Clinical Aspects of Pregnancy Flashcards
What are the major complications that account for 80% of all maternal death?
severe bleeding (usually HTN - eclampsia Obstructed labor Unsafe abortion
remainder are caused by diseases like malaria, anemia and HIV/AIDS
How many pregnancies are complicated by gestational diabetes?
7% are complicated by DM and 90% of that is classified as gestational DM
Why do we care about gestational diabetes
after 12 weeks, the maternal glucose can cross the placenta and fetal beta cells can produce insulin in response
if maternal glucose is elevated, fetal insulin production will increase, which triggers growth producing macrosomia
also…hyperglycemia in the first 10 weeks of pregnancy while organogensis is taking place is teratogenic and associated with 2-3x increase in congenital malformations and miscarriage (but this isn’t identified by current screening)
What percentage of deliveries of women with GDM are macrosomic?
20% - over 8 pounds 13 ounces
WHen do we screen for asymptomatic gestational diabetes?
24-28 weeks
What are the risk factors for GDM?
35 yrs and older BMI over 25 family hx of DM history of previous GDM macrosomia in previous pregnancy high risk ehtnic group: hispanic, asian, native, african, pacific islander)
test using the ADA criteria for nonpregnancy adults
How do we treat GDM?
diet
glyburide (micronase0
glucophage (metformin)
intensive insulin therapy
Treatment aims to achiee glucose levels of 130 per dL one hour postprandially
Does early induction for macrosomia help outcomes?
it reduces the risk of macrosomia, but doesn’t reduce rates of brachial injuries, hypoglycemia or clavicle fractures
True or false: most women will continue needing insulin after delivery for a few months
false - usually can stop right away
What percentage of women with GDM will devlop T2DM within 5-10 years?
50%
so continue screening with oral glucose tolerance test at three year intervals
What is the definition of preterm labor?
cervical change associated with uterine contractions prior to 37 weeks
in nulliparous women, this is uterine contractions with 2 cm dilation and 80%+ effacement
What is the incidence of preterm labor in the US?
11% of pregnancies
What are the risk factors for preterm labor?
premature rupture of membranes (PROM) multiple gestation previous preterm birth hydramnios uterine anommaly hx of cervical cone biopsy cocain abuse african american abdominal trauma pyelonephritis abdominal surgery in preg
What are some general causes of preterm labor?
UTI cervical infection bacterial vaginosis generalized infection trauma or abruption hydramnios multiple gestation idiopathic
What are the important questions to ask in the initial assessment of a patient with premature contractions?
- what is the gestational age
- are the membranes ruptured?
- is patient in active labor?
- is there an infection>
- What is the likelihood that the patient will deliver prematurely?
What should you do in the evaluation of premature labor?
speculum exam to rule out PROM
culture for GBS, chlamydia and gonorrhdea
check fetal fibronectin
ultrasound for EDD, expected fetal weight, fetal presentation, biophysical profile, cervix length
digital exam to see how far she’s dilated
What is fetal fibronectin and what does it tell us?
It’s a large glycoprotein thought to act as an adhesive of fetal membranes to the decidua
A high value is better at predicting imminent delivery than cervical dilation or uterine activity
high negative predictive value -
if it’s normal - they’re not going to be preterm
What should your orders be based on cervical length seen on US?
less than 16 mm -
consider cerclage
16-20 - bed rest and remeasure in one week
21-25 mm, reduce physical activity and remeasure in 2 weeks
What can you give antenatal for lung maturation if premature delivery is likely?
betamethasone (two 12 mg intramusuclar doses 24 hr apart) or dexamethasone ( mg intramuscularly every 12 hours for 4 doses)
You can also give tocolytics to slow down the premature labor. What are some drug options for this?
nifedipine
indomethacin
terbutaline
What percent of pregnancies will be affected by UTI?
5%
Bacterial vaginosis increases the risk for what?
prematur fupture of membranes, preterm delivery and peurperal infections
How do we treat bacterial vaginosis in pregnancy?
vaginal metronidazole to decrease nausea
What is chorioamnionitis?
infection of the placenta - presents with maternal fevers, elevated maternal white blood count and uterine tenderness
fetal tachycardia
What are the typical infections that can affect the fetus?
TORCH Toxoplasmosis Other: Parvovirus, HIV, Niesserie gonorrhea, chlamydia, hepatitis B, syphilis Rubella CMV HSV
What is the risk with parvovivrus?
fetal hemolytic anemia (fetal hydrops)
What is associated with congenital rubella syndrome?
deafness
cardiac abnormalities
cataracts
mental retardation
True or false: a woman with HIV should decrease her anti-HIV drugs to avoid teratogenic effects.
false - she should stay on regular triple therapy
What issues can be associcated with toxoplasmosis?
severe if transmitted to the fetus during the first trimester - seizures, hydro/microcephaly, hepatosplenomegaly, jaundice, chorioretinitis
If someone comes in with vaginal bleeding during pregnancy, what should you do in workup?
abdominal ultrasound FIRST!
gentle speculum exam
no binary exam
What are the two main concerns with antepartum bleeding?
placenta previa
placenta abruption
What would be the issue with painless bleeding?
previa
What would be the issue with bleeding associated painful contractions?
placenta abruption
What is complete placenta previa?
whne the placenta completely covers the internal cervical os
WHat is partial placenta previa?
when the placenta partially coveres the internal cervical os
What is a low lying placent?
when the edge of the placenta is within 2-3 cm of the internal cervical os
What is placental abruption?
premature separation of a normally implanted placenta
What is vasa previa?
