Pregnancy Complications Flashcards
(102 cards)
1
Q
Complications of Pregnancy
A
Spontaneous abortion Ectopic pregnancy Gestational trophoblastic disease Placental abnormalities Hyperemesis gravidarum Premature rupture of membranes DM Thyroid disease
2
Q
Define Spontaneous Abortion
A
Loss of a fetus at less than 20 weeks gestation
“Miscarriage”
3
Q
Etiology of Spontaneous Abortion
A
Chromosomal defects (60%) Maternal trauma Infections Dietary deficiencies DM Hypothyroidism Anatomic malformations: incompetent cervix Undetermined (25%)
4
Q
Risk Factors for Spontaneous Abortion
A
Advanced maternal age
Previous spontaneous abortion
Maternal smoking
5
Q
Symptoms of Spontaneous Abortion
A
Bleeding: bright red, heavy Midline cramping Low back pain Open or close cervical os Complete or partial expulsion of products of conception
6
Q
Subtypes of Spontaneous Abortion
A
Threatened Inevitable Incomplete Complete Missed
7
Q
Define Threatened Spontaneous Abortion
A
Os close
Unpredictable outcome: can have a viable pregnancy
8
Q
Define Inevitable Spontaneous Abortion
A
Os open
Products of conception have not passed
Pregnancy can not be saved
9
Q
Define Incomplete Spontaneous Abortion
A
Os open
Some products of conception have passed
10
Q
Define Complete Spontaneous Abortion
A
Os open or closed
Products of conception have passed
11
Q
Define Miss Spontaneous Abortion
A
Pregnancy didn’t develop
+ pregnancy test, then heavy period week later
12
Q
Threatened Abortion
A
Slight bleeding Abdominal cramping Cervical os closed Uterine size compatible with dates No products of conception are passed Prognosis is unpredictable
13
Q
Treatment Measures for Threatened Abortion
A
Best rest for 24-48 hours with gradual resumption of usual activities
No work, child care, or sexual intercourse
Rest in horizontal position except bathing & using toilet
Infection: antibiotics
Hydration
Explicit instructions when to report signs/symptoms
Definitive follow up date
14
Q
Treatment Contraindications for Threatened Abortion
A
Hormonal therapy
15
Q
Inevitable Abortion
A
Moderate bleeding Moderate/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 poor
16
Q
Incomplete Abortion
A
Heavy bleeding Moderate/severe abdominal cramping Low back pain Cervical os is DILATED Uterine size is compatible with dates Some portion of the productions of conception remain in the uterus Pregnancy cannot be saved
17
Q
Missed Abortion
A
Pregnancy ceased to develop, products of conception have not been expelled
Symptoms of pregnancy disappear
Brownish vaginal discharge but no free bleeding
Pain does not develop
Cervix is semi-firm & slightly dilated
Uterus becomes smaller & irregularly softened
18
Q
Treatment for Missed, Inevitable, and Incomplete Abortions
A
Counseling regarding fate of pregnancy
Assess Rh factor & administer immunoglobulin
Planning for elective termination
19
Q
Elective Termination Strategies
A
D&C: empty all products of conception; prevent infection & hemorrhage
Insertion of laminar to dilate cervix follow by aspiration (missed)
Prostaglandin vaginal suppositories (alternate)
20
Q
Complete Abortion
A
Bleeding may be heavy or minimal Moderate/severe abdominal cramping Low back pain Fetus & placenta completely expelled Pain ceases but spotting may persist Cervical os open or closed Uterus is normal pre-pregnancy size
21
Q
Define Habitual Abortions
A
Recurrent pregnancy loss/habitual abortions if 3 previous pregnancies
22
Q
Evaluation of Suspected Spontaneous Abortion
A
H&P
+/- fetal doppler
+/- transvaginal US
+/- labs: serum hCG, blood type & Rh factor
23
Q
Workup for Recurrent Pregnancy Loss
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Assessment of uterine structure* Rule out lupus* TSH* Blood glucose Genetic: maternal & paternal Day 3 FSH levels Progesterone levels
24
Q
Follow Up of Spontaneous Abortion
A
GYN exam 2-3 weeks later
Contraception for 3 months to allow complete healing & regeneration of endometrial lining
25
Define Ectopic Pregnancy
Implantation of fertilized ovum outside of the uterine cavity
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Locations for Ectopic Pregnancy
