Complicated OB Flashcards
Ectopic pregnancy
- define
- risk
- Developing blastocyst implants at a site other than endometrium
- hemorrhage from ectopic preg is leading cause of preg related maternal death in first trimester
Ectopic Pregnancy
- risk factors
- *anything that messes with the tube**
- previous ectopic
- tubal pathology/sx
- prev genital infections
- IUD
- infertility
- multiple sex partners
- smoking
- in-vitro fertilization
- vaginal douching
- extremes of age
Ectopic Pregnancy
- locations including MC
- MC: fallopian tubes (70%)
- cervix
- ovary
- cornea (where fallopian tube enters uterus, doesn’t stretch)
- hysterotomy scar
- abdomen
what is a heterotopic pregnancy?
rare - ectopic AND viable intrauterine pregnancy at the same time
Ectopic Pregnancy
- Dx
if pt presents with suspicious history and/or clinical picture:
- quantitative b-hCG
AND
- findings on high resolution TVUS
Ectopic Pregnancy
- hCG behavior
- rises much slower in most (but not all) ectopic and nonviable IUP than in viable IUP
- falling hCG is sign of failing pregnancy (regardless of its location)
*in 85% of viable IUP, concentrations rise by 66% Q48 hours during first 40 days
Sx that indicate ectopic preg until proven otherwise
- positive preg test
- abdominal/pelvic pain
- +/- bleeding
Ectopic Pregnancy
- sx
Classic (ruptured and non-ruptured):
- abd pain (99%)
- amenorrhea (74%) bc pregnant…
- vaginal bleeding (56%)
- If hemodynamically unstable and/or acute abdomen - means lots of blood loss
- may be able to palpate pelvic mass
Ectopic Pregnancy
- ddx
- UTI
- Kidney stones
- diverticulitis
- appendicitis
- ovarian neoplasm
- endometriosis
- Leiomyomas
- PID/endometriosis
- preg-related: abortion, ruptured corpus luteal cysts, torsed ovary, degenerating fibroids
Ectopic Pregnancy
- medical management
- Methotrexate
- folic acid antagonist, inhibits DNA synthesis and cell reproduction, especially in proliferating cells
- rapidly cleared by kidneys
- dose based on surface area
Ectopic Pregnancy
- indications for sx management
- hemodynamically unstable/ruptured
- CI to methotrexate
- Heterotropic pregnancy
- poor medical candidate
- desire for permanent sterilization
- known tubal disease, planned in vitro fert for future pregnancy
- failed medical therpay
Ectopic Pregnancy
- sx options
Laparoscopic vs. laparotomy
- depends on many factors
- laparoscopic is standard approach
Salpingostomy (open, remove, close) vs. salpingectomy (remove tube with ectopic)
Ectopic Pregnancy
- post sx f/u
- ensure recover
- follow hCG to ensure complete success (all the way to zero!)
- can attempt conception once recovered and hCG is zero
Gestational Trophoblastic Disease
- overview
- Proliferative disorder of trophoblastic cells
- Maternal tumor arises from gestational tissue (not maternal)
- Defined by beta-hCG
Gestational Trophoblastic Disease
- list the four types
- Hydatidiform mole (complete or partial)
- Persistent/invasive gestational trophoblastic neoplasia (GTN)
- Choriocarcinoma
- Placental site trophoblastic tumors
Gestational Trophoblastic Disease
- Risk factors
- extremes of age
- Hx of GTD
- smoking >15 cig a day
- Maternal blood AB, A, B (not O)
- Nulliparity
- Hx infertility
- Use of OCP (very small risk)
Gestational Trophoblastic Disease
- Clinical sx
- vaginal bleeding
- enlarged uterus (rapid proliferation)
- Theca lutein cysts
- anemia
- hyperemesis gravidarum (high level hCG)
- hyperthyroid (hCG mimics TSH)
- preeclampsia before 20 weeks gestation
- vaginal passage of hydronic vesicles
Gestational Trophoblastic Disease
- complete vs. partial mole
Complete
- complete set of chromosomes. 46XX (MC) or 46XY
- more likely to be persistent and turn into cancer
Incomplete
- triploid set of chromosomes (partially molar)
- more likely to have actual fetus
Gestational Trophoblastic Disease
- management of Hydatidiform mole
- Preoperative baseline hCG
- Lab to rule out concomitant morbidity
- D&C evacuation, send tissue to pathology to confirm dx
- Serial hCG until 0
- can attempt conception after hCG 0 for 12 months
Spontaneous Abortion
- Overview
- preg that ends spontaneously before viable gestational age (20 weeks)
- most common complication of early pregnancy
