Complications of Pregnancy Flashcards
(215 cards)
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
2
Q
What are risk factors for ectopic pregnancy?
A
- Prior ectopic pregnancy - scarring in the tube
- STDs
- PID
- Assisted reproductive technology
- IUD
3
Q
What does the patient complain of with a ectopic pregnancy?
A
- Vaginal bleeding
- Lower abdominal pain
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
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)
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
7
Q
What is a heterotropic pregnancy?
A
- IUP and ectopic pregnancy
- Especially worrisome with ART patients
8
Q
What is pathoneumonic for ectopic pregnancy?
A
Donut sign
9
Q
How is ectopic pregnancy treated?
A
- Methotrexate: folic acid antagonist that is highly effective against rapidly proliferating tissue (ie trophoblasts)
- Laparoscopy
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
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
12
Q
What labs should be checked before administering methotrexate?
A
- CMP
- CBC
13
Q
How is methotrexate dosed?
A
Single dose
Multidose
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
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!
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
17
Q
What is considered an abortion?
`
A
Pregnancy that ends before 20 weeks gestation
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
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
20
Q
What will be seen on ultrasound of a complete abortion?
A
Nothing inside the uterus
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
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
23
Q
What will be seen on ultrasound of a incomplete abortion?
A
Nonviable intrauterine pregnancy
24
Q
What is treatment of a incomplete abortion?
A
- Curettage
- Prostaglandins
- Expectant management
25
What will be found on history and physical of a patient with inevitable abortion?
* Cervical dilation
* Rupture of membranes or vaginal bleeding
26
What will be seen on ultrasound of a patient with inevitable abortion?
* Intrauterine pregnancy
27
What is treatment for inevitable abortion?
* Prostaglandins
* Expectant management
28
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?
Missed abortion
29
What is treatment of a missed abortion?
* Curettage
* Prostaglandins
* Expectant management
30
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?
Threatened abortion
31
What is treatment for threatened abortion?
Pelvic rest
Monitor closely
32
What should Rh negative females receive?
RhoGAM
33
What is the mechanism of action of RhoGAM?
Suppresses the immune response and antibody formation of Rh negative individuals to Rh positive red blood cells
34
What is a molar pregnancy?
Excessively edematous immature placenta
35
What are characteristics of a molar pregnancy?
* Villous stromal edema
* Trophoblast proliferation
* Caused by chromosomally abnormal fertilizations
36
What are risk factors for a molar pregnancy?
* Age 12-20 or older than 30
* History of prior mole
37
What are types of moles?
Partial
Complete
38
What is a complete mole?
* 46, XX or XY with both sets of chromosomes paternal in origin. Chromosomes of ovum absent or inactivated
39
What is the clinical presentation of complete mole?
* 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
40
What is the pathology of complete mole?
No fetal parts
Edematous villi
41
What is a partial mole?
* 69 XXX or XXY occasionally XYY
* Two paternal haploid sets of chromosomes and one maternal haploid set
42
What is the clinical presentation of partial mole?
* Missed abortion
* Small for dates
43
What is the pathology of partial mole?
Fetal parts present
44
How is a molar pregnancy diagnosed?
* 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
45
What is common sequelae of molar pregnancy?
* 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)
46
How is molar pregnancy managed?
* 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
47
What postevacuation surveillance should be done for a molar pregnancy?
* 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
48
Bleeding that occurs with a viable mature fetus (typically considered >24 weeks)
Antepartum bleeding
49
Where can antepartum bleeding come from?
Bladder, rectum, or vagina
50
What is a common cause of antepartum bleeding that can be related to recent sexual activity?
Cervicitis
51
Separation of placenta either partially or totally from its implantation site before delivery
Placental abruption
52
What causes placental abruption? What are categories of placental abruption?
* Hemorrhage into decidua
* Complete or partial
* Concealed or revealed
53
What are symptoms of placental abruption?
* Active bleeding and lots of pain
54
Placental abruption can occur early in pregnancy. What is this considered and what can it be associated with?
