Complicated Pregnancy Flashcards
Threatened Abortion
Bleeding w or w/o cramping. CLOSED CERVIX
Inevitable Abortion
Bleeding w or w/o cramping. CERVIX IS DILATED
Complete abortion
All POC have been expelled
Missed Abortion
Embryo or fetus dies, but POC are retained. Needs a D&C
Incomplete abortion
Some portion of POC remains in the uterus. Needs a D&C
Habitual Abortion
3 or more abortions in succession. Usually spontaneous
Spontaneous Abortion
Miscarriage. Pregnancy terminating before the 20th week
How many pregnancies terminate in a spontaneous abortion?
20%. Most of those are before 6 weeks, and before the woman even realizes she’s pregnant. These are usually due to chromosomal abnormalities that are incompatible with life.
What is an abortus
Fetus lost before 20 weeks
Sx of an abortion
Bleeding
Cramping
Abd pain
Decreased pregnancy sx
PE in an abortion
Vitals to R/O shock
Febrile illness
Pelvic exam
Txing an Abortion
Stabilize if hypotensive Monitor for bleeding/infection Send POC to patho \+/- D&C and misoprostol for dilation Rh -? Rhogam
What is an incompetent cervix? When does it usually occur?
Painless dilation of the cervix. Usually occurs during the second trimester.
RF for having an incompetent cervix
Cervical surgery or trauma
Uterine anomalies
Hx of DES exposure
Risks of an incompetent cervix
Spontaneous abortion
Fetal membranes being exposed to vaginal flora
Inc risk of fetal trauma (ROM)
When does a second trimester abortion occur
12-20 weeks
Options for removing a second tirimester abortion, and what is often the deciding factor
D&C, D&E (dilation and evacuation) or IOL (induction of labor)
Very few clinicians can do a D&C at >20 weeks, so if the fetus is 16-24 weeks it’s either D&C or IOL. Later is is, the more likely it will be an IOL
Tx for incompetent cervix
Cerclage
Then depends on if the fetus is previable or not
What is cerclage
Putting a suture into the cervix to keep it shut. Can be at the internal or external os. Goes with the risks of ROM, PTL or infection.
Previable management of an incompetent cervix
Expectant management (we know this is going on and expect it) and elective termination
Viable management of an incompetent cervix
Betamethasone (in case the kid delivers)
Strict bed rest
Tocolysis if preterm ctx (terbutaline)
DIfference between PTL and incompetent cervix
PTL will have associated contractions. Sometimes it can be really hard to tell though
Three types of cerclage
1) Emergent- for managing a previable pregnancy
2) Elective- if there was a prev pregnancy loss and we’re suspicious it was because of an incompetent cervix.
3) Transabdominal- if both other types of cerclage have failed
If a woman gets a transabdominal cerclage, how must she deliver the baby?
C-section
What is an ectopic pregnancy? What is the most common site?
Pregnancy that implants outside the uterus. 99% of these occurs in the fallopian tubes.
What two symptoms should automatically make you get an HCG to RO ectopic?
Vaginal bleeding and abdominal pain
RF for an ectopic pregnancy
IVF, IUD, PID, tubal surgery, OCP, DES exposure, smoking
PE of a ruptured ectopic
Hypotensive, unresponsive, peritoneal irritation secondary to hemoperitoneum
HCG levels in ectopic
HCG does not rise appropriately
US findings in an ectopic pregnancy
Adnexal mass, extrauterine pregnancy, ring of fire
Parameters for giving methotrexate
<4 cm without FH, reliable pt
Baseline CBC, transminases, creatinine, HCG
Repeat HCG after.
If they’re not a good methotrexate candidate, go for surgery
Management of a ruptured ectopic pregnancy
Stabilize the patient!
IVF, blood products, pressors if necessary
Exploratory lap to control bleeding and remove the ectopic pregnancy
RHogam if RH neg
What is a heterotopic pregnancy? What inc the chances of this happen?
Rare! Intrauterine and ectopic pregnancy at the same time.
Most common with IVF ladies
What happens to the kiddo if mom never got her rhogam and has anti-D ab?
Massive hemolysis, CHF, hydrops or even death
What is Gestational Trophoblastic Disease?
(GTD). Trophoblastic=placental
Diverse group of disease, results in abnormal proliferation of trophoblastic (placental) tissue.
