Complicated Pregnancy Flashcards
What are 3 risk factors for a high-risk pregancy?
Advanced maternal age (AMA) mother
Adolescent pregnancy
History of complicated pregnancy
What is the definition of Advanced Maternal Age (AMA)?
Definition: age >35 at delivery
What are 7 pregnancy risks of AMA?
Presence of underlying medical problems (HTN/DM) Spontaneous abortion (GDM, Aneuploidy)
Ectopic pregnancy (4-8X increase) Placenta previa (3x risk at 35yo)
C-section rate (avg 30%, inc to 80% >50yo)
LBW—2.3X if >40 vs 20-24
Preterm delivery—–similar increase in risk
What is the defintion of adolescent (high risk) pregnancy?
Definition: age < 20 at time of delivery
What are some of the contributing factors that add to risk in adolescent pregnancy?
Most from low socioeconomic background—contributing factors
INADEQUATE NUTRITION
Poor education
Cigarette smoking
Drug abuse
STD’s
Deficient prenatal care
What are some adolescent pregnancy risks?
Iron deficiency anemia
Preeclampsia-eclampsia
Prematurity
Low Birth Weight
SGA infants
Operative delivery
What constitutes a Complicated Pregnancy History?
(8 lines)
Recurrent abortion - >or=2 consecutive losses
IUFD - EGA >20wk but prior to labor
PTL, LBW, SGA, IUGR
Macrosomia, LGA
Grand multiparity - 5 or more
PIH
Termination for a medical condition
Rapid succession, operative, atony, psych
IUFD?
Intrauterine fetal demise; death of fetus >20 weeks
PTL?
preterm labor; labor prior to 37 weeks
Macrosomia?
weight >4.0 kg
LBW?
VLBW?
ELBW?
LBW: low birth weight 1.5-2.5 kg
VLBW: 1-1.49 kg
ELBW: 0.5- 0.99kg
SGA?
small for gestational age; weight
IUGR?
What are the types?
intrauterine growth retardation/restriction
Fetus has not reached its growth potential due to genetic or environmental factors
May be symmetric (Type I) or asymmetric (Type II)
Type II IUGR preserves head size
PIH?
PIH: Pregnancy-induced hypertension
What are some Unique Pregnancy Complications?
PTL (Preterm Labor) and cervical incompetence
Preterm/Premature rupture of membranes (PPROM)
Post-dates pregnancy
Multiple gestation
What is the #1 cause of neonatal morbidity & mortality?
Preterm Labor (Birth)
causes 75% of neonatal deaths not due to congenital anomalies
Preterm labor causes how much risk increase of cerebral palsy (%) between weeks (?) to (?)
Cerebral Palsy risk of infants born 23-27 weeks 80X that of term births
Preterm labor complicates how many (in %) of pregnancies?
Complicates 10-15% of pregnancies
Test Question
Preterm labor is defined as labor between (__) and (__) weeks EGA
AND
Documented uterine contractions of (?/20min or ?/80min)
AND
one of what other 3 things?
Labor between 20 and 37 weeks EGA
“Labor” defined as:
AND
Documented uterine contractions(4/20min or 8/60min)
AND
- Documented cervical change or
- Effacement of 80% or
- Dilation 2 cm or more
What are some known causes of preterm labor?
- *Maternal medical problems:** Trauma, preeclampsia (HTN & proteinuria), hypertension, DM
- *Infection** (increased phospholipase A activity): UTI, bacterial vaginosis, cervical infections
- *Anatomic abnormalities**: Cervical incompetence or shortening, bicornate uterus, didelphys. Placental abruption, placenta previa. Fetal anomalies
- *Uterine overdistension**: Multiple gestation, polyhydramnios
How do you diagnose preterm labor?
1) Cervical length by ultrasound
>30mm very low risk of PTB (Preterm birth)
2) Fetal fibronectin
Obtain PRIOR to digital examination; submit IF exam is non-reassuring (ie cervical length 20-30mm)
3)Digital cervical exam
notes change in effacement or dilation over time
How do you manage preterm labor?
1) Ensure hydration
2) R/O Infxn (GBS culture, STI, Wet prep for BV, UA cult)
3) R/O fetal anomolies via ultrasound
3) Determine EFW, presentation,cerv length, AFI (testQ).>26 at risk
4) Steroids (w/o infxn) if 24-34 weeks (none after 34 wks – ACOG - unless lungs immature)
How do you manage preterm labor
1) Hospitalize
2) Hydrate
3) Betamethasone (reduced intravent hemorrhage and necrotizing enterocolitis)
4) GBS prophylaxis if indicated
5) Tocolytic therapy up to 48 hrs
6) Antibiotics for positive cultures
7) Magnesium sulfate if 24-32 weeks—neuroprotective effect
When should you consider tocolytic therapy?
What should you administer with tocolytics and what for?
