complicated pregnancy Flashcards
spontaneous abortion
- aka miscarriage
- termed before week 20
- majority occur < 8 weeks
- often d/t major chromosomal abnormalities
abortus
- fetus lost before 20 weeks, < 500g or < 25 cm
threatened ab
- bleeding +/- cramping
- closed cervix
- very common
inevitable ab
- bleeding +/- cramping
- dilated cervix
- often pass contents on own
complete ab
- all products expelled
missed ab
- embryo or fetus dies but but all products of conception retained
incomplete ab
- some portion of products remain in uterus
habitual ab
- 3+ abortions in succession
tx of ab
- stabilize pt if hypotensive
- monitor for bleeding and infx
- send tissue to pathology
- +/- D&C or prostaglandins
- rhogam for Rh neg pts
second trimester abortion
- 12-20 weeks
- D&C vs D&E
- if 16-24 weeks either et D&E or IOL
possible causes for 2nd trimester abortions
- infection
- uterine or cervical anatomic defects
- maternal systemic disease
- exposure to fetotoxic agent
- trauma
- PTL
- incompetent cervix
incompetent cervix
- aka cervical insufficiency
- painless dilation and effacement of cervix
- most often in 2nd trimester
why is incompetent cervix bad
- fetus exposed to vaginal flora
- risk of trauma, infection ROM
risk factors for incompetent cervix
- cervical surgery or trauma
- uterine anomalies
- hx of DES exposure
tx for incompetent cervix
- cerclage
- if previable- expectant mgmt or elective termination
- if viable- betamethasone, bed rest, tocolytics if ctx
what is cerclage
- suture placed vaginally around cervix to close it
- elective. vs emergent, vs transabdominal (last line)
ectopic pregnancy
- pregnancy implants outside of uterus
- 99% in fallopian tubes
- if vaginal bleeding + abd pain eval for ectopic
risk factors for ectopic pregnancy
- 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
dx of ectopic
- pain + bleeding
- uterus small for GA
- hcg doesnt rise appropriately
- ruptured- hypotensive, unresponsive, peritoneal irritation
- US- ring of fire*, adenexal mass, extrauterine pregnancy
tx of ruptured ectopic
- stabilize pt first with IVF, blood, pressors
- exploratory laparotomy to control bleeding and remove ectopic
- salpingostomy vs salpingectomy
- rhogam if Rh neg
tx of unruptured ectopic
- rhogam if Rh neg
- surgery
- medical tx with methotrexate
use of methotrexate for unruptured ectopic
- 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
hetertopic pregnancy
- rare
- intrauterine pregnancy + ectopic at same time
- most common with assisted pregnancy
Rh incompatability
- 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
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
complete mole
- molar degeneration with no associated fetus
partial mole
- molar degeneration in association with abnormal fetus
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
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
PE findings for molar pregnancy
- preeclampsia
- hyperthyroidism
- absence of fetal heart tones
- uterine size GA
- grape like molar clusters from cervix
- theca leutein cysts
US findings for molar pregnancy
- diffused mixed echogenic pattern
- villi and intrauterine clots
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
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
malignant GTD
- majority are due to persistent/ invasive moles
- rest are choriocarcinoma
classification of malignant GTD
- non-metastatic
- metastatic- good vs poor prognosis
good prognosis of metastatic GTD
- short duration
- hcg < 40,000
- no mets to liver or brain
- no hx of chemo
poor prognosis of metastatic GTD
- long duration > 4 mo
- hcg > 40,000
- mets to brain or liver
- unsuccessful prior chemo
- GTD following term pregnancy
persistent/ invasive moles
- usu after molar pregnancy
- dx based on high hcg levels, pelvic us
- rarely metastasizes
tx and f/u for persistent/ invasive moles
- chemo + mtx or actinomycin-d
- f/u with serial hcg and reliable contraception
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
tx of choriocarcinoma
- chemo either single or multiagent
placental site trophoblastic tumors
- very rare
- arise from placental implantation site
- sx- irregular bleeding, enlarged uterus, chronic low hcg
tx of placental site trophoblastic disease
- not chemosensitive
- hysterectomy
- f/u with multiagent chemo to prevent recurrence
complete previa
- placenta completely covers internal os
partial previa
- placenta covers portion of internal os
marginal previa
- edge of placenta reaches the margin of os
low lying placenta
- placenta implanted in lower uterine segment in close proximity to os
vasa previa
- fetal vessel lies over cervix
- rare
risk factors for placenta previa
- prior c/s or uterine surgery
- multiparity, multiple gestations
- erythroblastosis
- smoking
- hx of previa
- AMA
fetal complications of previa
- preterm delivery
- PPROM
- IUGR
- malpresentation
- vasa previa
- congenital abnormalities
placenta accreta
- superficial invasion of placenta into myometrium
- inability of placenta to properly separate from uterine wall after delivery
- can lead to hemorrhage, shock
increta
- placenta invades myometrium
percreta
- placenta invades through myometrium into uterine serosa
signs of accreta
- common with previa
- painless vaginal bleeding (recurrent)
- vaginal exams C/I
treatment for accreta
- pelvic rest
- +/- modified bed rest
- c/s at 36 or 37 weeks- confirm lung maturity with amnio first
placental abruption
- premature separation of placenta from uterine wall
- causes hemorrhage
