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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
what diseases are included in gestational trophoblastic disease
- molar pregnancy (complete vs incomplete) - persistent/ invasive moles - choriocarcinoma - placental site trophoblastic tumors - all are abnormal placental tissue
26
complete mole
- molar degeneration with no associated fetus
27
partial mole
- molar degeneration in association with abnormal fetus
28
risk factors for molar pregnancies
- extremes in age - prior hx GTD - nulliparity - infertility - OCP use - smoking - diet low in beta carotine, folic acid, animal fat
29
dx of molar pregnancy
- usu dx in first trimester - hx of heavy/ irregular bleeding - sx of high hct- hyperemesis, preeclampsia, hyperthyroidism - preeclampsia < 20 weeks= pathognomonic
30
PE findings for molar pregnancy
- preeclampsia - hyperthyroidism - absence of fetal heart tones - uterine size GA - grape like molar clusters from cervix - theca leutein cysts
31
US findings for molar pregnancy
- diffused mixed echogenic pattern | - villi and intrauterine clots
32
tx of molar pregnancy
- 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
33
follow up for molar pregnancy
- 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
34
malignant GTD
- majority are due to persistent/ invasive moles | - rest are choriocarcinoma
35
classification of malignant GTD
- non-metastatic | - metastatic- good vs poor prognosis
36
good prognosis of metastatic GTD
- short duration - hcg < 40,000 - no mets to liver or brain - no hx of chemo
37
poor prognosis of metastatic GTD
- long duration > 4 mo - hcg > 40,000 - mets to brain or liver - unsuccessful prior chemo - GTD following term pregnancy
38
persistent/ invasive moles
- usu after molar pregnancy - dx based on high hcg levels, pelvic us - rarely metastasizes
39
tx and f/u for persistent/ invasive moles
- chemo + mtx or actinomycin-d | - f/u with serial hcg and reliable contraception
40
choriocarcinoma
- malignant necrotizing tumor - usu metastatic: lungs, vagina, pelvis, brain, liver, intestines, kidneys - sx- irregular uterine bleeding or sings of metastatic disease, hct abnormally high
41
tx of choriocarcinoma
- chemo either single or multiagent
42
placental site trophoblastic tumors
- very rare - arise from placental implantation site - sx- irregular bleeding, enlarged uterus, chronic low hcg
43
tx of placental site trophoblastic disease
- not chemosensitive - hysterectomy - f/u with multiagent chemo to prevent recurrence
44
complete previa
- placenta completely covers internal os
45
partial previa
- placenta covers portion of internal os
46
marginal previa
- edge of placenta reaches the margin of os
47
low lying placenta
- placenta implanted in lower uterine segment in close proximity to os
48
vasa previa
- fetal vessel lies over cervix | - rare
49
risk factors for placenta previa
- prior c/s or uterine surgery - multiparity, multiple gestations - erythroblastosis - smoking - hx of previa - AMA
50
fetal complications of previa
- preterm delivery - PPROM - IUGR - malpresentation - vasa previa - congenital abnormalities
51
placenta accreta
- superficial invasion of placenta into myometrium - inability of placenta to properly separate from uterine wall after delivery - can lead to hemorrhage, shock
52
increta
- placenta invades myometrium
53
percreta
- placenta invades through myometrium into uterine serosa
54
signs of accreta
- common with previa - painless vaginal bleeding (recurrent) - vaginal exams C/I
55
treatment for accreta
- pelvic rest - +/- modified bed rest - c/s at 36 or 37 weeks- confirm lung maturity with amnio first
56
placental abruption
- premature separation of placenta from uterine wall - causes hemorrhage - half occur before labor > 30 weeks - concealed bleeding vs presenting with vaginal bleeding
57
complications of placental abruption
- premature delivery - uterine tetany - DIC - hypovolemic shock - rarely fatal for mother - fetal mortality risk d/t hypoxia
58
si/sx of placental aburption
- 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
couvelaire uterus
- blood from abruption penetrates uterine musculature - purple discoloration - classic sign of abruption at c section
60
treatment of placental abruption
- 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
who gets ASA in pregnancy
- any high risk factor for PEC and 1 or more mod risk factor | - get at 12 weeks until delivery
62
high risk factors for PEC
- prev pregnancy with PEC - multifetal gestation - renal or autoimmune disease - DM1 or DM2 - chronic HTN
63
mod risk factors for PEC
- first pregnancy - AMA - BMI > 30 - family hx PEC - low SES - personal hx of PEC
64
gestational HTN
- HTN >140/ >90 without proteinuria - dev after 20 weeks - BP returns to normal PP
65
preeclampsia
- HTN >140/>90 AND proteinuria - dev after 20 weeks - proteinuria= > 0.3 g protein in 24 hour urine
66
maternal complications of PEC
