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Women's Health > Complications of Pregnancy > Flashcards

Complications of Pregnancy Flashcards

1
Q

Pregnancy that implants outside of the uterine cavity

A

Ectopic Pregnancy

99% of time is in the fallopian tube, MC ampulla but can occur in ovary, cervix, abdominal wall

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2
Q

What are risk factors for ectopic pregnancy?

A
  • Prior ectopic pregnancy - scarring in the tube
  • STDs
  • PID
  • Assisted reproductive technology
  • IUD
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3
Q

What does the patient complain of with a ectopic pregnancy?

A
  • Vaginal bleeding
  • Lower abdominal pain
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4
Q

What should you expect on physical exam of a patient with ectopic pregnancy?

A
  • Adnexal mass
  • Tenderness on pelvic exam
  • When ectopic is ruptured, patient may be hypotensive, unresponsive, signs of peritoneal irritation
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5
Q

What are lab findings with ectopic pregnancy?

A
  • +bhCG but does not double every 48h as it does with a normal IUP
  • Level of b-hCG at which a pregnancy should be seen in the uterus - discriminatory zone (1500-2000)
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6
Q

What are findings on ultrasound of a patient with ectopic pregnancy?

A
  • Empty uterus or pseudo-gestational sac
  • Adnexal mass or extra uterine pregnancy
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7
Q

What is a heterotropic pregnancy?

A
  • IUP and ectopic pregnancy
  • Especially worrisome with ART patients
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8
Q

What is pathoneumonic for ectopic pregnancy?

A

Donut sign

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9
Q

How is ectopic pregnancy treated?

A
  • Methotrexate: folic acid antagonist that is highly effective against rapidly proliferating tissue (ie trophoblasts)
  • Laparoscopy
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10
Q

What patients can be selected for medical management with methotrexate for ectopic pregnancy?

A
  • Asymptomatic, motivated, compliant
  • Low initial B-hCG (<5000)
  • Small ectopic size (<3.5 cm)
  • Absent fetal cardiac activity
  • No evidence of intraabdominal bleeding
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11
Q

What are contraindications to methotrexate?

A
  • Sensitivity to MTX
  • Evidence of tubal rupture
  • Breast feeding
  • IUP
  • Hepatic, renal, or hematologic dysfunction
  • Peptic ulcer disease
  • Active pulmonary disease
  • Evidence of immunodeficiency
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12
Q

What labs should be checked before administering methotrexate?

A
  • CMP
  • CBC
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13
Q

How is methotrexate dosed?

A

Single dose
Multidose

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14
Q

How is a single dose regimen of methotrexate monitored?

A
  • Check B-hCG on day 1 then 4 then 7
  • Should decrease by 15% from day 4-7
  • Can consider repeating dose of methotrexate if first not effective
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15
Q

What are side effects of methotrexate?

A
  • Separation pain: increasing abdominal pain beginning a few days after therapy. mild and relieved with analgesics
  • Liver
  • Stomatitis
  • Gastroenteritis
  • Bone marrow depression
  • Avoid leafy veggies!
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16
Q

What is the preferred surgical treatment for ectopic pregnancy?

`

A
  • Laparoscopy salpinostomy or salpingectomy (done more often)
  • Salpinostomy has higher subsequent uterine pregnancy and persistent functioning trophoblast
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17
Q

What is considered an abortion?

`

A

Pregnancy that ends before 20 weeks gestation

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18
Q

What are types of abortions?

A
  • Complete abortion: complete expulsion of all products of conception before 20 weeks
  • Incomplete abortion: partial expulsion of some but not all POC before 20 weeks
  • Inevitable abortion: no expulsion of products, but vaginal bleeding and dilation of the cervix such that a viable pregnancy is unlikely
  • Missed abortion: death of embryo or fetus before 20 weeks with complete retention of all POC
  • Threatened abortion: any vaginal bleeding before 20 weeks without dilation of the cervix or expulsion of any POC
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19
Q

What will be found on history and physical exam of a complete abortion?

A
  • History of vaginal bleeding and passage of tissue
  • Cervical os closed
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20
Q

What will be seen on ultrasound of a complete abortion?

A

Nothing inside the uterus

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21
Q

What is treatment of a complete abortion?

A
  • If patient brought POC, send to pathology
  • No medical treatment necessary
  • Follow up important if no evidence of POC because cannot rule out ectopic
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22
Q

What will be found on history and physical of a incomplete abortion?

A
  • Vaginal bleeding and abdominal cramping
  • POC protruding through dilated os or active vaginal bleeding
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23
Q

What will be seen on ultrasound of a incomplete abortion?

A

Nonviable intrauterine pregnancy

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24
Q

What is treatment of a incomplete abortion?

A
  • Curettage
  • Prostaglandins
  • Expectant management
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25
Q

What will be found on history and physical of a patient with inevitable abortion?

A
  • Cervical dilation
  • Rupture of membranes or vaginal bleeding
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26
Q

What will be seen on ultrasound of a patient with inevitable abortion?

A
  • Intrauterine pregnancy
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27
Q

What is treatment for inevitable abortion?

A
  • Prostaglandins
  • Expectant management
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28
Q

On history and physical exam, you see a closed cervical os with the absence of uterine growth and on ultrasound you see a nonviable intrauterine pregnancy. What type of abortion is this?

A

Missed abortion

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29
Q

What is treatment of a missed abortion?

