complications of pregnancy Flashcards
what is pregnancy implantation that occurs at a site other than the endometrium
ectopic pregnancy
what population is more likely to die from ectopic pregnancy
black non-hispanic 6.8x more likely than white non-hispanic people
what are risk factors for ectopic pregnancies
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
what is the typical presentation of ectopic pregnancy
abdominal pain and vaginal bleeding -> 7 weeks after LMP
how is ectopic pregnancy diagnosed
TVUS and positive serum beta HCG test
sometimes serial US and/or serum beta HCG levels are required to confirm diagnosis
if a gestational sac is not visualized in uterus, what needs to be investigated
ectopic location for pregnancy
what is the treatment for ectopic pregnancy
medical management: (early diagnosis and stable patient)
-methotrexate (MTX) outcomes comparable to surgery
surgical: laparoscopy salpingostomy - tube saving procedure or Laparotomy - unstable patients
what is the goal of treatment with ectopic pregnancies
prevent death, facilitate rapid recovery and help preserve future fertility, while keeping costs low
how many pregnancies end in miscarriage
1 in 4
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
spontaneous pregnancy loss
what are signs and symptoms of spontaneous pregnancy loss
vaginal bleeding and uterine cramping
- same symptoms can occur in normal, ectopic and molar pregnancies
when is the most common time during the pregnancy to have a spontaneous pregnancy loss
first trimester 80%
what are risk factors for spontaneous pregnancy loss
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
what is the management options for spontaneous pregnancy loss
expectant
medical
surgical
what should be given in birthing person is RH NEG
Rhogam
what is the medical management of pregnancy loss
intravaginal misoprostol
what patients are not eligible for medical management of pregnancy loss
pts who prefer expectant or surgical management
embryonic age >10weeks
hemodynamically unstable
allergies to prostaglandins or NSAIDs
pts who are anticoagulated
signs of infection
what are the surgical management of pregnancy loss
surgical evacuation performed in the office - rarely need an OR - unless patient requests sedation/anesthesia
what is gestational trophoblastic disease
appears as a “cluster of grapes” on US, usually without evidence of embryo
what is the presentation of gestational trophoblastic disease
vaginal bleeding and enlarged uterus
abnormally high HcG levels and no evidence of HR
“cluster of grapes” on US
what are the risk factors for gestational trophoblastic disease
extremes of reproductive age, history of prior molar pregnancy, history of spontaneous pregnancy loss
what are the types of gestational trophoblastic disease
hydatidiform Mole (molar pregnancy)
gestational trophoblastic neoplasia
what is hydatidiform mole
tumor that develops in the uterus as a result of non-viable pregnancy
normally non-cancerous, but can become malignant
what are the types of hydatidiform mole pregnancy
complete molar pregnancy or partial molar pregnancy
what is gestational trophoblastic neoplasia
rare forms of cancer
-choriocarcinoma
aka invasive mole
what is the treatment for molar pregnancy
surgical evacuation with D&C (even if fetus present with partial)
chemo/radiation therapy
older pts may undergo hysterectomy
what are hypertensive disorders of pregnancy
gestational hypertension
preeclampsia
eclampsia
Hemolysis, Elevated Liver enzymes, and Low Platelet count syndrome (HELLP)
chronic HTN
chronic HTN with superimposed preeclampsia
after molar pregnancy, how long do patients have to wait to get pregnant after treatment
at least 1 year
what are antihypertensive management options during pregnancy
for BP persistently above 160/110 :
methylopa, labetalol, hydralazine or nifedipine
what medications for HTN are contraindicated during pregnancy
ACE inhibitors - cause renal injury to developing fetus in 2nd and 3rd trimester
what are antenatal fetal surveillance
non-stress test
US screening for fetal growth restriction
biophysical profile if: required antiHTN therapy, superimposed pre-eclampsia, fetal growth restriction
what is the most common cause of intrauterine growth restrictions (IUGR)
chronic HTN
what is chronic HTN during pregnancy
gestational BP elevation before the 20th of gestation
HTN diagnosed for the first-time during pregnancy and does not resolve postpartum
what is gestational HTN
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
what does gestational HTN increase your risk for
preeclampsia especially if HTN diagnosed before 35 weeks
what is preeclampsia
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
what are the signs and symptoms of preeclampsia
Severe HA, swollen face, visual disturbances, high BP, swollen hands and fingers, epigastric (chest) pain, proteinuria/oliguria, swollen feet and legs
how can at risk patients at risk of preeclampsia treat preventatively
low dose ASA after 12 weeks gestation
what are high risk factors for preeclampsia
preeclampsia in prior pregnancy
multiple gestation
chronic HTN
type 1 or 2 diabetes
renal disease
autoimmune disease
what are other risk factors for preeclampsia
birthing person > 35yo
nulliparity
family hx
obesity
poor outcome in prior pregnancy
assisted reproductive technology
what is the management of preeclampsia
deliver is the only cure (get placenta out)
what is HELLP syndrome
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
what is the treatment of preeclampsia with severe features or HELLP
magnesium therapy
what is eclampsia
new onset of grand mal seizures in a patient with preeclampsia
what needs to be ruled out with eclampsia
hx of seizure disorder
head trauma
ruptured aneurysm
arteriovenous (AV) malformation
what is the management of eclampsia
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
what are indications for delivery
indicated for unstable birthing person or fetal condition
mode determined by fetal gestational age, presentation, cervical status, and birthing person/fetal condition
what is the post partum management of HTN
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
what are some causes of vaginal bleeding in late pregnancy
placenta abruption
placenta previa
cervical trauma
vaginal infection
“bloody show”
what is placental abruption
premature seperation of normally implanted placenta from uterus
what are the US findings with placental abruption