```
Fallopian tube (98%)
Cervix
Ovary
Abdominal cavity
```
27
Ectopic Pregnancy
Rupture inevitable
Potentially life-threatening
MAJOR CAUSE OF MATER DEATH DURING 1ST TRIMESTER
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Risk Factors of Ectopic Pregnancy
```
History of genital infections*
History of infertility*
History of tubal pregnancy*
History of any ectopic pregnancy*
Intrauterine devices*
Abdominal or pelvic surgery
History of ruptured appendix
Intrauterine exposure to DES
Use of drugs that slow ovum transport
```
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Natural History of Ectopic Pregnancy
Rupture: significant hemorrhage
Abortion: expulsion of products
Spontaneously resolve
30
Classic Presentation of Ectopic Pregnancy
```
1-2 months of amenorrhea
Morning sickness
Breast tenderness
Diarrhea, urge to defecate
Malaise & syncope
Lower abdominal/pelvic pain: sudden/severe, especially adnexal
referral of pain to shoulder
```
31
Atypical Presentation of Ectopic Pregnancy
Vague or subacute symptoms
| Menstrual irregularity
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PE Findings with Ectopic Pregnancy
Tachycardia
Hypotension
Adnexal, cervical motion, and/or abdominal tenderness on pelvic exam
Pelvic: brick red to brown blood
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Differential of Ectopic Pregnancy
```
PID
Ovarian tyst
Ovarian tumor
Intrauterine pregnancy
Recent spontaneous abortion
Early hydatidiform degeneration
Acute appendicitis
Other bowel related disorders
```
34
Labs for Ectopic Pregnancy
B-hCG: lower than expected
CBC: anemia or leukocytosis
Rh factor
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Imaging for Ectopic Pregnancy
Transvaginal US: empty uterus + hCG levels
| Laparoscopy or laparotomy (severe)
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Indications for Surgical Management of Ectopic Pregnancy
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
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Medical Management of Ectopic Pregnancies
Methotrexate
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Indications for Methotrexate Use in Ectopic Pregnancy
Accept medical therapy early in ectopic pregnancy
Hemodynamically stable
Willing to comply with follow up
Have hCG
39
Follow Up for Ectopic Pregnancy
Rhogam
Contraception for 2+ months to allow adequate healing & repair
Pelvic rest until B-hCG negative
Follow up 2 weeks post surgery
40
Types of Gestation Trophoblastic Diseases
Hydatidiform Mole*
Choriocarcinoma*
Persistent/invasive gestational trophoblastic neoplasia
Placental site trophoblastic tumors
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Define Hydatidiform Mole
Benign neoplasm of the chorion in which chorionic villi degenerate & become transparent vesicles containing clear, viscous fluid
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When does a hydatidiform mole occur?
Single sperm fertilizes an egg without a nuclus
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Define Partial Hydatidiform Mole
Fetus or evidence of an amniotic sac is present
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Define Complete Hydatidiform Mole
No fetus or amnion is found
| May become choriocarcinoma
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Risk Factors for Hydatidiform Mole
Low socioeconomic status
| History of mole
46
Clinical Presentation of Hydatidiform Mole
```
Vaginal bleeding
Enlarged uterus
Pelvic pressure or pain
Theca lutein cysts
Anemia
Hyperemesis gravidarium
Hyperthyroidism
Pre-eclampsia before 20 weeks gestation
Vaginal passable of hydraulic vesicles
No fetal heart tones or activity
```
47
Labs & Imaging for Hydatidiform Mole
B-hCG: extremely high for age
Ultrasound
Chest x-ray
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What are we looking for on ultrasound with a hydatidiform mole?
Absence of gestational sac
| Characteristic multiple echogenic region "snowy" within uterus
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What are we looking to rule out on chest x-ray with a hydatidiform mole?
