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6. Women's Health > 3- Abnormal Pregnancy I & II > Flashcards

3- Abnormal Pregnancy I & II Flashcards

1
Q

An ectopic pregnancy occurs outside of the uterine cavity. What is the most common location?

A

Fallopian tube

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2
Q

What is the pathophysiology of an ectopic pregnancy?

A

Disruption of normal tube anatomy or functional impairment that prevents transport of embryo to uterine cavity

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3
Q

What factors place a pt at high risk for ectopic pregnancy? (5)

A

Previous ectopic pregnancy

Previous tubal surgery/ ligation

Tubal pathology

In utero DES exposure

Current IUD use

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4
Q

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)

A

Ectopic pregnancy

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5
Q

For normal intrauterine pregnancy, when should landmarks be visible on TVUS according to quantitative beta hCG values?

A

Once discriminatory zone is reached (3500 IU/mL)

Landmarks: “double ring” sign/ fetal pole w/ cardiac activity
(5-6 weeks)

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6
Q

Can a single beta hCG measurement diagnose the viability/ location of a gestation?

A

No

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7
Q

If unable to locate a pregnancy on TVUS once discriminatory zone is reached, what is the next step?

A

Considered “pregnancy of unknown location”

Repeat beta hCG in 48-72 hrs

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8
Q

When is expectant management appropriate for an ectopic pregnancy?

A

Asx + objective evidence of ectopic pregnancy resolution

Pt is reliable for f/u

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9
Q

What is included in expectant management of ectopic pregnancy?

A

Beta hCG q 48-72 hrs w/ US prn

If beta hCG < 200 → resolution of pregnancy

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10
Q

What risks are a/w expectant management of ectopic pregnancy? (3)

A

Tubal rupture, hemorrhage, need for emergency surgery

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11
Q

What is used for medical management of ectopic pregnancy (efficacy: 70-95%) and what is the greatest SE?

A

Methotrexate- affects actively replicating tissue

SE: Abd pain 1-3 days post admin

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12
Q

What are the indications for use of medical management of ectopic pregnancy? (4)

A

Hemodynamically stable

Unruptured mass

No absolute c/i - intrauterine preg, pancytopenia, IMC, active pulmonary disease/PUD/renal dysfunction, breast feeding

Reliable for f/u

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13
Q

Aside from methotrexate, what is included in the medical management of ectopic pregnancy?

A

Serial hCG levels until non-pregnancy level is reached (~2-4 wks)

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14
Q

Failure of hCG level to decrease by 15% from day 4-7 is a/w high risk of tx failure and requires what?

A

Additional methotrexate admin or surgical intervention

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15
Q

What pt edu should be provided for medical management of ectopic pregnancy with methotrexate? (5)

A

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)

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16
Q

In addition to failed medical management, absolute contraindications to medical management and patient request, when is surgical management of ecoptic pregnancy indicated? (3)

A

Hemodynamically unstable

Sxs of ongoing ruptured ectopic mass

Signs of intraperitoneal bleeding

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17
Q

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?

A

Salpingostomy

Risk of repeat ectopic pregnancy

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18
Q

What surgical management of ectopic pregnancy involves removal of part of all of the affected fallopian tube? When is this method preferred?

A

Salpingectomy

Preferred if: severe tubal damage, significant bleeding

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19
Q

What must be done following a salpingostomy?

A

Monitor seial hCG measurements to non-pregnancy level

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20
Q

What is defined as a group of conditions that consist of an abnormal proliferation of trophoblastic (placental) tissue?

A

Gestational trophoblastic disease

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21
Q

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)

A

Hydatidiform mole

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22
Q

What RFs are a/w hydatidiform mole?

A

Extremes in age (< 20, > 35)

Hx of previous GTD

Nulliparity

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23
Q

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?

A

Complete hydatidiform mole

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24
Q

Complete hydatidiform mole is derived from where and leads to presence or absence of a fetus?

