Complications of Pregnancy Flashcards
14 Complications of Pregnancy
Abortion Ectopic Pregnancy Gestational Trophoblastic Disease Multiple Gestation Hypertension in Pregnancy Rh Incompatability Gestational Diabetes Premature Rupture of Membranes Placenta Previa Abruptio Placentae Dystocia Fetal Distress Cesarean Section Postpartum Hemorrhage
Human Chorionic Gonadotropin (HCG) values
Titer < 5 IU/L is negative
Titer > 20 – 25 IU/L is positive
Urine Test detects > 25 IU/L
will double every 48 hours
What is Human Chorionic Gonadotropin (HCG)
is a hormone produced by the syncytiotrophoblast, a portion of the placenta, following implantation
Ultrasound (Transvaginal)
Gestational sac visible @ 5 weeks gestation
Diagnostic Classification for abortions
Threatened Missed Empty Sac (blighted ovum) Inevitable Incomplete Complete Septic Recurrent Elective
Spontaneous Abortion
Recognized pregnancy loss before 20th week.
Most common complication of early pregnancy.
8-20% of clinically recognized pregnancies less than 20 weeks of gestation will undergo spontaneous abortion.
80% of these occur in the first 12 weeks of gestation.
what are 5 fetal factors?
Chromosomal abnormalities 50% of the time they have abnormal chromosomes
Congenital anomalies chromosomal deletions etc
Exposure to teratogens high percent abort
Trauma
Only about 2% of babies have abnormalities
What maternal factors make for higher risk of abortion?
Advanced maternal Age Previous spontaneous abortion Uterine structural issues Maternal disease thyroid dz etc Maternal smoking Unexplained alcohol/ cocaine/ NSAIDs extremes in maternal weight
3 clinical presentations common with abortion?
Vaginal Bleeding
Pelvic pain
Incidental finding on ultrasound
What is the most useful exam for abortion?
U/S
can detect fetal activity at ~5.5 weeks
What are 4 potential predictors of failed pregnancy
Abnormal Gestational Sac Should be round some might be irregular Abnormal Yolk Sac Slow Fetal Heart Rate <100 beats per min might be indication that might be abort Subchorionic Hemorrhage
3 lab evals done for abortion
HCG
Blood Type and Antibody Screen
CBC
What is a threatened abortion?
cervix closed
used to describe vaginal bleeding that occurs in the first 20 weeks of pregnancy. Vaginal bleeding could indicate risk of miscarriage.
stomach cramps
expectant management
Inevitable abortion?
Cervix is opened Bleeding usually heavier Cramps or pain lower abdomen Treatment Await spontaneous abortion Consider surgical removal
Missed abortion?
Fetus has died but still in the uterus Spotting may or may not be present No pain Uterus enlarged but may be smaller than expected Treatment Await spontaneous abortion Surgical removal
What is a complete abortion?
Pregnancy completely expelled from uterus
What are 6 symptoms of complete abortion?
Bleeding Pain Passage of tissue Cervix closed Uterus smaller than expected Tissue may be present in vagina Follow serial HCG until <5
What is an incomplete abortion?
Only part of pregnancy expelled
Surgical removal as soon as possible
What are symptoms of incomplete abortion?
Bleeding Cramps Passage of tissue Cervix open Tissue at cervical os or in vagina
What is septic abortion?
form of abortion with intrauterine infection
Uncommon with spontaneous abortion/very rare
Frequently associated with induced abortion
Can be life-threatening
Usually caused by Staphylococcus aureus
What are symptoms of septic abortion?
Fever, chills, malaise Abdominal pain Vaginal bleeding and discharge which is sanguinopurulent Tachycardia Low abdominal tenderness Boggy, tender uterus with dilated cervix
What is the treatment for septic abortion?
Parenteral antibiotics
Evacuate uterus
What is recurrent abortion?
Three or more consecutive losses of clinically recognized pregnancies prior to the 20th week.
Spontaneous abortion occurs about 10-15 % of the time
What are the chances of having another spontaneous abortion after 1?
after 2?