when the umbilical cord vessels insert into the membranes with the vessels overlying the interal cervical os
raises concern for fetal exsanguination upon rupture of the membranes
A history of post coital spotting earlier during pregnancy suggests what?
placenta previa
What are the risk factors for placetna previa?
grand multiparity prior C-section prior uterine curettage previous palcenta previa multiple gestation
What is the management for placental previa?
delivery by C-section
WHat is placenta accreta?
invasion of the placenta into the uterus - which is more common with placenta previa
What are the predisposing/precipitating factors for placental abruption?
hypertension advanced maternal age multiparity multiple pregnancy diabetes mellitus trauma external/internal version delivery of first twin rupture of membranes with polyhydramnios
What percentage of pregnancies are affected by abruption? what’s the mortality rate?
ocurs in 1-5% of pregnancys ( is the cause of 30% of third trimester bleeding)
15% mortality rate
What is the treatment for abruption?
stabilize the patient
prepare for the possibility of future hemorrhage
prepare for preterm delivery
deliver if bleeding is life threatening or fetal testing is non-reassuring
What are the variations of the breech presentation?
complete breech
incomplete breech
frank breech
After a breech extraction and delivery, what do you need to check for in the baby?
hip dysplasia
What do we attempt if someone is breech? Does it work?
external podalic version
usually most successful if you do it and then induce right after because baby will just flip back around because there’s usually a reason fro the breech presentation!!
What is the biggest concern with all the abnormal presentations?
prolapsed umbilical cord
What are the 5 general itiologies for hypertension in pregnancy?
chronic hypertension (just continuing on) pregnancy-induced HTN pre-eclampsia Eclampsia HELLP syndrome
WHen do we call it chronic hypertension?
BP 140/90 before pregnancy or at less than 20 weeks gestation
Treatment of chornic hypertension in pregnancy is controbersion, but what are some options?
beta blockers
calcium channel blockers
methyldopa
diuretics
What hypertension drug do you NOT give in pregnancy
ACE inhibitors - associated with neonatal renal failure
When do we call it pregnancy-induced hypertension?
hypertension without proteinuria at greater than 20 weeks gestation
usually mild to moderate. maternal risks are small
When do we call it pre-eclampsia?
over 140/90 after 20 weeks of gestation in a woman whos BOP was previously normal WITH proteinuria
non-dependent edema is usually present, but not a criterion
What percentage of pregnancies are effected by pre-eclampsia?
5-8%
What do we think pre-eclapsia is caused by?
probably some sort of placental vasospasm
True or false: pre-eclampsia is more common in a woman’s first pregnancy.
true - but this may be because women who have pre-eclampsia are more likely to chose not to get pregnant a second time.
What are the risk factors for pre-eclapsia?
previous pre-eclampsia in other pregnancies
chronic hypertension
low dietary calcium
How can you reduce the risk for pre-eclampsia?
calcium supplementation
low dose aspirin if they have a history of Pre-ec, chronic hypertension, diabetes, autoimmune disease, renal disease or gestational hypertension
What are the complications of pre-eclampsia?
eclampsia (seizures) placenta abruption coagulopathies renal failure hepatic subcapsular hematoma hepatic rupture uteroplacental insufficiency
At what BP do we consider the pre-ec severe?
160/110
At what level of proteinuria do we consider it severe?
over 5 g in 24 hours
What are some other signs of severe pre-eclampsia?
oliguria pulmonary edema or cyanosis impariment of liver funtion visual or cerebral disturbnances pain in epigastric or RUQ decreased platelets intrauterine growth restriction
What is the treatment for pre-ec?
delivery!
control BP wth hydralazine or labetolol
Magnesium sulfate to prevent seizures
What is hELLP syndome?
Hemolysis (DIC)
Elevated Liver enzymes
Low Platelet counc
What fetal monitoring would you do in pre-ec or other hypertension?
you try to buy time before having to deliver…
- obtain nonstress test twice weekly
- biophysical profile weekly
- ultrasonogrphay every 3-4 weeks
True or false: If you are concerned, yo can tell the woman to count fetal movements
false - doesn’t improve outcomes and increases anxiety leading ot more triage evaluations
How do we do non-stree testint?
patient is connected to the montiro to measure baby’s heart rate, which hsould go up when baby moves
When do you do an oxytocin stress test?
WHen the non-stress test was concerning
How do you do a oxytocin stress test?
give IV oxytocin to induce contractions
the FHT should show VARIABILITY without decelerations with the contractions
What is assessed in the biophysical profile/
five categories with 0-2 score
amniotic fluid volume fetal tone fetal activity fetal breathing movements fetal heart rate reactivity (nonstress0
What is considered a normal biophysical profile score?
8-10
BIshop’s score for induction is used for what?
guides us about whether we can successfully attempt induction
What are the 5 things that go into a bishops score?
position of the cervix consistency of the cervix effacement dilation fetal station
each one goes from 0-3
A score of ___ would suggest favorable induction?
10
What are the methods to ripen the cervix?
mechanical with balloon catheter
oxytocin
prostaglandins (Dinoprostone - Cervidil or Misoprosol - Cytotec)
What drugs can you use during pregnancy to treat depression?
you can use TCAs, but prefer SSRIs
Save buproprion for smoking cessation typically, but can use if nothing else worked
Can you use these during breast feeding as well?
yes
there will be byproducts in the milk, but this doesn’t seem to affect the infant
What are the three screening tools for postpartum depression?
Edinburgh Postnatal Depression Scale
PHQ-9
Beck Depression Inventory