A

Paternally derived (46xx)

Absence of a fetus

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25
Q

How is a complete hydatidiform mole diagnosed? (3)

A

Beta hCG: high, > 100,000

US: “snow storm appearance”

Definitive: tissue pathology

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26
Q

What is included in the management for complete hydatidiform mole?

A

Immediate removal of uterine products

Measure serial hCG weekly until (-) for 3 consec. weeks

OCP until documented resolution

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27
Q

What is the protocol for future pregnancies following a complete hydatidiform mole?

A

Closely monitor w/ early US and hCG levels

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28
Q

Pt presents with delayed menses and pregnancy diagnosis or vaginal bleeding from miscarriage/ incomplete abortion. What type of GTD are you concerned for?

A

Partial hydatidiform mole

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29
Q

Partial hydatidiform mole is derived from where and leads to presence or absence of a fetus?

A

Paternally and maternally derived

Presence of a fetus

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30
Q

How is a partial hydatidiform mole diagnosed? (2)

A

Beta hCG: N-high

US: “swiss cheese” appearance of intrauterine tissue, fetus w/ anomalies

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31
Q

What is included in management of partial hydatidiform mole?

A

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

32
Q

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?

A

Invasive molar pregnancy

33
Q

What will US show if invasive molar pregnancy?

A

Intrauterine mass, increased vascularity w/i myometrium

34
Q

What is included in the management of invasive molar pregnancy aside from serial hCG monitoring and OCP?

A

Single agent chemotherapy w/ methotrexate or actinomycin-D

35
Q

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)

A

Choriocarcinoma

Tx w/ single agent methotrexate (if good prognostics) vs multi-agent EMACO (if poor prognosis)

36
Q

What GTD is defined as a tumor that arises from the placental implantation site and what is the tx?

A

Placental site trophoblastic tumor

Tx w/ hysterectomy

37
Q

What is defined as persistent N/V that results in dehydration, weight loss, and potential electrolyte abns in pregnancy?

A

Hyperemesis gravidarum

38
Q

What is included in the general management of hyperemesis gravidarum? (3)

A

IV hydration

Banana bag w/ multivitamins (prevents Wernicke encephalopathy if vit B1 deficient)

Anti-emetics

39
Q

What anti-emetics are included in the tx of hyperemesis gravidarum?

A

1st line- vit B6 + doxylamine

2nd line- diphenhydramine/ prochlorperazine/ promethazine

3rd line- ondansetron, metoclopramide

4th line- clorpromazine/ methylprednisolone

40
Q

When does Rh incompatibility and alloimmunization occur?

A

Mother Rh (-), fetus Rh (+) → mixing of maternal/ fetal blood → development of maternal antibodies to Rh antigen

Does not affect current pregnancy, only future pregnancies

41
Q

What are the complications of Rh incompatibility and alloimmunization once the maternal antibodies to the Rh antigen cross the placenta?

A

Destruction of fetal RBCs → fetal hemolytic anemia → erythroblastosis fetalis

(HF, diffuse edema, ascites, pericardial effusion)

42
Q

What is the primary goal of management for an unsensitized Rh (-) pt and how is this done?

A

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
43
Q

What is RhoGAM?

A

Anti-D immunoglobulin

44
Q

What is the protocol for a sensitized Rh (-) pt? (6 steps)

(sensitized: antibody screen (+) for Rh (D) antigen)

A

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)

45
Q

What is the leading cause of maternal morbidity and mortality in developed nations?

A

HTN

46
Q

What is defined as chronic HTN diagnosed/ present before pregnancy or diagnosed prior to 20 weeks gestation?

A

Chronic HTN

47
Q

What is defined as HTN diagnosed after 20 weeks gestation in a woman w/ previously normal BP?

A

Gestational HTN

140 SBP +/- 90 DBP on 2 occasions at least 4 hrs apart

48
Q

What BP is determined severe gestational HTN?

A

> 160/ 110

Tx w/ IV antihypertensives

49
Q

How can you differentiate between pre-eclampsia and superimposed pre-eclampsia?

