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Clin Med III > complicated pregnancy > Flashcards

complicated pregnancy Flashcards

1
Q

spontaneous abortion

A
  • aka miscarriage
  • termed before week 20
  • majority occur < 8 weeks
  • often d/t major chromosomal abnormalities
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2
Q

abortus

A
  • fetus lost before 20 weeks, < 500g or < 25 cm
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3
Q

threatened ab

A
  • bleeding +/- cramping
  • closed cervix
  • very common
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4
Q

inevitable ab

A
  • bleeding +/- cramping
  • dilated cervix
  • often pass contents on own
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5
Q

complete ab

A
  • all products expelled
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6
Q

missed ab

A
  • embryo or fetus dies but but all products of conception retained
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7
Q

incomplete ab

A
  • some portion of products remain in uterus
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8
Q

habitual ab

A
  • 3+ abortions in succession
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9
Q

tx of ab

A
  • stabilize pt if hypotensive
  • monitor for bleeding and infx
  • send tissue to pathology
  • +/- D&C or prostaglandins
  • rhogam for Rh neg pts
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10
Q

second trimester abortion

A
  • 12-20 weeks
  • D&C vs D&E
  • if 16-24 weeks either et D&E or IOL
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11
Q

possible causes for 2nd trimester abortions

A
  • infection
  • uterine or cervical anatomic defects
  • maternal systemic disease
  • exposure to fetotoxic agent
  • trauma
  • PTL
  • incompetent cervix
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12
Q

incompetent cervix

A
  • aka cervical insufficiency
  • painless dilation and effacement of cervix
  • most often in 2nd trimester
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13
Q

why is incompetent cervix bad

A
  • fetus exposed to vaginal flora

- risk of trauma, infection ROM

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14
Q

risk factors for incompetent cervix

A
  • cervical surgery or trauma
  • uterine anomalies
  • hx of DES exposure
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15
Q

tx for incompetent cervix

A
  • cerclage
  • if previable- expectant mgmt or elective termination
  • if viable- betamethasone, bed rest, tocolytics if ctx
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16
Q

what is cerclage

A
  • suture placed vaginally around cervix to close it

- elective. vs emergent, vs transabdominal (last line)

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17
Q

ectopic pregnancy

A
  • pregnancy implants outside of uterus
  • 99% in fallopian tubes
  • if vaginal bleeding + abd pain eval for ectopic
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18
Q

risk factors for ectopic pregnancy

A
  • hx of STI or PID
  • prior ectopic pregnancy or tubal surgery
  • prior pelvic or abd surgery
  • endometriosis or tubal abnorm
  • current use of exogenous hormones or IUD
  • IVF or assisted reproduction
  • DES exposure
  • smoking
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19
Q

dx of ectopic

A
  • pain + bleeding
  • uterus small for GA
  • hcg doesnt rise appropriately
  • ruptured- hypotensive, unresponsive, peritoneal irritation
  • US- ring of fire*, adenexal mass, extrauterine pregnancy
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20
Q

tx of ruptured ectopic

A
  • stabilize pt first with IVF, blood, pressors
  • exploratory laparotomy to control bleeding and remove ectopic
  • salpingostomy vs salpingectomy
  • rhogam if Rh neg
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21
Q

tx of unruptured ectopic

A
  • rhogam if Rh neg
  • surgery
  • medical tx with methotrexate
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22
Q

use of methotrexate for unruptured ectopic

A
  • get baseline CBC, transaminases, Cr, hcg
  • IM inj based on BSA
  • repeat hcg levels at day 4 and 7- should drop by 15%
  • second dose if inappropriate fall
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23
Q

hetertopic pregnancy

A
  • rare
  • intrauterine pregnancy + ectopic at same time
  • most common with assisted pregnancy
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24
Q

Rh incompatability

A
  • Rh neg women dont have anti-D
  • Rh pos blood from fetus -> sensitization and formation of anti-D
  • subsequent Rh pos pregnancies will attack fetus RBC
  • causes hemolysis, CHF, hydrops, death
  • why you give rhogam at 28 weeks
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25
Q

what diseases are included in gestational trophoblastic disease

A
  • molar pregnancy (complete vs incomplete)
  • persistent/ invasive moles
  • choriocarcinoma
  • placental site trophoblastic tumors
  • all are abnormal placental tissue
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26
Q

complete mole

A
  • molar degeneration with no associated fetus
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27
Q

partial mole

A
  • molar degeneration in association with abnormal fetus
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28
Q

risk factors for molar pregnancies

A
  • extremes in age
  • prior hx GTD
  • nulliparity
  • infertility
  • OCP use
  • smoking
  • diet low in beta carotine, folic acid, animal fat
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29
Q

dx of molar pregnancy

A
  • usu dx in first trimester
  • hx of heavy/ irregular bleeding
  • sx of high hct- hyperemesis, preeclampsia, hyperthyroidism
  • preeclampsia < 20 weeks= pathognomonic
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30
Q

