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Clin Med3: Womens Health > complications of pregnancy > Flashcards

complications of pregnancy Flashcards

1
Q

what is pregnancy implantation that occurs at a site other than the endometrium

A

ectopic pregnancy

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2
Q

what population is more likely to die from ectopic pregnancy

A

black non-hispanic 6.8x more likely than white non-hispanic people

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3
Q

what are risk factors for ectopic pregnancies

A

prior ectopic pregnancy
assisted reproduction
damage to fallopian tube
birthing person aged 35-44y
smoking
congenital tube defect
IUD in place lowers the risk, BUT incidence of ectopic pregnancy is higher

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4
Q

what is the typical presentation of ectopic pregnancy

A

abdominal pain and vaginal bleeding -> 7 weeks after LMP

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5
Q

how is ectopic pregnancy diagnosed

A

TVUS and positive serum beta HCG test
sometimes serial US and/or serum beta HCG levels are required to confirm diagnosis

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6
Q

if a gestational sac is not visualized in uterus, what needs to be investigated

A

ectopic location for pregnancy

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7
Q

what is the treatment for ectopic pregnancy

A

medical management: (early diagnosis and stable patient)
-methotrexate (MTX) outcomes comparable to surgery
surgical: laparoscopy salpingostomy - tube saving procedure or Laparotomy - unstable patients

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8
Q

what is the goal of treatment with ectopic pregnancies

A

prevent death, facilitate rapid recovery and help preserve future fertility, while keeping costs low

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9
Q

how many pregnancies end in miscarriage

A

1 in 4

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10
Q

what is a non-viable intrauterine pregnancy with either an empty gestational sac or a gestational sac with an embryo without evidence of cardiac activity within the first 12 6/7 weeks gestation

A

spontaneous pregnancy loss

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11
Q

what are signs and symptoms of spontaneous pregnancy loss

A

vaginal bleeding and uterine cramping
- same symptoms can occur in normal, ectopic and molar pregnancies

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12
Q

when is the most common time during the pregnancy to have a spontaneous pregnancy loss

A

first trimester 80%

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13
Q

what are risk factors for spontaneous pregnancy loss

A

advanced birthing person age
thyroid abnormalities
diabetes
obesity
anatomical abnormalities
trauma
autoimmune disease/antibodies to fetus
drugs/chemical/noxious agents
severe birthing person illness
infections
prior spontaneous pregnancy loss

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14
Q

what is the management options for spontaneous pregnancy loss

A

expectant
medical
surgical

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15
Q

what should be given in birthing person is RH NEG

A

Rhogam

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16
Q

what is the medical management of pregnancy loss

A

intravaginal misoprostol

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17
Q

what patients are not eligible for medical management of pregnancy loss

A

pts who prefer expectant or surgical management
embryonic age >10weeks
hemodynamically unstable
allergies to prostaglandins or NSAIDs
pts who are anticoagulated
signs of infection

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18
Q

what are the surgical management of pregnancy loss

A

surgical evacuation performed in the office - rarely need an OR - unless patient requests sedation/anesthesia

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19
Q

what is gestational trophoblastic disease

A

appears as a “cluster of grapes” on US, usually without evidence of embryo

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20
Q

what is the presentation of gestational trophoblastic disease

A

vaginal bleeding and enlarged uterus
abnormally high HcG levels and no evidence of HR
“cluster of grapes” on US

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21
Q

what are the risk factors for gestational trophoblastic disease

A

extremes of reproductive age, history of prior molar pregnancy, history of spontaneous pregnancy loss

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22
Q

what are the types of gestational trophoblastic disease

A

hydatidiform Mole (molar pregnancy)
gestational trophoblastic neoplasia

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23
Q

what is hydatidiform mole

A

tumor that develops in the uterus as a result of non-viable pregnancy
normally non-cancerous, but can become malignant

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24
Q

what are the types of hydatidiform mole pregnancy

A

complete molar pregnancy or partial molar pregnancy

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25
Q

what is gestational trophoblastic neoplasia

A

rare forms of cancer
-choriocarcinoma
aka invasive mole

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26
Q

what is the treatment for molar pregnancy

A

surgical evacuation with D&C (even if fetus present with partial)
chemo/radiation therapy
older pts may undergo hysterectomy

