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x REPRO > 4/14 Complications + Pathophysiology of Pregnancy > Flashcards

4/14 Complications + Pathophysiology of Pregnancy Flashcards

1
Q

causes of maternal mortality in us?

A
  • infection
  • Hemorrhage
  • HTN d/o of pregnancy
  • Venous thromboembolism
  • Indirect causes such cardiovascular disease and non-obstetric injuries
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2
Q

What is Puerperal fever in pregnancy?

A

defined as T ≥100.4°F (38°C) that occurs for ≥2 consecutive days during the first 10 postpartum days

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3
Q

What are causes of puerperal sepsis?

complications?

A

causes:

  • endometritis (infection in the uterus)
  • perineal wounds
  • C-section wounds

complications:

  • risk of septic shock
  • pelvic thrombophlebitis
  • pelvic abscess
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4
Q

What is endometritis and how does it occur?

A

endometritis (infection in the uterus)

  • occur due to ∆s at the placenta-maternal interface, where
    • alkaline amniotic fluid, blood, and lochia (vaginal discharge) neutralize vaginal pH allowing bacterial growth
      • normally, vagina acidity (pH 4-5) usually protects against overgrowth of bacteria
  • Necrotic endometrium and placenta fragments make the uterine cavity favorable for the growth anaerobic bacteria
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5
Q

What are the common pathogens of endometritis?

A

70% caused by mixed anaerobic organisms

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6
Q

risk factors for endometritis?

A
  • Poor nutrition and hygiene
  • Premature or prolonged rupture of membranes
  • Chorioamnionitis
  • Prolonged labor
  • Numerous vaginal examinations or manual removal of placenta
  • C-section
  • Retained placental fragments or fetal membrane
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7
Q

What are the major causes of

ANTEPARTUM HEMORRHAGE?

POSTPARTUM HEMORRHAGE?

A

ante: placenta previa + placenta abruptio
post: uterine atony (80% of cases)

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8
Q

What is placenta previa?

How do you tell if a woman has it?

A

“latin root of previa – going before”

placenta is partially or wholly in the lower uterine segment, over the cervical os

presentation: painless vaginal bleeding (70%)

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9
Q

What are the 4 types of placenta previa?

A
  • Total/complete - placenta covers internal os completely
  • Partial - placenta covers internal os partially
  • Marginal - lower edge of placenta reaches internal os, but does not cover it
  • Low-lying - Placenta is in lower segment, but the lower edge does not reach
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10
Q

Risk factors for placenta previa?

A
  • Multiparity/multi-gestation – women with a lot of babies
  • Older maternal age
  • Prior hx of placenta previa
  • Prior C-section (placenta may adhere to scarred uterus)
  • Tobacco use
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11
Q

How do you diagnose placenta previa?

A

US (transabdominal or transvaginal)

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12
Q

What is placenta abruptio?

How does a patient typically present?

A

premature separation of the “normally” implanted placenta due rupturing of maternal spiral arterioles in the decidua basalis, where it interfaces with the anchoring villi of the placenta; accumulating blood separates the decidua from its placental attachment to the uterus

presentation: painful vaginal bleeding, uterine tenderness and contractions

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13
Q

How does Placental abruptio form?

A

hypothesized to be an underlying abnormality in how the placenta has attached to the decidua or an inherent weakness or abnormality in the spiral arterioles, or trauma

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14
Q

What happens if there is a complete placental abruptio?

A
  • fetal death - detached portion of the placenta is unable to exchange gases and nutrients; when the remaining fetoplacental unit is unable to compensate for this loss of function
  • placenta will also become infarcted since it’s not being perfused properly
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15
Q

2 types of placental abruptio?

A
  • Concealed hemorrhage occurs when blood dissects upward toward the fundus without vaginal bleeding
  • External or revealed hemorrhage occurs when blood dissects towards the cervix; presents with vaginal bleeding
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16
Q

Risk factors for placental abruptio?

A
  • Maternal HTN
  • Placental abruption in a prior pregnancy
  • Trauma (blunt, falls, MVC) – big risk factor
  • Polyhydramnios with rapid decompression – rapid ∆ of the placental shape -> shearing force
  • Premature rupture of membranes
  • Tobacco use
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17
Q

How do you diagnose placenta abruptio?

A

US (identifies abruption only 50% of the time!)

  • US is indicated to exclude previa, since abruptio may coexist with a previa
18
Q

When does postpartum hemorrhage usually occur?

how is it diagnosed?

A
  • usually occurs immediately following delivery
  • Hemorrhage criteria:
    • 10% drop in hematocrit
    • need for transfusion
    • signs/sx of acute anemia after a vaginal delivery or C-section
19
Q

Major cause of postpartum hemorrhage and how does it occur?

A

Uterine atony (80%) ****

  • Normally the myometrium contracts around the myometrial spiral arterioles and decidual veins of the intervillous spaces and acts as a physiologic “ligature” to cut off blood flow
  • failure of the uterus to contract after placental separation (atony) puts these vessels at risk of bleeding post-partum
20
Q

Other potential causes post-partum hemorrhage

A
  • Genital tract trauma/laceration during delivery
  • Cervix, vagina, perineum, extension of hysterotomy with laceration of uterine arteries
  • Retained placental tissue
  • Low placental implantation in the uterus
  • Uterine inversion –uterus inverts as the placenta is delivered
  • Coagulation disorders

UTERINE ATONY is the major cause

21
Q

Risk Factors of postpartum hemorrhage?