PE findings for molar pregnancy

A
  • preeclampsia
  • hyperthyroidism
  • absence of fetal heart tones
  • uterine size GA
  • grape like molar clusters from cervix
  • theca leutein cysts
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31
Q

US findings for molar pregnancy

A
  • diffused mixed echogenic pattern

- villi and intrauterine clots

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32
Q

tx of molar pregnancy

A
  • immed removal of uterine contents by suction D&C
  • if signs of PEC give anti-HTN
  • if hcg induced hyperthyroidism give BB
  • if completed child bearing -> hysterectomy
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33
Q

follow up for molar pregnancy

A
  • serial hct titers weekly until neg X 3 weeks
  • avg time to normalization is 14 weeks for complete, 8 weeks for partial
  • prevent pregnancy with OCPs for one year
  • subsequent pregnancies get early US and hcg levels
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34
Q

malignant GTD

A
  • majority are due to persistent/ invasive moles

- rest are choriocarcinoma

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35
Q

classification of malignant GTD

A
  • non-metastatic

- metastatic- good vs poor prognosis

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36
Q

good prognosis of metastatic GTD

A
  • short duration
  • hcg < 40,000
  • no mets to liver or brain
  • no hx of chemo
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37
Q

poor prognosis of metastatic GTD

A
  • long duration > 4 mo
  • hcg > 40,000
  • mets to brain or liver
  • unsuccessful prior chemo
  • GTD following term pregnancy
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38
Q

persistent/ invasive moles

A
  • usu after molar pregnancy
  • dx based on high hcg levels, pelvic us
  • rarely metastasizes
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39
Q

tx and f/u for persistent/ invasive moles

A
  • chemo + mtx or actinomycin-d

- f/u with serial hcg and reliable contraception

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40
Q

choriocarcinoma

A
  • malignant necrotizing tumor
  • usu metastatic: lungs, vagina, pelvis, brain, liver, intestines, kidneys
  • sx- irregular uterine bleeding or sings of metastatic disease, hct abnormally high
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41
Q

tx of choriocarcinoma

A
  • chemo either single or multiagent
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42
Q

placental site trophoblastic tumors

A
  • very rare
  • arise from placental implantation site
  • sx- irregular bleeding, enlarged uterus, chronic low hcg
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43
Q

tx of placental site trophoblastic disease

A
  • not chemosensitive
  • hysterectomy
  • f/u with multiagent chemo to prevent recurrence
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44
Q

complete previa

A
  • placenta completely covers internal os
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45
Q

partial previa

A
  • placenta covers portion of internal os
46
Q

marginal previa

A
  • edge of placenta reaches the margin of os
47
Q

low lying placenta

A
  • placenta implanted in lower uterine segment in close proximity to os
48
Q

vasa previa

A
  • fetal vessel lies over cervix

- rare

49
Q

risk factors for placenta previa

A
  • prior c/s or uterine surgery
  • multiparity, multiple gestations
  • erythroblastosis
  • smoking
  • hx of previa
  • AMA
50
Q

fetal complications of previa

A
  • preterm delivery
  • PPROM
  • IUGR
  • malpresentation
  • vasa previa
  • congenital abnormalities
51
Q

placenta accreta

A
  • superficial invasion of placenta into myometrium
  • inability of placenta to properly separate from uterine wall after delivery
  • can lead to hemorrhage, shock
52
Q

increta

A
  • placenta invades myometrium
53
Q

percreta

A
  • placenta invades through myometrium into uterine serosa
54
Q

signs of accreta

A
  • common with previa
  • painless vaginal bleeding (recurrent)
  • vaginal exams C/I
55
Q

treatment for accreta

A
  • pelvic rest
  • +/- modified bed rest
  • c/s at 36 or 37 weeks- confirm lung maturity with amnio first
56
Q

placental abruption

A
  • premature separation of placenta from uterine wall
  • causes hemorrhage
  • half occur before labor > 30 weeks
  • concealed bleeding vs presenting with vaginal bleeding
57
Q

complications of placental abruption

A
  • premature delivery
  • uterine tetany
  • DIC
  • hypovolemic shock
  • rarely fatal for mother
  • fetal mortality risk d/t hypoxia
58
Q