- half occur before labor > 30 weeks
- concealed bleeding vs presenting with vaginal bleeding
complications of placental abruption
- premature delivery
- uterine tetany
- DIC
- hypovolemic shock
- rarely fatal for mother
- fetal mortality risk d/t hypoxia
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
couvelaire uterus
- blood from abruption penetrates uterine musculature
- purple discoloration
- classic sign of abruption at c section
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
who gets ASA in pregnancy
- any high risk factor for PEC and 1 or more mod risk factor
- get at 12 weeks until delivery
high risk factors for PEC
- prev pregnancy with PEC
- multifetal gestation
- renal or autoimmune disease
- DM1 or DM2
- chronic HTN
mod risk factors for PEC
- first pregnancy
- AMA
- BMI > 30
- family hx PEC
- low SES
- personal hx of PEC
gestational HTN
- HTN >140/ >90 without proteinuria
- dev after 20 weeks
- BP returns to normal PP
preeclampsia
- HTN >140/>90 AND proteinuria
- dev after 20 weeks
- proteinuria= > 0.3 g protein in 24 hour urine
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
fetal complications of PEC
- premature birth, still birth
- intrapartum fetal distress
- asymmetric or symmetric SGA fetus
- IUGR
- oligohydramnios
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
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
signs of mg toxicity
- loss of patellar reflex
- respiratory paralysis
- cardiac arrest
- assess pt every 4 hours, check lev 6-8 hours
tx of mg toxicity
- calcium gluconate
tx for chronic HTN in pregnancy
- labetalol
- nifedipine
- d/c ACEI/ARBs
superimposed PEC
- new onset proteinuria in woman with CHTN
- sudden increase in proteinuia if already present
- sudden increase in HTN
- dev of HELLP syndrome
eclampsia
- HTN plus proteinuria plus new onset grand mal seizures
tx of eclampsia
- seizure mgmt
- BP control
- ppx from other convulsions
- give MgSO4 from dx to pp
- delivery after convulsions controlled
HELLP syndrome
- hemolytic anemia- schistocytes, elevated LDH and t bili
- elevated liver enzymes- AST/ALT
- low platelets
- pt may dev DIC or hepatic rupture
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
tx of acute fatty liver of pregnancy
- mostly supportive
- liver transplant PRN
- possible spontaneous resolution
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
risks of GDM
- fetal macrosomia
- birth injuries
- neonatal hypoglycemia
- hypocalcemia
- hyperbilirubinemia
- polycythemia
- 4-10X risk of dev DM2
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
GDMA1
- diet controlled
GDMA2
- medication controlled
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
GDM follow up
- 50% of pts will experience GDM in subsequent pregancys
- 25% dev DM2 within 5 years
- screen at pp visits and yearly
fetal complications of pregestational DM
- delayed organ maturity- esp pulm and pituitary-thryoid axis
- congenital malformations
- IUFD
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
prep for shoulder dystocia
- prep if RF are present
- pt in dorsal lithotomy position
- adequate anesthesia
- experienced staff
- episiotomy prn (rarely needed)
- turtle sign
turtle sign
- incomplete delivery of head or chin tucking up against perineum
- sign of shoulder dystocia
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
rubin maneuver
- pressure on shoulder
- push towards ant chest wall
- used for shoulder dystocia delivery
woods corkscrew
- pressure from behind shoulder to rotate infant
- used for shoulder dystocia delivery
zanavelli maneuver
- done if all other maneuvers fail for shoulder dystocia
- place infants head back into pelvis and c/s
postpartum hemorrhage (PPH)
- > 500 ml blood loss from vaginal delivery
- > 1,000 ml blood loss from c/s
early PPH
- hemorrhage within first 24 hours
late or delayed PPH
- hemorrhage > 24 hours
how much blood loss puts pt at risk of DIC
- 2-3 L
sheehan syndrome
- pituitary infarct
- from acute and abrupt hypovolemia and hypotension
- sx= no lactation
risk factors for PPH
- abnormal placentation- previa, accreta, mole
- trauma
- uterine atony
- coag defects
- four Ts: tone, trauma, tissue, thrombin
tx of PPH
- transfuse RBC, platelet, clotting factors, pressors if needed
- ICU
- uterine packing/ tamponade
- vessel embolization, ligation, compression sutures
- hysterectomy
what is the most common indication for primary c/s
- failure to progress
- 2 hours without progression when adequate uterine contractions
most common indication for c/s
- previous c/s
maternal indications for c/s
- genital herpes, HIV, cervical ca
- prior uterine surgery or rupture
- obstruction of birth canal
fetal indications for c/s
- non-reassuring FHT
- cord prolapse
- malpresentation
- multiple gestations
- fetal anomalies- hydrocephalus, osteogenesis imperfecta
placental indications for c/s
- previa
- abruption
identical twins
- fertilized ovum divides into 2 seperate ova
- monozygotic twins
fraternal twins
- ovulation produces 2 ova
- both get fertilized
- dizigotic twins
what is the avg delivery of twins
- 36-37 weeks
dx of multiple gestations
- US
- suspect if rapid uterine growth, excess maternal wt gain, palpation
- high level hcg, human placental lactogen, alpha fetoprotein
obstetric complications of multiple gestations
- preterm labor
- placenta previa
- cord prolapse
- PPH
- cervical incompetence
- GDM, PEC
galactorrhea
- spont flow of milk from breasts
- d/t prolactin produced by pituitary
- assoc with pregnancy, pituitary adenomas, hypothyroidism, stress, meds