Most common form of GTD
Molar pregnancy. Abnormal fetal tissue resulting in a maternal tumor. They’ll produce an absurd amount of HCG
GTD and chemotherapy
Extremely sensitive. It’s the “most curable” or whatever that means
Are molar pregnancies (hydatidiform moles) malignant?
No way, super benign GTD
Two types of molar pregnancies
1) Complete mole- 90%. Totally just molar tissue, no fetus
2) Partial- 10%. Molar tissue and some fetal tissue
Rf for molar pregnancy
Extremes in age Prior hx of GTD Nullpar Smoking Infertility OCP use
Sx of a molar pregnancy
Irregular or heavy vaginal bleeding
Insanely high HCG levels, which cause these crazy pregnancy symptoms right off the bat in the first trimester (preeclampsia, hyperemesis, hypoerthyroidism)
Pathognomonic for molar pregnancy
Preeclampsia in the first trimester
Postmolar malignant sequelae
Post molar D&C, send the tissue down to pathology so they can determine if there’s any sequelae. Wicked rare, but these sequelae can turn your benign mole into a proper tumor
US Findings of a molar pregnancy
Molar tissue has this mixed echogenic pattern replacing the placenta. Has these villi and intrauterine blood clots.
How to manage a molar pregnancy
Immediate removal, suction D&C or hysterectomy. Curative, 95-100%
Also symptomatic relief
a) mole caused PEC? Give antihypertensives to prevent stroke
b) HCG caused hyperthyroidism? BB to prevent thyroid storm
Persist disease (malignant GTD) post mole DC is rare, but which type of mole is it more common in? When does it present?
Complete. These patients will develop malignant GTD months to years after a molar pregnancy
How do we FU a molar pregnancy?
Serial HCG titers weekly until they’re negative. If we see a plateau or a rise >6mo post DC, think persistent disease
How long should you wait to get pregnant after a molar pregnancy?
1 yr
Two types of malignant GTD (and which is more common)
1) Persistent/invasive moles 75% (months to years post molar pregnancy)
2) Choriocarcinoma (placental carcinoma)- 25%
Which type of malignant GTD is more likely to occur right after a normal pregnancy, miscarriage, ectopic or abortion (something with a real fetus)?
Choriocarcinoma
Signs of a persistent/invasive mole
HCG level plateau, rise.
Intrauterine masses on US, we’ll see this large swollen villi in the myometrium.
These guys rarely rupture and metastasize.
Tx of a persistent/invasive mole
Single agent chemo w/ MTX
FU of a persistent/invasive mole post chemo
Serial HCG and really really good contraceptives
What is a choriocarcinoma? How bad is it?
It’s a malignant necrotizing tumor. Scary GTD
Invades uterine wall and vasculature, metastasizing and potentially causing severe hemorrhage.
Where does choriocarcinoma usually spread
Brain, liver, intestines, lungs, kidneys, liver (VASCULAR HEMATOLOGIC SPREAD)
Presentation of a choriocarcinoma
Irregular uterine bleeding or signs of metastatic disease
Leading causes of metastatic cancer in women in africa
Choriocarcinoma. .Wacky right
Choriocarinoma tx
chemo. The type depends on the prog
What is a placental site trophoblastic tumor (PSTT)
Wicked rare tumor that arises from placental implantation site.
Presentation of a PSTT
Irregular bleeding, enlarged uterus, chronic low HCG
Tx of a PSTT
These guys are NOT sensitive to chemo. Hysterectomy is tx of choice, followed up by some “just in case” chemo
Placenta previa
Low lying placenta, instead of being up by the fundus it’s hanging out down low. Graded by how much of it is sitting over the cervix. ***Remember the placenta is that chunk in the back with the “tree of life” appearance
Complete previa
Placenta completely covers the internal os. Baby is probably breech
Partial previa
Placenta covers a portion of the internal os
Marginal previa
The edge of the placenta covers the margin of the os
Low lying placenta
placenta is implanta in close proximity to the os
Vasa previa
Fetal vessel lies over the cervix -really really scary. Also really rare
Placenta accreta? Risks?
Abnormal invasion of the placenta into the uterine wall. Makes it so the placenta can’t separate from the uterine wall properly after delivery. Huge risk for hemorrage, shock, and maternal MM
Placenta accreta invasion site
Superficial Myometrium
Placenta Increta invasion site
invades into the myometrium, deeper than an accreta
Placenta Percreta
Invasion through the myometrium and into the uterine serosa. Yikes
What happens when you have a previa and an accreta (5% of them present like this!)