A
  • Prolonged labor, augmented labor, or rapid labor
  • History of postpartum hemorrhage
  • Overdistended uterus (macrosomia, twins, hydramnios) – uterus doesn’t have the ability to contract down well
  • Operative delivery
  • Magnesium sulfate (agent used to relax smooth muscles)
  • Infection
  • Chorioamnionitis
22
Q

What are the major hypertensive d/o of pregnancy?

A

pre-eclampsia + eclampsia

23
Q

How often does hypertensive d/o in pregnancy occur?

A

occurs in 7-10% of pregnancies; accounts for ~20% of maternal deaths in US (usually due to maternal-cerebrovascular accidents)

24
Q

What are the characteristic features of pre-eclampsia?

A

HTN, proteinuria, edema (leads toweight gain)

25
Q

When does pre-eclampsia occur?

A
  • usually in the FIRST pregnancy (unusual in subsequent pregnancies)
  • usually 3rd trimester problem
26
Q

How is pre-eclampsia theorized to form?

A
  • Imbalance of decr. angiogenic (VEGF, PGF) and incr. anti-angiogenic factors (sFlt1, endoglin)
  • abnormal cytotrophoblast invasion and remodeling of uterine spiral arterioles at the time of implantation leads to placental hypoxia/ischemia
  • Endothelial dysfunction leads to an imbalance of vasoactive substances -> vasoconstriction
    • decr. PG-E2 and prostacyclin (vasodilators)
    • decr. Endothelial NO - (vasodilator and platelet-aggregation inhibitor)
    • incr. PG-F and thromboxane (vasoconstrictors)
    • incr. Endothelin-1 (vasoconstrictor and activator of platelets aggregation)
27
Q

Risk factors for pre-eclampsia?

A
  • pre-existing HTN
  • Glucose intolerance of pregnancy
  • Baseline thrombophilia
  • More trophoblast (twins/triplets)
28
Q

systemic effects of pre-eclampsia: cardiovascular

A

incr. SVR, HTN -> edema

29
Q

systemic effects of pre-eclampsia: renal

A

afferent arteriolar constriction -> decr. GFR , GBM injury -> HTN, proteinuria, oliguria, or ARF

30
Q

systemic effects of pre-eclampsia: GI system

A

hepatic vasoconstriction with periportal necrosis and hemorrhage, incr. LFT, RUQ pain, and rarely hepatic hematoma, capsule rupture

31
Q

systemic effects of pre-eclampsia: CNS

A

cerebral vasoconstriction -> incr. resistance of cerebral vascular blood flow, decr. cerebral O2 delivery, HA, vision hallucinations, seizures, hyperreflexia, encephalopathy, stroke

32
Q

systemic effects of pre-eclampsia: respiratory

A

incr. capillary permeability -> pulmonary edema

33
Q

systemic effects of pre-eclampsia: reproductive

A

incr. uterine artery vascular resistance, decr. placental blood flow, nutrient/O2 delivery, abruptio placentae

34
Q

systemic effects of pre-eclampsia: Fetal and neonatal complications

A

growth restriction, prematurity, and perinatal

35
Q

What is the difference between mild + severe pre-eclampsia?

A
  • MILD Preeclampsia
    • New-onset HTN after 20 wks; systolic ≥ 140 mmHg or diastolic ≥ 90 mmHg
    • New-onset proteinuria > 300 mg/ 24 hrs (2+) after 20 weeks
  • SEVERE Preeclampsia
    • Systolic ≥ 160 mmHg or diastolic ≥ 110 mmHg on two occasions at least 6 hr apart
    • Proteinuria > 5 g/24 hr or qualitative value of 3+ in urine dips 4 hr apart
    • Oliguria <500 mL in 24 hr
36
Q

What is SEVERE Preeclampsia most at risk for?

A

seizures (eclampsia)

37
Q

What is HELLP?

What is it caused by?

A

HELLP syndrome - variant of severe preeclampsia w/ high morbidity

Hemolysis

Elevated Liver enzymes

Low Platelet count

problem: general activation of thecoagulation cascade

  • fibrin -> MAHA (microangiopathic hemolytic anemia)
  • periportal necrosis - main site where this occurs
  • consumption of platelets -> DIC + thrombocytopenia
38
Q

How would you treat a patient with pre-eclampsia early in the pregnancy? late in the pregnancy?

A
  • Hydrate
  • treat HTN
  • anti-seizure Rx prophylaxis
  • if later in the term: delivery to get rid of placenta (remember, this is a placental problem!)
39
Q

What are the characteristic features of eclampsia?

when does it occur?

A

(tonic clonic) SEIZURES + hypertension, proteinuria, edema

Timing is variable with most cases < 24 hours following delivery

40
Q

What’s going on in these two pictures?

A

Top: normal – myometrium + decidua is ready for implantation. Trophoblasts invade maternal blood vessels (spiral arteries) and make them bigger so that the placenta is adequately perfused

Bottom: Pre-eclampsia – no remodeling of spiral arteries (no invasion of trophoblasts) -> underperfusion of placenta

x REPRO (37 decks)

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