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27
Q

what are hypertensive disorders of pregnancy

A

gestational hypertension
preeclampsia
eclampsia
Hemolysis, Elevated Liver enzymes, and Low Platelet count syndrome (HELLP)
chronic HTN
chronic HTN with superimposed preeclampsia

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28
Q

after molar pregnancy, how long do patients have to wait to get pregnant after treatment

A

at least 1 year

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29
Q

what are antihypertensive management options during pregnancy

A

for BP persistently above 160/110 :
methylopa, labetalol, hydralazine or nifedipine

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30
Q

what medications for HTN are contraindicated during pregnancy

A

ACE inhibitors - cause renal injury to developing fetus in 2nd and 3rd trimester

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31
Q

what are antenatal fetal surveillance

A

non-stress test
US screening for fetal growth restriction
biophysical profile if: required antiHTN therapy, superimposed pre-eclampsia, fetal growth restriction

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32
Q

what is the most common cause of intrauterine growth restrictions (IUGR)

A

chronic HTN

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33
Q

what is chronic HTN during pregnancy

A

gestational BP elevation before the 20th of gestation
HTN diagnosed for the first-time during pregnancy and does not resolve postpartum

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34
Q

what is gestational HTN

A

transient HTN - returns to normal by 12 weeks into post partum period
defined as HTN without proteinuria or severe features that develops after 20 weeks of gestation

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35
Q

what does gestational HTN increase your risk for

A

preeclampsia especially if HTN diagnosed before 35 weeks

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36
Q

what is preeclampsia

A

new onset HTN with proteinuria diagnosed after 20 weeks of pregnancy
OR
in absence of proteinuria, new-onset HTN diagnosed after 20 weeks with 1 or more severe features

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37
Q

what are the signs and symptoms of preeclampsia

A

Severe HA, swollen face, visual disturbances, high BP, swollen hands and fingers, epigastric (chest) pain, proteinuria/oliguria, swollen feet and legs

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38
Q

how can at risk patients at risk of preeclampsia treat preventatively

A

low dose ASA after 12 weeks gestation

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39
Q

what are high risk factors for preeclampsia

A

preeclampsia in prior pregnancy
multiple gestation
chronic HTN
type 1 or 2 diabetes
renal disease
autoimmune disease

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40
Q

what are other risk factors for preeclampsia

A

birthing person > 35yo
nulliparity
family hx
obesity
poor outcome in prior pregnancy
assisted reproductive technology

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41
Q

what is the management of preeclampsia

A

deliver is the only cure (get placenta out)

42
Q

what is HELLP syndrome

A

Hemolysis elevated liver enzymes low platelets
- variant of preeclampsia: antepartum or postpartum
associated with poor birthing person outcomes; increased risk for pulmonary edea and acute renal failure

43
Q

what is the treatment of preeclampsia with severe features or HELLP

A

magnesium therapy

44
Q

what is eclampsia

A

new onset of grand mal seizures in a patient with preeclampsia

45
Q

what needs to be ruled out with eclampsia

A

hx of seizure disorder
head trauma
ruptured aneurysm
arteriovenous (AV) malformation

46
Q

what is the management of eclampsia

A

stablilize, safety measures
typically see fetal bradycardia during seizures
control convulsions/keep airway open- magnesium sulfate: 4-6mg loading dose
delivery when patient is stable
antiHTN meds if persistent pressures >160/110

47
Q

what are indications for delivery

A

indicated for unstable birthing person or fetal condition
mode determined by fetal gestational age, presentation, cervical status, and birthing person/fetal condition

48
Q

what is the post partum management of HTN

A

monitor BP at least 72 hours postpartum
re-evaluate BP 7-10 days after deliver
postpartum HTN most likely to persist if higher urinary protein, serum uric acid, and BUN

49
Q

what are some causes of vaginal bleeding in late pregnancy

A

placenta abruption
placenta previa
cervical trauma
vaginal infection
“bloody show”