After one spontaneous abortion the chance of a second is about 15%
It rises after 2 consecutive spontaneous abortion to 17-31%
25-46% after three consecutive spontaneous abortions
What are 5 causes of recurrent abortion?
Uterine factors Endocrine uncontrolled thyroid or polycystic ovarin Karyotype abnormalities Environmental toxins Autoimmune disease lupus
What is an empty sac?
Where the embryonic development arrested at a very early stage or failed altogether
Defined sonographically as a gestational sac larger than 25 mm without evidence of embryonic tissue
Can present as a missed, inevitable, incomplete or complete abortion
What is an ectopic pregnancy?
It is an extrauterine pregnancy
98% occur in the fallopian tube
Ampullary portion of tube most common
Isthmic next most frequent site.
What are high risk factors for having ectopic pregnancy?
previous ectopic pregnancy previous tubal surgery current IUD use tubal ligation, tubal patho in utero DES exposure
Incidence and epidemiology of ectopic pregnancy
The prevalence of ectopic pregnancy of woman who go to the ED for first trimester bleeding, pain or both ranges from 6-16%.
The overall incidence has increased in the mid twentieth century, plateauing at approx. 20 per 1000 pregnancies in the early 1990’s
The rising incidence associated with pelvic inflammatory disease
What is a tubal abortion?
body forces the pregnancy out the fallopian tube
What is a tubal rupture?
pregnancy blows out the fallopian tube
What is an abdominal pregnancy?
body sends the pregnancy out but it gets stuck in the abdomen
How do you diagnose an ectopic pregnancy?
Based on measurement of serum HCG & transvaginal ultrasound, Hgb, HCT
Accounts for 4-10% of all pregnancy related deaths
HCG should double every 48 hours in a normal pregnancy if it doesn’t think its abnormal or ectopic
Signs and symptoms for ectopic pregnancy?
Vaginal bleeding and/or abdominal – pelvic pain Asymptomatic Abnormal menstruation Uterine changes Blood pressure & pulse Temperature Pelvic mass
What is the leading cause of pregnancy related maternal death in the 1st trimester?
Hemorrhage from ectopic
What are 3 treatments for ectopic pregnancy?
Dilatation & Curettage
Laparoscopy
Laparotomy= unstable patients
2 types of laparoscopy?
Salpingostomy= open the fallopian tube Salpingectomy= remove the fallopian tube
What is the criteria to use medical management?
< 6 weeks Tubal mass < 3.5 cm in diameter Fetus has died B-HCG < 15,000 mIU Patient has to be willing to do blood work
Medical management used for ectopic pregnancy?
Methotrexate Inhibits DNA synthesis
Contraindications for the use of methotrexate?
Breastfeeding Immunodeficiency Alcoholism Liver or kidney disease Blood dyscrasias Active pulmonary disease Peptic ulcer
What are the side effects of medical management for ectopic pregnancy
Liver dysfunction
Stomatitis
Gastroenteritis
Pneumonitis
What is the prognosis of ectopic pregnancy
Recurrent ectopic 4-28%
Intrauterine pregnancy 38-89%
Gestational Trophoblastic Disease
is a group of conditions in which tumors grow inside a woman’s uterus (womb). The abnormal cells start in the tissue that would normally become the placenta
4 distinct types of GTD
Hydatidiform Mole (complete is MC or partial)
Persistent/invasive gestational trophoblastic neoplasia (GTN)
Choriocarcinoma
Placental site trophoblastic tumors
What are complete and partial moles of GTD?
noninvasive localized tumors that develop as a result of an aberrant fertilization event that leads to a proliferative process
They comprise 90% of GTD cases
The other three categories represent malignant disease
What are partial moles?
Originates from one maternal and usually two paternal haploid compliments
Fetus of partial mole has triploidy with congenital malformations & IUGR, and it is usually nonviable
Gestational Trophoblastic Disease epidemiology
Varies worldwide
North American & European countries 1 per 1000 to 1500 pregnancies
Asia & Latin America 1 per 12 to 500 pregnancies
What are 2 risk factors of GTD?
