Antepartum abnormal Flashcards
Transient HTN
BP >= 140/90 for first time w/o proteinuria if preeclampsia does not develop and the BP has returned to normal by 12 wks pp
Preeclampsia
BP >=140/90 after 20 wks GA with proteinuria (>=300mg/24hr or persistent 30mg/dL or 1+ on urine dipstick
Theories of etiology of preeclampsia (7)
Abnormal trophoblast invasion Coagulation abnormalities Vascular endothelial damage Cardiovascular maladaptation Immunologic phenomena Genetic pre-disposition Dietary deficiencies or excesses
Eclampsia
Clonic-tonic seizures before, during or up to 10 days pp that are not attributable to other causes.
Superimposed Preeclampsia
New onset proteinuria in HTN after 20 wks GA
Sudden increase in proteinuria and BP and decrease in platelets <100K in women with proteinuria before 20wks GA.
HELLP Syndrome
Hemolysis, Elevated Liver enzymes, Low Platelets
HTN risk factors (8)
Nulliparous New father Adverse med hx Fam hx of preeclampsia Multiple gestation, fetal hydrops Race Obesity >35 y/o
S/S of abnormal HTN disorders (7)
HTN: BP >= 140/90 Proteinuria: 30mg/dL random, 1-2+ on dipstick; >300mg/24hr Thrombocytopenia (Platelets > 100K) Headache (resistant to meds) Visual distrubances Decreased urine output Epigastric/right upper quadrant pain
Management plan: Early, mild hypertension (home care) (7)
Left lateral bedrest 2hrs am and pm Daily BP checks Daily weight Daily urine dipsticks Bi-weekly office visits Daily fetal kick counts Consult and education pt
Preeclamsia in-patient management (9)
Bed rest decreased environmental stimulation 24hr I&Os Labs: 24hr urine for protein and creatinine clearance Liver function tests (AST/ALT) High Protein dit NSTs bi-weekly US if <36 weeks ega to assess IUGR BP q2-4hrs, routine VS and FHT otherwise Deliver at term
Eclampsia management (4)
Call for help (notify physician stat)
Observe seizure
Prevent injury (side rails up, turn to left side, don’t restrain)
Mag sulfate IV
What to do after eclampsia seizure (7)
Clear airway Oxygen 8L/min EFM Evaluate Contractions and labor Examine for injury Maternal Blood gasses, electrolytes and serum Magnesium levels
CMV
most common congenital virus from the herpes family.
Clinical signs of CMV maternal (4)
Adenopathy
Mono symptoms
Rare fever or hepatitis
More severe if immunocompromised
Neonatal signs CMV (8)
SGA Microcephaly (fetal hydrops), thrombocytopenia petechiae jaundice retinitis hyperbilirubinemia splenomegaly
Long term sequelae of CMV (neonate) (5)
Hearing loss (most common) Various neurological symptoms Mental retardation Retinitis Developmental delay
Fetal transmission by trimester
1st and early 2nd = more serious (eg microcephaly)
3rd trimester = fetal hepatitis and thrombocytopenia
Toxoplasmosis transmission
more likely to have transmission as pregnancy increases but severity is less
1st = 15%
2nd = 25%
3rd = 60%
May slightly increase risk of stillbirths
Toxoplasmosis for neonate
75% asymptomatic; if symptomatic 10-12% mortality IUGR, Retinitis Jaundice hepatosplenomegaly pneumonia adenopathy anemia thrombocytopenia
Treatment/Management with toxoplasmosis
Pyrimethanine, folic acid and sulfadiazine
Prevention: No raw meat, cat litter handling, hand wash foods from contaminated soil
Varicella (Chicken Pox)
A herpes virus transmitted via arosol with perinatal transmission usually within 1st 20 weeks
S/S of varicella
Fever, chills, cough
Rash (starts maculopapular on trunk, progress to vessicles and crust)
possible development of pneumonia (with high risk of mortality
Increased risk of Preterm birth
Fetal congenital infection of Varicella (8)
Greatest risk 13-20wks Skin scarring Microcephaly and micro-ophthalmia Limb reduction Growth restriction Polyhydramnios Dextrocardia 30% neonatal mortality rate if infected near birth
Treatment Varicella
acyclovir IV if symptomatic with complications
Rubella transmission
14-21 day incubation period through nasaopharyngeal secretions
1st timester exposure results in 20-80% congenital abnormalities
No documented defecte beyond 20 wks
Fetal s/s of rubella (9)
Fetal growth restriction Cateracts Congenital Heart disease Bone lesions Hepatosplenomegaly Congenital deafness petechiae anmeia microcephaly
Late neonatal sequelae of rubella (5)
Mental retardation Diabetes Thyroid disease Visual Damage Encephalitis
Management of Rubella
Treatment is palliative
Vaccination of children and susceptible women of childbearing age
Vaccine contraindicated in pregnancy
Thyroid changes in preg
Moderate thyroid enlargement
Fetus uses maternal iodide up to 20 wks GA
Increased maternal renal clearance of iodide
TSH does not change in pregnancy
Management of thyroid in preg
Sig increase in size, goiter or nodule requires evaluation.
