Complicated Pregnancy Flashcards
Spontaneous abortion occurs before how many weeks
20 weeks
Threatened abortion
bleeding with or without cramping with a closed cervix
Inevitable abortion
bleeding with or without cramping with dilation of cervix
Complete abortion
all products have been expelled
Missed abortion
embryo or fetus dies but products of conception are retained
Incomplete abortion
some portion of POCs remain in the uterus
Habitual abortion
3 or more abortions in succession
Etiology of second trimester abortions
- infection
- maternal uterine/cervical anatomic defect
- maternal systemic disease
- exposure to fetotoxic agents
- trauma
- pre term labor/incompetent cervix
What is an incompetent cervix
painless dilation and effacement of the cervix
Why is an incompetent cervix bad?
fetal membranes are exposed to vaginal flora and there is a increased risk of trauma
Risk factors of incompetent cervix
- cervical surgery or trauma
- uterine anomalies
- hx of DES exposure
Treatment of incompetent cervix
- cerclage (suture to close cervix)
- previable: expectant management and elective termination
- viable: betamethasone, bed rest, tocolysis if preterm contraction
When is emergent cerclage done
management in a previable pregnancy
When is an elective cerclage done
if incompetent cervix suspected in previous pregnancy loss (12-14 weeks)
When is a transabdominal cerclage done
if both other types of cerclage failed
baby must be delivered via c/s
Risk factors for ectopic pregnancy
- hx of STI/PID
- prior ectopic preg
- previous tubal surg
- adhesions
- endometriosis
- exogenous hormone use
- IVF
- DES exposed pts
- IUD use
- smoking
Ectopic pregnancy on physical exam
- adnexal mass may be tender
- uterus small for GA
- bleeding from cervix
Ectopic pregnancy on US
- adnexal mass
- extrauterine pregnancy
- ring of fire
Management of rupture ectopic pregnancy
- stabalize (IV fluids, blood products, pressors)
- exploratory lap
- rhogam if Rh negative
Management of unruptured ectopic pregnancy
- rhogam if Rh negative
- surgical
- methotrexate
What is a heterotopic pregnancy
rare co existance of intrauterine with ectopic pregnancy
What is a gestational trophoblastic disease
abnormal proliferation of placental tissue
What are the gestational trophoblastic diseases
- molar pregnancy
- persistent/invasive moles
- choriocarcinoma
- placental site trophoblastic tumor
What is the begning GTD
molar pregnancy
What are the two types of molar pregnancies
- complete (no fetal abnormality)
- partial (fetal abnormality)
Risk factors for a molar pregnancy
- extremes in age
- prior hx of GTD
- nulliparity
- diets low in beta carotine, folic acid and animal fat
- smoking
- infertility
- OCP use
Molar pregnancy on physical exam
- preeclampsia
- hyperthyroid
- absence of fetal heat tones
- uterine size greater than GA
- grape like molar clusted extruding from cervix
- theca lutein cysts
Molar pregnancy on US
- molar tissue id as diffuse mixed echogenic patterns replacing the placent
- produced by villi and intrauterine blood clots
Hx of a patient with a molar pregnancy
- irregular or heavy vaginal bleeding
- sx attributed to high hCG levels
Management of molar pregnancy
- immediate removal of uterine contents by suction D&C
- treat other conditions (preeclampsia, hyperthyroid)
- hysterectomy is patient is done having children
Good prognostic markers for metastatic malignant GTD
- short duration (<4 months)
- serum hCG <40k
- no brain or liver mets
- no hx of chemo
Poor prognostic markers of malignant metastatic GTD
- long duration (>4 months)
- serum hCG >40,000
- metastases to brain or liver
- unsuccessful prior chemo
- GTD following term pregnancy
When does a persistent/invasive mole commonly occur?