Pulmonary metastases of trophoblast
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Treatment of Hydatidiform Mole
```
D&C
pathologic exam on curating
Effective birth control
Weekly quantitative B-hCG
No pregnancy until hCG levels remain normal for 1 year
```
51
What can choriocarcinoma follow?
```
Hydatidiform mole
Invasion mole
Abortion
Normal pregnancy
Ectopic pregnancy
```
52
What does choriocarcinoma cause?
Ulcerating surfaces into the endometrial cavity
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How do the malignant cells get transported to the lungs, brain, or elsewhere?
Malignant cells enter the circulation through open blood vessels in the endometrial cavity
54
Treatment of Choriocarcinoma
Highly sensitive to chemo
| Surgery (if resistant to chemo)
55
4 Major Causes of Bleeding in the 1st Trimester
Physiologic: implantation
Ectopic pregnancy
Impending or complete abortion
Cervical, vaginal, or uterine pathology
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Work up of 1st Trimester Bleeding
Assess stability of patient & degree of bleeding
Ultrasound
CBC
Serial B-hCG
57
Types of Placental Problems
Placenta previa
Abruptio placentae
Placenta Accretas
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Define Placenta Previa
Placenta implanted in lower segment of the uterus & extends over or lies proximal to the internal cervical os
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3 Types of Placenta Previa
Total or complete
Partial
Marginal or low-lying
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Define Total or Complete Placent Previa
Entire os covered
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Define Partial Placenta Previa
Internal os partially covered
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Define Marginal or Low-Lying Placenta Previa
Edge of placenta at os but does not cause obstruction
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Risk Factors for Placenta Previa
```
Previous placental previa
Multiparity
Multiple gestation
Previous cesarean section
Trauma
Smoking
Advanced maternal age
Infertility treatment
Previous intrauterine surgical procedure
```
64
Presentation of Placenta Previa
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Painless bleeding in 3rd trimester
Bright red blood
May have shock symptoms if severe bleeding
VS stable
Fetal heart tones normal
Fetal activity present
```
65
What should you not do if you suspect placenta previa?
Do not perform a vaginal or speculum exam
66
Diagnostic Test for Placenta Previa
Ultrasound
67
Treatment of Placenta Previa in an Acute Bleeding Episode
Supportive care to maintain hemodynamic stability
Fetal HR monitor
IV NS or LR
Magnesium sulfate & corticosteroids if
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Treatment of Placenta Previa with Indications for Delivery (C-section)r
Non-reassuring fetal HR
Life threatening maternal hemorrhage
Significant vaginal bleeding after 34 weeks
69
Conservative Management of Placenta Previa Post Bleed
Sometimes need to be hospitalized until delivery
High risk for re-bleeding & premature rupture of membranes
Stable: deliver at 36-37 weeks
70
Define Abruptio Placentae
Partial or complete detachment of a normally implanted placenta at any time prior to delivery
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Epidemiology of Abruptio Placentae
More frequent during 3rd trimester
Anytime after 20 weeks
Significant cause of maternal & fetal morbidity & mortality
72
Risk Factors for Placental Abruption
```
Previous abruption
Abdominal trauma
Cocaine
Smoking
Eclampsia
Pregnancy induced HTN
```
73
Presentation of Placental Abruption
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Mild to severe vaginal bleeding
Abdominal pain or back pain
Uterine contractions
Uterine tenderness
Non-reassuring fetal HR pattern
```
74
Maternal Complications of Placental Abruption
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Hemorrhagic shock
Coagulopathy/DIC
Uterine rupture
Renal failure
Ischemic necrosis of distal organs
```
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Fetal Complications of Placental Abruption
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Hypoxia
Anemia
Growth retardation
CNS anomalies
Fetal death
```
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Diagnostic Evaluation of Placental Abruption
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Early markers of ischemic placental disease during routine care
Elevated AFP with no other explanation
Elevated B-hCG
Fibrinogen to evaluate for DIC
Retroplacental hematoma on imaging
```
77
Treatment of Placental Abruption
```
Continuous fetal monitoring
IV access for mom
Maintain maternal O2 sats >95%
CBC
Blood type (cross & screen)
Coagulation studies
Treatment of DIC as indicated
Severe abruption: delivery baby regardless of age
```
78
Define Placenta Accretas
Placenta attaches too deeply into the wall of the uterus
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What is placenta accretas associated with a history of?
