3- Abnormal Pregnancy I & II Flashcards
An ectopic pregnancy occurs outside of the uterine cavity. What is the most common location?
Fallopian tube
What is the pathophysiology of an ectopic pregnancy?
Disruption of normal tube anatomy or functional impairment that prevents transport of embryo to uterine cavity
What factors place a pt at high risk for ectopic pregnancy? (5)
Previous ectopic pregnancy
Previous tubal surgery/ ligation
Tubal pathology
In utero DES exposure
Current IUD use
Pt presents with first trimester vaginal bleeding and abdominal pain. VS show hypotension and tachycardia. Abdomen (+) for tenderness, rebound, and guarding. What are you concerned for?
(+/- breast tenderness, dizziness/ fainting, back/ shoulder pain, bleeding/ tenderness on pelvic exam)
Ectopic pregnancy
For normal intrauterine pregnancy, when should landmarks be visible on TVUS according to quantitative beta hCG values?
Once discriminatory zone is reached (3500 IU/mL)
Landmarks: “double ring” sign/ fetal pole w/ cardiac activity
(5-6 weeks)
Can a single beta hCG measurement diagnose the viability/ location of a gestation?
No
If unable to locate a pregnancy on TVUS once discriminatory zone is reached, what is the next step?
Considered “pregnancy of unknown location”
Repeat beta hCG in 48-72 hrs
When is expectant management appropriate for an ectopic pregnancy?
Asx + objective evidence of ectopic pregnancy resolution
Pt is reliable for f/u
What is included in expectant management of ectopic pregnancy?
Beta hCG q 48-72 hrs w/ US prn
If beta hCG < 200 → resolution of pregnancy
What risks are a/w expectant management of ectopic pregnancy? (3)
Tubal rupture, hemorrhage, need for emergency surgery
What is used for medical management of ectopic pregnancy (efficacy: 70-95%) and what is the greatest SE?
Methotrexate- affects actively replicating tissue
SE: Abd pain 1-3 days post admin
What are the indications for use of medical management of ectopic pregnancy? (4)
Hemodynamically stable
Unruptured mass
No absolute c/i - intrauterine preg, pancytopenia, IMC, active pulmonary disease/PUD/renal dysfunction, breast feeding
Reliable for f/u
Aside from methotrexate, what is included in the medical management of ectopic pregnancy?
Serial hCG levels until non-pregnancy level is reached (~2-4 wks)
Failure of hCG level to decrease by 15% from day 4-7 is a/w high risk of tx failure and requires what?
Additional methotrexate admin or surgical intervention
What pt edu should be provided for medical management of ectopic pregnancy with methotrexate? (5)
Risk of tubal pregnancy rupture/ sxs
Avoid folate containing foods/ drugs/ supplements
Avoid vigorous activity/ sex
Limit sunlight exposure
Avoid pregnancy for 3 mos following admin (teratogenic)
In addition to failed medical management, absolute contraindications to medical management and patient request, when is surgical management of ecoptic pregnancy indicated? (3)
Hemodynamically unstable
Sxs of ongoing ruptured ectopic mass
Signs of intraperitoneal bleeding
What surgical management of ectopic pregnancy involves removal of the ectopic pregnancy while leaving the affected fallopian tube in situ? What are the associated risks?
Salpingostomy
Risk of repeat ectopic pregnancy
What surgical management of ectopic pregnancy involves removal of part of all of the affected fallopian tube? When is this method preferred?
Salpingectomy
Preferred if: severe tubal damage, significant bleeding
What must be done following a salpingostomy?
Monitor seial hCG measurements to non-pregnancy level
What is defined as a group of conditions that consist of an abnormal proliferation of trophoblastic (placental) tissue?
Gestational trophoblastic disease
What is the most common form of gestational trophoblastic disease and is characterized by abns of chorionic villi consisting of varying degrees of trophoblastic proliferation/ edema of villous stroma?
(may be complete, partial, or invasive)
Hydatidiform mole
What RFs are a/w hydatidiform mole?
Extremes in age (< 20, > 35)
Hx of previous GTD
Nulliparity
Pt presents with irregular/ heavy vaginal bleeding and an enlarged uterus. +/- hyperthyroidism, pre-eclampsia, hyperemesis gravidarum, theca lutein cysts due to high hCG. What type of GTD are you concerned for?
Complete hydatidiform mole
Complete hydatidiform mole is derived from where and leads to presence or absence of a fetus?
Paternally derived (46xx)
Absence of a fetus
How is a complete hydatidiform mole diagnosed? (3)
Beta hCG: high, > 100,000
US: “snow storm appearance”
Definitive: tissue pathology
What is included in the management for complete hydatidiform mole?