- frequency decreases with increased gestational age
Spontaneous Abortion
- Risk Factors
- age
- previous SAB
- smoking
- cocaine
- NSAIDs (high dose)
- Caffeine (>200 mg a day)
- Prolonged ovulation to implantation
- prolonged time to pregnancy
- low folate
- BMI >18.5
- Untx celiac dz
Spontaneous Abortion
- 5 Etiologies
- Chromosomal abnl
- Congenital abnl
- Trauma (CVS and amniocentesis)
- Host factors
- Unexplained
Spontaneous Abortion
- Chromosomal abnormalities
- 50% SAB
- Most frequent
Autosomal trisomies
polyploidies
Monosomy X - Most arise de novo, rarely d/t inherited karyotypic abnl
Spontaneous Abortion
- 5 Host factors
- Maternal uterine abnl (uterine septum, submucosal leiomyoma, intrauterine adhesions)
- Acute maternal infection (listeria, toxoplasmosis, CMV, rubella, herpes simplex, parvovirus B19)
- Maternal (uncontrolled) endocrinopathies (Thyroid, Cushings, PCOS, DM, corpus luteum dysfunction)
- Teratogens (drug, physical stress like fever, env chemicals)
- Hypercoagulable state (SLE, antiphospholipid syndrome, thrombophilias)
Spontaneous Abortion
- Sx
- amenorrhea
- vaginal bleeding
- pelvic pain
- loss of fetal cardiac activity on US
- cervix may or may not be dilated
Spontaneous Abortion
- List the 5 categories of
- Missed
- Complete
- Incomplete
- Threatened
- Inevitable
Spontaneous Abortion
- Missed
had no idea, in for routine exam and pregnancy no longer viable
- no vaginal bleeding, cervical dilation, or cardiac activity
Spontaneous Abortion
- Complete
- fetal tissue already gone
- yes vaginal bleeding
- no cervical dilation or cardiac activity
Spontaneous Abortion
- Incomplete
- had sig bleeding, part of tissue still remains in uterus
- yes vaginal bleeding and cervical dilation
- no cardiac activity
Spontaneous Abortion
- Threatened
- any vaginal bleeding in first trimester of pregnancy
- yes vaginal bleeding and cardiac activity
- no cervical dilation
Spontaneous Abortion
- Inevitable
- hasn’t occurred yet but def will happen
- Yes vaginal bleeding, cervical dilation
- Yes/No cardiac activity
Spontaneous Abortion
- septic
- fever, chills, other signs of infection
- lower abd tenderness
- boggy, tender uterus w/ dilated cervix
Spontaneous Abortion
- organisms that cause septic
- staph aureus
- gram neg bacilli
- gram pos cocci
- mixed
- anaerobic orgs
- fungi
Spontaneous Abortion
- management
- Expectant: let it pass on its own, usually within first 2 weeks
- Medical: expedite or control over when will occur. U
- Surgical: suction D&C (dilation and curettage) or D&E (dilation and evacuation)
Spontaneous Abortion
- medical management uses what med
Misoprostol
- prostaglandins E1 analog
Spontaneous Abortion
- What must not forget to assess
RH status - will affect future pregnancies
Recurrent pregnancy loss (RPL)
- definition
- three or more consecutive losses of clinically recognized pregnancies prior to 20 weeks gestation
- Excludes ectopic, molar, biochemical pregnancies
- can be primary (never have had live birth) or secondary (had normal first preg and now this)
Recurrent pregnancy loss (RPL)
- risk factors (6)
- previous preg loss
- uterine factors
- immunologic factors
- Endocrine factors
- Genetic
- Thrombophilia and fibrinolytic factors
Recurrent pregnancy loss (RPL)
- Uterine factors
- impaired uterine distention or abnl implantation d/t decreased vascularity, increased inflammation, reduction in sensitivity to steroid hormones
- fibroids (leiomyomas)
- endometrial polyps
- intrauterine adhesions (prior curettage)
- uterine septum
Recurrent pregnancy loss (RPL)
- endocrine factors
- poorly controlled DM
- PCOS
- Hyper- or hypothyroidism
- HyperPRL
Recurrent pregnancy loss (RPL)
- evaluation first step
- Extensive history and PE is paramount
Recurrent pregnancy loss (RPL)
- useful tests
- karyotyping
- uterine assessment
- anticardiolipin abs and lupus anticoagulant
- thyroid tests
- PRL levels
- hgb A1C
Placental Infections
- Two vulnerable portals
- fetal membranes overlying cervix: direct access to pathogens ascending from vagina and cervix
- Placental intervillous space and fetal villi - hematogenous access
Placenal Infections
- Chorioamnionitis overview
- inflammation of chorion and or amnion
- can be sx or silent
Placenal Infections
- Chorioamnionitis sx