- seizure - cerebral hemorrhage, DIC, thrombocytoepnia - renal failure - hepatic rupture or failure - pulm edema - uteroplacental insufficiency, placental abruption - increased premature deliveries and c/s
67
fetal complications of PEC
- premature birth, still birth - intrapartum fetal distress - asymmetric or symmetric SGA fetus - IUGR - oligohydramnios
68
PEC with severe features
- 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
tx of PEC
- 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
signs of mg toxicity
- loss of patellar reflex - respiratory paralysis - cardiac arrest - assess pt every 4 hours, check lev 6-8 hours
71
tx of mg toxicity
- calcium gluconate
72
tx for chronic HTN in pregnancy
- labetalol - nifedipine - d/c ACEI/ARBs
73
superimposed PEC
- new onset proteinuria in woman with CHTN - sudden increase in proteinuia if already present - sudden increase in HTN - dev of HELLP syndrome
74
eclampsia
- HTN plus proteinuria plus new onset grand mal seizures
75
tx of eclampsia
- seizure mgmt - BP control - ppx from other convulsions - give MgSO4 from dx to pp - delivery after convulsions controlled
76
HELLP syndrome
- hemolytic anemia- schistocytes, elevated LDH and t bili - elevated liver enzymes- AST/ALT - low platelets - pt may dev DIC or hepatic rupture
77
acute fatty liver of pregnancy
- 50% of pts also have HTN and proteinuria - high mortality rates - elevated ammonia - BS < 50 - reduced fibrinogen and antithrombin II
78
tx of acute fatty liver of pregnancy
- mostly supportive - liver transplant PRN - possible spontaneous resolution
79
gestational DM
- 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
risks of GDM
- fetal macrosomia - birth injuries - neonatal hypoglycemia - hypocalcemia - hyperbilirubinemia - polycythemia - 4-10X risk of dev DM2
81
GDM tx
- 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
GDMA1
- diet controlled
83
GDMA2
- medication controlled
84
delivery mgmt of GDM
- 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
GDM follow up
- 50% of pts will experience GDM in subsequent pregancys - 25% dev DM2 within 5 years - screen at pp visits and yearly
86
fetal complications of pregestational DM
- delayed organ maturity- esp pulm and pituitary-thryoid axis - congenital malformations - IUFD
87
shoulder dystocia
- 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
prep for shoulder dystocia
- prep if RF are present - pt in dorsal lithotomy position - adequate anesthesia - experienced staff - episiotomy prn (rarely needed) - turtle sign
89
turtle sign
- incomplete delivery of head or chin tucking up against perineum - sign of shoulder dystocia
90
delivery of baby with shoulder dystocia
- 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
rubin maneuver
- pressure on shoulder - push towards ant chest wall - used for shoulder dystocia delivery
92
woods corkscrew
- pressure from behind shoulder to rotate infant | - used for shoulder dystocia delivery
93
zanavelli maneuver
- done if all other maneuvers fail for shoulder dystocia | - place infants head back into pelvis and c/s
94
postpartum hemorrhage (PPH)
- > 500 ml blood loss from vaginal delivery | - > 1,000 ml blood loss from c/s
95
early PPH
- hemorrhage within first 24 hours
96
late or delayed PPH
- hemorrhage > 24 hours
97
how much blood loss puts pt at risk of DIC
- 2-3 L
98
sheehan syndrome
- pituitary infarct - from acute and abrupt hypovolemia and hypotension - sx= no lactation
99
risk factors for PPH
- abnormal placentation- previa, accreta, mole - trauma - uterine atony - coag defects - four Ts: tone, trauma, tissue, thrombin
100
tx of PPH
- transfuse RBC, platelet, clotting factors, pressors if needed - ICU - uterine packing/ tamponade - vessel embolization, ligation, compression sutures - hysterectomy
101
what is the most common indication for primary c/s
- failure to progress | - 2 hours without progression when adequate uterine contractions
102
most common indication for c/s
- previous c/s
103
maternal indications for c/s
- genital herpes, HIV, cervical ca - prior uterine surgery or rupture - obstruction of birth canal
104
fetal indications for c/s
- non-reassuring FHT - cord prolapse - malpresentation - multiple gestations - fetal anomalies- hydrocephalus, osteogenesis imperfecta
105
placental indications for c/s
- previa | - abruption
106
identical twins
- fertilized ovum divides into 2 seperate ova | - monozygotic twins
107
fraternal twins
- ovulation produces 2 ova - both get fertilized - dizigotic twins
108
what is the avg delivery of twins
- 36-37 weeks
109
dx of multiple gestations
- US - suspect if rapid uterine growth, excess maternal wt gain, palpation - high level hcg, human placental lactogen, alpha fetoprotein
110
obstetric complications of multiple gestations
- preterm labor - placenta previa - cord prolapse - PPH - cervical incompetence - GDM, PEC
111
galactorrhea
- 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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