. missed: pregnancy didn’t develop

Question 6

Signs and sxs of threatened abortion?

Answer 6

• slight bleeding
• abdominal cramping
• cervical os is closed
• uterine size is compatible with dates
• no products of conception are passed
• prognosis is unpredictable

Question 7

Tx measures for threatened abortion?

Answer 7

• bed rest from 24-48 hrs with gradual resumption of usual activities
• no work, no child care responsibilities
• rest in horizontal postion except when bathing or using toilet
• no sex
• abx only if there are signs of infection
• hormonal tx is CI
• hydration
• explicit instructions on when to report signs and sxs
• definitive f/u date

Question 8

What ar the signs and sxs of an inevitable abortion?

Answer 8

• 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 can’t be saved

Question 9

Signs and sxs of an incomplete abortion?

Answer 9

• heavy bleeding
• moderate to severe abdominal cramping
• low back pain
• cervical os is dilated
• uterine size is compatible with dates
• some portion of productions of conception (usually placenta) remain in uterus
• pregnancy can’t be saved

Question 10

What is a missed abortion?

Answer 10

• pregnancy ceased to develop but products of conception haven’t been expelled
• sxs of pregnancy disappear
• brownish vaginal d/c but no free bleeding
• pain doesn’t develop develop
• cervix is semi-firm and slightly dilated
• uterus becomes smaller and irregularly softened

Question 11

Tx for missed, inevitable and incomplete abortions?

Answer 11

• counseling regarding fate of pregnancy
• assess Rh factor and admin immunoglobulin to Rh negative, unsensitized woman
• planning for elective termination:
  empty all products of conception to prevent infection and uterine hemorrhage with DandC
  insertion of laminaria to dilate cervix followed by aspiration is method of choice for missed abortion
  prostaglandin vaginal supps are an effective alternative

Question 12

Signs and sxs of a complete abortion?

Answer 12

• bleeding may be heavy or minimal
• moderate to severe abdominal cramping
• low back pain
• fetus and placenta are completely expelled
• pain then ceases, but spotting may persist
• cervical os may be opened or closed
• uterus is normal pre-pregnancy size

Question 13

What are habitual abortions?

Answer 13

• considered recurrent pregnancy loss/habitual abortions if 3 previous pregnancies
• 3 previous pregnancies - 70-80% chance of carrying a fetus to viability
• 4 or more - 65-70% chance of carrying a fetus to viability

Question 14

Eval of suspected spontaneous abortion?

Answer 14

• hx
• PE including pelvic exam and visualization of cervix
• +/- fetal doppler
• +/- transvaginal US
• lab eval:
  serum hCG (should double normally)
  blood type and ab screen if suspected RH negative mother

Question 15

Workup for recurrent pregnancy loss?

Answer 15

• most useful tests:
  assessment of uterine structure, rule out lupus (anticardiolipin ab, lupus anticoag), TSH
• less useful tests:
  blood glucose
  genetic (only if other testing normal): maternal and paternal
• day 3 FSH levels
• progesterone levels

Question 16

F/U for spontaneous abortion?

Answer 16

• GYN exam 2-3 wks after termination
• use contraception for 3 months to allow complete maternal healing and regeneration of endometrial lining
• follow hCG (make sure it goes back down)

Question 17

What is an ectopic pregnancy? Sites?

Answer 17

- implantation of fertilized ovum outside of the uterine cavity:
fallopian tube: MC site (98%)
cervix
ovary
in abdominal cavity
- rupture is inevitable
- potentially life threatening condition
- incidence: 1/80 pregnancies
- Major cause of maternal death during 1st trimester

Question 18

RFs for ectopic pregnancy? Lower risk factors?

Answer 18

RFs:

• hx of genital infections (PID)
• hx of infertility
• hx of tubal pregnancy (ligation or reconstruction)
• hx of any ectopic pregnancy
• IUD

lower risk:

• abdominal or pelvic surgery
• hx of ruptured appendix
• intrauterine exposure to DES
• use of drugs that slow ovum transport (mini-pill)

Question 19

DES - shown to cause what?