Extremes in age, older than 35 and < 20
History of previous GTD
Clinical Manifestations of Gestational Trophoblastic Disease
Vaginal bleeding Enlarged uterus Pelvic pressure or pain Theca lutein cysts get large, tumors of the ovaries usually bilateral and can get to 10-15mm in size Anemia hyperthyroid preeclampsia before 20 wks
How to diagnose Gestational Trophoblastic Disease
High levels of hCG Ultrasound Absence of embryo or fetus No amniotic fluid Snowstorm pattern Theca lutein cysts= can produce testosterone
How to treat Hydatidiform mole
Immediate evacuation
Measure serum hCG, q2 weeks, once negative , monthly for 6 months.
Pregnancy allowed after 6 months
Persistent/invasive Gestational Trophoblastic Disease mole
20% of molar pregnancies can develop this
Usually limited to the uterus
Good prognosis with chemotherapy
3% relapse
Choriocarcinoma
uncommon cancer that occurs during pregnancy. A baby may or may not develop in this type of pregnancy
What do you need to check for if you find choriocarcinoma
Check for metastasis
Lung, Vagina, Vulva, Kidneys
Liver, Ovaries, Brain, Bowel
How do you treat Choriocarcinoma?
Immediate evacuation
Chemotherapy
Methotrexate
Actinomycin D
What is Placental site trophoblastic tumors
Rare malignant tumors that originate from intermediate cytotrophoblast cells
Arise months to years after a term gestation
Can occur after a spontaneous abortion or a molar pregnancy
Patients present with abnormal uterine bleeding, mass in uterus or amenorrhea
Secrete small amounts of B-HCG
Epidemiology of Placental site trophoblastic tumors
70% of tumors are confined to the uterus
30% of patients present with metastatic disease
Mortality 50% with metastasis present
Prolonged remission possible with combined chemotherapy
Placental site trophoblastic tumors prognosis?
Nonmetastatic malignant trophoblastic disease
Extremely good prognosis
Metastatic disease
Remission 45-65%
epidemiology of multiple gestations?
Twins naturally occur in approximately 1 in 80 pregnancies
Triplets naturally occur in approximately 1 in 8,000 pregnancies
Multiple pregnancies increasing disproportionately in the US
Due to older age & use of fertility treatments
What is the cause of multiple gestations?
Monozygotic twins unknown
Dizygotic twins results from ovulation of multiple follicles
Dizygotic twins result from fertilization of 2 separate ova during a single ovulatory cycle
Monozygotic twins result from a single fertilized ovum that subsequently divides into 2 separate individuals
What are the 4 types of placentation
Diamniotic, dichorionic placentation occurs with division prior to the morula stage(within 3 days postovulation)
Diamniotic, monochorionic placentation occurs with division between days 4-8 days postovulation
Monoamniotic, monochorionic placentation occurs with division between 8-12 days postovulation
One of the worst types
Division at or after day 13 results in conjoined twins
Siamese twins
What are Monoamniotic twins
same amniotic sac Increases perinatal mortality Cord entanglement Congenital anomalies Discordant birth weight (twin-twin transfusion syndrome) One twin takes things
How are multiple gestations diagnosed?
Ultrasound
Uterine size
Fetal heart sounds
Maternal adaptation involves what? (6)
Increase nausea & vomiting
Increase blood volume expansion
Increase in iron & folate requirements
Increase cardiac output due to increase stroke volume and heart rate
Displacement of many abdominal viscera
Displacement of lungs by elevated diaphragm
What is the outcome of multiple gestations?
Abortion Malformations Birth weight lower Prematurity Operative deliver
How are most conjoined twins attached?
Ventral union 87% (joined in the front)
What needs to be available during delivery with multiple gestations?