A

Pre-eclampsia: gestational HTN + proteinuria > 300mg

Superimposed pre-eclampsia: chronic HTN + pre-eclampsia

50
Q

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?

A

Pre-eclampsia

51
Q

What is defined as pre-eclampsia + new onset of generalized, tonic-clonic seizures?

A

Eclampsia

52
Q

What is the general pathophysiology of pre-eclampsia?

A

Failure to establish adequate uteroplacental BF

53
Q

How is presence of proteinuria confirmed when diagnosing pre-eclampsia?

A

SPOT

(+) if > 300mg

54
Q

What is included in the management of pre-eclampsia without severe features?

A

Out-pt management

Delivery at 37 0/7 weeks

55
Q

What is included in the management of pre-eclampsia with severe features? (5)

A

In-pt management

Delivery @ 34 0/7 weeks

Tx severe HTN- IV labetalol, IV hydralazine, PO nifedipine

Mg sulfate for seizure prophylaxis

Glucocorticoids

56
Q

What is included in the management of eclampsia? (4)

A

Prevent maternal hypoxia/ trauma

Prompt delivery (usually C-section)

Tx severe HTN- IV labetalol, IV hydralazine, PO nifedipine

Mg sulfate for seizure prophylaxis

57
Q

What is HELLP sydrome a/w (severe form of pre-eclampsia)?

A

Hemolysis

Elevated liver enzymes

Low platelet count

58
Q

What is included in the management of HELLP syndrome?

A

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

59
Q

What is often seen with lab values of a pt with HELLP syndrome?

A

Continue to worsen following delivery for 24-48 hrs

May require ICU

60
Q

What is defined as an estimated fetal weight (EFW) below the 10th percentile for gestational age in the 2nd half of pregnancy?

A

Intrauterine growth restriction

61
Q

EFW is determined by which 4 measurements?

A

Biparietal diameter

Head circumference

Abd circumference

Femur length

62
Q

What infections can be a/w intrauterine growth restriction?

A

TORCH

Toxoplasmosis

Other (Syphilis, Varicella)

Rubella

Cytomegalovirus

HSV

63
Q

Intrauterine growth restriction is a/w with increased risk of what?

A

Perinatal/ neonatal morbidity and mortality

64
Q

How do you screen for intrauterine growth restriction?

A

Fundal height measurements starting at 16 weeks gestation

If > 3cm off → consider LGA/ SGA → US

65
Q

In screening for intrauterine growth restriction, what test is used to eval EFW, amniotic fluid volume, and umbilical artery BF?

A

US

66
Q

In screening for intrauterine growth restriction, what test is used to identify fetus at risk for uteroplacental insufficiency (may require early delivery)?

A

Uterine artery dopplers

67
Q

What is the goal of management for intrauterine growth restriction?

A

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)

68
Q

When is delivery indicated for IUGR if no complications?

A

38 0/7 to 39 6/7

69
Q

When is delivery indicated for IUGR if abnormal uterine dopplers?

A

32 0/7 to 37 0/7

70
Q

When is delivery indicated for IUGR w/ other conditions?

(GDM, HTN, oligohydraminos)

A

34 0/7 to 37 6/7

71
Q

GDM is a/w what maternal/ infant risks?

A

Maternal- pre-eclampsia, c-section, T2DM later in life

Infant- T2DM, adult-onset obesity

72
Q

What is the pathophysiology of GDM?

A

Pregnant state = insulin resistance (provides for ample nutrients)

Pancreatic function insufficient to overcome insulin resistance

73
Q

When is screening performed for GDM if RFs vs routine?

A

If RFs = 1st trimester

Routine = 24-28 weeks

74
Q

What is the protocol for screening of GDM?

A

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
75
Q

What is included in the initial management of GDM?

A

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

76
Q

What is included in the management of GDM if refractory to lifestyle changes?

A

Insulin initiation (1st line)

Metformin

77
Q

If pt requires meds to control GDM, what is required?

A

Monitoring w/ growth US, BPP, delivery by 39 0/7 weeks or sooner

6. Women's Health (13 decks)

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