Complications of Pregnancy Flashcards
1st Trimester Screen
- Screening test for genetic defects and fetal abnormalities
- Includes lab test and nuchal translucency ultrasound
- Timing 11w0d to 13w6d
Timing of 1st Trimester Screen
11w0d to 13w6d
Benefit of early US
- Detection of spontaneous abortions
- Anatomic defects
- Enlarged nuchal fold can also be found in cardiac defects (37% detection)
- Cystic Hygroma- defect of lymphatics- build up fluid in nuchal fold
Quad Marker Screen
- Screening test for genetic defects and some anatomic defects
- Strictly lab testing
- Labs- hCG, inhibin, Estriol, alpha fetoprotein (AFP)
Quad Marker Screen timing
15w0d to 22w6d ideally 15-18wks
Anatomy Ultrasound
- Standard 20 week ultrasound evaluating most fetal anatomy
Anatomy that can be visualized during an anatomy US
- Head
- Face/Neck
- Chest/Heart
- Abdomen
- Spine
- Extremities
- Genitalia
- Umbilical Cord
- Placenta
- Maternal Anatomy
Spontaneous Abortion (pregnancy loss or miscarriage) definition
Defined as nonviable intrauterine pregnancy prior to 20 weeks
15% of women experience one in their life
Spontaneous Abortion
Management of Spontaneous Abortions
- Complete Ab- Urine pregnancy test in 2 weeks
- Incomplete Ab- Evaluate bleeding, urgency to complete abortion
- May require D&C or medication, blood transfusion
- Inevitable Ab- Expectant, medical, surgical management
- Threatened Ab- 15-20% of pregnancies- 90% of pregnancies in this situation are not lost if fetal heart rate seen between 7-11 wks
Typically occurs due to incomplete abortion
Hemorrhage
Complications of Spontaneous Abortions: infection
- Will require D&C
- IV antibiotics
- Called Septic abortion
Recurrent Pregnancy Loss
Defined as 2 or more consecutive ultrasound-confirmed pregnancies lost.
3 consecutive pregnancy losses (do not need to be intrauterine)
Miscarriage risks per number of pregnancies
First pregnancy- miscarriage risk 11-13%
After 1 miscarriage- miscarriage risk 14-21%
After 2 miscarriages- 24-29%
After 3 miscarriages- 31-33%
Causes of recurrent Pregnancy Loss
- Advanced maternal age
- Uterine anomalies
- Fibroids, uterine septum, polyps, adenomyosis,
intrauterine adhesions, - Clotting issues
- Antiphospholipid antibody syndrome,
thrombophilias - Endocrine disorders
- Diabetes, Thyroid, PCOS, Luteal phase defect
- Autoimmune disorders
- Genetic defects
- Aneuploidy, chromosomal rearrangements
- External factors
- Environmental, chemicals
- 50% of the time, no cause is found
Workup for suspicion of recurrent pregnancy loss
Low hanging fruit first
A1C, TSH,
Antiphospholipid antibody testing
- B2 microglobulin, Anticardiolipin antibody, lupus anticoagulant
Uterine evaluation
- Hysteroscopy, saline infusion ultrasound, hysterosalpingogram, MRI
Genetic evaluation
Fertility specialist referral
Ectopic Pregnancy
- Definition- Extrauterine pregnancy
- Most in the fallopian tube, but also ovary, c-section scar, abdomen, etc.
- Rarely heterotopic ectopic includes intrauterine and ectopic pregnancy (IVF more common)
Clinical presentation of ectopic pregnancy
Most commonly vaginal bleeding and abdominal pain
- Some are found when the patient is asymptomatic
- Positive hCG, Ultrasound shows no intrauterine pregnancy
- Sometimes shows a pseudo-sac, but no yolk sac or fetal pole
- hCG over 3500 should be able to see an intrauterine pregnancy with fetal pole (not with twins)
- Presents either ruptured or unruptured
Risk factors for ectopic pregnancy
- Previous adnexal surgery, IUD in place, IVF, hx of PID, endometriosis, fibroids
Diagnosis of ectopic pregnancy
- Ultrasound (note- ovarian cyst is not diagnostic)
- hCG
- Clinical evaluation
- US with adnexal pregnancy with FHR
- Visualization during surgery
Ectopic Pregnancy- Management
- Takes more time, not a guarantee it will work
- Minimally invasive
- Methotrexate- folic acid antagonist- Give in ED
and follow hCG levels to 0 - Only specific candidates apply (Size of mass,
hCG level, kidney/liver function) - Surgical management
Ectopic Pregnancy- Surgical Management
- Quick and definitive
- Laparoscopy, can consider evacuating uterus
as well - Will likely loose tube
- Complications of surgery
Molar Pregnancy
Definition- “Hydatidiform Mole” abnormal pregnancy caused by aberrant
fertilization. Characterized by abnormal chorionic villi
Complete vs. partial mole
Complete mole- 2 sperm in an empty egg. Higher hCG (300,000), 80% this type, cancer risk, increased theca lutein cysts, hyperemesis
Partial mole- 2 sperm + normal egg. Lower hCG, can have a fetus with heartbeat. Become hydropic. Misdiagnosed as abortion at times
This can turn into neoplasia
“Hydatidiform Mole” / molar pregnancy
Molar Pregnancy- Clinical presentation
Missed period, positive pregnancy test, nausea and vomiting, bleeding, hyperemesis
Normally found on first ultrasound in pregnancy (Snow storm appearance). Look
for ovarian cysts, hyperthyroidism (beta subunit of hCG)
Heavy bleeding
Only incidence where someone can get Preeclampsia prior to 20 wks
Molar Pregnancy eval and diagnosis
Evaluation- History and physical, ultrasound, hCG, type and screen, CBC, manage
clinical symptoms.