Chronic abruption. Elevated AFP. Should monitor closely throughout pregnancy
55
What are risk factors for placental abruption?
* Trauma
* Increasing maternal age
* Hypertension/preeclampsia
* Preterm premature ruptured membranes
* Cigarette smoking
* Cocaine
* Lupus anticoagulant and thrombophilias
* Uterine fibroids
* Recurrent abruption
56
What are clinical findings of placental abruption?
* Sudden onset abdominal pain
* Vaginal bleeding
* Uterine tenderness
57
How is placental abruption diagnosed?
* Diagnosis of exclusion
* US: limited use because negative findings do not exclude abruption
58
What are complications of placental abruption?
* Hypovolemic shock (will need to be delivered ASAP) due to maternal blood loss
* Consumptive coagulopathy (or DIC)
* Acute kidney injury
* Couvelaire uterus
59
How is hypovolemic shock due to placental abruption managed?
Crystalloid and blood infusion
60
What causes consumptive coagulopathy during placental abruption?
* Intravascular activation of clotting
61
How does placental abruption cause acute kidney injury?
* Hypovolemia leads to inadequate renal perfusion and oliguria
* Can be prevented with treatment of hypovolemia
62
What is Couvelaire uterus?
Wide spread extravasation of blood into the uterine musculature beneath the serosa
63
How is placental abruption managed?
* 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
64
Placenta that is implanted somewhere in the lower uterine segment either over or very near the internal cervical os
Placenta previa
65
How is placenta previa classified?
* 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
66
What are risk factors for placenta previa?
* Increasing maternal age
* Increasing parity
* Prior cesarean delivery
* Cigarette smoking
* Elevated MSAFP
67
What are clinical features of placental previa?
* Painless vaginal bleeding, usually after second trimester
68
What causes painless vaginal bleeding in the second trimester with placental previa?
* 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
69
How is placenta previa diagnosed?
* Transvaginal ultrasound
70
What should not be performed until previa is ruled out?!
Digital exam!! Can cause severe hemorrhage
71
What is placental migration in placenta previa?
* 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
72
Low lying placenta is more likely to persist if a patient has a history of what?
* Prior cesarean or hysterotomy scar
73
How is placenta previa managed?
* 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
74
What is placenta accrete syndrome?
* 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
75
What is placenta accreta?
Villi attached to myometrium
76
What is placenta increta?
Villi invade myometrium
77
What is placenta percreta?
Villi penetrate through the myometrium and to or through the serosa
78
What are risk factors for placenta accrete syndromes?
* Associated placenta previa
* Prior cesarean delivery
79
What is the clinical presentation of placenta accrete syndromes?
No symptoms, picked up on US
80
How is placenta accrete syndrome diagnosed?
* Ultrasound
* Delivery
* Pathology: confirms diagnosis and extent of invasion
81
How is placenta accrete syndrome managed?
* 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
82
What is cervical insufficiency?
* Painless cervical dilatation in the second trimester
* Followed by prolapsing and ballooning of membranes into the vagina and ultimately expulsion of immature fetus
83
What are risk factors for cervical insufficiency?
* Prior cervical trauma: dilation and curettage, conization, cauterization of the cervix
* DES exposure
84
How is cervical insufficiency evaluated?
Ultrasound confirms living fetus
Cervical swabs for infection
85
What is expectant management for cervical insufficiency?
* Trendelenburg position
* Pelvic rest
* Delivery?
* Cerclage?
86
What is treatment for cervical insufficiency?
* Usually with next pregnancy
* Cerclage: purse string suture that reinforces weak cervix
87
What are indications for cerclage?
* 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
When is a rescue cerclage performed?
Emergently when cervix dilated, effaced or both
89
When is an elective cerclage performed?
* 12-14 weeks gestation with next pregnancy
90
What are 4 reasons for preterm birth?
* 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
Regular uterine contractions that cause cervical change and ends with delivery of the newborn
Labor
92
What are common causes of preterm labor?