si/sx of placental aburption

A
  • 3rd trimester vaginal bleeding
  • severe bad pain and/or frequent contractions
  • bleeding may be occult- still consider with abd pain
  • firm tender uterus
  • nonreassuring FHT secondary to hypoxia
59
Q

couvelaire uterus

A
  • blood from abruption penetrates uterine musculature
  • purple discoloration
  • classic sign of abruption at c section
60
Q

treatment of placental abruption

A
  • stabilize pt, rhogam if needed
  • prep for future hemorrhage with anti-shock measures
  • prepare for preterm delivery
  • deliver if bleeding is life threatening or non-reassuring fetal testing
61
Q

who gets ASA in pregnancy

A
  • any high risk factor for PEC and 1 or more mod risk factor

- get at 12 weeks until delivery

62
Q

high risk factors for PEC

A
  • prev pregnancy with PEC
  • multifetal gestation
  • renal or autoimmune disease
  • DM1 or DM2
  • chronic HTN
63
Q

mod risk factors for PEC

A
  • first pregnancy
  • AMA
  • BMI > 30
  • family hx PEC
  • low SES
  • personal hx of PEC
64
Q

gestational HTN

A
  • HTN >140/ >90 without proteinuria
  • dev after 20 weeks
  • BP returns to normal PP
65
Q

preeclampsia

A
  • HTN >140/>90 AND proteinuria
  • dev after 20 weeks
  • proteinuria= > 0.3 g protein in 24 hour urine
66
Q

maternal complications of PEC

A
  • seizure
  • cerebral hemorrhage, DIC, thrombocytoepnia
  • renal failure
  • hepatic rupture or failure
  • pulm edema
  • uteroplacental insufficiency, placental abruption
  • increased premature deliveries and c/s
67
Q

fetal complications of PEC

A
  • premature birth, still birth
  • intrapartum fetal distress
  • asymmetric or symmetric SGA fetus
  • IUGR
  • oligohydramnios
68
Q

PEC with severe features

A
  • BP > 160/110 on 2 occasions
  • thrombocytopenia
  • elevated AST/ ALT
  • severe or persistent RUQ or epigastric pain
  • renal insufficiency (Cr > 1.1)
  • pulmonary edema
  • new onset HA unresponsive to meds and not a migraine
  • visual disturbances
69
Q

tx of PEC

A
  • ultimate tx= delivery
  • if GHTN or PEC without severe features at 37+ weeks- deliver
  • if GHTN or PEC with severe features at 34+ weeks- deliver
  • stable preterm pts- betamethasone and expectant mgmt
  • mg sulfate for seizure ppx during labor, delivery, 12-24 hours pp
70
Q

signs of mg toxicity

A
  • loss of patellar reflex
  • respiratory paralysis
  • cardiac arrest
  • assess pt every 4 hours, check lev 6-8 hours
71
Q

tx of mg toxicity

A
  • calcium gluconate
72
Q

tx for chronic HTN in pregnancy

A
  • labetalol
  • nifedipine
  • d/c ACEI/ARBs
73
Q

superimposed PEC

A
  • new onset proteinuria in woman with CHTN
  • sudden increase in proteinuia if already present
  • sudden increase in HTN
  • dev of HELLP syndrome
74
Q

eclampsia

A
  • HTN plus proteinuria plus new onset grand mal seizures
75
Q

tx of eclampsia

A
  • seizure mgmt
  • BP control
  • ppx from other convulsions
  • give MgSO4 from dx to pp
  • delivery after convulsions controlled
76
Q

HELLP syndrome

A
  • hemolytic anemia- schistocytes, elevated LDH and t bili
  • elevated liver enzymes- AST/ALT
  • low platelets
  • pt may dev DIC or hepatic rupture
77
Q

acute fatty liver of pregnancy

A
  • 50% of pts also have HTN and proteinuria
  • high mortality rates
  • elevated ammonia
  • BS < 50
  • reduced fibrinogen and antithrombin II
78
Q

tx of acute fatty liver of pregnancy

A
  • mostly supportive
  • liver transplant PRN
  • possible spontaneous resolution
79
Q

gestational DM

A
  • impairment of CHO metabolism that first manifests in pregnancy, esp CHO bolus
  • placenta produces anti-insulin hormones, increase with size and fn of placenta
  • usu presents in 2nd and 3rd trimesters
80
Q

risks of GDM

A
  • fetal macrosomia
  • birth injuries
  • neonatal hypoglycemia
  • hypocalcemia
  • hyperbilirubinemia
  • polycythemia
  • 4-10X risk of dev DM2
81
Q

GDM tx

A
  • ADA diet of 2,000 cal/d
  • 200-220 g CHO/day
  • QID BS testing- fasting and postprandia
  • walking
  • give insulin or hypoglycemic agent
82
Q