Diagnosis- Ultrasound diagnosis taking in clinical situation with hCG is suggestive,
but diagnosis is histologic
Treatment of a molar pregnancy
Treatment- Uterine evacuation, need to follow hCG quants to 0 (need contraception
during monitoring) Wise to put blood on hold
Complete mole- GTN 15-20% get to 0, then monthly for 3 months
Partial mole- GTN 1-5%. Get to 0, then one more hCG in 1 month
Gestational Trophoblastic Disease
Includes a heterogenous group of related
lesions arising from abnormal proliferation of
trophoblasts of the placenta
Gestational trophoblastic disease- benign non-neoplastic lesions including moles with potential to become cancer
Gestational trophoblastic neoplasia- Gestational neoplasms
- Choriocarcinoma, Placental site trophoblastic
tumor, invasive mole
Gestational Trophoblastic Disease clinical presentation
After pregnancy (molar) with persistently elevated hCG
- AUB, Pulmonary, Pelvic Pain,
- Metastases- Pulmonary, vaginal, CNS, Hepatic
Gestational Trophoblastic Disease eval and diagnosis
Evaluation- Confirm hCG, evaluate for metastases (vagina, lungs), chest x-ray, pelvic
ultrasound,
Diagnosis- Clinical diagnosis, do not need biopsy of lesions, persistently elevated
hCG after molar pregnancy
Gestational Trophoblastic Disease treatment
Methotrexate vs EMA-CO (5 different chemotherapies)
Causes of UTIs in Pregnancy
Dilation of urethra, pressure from uterus slows flow in ureters causing dilation and stasis of urine increasing susceptibility to infection
Elevated TSH in pregnancy
Diagnosed by elevated TSH (TSH range changes through pregnancy normally
upper limit of 4, but ideal number in pregnancy is 2.5 and below and low free T4
Between TSH 2.5-4, check TPO antibodies
Treating hypothyroidism in pregnancy
Treat with levothyroxine, recheck every 4 weeks, then every trimester once stable
Hypothyroidism consequences
Some increased risk in cognitive
impairment, preeclampsia, abruption,
fetal distress, preterm delivery, low birth
weight, hemorrhage, etc.
Major Depressive Disorder treatment in pregnancy
SSRI best- particularly Zoloft (Sertraline) least crossing of placenta, particularly low
amount of it gets in the breast milk.
Avoid Paroxetine (Paxil)- possible association with VSD
Cervical Insufficiency
The inability of the uterine cervix to retain a pregnancy in the 2nd trimester in the absence of clinical contractions, labor, or both.” ACOG
Cervical Insufficiency presentation
Normally presents with vaginal bleeding between 14-24 wks with
vaginal bleeding, pelvic pressure, low back pain, and advanced cervical dilation
Diagnosis of Cervical Insufficiency
History (previous preterm birth), ultrasound (cervical length), physical
exam (Cervical dilation)
Risk factors of Cervical Insufficiency
History of insufficiency, cervical trauma or surgery (LEEP, cervical trauma in birth), congenital abnormalities (Ehlers Danlos)
Cervical Insufficiency treatment
Pre-treatment- Rule out infection (consider amniocentesis), labor, abruption/previa
Treatment- Vaginal progesterone, cervical cerclage, (Pessary controversial)
Diamniotic/Dichorionic pregnancy
Each twin has a separate sac and separate placenta- 38wks
Diamniotic/Monochorionic pregnancy
Each twin has a separate sac, but share a placenta- 36 wk
Monoamniotic/Monochorionic pregnancy
Each twin shares a sac and placenta- 32-34 wks
Etiologies for having twins
ART (Assisted reproductive
technology), Ovulation induction
IVF, Clomiphene Citrate, Femara, IUI
(Intrauterine insemination)
Delivery- Twins
Vaginal- Only for Mono/Di or Di/Di, Baby A head down, possible breech extraction
of 2nd twin- baby B must be concordant growth. Risk of head entrapment
C-section- Every other situation
Fetal Growth Restriction
Estimated fetal weight (EFW) or abdominal circumference (AC) by ultrasound
<10% for gestational age
Severe- <3%ile, or with abnormal dopplers
Concern is placental resistance causing poor blood flow leading to the baby not growing
appropriately. The first area to be affected is typically the abdominal circumference.