* Multifetal pregnancy
* Intrauterine infection
* Bleeding
* Placental infarction
* Premature cervical dilation
* Cervical insufficiency
* Hydramnios
* Uterine fundal abnormalities
* Fetal anomalies
93
What are risk factors for preterm labor?
* 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
What are signs and symptoms of preterm labor?
* 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
What is work up for preterm labor?
* Fetal fibronectin
* Cervical length
* Sterile vaginal exam
* Sterile speculum exam
* Check urinalysis and culture
96
What is fetal fibronection?
* 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
What cervical length indicates patient is not in labor?
>3 cm
98
What is checked on sterile speculum exam for preterm labor?
* 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
What is medication treatment for preterm labor?
* 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
What corticosteroids are used during preterm labor?
Betamethasone or dexamethasone between 24-34 weeks gestation and up to 36 weeks
101
What is prevention of preterm labor?
* 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
What is given for neuroprotection during preterm labor?
Prevent intracranial hemorrhage with magnesium sulfate given from 24-32 weeks gestation for at least 12 hours
103
What are risk factors for PPROM?
* Genital tract infection
* History of PPROM
* Antepartum bleeding
* Cigarette smoking
104
How is PPROM diagnosed?
* Speculum exam showing pooling
* Nitrazine swab
* Ferning
* Ultrasound with low amniotic fluid index
105
How is PPROM managed?
* 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
What is expectant management for delivery in PPROM until 34 weeks?
* Average latent period = 1 weeks
* Proceed to delivery at 34 weeks
* If patient develops clinical chorioamnionitis, proceed to delivery
107
What are symptoms of chorioamnionitis?
* Fever, uterine tenderness, malodorous vaginal discharge, fetal or maternal tachycardia
108
What is treatment of chorioamnionitis?
Delivery
109
What are complications of PPROM?
* Placental abruption
* Chorioamnionitis
* Sepsis
* Cord prolapse
110
Impairment of fetal growth, preventing the fetus from achieving its individual growth potential
Intrauterine growth restriction
111
What are maternal risk factors for IUGR?
* 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
What are fetal risk factors for IUGR?
* Multiple gestation
* Anomalies
* Infections --> TORCH
113
What are placental factors for IUGR?
* Abruption
* Previa
114
What can IUGR cause relating to fetal morbidity and mortality?
* Stillbirth
* Neonatal encephalopathy
* Cerebral palsy
115
How is IUGR diagnosed?
* Abdominal palpation
* Ultrasound with abdominal circumference and estimated fetal weight
116
How is IUGR managed antepartum?
* 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
Absent or reverse end diastolic flow on umbilical artery doppler velocimetry can indicate what?
* Fetal compromise and need for delivery
118
Intrauterine death of a fetus at any gestational age
Fetal death
119
When is reporting of fetal death typically required?
At >20 weeks or with birthweight >350 g
120
What are causes of fetal death?
* Obstetrical complications
* Plavental abnormalities
* Fetal malformations
* Infection
* Umbilical cord abnormalities
* Hypertensive disorders
* Medical complications
* Undetermined
121
What are risk factors for fetal death?
* AMA
* African american race
* Smoking
* Illicit drug use
* Maternal medical diseases
* ART
* Nulliparity
* Obesity
* Previous adverse pregnancy outcomes
122
How is fetal death diagnosed?
* Usually incidental
* Found during fetal assessment
123
How is fetal death managed?
* 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
How are future pregnancies managed after fetal death?
* 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
What is considered hypertension in pregnancy?
* Elevation of BP >140 mmHg and/or 90 mmHg diastolic, on two occasions at least 6 hours apart
126
What are classifications of maternal hypertension?
Chronic hypertension
Gestational hypertension
Preeclampsia
Preeclampsia superimposed on chronic hypertension
HELLP
127
What is the definition of chronic hypertension?
* Systolic pressure >140 mmHg, diastolic pressures >90 mmHg, or both
* Present before 20 weeks gestation or persists longer than 12 weeks postpartum
128
What are the effects of pregnancy on chronic hypertension?