GDMA1

A
  • diet controlled
83
Q

GDMA2

A
  • medication controlled
84
Q

delivery mgmt of GDM

A
  • GDMA1- random BS on admission, if normal then no intervention
  • IOL at 39 wks for GDMA2
  • weight > 4,000 g risk of shoulder dystocia
  • weight > 4,500 g offer elective c/s
85
Q

GDM follow up

A
  • 50% of pts will experience GDM in subsequent pregancys
  • 25% dev DM2 within 5 years
  • screen at pp visits and yearly
86
Q

fetal complications of pregestational DM

A
  • delayed organ maturity- esp pulm and pituitary-thryoid axis
  • congenital malformations
  • IUFD
87
Q

shoulder dystocia

A
  • dif delivering shoulders after head of fetus is delivered
  • impaction of ant shoulder behind pubic symphesis
  • dx when routine obstetric maneuvers fail to deliver fetus
  • obstetric emergency
88
Q

prep for shoulder dystocia

A
  • prep if RF are present
  • pt in dorsal lithotomy position
  • adequate anesthesia
  • experienced staff
  • episiotomy prn (rarely needed)
  • turtle sign
89
Q

turtle sign

A
  • incomplete delivery of head or chin tucking up against perineum
  • sign of shoulder dystocia
90
Q

delivery of baby with shoulder dystocia

A
  • must deliver in < 5 min
  • 2 people hold legs up by moms head (McRoberts maneuver)
  • suprapubic pressure
  • rubin maneuver
  • woods corckscrew
  • delivery post shoulder by sweeping arm across chest
  • fx clavicle
  • cut maternal pubic symphysis
  • zanavelli maneuver
91
Q

rubin maneuver

A
  • pressure on shoulder
  • push towards ant chest wall
  • used for shoulder dystocia delivery
92
Q

woods corkscrew

A
  • pressure from behind shoulder to rotate infant

- used for shoulder dystocia delivery

93
Q

zanavelli maneuver

A
  • done if all other maneuvers fail for shoulder dystocia

- place infants head back into pelvis and c/s

94
Q

postpartum hemorrhage (PPH)

A
  • > 500 ml blood loss from vaginal delivery

- > 1,000 ml blood loss from c/s

95
Q

early PPH

A
  • hemorrhage within first 24 hours
96
Q

late or delayed PPH

A
  • hemorrhage > 24 hours
97
Q

how much blood loss puts pt at risk of DIC

A
  • 2-3 L
98
Q

sheehan syndrome

A
  • pituitary infarct
  • from acute and abrupt hypovolemia and hypotension
  • sx= no lactation
99
Q

risk factors for PPH

A
  • abnormal placentation- previa, accreta, mole
  • trauma
  • uterine atony
  • coag defects
  • four Ts: tone, trauma, tissue, thrombin
100
Q

tx of PPH

A
  • transfuse RBC, platelet, clotting factors, pressors if needed
  • ICU
  • uterine packing/ tamponade
  • vessel embolization, ligation, compression sutures
  • hysterectomy
101
Q

what is the most common indication for primary c/s

A
  • failure to progress

- 2 hours without progression when adequate uterine contractions

102
Q

most common indication for c/s

A
  • previous c/s
103
Q

maternal indications for c/s

A
  • genital herpes, HIV, cervical ca
  • prior uterine surgery or rupture
  • obstruction of birth canal
104
Q

fetal indications for c/s

A
  • non-reassuring FHT
  • cord prolapse
  • malpresentation
  • multiple gestations
  • fetal anomalies- hydrocephalus, osteogenesis imperfecta
105
Q

placental indications for c/s

A
  • previa

- abruption

106
Q

identical twins

A
  • fertilized ovum divides into 2 seperate ova

- monozygotic twins

107
Q

fraternal twins

A
  • ovulation produces 2 ova
  • both get fertilized
  • dizigotic twins
108
Q

what is the avg delivery of twins

A
  • 36-37 weeks
109
Q

dx of multiple gestations

A
  • US
  • suspect if rapid uterine growth, excess maternal wt gain, palpation
  • high level hcg, human placental lactogen, alpha fetoprotein
110
Q

obstetric complications of multiple gestations

A
  • preterm labor
  • placenta previa
  • cord prolapse
  • PPH
  • cervical incompetence
  • GDM, PEC
111
Q

galactorrhea

A
  • spont flow of milk from breasts
  • d/t prolactin produced by pituitary
  • assoc with pregnancy, pituitary adenomas, hypothyroidism, stress, meds

Clin Med III (26 decks)

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