Immediate removal of uterine products
Measure serial hCG weekly until (-) for 3 consec. weeks
OCP until documented resolution
What is the protocol for future pregnancies following a complete hydatidiform mole?
Closely monitor w/ early US and hCG levels
Pt presents with delayed menses and pregnancy diagnosis or vaginal bleeding from miscarriage/ incomplete abortion. What type of GTD are you concerned for?
Partial hydatidiform mole
Partial hydatidiform mole is derived from where and leads to presence or absence of a fetus?
Paternally and maternally derived
Presence of a fetus
How is a partial hydatidiform mole diagnosed? (2)
Beta hCG: N-high
US: “swiss cheese” appearance of intrauterine tissue, fetus w/ anomalies
What is included in management of partial hydatidiform mole?
Immediate removal of uterine contents
Measure serial hCG weekly until (-) for 3 consec. weeks
OCP until documented resolution
If coexistent w/ N preg w/o complications → proceed to delivery
Low risk of development of persistent malignant disease
Pt presents w/ persistent abn uterine bleeding with a plateauing or rising beta hCG following tx of GTD (removal of uterine contents). What are you concerned for?
Invasive molar pregnancy
What will US show if invasive molar pregnancy?
Intrauterine mass, increased vascularity w/i myometrium
What is included in the management of invasive molar pregnancy aside from serial hCG monitoring and OCP?
Single agent chemotherapy w/ methotrexate or actinomycin-D
What GTD is defined as a malignant necrotizing tumor that develops weeks to years after any type of pregnancy and what is the tx?
(most common after abn pregnancy)
Choriocarcinoma
Tx w/ single agent methotrexate (if good prognostics) vs multi-agent EMACO (if poor prognosis)
What GTD is defined as a tumor that arises from the placental implantation site and what is the tx?
Placental site trophoblastic tumor
Tx w/ hysterectomy
What is defined as persistent N/V that results in dehydration, weight loss, and potential electrolyte abns in pregnancy?
Hyperemesis gravidarum
What is included in the general management of hyperemesis gravidarum? (3)
IV hydration
Banana bag w/ multivitamins (prevents Wernicke encephalopathy if vit B1 deficient)
Anti-emetics
What anti-emetics are included in the tx of hyperemesis gravidarum?
1st line- vit B6 + doxylamine
2nd line- diphenhydramine/ prochlorperazine/ promethazine
3rd line- ondansetron, metoclopramide
4th line- clorpromazine/ methylprednisolone
When does Rh incompatibility and alloimmunization occur?
Mother Rh (-), fetus Rh (+) → mixing of maternal/ fetal blood → development of maternal antibodies to Rh antigen
Does not affect current pregnancy, only future pregnancies
What are the complications of Rh incompatibility and alloimmunization once the maternal antibodies to the Rh antigen cross the placenta?
Destruction of fetal RBCs → fetal hemolytic anemia → erythroblastosis fetalis
(HF, diffuse edema, ascites, pericardial effusion)
What is the primary goal of management for an unsensitized Rh (-) pt and how is this done?
Keep from being sensitized
- Type/ screen @ prenatal visit
- Type/ screen @ 28 wks + RhoGAM
- If neonate is Rh (+) → RhoGAM postpartum
- Exposure to fetal blood cells → RhoGAM
What is RhoGAM?
Anti-D immunoglobulin
What is the protocol for a sensitized Rh (-) pt? (6 steps)
(sensitized: antibody screen (+) for Rh (D) antigen)
Collect titers
↓
Titer followed q 4 weeks
↓
< 1:16 = expectant management
> 1:16 = amniocentesis
↓
Fetal blood type (-) = expectant management
Fetal blood type (+) = screen for fetal anemia (MCA doppler)
↓
Anemia suspected = percutaneous umbilical blood sampling (PUBS)
↓
Anemia detected = intrauterine transfusion
(≥ 1:16 = risk of fetal hydrops)
What is the leading cause of maternal morbidity and mortality in developed nations?
HTN
What is defined as chronic HTN diagnosed/ present before pregnancy or diagnosed prior to 20 weeks gestation?
Chronic HTN
What is defined as HTN diagnosed after 20 weeks gestation in a woman w/ previously normal BP?
Gestational HTN
140 SBP +/- 90 DBP on 2 occasions at least 4 hrs apart
What BP is determined severe gestational HTN?
> 160/ 110
Tx w/ IV antihypertensives
How can you differentiate between pre-eclampsia and superimposed pre-eclampsia?