* BP falls in early pregnancy
* BP rises again in third trimester
* Elevated vascular resistance and reduced intravascular volume
129
What antihypertensives are contraindicated in pregnancy?
* ACE inhibitors
* Angiotensin receptor antagonists
130
What are potential maternal effects of chronic hypertension?
* Superimposed preeclapmsia
* HELLP
* Stroke
* Acute kidney injury
* Heart failure
* Hypertensive cardiomyopathy
* Myocardial infarction
* Placental abruption
* Maternal death
131
What are potential effects of chronic hypertension on the fetus?
* Fetal death
* Growth restriction
* Preterm delivery
* Neonatal death
* Neonatal morbidity
132
What tests should be run on pregnant women with chronic hypertension?
* 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
How is chronic hypertension treated during pregnancy?
* 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
Which medications are recommended for chronic hypertension during pregnancy?
* Labetolol
* Calcium channel blockers
132
What should you be observing during pregnancy for chronic hypertension patients?
* Restricted activity
* Close maternal and fetal monitoring: BP, signs and symptoms of preeclampsia
* Antepartum assessment: NSTs, BPPs, growth ultrasounds
133
BP >140/90 after 20 weeks in previously normotensive women, usually resolves by 12 weeks postpartum
Gestational hypertension
134
What is a risk of gestational hypertension?
Can progress onto preeclampsia in about 50% of cases
135
How is gestational hypertension treated/managed?
Similar to chronic hypertension
136
What is the definition of preeclampsia?
* 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
What can preeclampsia present with in addition to hypertension and proteinuria?
* Thrombocytopenia
* Renal insufficiency
* Liver involvement
* Cerebral symptoms
* Pulmonary edema
* Widely variable in clinical expression
138
What is the pathophysiology of preeclampsia?
* Abnormal trophoblastic invasion
* Endothelial cell activation
* Genetic factors
139
What are risk factors for preeclampsia?
* First pregnancy
* Young women
* Multifetal gestations
* Presence of certain vascular disorders: DM, SLE, renal disease
* Obesity
* African American race
* Chronic hypertension
140
What is eclampsia?
* Occurance of generalized convulsion and/or coma in setting of preeclampsia, with no other neurologic condition
* May occur before, during, or after labor
141
What is preeclampsia superimposed on chronic hypertension?
* 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
What is HELLP?
* Hemolysis
* Elevated liver enzymes
* Low platelet count
* RUQ pain because liver bleeds and distends capsule
143
What does HELLP increase the risk of?
* Hepatic hematoma
* Hepatic rupture
* Indicator of severe preeclampsia and associated with worse outcome
144
How is preeclampsia treated?
* 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
## Footnote
Continue magnesium sulfate after delivery until patient diuresing and BP normalize
145
What medications should be given for prevention of cerebrovascular hemorrhage and hypertensive encephalopathy in preeclampsia (If BP >110 diastolic or 160 systolic)?
* IV labetolol
* IV hydralazine
* PO nifedipine
146
What is pregestational diabetes?
* Diagnosis of diabetes before pregnancy
* Type 1 diabetes: absolute insulin deficiency
* Type 2 diabetes: defective insulin secretion, insulin resistance, or increased glucose production
147
What is gestational diabetes?
Diagnosis of diabetes during pregnancy that is not clearly type 1 or type 2
## Footnote
Many women with gestational diabetes actually have type 2 and were not previously diagnosed
148
How is pregestational diabetes diagnosed?
* 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
What are the recommendations for pregestational diabetes by the IADPSG at prenatal care initiation?
* Fasting plasma glucose >125 mg/dL
* Hemoglobin A1c >6.5%
* Random plasma glucose >200 plus confirmation
150
What is the impact of pregestational diabetes on pregnancy?
* 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
What are fetal complications of pregestational diabetes?
* 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
What are neonatal effects of pregestational diabetes?