You’ve basically guarenteed yourself a hysterectomy at the time of delivery
Sx of a placenta previa
Painless vaginal bleeding in pregnancy. Usually will occur after 28 weeks
Tx of placenta previa
Pelvic rest (no intercourse)
Bed red
C section at 36-37 weeks, once lung maturity is confirmed
Obstetric causes for antepartum bleeding
1) Placental- previa, abruption, vasa previa
2) Maternal- uterine rupture
3) Fetal- fetal vessel rupture
Non-OB causes for antepartum bleeding
1) Cervical- severe cervicitis, polyps, cancer
2) Vaginal/vulvar- lacs, varices, cancer
3) Other- your classic vaginal bleeding causes. Hemorrhoids, trauma, hematuria
What is placental abruption? What can it lead to?
Premature separation of the placenta (properly implanted) from the uterine wall. Causes a massive hemorrhage.
Can cause premature delivery, uterine tetany (hypercontract), DIC and hypovolemic shock
RF for placental abruption
HTN AMA Hydraminios DM COCAINE- get a tox DM EtOH (>14 drinks/week) Multiple gestation
Precipitating factors for a placental abruption
Trauma External/internal version (when we're trying to turn the baby) MVA- inertia can cause it to shear Delivery of 1st twin ROM w/ polyhydraminos PPROM
Where does the blood go in a placental abruption?
80% of the time it goes outward towards the cervix, it’s an external hemorrhage and you know what you’re working with.
20% of the time it’s occult and is confined/concealed within the uterus. This is scary, but remember that when you feel a rock hard uterus
Classic sign of a placental abruption
Couvelaire sign. The blood from the abruption penetrates the uterine muscle, you’ll have this rock hard uterus that is purple too. You’ll see the purple when you’re doing a c section
Classic presentation of a placental abruption
3rd trimester vaginal bleeding with severe abdominal pain and frequent/strong cxn
Vaginal delivery in a placental abruption?
If the baby looks good and there’s not that much blood then go for it. The blood will usually make the uterus hyperactive and you’ll have a rapid labor.
PROM
Premature ROM. or, ROM before the onset of labor
PPROM
Preterm Premature ROM. PROM before 37 weeks
Prolonged ROM. What’s the risk here
ROM lasting >18 hours w/o deliverying the baby. Risk of chorioamnionitis. Longer the pROM lasts, greater the risk of this.
What do we do if ROM occurs but it’s after week 36
Roll with it man, let’s induce a lady.
Gestational HTN
HTN w/on proteinuria. Develops after 20 wks, returns to normal PP.
> 140/90. Must have normal BP prior for it to be gestational
Difference between preeclampsia and gestational HTN
Proteinuria!!
> 0.3g of protein in a 24 hour urine
RF for PEC
CHTN, CKI, SLE, DM, AA
Ultimate treatment for preeclampsia
Delivery
What’s the treatment for
a) Term pregnancy w/ PEC
b) Unstable preterm w/ PEC
c) Evidence of fetal lung maturity w/PEC
Induction of labor! Just gotta deliver the kid if the kid’s ready or if the mom is unstable. No baby is going to grow in an unstable mom.
If mom is really unstable just run to the OR
What’s the treatment for PEC in a stable, preterm mom
Bed rest
Expectant management
Betamethasone to beef up the kid’s lungs 2 doses within 24 hours
When would MgSulfate come into play
also what’s Mg’s effect on labor
Seizure ppx during labor, delivery and 12-24 hours PP.
4g loading and 2g/hr for maintenance
***If mom is stable, hold off on Mg until active labor. It can make the labor drag on and you’ll be more likely to have a csection dt labor failing to progress
Superimposed PEC
New onset proteinuria in a woman with CHTN
OR
Sudden increase in proteinuria (that she had prior to gestation) OR
Sudden sharp inc in HTN OR
HELLP Syndrome
How do we tx superimposed PEC
just like regular PEC!
What’s a funky way superimposed PEC might present
Women with CHTN who suddenly develop HA, scotoma, or epigastric pain
Severe PEC “deliver immediately” signs
>32 weeks Signs of LF or RF Pulmonary edema HELLP DIC
Signs of severe PEC (more of a read and understand)
One of more of the following:
> 160/110 on two occasions 6 hrs apart when pt is in bed
Proteinuria >5g on 24 or >3g on 2 random spots
Oliguria (<500ml)
Cerebral/visual disturbances (scotoma)
Pulmonary edema- vessels get leaky. Flash E happens fast
Epigastric pain
Impaired LF
Thrombocytopenia
Fetal growth restriction
What is fetal growth restriction considered in severe PEC
End organ damage. It’s a sign that the BP is affecting the baby
Difference between Severe PEC and EC
Grand mal serizures!