ACOG: Thyroid testing only performed on symptomatic women with personal hx of the disease or other conditions associated with disease (i.e. DM)
Thyroid storm
Medical emergency: extreme hypermatabolic state with risk of maternal heart failure; s/s = fever, tachycardia, changed mental status, vomiting, diarrhea, cardiac arrhythmia
Dizygotic twins
multiple ova fertilized by different sperm
2 separate placentas and 2 separate membranes
Runs in families
69% of twins
More likely in AA women
Monozygotic twins (identical)
31% of twins
Data suggest small increase with ovulatory stimulants
Relationship of # of placenta/membranes depends on timing of division
monoamniotic/monochorionic
diamniotic/monochorionic
diamniotic/monoamniotic
Maternal risks of multiple gestation (4)
HTN (10-25%)
Abruption (2-6%)
PP hemorrhage (10-20%)
Preterm birth (25-50%)
Fetal risks of multiple gestation
Growth restriction
Preterm birth
Demise of more than one twin (more common in mono twins)
twin-twin transfusion
Genital Warts risks in preg
Potential lesions on vocal chords or in the upper airway and can result in rare respiratory papillomatosis
Management of Genital warts
Immiquimod (class B) or topical TriChloractic acid Podophyllin & podofilox are contraindicated
HSV risks in preg
Neonatal infection
HSV management in preg
C/S if active lesion or prodromal symptoms at onset of labor
Prophylaxis with acyclovir in last month of pregnancy
Gonorrhea risks in preg
Neonatal blindness
Gonorrhea management in preg
Neonatal prophylaxis at birth
maternal tx Ceftriaxone 250mg IM once
Chlamydia risks in preg
Opthalmia neonatorum (not liked to blindness) Neonatal pneumonia (tx during preg may reduce risk)
Chlamydia management in preg
Azithromycin 2g one time dose (maternal)
Neonatal eye prophylaxis at birth
Syphilis risks in preg
Congenital syph: cataracts, microcphaly, hutchinson’s teeth (notched teeth), hepatoslenomegaly
Management of Syphilis in preg
Treat ASAP to minimize neonatal effects
Treat as latent (3 injections of benzathine penicillin 1 each week for 3 wks).
If allergic, desensitize with PCN, cuz erythromycin has poor placental crossing (woman may be treated, but not fetus)
HIV risks in preg
Perinatal transmissions may occur esp with vaginal birth or BF if viral load is not suppressed.
Management of HIV in preg
Antiretroviral therapy during preg and neonatal periods
C/S recommended if viral load is not suppressed
No BF
Bleeding in preg how often and how is it related to SAB
25% of women in 1st and 2nd trimesters will experience bleeding and approximately 13% or half will experience SAB
ABs, Moles, ectopics, blighted ovums
Def of Threatened AB (4)
Continuation of preg is in doubt
Does not always culminate in AB
Usually pain is absent of minimal; if present, it is an ominous sign.
The cervix is closed and not effaced
Inevitable AB (3)
Termination of preg is in progress
Usually characterized by dilated cervix with accompanying pain, bleeding or rupture of membranes
Inevitable abortion usually proceeds to complete or incomplete AB
Incomplete AB
Products of conception protrude through the cervical os
Bleeding is apt to be more severe than other types of abortions often necessitating a D & E
Missed AB
Fetal death occur w/o expulsion of POC for several weeks
Bleeding may or may not occur and may be light if it does
Uterus is smaller than expected
Blighted ovum (no embryo)
Unknown etiology
Gestational sac develops, but no embryo
Usually treated as inevitable or incomplete abortion
Ectopic Preg
Preg outside the uterine cavity
usually assoc with pain, irregular bleeding and possible adenexal mass or fullness on one side
Gestational trophoblastic disease (molar preg)
Abnormal chorionic villi that form grape like vessicles, may occur with fetus (incomplete mole) or in absences of a fetus (complete mole)
Uterus large or small for dates.