Prior c-section
Hx of uterine instrumentation or surgery
Placenta previa
80
Risks Associated with Placenta Accretas
Preterm delivery
| Severe postpartum hemorrhage
81
Treatment of Placenta Accreta
Little can be done
Monitor pregnancy
Schedule a delivery & using surgery to spare uterus
Hysterectomy: severe cases
82
Define Hyperemesis Gravidarium
Persistant, severe, intractable vomiting during pregnancy
| Weight loss of 5+% of pre-pregnancy weight
83
Evaluation of Excessive Nausea & Vomiting During Pregnancy
```
Weight
Orthostatic VS
Electrolytes
UA
Obstetrical ultrasound to rule out gestational trophoblastic disease or multiple gestation
```
84
Treatment of Hyperemesis Gravidarium
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Hospitalization
NPO x 48 hours
Maintain hydration & electrolyte balance & vitamins
Dry diet with 6 small feedings/day
Clear liquids
IV fluids with thiamine if dehydrated
Steroids after 1st trimester
TPN if can't keep anything down
```
85
First Line Medical Therapy For Hyperemesis Gravidarium
Vitamin B6 TID to QID
| Doxylamine (Unisom)
86
Second Line Medical Therapy for Hyperemesis Gravidarium
DC doxylamine
| + prochloperazine (Compazine) or metaclpramide (Reglan)
87
Third Line Medical therapy for Hyperemesis Gravidarium
Odansetron (Zofran)
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Diagnosing Preterm Premature Rupture of the Membranes (PPROM)
Visualization of fluid in the vagina of a pregnancy woman who presents with a history of leaking fluid
89
Testing for Preterm Premature Rupture of the Membranes (PPROM)
pH paper
Ferning
Ultrasound
Instillation of indigo carmine into amniotic fluid
Placental alpha microglobulin-1 protein assay
Placental fibronectin
90
Ferning: Amniotic Fluid
Delicate fern pattern
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Ferning: Cervical Mucous
Dense & thick ferm pattern
92
Ultrasound
Check for volume of amniotic fluid
93
Injection of Indigo Carmine into Amniotic Fluid
Place tampon in vagina for 20 minutes
| Blue = leak
94
Management of Preterm Premature Rupture of the Membranes (PPROM)
Patient & fetus stable or unstable
Unstable: deliver
Stable: hospitalize until delivery; antibiotics, corticosteroids & monitor for stability
95
DM & Pregnancy
2 times risk of pregnancy induced HTN or pre-eclampsia
| Worsening nephropathy & retinopathy
96
DM and Risks to the Fetus
Congenital anomalies = 6x that of average
Cardiac, CNS, renal, limb deformity, sacral agenesis
Increased risk of spontaneous abortion & stillbirth
Macrosomia
Uteroplacental insufficiency
Intrauterine growth retardation
polydyramnios
97
Neonatal Risks of DM
Hypoglycemia
Hyperbilirubinemia
Hypocalcemia
Polycythemia
98
Management of DM in Pregnancy
Frequent blood glucose monitoring
Airm for optimal glucose control through diet, exercise, & insulin therapy
Insulin requirements increase throughout pregnancy
Requires follow up every 1-2 weeks through 2nd trimester; weekly in 3rd trimester
99
Screening for Gestational DM
24-28 weeks: oral glucose challenge
| Fail?: 3 hour glucose tolerance test
100
Management of Gestational DM
Diet
| Blood sugar goals: fasting
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DM During Pregnancy
Increased risk for UTI & pyelonephritis
Induce labor at 39 weeks
Macrosomia: shoulder dystocia
102
Thyroid Disease & Pregnancy
Thyroxine requirements increase with hypothyroidism
Adjust dose at 4 week intervals as needed
Postpartum thyroiditis
Thyroid binding globulins increase
Increased free T4 in 1st trimester