Fetal Growth Restriction risk factors
Hypertension, type I DM, chronic kidney disease, preeclampsia, aneuploidy,
smoking, drug use, thrombophilia, placental abnormalities, cord abnormalities
Fetal Growth Restriction clinical presentation
Size less than dates on measurements,
otherwise by ultrasound due to some risk facto
Fetal Growth Restriction eval and diagnosis
Evaluation- Growth ultrasound, evaluation of risk for aneuploidy,
Doppler velocimetry, NST
Diagnosis- Ultrasound-based diagnosis
Fetal Growth Restriction treatment
depending on elevated dopplers, severity of growth restriction
Gestational Diabetes
New onset diabetes after 20 weeks of pregnancy - pancreas is unable to
overcome insulin resistance caused by pregnancy
Pregnancy and insulin
Pregnancy causes insulin resistance through hormones like HPL (Human placental
lactogen) which causes insulin resistance for the sake of the fetus
If there is baseline risk for preexisting insulin resistance, it compounds to Diabetes
Different from preexisting type I or II diabetes
Gestational Diabetes clinical presentation
Normally no
symptoms- test is screening prior
to symptoms
Diagnosis of gestational diabetes
Screening test- 1 hour
Glucose Challenge Test (GCT)
Confirmatory test- 3 hour Glucose
Tolerance Test (GTT)
Risk factors for GDM
- Age >35
- Preexisting insulin resistance (PCOS)
- Obesity
- History of GDM
- Previous large baby
- Certain high risk groups- Native american etc
Short-term increased risks of GDM
- Preeclampsia
- LGA baby (Large for gest. age)
- Operative delivery
- Cesarean section
- Perinatal mortality
- Fetal hypertrophic cardiomyopathy
- Neonatal problems
- Hypoglycemia, jaundice, etc
- Polyhydramnios
Long-term increased risks of GDM
Maternal increased risk of
- Outright diabetes
- Cardiac disease
- Metabolic syndrome
Fetal risk as an adolescent or adult
- Obesity
- Hypertension
- Metabolic syndrome
- Diabetes
Does insulin cross the placenta?
No
Gold standard treatment of GDM
Insulin
Gestational hypertension
New onset systolic bp >140 mmHg and/or diastolic bp >90 mmHg on at least 2 occasions 4 hours apart after 20 weeks of gestation in a previously normotensive individual
And
- no proteinuria
- no s/s preeclampsia
Risk factors of gestational hypertension
Nulliparous, multifetal pregnancy, obesity, pregestational diabetes, Lupus,
antiphospholipid antibody syndrome, chronic kidney disease, advanced maternal age, IVF
Clinical Presentation of gestational hypertension
Incidentally found elevated pressure in clinic, need to rule out white coat
hypertension, normally no PreE symptoms.
Evaluation of gestational hypertension
See if it’s preeclampsia- CBC, CMP, Urine protein (Protein to Creatinine ratio), (24 hr
urine is gold standard) evaluate for severe disease, assess fetal wellbeing
Treatment of gestational hypertension
treat the same way as PreE. Delivery at 37 weeks. Prior to 37 wks, weekly labs, fetal
surveillance (NSTs, BPP), blood pressure log at home, precautions for severe features. Steroids?