50
Q

what is placental abruption

A

premature seperation of normally implanted placenta from uterus

51
Q

what are the US findings with placental abruption

A

adherent retro-placental blot with depression or disruption in underlying tissue

52
Q

what are the triad of clinical findings with placental abruption

A

external or occult bleeding (dark blood)
uterine hyper-tonus/hyperactivity/uterine pain
fetal distress/death

53
Q

what are increased risk factors for placental abruption

A

advanced birthing are or parity, smoking, poor nuturtion, use of cocaine, chorioamnionitis
birthing person HTN
blunt external abd trauma (MVA/DV)
abruption in prior pregnancies

54
Q

what is the hallmark presentation time of placental abruption

A

3rd trimerster

55
Q

what is the management of placental abruption

A

rule out placenta previa (r/o other causes first)
precautions: 2 large bore IV, 4 unites PRBCs available, coagulation studies/lab draw, continuous fetal monitoring

56
Q

what are the abruption deliveries

A

if birthing person and fetal are stable - initiation of labor (IOL)
if unstable/deteriorating, expedited delivery via cesarean

57
Q

what is placenta previa

A

impantation of placenta over cervical os
-total, partial, marginal

58
Q

what is the leading cause of 3rd trimester painless, bright red bleeding

A

placenta previa

59
Q

what are risk factors for placenta previa

A

previa in prior pregnancy
birthing person > 35 yo
minority race
prior cesarean
cocaine and tobacco

60
Q

when is the diagnosis of placenta previa typically made

A

during the 2nd trimester with the anatomy scan

61
Q

what is the management of placenta previa

A

depend on gestational age; amount of bleeding; fetal condition and presentation
previa often causes malpresentation
if preterm and stable: expectant management
if>37 weeks: c-section

62
Q

what is the birthing person at a greater risk for with placenta previa

A

hemorrhage - blood should always be available

63
Q

what is monozygotic

A

single fertilized ovum splits - same sex, genetically identical

64
Q

what is dizygotic

A

two separate ova are fertilized, same or opposite sex, genetically distinct children

65
Q

what are the twin types

A

monochorionic-monoaminionic
monochorionic-diamnionic
dichorionic-diamnionic

66
Q

what is monochorionic-monoamnionic twins

A

one placenta, one sac, always monozygotic - increased risk for twin to twin transfusion syndrome (TTS)

67
Q

what is monochorionic-diamnionic

A

one placenta, two sacs; blood vessel communication between fetal circulation, increased risk for TTS, usu. monozygotic

68
Q

what is dichorionic-diamnionic

A

two sacs, two placentas (sometimes 2 separate placentas intertwine); occurs in almost all dizygotic twins, lowest mortality rate

69
Q

what is carbohydrate intolerance that starts during pregnancy

A

gestational diabetets

70
Q

how often should glucose be checked per day with gestational diabetes

A

4x/day

71
Q

when is insulin started with gestational diabetes

A

> 4 abnormal values/day, or noticing trends

72
Q

what are the complication risks associated with GDM

A

gestational HTN
preeclampsia
premature delivery
large for gestational age/shoulder dystocia/cesarean delivery
stillbirth
7x increase for developing diabetes later in life

73
Q

what is postpartum care for GDM

A

6-12 week postpartum: 75mg load, 2 h postprandial lab draw
encourage weight loss to normal BMI range
breast feeding
increased risk of T2DM

74
Q

what is an incompetent cervix

A

inability of the uterine cervix to retain a pregnancy in the second trimester, in the absence of uterine contractions

75
Q

what are risk factors for incompetent cervix

A

prior second trimester pregnancy loss
short cervix identified on TVUS associated with prior second trimester pregnancy loss
fetal fibronectin testing + short cervical length helps to predict preterm delivery

76
Q

what is the presentation of incompetent cervix in a pt who has had a previous second trimester pregnancy loss with the following:

A

-painless cervical dilation and bulging fetal membranes in second trimester
-preterm premature rupture of membranes
-rapid delivery of a pre-viable infant
-rare or absent contraction

77
Q

what is the presentation of incompetent cervix of a patient who has NOT had a previous second trimester pregnancy loss