A
  • Curettage
  • Prostaglandins
  • Expectant management
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30
Q

A patient has a closed cervical os and vaginal spotting on history and physical exam before 20 weeks. They have a viable intrauterine pregnancy on ultrasound. What do you suspect they have?

A

Threatened abortion

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31
Q

What is treatment for threatened abortion?

A

Pelvic rest
Monitor closely

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32
Q

What should Rh negative females receive?

A

RhoGAM

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33
Q

What is the mechanism of action of RhoGAM?

A

Suppresses the immune response and antibody formation of Rh negative individuals to Rh positive red blood cells

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34
Q

What is a molar pregnancy?

A

Excessively edematous immature placenta

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35
Q

What are characteristics of a molar pregnancy?

A
  • Villous stromal edema
  • Trophoblast proliferation
  • Caused by chromosomally abnormal fertilizations
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36
Q

What are risk factors for a molar pregnancy?

A
  • Age 12-20 or older than 30
  • History of prior mole
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37
Q

What are types of moles?

A

Partial
Complete

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38
Q

What is a complete mole?

A
  • 46, XX or XY with both sets of chromosomes paternal in origin. Chromosomes of ovum absent or inactivated
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39
Q

What is the clinical presentation of complete mole?

A
  • Vaginal bleeding
  • Large for date: soft consistency of uterus
  • hCG of >100,000
  • Theca lutein cysts present due to overstimulation of lutein elements by hCG
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40
Q

What is the pathology of complete mole?

A

No fetal parts
Edematous villi

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41
Q

What is a partial mole?

A
  • 69 XXX or XXY occasionally XYY
  • Two paternal haploid sets of chromosomes and one maternal haploid set
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42
Q

What is the clinical presentation of partial mole?

A
  • Missed abortion
  • Small for dates
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43
Q

What is the pathology of partial mole?

A

Fetal parts present

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44
Q

How is a molar pregnancy diagnosed?

A
  • Serum hCG
  • Ultrasound: complete mole with echogenic uterine mass with numerous anechoic cystic spaces but without fetus or amnionic sac –>SNOWSTORM APPEARANCE; partial mole: thickened, multicystic placenta along with a fetus or fetal tissue
  • Confirmed with pathology
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45
Q

What is common sequelae of molar pregnancy?

A
  • Thyroid storm: elevated hCG –> elevated TSH which elevates fT4, normalizes after uterine evacuation
  • Hyperemesis gravidarum
  • Preeclampsia/eclampsia (rarely seen due to early diagnosis and evacuation)
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46
Q

How is molar pregnancy managed?

A
  • Preop evaluation of thyroid studies, CBC, CMP, CXR (if it were to become cancer mets common), EKG (if it were to become cancer arrhythmias common), Type and screen
  • Suction dilation and curettage: pitocin as evacuation begins and Rhogam if Rh negative
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47
Q

What postevacuation surveillance should be done for a molar pregnancy?

A
  • Follow B-hCG levels and check 48 h postevacuation then every 1-2 weeks until undetectable
  • Check monthly for 6 months, if remains undetectable ok to allow pregnancy. Should have reliable contraception prior
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48
Q

Bleeding that occurs with a viable mature fetus (typically considered >24 weeks)

A

Antepartum bleeding

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49
Q

Where can antepartum bleeding come from?

A

Bladder, rectum, or vagina

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50
Q

What is a common cause of antepartum bleeding that can be related to recent sexual activity?

A

Cervicitis

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51
Q

Separation of placenta either partially or totally from its implantation site before delivery

A

Placental abruption

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52
Q

What causes placental abruption? What are categories of placental abruption?

A
  • Hemorrhage into decidua
  • Complete or partial
  • Concealed or revealed
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53
Q

What are symptoms of placental abruption?

A
  • Active bleeding and lots of pain
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54
Q

Placental abruption can occur early in pregnancy. What is this considered and what can it be associated with?

A

Chronic abruption. Elevated AFP. Should monitor closely throughout pregnancy

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55
Q

What are risk factors for placental abruption?

A
  • Trauma
  • Increasing maternal age
  • Hypertension/preeclampsia
  • Preterm premature ruptured membranes
  • Cigarette smoking
  • Cocaine
  • Lupus anticoagulant and thrombophilias
  • Uterine fibroids
  • Recurrent abruption
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56
Q

What are clinical findings of placental abruption?

A
  • Sudden onset abdominal pain
  • Vaginal bleeding
  • Uterine tenderness
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57
Q

How is placental abruption diagnosed?

A
  • Diagnosis of exclusion
  • US: limited use because negative findings do not exclude abruption
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58
Q

What are complications of placental abruption?

A
  • Hypovolemic shock (will need to be delivered ASAP) due to maternal blood loss
  • Consumptive coagulopathy (or DIC)
  • Acute kidney injury
  • Couvelaire uterus
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59
Q

How is hypovolemic shock due to placental abruption managed?

A

Crystalloid and blood infusion

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60
Q

What causes consumptive coagulopathy during placental abruption?

A
  • Intravascular activation of clotting
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61
Q

How does placental abruption cause acute kidney injury?

A
  • Hypovolemia leads to inadequate renal perfusion and oliguria
  • Can be prevented with treatment of hypovolemia
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62
Q

What is Couvelaire uterus?