Answer 19

• given to preg ladies from 1940-1970 b/c of the belief it would reduce complications and miscarriages
• cause rare vaginal tumor in girls and young women exposed to drug in utero
• daughters also have slightly increased risk of breast cancer after 40

Question 20

Natural hx of ectopic pregnancy?

Answer 20

• rupture: assoc with profound hemorrhage that can be fatal
• abortion: expulsion of products of conception through fimbria and absorption of tissue
• some can spontaneously resolve

Question 21

Classic presentation of ectopic pregnancy?

Answer 21

• 1-2 months of amenorrhea
• morning sickness
• breast tenderness
• diarrhea, urge to defecate
• malaise and syncope
• lower abdominal/pelvic pain: sudden and severe, especially adnexal (lateralizes to one side)
• referral of pain to shoulder

Question 22

Atypical presentation of ectopic pregnancy?

Answer 22

• vague or subacute sxs
• menstrual irregularity
• signs and sxs don’t always correlate with severity of condition

Question 23

PE - on pt with suspected ectopic pregnancy?

Answer 23

• vital signs may reveal orthostatic changes: tachycardia, hypotension
• adnexal, cervical motion and or abdominal tenderness on pelvic exam
• pelvic exam: normal appearing cervix, marked tenderness, vaginal vault may be bloody, usually brick red to brown in color
  tender adnexal mass may be palpated
• This can KILL your PT
• be vigilant about vital signs and maintaining IV access
• emergency surgery is only thing that can save them once rupture with hemorrhage has occurred: pt w/ tachycardia, hypotension and + pregnancy test needs surgery b/f they bleed out

Question 24

Differential once you have ruled out ectopic pregnancy?

Answer 24

• PID
• ovarian cyst
• ovarian tumor
• intruterine pregnancy
• recent spontaneous abortion
• early hydatidifrom degeneration
• acute appendicitis
• other bowel related disorders

Question 25

Labs for suspected ectopic pregnancy?

Answer 25

- b-hCG: will be lower than expected for normal pregnancies of sam duration if followed over few days: there may be slow rise or plateau rather than near doubling q 2 days assoc with normal PG or falling levels assoc with spontaneous abortion - CBC: may show anemia or slight leukocytosis - Rh factor

Question 26

Imaging for suspected ectopic pregnancy? What is the correlation b/t US and hCG?

Answer 26

- transvaginal US: empty uterine cavity - correlation b/t U/S and hCG - hCG level of 6500 U/ml with an empty uterine cavity by US virtually dx of ectopic pregnancy

Question 27

Dx and tx of ectopic pregnancy?

Answer 27

- laparoscopy is definitive - depending on size of ectopic and whether or not it has ruptured, salpingostomy with removal of ectopic or partial or complete salpinectomy can be performed pelvicscopically - may need laparotomy to manage if severe

Question 28

Indications for surgical management for ectopic pregnancy?

Answer 28

- hemodynamic instability - impending or ongoing ectopic mass rupture - not able or willing to comply with medical therapy post tx f/u - lack of timely access for medical care in case tube rupture - failed medical therapy

Question 29

Medical management of ectopic pregnancy?

Answer 29

- methotrexate given systemically as a single or multiple doses is acceptable medical therapy for early ectopic pregnancy who are: - hemodynamically stable - are willing and able to comply with post tx f/u - have an hCG of less than or equal to 5000 miU/mL - have no fetal cardiac activity - size of ectopic is less than 3.5 cm with no active bleeding - MTX: stops growth of cells and most times will absorb (still taking a risk - could rupture)

Question 30

F/U after tx of ectopic pregnancy?

Answer 30

- 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 - F/U appt w/in 2 wks of surgery

Question 31

What are the 4 types of gestational trophoblastic disease?

Answer 31

1. hydatidiform mole 2. persistent/invasive gestational trophoblastic neoplasia 3. choriocarcinoma 4. placental site trophoblastic tumors

Question 32

What is a hydatidiform mole? Diff b/t partial and complete?

Answer 32

- MC type of trophoblastic disease - BENIGN neoplasm of the chorion in which chorionic villi degenerate and become transparent vesicles containing clear, viscous fluid - occurs when single sperm fertilizes an egg w/o a nucleus - partial: a fetus or evidence of an amniotic sac is present - complete: no fetus or amnion is found (have a tendency to become choriocarcinoma)

Question 33

RFs for hydatidiform mole?