* 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
What are maternal effects of pregestational diabetes?
* 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
What are components of preconceptional diabetes care?
* 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
What are aspects of first trimester care for pregestational diabetes?
* 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
What are aspects of second trimester care for pregestational diabetes?
* 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
What are aspects of third trimester care for pregestational diabetes?
* 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
What are aspects of delivery care with pregestational diabetes?
* Insulin drip may be needed
* Vaginal or cesarean delivery as indicated
* If 4500 g<, consider cesarean delivery
159
What are aspects of care for pregestational diabetes postpartum?
* Insulin requirements may need to be decreased by half and monitored closely in subsequent weeks
* Risk of infection increased
160
What are risk factors for gestational diabetes?
* 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
How is gestational diabetes screened and diagnosed?
* 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
How is gestational diabetes managed during pregnancy?
* 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
How is gestational diabetes managed postpartum?
75 g 2 hour glucose tolerance test at 6-12 weeks postpartum
164
What are maternal and fetal effects of gestational diabetes?
* Increase rate of stillbirth, especially with elevated fasting levels
* Fetal macrosomia: increase risk of shoulder dystocia and difficult delivery
* Neonatal hypoglycemia
* Maternal obesity
165
What lifelong effects does gesetational diabetes increase the risk of in the fetus?
* Childhood obesity
* Adult onset obesity
166
What is the increase in rate and number of multifetal births from 1980 to 2009 associated with?
Rise in infertility therapy
167
Twins can result from the fertilization of two ova, called what? Or from single fertilized ovum that divides, called what?
* Dizygotic (like pair of siblings)
* Monozygotic (increased frequency with ART)
168
What is vanishing twin?
* Twin incidence high in first trimester
* One twin vanishes or is lost before second trimester
* Occurs in 10-40% of all twin pregnancies
169
How is multifetal gestation diagnosed?
* Uterine size larger during second trimester than expected
* Ultrasound during first trimester
170
Two separate placentas with a thick dividing membrane and twin peak sign
Dichorionic
171
Thin dividing membrane on ultrasound with T sign
Monochorionic
172
Triangular projection of placental tissue extending a short distance between the layers of the dividing membrane, also referred to as lambda or delta sign
Twin peak sign
173
Right angle relationship between the membranes and placenta and no apparent extension of placenta between dividing membranes
T sign (sign of monochorionic)
174
What are pregnancy complications of multifetal gestations?
* 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
What are fetal complications of monochorionic monoamniotic twins?
* 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
How should monochorionic monoamniotic twins be managed?
* 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
Occurs in monochorionic diamniotic twins due to placental vascular anastomotic connection. Blood transfused from donor twin to recipient sibling
Twin twin transfusion syndrome
178
What are complications for the fetuses of twin twin transfusion syndrome?
* Donor anemic and growth restricted
* Recipient heart failure, polycythemia, and severe hypervolemia
179
What is treatment of twin twin transfusion syndrome?
* Laser ablation of anastomosis is preferred
* Selective reduction can be considered
180
What is recommended for weight gain of multifetal gestations?
* 37-54 lb
181
What is a complication in 50% of twin pregnancies that pessary use has showed some promise in?
* Preterm birth
## Footnote
No evidence for bed rest, prophylactic tocolysis, IM progesterone, vaginal progesterone or cervical cerclage
182
When should dichorionic diamniotic twins be delivered? Monochorionic diamniotic? Monochorionic monoamniotic?
* 38 weeks
* 34-37 weeks
* 32-34 weeks
183
What should you be prepared for in a vaginal delivery of multifetal gestation?
* Any change in fetal position
* Cephalic-cephalic presentation ideal
184
What is recommended for breech presentation of first twin and especially breech-vertex presentation? Also for monoamniotic twins?
* Cesarean delivery
* Monoamniotic twins should be delivered by cesarean to avoid umbilical cord complication
185
When does the fetal thyroid gland begin concentrating iodine and synthesizing thyroid hormone?