Definition of Preeclampsia Without Severe Features
New onset systolic bp >140 mmHg and/or diastolic bp >90 mmHg on at least 2 occasions 4 hours apart after 20 weeks of gestation in a previously normotensive individual
AND
- proteinuria
RFs for Preeclampsia
gHTN. Deliver at 37 wks
Comes from both placental and maternal factors- Failure of spiral artery remodeling
leading to underperfusion, oxidative stress leading to release of antiangiogenic factors to
maternal circulation lead to HTN
Clinical features of Preeclampsia
watch for heavy swelling (Every mom has some swelling), high weight
gain in small amount of time, HA, vision changes, epigastric pain, oliguria
Preeclampsia with Severe Features
- New onset systolic bp >160 mmHg and/or diastolic bp >10 mmHg on at least 2 occasions 4 hours apart
- thrombocytopenia
- Impaired liver function
- Progressive renal insufficiency
- Pulmonary edema
- Persistent Cerebral or visual disturbances
Indication to deliver with severe preeeclampsia
Indication is to deliver at 34 weeks, or earlier if clinically needed. Inpatient management
Treatment of preeclampsia
Once Severe preeclampsia diagnosed, oral antihypertensives (labetalol, nifedipine) can be used to control BPs. IV
Labetalol or hydralazine for acute pressures
Magnesium 4g bolus, 2g/hr infusion required to prevent progression to eclampsia
Eclampsia
In a patient with preeclampsia, presence of a generalized seizure that cannot be attributed to other causes
HELLP syndrome
Hemolysis
Elevated Liver enzymes
Low Platelets
Hypertension may be present
HELLP
HELLP diagnosis
Hemolysis evaluated by LDH >600
Placenta Previa
Growth of the placenta over the
cervical os
Trophotropism
placenta grows towards more
blood flow, away from the cervix with time
Presentation of placenta previa
painless bleeding in the 3rd trimester
Eval and diagnosis of placenta previa
Evaluation- Bleeding without ultrasound showing no
previa requires ultrasound prior to digital exam.
Diagnosis- Diagnosis is strictly ultrasound-based
Management of plalcenta previa
Management- US at 20 wks, 32 weeks, then 36ish
weeks. Avoid sexual activity, moderate exercise
Delivery at 36-37 weeks
Required cesarean delivery
Low-lying placenta (Marginal)
When the placenta is <2cm away from the
cervical os
If placenta is <1 cm from the os, c-section best.
Risk of requiring section - 45%
If >1 cm and <2 cm from the os, vaginal delivery
could be attempted, but higher risk of cesarean
due to bleeding Risk of requiring section - 14%
>2cm risk of section 10%
Premature separation of the placenta
after 20 weeks
Placental abruption
Clinical Presentation of placental abruption
Painful vaginal bleeding
typically with contractions, uterine tenderness,
sometimes nonreassuring fetal status
Where is the blood coming from in placental abruption?
Bleeding comes from maternal vessels in the
decidua, not baby’s blood
Placental Abruption risk factors
Trauma, previous abruption, HTN,
structural anomalies, drus (Cocaine), COVID?
Placental Abruption eval & diagnosis
Evaluation- Monitor baby, labs- CBC, Coags, Kleihauer-Betke, Ultrasound
Diagnosis- Clinical diagnosis (No US or lab value will diagnose, take in all info)
Placental Abruption treatment
Monitor baby, IV access with fluid, quantify blood loss, steroids if
needed, Could stop, continue, or get worse, treat accordingly.
Delivery can be vaginal if stable, C-section if bleeding too heavy
PPROM
preterm prelabor rupture of membranes
Rupture of fetal membranes prior to 37 wks
PPROM clinical presentation
Typically experiences a gush of fluid, not always large gush
PPROM eval and diagnosis
Evaluation- Sterile speculum exam- no digital exam if possible. Watch for pooling, ferning,
nitrazine, Ultrasound, ROM+
Diagnosis- Clinical diagnosis
PPROM treatment
Treatment- >34 wks- consider steroids, and deliver. Vaginal delivery is ok
<34 wks- rule out infection, give steroids, tocolysis optional, Mg if <32 wks. Latency
antibiotics- antibiotics for 7 days to keep someone pregnant.
Preterm Labor
Contractions prior to 37 weeks causing cervical dilation 12% incidence
Clinical Presentation of preterm labor
Typically more than Braxton-Hicks. Painful contractions for 2
consecutive hours every 5-10 minutes required evaluation
Evaluation of preterm labor
Fetal wellbeing, contractions strength and frequency, serial cervical exams, check
UA, wet mount, CBC for signs of infection. (Infection anywhere in the body can cause
contractions), rule out abruption, infection. Draw GBS if needed
Preterm Labor diagnosis
Contractions at least 1 every 10 minutes with one of following: >3cm
dilation, or <2cm CL, or 2-3cm CL with +FFN
Treatment for preterm labor
> 34 wks, admit for observation, consider steroids, GBS
<34 Admit, steroids, tocolysis for 48 hrs, Mg if needed, GBS
Steroids typically Betamethasone, some use Dexamethasone
Tocolytics- Indomethacin (up to 32 wks), Nifedipine, terbutaline
Let it declare, will either progress or not
Maternal monitoring after trauma or fall
Evaluation- History and physical, ultrasound, abdominal and vaginal exam looking
for trauma injury, signs of abruption, rupture of membrane, fetal evaluation with
monitoring for at least 4 hours. High risk of abruption
Low impact trauma- fall etc- will need 4 hrs of monitoring on L&D, CBC, Coags, Kb,
if all is well, she can go home with precautions