Answer 33

- low socioeconomic status - hx of mole - age below 18 - age over 40

Question 34

Clinical presentation of hydatidiform mole?

Answer 34

- vaginal bleeding - enlarged uterus - pelvic pressur or pain - theca lutein cysts - hyperemesis gravidarium - hyperthyroidism (about 5%) - preeclampsia b/f 20 wks gestation - vaginal passable of hydropic vesicles - no fetal heart tones or fetal activity - N/V

Question 35

Labs and imaging for suspected hydatidifrom mole?

Answer 35

- b-hCG: extremely high for gestational age, above 40,000 mU/ml - U/S: absence of gestational sac, characteristic multiple echogenic region "snowy" w/in the uterus - CXR to rule out pulmonary mets of trophoblast

Question 36

Tx of hydatidiform mole?

Answer 36

- DandC immediately - pathologic exam on curettings - if malignant=chemo - effective birth control - weekly quantitative B-hCG: after 2 decreasing weekly tests, interval is increased to monthlyx6 mos, then q 2 months for total of one year, no further investigation if hCG levels decrease to normal If levels plateau or begins to rise, should be evaluated with CXR, then DandC and chemo - no pregnancy until hCG levels remain normal for min. of 1 yr

Question 37

How common are choriocarcinomas? What may they follow? PP?

Answer 37

- rare, highly malignant GTTD - may follow HM, invasion mole, abortion, normal pregnancy, ectopic pregnany - causes ulcerating surfaces into endometrial cavity - malignant tumor cells enter circulation through open blood vessels in the endometrial cavity and are transported to lungs, brain or to other distant sites

Question 38

Tx for choriocarcinoma?

Answer 38

- highly sensitive to chemo, which is TOC - surgery - little place (high vascularity and effectiveness of chemo) - it is indicated for tumor resistant to chemo and single mets persisting despite chemo

Question 39

4 major causes of 1st trimester bleeding?

Answer 39

1. physiologic: implantation 2. ectopic pregnancy 3. impending or complete abortion 4. cervical, vaginal or uterine path: polyps, inflammation, infection, trophoblastic disease

Question 40

W/U of 1st trimester bleeding?

Answer 40

- assess stability of pt and degree of bleeding - US - CBC - serial B-hCG if threatened abortion

Question 41

What is placenta previa? 3 diff types?

Answer 41

- placenta implanted in lower segment of uterus and extends over or lies proximal to the internal cervical os - 3 types: total or complete: entire os covered partial: internal os partially covered marginal or low-lying: edge of placenta at os but doesn't cause obstruction

Question 42

RFs for placenta previa?

Answer 42

- previous placenta previa - multiparity - multiple gestation - previous C-section - trauma - smoking - advanced maternal age - infertility tx - previous intruterine surgical procedure (myomectomy)

Question 43

Presentation of placenta previous? What should not be done? Dx made by?

Answer 43

- painless bleeding in 3rd trimester - bright red blood - may have shock sxs if bleeding is severe - VS stable - FHT normal - fetal activity present - NO vaginal or speculum exam should be done - dx best made with transvaginal US

Question 44

Tx of placenta previa if acutely bleeding?

Answer 44

- dx: US acute bleeding episode: - supportive care to maintain hemodynamic stability - FHR monitor - IV NS or LR - Mg sulfate and corticosteroids if in labor and less than 34 wks - about half respond to conservative management

Question 45

Tx of placenta previa - indications for a c-section and conservative management postbleed?

Answer 45

- indications for c-section delivery: nonreassuring fetal HR, life threatening maternal hemorrhage, sig vaginal bleeding after 34 wks - conservative management post bleed: sometimes need to be hospitalized until delivery, depends on clinical situation, at high risk for rebleeding as well as PROM, if stable will deliver by c-section at 36-37 wks old

Question 46

What is abruptio placentae?

Answer 46

- placental abruption - partial or complete detachment of a normally implanted placenta at any time prior to delivery - more frequent during 3rd trimester - may occur anytime after 20 wks gestation - sig cause of maternal and fetal morbidity and mortality

Question 47

MC RFs for placental abruption?

