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a_GYNGU > 11/5- Complications of Late Pregnancy > Flashcards

11/5- Complications of Late Pregnancy Flashcards

1
Q

What are the 4 common complications of late pregnancy?

A
  • Hypertensive disorders of pregnancy
  • Preterm labor
  • Fetal death/stillbirth
  • Amniotic fluid abnormalities
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2
Q

Case 1)

  • Mrs. Williams presents to your office at 32 weeks gestation for a routine prenatal visit. Her pregnancy has been uncomplicated so far.
  • Today she complains of ankle swelling and a mild headache. Your nurse reports the patient’s blood pressure as 155/92.
  • Urinalysis reveals 2+ proteinuria.
  • Should you send the patient home or to the hospital?
A

To the hospital!

  • There are many hypertensive disorders in pregnancy to think about
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3
Q

How does blood pressure change in pregnancy?

A
  • At the beginning, it goes down a little
  • In 3rd TM, it begins to rise
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4
Q

What are some hypertensive disorders that may be present in pregnancy?

A
  • Chronic hypertension
  • Preeclampsia/eclampsia
  • Gestational hypertension
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5
Q

Define: chronic hypertension

A
  • Present before conception
  • Dx before 20 wk, or persists > 6 wk postpartum
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6
Q

Define: preeclampsia/eclampsia

A

Hypertension appearing after 20 wk gestation in association with proteinuria

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7
Q

Define: gestational hypertension

A

Hypertension appearing after 20 wk with no other evidence of preeclampsia (e.g. preeclampsia without the signs)

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8
Q

What is the epidemiology of preeclampsia?

  • Prevalence
  • More common in what populations/conditions
A

5-6% of pregnant pts

More common in:

  • Maternal age < 20 or > 35
  • African-Americans
  • Nulliparas (never given birth before)
  • Diabetes
  • Obesity
  • Systemic Lupus Erythematosus
  • Multiple gestations
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9
Q

What are the diagnostic criteria for preeclampsia?

A

Hypertensive criteria

  • Systolic blood pressure ≥ 140 mm Hg or diastolic blood pressure ≥ 90 mm Hg
  • On 2 occasions at least 4 hours apart
  • After 20 weeks pregnant with previously normal blood pressure

OR

  • Systolic blood pressure ≥ 160 mm Hg or diastolic blood pressure ≥ 110 mm Hg

PLUS Protein/symptomatic criteria

  • Proteinuria > 300 mg/day (protein/creatinine ratio 0.3, urine dipstick +1 if no other method available)

OR

  • Thrombocytopenia (Platelets < 100,000/microliter)
  • Renal insufficiency (Cr >1.1, or doubling of serum cr)
  • Impaired liver function (transaminases 2x normal)
  • Pulmonary edema
  • Cerebral or visual symptoms
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10
Q

What are the diagnostic criteria for preeclampsia with severe features?

A
  • Systolic bp >160 mm Hg or diastolic bp >110 mm Hg on two occasions at least 4 hours apart
  • Thrombocytopenia (Platelets under 100,000/microliter)
  • Impaired liver function (transaminases twice normal)
  • Severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by other diagnosis
  • Renal insufficiency (Cr >1.1, or doubling of serum creatinine in absence of other renal disease)
  • Pulmonary edema
  • Cerebral or visual symptoms
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11
Q

Describe the pathogenesis of preeclampsia

A
  • Endothelial cell injury
  • “Rejection” phenomenon (insufficient blocking antibodies)
  • Abnormal placentation (incomplete invasion of trophoblast as placenta implants in uterus)
  • Imbalance between thromboxane and prostacyclin
  • Dietary factors
  • Genetic factors
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12
Q

T/F: Preeclampsia is a multisystem disorder

A

True

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13
Q

What systems are affected in preeclampsia? How?

A
  • CNS: arteriolar thrombosis, microinfarcts, petechial hemorrhages
  • Pulmonary: pulmonary edema, ARDS
  • Cardiovascular: depleted intravascular volume
  • Liver: hepatocellular damage, hemorrhage, rupture
  • Renal: decreased GFR, swollen and leaky glomerular capillaries, acute tubular necrosis
  • Hematologic: low platelets, hemolytic anemia, DIC, HELLP
  • Placental: poor intervillous blood flow, infarctions, IUGR
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14
Q

What is the prevalence of eclampsia?