A

Wide spread extravasation of blood into the uterine musculature beneath the serosa

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63
Q

How is placental abruption managed?

A
  • Varies depending on clinical condition, gestational age, and associated hemorrhage
  • Cesarean delivery vs vaginal delivery: cesarean quicker but risk of consumptive coagulopathy causing increased bleeding. If deceased fetus, vaginal delivery preferred
  • Expectant management: should be considered with premature fetus
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64
Q

Placenta that is implanted somewhere in the lower uterine segment either over or very near the internal cervical os

A

Placenta previa

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65
Q

How is placenta previa classified?

A
  • Placenta previa: internal os is covered partially or completely by placenta
  • Low-lying placenta: implantation in lower uterine segment is such that placental edge does not reach internal os and remains outside a 2 cm wide perimeter around the os
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66
Q

What are risk factors for placenta previa?

A
  • Increasing maternal age
  • Increasing parity
  • Prior cesarean delivery
  • Cigarette smoking
  • Elevated MSAFP
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67
Q

What are clinical features of placental previa?

A
  • Painless vaginal bleeding, usually after second trimester
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68
Q

What causes painless vaginal bleeding in the second trimester with placental previa?

A
  • Uterine body remodeling to form lower uterine segment
  • Internal os dilates and some of the placenta inevitably separates
  • Bleeding occurs and myometrium is unable to contract to stop
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69
Q

How is placenta previa diagnosed?

A
  • Transvaginal ultrasound
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70
Q

What should not be performed until previa is ruled out?!

A

Digital exam!! Can cause severe hemorrhage

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71
Q

What is placental migration in placenta previa?

A
  • Movement of the placenta away from the internal os
  • Differential growth of lower and upper uterine segments as pregnancy progresses
  • Greater upper uterine blood flow leads to placental growth towards the fundus
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72
Q

Low lying placenta is more likely to persist if a patient has a history of what?

A
  • Prior cesarean or hysterotomy scar
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73
Q

How is placenta previa managed?

A
  • Consider fetal maturity, labor, and amount of bleeding
  • Preterm fetus: no persistent active vaginal bleeding –> observe
  • Preterm fetus: persistent active vaginal bleeding –> delivery
  • Term fetus: deliver by cesarean section
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74
Q

What is placenta accrete syndrome?

A
  • Abnormally implanted, invasive, or adhered placenta
  • Abnormal firm adherence to myometrium because of partial or total absence of the decidua basalis and imperfect development of fibrinoid layer
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75
Q

What is placenta accreta?

A

Villi attached to myometrium

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76
Q

What is placenta increta?

A

Villi invade myometrium

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77
Q

What is placenta percreta?

A

Villi penetrate through the myometrium and to or through the serosa

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78
Q

What are risk factors for placenta accrete syndromes?

A
  • Associated placenta previa
  • Prior cesarean delivery
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79
Q

What is the clinical presentation of placenta accrete syndromes?

A

No symptoms, picked up on US

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80
Q

How is placenta accrete syndrome diagnosed?

A
  • Ultrasound
  • Delivery
  • Pathology: confirms diagnosis and extent of invasion
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81
Q

How is placenta accrete syndrome managed?

A
  • Planned delivery at tertiary center around 34-36 weeks to avoid emergency cesarean delivery
  • Risk of hysterectomy discussed
  • Preop uterine artery embolization considered
  • Consider leaving placenta in situ to absorb and subsequent hysterectomy when blood loss lessened
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82
Q

What is cervical insufficiency?

A
  • Painless cervical dilatation in the second trimester
  • Followed by prolapsing and ballooning of membranes into the vagina and ultimately expulsion of immature fetus
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83
Q

What are risk factors for cervical insufficiency?

A
  • Prior cervical trauma: dilation and curettage, conization, cauterization of the cervix
  • DES exposure
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84
Q

How is cervical insufficiency evaluated?

A

Ultrasound confirms living fetus
Cervical swabs for infection

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85
Q

What is expectant management for cervical insufficiency?

A
  • Trendelenburg position
  • Pelvic rest
  • Delivery?
  • Cerclage?
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86
Q

What is treatment for cervical insufficiency?

A
  • Usually with next pregnancy
  • Cerclage: purse string suture that reinforces weak cervix
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87
Q

What are indications for cerclage?

A
  • History of recurrent midtrimester losses and diagnosis of cervical insufficiency
  • Women identified by ultrasound to have short cervix (<25 mm)
  • Rescue cerclage = done emergently when cervical incompetence identified in woman with threatened preterm labor
88
Q

When is a rescue cerclage performed?

A

Emergently when cervix dilated, effaced or both

89
Q

When is an elective cerclage performed?

A
  • 12-14 weeks gestation with next pregnancy
90
Q

What are 4 reasons for preterm birth?

A
  • Spontaneous unexplained preterm labor with intact membranes (including cervical insufficiency)
  • Idiopathic preterm premature rupture of membranes (PPROM)
  • Delivery for maternal or fetal indication (preeclampsia)
  • Twins and higher order multifetal births
91
Q

Regular uterine contractions that cause cervical change and ends with delivery of the newborn

A

Labor

92
Q

What are common causes of preterm labor?

A
  • Multifetal pregnancy
  • Intrauterine infection
  • Bleeding
  • Placental infarction
  • Premature cervical dilation
  • Cervical insufficiency
  • Hydramnios
  • Uterine fundal abnormalities
  • Fetal anomalies
93
Q

What are risk factors for preterm labor?