Answer 47

- previous abruption - abdominal trauma - cocaine - smoking (risk increases by 40% for each pack/day smoked) - eclampsia - pregnancy induced HTN

Question 48

Presentation of placental abruption?

Answer 48

- vaginal bleeding: mild to severe (amt doesn't correlate with degree of separation) - abdominal pain or back pain - uterine contractions - uterine tenderness to palpation - nonreassuring FHR pattern * *all preg women with abdominal pain, uterine contractions and vaginal bleeding need to have this ruled out

Question 49

Complications of placental abruption: maternal and fetal?

Answer 49

``` - maternal: hemorrhagic shock coagulopathy/DIC uterine rupture renal failure ischemic necrosis of distal organs (hepatic, adrenal, pituitary) - fetal: hypoxia anemia growth retardation CNS anomalies fetal death: if 50% of placenta is separated ```

Question 50

Dx eval of placental abruption?

Answer 50

- early markers of ischemic disease during routine care: elevated AFP with no other explanation and elevated B-hCG - fibrinogen to eval for DIC: decreased fibrinogen, elevated fibrin degradation products and elevated D-dimer - imaging: classic finding in a retroplacental hematoma (US)

Question 51

Tx of placental abruption?

Answer 51

* *these pts can have sudden worsening abruption at any time so be prepared for the worst - continous fetal monitoring - IV access for mother - maintain maternal O2 sats over 95% - CBC, blood type (cross and screen), coag studies (eval for DIC) - tx of DIC if indicated - severe abruption may reqr delivery of baby regardless of gestational age: if 36 wks or more then tx is to deliver.

Question 52

What is placenta accrete? 3 forms?

Answer 52

- placenta attaches too deeply into the wall of the uterus - 3 forms: placenta accreta placenta increta placenta percreta - dist. by severity and deepness of placenta attachment - approx 1/2500 pregancies experience placenta accreta, increta, or percreta

Question 53

RFs for placenta accreta?

Answer 53

- all 3 forms are assoc with hx of prior c-section, hx of uterine instrumentation or surgery or placenta previa - rarely abdnormal attachment is seen in absence of prior surgery and in the absence of placenta previa

Question 54

Risks assoc with placenta accreta?

Answer 54

- preterm delivery | - severe PPH

Question 55

Tx of placenta accreta?

Answer 55

- little can be done for tx once placenta accreta has been dx - monitor pregnancy with intent of scheduling a delivery and using a surgery that may spare the uterus - unfortunately placenta accreta may be severe enough that a hysterectomy may be needed

Question 56

What needs to be ruled out b/f vaginal exam if pt has bleeding after 1st trimester? What is go to dx test for bleeding during this time?

Answer 56

- all vaginal bleeding needs an eval - US is go to dx test - need to r/o placenta previa b/f speculum or vaginal exam - have to continually assess hemodynamic status of pt

Question 57

Diff b/t normal N/V of pregnancy and hyperemesis gravidarium?

Answer 57

- normal: peak incidence 8-12 wks, should resolve by 20 wks - hyperemesis gravidarium: persistent, severe, intractable vomiting during pregnancy wt loss of 5% or more of pre-pregnancy wt, + ketonuria not from other causes in 1st trimester

Question 58

Eval of excessive N/V during pregnancy?

Answer 58

- wt - orthostatic VS - electrolytes (BMP) - UA: ketones - obstetrical US to rule out gestational trophoblastic disease or multiple gestation

Question 59

Tx of hyperemesis gravidarium?

Answer 59

- hospitalization with bed rest - NPO x 48 hrs - maintain hydration and electrolyte balance and vitamins with parenteral IV fluids - As soon as possible - place pt on dry diet consisting of six small feedings daily plus clear liquids - after stabilization: pt can be maintained at home even if she reqrs IV fluids in addition to her oral intake

Question 60

Meds for hyperemesis gravidarium?

Answer 60

