Complicated pregnancies

Question 1

Obstetric problems 1

Answer 1

• Abnormal placentation: placenta previa (.5%), low lying placenta
• Complete previa: placenta completely covers internal os
• Partial previa: portion of placenta covers some of the os
• Placenta prevue usually presents as bright red painless bleeding around 30 wks +/- contractions
• PE: vaginal hemorrhage, hypotension, tachycardia, soft/non-tender uterus (do not perform vaginal/cervical exam b/c may elicit hemorrhage)

Question 2

Obstetric problems 2

Answer 2

• Risk factors for placenta previa: prior uterine surgery, prior placenta previa, mulitparity, advanced maternal age, multiple gestation, smoking
• Low lying placenta: implants in lower uterus are in close proximity but not extending to the os
• Accreta (placenta extends into decidua basalis), increta (placenta extends into myometrium) or precreta (placenta extends past serosa of uterus)

Question 3

Obstetric problems 3

Answer 3

• Abruption: premature separation of nl implanted placenta from uterine wall, resulting in hemorrhage btwn the uterine wall and placenta
• Only .5% of pregnancies, but fetal mortality is 15%
• Risk factors: HTN, previous Hx of abruption, advanced maternal age, smoking, cocaine, trauma, uterine fibroids/anomalies, premature rupture of membranes
• Presentation of abruption: +/- bleeding, uterine tenderness, varying degrees of hypotension/tachycardia, fetal distress, may lead to shock/DIC/fetal death

Question 4

Preeclampsia 1

Answer 4

• A triad of maternal HTN (>140/90), proteinuria (>300mg/24 hrs), both taking place after 20 wks of pregnancy
• Cause is unknown, but associated w/ generalized constriction and edema
• Complications of preeclampsia: seizures, cerebral edema or hemorrhage, thrombocytopenia, renal failure, hepatic rupture

Question 5

Preeclampsia 2

Answer 5

• Fetal complications: oligohydramnios, intrauterine growth restriction (IUGR), stillbirth, placental abruption, fetal distress, premature delivery
• Severe preeclampsia (only need 1): BP ≥160/110, HA, visual changes, RUQ/epigastric pain, elevated liver nzs (2x nl), pulm edema, retail failure (Cr >1.1), thrombocytopenia (<100k)
• Rx: MgSO4 to Rx seizures (and for seizure prophylaxis), need to deliver fetus (34 wks if severe, 37 wks is goal if not severe)

Question 6

Diabetes 1

Answer 6

• Affects 3-10% of pregnancies, 10% of those are pregestational, 90% are gestational cases
• Gestational diabetes: increased placental steroids and peptide hormones promote insulin resistance, elevated maternal glc levels, fetal hyperglycemia and hyperinsulinemia
• Leads to 50% chance of developing DM later in life (mother or baby?)
• Risk factors: family Hx of DM, obesity, sedentary lifestyle, hispanic and asians, Hx in GDM in previous pregnancy, previous baby over 9 lbs, excessive weight gain in pregnancy

Question 7

Diabetes 2

Answer 7

• Complications: polyhydramnios, preeclampsia, misscarriage, infection, congenital abnormalities/fetal death (cardiac malformations most common), neonatal respiratory distress, IUGR (DM1), macrosomia (increases risk for shoulder dystocia and brachial plexus injury)
• Fetal congenital abnormalities seen in pre-gestational DM, DM1 leads to small babies and DM2 leads to big babies
• Brachial plexus injuries: erb palsy (waiter’s tip), and klumpke’s palsy (claw hand)
• Rx: counseling, diet, exercise, insulin, C section should be offered if fetus is >4.5kg

Question 8

Post partum complications: PPH

Answer 8

• Postpartum hemorrhage (PPH): >500ml blood after vaginal delivery or >1000ml blood after C section
• Causes: uterine atony (most common, there is no clamping down on vessels after expelling the placenta), retained placenta, lacerations, uterine inversion (uterus comes out of cervix), coagulopathy
• Sheehan syndrome: pit infarct from hypovolemia/hypotension as a result from PPH, leads to failure of lactation and menstruation

Question 9

Post partum depression

Answer 9

• Postpartum blues are common, depression seen in 10-15% of pregnancies, psychosis in .2%
• Depression: low energy level, anorexia, insomnia, hyper somnolence, extreme sadness, sometimes suicidal/homicidal ideation, lasts for more than a few weeks
• Rx: SSRI, support, social work
• Hospitalize if psychotic, suicidal or homicidal

Question 10

Prematurity

Answer 10

• Delivery before 37 wks gestation (12% of pregnancies)
• Risk factors: premature rupture of membranes, infection, multiple gestation, uterine anomalies, prior preterm birth, abruption, peeclampsia, low socioeconomic status, cervical insufficiency
• Rx: tocolytics (MgSO4, nifedipine, indomethacin, terbutaline) and corticosteroids (matures fetal lungs rapidly)
• Complications: respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, electrolyte abnormalities, retinopathy, deafness/blindness, cerebral palsy, mental retardation, death

Question 11

Post-term deliveries

Answer 11

• After 42 wks gestation
• Increased risk of complications: macrosomia, oligohydramnios, meconium aspiration, intrauterine fetal demise
• Postmaturity syndrome: dry, peeling, loose skin, long finger and toe nails, appear emaciated, prone to hypoglycemia