Pre-eclampsia: gestational HTN + proteinuria > 300mg
Superimposed pre-eclampsia: chronic HTN + pre-eclampsia
Pt presents with HTN after 20 weeks gestation plus 1+ of the following:
- thrombocytopenia
- renal insufficiency
- impaired LFTs
- pulm edema
- new onset HA unresponsive to meds
What are you concerned for?
Pre-eclampsia
What is defined as pre-eclampsia + new onset of generalized, tonic-clonic seizures?
Eclampsia
What is the general pathophysiology of pre-eclampsia?
Failure to establish adequate uteroplacental BF
How is presence of proteinuria confirmed when diagnosing pre-eclampsia?
SPOT
(+) if > 300mg
What is included in the management of pre-eclampsia without severe features?
Out-pt management
Delivery at 37 0/7 weeks
What is included in the management of pre-eclampsia with severe features? (5)
In-pt management
Delivery @ 34 0/7 weeks
Tx severe HTN- IV labetalol, IV hydralazine, PO nifedipine
Mg sulfate for seizure prophylaxis
Glucocorticoids
What is included in the management of eclampsia? (4)
Prevent maternal hypoxia/ trauma
Prompt delivery (usually C-section)
Tx severe HTN- IV labetalol, IV hydralazine, PO nifedipine
Mg sulfate for seizure prophylaxis
What is HELLP sydrome a/w (severe form of pre-eclampsia)?
Hemolysis
Elevated liver enzymes
Low platelet count
What is included in the management of HELLP syndrome?
Maternal stabilization- platelet transfusion if < 50 for c-section, < 20 for vaginal
Prompt delivery
Tx severe HTN- IV labetalol, IV hydralazine, PO nifedipine
Mg sulfate for seizure prophylaxis
What is often seen with lab values of a pt with HELLP syndrome?
Continue to worsen following delivery for 24-48 hrs
May require ICU
What is defined as an estimated fetal weight (EFW) below the 10th percentile for gestational age in the 2nd half of pregnancy?
Intrauterine growth restriction
EFW is determined by which 4 measurements?
Biparietal diameter
Head circumference
Abd circumference
Femur length
What infections can be a/w intrauterine growth restriction?
TORCH
Toxoplasmosis
Other (Syphilis, Varicella)
Rubella
Cytomegalovirus
HSV
Intrauterine growth restriction is a/w with increased risk of what?
Perinatal/ neonatal morbidity and mortality
How do you screen for intrauterine growth restriction?
Fundal height measurements starting at 16 weeks gestation
If > 3cm off → consider LGA/ SGA → US
In screening for intrauterine growth restriction, what test is used to eval EFW, amniotic fluid volume, and umbilical artery BF?
US
In screening for intrauterine growth restriction, what test is used to identify fetus at risk for uteroplacental insufficiency (may require early delivery)?
Uterine artery dopplers
What is the goal of management for intrauterine growth restriction?
Provide fetal surveillance until risk of intrauterine demise > than risk of early delivery
(fetal surveillance via US q 3 weeks, BPP 2x weekly w/ umbilical artery dopplers, NST, fetal kick counts)
When is delivery indicated for IUGR if no complications?
38 0/7 to 39 6/7
When is delivery indicated for IUGR if abnormal uterine dopplers?
32 0/7 to 37 0/7
When is delivery indicated for IUGR w/ other conditions?
(GDM, HTN, oligohydraminos)
34 0/7 to 37 6/7
GDM is a/w what maternal/ infant risks?
Maternal- pre-eclampsia, c-section, T2DM later in life
Infant- T2DM, adult-onset obesity
What is the pathophysiology of GDM?
Pregnant state = insulin resistance (provides for ample nutrients)
Pancreatic function insufficient to overcome insulin resistance
When is screening performed for GDM if RFs vs routine?
If RFs = 1st trimester
Routine = 24-28 weeks
What is the protocol for screening of GDM?
1 hr glucose tolerance test
- If ≥ 135 → 3 hr tolerance test + A1c
- If ≥ 200 → GDM
3 hr glucose tolerance test:
- 8 hrs fasting
- 2+ elevated values → GDM
- fasting- 95
- 1 hr- 180
- 2 hr- 155
- 3 hr- 140
What is included in the initial management of GDM?
Diabetic educator (ADA diet, fasting 1-2 hrs prior to meals)
- Fasting < 95
- 1 hr post-prandial < 140
- 2 hr post-prandial < 120
Increase activity
What is included in the management of GDM if refractory to lifestyle changes?
Insulin initiation (1st line)
Metformin
If pt requires meds to control GDM, what is required?
Monitoring w/ growth US, BPP, delivery by 39 0/7 weeks or sooner