Giving Mg in an EC pt
Give mg from the time they’re diagnosed until they’re 12-24hrs PP
Tx the mom:
Tx the baby?
Mom: Stop the seizures and book it to an OR
Baby: Fix mom. Decels are going on because mom is seizing. Fix mom, you fix the baby
What does HELLP stand for?
What might HELLP patients develop
Hemolytic Anemia (LDH, Bili, schistocytes)
Elevated Liver enzymes (inc AST/ALT)
Low platelets. (LIKE REAL LOW, plt 9?)
They might develop DIC or hepatic rupture
Acute Fatty Liver of Pregnancy- these patients will commonly have what two symptoms normally associated with PEC
HTN and proteinuria.
How can we differentiate acute fatty liver of pregnancy from HELLP
Labs will show ammonia, reduced fibrinogen and antithrombin II (liver labs)
What is true GDM caused by
anti-insulin agents produced by the placenta. Increases with size/function of the placenta, so we don’t usually see this until the 2nd/3rd trimester
When do we screen for GDM
28 weeks, unless they’re high risk
What makes someone high risk for GDM
Not white AMA Obese Fhx of DM Biggo kiddo previously
What is a GLT? Screening or diagnositic?
Glucode loading test. Screening test done at 28wks for GDM.
Give 50g of glucose as a loading dose and check serum glucose 1 hr later. If >140, go ahead and do the GTT
What is the GTT? Screening or diagnostic?
Diagnostic test for GDM. We take a fasting serum glu, then give 100g of PO glucose as a loading dose. Then we take a serum glucose 1,2 and 3 hours after that loading dose. If two or more of these values are elevated, that’s diagnostic for GDM
GTT Glucose levels
Fasting >95
1hr >180
2hr> 155
3 hr>140
Mainstay of tx for GDM
Diet! True GDM is an issue of CHO digestion. Limit calories, carbs to 220g a day. Promote walking and exercise
When to consider insulin for GDM
When >25-30% of BG are elevated.
Hard to ask this in a question. “True” GDM will have _ fasting glucose and _ PP glucode
Normal fasting and elevated PP, since the issue is with glucose digestion
White classification for GDM
It’s how we classify GDM.
Class A is when you just have GDM, and you’re in category 1 or 2 depending on whether or not you’re medicated. The other classes are all based on if you have preexisting DM, looks at things like age of onset, end organ damage, stuff like that
When do we US GDM mom’s for macrosomia
Weeks 34-37. We might base the delivery plan around this
What do we do if a GDMA1 mom comes in for delivery?
Take a random BG. If it’s normal, we just deliver the babe as per usual
How do we manage GDMA2 when mom comes in for IOL
Laboring women don’t exactly eat regular meals, so we keep them on a dextrose/insulin drip to keep the BS <120
GDM, baby weighs >4,000g
Inc risk of shoulder dystocia. Avoid forceps/vacuum, be quicker to go for a cesarean
GDM, baby weights >4,500g
Offer elective cesarean. This weight is a guarenteed birth injury
Why is diet education so important for PP GDM mom;s
Because they have SUCH a high risk of developing DM later on in life/in future pregnancies
RF for shoulder dystocia
Macrosomia, diabetes of all kinds, maternal obesity, postterm pregnancy (biggo kiddo), prolonged 2nd stage of labor
Fetal complications of shoulder dystocia
Fx of humerus or clavicle Brachial plexus nerve injuries dt hyperflexion of the neck (Erb's palsy) Other palsies Brain injury (hypoxia) Death
Hallmark sign for shoulder dystocia
Turtle sign. Incomplete delivery of head, or the chin tucking up against maternal perineum. Kid will bob in and out
Why might we do an episiotomy for a shoulder dystocia
If we can’t fit our hands in there to rotate the baby. This is a bone issue, an episiotomy will not get the baby out on its own
How much time do you have to deliver the kid in a shoulder dystocia
5 min before brain death
Is a shoulder dystocia an emergency
Heck yeah it is
Three main maneuvers for shoulder dystocia
1) McRoberts- sharp flexion of maternal hips to decrease pelvis inclincation and just max out the diameter. Always done w/ #2 as the primary maneuver.