- 1st line: Vit B6 25 mg po TID to QID - + doxylamine (unisom) 25 mg-50 mg po q 4-6 hrs - 2nd line: DC doxylamine and try prochlorperazine (compazine) or metaclopramide (reglan) - 3rd line or if severe reqring hosp. due to dehydration: odansetron (zofran) - may be related to cardiac defects and cleft palate - IV fluids with thiamine if dehydration is noted - glucocorticoids after 1st trimester (decrease nausea) - TPN if unable to keep anything down

Question 61

PPROM - dx can be?

Answer 61

- clinical | visualization of fluid in vagina of preg lady who presents with hx of leaking fluid

Question 62

Testing for PROM?

Answer 62

- pH paper (nitrazine test) - amniotic - 7-7.3, vaginal: 3.8 - ferning - sawb onto glass slide, air dry for 10 min amniotic: delicate pattern cervical: dense and thick - US - check amniotic fluid level - instillation of indigo carmine into amniotic fluid: place tampon in vagina for 20 min - if turns blue - there is a leak - placental alpha microglobulin 1 protein assay (amnisure): immunochromatography, sterile swab in vagina - spendy - placental fibronectin - from vaginal secretions (if negative supports no membrane rupture)

Question 63

Management of PROM?

Answer 63

- once dx confirmed determine if pt and fetus are stable or unstable - if unstable deliver - if stable: keep in hosp until delivery - administer abx, corticosteroids and monitor for stability of mom and baby and deliver at 34 wks

Question 64

How common is diabetes in pregnancy?

Answer 64

- occurs in 7% of preg (dx of DM prior to pregnancy and during) - carries an increased risk of congenital abnormalities if HgBA1C is more than 9.5% - mothers have increased risk for DKA - 2x risk of PIH or pre-eclampsia - worsening diabetic nephropathy and retinopathy

Question 65

Risks of maternal diabetes to fetus?

Answer 65

- risk of congenital anomalies is 6x that of average - cardiac, CNS, renal, limb deformity, sacral agenesis - increased risk of spontaneous abortion and stilbirth - macrosomia (wt over 4000-4500 g) - sometimes uteroplacental insufficiency and IUGR - polyhydramnios: (amniotic fluid of more than 2 L) - increased risk for placental abruption, preterm labor, and post partum uterine atony - neonatal period: at higher risk of neonatal hypoglycemia, hyperbilirubinemia, hypocalcemia, and polycythemia

Question 66

DM management?

Answer 66

- frequent BG monitoring - aim for optimal glucose control through diet, exercise, and insulin therapy - insulin requirements increase throughout the pregnancy, most markedly at 28-32 wks - reqrs FU q 1-2 wks for first 2 trimesters then once weekly for 3rd

Question 67

Screening for gestational DM?

Answer 67

screen 24-28 wks with 50 g 1 hr oral glucose challenge: no need to fast - if BG greater than 140 mg/dL then they need a 3 hr glucose tolerance test

Question 68

DM management during pregnancy?

Answer 68

- mainstay of Gestational DM tx is diet and to maintain 30kcal/kg of IBW/day - blood sugar goals: fasting less than 95 1 hr postprandial: 130-140 2 hr post: less than 120 - if unable to attain goals with diet then move to insulin therapy and now starting to use some oral hypoglycemics (glyburide and metformin)

Question 69

Risks of having diabetes during pregnancy?

Answer 69

- increased risk for UTI and pyelonephritis with DM - often induce at 39 wks - babies large due to increased insulin and other hormonal changes = shoulder dystocia - mother may need an IV drip of 5% dextrose during labor to maintain BG of 100 - with GDM the blood sugar may return to normal within 2 hrs of delivering the placenta

Question 70

Tx of thyroid disease during pregnancy?

Answer 70

- tx of hypothyroidism is with levothyroxine - maternal thyroxine requirements increase in women with hypothyroidism dx prior to pregnancy - adjust dose at 4 wk intervals and once stable check a TSH once q trimester - post partum thyroiditis can occur for up to a year post delivery (w/ or w/o prior hx of hypothyroidism)

Question 71

PP of thyroid disease during pregnancy?

Answer 71

- TBG increase during pregnancy - free T4 may increase in 1st trimester - TSH decreases in first 10 wks - no routine screening needed just check TSH in those with known thyroid disease - gestational trophoblastic disease and hyperemesis gravidarium may affect thyroid fxn - if hyperthyroid pre-preg, likely will need to adjust meds during pregnancy