  • Occurs when
A
  • Occurs in 0.2-0.5% of pregnancies
  • Approximately 75% occur antepartum
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15
Q

What are the symptoms of eclampsia?

  • Cause
  • Etiology
A
  • Tonic-clonic (grand mal) seizure activity
  • Poor correlation between severity of HTN and occurrence of seizures
  • Precise etiology of seizures is unknown (perhaps vasospasm)
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16
Q

What is shown here?

A

MRI findings with posterior reversible encephalopathy

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17
Q

How is preeclapmsia managed?

A
  • Delivery is the only cure (think it has to do with placenta; got to get it out of there)
  • Control hypertension:
  • Hydralazine
  • Labetolol
  • Nifedipine
  • Prevent seizures:
  • Parenteral magnesium sulfate
  • Optimize fetal outcome
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18
Q

Case 2)

  • C.N. is a 23 year old G1 at 30 weeks gestation, and presents to your office complaining of lower abdominal pain and pelvic pressure.
  • She is currently unemployed and is “stressed out” over financial issues. She is found to be having contractions every 4 minutes, and her cervix is partially dilated.
  • Appropriate management includes admission to L/D and what additional measures?
A
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19
Q

____ is the #1 killer of neonates?

  • Prevalence?
A

Prematurity is the #1 killer of neonates

  • Difficult to detect and treat
  • Multiple etiologies
  • Affects ~10% of US pregnancies
20
Q

The preterm birth rate is _______ (increasing/decreasing)? Why?

A

Preterm birth rate is increasing

  • Multiple gestation rate is increasing
  • Increased obstetric interventions (to prevent fetal death)
  • Increased use of US-dating of pregnancies
21
Q

What is the mortality rate with prematurity?

A
  • Pretty much 100% before 24 wks
22
Q

What are risk factors for high mortality with prematurity?

A
  • Low gestational age
  • Low birth weight
  • Male
  • No steroids
23
Q

What is the neurologic morbidity of prematurity? (table)

A
  • At 22 wks, none born live were alive at 6 mo
  • At 24 wks, 56% were still alive at 6 mo but only 21% did not have severe brain abnormalities
  • At 25 wks, 79% were alive at 6 mo and 72% did not have severe brain abnormalities (pic 494)
24
Q

What is a big risk with prematurity?

  • Risk factors?
A

Intraventricular hemorrhage

  • Higher risk with lower infant weight

(50% if under 1kg but only 2% if > 2 kg)

25
Q

How is preterm labor diagnosed/defined?

A

Painful uterine contractions with progressive cervical change at gestational age between 20 weeks and 36+6 weeks.

26
Q

What are risk factors for preterm labor?

  • Maternal
  • Genetic
A

Maternal

  • Low maternal weight gain
  • Low socioeconomic status
  • Substance abuse
  • Young maternal age
  • Psychologic stress

- Previous preterm labor

Genetic

  • Collagen defects
  • Uterine anomalies
27
Q

T/F: most cases of preterm labor are of unknown etiology

A

True

28
Q

What is the role of infection in preterm labor?

A

In the decidua and/or amnion:

  • Bacteria products may activate monocytes to produce IL-1, IL-6, and TNF
  • These cause release of arachidonic acid (platelet activating factors)
  • Release of PGE2 and F2a
  • Results in myometrium and uterine contractions
29
Q

What is PROM?

  • Describe the process
  • How to manage
A

Premature Rupture of Membranes

  • Loss of mechanical barrier to infection
  • Release of prostaglandins secondary to inflammatory change
  • Majority will deliver within 48 hours of PROM
  • Management dependent on suspicion of intra-amniotic infection
30
Q

What are complications of PROM?

  • Fetal
  • Maternal
A

Fetal

  • Prematurity
  • Pulmonary hypoplasia
  • Infectious complications
  • Structural deformities

Maternal

  • Uterine infection
  • Sepsis
31
Q

How to manage preterm labor?