- preterm labor
- preterm premature rupture of membranes
- prolonged labor
- neonatal infection
Placenal Infections
- Chorioamnionitis microbiology
Often polymicrobial
- GBS
- E. coli
- Ureaplasma
- Fusobacterium
- Mycoplasma
- anaerobes
Placenal Infections
- Chorioamnionitis dx
Maternal fever (38C) AND 2 of the following:
- maternal leukocytosis (>15k)
- maternal tachycardia (>100)
- fetal tachycardia (>160)
- uterine tenderness
- amniotic fluid has foul odor
Placenal Infections
- Chorioamnionitis risk factors (7)
- nulliparity
- spontaneous labor
- longer length of labor, esp if membranes are ruptured (rate doubles after 24 hours)
- meconium-stained amniotic fluid
- internal fetal/uterine monitoring
- presence of genital tract pathogens (GC…)
- Multiple vaginal examinations
Placenal Infections
- Chorioamnionitis tx
- initiate abx
- expedite delivery
Vaginal bleeding during pregnancy
- overview
- common event at all stages of pregnancy
- almost always maternal, not fetal
- disruption of decidual blood vessels or discrete cervical/vaginal lesions
Vaginal bleeding during pregnancy
- 1st Trimester
- 20-40% all women
- light, heavy, intermittent, constant, painless, painful
Four major causes: - ectopic pregnancy
- miscarriage
- Implantation of pregnancy
- cervical/vaginal/uterine pathology
Vaginal bleeding during pregnancy
- 2nd and 3rd trimester
- less common major causes: - bloody show assoc. with cervical insufficiency - placenta previa - abrupt placenta - uterine rupture - vasa previa - cervical/vaginal/uterine pathology
Placenta previa
- placent covers the cervix
- can be complete or partial
- ok as long as 2 cm away from edge
- not painful, just locate of placenta
Abruptio placenta
- painful
- blood gets in between placenta and uterus
Vasa previa
- blood vessels are over cervix
- very bad
Vaginal bleeding during pregnancy
- evaluation
- complete hx and PE
- AVOID DIGITAL VAGINAL EXAM if you don’t know where the placenta is
Vaginal bleeding during pregnancy
- prognosis
depends on gestational age
Vaginal bleeding during pregnancy
- management
Depends on
- gestational age
- cause of bleeding
- severity of bleeding
- fetal status
Vaginal bleeding postpartum
- post partum hemorrhage (PPH) overview
- true emergency
- major cause of morbidity
- leading cause of admission to ICU in OB
- Most preventable cause of maternal mortality
- 1-5% deliveries
- 10% recurrent in subsequent pregnancies
Vaginal bleeding postpartum
- Post partum hemorrhage definitions
- excessive bleeding that makes the pt sx or hypovolemic
- > 500 cc vaginal
- > 1000 cc C-section
- > 1500 cc cesarean hysterectomy
Vaginal bleeding postpartum
- postpartum hemorrhage: what is very helpful vital sign
- pulse: tachycardia will occur before falling BP
- > 120 is a problem
- > 140 is a major problem
Vaginal bleeding postpartum
- What controls uterine bleeding post delivery
- contraction of myometrium constricts blood flow
- local decidual hemostatic factors aid in hemostasis
Vaginal bleeding postpartum
- 4 causes of postpartum hemorrhage
- Uterine atony (MC, 80%)
- Trauma
- Coagulation defects
- Retained products of conception
postpartum hemorrhage
- uterine atony
Uterus is tired:
- overdistention (twins, big baby)
- Uterine infection
- Drugs (mg relaxes muscle)
- Uterine fatigue dt prolonged labor
- Uterine inversion
postpartum hemorrhage
- complications
- Morbidity: shock, renal failure, ARDS
- Sheehan’s syndrome
postpartum hemorrhage
- management
- Tx like any other trauma/hemorrhage
- Non-operative and operative combos:
- restore circulator volume
- restore tissue O2
- Reverse/prevent coagulopathy
Hypertensive disorders
- Intro
- MC med complication of pregnancy
- 2nd MC cause of maternal mortality
- 5-10% incidence
Hypertensive disorders
- variation of presentation (4)
- Gestational hypertension
- Preeclampsia
- Chronic hypertension (preexisting)
- chronic HTN and preeclampsia
Hypertensive disorders
- pathophys
- do NOT know cause
- likely involves both maternal and fetal factors
- abnl in placental vasculature early in preg
- circulating antiangiogenic factors that cause maternal endothelial dysfunction
- environmental factors
- paternal (more likely if paternal mother had preeclampsia!)