after a molar pregnancy
How do you diagnose a persistent/invasive mole
- hCG level plateau or rise
- pelvic US may show one or more intrauterine masses with high vascular flow
Rare complications of persistent/invasive mole
- uterine rupture
- hemoperitoneum
Tx of persistent/invasive mole
single agent chemo w/ MTX or actinomycin-D
What is chriocarcinoma
a malignant necrotizing tumor
-pure epithelial tumor that invades uterine wall and vasculature causing destruction of tissue, necrosis and potentially severe hemorrhage
Patient presentation with choriocarcinoma
- irregular signs of uterine bleeding
- signs on metastatic disease
How do you diagnose choriocarcinoma
- hCG levels
- pelvic US
- CXR/CT/MRI of chest, abd/pelvic and brain
Tx of choriocarcinoma
either single or multiagent chemo depending on prognosis
Where do placental site trophoblastic tumors arise from
the placental implantation site
Diagnosis of PSTT
- irregular bleeding
- enlarged uterus
- chronic low hCG
- pelvic US
- histology shows absence of villi
Treatment of PSTT
-hysterectomy followed by multiagent chemo to prevent recurrence
Four categories of placenta previa
- complete previa
- partial previa
- marginal previa
- low lying placenta
What is placenta previa caused by
events that prevent normal progressive development of the lower uterine segment
Risk factors for placenta previa
- prior c/s or uterine surg
- multiparity/ multiple gestation
- erythroblastosis
- hx of previa
- smoking
- increasing maternal age
Fetal complications associated with placenta previa
- preterm delivery
- preterm premature rupture of membranes
- intrauterine growth restriction
- malpresentation
- vasa previa
- congenital abnormalities
What is placenta accreta
abnormal invasion of placenta into the uterine wall
What happen in placenta accreta? What complication does it cause?
inability of placenta to properly separate from uterine wall after delivery
-complications: hemorrhage, shock, maternal morbidity and mortality
Three categories of placenta accreta
- accreta: superficial invasion into myometrium
- increta: placenta invades myometrium
percreta: invasion through myometrium into uterine serosa
How do you diagnose placenta previa
-ultrasound
vaginal exam is contraindicated!
Treatment for placenta previa
- pelvic rest (no sex)
- modified bed rest
- cesarean delivery at 36/37 weeks after lung maturity confirmed by amnio
What is a placenta abruption
premature separation of normally implanted placenta from uterine wall
When do most placental abruptions occur
before labor and after 30 weeks (50%)
What can a large placental abruption result in
- premature delivery
- uterine tetany
- DIC
- hypovolemic shock
What factors can predispose a patient for placental abruption
- HTN
- hx of abruption
- advance maternal age
- multiparity/multiple pregnancy
- uterine distension
- vascular/collagen deficiency
- DM
- cocaine/cigarette/alcohol
- short umbilical cord
- circumvallate placenta
What is a circumvallate placenta
membranes double back over edge of placenta
Precipitating factors for placental abruption
- trauma/abdominal trauma
- MVA
- sudden uterine volume loss
- delivery of 1st twin
- rupture of membranes with polyhydramnios
- preterm premature rupture of membranes
Classic presentation of placental abruption
3rd trimester vaginal bleeding associated with severe abd pain and/or frequent, strong contractions
What type of contractions would a pt with placental abruption experience? Fetal heart tones?
tetanic contractions with non reassuring fetal heart tones secondary to hypoxia
Classic sign of placental abruption when c/s is done
couvelaire uterus (blood from abruption penetrates uterine musculature)
How do you treat a placental abruption?
STABILIZE
- hospitalization, prepare for hemorrhage
- continuous EFM
- IV access
- labs (CBC, type and cross_
- RhoGAM if necessary
When do you need to deliver the baby with a placental abruption
- if life threatening bleeding
- fetal testing is non reassuring
What type of deliver is preferred with a placental abruption
vaginal delivery (if safe)
What is “premature rupture of membranes” (PROM)?
rupture of membranes before the onset of labor
What is “preterm premature rupture of membranes” (PPROM)
rupture of the membranes before week 37
Prolonged ROM
rupture of membranes lasting longer than 18hrs before delivery
What is the most common concern with PROM
chorioamnionitis
If ROM occurs after 36 weeks what is done?
labor is induced
What is gestational HTN
HTN without proteinuria that develops after 20 weeks with return to normal postpartum
Diagnosis of gestational HTN?
systolic >140 or diastolic >90 occurring after 20 wks in a woman with previously normal BP
What is preeclampsia
HTN and proteinuria that occurs after 20 weeks
What are some maternal complications of preeeclampsia
- seixure
- cerebral hemorrhage
- DIC/thrombocytopenia
- renla fialure
- hepatic rupture/failure
- pulmonary edema
- placental abruption
Fetal complications with preeclampsia
- premature birth
- intrapartum fetal distress
- stillbirth
- asymmetric or symmetric SGA fetus
- IUGR
- oligohydramnios
Ultimate treatment for preeclampsia
delivery
When is induction of labor treatment of choice for preeclampsia? What type of delivery is preferred?