A
  • Threatened abortion during this pregnancy
  • Cigarette smoking
  • Inadequate weight gain during pregnancy
  • Illicit drug use
  • Depression, anxiety, chronic stress
  • Short interval between pregnancies
  • Prior preterm birth
  • Periodontal disease
  • Infection
94
Q

What are signs and symptoms of preterm labor?

A
  • Mild, menstrual-like cramps
  • Constant low backache
  • Painless or painful uterine contractions
  • Increase in vaginal discharge
  • Cervical change: dilation and effacement
  • Effacement of cervix
95
Q

What is work up for preterm labor?

A
  • Fetal fibronectin
  • Cervical length
  • Sterile vaginal exam
  • Sterile speculum exam
  • Check urinalysis and culture
96
Q

What is fetal fibronection?

A
  • Glycoprotein detected vaginally in labor that reflects stromal remodeling of cervix
  • Can perform swab between 24-34 weeks
  • Should not perform if had sex or anything in vagina within last 24 hours
  • If negative <1% chance will go into labor in next 2 weeks
97
Q

What cervical length indicates patient is not in labor?

A

> 3 cm

98
Q

What is checked on sterile speculum exam for preterm labor?

A
  • Vaginal cultures for gonorrhea, chlamydia, candidiasis, group B strep
  • Check nitrazine: normal vaginal pH-4.5-5.5, amniotic fluid pH 7-7.5, evaluates pH of vaginal fluid and turns blue if amniotic fluid present
99
Q

What is medication treatment for preterm labor?

A
  • Tocolysis: stopping contractions, may delay delivery 48 hours
  • Magnesium sulfate
  • Calcium channel blockers: nifedipine
  • Prostaglandin synthetase inhibitors: indomethacin, not used past 2nd trimester because can close ductus arteriosus
  • B-agonists: terbutaline
  • Corticosteroids for fetal lung maturation
100
Q

What corticosteroids are used during preterm labor?

A

Betamethasone or dexamethasone between 24-34 weeks gestation and up to 36 weeks

101
Q

What is prevention of preterm labor?

A
  • Cervical cerclage, if cervical length <25 mm
  • Progesterone therapy IM if history of preterm birth (inj at 16 weeks til 36 weeks) or vaginal for women with shortened cervix
102
Q

What is given for neuroprotection during preterm labor?

A

Prevent intracranial hemorrhage with magnesium sulfate given from 24-32 weeks gestation for at least 12 hours

103
Q

What are risk factors for PPROM?

A
  • Genital tract infection
  • History of PPROM
  • Antepartum bleeding
  • Cigarette smoking
104
Q

How is PPROM diagnosed?

A
  • Speculum exam showing pooling
  • Nitrazine swab
  • Ferning
  • Ultrasound with low amniotic fluid index
105
Q

How is PPROM managed?

A
  • Hospitalization for remainder of pregnancy
  • Corticosteroids for lung maturity
  • Tocolysis: utilized to administer corticosteroids and transport patient
  • Antibiotics for latency (extends time period befor delivery): ampicillin for 48 hours then amoxicillin for 5 days, erythromycin IV for 48 hours then erythromycin for 5 days
106
Q

What is expectant management for delivery in PPROM until 34 weeks?

A
  • Average latent period = 1 weeks
  • Proceed to delivery at 34 weeks
  • If patient develops clinical chorioamnionitis, proceed to delivery
107
Q

What are symptoms of chorioamnionitis?

A
  • Fever, uterine tenderness, malodorous vaginal discharge, fetal or maternal tachycardia
108
Q

What is treatment of chorioamnionitis?

A

Delivery

109
Q

What are complications of PPROM?

A
  • Placental abruption
  • Chorioamnionitis
  • Sepsis
  • Cord prolapse
110
Q

Impairment of fetal growth, preventing the fetus from achieving its individual growth potential

A

Intrauterine growth restriction

111
Q

What are maternal risk factors for IUGR?

A
  • Smoking
  • Alcohol
  • Low pre-pregnancy weight
  • Poor weight gain
  • Malnutrition
  • DM
  • SLE
  • Chronic hypertension
  • Preeclampsia
  • Medications: corticosteroids, methotrexate, antiseizure agents
  • Low maternal socioeconomic status
112
Q

What are fetal risk factors for IUGR?

A
  • Multiple gestation
  • Anomalies
  • Infections –> TORCH
113
Q

What are placental factors for IUGR?

A
  • Abruption
  • Previa
114
Q

What can IUGR cause relating to fetal morbidity and mortality?

A
  • Stillbirth
  • Neonatal encephalopathy
  • Cerebral palsy
115
Q

How is IUGR diagnosed?

A
  • Abdominal palpation
  • Ultrasound with abdominal circumference and estimated fetal weight
116
Q

How is IUGR managed antepartum?

A
  • Amniotic fluid volume measurement weekly after 34 weeks
  • Umbilical artery doppler velocimetry beginning around 28 weeks and repeating every 1-2 weeks
  • Growth ultrasound: repeat growth measurements every 3-4 weeks after 18 weeks gestation
  • Fetal surveillance with biophysical profile and NST
  • Plan for delivery at 38 weeks unless fetal compromise
117
Q

Absent or reverse end diastolic flow on umbilical artery doppler velocimetry can indicate what?