A

painless cervical dilation on PE in second trimester

78
Q

what is the management of cervical insufficiency

A

cervical cerclage

79
Q

what are contraindications of cerclage

A

lethal fetal anomaly
intrauterine infection
active bleeding
preterm labor
ruptured membranes
retal demise

80
Q

what is a spontaneous rupture of fetal membranes before onset of labor

A

premature rupture of membranes

81
Q

what is the most common presentation of premature rupture of membranes

A

gush of fluid from vagina followed by persistent, uncontrolled leakage

82
Q

what is premature preterm rupture of membranes (PPRoM)

A

spontaneous rupture of membranes prior to onset of labor and prior to 37 weeks gestation
-evidence of associated infection

83
Q

what is the presentation of P-PRoM

A

gush of fluid followed by uncontrollable leaking or slow steady trickle

84
Q

how do you diagnose P-PRoM

A

sterile speculum exam
digital exam should be avoided

85
Q

what is ferning

A

when allowed to dry on clean slide, amniotic fluid produces microscopic cystralization in a ‘fern pattern”

86
Q

what is the management of P-PRoM

A

US for amniotic fluid volume
indications for immediate delivery should be ruled out first
principle indication for delivery is chorioamnionitis

87
Q

what is the most dangerous risk of P-PRoM

A

umbilical cord prolapse

88
Q

what is shoulder dystocia

A

obstetrical emergency
anterior shoulder stuck or needs significant manipulation to pass below pubic symphysis

89
Q

when is shoulder dystocia diagnosed

A

when shoulders do not deliver shortly after the fetal head

90
Q

what are risk factors of shoulder dystocia

A

shoulder dystocia in pervious pregnancy
GDM
obesity
induction of labor
long labor
forceps or vacuum assisted delivery
fetal weight; but most cases occur in babies under 9lbs

91
Q

what is the management of shoulder dystocia

A

prompt reduction of shoulder and delivery helps reduce adverse outcomes
- call for HELP
-suprapubic pressure
-obstetrics maneuvers for reducing shoulder
-manual delivery of posterior arm
-episotomy
-last resort - intentionally fracture fetal clavicle

92
Q

what are the maneuvers for reducing shoulder dystocia

A

McRoberts Maneuver (hip hyperflexion) and suprapubic pressure
Wood’s corkscrew:180 degree rotation of poterior shoulder

93
Q

what do more maneuvers for shoulder dystocia increase

A

chance of success and increased risk for fetal injury

94
Q

what are fetal complications of shoulder dystocia

A

brachial plexus injury
diaphragmatic paralysis
facial nerve injury
horners syndrome
clavicle fracture
hypoxic ischemic encephalopathy (HIE)
death

95
Q

what are birthing person complications of shoulder dystocia

A

lacerations: bladder, urethra, vagina, anal sphincter, rectum
lateral femoral cutaneous neuropathy
postpartum hemorrhage
separation of the pubic symphysis
uterine rupture

96
Q

how quickly does the body need to be delivered with shoulder dysocia

A

<5min or risk of Hypoxic ischemic encephalopathy (HIE)

97
Q

what is postpartum hemorrhage

A

> 1000mL blood loss OR blood loss associated with signs or symptoms of hypovolemia

98
Q

what do postpartum hemorrhages usually require

A

transfusion

99
Q

what are risk factors for postpartum hemorrhage

A

prolonged labor, augemented labor, rapid labor
history of PPH
over distended uterus
operative delivery
chorioamnionitis
preeclampsia

100
Q

what is the prevention of postpartum hemorrhage

A

correct anemia
avoid routine episiotomy
infant to breast after delivery
routine use of medicine after delivery of placenta
active management of the third stage of labor

101
Q

what are the casues of early postpartum hemorrhage

A

uterine atony
genital tract trauma
retained placental tissue
coagulation disorder

102
Q

what is the management of uterine atony

A

deliver the placenta
uterine massage to help tone uterus
removal of clots
give uterotonics: oxytocin, misoprostol, methergine and hemabate
bimanual compression
possible D&C for retained products

Clin Med3: Womens Health (13 decks)

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