- term patients
- unstable preterm
- pregnancies with evidence of fetal lung maturity
VAGINAL delviery
Treatment for stable preterm patients with preeclampsia
- bed rest
- expectant management
- betamethasone
What is given for prophylaxis in women with preeclampsia? When? Dose?
mag sulfate for seizure ppx during labor, delivery and 12 to 24 hrs postparturm
4g loading and 2g/hr after
What is superimposed preeclampsia
-new onset of proteinuria in a women with CHTN
OR
-a sudden increase in proteinuria if already present in early pregnancy
OR
-a sudden increase in HTN
OR
-development of HELLP syndrome
When should you suspect superimposed PEC
women with CHTN that develop HA, scotoma or epigastric pain
Treatment for superimposed PEC
treat like regular PEC
-treat CHTN with labetalol of nifedipine
When is preeclampsia considered severe?
one of more of the following
- systolic >160 or diasolitc >110 on 2 or more occasions 6 hrs apart while on bed rest
- proteinuria of >5g in 24hr or >3+ on 2 random 4 hrs apart
- oliguria less than 500ml in 24hrs
- cerebral/visual disturbances
- pulmonary edema or cyanosis
- epigastric of RUG pain
- impaired liver function
- thrombocytopenia
- fetal growth restrication
When do you deliver immediately in a patient with severe PEC
- greater than 32 weeks
- signs of renal or liver failure
- pulmonary edema
- HELLP
- DIC
What is eclampsia
new onset grand mal seizure in a women with preeclampsia
What is the treatment for eclampsia
- BP control
- seizure management/PPX
MgSO4 from tiem of diagnosis through 12-23 hrs postpartum
When should delivery be initiated in a patient with eclampsia
after pt has been stabilized and convulsions have been controlled
What is a common complication of eclampsia? How do you treat it?
-fetal heart rate decelerations, tx my stabilizing mother
What is HELLP syndrome
- hemolytic anemia
- elevated liver enzymes (AST/ALT)
- low platelets (thrombocytopenia)
- hepatic rupture or DIC
Hemolytic anemia with HELLP syndrome
- schistocytes
- elevated LDH
- elevated total bilirubin
How do you diagnose acute fatty liver of pregnancy
differentiate from HELLP
- elevated ammonia
- blood sugar <50
- reduced fibroginogen
- reduced antithrobin III
When does gestational diabetes typically manifest?
Why?
late 2nd trimester or early 3rd trimester because hormones increase in volume with size and function of placenta
Gestational diabetes leads to an increased risk for what things
- fetal macrosomia
- birth injuries
- neonatal hypoglycemia, hypocalcemia, hyperbillirubinemia, polycythemia
What are some risk factors for developing gestational diabetes
- hispanic/latina
- asian
- native american
- advanced maternal age
- obesity
- family hx of DM
- previous infant weighting >4000g
- previous stillborn
When are women screened for gestational diabetes
between 24 and 28 weeks
Screening for gestational diabetes
- glucose loading test
- glucose tolerance test
What is the glucose loading test
50g of oral glucose, check serum glucose 1hr later
if >140 do GTT
How is a glucose tolerance test done
check fasting serum glucose, 100g oral glucose, check serum glucose 1/2/3 hours after dose
Elevation of __ of more values indicates GDM. What are the values
2 or more
fasting >95
1hr >180
2hr >155
3hr >140
Treatment for GDM
- 2,200 calories a day
- 200 to 220g of carbs
- QID blood sugar testing
- exercise
- insulin or oral hypoglycemic agent
When do you do fetal monitoring with GDM?What do you do?