adherent retro-placental blot with depression or disruption in underlying tissue
what are the triad of clinical findings with placental abruption
external or occult bleeding (dark blood)
uterine hyper-tonus/hyperactivity/uterine pain
fetal distress/death
what are increased risk factors for placental abruption
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
what is the hallmark presentation time of placental abruption
3rd trimerster
what is the management of placental abruption
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
what are the abruption deliveries
if birthing person and fetal are stable - initiation of labor (IOL)
if unstable/deteriorating, expedited delivery via cesarean
what is placenta previa
impantation of placenta over cervical os
-total, partial, marginal
what is the leading cause of 3rd trimester painless, bright red bleeding
placenta previa
what are risk factors for placenta previa
previa in prior pregnancy
birthing person > 35 yo
minority race
prior cesarean
cocaine and tobacco
when is the diagnosis of placenta previa typically made
during the 2nd trimester with the anatomy scan
what is the management of placenta previa
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
what is the birthing person at a greater risk for with placenta previa
hemorrhage - blood should always be available
what is monozygotic
single fertilized ovum splits - same sex, genetically identical
what is dizygotic
two separate ova are fertilized, same or opposite sex, genetically distinct children
what are the twin types
monochorionic-monoaminionic
monochorionic-diamnionic
dichorionic-diamnionic
what is monochorionic-monoamnionic twins
one placenta, one sac, always monozygotic - increased risk for twin to twin transfusion syndrome (TTS)
what is monochorionic-diamnionic
one placenta, two sacs; blood vessel communication between fetal circulation, increased risk for TTS, usu. monozygotic
what is dichorionic-diamnionic
two sacs, two placentas (sometimes 2 separate placentas intertwine); occurs in almost all dizygotic twins, lowest mortality rate
what is carbohydrate intolerance that starts during pregnancy
gestational diabetets
how often should glucose be checked per day with gestational diabetes
4x/day
when is insulin started with gestational diabetes
> 4 abnormal values/day, or noticing trends
what are the complication risks associated with GDM
gestational HTN
preeclampsia
premature delivery
large for gestational age/shoulder dystocia/cesarean delivery
stillbirth
7x increase for developing diabetes later in life
what is postpartum care for GDM
6-12 week postpartum: 75mg load, 2 h postprandial lab draw
encourage weight loss to normal BMI range
breast feeding
increased risk of T2DM
what is an incompetent cervix
inability of the uterine cervix to retain a pregnancy in the second trimester, in the absence of uterine contractions
what are risk factors for incompetent cervix
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
what is the presentation of incompetent cervix in a pt who has had a previous second trimester pregnancy loss with the following:
-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
what is the presentation of incompetent cervix of a patient who has NOT had a previous second trimester pregnancy loss
painless cervical dilation on PE in second trimester
what is the management of cervical insufficiency
cervical cerclage
what are contraindications of cerclage
lethal fetal anomaly
intrauterine infection
active bleeding
preterm labor
ruptured membranes
retal demise
what is a spontaneous rupture of fetal membranes before onset of labor
premature rupture of membranes
what is the most common presentation of premature rupture of membranes
gush of fluid from vagina followed by persistent, uncontrolled leakage
what is premature preterm rupture of membranes (PPRoM)
spontaneous rupture of membranes prior to onset of labor and prior to 37 weeks gestation
-evidence of associated infection
what is the presentation of P-PRoM
gush of fluid followed by uncontrollable leaking or slow steady trickle
how do you diagnose P-PRoM
sterile speculum exam
digital exam should be avoided
what is ferning
when allowed to dry on clean slide, amniotic fluid produces microscopic cystralization in a ‘fern pattern”
what is the management of P-PRoM
US for amniotic fluid volume
indications for immediate delivery should be ruled out first
principle indication for delivery is chorioamnionitis
what is the most dangerous risk of P-PRoM
umbilical cord prolapse
what is shoulder dystocia
obstetrical emergency
anterior shoulder stuck or needs significant manipulation to pass below pubic symphysis
when is shoulder dystocia diagnosed
when shoulders do not deliver shortly after the fetal head
what are risk factors of shoulder dystocia
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
what is the management of shoulder dystocia
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
what are the maneuvers for reducing shoulder dystocia
McRoberts Maneuver (hip hyperflexion) and suprapubic pressure
Wood’s corkscrew:180 degree rotation of poterior shoulder
what do more maneuvers for shoulder dystocia increase
chance of success and increased risk for fetal injury
what are fetal complications of shoulder dystocia
brachial plexus injury
diaphragmatic paralysis
facial nerve injury
horners syndrome
clavicle fracture
hypoxic ischemic encephalopathy (HIE)
death
what are birthing person complications of shoulder dystocia
lacerations: bladder, urethra, vagina, anal sphincter, rectum
lateral femoral cutaneous neuropathy
postpartum hemorrhage
separation of the pubic symphysis
uterine rupture
how quickly does the body need to be delivered with shoulder dysocia
<5min or risk of Hypoxic ischemic encephalopathy (HIE)
what is postpartum hemorrhage
> 1000mL blood loss OR blood loss associated with signs or symptoms of hypovolemia
what do postpartum hemorrhages usually require
transfusion
what are risk factors for postpartum hemorrhage
prolonged labor, augemented labor, rapid labor
history of PPH
over distended uterus
operative delivery
chorioamnionitis
preeclampsia
what is the prevention of postpartum hemorrhage
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
what are the casues of early postpartum hemorrhage
uterine atony
genital tract trauma
retained placental tissue
coagulation disorder
what is the management of uterine atony
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