A
  • Fetal compromise and need for delivery
118
Q

Intrauterine death of a fetus at any gestational age

A

Fetal death

119
Q

When is reporting of fetal death typically required?

A

At >20 weeks or with birthweight >350 g

120
Q

What are causes of fetal death?

A
  • Obstetrical complications
  • Plavental abnormalities
  • Fetal malformations
  • Infection
  • Umbilical cord abnormalities
  • Hypertensive disorders
  • Medical complications
  • Undetermined
121
Q

What are risk factors for fetal death?

A
  • AMA
  • African american race
  • Smoking
  • Illicit drug use
  • Maternal medical diseases
  • ART
  • Nulliparity
  • Obesity
  • Previous adverse pregnancy outcomes
122
Q

How is fetal death diagnosed?

A
  • Usually incidental
  • Found during fetal assessment
123
Q

How is fetal death managed?

A
  • Plan for delivery
  • Evaluate fetus after delivery - optional for parents, recommend autopsy, karyotyping, examination of placenta, cord, and membranes, cultures to test for infection
124
Q

How are future pregnancies managed after fetal death?

A
  • Control modifiable risk factors
  • Offer routine genetic testing
  • Obtain anatomy scan at 18 weeks and then serial growth ultrasounds beginning at 28 weeks
  • Begin antepartum surveillance at 32 weeks or 1-2 weeks prior to stillbirth
  • Elective induction or cesarean at 39 weeks
125
Q

What is considered hypertension in pregnancy?

A
  • Elevation of BP >140 mmHg and/or 90 mmHg diastolic, on two occasions at least 6 hours apart
126
Q

What are classifications of maternal hypertension?

A

Chronic hypertension
Gestational hypertension
Preeclampsia
Preeclampsia superimposed on chronic hypertension
HELLP

127
Q

What is the definition of chronic hypertension?

A
  • Systolic pressure >140 mmHg, diastolic pressures >90 mmHg, or both
  • Present before 20 weeks gestation or persists longer than 12 weeks postpartum
128
Q

What are the effects of pregnancy on chronic hypertension?

A
  • BP falls in early pregnancy
  • BP rises again in third trimester
  • Elevated vascular resistance and reduced intravascular volume
129
Q

What antihypertensives are contraindicated in pregnancy?

A
  • ACE inhibitors
  • Angiotensin receptor antagonists
130
Q

What are potential maternal effects of chronic hypertension?

A
  • Superimposed preeclapmsia
  • HELLP
  • Stroke
  • Acute kidney injury
  • Heart failure
  • Hypertensive cardiomyopathy
  • Myocardial infarction
  • Placental abruption
  • Maternal death
131
Q

What are potential effects of chronic hypertension on the fetus?

A
  • Fetal death
  • Growth restriction
  • Preterm delivery
  • Neonatal death
  • Neonatal morbidity
132
Q

What tests should be run on pregnant women with chronic hypertension?

A
  • Electrocardiogram
  • Echocardiogram if have had it long term
  • Baseline labs: CBC (Hgb, Plts)
  • Renal function (Cr, UA, Albumin)
  • Liver function (AST, ALT, ALP, LD)
  • Coagulation (PT, PTT, INR, Fibrinogen)
  • Urine protein (dispstick, 24 hour)
132
Q

How is chronic hypertension treated during pregnancy?

A
  • Taper or discontinue meds for women with blood pressures less than 120/80 in 1st trimester
  • Reinstate or initiate therapy for persistent diastolic pressures >95 mmHg, systolic presures >150 mmHg, or signs of hypertensive end organ damage
  • 81-162 mg aspirin (studies show reduces risk of superimposed preeclampsia)
  • Delivery at 37-39 weeks if without complications
132
Q

Which medications are recommended for chronic hypertension during pregnancy?

A
  • Labetolol
  • Calcium channel blockers
132
Q

What should you be observing during pregnancy for chronic hypertension patients?

A
  • Restricted activity
  • Close maternal and fetal monitoring: BP, signs and symptoms of preeclampsia
  • Antepartum assessment: NSTs, BPPs, growth ultrasounds
133
Q

BP >140/90 after 20 weeks in previously normotensive women, usually resolves by 12 weeks postpartum

A

Gestational hypertension

134
Q

What is a risk of gestational hypertension?

A

Can progress onto preeclampsia in about 50% of cases

135
Q

How is gestational hypertension treated/managed?

A

Similar to chronic hypertension

136
Q

What is the definition of preeclampsia?

A
  • New onset of hypertension and proteinuria after 20 weeks gestation
  • Systolic blood pressure >140 mmHg or diastolic blood pressure >90
  • Proteinuria of .3 or greater in a 24 hour urine specimen
137
Q

What can preeclampsia present with in addition to hypertension and proteinuria?

A
  • Thrombocytopenia
  • Renal insufficiency
  • Liver involvement
  • Cerebral symptoms
  • Pulmonary edema
  • Widely variable in clinical expression
138
Q

What is the pathophysiology of preeclampsia?

A
  • Abnormal trophoblastic invasion
  • Endothelial cell activation
  • Genetic factors
139
Q

What are risk factors for preeclampsia?

A
  • First pregnancy
  • Young women
  • Multifetal gestations
  • Presence of certain vascular disorders: DM, SLE, renal disease
  • Obesity
  • African American race
  • Chronic hypertension
140
Q

What is eclampsia?