Hypertensive disorders
- mild preeclampsia bp and proteinuria
- BP >140/90 mmHG
- Proteinuria >300 mg/dL/24 hours
Hypertensive disorders
- severe preeclampsia bp and proteinuria
- BP > 160/110
- Proteinuria >5000
Hypertensive disorders
- gestational HTN
elevated BP without proteinuria
Hypertensive disorders
- severe preeclampsia sx
- Oliguria (<500 cc/24 hours)
- Cerebral/visual disturbances (blindness or scotomota)
- pulmonary edema
- RUQ/epigastric pain
- impaired liver fn
- thrombocytopenia
- fetal growth restriction
scotomota
spots of blindness
Hypertensive disorders
- HELLP syndrome
- severe subset of severe preeclampsia
- Dx requires three:
Hemolysis (LDH >600)
Elevated LFTs (2x nl)
Low platelets (<100K)
Hypertensive disorders
- preeclampsia risk factors
SO MANY
- nulliparity
- hx preeclampsia
- extremes of age
- fam hx
- chronic HTN
- chronic renal dz
- thrombophilia
- vascular/CT disease
- DM
- multiple gestation
- high BMI
** Smoking is NOT a risk factor
Hypertensive disorders
- Preeclampsia dx
- have a high index of suspicion
- Lab (CBC, CMP, Uric acid, LDH, quantitative urine protein)
- Increased antepartum fetal surveillance (US, amniotic fluid index, non-stress testing)
Hypertensive disorders
- preeclampsia managment
- variable, depends on situation
- assess maternal status for end-organ damage
- Control blood pressure (<160/105)
Hypertensive disorders
- preeclampsia antihypertensive meds
- Alpha-methyl dopa (aldomet)
- Hydralazine (Apresoline)
- Labetalol
- Nifedipine (Procardia, Adatta) 1st line
Hypertensive disorders
- preeclampsia seizure prophylaxis
- IV Mg (can be toxic so monitor)
- Phenytoin is alt option, requires continuous heart monitoring
Hypertensive disorders
- eclampsia
- Have had a seizure
- Administer Mg
- for persistent convulsions: diazepam or lorazepam, sodium amobarbital
- fetal resuscitation is via maternal resuscitation
- delivery is only treatment
Diabetes in Pregnancy
- types
- Pregestational DM (T1 or T2 before preg)
- Gestational DM
Diabetes in Pregnancy
- overview
- Pregnancy is a state of insulin resistant and hyperinsulinemia
- maternal insulin resistant is nl. Starts in the second trimester and peaks in third.
- Results from increased placental secretion of diabetogenic hormones (GH, CRH, hCS/human placental lactose, progesterone)
- HCS plays major role in maternal insulin resistance, peaking at 30 weeks gestation
Diabetes in Pregnancy
- Diagnosis of overt DM
- Fasting glucose >125
- A1C >6.4%
- Random glucose >199
Diabetes in Pregnancy
- Dx of Gestational DM
- test at 24-28 weeks
- 1 hour OGTT >135
- confirm with 3 hour OGTT
Diabetes in Pregnancy
- complications of gDM
- preeclampsia
- hydramnios (big with gDM and small with T1DM)
- fetal macrosomia (big baby)
- fetal organomegaly
- birth trauma (bc big baby)
- operative delivery
- perinatal mortality (stillbirth)
- Neonatal respiratory problems and metabolic complications
Diabetes in Pregnancy
- fetal/neonatal complications of pre-gestational DM
- congenital malformations
- spontaneous abortion
- macrosomnia (big baby)
- polyhydramnios
- preterm baby
- perinatal mortality (stillbirth)
- neurodevelopment outcomes
Diabetes in Pregnancy
- maternal complications of pre-gestational DM
same issues as DM in general
- retinopathy, nephropathy, etc.
Diabetes in Pregnancy
- general management
- nutrition
- exercise (increases sensitivity to insulin)
- Glucose monitoring (A1C pre-preg 6-7%)
- Antenatal fetal testing
- Assessment of fetal growth
- Timing of delivery (early if poor glycemic control, 37-39 weeks)
- Intrapartum glycemic control
Diabetes in Pregnancy
- glycemic control
- via diet and exercise
- A1C 6-7%
- Oral meds: sulfonylurea is standard, metformin is an option
- Insulin: studies show better outcomes vs. oral meds.
Diabetes in Pregnancy
- postpartum management
- avoid hypoglycemia!
