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