A
  • Occurance of generalized convulsion and/or coma in setting of preeclampsia, with no other neurologic condition
  • May occur before, during, or after labor
141
Q

What is preeclampsia superimposed on chronic hypertension?

A
  • Preexisting hypertension with additional signs/symptoms
  • New onset proteinuria
  • Sudden increase in blood pressure
  • Development of any component of HELLP syndrome or symptoms of severe preeclampsia
142
Q

What is HELLP?

A
  • Hemolysis
  • Elevated liver enzymes
  • Low platelet count
  • RUQ pain because liver bleeds and distends capsule
143
Q

What does HELLP increase the risk of?

A
  • Hepatic hematoma
  • Hepatic rupture
  • Indicator of severe preeclampsia and associated with worse outcome
144
Q

How is preeclampsia treated?

A
  • Severe preeclampsia –> Delivery depending on gestational age
  • Mild preeclampsia monitored closely with hospitalization and expectant management
  • Diastolic BP >110 or systolic BP >160 is indication for antihypertensive to prevent cerebrovascular hemorrhage and hypertensive encephalopathy
  • Magnesium sulfate (anticonvulsant that avoids CNS depression)
  • Corticosteroids for fetal lung maturation between 24-34 weeks

Continue magnesium sulfate after delivery until patient diuresing and BP normalize

145
Q

What medications should be given for prevention of cerebrovascular hemorrhage and hypertensive encephalopathy in preeclampsia (If BP >110 diastolic or 160 systolic)?

A
  • IV labetolol
  • IV hydralazine
  • PO nifedipine
146
Q

What is pregestational diabetes?

A
  • Diagnosis of diabetes before pregnancy
  • Type 1 diabetes: absolute insulin deficiency
  • Type 2 diabetes: defective insulin secretion, insulin resistance, or increased glucose production
147
Q

What is gestational diabetes?

A

Diagnosis of diabetes during pregnancy that is not clearly type 1 or type 2

Many women with gestational diabetes actually have type 2 and were not previously diagnosed

148
Q

How is pregestational diabetes diagnosed?

A
  • High plasma glucose levels
  • Glucosuria
  • Ketoacidosis
  • Random plasma glucose >200 mg/dL plus symptoms such as polydipsia, polyuria, and unexplained weight loss
  • Fasting glucose >125 mg/dL
149
Q

What are the recommendations for pregestational diabetes by the IADPSG at prenatal care initiation?

A
  • Fasting plasma glucose >125 mg/dL
  • Hemoglobin A1c >6.5%
  • Random plasma glucose >200 plus confirmation
150
Q

What is the impact of pregestational diabetes on pregnancy?

A
  • Outcomes directly related to glycemic control
  • Hgb A1c >12 or preprandial glucose >120 mg/dL at increased risk
  • Outcomes worsened by cardiovascular or renal disease
151
Q

What are fetal complications of pregestational diabetes?

A
  • Spontaneous abortion
  • Preterm delivery
  • Malformations (diabetes, cardiac defects, caudal regression sequence)
  • Altered fetal growth (IUGR and macrosomia): BG>130 mg/dL increases risk
  • Unexplained fetal demise
  • Hydramnios
152
Q

What are neonatal effects of pregestational diabetes?

A
  • Respiratory distress syndrome
  • Hypoglycemia- insulin does not cross placenta leading to rapid drop in plasma glucose after delivery (infant over produces insulin)
  • Hypocalcemia
  • Hyperbilirubinemia and polycythemia
  • Cardiomyopathy
  • Long term cognitive defects
153
Q

What are maternal effects of pregestational diabetes?

A
  • Preeclampsia
  • Preterm delivery
  • Diabetic nephropathy
  • Diabetic retinopathy
  • Diabetic neuropathy
  • Diabetic ketoacidosis: associated with hyperemesis gravidarum, B-mimetic drugs for tocolysis, infection, and corticosteroids and often in Type 1 DM
154
Q

What are components of preconceptional diabetes care?

A
  • Optimal glucose control: preprandial 70-100, peak postprandial 100-129, mean daily <110, HgbA1c: <7
  • Should be evaluated for retinopathy and nephropathy
  • Folic acid 400 ug/day orally
155
Q

What are aspects of first trimester care for pregestational diabetes?

A
  • Careful glucose monitoring: fasting <95, 1 hr postprandial <140, Hgb A1C <6
  • Optimal management with insulin
  • Nutritional counseling, opthalmologist, dietician, etc.
  • Consider maternal echocardiogram, EKG
  • 81 mg of aspirin (risk factor for preeclampsia)
  • Frequent visits and high risk consult
  • 24 hour urine
156
Q

What are aspects of second trimester care for pregestational diabetes?

A
  • Targeted ultrasound between 18-20 weeks
  • Fetal echocardiogram between 20-24 weeks
  • Continued glycemic control: if on oral agents and not euglycemic, consider insulin; if on insulin and not euglycemic, consider insulin pump
157
Q

What are aspects of third trimester care for pregestational diabetes?

A
  • Initiate antepartum testing at 32-34 weeks and earlier if uncontrolled diabetes or nephropathy, NSTs with AFIs weekly, growth monitored every 4 weeks
  • Delivery planned for 36-40 weeks based on glucose control, associated maternal vasulopathy, nephropathy, or prior stillbirth
158
Q

What are aspects of delivery care with pregestational diabetes?