2) Suprapubic pressure- Pressure directed at an oblique angle to dislodge that anterior shoulder out from the pubic symphysis
3 )If the two above fail, we do the Rubin maneuver where we stick our hands all the way in and push the shoulder towards the anterior chest wall to dislodge it.
What are some other things we can do for a shoulder!
1) Wood’s corkscrew- apply pressure to the posterior shoulder and try and rotate the infant
2) Deliver the posterior arm/shoulder, free up space
3) Fx fetal clavicle
4) Cut maternal pubic symphysis
5) ZavanellI!
ml of blood loss to define a PPH
> 500ml for vag and >1,000 for c section
Early vs late PPH
<24 hours after delivery =early
>24 hours after delivery = late
> ___L we get worried about DIC. What do we give?
2-3L
Give coag factors and platelets. Which is a normal part of a massive transfusion protocol
What is Sheehan syndrome? When would we see it? Manifestations?
Sheehan syndrome is a pit infarct that can happen during a PPH because of the hypotensive/hypovolemic state.
Manifests as a lack of lactation dt lack of prolactin or amenorrhea dt lack of GnRH. Bc the pit is totally blown out
RF for PPH
abnormal placenta
trauma during LD
Uterine atony
Coagulation defects
Causes of a PPH-vag
Vaginal lacs Cervical lacs Uterine atony Placenta accreta Retained POC Uterine inversion Uterine rupture (yikes)
Causes of a PPH- csection
Uterine atony
Surgical blood loss
Placenta accreta
Uterine rupture (also yikes)
Four T’s of a PPH
1) Tone- Give uterotonic agents if the contractions are crummy
2) Trauma- suture any lacs. General or inversion of uterus
3) Tissue: Is the placenta retained? D&C?
4) Thrombin- are they clotting? Do they need plt/cofactor?
Prolonged Decel
FHR <110 for >2min
Fetal brachycardia
prolonged decel for >10min
3 Etiologies of FHR decel
1) Preuterine- Any event that leads to maternal hypotension or hypoxia
2) Uteroplacental- Abruption, infarction, hemorrhaging previa
3) Postplacental- cord prolapse, compression, rupture of fetal vessel
Managing FHR decel
Conservative at first!
- Move position
- Nasal O2 for mom
- Did mom get an epidural and this is probably caused by a drop in BP? Consider giving a pressor
- Stop pitocin drip if baby is deceling
Most common reason for a c-section
Labor failing to progress. 2 hrs in active phase of labor without cervical change. This is when the uterine cxn are more than adequate
3 P’s of failure to progress
Power: Strength of contractions
Passenger: Is the baby okay
Passage: if the pelvis/vagina big enough to support this kiddo
Maternal indications for a CS
Maternal dx (genital herpes, HIV, cervical cancer)
Prior uterine surgery
Prior uterine rupture
Obstruction of birth canal (fibroids, ovarian tumor)
Fetal indications for a CS
Nonreassuring FHT (brady, asbsence of variability, acidodic) Cord prolapse Malpresentation (breech, brow) Multiple gestations Fetal anomalies (hydrocephalus)
What direction should the incisions go in?
Horizontal if you can! OK to do vertical on the skin, but never on the uterus
When would we do a single layer uterine closure?
If we’re going to go back and do a tubal ligation. Otherwise do a double
Monozygotic twins
1 Fertilized ovum divides into two separate ova
Dizygotic twins
Ovulation produces two eggs which are both fertilized
TTS- Twin to Twin Transfusion Syndrome
One twin “eats” the other. Most common with Monochorionic (one placenta), diamnionic twins (two sacs)
Mono/di-chorionic
of placenta
Mono/di-amnionic
of amniotic saccs
Monochorionic/monoamnionic twins MM
Crazy high due to risk of entangling cords
What determines amnionicity/chorionicity?
When the monozygotic twin cleaves! Cleavage between... 1-3 days? Di/Di 4-8 days? Mono/Di 8-13? Mono/Mono 13-15? Conjoined
What is mastitis? What causes it?
Regional infection of the breast. Caused by pts skin flora or infants mouth flora
Tx for mastitis
Dicloxacillin. Keep pumping. If unresponsive to PO abx give IV abx until 48hrs afebrile