Administer steroids for fetal lung maturity
What are Contraindications to Tocolysis?
Nonreassuring fetal status (get baby out)
Chorioamnionitis (amniotic infxn)
Severe preeclampsia or eclampsia
Fetal Demise (IUFD; dead baby)
Fetal Maturity (lungs good-to-go)
Maternal hemodynamic instability
Advanced cervical dilitation (>3cm)
Severe IUGR (unhappy fetus)
What are the 4 drugs used as tocolytics?
ß-agonists (relax smooth muscle)
Calcium channel blockers (same)
Magnesium sulfate
Prostaglandin synthetase inhibitors
What ß-agonist is used as a tocolytic?
How does it work?
SC or IV terbutaline
Bind with B2 receptors causing uterine relaxation (Uterus has B2 receptors)
What Calcium channel blocker is used as a tocolytic?
How does it work?
nifedipine
Block influx of Ca++; Best outcome with HIGH dose
Note:
Fetal effects—decreased uterine/umbilical blood flow. Monitor with ultrasound?
Using magnesium sulfate as a tocolytic,
What is the dose?
How dong do you use after conractions stop?
What is the antidote for magnesium sulfate?
2-6gm IV bolus, then 1-4gm/hr drip
Once contractions stop, continued for 12 hours or until steroids for fetal lung maturity on board
Antidote=Calcium gluconate (10ml of 10% soln IV)
Using magnesium sulfate as a tocolytic.
What are some side effects?
How do you monitor for toxicity?
SE: warmth/flushing; respiratory depression, cardiac conduction defects/arrest at very high levels
Monitor: Deep tendon reflexes, lung exam and I/O’s
1) For tocolytic use, what is the Prostaglandin Synthetase Inhibitors of choice?
2) How long can you use it for and at what time of pregnancy?
3) What are some consequences of using PSI’s too long?
4) What do you need to monitor when using a PSI?
1) Indomethacin (PO or PR)
2) Short term(
3) possible fetal complications:
Oligohydramnios, premature ductus closure, intracranial bleed, necrotizing enterocolitis
4) Monitor amniotic fluid/ductus blood flow in fetus with US
1) What is the definition of cervical incompetence?
2) What size does the cervix present?
3) Amniotic bulging has to be in the presence of what?
4) How can it be treated? (mentioned in class)
1) Passive painless 2nd trimester dilation
2) Classically > 4 cm
3) Classic: bulging amniotic sac in absence of:
Uterine contractions (UCs)
Vaginal bleeding (VB)
Infection
Amniorrhexis…PROM or PPROM
4) Cerclagia- Stitch to hold cervix?
What is the definition of Premature rupture of membranes (PROM)?
PPROM?
Whats at risk for PPROM
PPPROM?
Definition: rupture of membranes before the onset of labor (PROM)
If rupture of membranes and fetus is preterm, ie
Prior to 24 wks can lead to lung hypoplasia
Considered “prolonged” if greater than 24 hours elapse before labor begins (PPPROM)
What are Causes of PROM/PPROM?
Maternal Infection - UTI, chlamydia, gonorrhea
Chorioamnionitis (mom/baby infxn)
Cervical incompetence
***Polyhydramnios (AFI >26)
Multiple gestation
What are Risk Factors for PPROM?
Previous PPROM—3X risk
Genital infection—single most identifiable factor
Antepartum bleeding—3-7X risk
Smoking—2-4X risk “interesting”
How do you diagnosis PROM?
Pooling: Most reliable indicator for rupture (have valsava in lithotomy)
Nitrazine (pH more acidic in amniotic)
Ferning
In PPROM: KEEP YOUR FINGERS OUT!
Sterile speculum exam (w/valsalva)
What are some advanced evaluations of PROM?
Obtain AFI: Less than 5 cm, Absence of 2X2 cm pocket
Indigo carmine dye via amniocentesis
Amnisure –immunochromatographic test from vaginal fluid (measure placental proteins; highly accurate)
What are the management steps of PROM? (>37wks)
PROM (term) (> 37wks)—induce with pitocin
FHR monitor to assess status
Can wait up to 24 hrs before inducing labor
Ripening associated with increased infection risk
Assess need for GBS prophylaxis
What are the management steps of PPROM?
Empiric antibiotics prolong latency; use if
Antenatal steroids if < 34 weeks
Tocolytics only to allow for antibx/steroids
Monitor for infection - induce if infected
When considering fetal lung maturity,
What is the EGA range?
what should be given? How long does it last? What risks does it decrease?
what can’t be present when giving?
what are the regimens?
1) For EGA 24-34
2) Antenatal corticosteroids; Decrease Respiratory Distress Syndrome, NEC and Intraventricular hemorrhage. Effects last for 7 days
3) absence of chorioamnionitis
4) Regimens
Betamethasone 12mg IM q24 hours x 2 doses
Dexamethasone 6mg IM q12 hours x 4 doses
1) What is the definition of post-date pregnancy?