A
  • Insulin drip may be needed
  • Vaginal or cesarean delivery as indicated
  • If 4500 g<, consider cesarean delivery
159
Q

What are aspects of care for pregestational diabetes postpartum?

A
  • Insulin requirements may need to be decreased by half and monitored closely in subsequent weeks
  • Risk of infection increased
160
Q

What are risk factors for gestational diabetes?

A
  • Ethnicity: hispanic, african american, native american, asian, or pacific islander women
  • Obesity
  • Increasing age
  • Sedentary lifestyle

Increases risk for: overt diabetes and metabolic syndrome

161
Q

How is gestational diabetes screened and diagnosed?

A
  • 50 g 1 hour oral glucose challenge test between 24-28 weeks (cut off of 135-140 mg/dL)
  • Test women with severe obesity, strong family history of diabetes, and previous history of gestational diabetes or macrosomic infant as early as possible
  • If positive 1 hour glucose challenge test proceed to 100 g 3 hour glucose tolerance test, fasting
  • Must have 2 abnormal 3 hour glucose tolerance test results to receive diagnosis
162
Q

How is gestational diabetes managed during pregnancy?

A
  • Monitor blood glucose with goal fasting <95 and 2 h postprandial <120
  • Diet modification and nutritional counseling (40% carbs, 20% protein, 40% fat)
  • Moderate exercise
  • Insulin (does not cross placenta)
  • Oral hypoglycemics (option before insulin, no evidence of increased outcomes)
  • Antepartum surveillance
  • Elective cesarean if fetus >4500 g (increased risk of shoulder dystocia)
163
Q

How is gestational diabetes managed postpartum?

A

75 g 2 hour glucose tolerance test at 6-12 weeks postpartum

164
Q

What are maternal and fetal effects of gestational diabetes?

A
  • Increase rate of stillbirth, especially with elevated fasting levels
  • Fetal macrosomia: increase risk of shoulder dystocia and difficult delivery
  • Neonatal hypoglycemia
  • Maternal obesity
165
Q

What lifelong effects does gesetational diabetes increase the risk of in the fetus?

A
  • Childhood obesity
  • Adult onset obesity
166
Q

What is the increase in rate and number of multifetal births from 1980 to 2009 associated with?

A

Rise in infertility therapy

167
Q

Twins can result from the fertilization of two ova, called what? Or from single fertilized ovum that divides, called what?

A
  • Dizygotic (like pair of siblings)
  • Monozygotic (increased frequency with ART)
168
Q

What is vanishing twin?

A
  • Twin incidence high in first trimester
  • One twin vanishes or is lost before second trimester
  • Occurs in 10-40% of all twin pregnancies
169
Q

How is multifetal gestation diagnosed?

A
  • Uterine size larger during second trimester than expected
  • Ultrasound during first trimester
170
Q

Two separate placentas with a thick dividing membrane and twin peak sign

A

Dichorionic

171
Q

Thin dividing membrane on ultrasound with T sign

A

Monochorionic

172
Q

Triangular projection of placental tissue extending a short distance between the layers of the dividing membrane, also referred to as lambda or delta sign

A

Twin peak sign

173
Q

Right angle relationship between the membranes and placenta and no apparent extension of placenta between dividing membranes

A

T sign (sign of monochorionic)

174
Q

What are pregnancy complications of multifetal gestations?

A
  • Spontaneous abortion
  • Congenital malformation
  • Low birthweight (related to PTL –> average gestational age at delivery is 36 weeks)
  • Hypertension (recommend 81 mg aspirin at 12 weeks)
  • Preterm birth
  • Size discordance: weight discordance >20% most accurately predicts adverse outcomes, more likely to fail a vaginal delivery if baby A is smaller than baby B
175
Q

What are fetal complications of monochorionic monoamniotic twins?

A
  • High fetal death rate due to cord entanglement, congenital anomalies, preterm birth, and twin twin transfusion syndrome
  • Increased risk of congenital cardiac disease –> fetal echo
176
Q

How should monochorionic monoamniotic twins be managed?

A
  • Antepartum testing at 24-28 weeks
  • Corticosteroids around 24-28 weeks
  • Cesarean delivery at 32-34 weeks (unless fetal testing not reassuring before this time)
177
Q

Occurs in monochorionic diamniotic twins due to placental vascular anastomotic connection. Blood transfused from donor twin to recipient sibling

A

Twin twin transfusion syndrome

178
Q

What are complications for the fetuses of twin twin transfusion syndrome?

A
  • Donor anemic and growth restricted
  • Recipient heart failure, polycythemia, and severe hypervolemia
179
Q

What is treatment of twin twin transfusion syndrome?

A
  • Laser ablation of anastomosis is preferred
  • Selective reduction can be considered
180
Q

What is recommended for weight gain of multifetal gestations?

A
  • 37-54 lb
181
Q

What is a complication in 50% of twin pregnancies that pessary use has showed some promise in?

A
  • Preterm birth

No evidence for bed rest, prophylactic tocolysis, IM progesterone, vaginal progesterone or cervical cerclage

182
Q

When should dichorionic diamniotic twins be delivered? Monochorionic diamniotic? Monochorionic monoamniotic?

A
  • 38 weeks
  • 34-37 weeks
  • 32-34 weeks
183
Q

What should you be prepared for in a vaginal delivery of multifetal gestation?