No FHT if complete mole
Assoc with early preeclampsia, hyperemesis gravidarum and very high HCG levels
May progress to invasive mole or choriaocarcinoma
Incomplete mole & complete mole
IM =May be result of fertilization with diploid sperm
CM = only paternal genetic material, possibly from 2 sperm fertilizing an ovum with no maternal genetic material
Other reasons for bleeding in preg (more gyne related)
Chlamydia, cervical eversion causing more postcoital bleeding and with paps and cervical polyps
Normal HCG levels in preg
rises 66-100% every 48 hrs until about week 8; rises slowly until week 10 and plateaus at 24 weeks
HCG in abnormal conditions (3)
Ectopic: < 66%/48hrs
GTD (mole): higher than expected
SAB (complete): <5 mIU/mL or less; may take several weeks to go down
Bleeding in late preg (6)
Previa (20%)
Abruption (30%)
Other Causes (50%)
Marginal placental separation, preterm labor, STI
Hypertonic uterus =
more likely due to abruption
Transvag US is best for identifying what condition
Preveia
Placental abruption (inconsistently identifiable)
No pelvic exam if previa
Emergency late preg bleeding
Emergency consult and obtain neonatal support if
- Brisk vaginal bleeding
- unstable vital signs
- Fetal distress
management of bleeding in late preg
maternal O2,
Trendelenburg position or at least pelvic tilt
Immediate IV access: 2 large bore IV (16-18 gauge)
Initiate IV LR solution
Order type & Cross 2 units of whole blood.
Post dates complications
Maternal= Birth trauma due to macrosomia/shoulder dystocia, increased incidence of operative delivery, secondary infection or hemorrhage Neonatal= Meconium aspiration syndrome, polycythemia, hyperbilirubinemia, hypoglycemia
Fetal surveillance postdates per ACOG
Despite lack of evidence that monitoring improves outcomes, its reasonable to initiate fetal surveillance between 41 and 42 wks GA with NST and AFI, performed biweekly
Asthma in preg: Patient outcomes
28% improve; 33% no effect; 35% worsen
Consultation or collaboration is necessary depending on severity
Maternal complication with asthma in preg (5)
Hyperemesis Preeclampsia CHTN Vaginal bleeding Preterm labor and birth
Management of Asthma in preg (6)
Careful observation of fetal size
Fetal kick counts
Continue peak flow diary
Condition likely to worsen at 29-36 wks GA
Avoid beta adrenergics; use of Mag SO4 controversial for PTL
Acute treatment in preg (8)
Admit if peak flow is 95% Continuous pulse ox EFT Pulmonary function tests Beta Adrenergics Mortality >40% if asthma requires intubation
GDM causes
Preg is a diabetogenic state due to fasting hypoglycemia, post prandial hyperglycemia and hyperinsulinemia.
hPL decreases insulin effectiveness
Progesterone thought to increase basal levels of insulin
Progesterone and Estrogen thought to have a role in increasing tissue resistance to insulin
In GDM mother cannot produce enough insulin to overcome peripheral insulin resistance
Screening for GDM
Average risk: at 24-28 wks GA
High risk: at first visit and repeat at 24-28wks GA.
ACOG recommend all preg women be screened by pt hx, clinical risk factors or 1hr GTT at 24-28wks
3hr GTT cut offs
Fasting >105 1hr >190 2hr >165 3hr >145 GDM diagnosed when 2 or more are over the cut off.
PROM and PPROM
Spontaneous ROM prior to onset of regular uterine contrx. PPROM if earlier than 37 wks GA
Assoc w/ complications such as PTL, chorio, prolapsed cord and malpresentation
The earlier in preg PROM occurs the longer the latent period (time b/t rupture and contrx)
Causes of PROM
Infection (bacteria weaken collagen in membranes and initiate prostaglandin synthesis)
Usually BV, Trich, GC/CT and GBS
Mgmt of PROM (induction vs expectant)
Induction = shortens latent period, avoid unnecessary vag exams, watch for s/s of infection Expectant = the longer latent period > chance of infection; 70% go into labor in 24h and 90% in 48hr; sterile spec exam, fetal kick counts, temps every 4 hrs, NST or BPP every 2 days; BPP <6 may mean amniomitis; pelvic rest
Mgmt of PPROM
Amnio to detect infection and assess fetal lung maturity; abx therapy; moreso expectant mgmt; admin of corticosteroids; prolong preg to 34 wks in absence of infection and fetal distress