2) What are ACOG’s recommendations and at what EGA?
1) Definition: gestation exceeding 294 days (42 weeks)
2) Induce! At 41 weeks (ACOG)—but no upper limit for expectant management
What are risks associated with post-date pregnancies?
Low transverse cesarean section rate doubles (macrosomia, fetal intolerance of labor) Birth trauma (shoulder dystocia, brachial plexus injury) Oligohydramnios/(fetal stress) meconium aspiration syndrome
What are Medical & Surgical Complications of Pregnancy?
Deep venous thrombosis (DVT)
Heart disease
Pulmonary disease
Diabetes mellitus (DM)
Thyroid disorders
Seizure disorders (epilepsy)
Hepatobiliary disorders
Surgical disorders
Psychiatric disorders
Hypertensive disorders
LTCS increases risk 3-16x in what complication of pregnancy and peripartum?
How do you diagnose?
How do you treat?
DVT
Dx with compressive ultrasound (doppler)
Heparin (risk of Thrombocytopenia) or
Lovenox (LMWH) less risk, less monitoring
1) What heart disease is a complication of pregancy?
2) What is it unique to?
3) How do you Dx?
4) How do you treat?
5) What’s different about delivery? (tools?)
6) What education needs to be given post-partum?
1) Peripartum cardiomyopathy (PP CM)
2) Unique to pregnancy and puerpurium (20wk)
3) Dx: echo, bx (exclusion)
4) Rx: supportive, Na restrict, digoxin, diuretics
5) Deliver via forceps, vacuum
6) No more pregnancies!!!
With asthma in pregnancy, can asthmatics continue their meds? Can they take a steroid burst if needed? What ultimately needs to be done?
Most common meds are safe in preg/lact
Oral steroid (burst) can cause S/E; avoid if possible
Consult!
Cystic fibrosis in pregancy increases risk of? What are ACOG recomendations?
Risk of IUGR/PTL&D
ACOG prenatal screening guidelines—genetic counseling
Diabetes is a big issue in first part of pregnancy, what hormones increase insulin resistance?
Growth hormone
Placental lactogen
Corticotropin releasing hormone
Progesterone
Of the International Association of Diabetes and Pregnancy Study Group (IADPSG Classification), findings of any off the following constitute what?
FPG > 126
HgbA1C > 6.5
Random plasma glucose > 200 subsequently confirmed by either of above parameters
Overt Diabetes
Of the International Association of Diabetes and Pregnancy Study Group (IADPSG Classification), findings of any off the following constitute what?
FPG > 92 < 126 at any gestational age
Abnormal 75gm 2hr OGTT at 24-28 wks
FPG > 92 or 1 hr > 180 or 2 hr > 153
Gestational Diabetes
In gestational diabetes, what test postpartum and when needs to be done?
What is the recurrence of GDM in subsequent pregnancies?
Follow up OGTT 6-12 wks postpartum
33-66% with GDM will repeat with subsequent pregnancies
(Also increased risk of cardiovascular Dz)
1) How do you manage a GDM patient?
2) What medications should be used and why?
1) Nutrition consult
Weight management
Close follow-up (someone else will follow)
2) Anti-hyperglycemics - Insulin (best for control, multidose)
Use if fasting glucose levels persistently >95
What are maternal Diabetes Complications?
Accelerated chronic HTN
PIH (2X risk)
UTI - Secondary to glucosuria
Pre-eclampsia
Operative delivery
What are some fetal Diabetes Complications?
Which ones are from pre-gestanional DM?
SAB
IUFD
Polyhydramnios (>2L)
Macrosomia (>4500g)
IUGR* (pre-gest)
Congenital anomalies* (pre-gest)
Cardiac, limb, sacral agenesis
The placenta produces what that can stimulate symmetric thyroid enlargement?
Human Chorionic Gonadotropin (hCG) and Human Chorionic Thyrotropin (hCT)
Patient presents with wt loss, tremor, tachycardia, exophthalmos, pretibial myxedema, onycholysis, enlarged thyroid, bruit. You suspect graves disease.
1) What medications can you give 1st trimester?
2) What medications can you give 2nd/3rd trimester?
3) What are the fetal risks of both?
1) PTU (1st trimest)
2) methimazole (blocks T3T4) (2nd,3rd trimest)
3) Both cross placenta - Fetal hypothyroid/goiter
Brow/face presentation/cephalopelvic dysproportion/LTCS
A pregnant woman presents with fatigue, cold intolerance, brittle hair, wt gain, constipation. She taking synthroid for her hypothyroidism.
Should she continue taking synthroid?
What are some Risks for hypothyroid?