A
  • Any change in fetal position
  • Cephalic-cephalic presentation ideal
184
Q

What is recommended for breech presentation of first twin and especially breech-vertex presentation? Also for monoamniotic twins?

A
  • Cesarean delivery
  • Monoamniotic twins should be delivered by cesarean to avoid umbilical cord complication
185
Q

When does the fetal thyroid gland begin concentrating iodine and synthesizing thyroid hormone?

A

12 weeks
Any thyroid need before 12 weeks is provided by mom

186
Q

What are the effects of pregnancy on thyroid hormone?

A
  • Increase thyroid binding globulin due to estrogen –> increase in T3/T4 production
  • Stimulation of TSH by hCG –> increase in total T3 and T4 and decrease in TSH
  • May appear to have subclinical hyperthyroidism which is normal
187
Q

What are symptoms of hypothyroidism in pregnancy?

A
  • Cold intolerance
  • Muscle cramps
  • Constipation
  • Fatigue
  • Weight gain
  • Insomnia
  • Hair loss
188
Q

If a patient has symptoms of hypothyroidism in pregnancy, what testing should be obtained?

A
  • TSH
  • If abnormal, check Free T4
189
Q

What is the most common cause of hypothyroidism in pregnancy?

A

Hashimoto’s thyroditis
Painless inflammation with progressive enlargement of thyroid gland

190
Q

What is diagnosis and treatment of Hashimoto’s thyroiditis?

A
  • Diagnosis: Elevated TSH/Low free T4
  • Treatment: Levothyroxine treatment of choice
  • Women with hyothyroidism will need to increase levothyroxine during pregnancy
191
Q

What is subclinical hypothyroidism?

A
  • Elevated TSH/normal Free T4
  • Studies suggest treatment with levothyroxine decreases risk of neurodevelopmental complications in offspring
192
Q

What is a possible pregnancy outcome due to hypothyroidism?

A

Congenital hypothyroidism: one of the most common treatable causes of mental retardation

193
Q

What are hallmark symptoms of major depressive disorder in pregnancy?

A
  • Depressed mood
  • Anhedonia

10-14% have MDD during pregnancy
25% have increase in symptoms

194
Q

What are risk factors for MDD in pregnancy?

A
  • History of depressive disorders
  • Low social support
  • Financial disadvantage
  • Adolescence
  • Unmarried
  • Recent adverse life events
  • History of abuse
195
Q

When should every patient be screened for depression?

A
  • Initial prenatal visit
  • If at risk, screen at every visit
196
Q

What is treatment for MDD in pregnancy?

A
  • Counseling
  • SSRIs and SNRIs first line
  • If no contraindication and mom stable on current med, continue
197
Q

What is untreated maternal depression associated with?

A
  • Low birth weight
  • Long term neurobehavioral issues with infant
198
Q

What is the first oral medication indicated for PPD and is a GABA A receptor positive modulator?

A

Zubanolone

199
Q

When is zuranolone used?

A
  • Severe PPD with onset in third trimester or within 4 weeks postpartum
  • Treatment daily for 14 days
  • Can be used as adjunct with SSRI or SNRI
200
Q

Pattern of abuse characterized by tolerance, craving, inability to control use and continued use despite adverse consequences

A

Substance abuse

201
Q

When should all pregnant patients be screened for use of substances? How should they be screened? What should you do if positive?

A
  • Prenatal visit
  • Urine toxicology
  • Considered high risk and should be referred to maternal fetal medicine specialist
202
Q

What are affects of substance abuse on pregnancy?

A
  • Preterm labor
  • Placental abruption
  • Intrauterine growth restriction
  • Fetal alcohol syndrome
  • Prolonged hospital stay for infant secondary to neonatal abstinence syndrome
203
Q

What can be used in pregnancy for opioid use?

A

Opioid substitution with methadone, suboxone, subutex (buprenorphine)
* Associated with neonatal withdrawal: methadone crosses placenta, subutex does not cross as readily

204
Q

What pregnancy changes are responsible for increase in UTIs?

A
  • Immunosuppression of pregnancy
  • Dilation of ureters
  • Compression of bladder by enlarging uterus causes stasis
205
Q

What is asymptomatic bacteriuria?

A

Positive urine culture in asymptomatic patient

206
Q

What are affects of asymptomatic bacteriuria during pregnancy? When should screening occur?

A

Impacts:
* Preterm birth
* Low birth weight
* Perinatal morbidity
* Screening with urine culture at initial prenatal visit

207
Q

What is treatment for asymptomatic bacteriuria during pregnancy?

A
  • Macrobid, Keflex
  • Repeat urine culture one week after completion of treatment
208
Q

What is treatment for women with persistent infection after 2 courses of treatment for asymptomatic bacteriuria?

A

Macrobid suppressive therapy

209
Q

How is pyelonephritis diagnosed?

A
  • CVA tenderness
  • Fever
  • Nausea and vomiting
  • Flank pain
210
Q

What are severe complications of pyelonephritis?

A
  • Acute respiratory distress syndrome
  • Septic shock

20% of pregnant women develop!

211
Q

What is treatment for pyelonephritis?

A
  • Hospitalization
  • IV antibiotics
  • Suppression therapy for duration of pregnancy to prevent recurrence
212
Q
A

Women's Health (5 decks)

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