12 weeks
Any thyroid need before 12 weeks is provided by mom
186
What are the effects of pregnancy on thyroid hormone?
* 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
What are symptoms of hypothyroidism in pregnancy?
* Cold intolerance
* Muscle cramps
* Constipation
* Fatigue
* Weight gain
* Insomnia
* Hair loss
188
If a patient has symptoms of hypothyroidism in pregnancy, what testing should be obtained?
* TSH
* If abnormal, check Free T4
189
What is the most common cause of hypothyroidism in pregnancy?
Hashimoto's thyroditis
Painless inflammation with progressive enlargement of thyroid gland
190
What is diagnosis and treatment of Hashimoto's thyroiditis?
* Diagnosis: Elevated TSH/Low free T4
* Treatment: Levothyroxine treatment of choice
* Women with hyothyroidism will need to increase levothyroxine during pregnancy
191
What is subclinical hypothyroidism?
* Elevated TSH/normal Free T4
* Studies suggest treatment with levothyroxine decreases risk of neurodevelopmental complications in offspring
192
What is a possible pregnancy outcome due to hypothyroidism?
Congenital hypothyroidism: one of the most common treatable causes of mental retardation
193
What are hallmark symptoms of major depressive disorder in pregnancy?
* Depressed mood
* Anhedonia
## Footnote
10-14% have MDD during pregnancy
25% have increase in symptoms
194
What are risk factors for MDD in pregnancy?
* History of depressive disorders
* Low social support
* Financial disadvantage
* Adolescence
* Unmarried
* Recent adverse life events
* History of abuse
195
When should every patient be screened for depression?
* Initial prenatal visit
* If at risk, screen at every visit
196
What is treatment for MDD in pregnancy?
* Counseling
* SSRIs and SNRIs first line
* If no contraindication and mom stable on current med, continue
197
What is untreated maternal depression associated with?
* Low birth weight
* Long term neurobehavioral issues with infant
198
What is the first oral medication indicated for PPD and is a GABA A receptor positive modulator?
Zubanolone
199
When is zuranolone used?
* 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
Pattern of abuse characterized by tolerance, craving, inability to control use and continued use despite adverse consequences
Substance abuse
201
When should all pregnant patients be screened for use of substances? How should they be screened? What should you do if positive?
* Prenatal visit
* Urine toxicology
* Considered high risk and should be referred to maternal fetal medicine specialist
202
What are affects of substance abuse on pregnancy?
* Preterm labor
* Placental abruption
* Intrauterine growth restriction
* Fetal alcohol syndrome
* Prolonged hospital stay for infant secondary to neonatal abstinence syndrome
203
What can be used in pregnancy for opioid use?
Opioid substitution with methadone, suboxone, subutex (buprenorphine)
* Associated with neonatal withdrawal: methadone crosses placenta, subutex does not cross as readily
204
What pregnancy changes are responsible for increase in UTIs?
* Immunosuppression of pregnancy
* Dilation of ureters
* Compression of bladder by enlarging uterus causes stasis
205
What is asymptomatic bacteriuria?
Positive urine culture in asymptomatic patient
206
What are affects of asymptomatic bacteriuria during pregnancy? When should screening occur?
Impacts:
* Preterm birth
* Low birth weight
* Perinatal morbidity
* Screening with urine culture at initial prenatal visit
207
What is treatment for asymptomatic bacteriuria during pregnancy?
* Macrobid, Keflex
* Repeat urine culture one week after completion of treatment
208
What is treatment for women with persistent infection after 2 courses of treatment for asymptomatic bacteriuria?
Macrobid suppressive therapy
209
How is pyelonephritis diagnosed?
* CVA tenderness
* Fever
* Nausea and vomiting
* Flank pain
210
What are severe complications of pyelonephritis?
* Acute respiratory distress syndrome
* Septic shock
## Footnote
20% of pregnant women develop!
211
What is treatment for pyelonephritis?
* Hospitalization
* IV antibiotics
* Suppression therapy for duration of pregnancy to prevent recurrence
212