GDMA2 on insulin or oral hypoglycemic agent
NST or BPP weekly or biweekly starting between 32 and 36 weeks
if GDMA2 how do you handle delivery
induction of labor at 39 weeks
Fetal weight of over 4,000 grams–> increased risk of ___. What do you avoid
increased risk of shoulder dystocia
avoid forceps and vacuum
When should you consider a cesarean with GDM
fetal weight >4,500g
Infants of pts with GDM are at an increased risk of what
- childhood obesity
- type 2 DM
Maternal complications with pregestatinal diabetes
- obstetric: polyhydraminos, preeclampsia, miscarriage, infection, PPH
- diabetic emergencies: hypoglycemia, ketoacidosis, diabetic coma
- vascular neurologic, end organ involvement
Fetal complications with pregestational diabets
- macrosomia
- delayed organ maturity
- congential malformations
- IUFD
What is shoulder dystocia
difficulty delivering shoulders after the head of the fetus is delivered (anterior shouldder gets stuck behind pubic symphysis)
What are risk factors for shoulder dystocia
- macrosomia
- diabetes of any kind
- hx
- maternal obesity
- postterm pregnancy
- prolonged second stage of labor
- operative vaginal delivery
Fetal complication of shoulder dystocia
- fracture of humerus or clavicle
- brachial plexus nerve injury
- phrenic nerve palsy
- hypoxic brain injury
- death
How do you prepare a patient for delivery if shoulder dystocia is suspected
- pt in dorsal lithotomy position
- adequate anesthesia
- experienced staff
- episiotomy prn
Increased suspicion of shoulder dystocia with ___. What is it
“turtle sign”
incomplete delivery of head or chin tucking up against maternal perineum
What should be done if fetus has shoulder dystocia during delivery
EMERGENCY
- designated someone to track time (delivery in less than 5 minutes)
- two people hold legs
- one person provides suprapubic pressure
- pediatric team should be called to delivery room
3 maneuvers for shoulder dystocia
- McRoberts
- Suprapubic
- Rubin
McRobert maneuver
sharp flexion of maternal hips to decrease inclination of pelvis and increased AP diameter
Suprapubic pressure
pressure directed at an oblique angle to dislodge anterior shoulder from behind pubis symphysis
Rubin maneuver
place pressure on shoulder and push toward anterior chest wall to decrease bisacromial diameter and free impacted shoulder
What classifies postpartum hemorrhage
> 500mL blood loss for vaginal delivery and >1,000mL for cesarean
Treatment for postpartum hemorrhage
- investigate cause
- start fluid resuscitation
- prepare for blood transfusion
If blood loss >2-3L pt may develop ___ give __ and ___
pt may develop DIC, give coagulation factors and platelets
Rare complication of postpartum hemorrhage
Sheehan syndrome (pituitary infarct)
Risk factors for PPH
- abnormal placentation
- trauma during labor and delivery
- uterine atony
- coagulation defects
Fetal heart rate deceleration
fetal heart rate <110 for loner than 2 minutes=prolonged
longer than 10 minutes= bradycardia
Etiology of fetal heart rate decelerations
- preuterine: anything leading to maternal hypotension of hypoxia
- uteroplacental: abruption, infarction, hemorrhage, uterine hyperstimulation
- postplacental: cord prolapse, cord compression, rupture of fetal vessel
Most common indication for primary cesarean section
failure to progress (2hrs without cervical change in the setting of adequate uterine ctxs in active phase of labor)
What are the 3 P’s of labor
Powers: contractions
Passage: pelvis and soft tissue
Passenger: the baby
Preparation for cesarean section
- IV fluids
- 1 to 2 grms of IV cefazolin
- spinal or epidural anesthesia
- foley to empty bladder
- local prep
Monozygotic twins
fertilized ovum divided into two separate ova, identical twins
Dizygotic twins
ovulation produces 2 ova and both are fertilized, fraternal twins
Obstetric complications of multiple gestation
- preterm labor
- placenta previa
- cord prolapse
- postpartum hemorrhage
- cervical incompetence
- gestation diabetes
- preeclampsia
Fetal complications of multiple gestation
- preterm delivery
- congenital abnormalities
- small for gestational age
- malpresentation
Average age of delivery of twins. Triplets.
twins: 36-37 weeks
triplets: 33-34 weeks
Galactorrhea
spontaneous flow of milk from the breast
What causes galactorrhea
production of prolactin by pituitary gland
What is mastitis
regional infection of the breast commonly causes by pt’s skin flora or oral flora from breastfeeding infants
Treatment of mastitis
dicloxacillin