A
  • Admission to L/D
  • IV hydration/urinalysis
  • Tocolytic agents
  • Maternal corticosteroids to induce fetal lung maturity
  • Antibiotics if delivery likely or with PPROM
32
Q

Describe the effects of giving the mother corticosteroids to induce fetal lung maturity

  • How long does this take
A
  • Corticosteroids enhance surfactant production by type 2 alveolar cells
  • Increase neonatal lung compliance
  • Decreased alveolar protein leakage
  • Stabilization of cellular architecture
  • REQUIRES 48 HOURS FOR OPTIMAL EFFECT
33
Q

What are tocolytic agents?

A
  • Beta mimetics
  • Magnesium sulfate
  • CCBs
  • Prostaglandin synthetase inhibitors
34
Q

What are the mechanisms of action/details of use for the following tocolytic agents?

  • Beta mimetics
  • Magnesium sulfate
  • CCBs
  • Prostaglandin synthetase inhibitors
A
  • Beta mimetics: B2 recep agonists cause uterine relaxation (turbuteline)
  • Not recommended for long-term/maintenance use
  • Magnesium sulfate: unknown action; presumed interference with Ca role in contractile apparatus
  • CCBs: block cellular entry of Ca, reducing contractility
  • Prostaglandin synthetase inhibitors (indosin)
  • Not used after 32 wks; may cause premature closure of ductus arteriosus in the heart
35
Q

What are adverse side effects of the following tocolytic agents?

  • Beta mimetics
  • Magnesium sulfate
  • CCBs
  • Prostaglandin synthetase inhibitors
A
  • Beta mimetics: tachycardia, hypotension, nausea/vomiting, hyperglycemia, hypokalemia
  • Magnesium sulfate: flushing, N/V, headache, weakness, diplopia, pulmonary edema, chest pain, hypotension, respiratory depression
  • CCBs: hypotension, tachycardia, headache, flushing, dizziness
  • Prostaglandin synthetase inhibitors: GI upset, coagulation disturbances, renal failure
  • Fetal: renal dysfunction, oligohydramnios, premature closure of ductus arteriosus
36
Q

Case 3)

  • A.S. is a 34 year old at 29 weeks gestation with her 3rd pregnancy. She has gestational diabetes and chronic hypertension.
  • During her office visit, she reports decreased fetal activity, and has felt none since this morning.
  • Ultrasound evaluation confirms fetal demise.
  • What is the likely etiology in this case?
A

Risk factors of stillbirth include:

  • Gestational diabetes
  • Chronic hypertension
37
Q

What is the definition of a stillbirth?

  • How many are for unknown reasons
A

Antepartum or intrapartum death of fetus > 500g

  • Determination of etiology requires rigorous investigation
  • Unexplained in 25-30% of cases (kind of good, because less risk of recurrence in later pregnancies)
38
Q

What are fetal causes of fetal death?

A
  • Chromosomal abnormalities
  • Other structural anomalies
  • Non-immune hydrops
  • Infection (think TORCH infections; Toxo, Parvo, CMV, Syphilis)
39
Q

What are placental causes of fetal death?

A
  • Abruption
  • Fetal-maternal hemorrhage (if blood types don’t match)
  • Cord accident (strangulation or knot)
  • Placental insufficiency
  • Intrapartum asphyxia
  • Twin transfusion syndrome
  • Chorioamnionitis
40
Q

What are maternal causes of fetal death?

A
  • Antiphospholipid antibodies
  • Diabetes
  • Hypertension
  • Trauma
  • Sepsis
  • Uterine rupture
  • Postdates pregnancy
41
Q

How is a stillbirth managed?

A
  • Delivery by usual means
  • Autopsy and other investigation
  • Allow for grieving
  • Follow-up visit (high risk for post-partum depression)
42
Q

Where should amniotic fluid be sampled?

A

All 4 quadrants

43
Q

What are some amniotic fluid abnormalities?

A

Hydramnios (polyhydramnios)

  • AFI > 90th%ile

Oligohydramnios

  • AFI < 10th%ile
  • Max vertical pocket < 2 cm
44
Q

What are causes of polyhadramnios?

A

Excessive production:

  • Maternal diabetes
  • Twins Impaired swallowing
  • Neurologic disorders GI obstruction
  • Intestinal atresia
45
Q

What are causes of oligohydramnios?

A
  • Impaired production:
  • Uteroplacental insufficiency
  • Renal dysplasias
  • Fetal renal obstruction
  • Leaking amniotic membranes

a_GYNGU (17 decks)

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