- F/u 4-6 weeks for 2 hour OGTT to r/o undiagnosed DM
- Pregestational DM return to primary care or endocrinologist for continued management
PTL and PPROM
- define
- PTL: preterm labor
- PPROM: preterm premature rupture of the membranes
PTL and PPROM
- overview
- leading cause of infant mortality in US
- relationship between neonatal mortality and gestational age is nonlinear
- <37 weeks is preterm
- 12% of births preterm in 2009
PTL and PPROM
- Risk factors
- stress
- occupational fatigue
- excessive/impaired uterine distention (twins!)
- cervical factors
- infection
- placental pathology
- fetal congenital anomalies
PTL
- preterm labor definition
painful uterine contractions that lead to cervical dilation
contraction WITHOUT cervical change is NOT preterm labor
PTL
- evaluation
- History (characterize the sx)
- PE (cervical exam)
- Determine gestational age
- Labs: urine culture, GBS, gonorrhea/chlamydia, fetal fibronectin (not used much anymore), drug screen?
- US
- +/- cervical length
PTL
- management
- Give steroids, even if not sure if in labor!! Reduces morbidity and mortality related to preterm birth
- Abx for GBS prophylaxis
- Tocolytic drugs for up to 48 hours to delay delivery, allow glucocorticoids to achieve max benefit
- Abx if positive gonorrhea/chlamydia
GBS prophylaxis
- Ampicillin or penicillin
- if PCN allergic, do culture
if GBS unknown, treat if there are risk factors:
- Rupture > 18 hours
- preterm <37 weeks
- GBS bacturia
- previous GBS sepsis in another infant
PTL
- Antenatal glucocorticoid administration
- Administer between 24 and 33 completed weeks of gestation
- Betamethasone and dexamethasone
PTL
- Benefits of antenatal glucocorticoid administration
Reduces:
- neonatal respiratory distress**
- intraventricular hemorrhage
- retinopathy of pregnancy
- necrotizing enterocolitis
PTL
- tocolytics
- Magnesium sulfate: decreases rates of cerebral palsy
- Procardia (CCB)
- Indomethacin (cyclooxygenase inhibitor, <32 weeks only to avoid fetal kidney damage)
- Terbutaline (beta-adrenergic receptor agonist): not used much anymore
PPROM
- overview
- definition
- treat just like PTL except also give abx
- PROM is membrane rupture prior to onset of uterine contractions
- PPROM is PROM <37th week
- management of PPROM is controversial!
PPROM
- evaluation
- Hx
- PE (cervical exam)
- Determine gestational age
- Labs: urine culture, GBS, gonorrhea/chlamydia, fetal fibronectin, drug screen?
- US +/- cervical length
- Sterile speculum exam: nitrazine, ferning test (looks like snowflake bc salty), pooling of fluid coming out cervix
PPROM
- management overview
- similar to PTL +/- tocolytics AND admin of latency abx (latent refers to period btwn breaking of membrane and delivery)
- expedite delivery in cases of overt infection
- Vaginal or cesarean route of delivery
PPROM
- latency abx
- ampicillin and erythromycin IV X 2D
- amoxicillin and erythromycin PO X 5D
Postpartum blues
- overview
- transient condition characterized by mild, often rapid, mood swings from elation to sadness, irritability, anxiety, decreased concentration, insomnia, tearfulness, crying spells
- 40-80% of women within 2-3 days of delivery
- resolves in 2 weeks
MAKE THIS NORMAL
Postpartum blues and depression
- Risk factors
- Hx of depression
- depressive sx during pregnancy
- Fam hx of depression
- Stress around child care
- Psychosocial impairment at work, relationships, leisure
- Postpartum blues = increased risk of postpartum depression
Postpartum blues
- treatment
- usually resolves over time with support and reassurance
- seek med attn if persist >2 weeks
Postpartum depression
- overview
- often unrecognized bc similar to dx of normal puerperium changes (time 6 weeks after delivery)
- 5% prevalence (maybe way higher)
Postpartum depression
- diagnosis
SIG E CAPS
- sleep
- interest
- guilt
- energy
- concentration
- appetite
- psychomotor retardation
- suicidal
- 5+ sx, present most of the day nearly every day for min 2 consecutive weeks.
- One sx must be either depressed mood or loss in interest or pleasure
Postpartum depression
- management
- address psychosocial and biologic factors
- Psychosocial therapy (mild to mod sx)
- light therapy
- Pharm for severe sx. Sertraline (least in breastmilk) or paroxetine, or anything that has worked in the past :)
- avoid bentos
- Severe: electroconvulsive therapy
- Hormone therapy