Yes: Rx: Continue synthroid; does not cross
Risks: SAB, IUFD, congenital malformations
90% patients with epilepsy have normal pregnancy (stated).
How should you supplement all?
Why would you supplement with vitamin K?
Folate for all
.
Supplement vitamin K for patients on phenytoin, phenobarbital, or primidone.
How do you treat acute seizure in pregnancy?
Same as non-pregnant
Airway and monitors
Correct precipitating factors
Acute anticonvulsant administration/GA
If no prior h/o seizures, probably Eclampsia…tx with magnesium sulfate
What is the most common cause of jaundice in pregnancy?
Viral hepatitis remains most common cause of jaundice during pregnancy
Do LFT’s go up or down during pregnancy; by how much and why?
2X increase in Alk Phos
Due to fetal skeleton
What is the Second most common cause of jaundice during pregnancy
Intrahepatic Cholestasis of Pregnancy
Intrahepatic Cholestasis of Pregnancy presents with intense pruritis, fatigue, jaundice, dark urine.
It usually occurs in what trimester?
What labs are elevated?
How do you treat?
Usually occurs in 3rd trimester
Elevated bile acids, bilirubin, extremely high alk phos
Tx: Symptomatic treatment for itching, cholestyramine may reduce bile acid levels and decrease intching
Acute Fatty Liver of Pregnancy occurs in 3rd trimester and or early postpartum. Presents with abdominal pain, N/V, jaundice.
What are some associations with AFLOP?
What labs do you anticipate are elevated?
What labs do you anticipate are lowered?
What is the treatment?
Associations: Preeclampsia or twin gestation
Labs
- *Elevated** transaminases, bilirubin, ammonia, uric acid
- *Low** glucose, prolonged coags
Tx: DELIVERY, supportive maternal care
What is the MOST frequent non-obstetric indication for surgery?
Appendicitis
Increased risk of perforation in third trimester
What is the SECOND most frequent non-obstetric indication for surgery?
Cholecystitis
How do the 3 different postpartum psychiatric disorders differ?
Blues?
Depression?
Psychosis?
blues (unique to pregnancy). Self-limited resolution
¡Weeping, forgetful, labile, negativity. Support and observation.
Depression= same >2wks. Possible tx w/SSRI
Psychosis=same 2-3months
What are some hypertensive disorders of pregancy?
Chronic HTN
Gestational hypertension
Pre-eclampsia (Pre-E)
Eclampsia
1) How is Chronic HTN diagnosed?
2) What are the preferred HTN meds in Pregnancy?
3) What are the blood pressure goals in Chronic HTN?
1) Diagnosed if >140/90 anytime prior to 20wk EGA or persistent >12 weeks PP
2) Labetalol and methyldopa preferred
3) HTN goals—maintain BP
1) What is the definition of Gestational Hypertension?
2) What will change the Dx to pre-eclampsia?
3) What will change the Dx to chronic HTN?
1) New HTN (>140/90) after 20 wk EGA w/o proteinuria that resolves prior to 12 weeks postpartum.
2) Preeclampsia if proteinuria develops
3) Chronic HTN if persists >12 weeks postpartum
Mild pre-eclampsia has to have what 2 criteria?
HTN p 20 wks (>140/90) (prev. nl BP)
Proteinuria (>0.3g but
Severe pre-eclampsia includes mild eclampsia criteria and what else?
BP >160/110
>5gm proteinuria
oliguria (
HA
Scotomata - visual defect
pulm edema
Cyanosis
Plts
RUQ/epigastric pn (liver)
In pre-eclampsia, what does HELLP syndrome stand for?
- *H**: Hemolysis - Severe anemia
- *EL**: Elevated Liver enzymes - increased transaminases
- *LP**: Low Platelet count - Thrombocytopenia (plt
Multip, >25, and >36 wks gestation
What are the risk factors for pre-clampsia?
Prior hx of Pre Eclampsia—7X
Pregestational DM—3.5X
Nulliparity—3X
Chronic HTN
Obesity
FH of Pre-E—3X
Multiple gestation—3X
What are the 4 steps to Managing Severe Preeclampsia?
- Seizure prophylaxis (first) - Magnesium sulfate
- Treat blood pressure - Hydralazine or Labetalol
- Consider pulmonary maturity (
- DELIVER, DELIVER regardless of EGA - Vaginal preferable
What are Severe preeclampsia sequellae in mother or fetus?
- *Maternal:** Cerebral hemorrhage, Hepatic rupture, Renal failure, Pulmonary edema, Seizures, Bleeding d/t thrombocytopenia.
- *Fetal:** Growth restriction, Placental abruption
What is eclampsia?
How do you manage eclampsia?
Pre-Eclampsia with seizure.
1) ABC’s
2) Treat seizures and prevent recurrent seizures
Magnesium Sulfate 4-6g load, then IV 2g/hr
3) Definitive treatment is DELIVERY