Experienced obstetrician Blood available IV access Anesthesiologist available Pediatrician available OR notified
4 Major HTN disorders in pregnancy
Gestational HTN
Chronic HTN
Preeclampsia – eclampsia
Preeclampsia – eclampsia superimposed on chronic HTN
What is gestational HTN
Increased BP after 20 weeks gestation
No proteinuria
What is chronic HTN
BP 140/90 or higher before pregnancy or before 20 weeks gestation
HTN first diagnosed after 20 weeks but persists after 12 weeks postpartum
What is Preeclampsia – eclampsia
Syndrome of new onset HTN & either proteinuria or end organ dysfunction, most often after 20 weeks gestation in a previously normotensive woman
Eclampsia diagnosed when seizures occur
What is Preeclampsia – eclampsia superimposed on chronic HTN
When chronic HTN develops worsening HTN with new onset of proteinuria or other features of preeclampsia (elevated liver enzymes, low platelets)
one of the four causes of maternal death
Preeclampsia with severe features are?
thrombocytopenia pulm edema renal insufficiency systolic >160 diastolic >110
What is the HELLP Syndrome= severe subset of preeclampsia
Hemolysis
Elevated Liver Enymes
Low Platelets
What is the prevelance of preeclampsia?
Prevalence of preeclampsia
- 5 % worldwide
- 4% in the US
Eclampsia
occurrence of seizures in a woman with preeclampsia that cannot be attributed to other causes.
The seizures are grand mal and may appear before, during or after labor.
Presents with headaches
Put on mag sulfate
How to manage eclampsia?
Termination of pregnancy with the least possible trauma to mother & fetus
Birth of an infant who subsequently thrives
Complete restoration of health to the mother
Antihypertensive therapy
Labetalol
Hydralazine
Anticonvulsive therapy
Magnesium sulfate
What is the cure for preeclampsia?
deliver the baby
What is Rh Incompatibility
Rhesus (Rh) negative woman who deliver an Rh positive baby or who are otherwise exposed to Rh positive RBC’s are at risk for developing anti-Rh antibodies.
Rh positive fetuses/neonates of these mothers are at risk for developing hemolytic disease of the fetus and newborn
What are the Rh Antigens
Rh negative (no D antigen) Rh positive (contains D antigen) D antigens are highly immunogenic Individuals who do not produce the D antigen (ie Rh negative) will produce anti-D if they encounter the D antigen (become Rh sensitized)
What occurs during the second pregnancy for Rh incompatability?
1st pregnancy mom built up antibodies 2nd pregnancy: IgG antibodies cross the placenta Maternal antibodies attach to fetal RBC antigen Hemolysis of fetal RBC’s
What happens to the baby with prolonged hemolysis?
Hepatomegaly Splenomegaly Hyperbilirubinemia fetal jaundice hydrops fetalis
How to diagnose Rh incompatability?
Detection of anti-Rh(D) antibody in maternal serum by performing a type and antibody screen
The antibody titer is then quantified.
If titer is above critical level further evaluation is indicated
The titer below which the fetus will not die from hemolytic disease is usually 1:16
What is hydrops fetalis?
serious condition in which abnormal amounts of fluid build up in two or more body areas of a fetus or newborn.
What does hyrops fetalis cause?
Hepatosplenomegaly Portal hypertension Ascites Fetal hypoxia Anemia Congestive cardiac failure Hyperproteinemia secondary to hepatic dysfunction
How to Prevent Rh Sensitization
Give Rh Immunoglobin: Pregnancy loss Termination of pregnancy Procedure-amniocentesis Any bleeding during pregnancy At 28-29 weeks Following delivery if baby is Rh positive
What is Gestational diabetes mellitus
defined as carbohydrate intolerance of variable severity with onset or first recognition during pregnancy
How do you screen for gestational diabetes mellitus
All pregnant woman are screened using 50-g of glucose
Screening is usually done after 26 weeks gestation
A value of > 135 mg/dl requires further evaluation with a 3 hour GTT
What happens during a 3 hour GTT
FBS 100-g glucose Values FBS – 95 1 hour – 180 2 hour – 155 3 hour – 140 Need 2 out of 3 to constitute gestational DM If FBS is abnormal patient has GDM
2 types of gestational diabetes mellitus
A1 Diet controlled gestational diabetes
A2 Insulin treated gestational diabetes
What are maternal and fetal affects due to gestational diabetes mellitus
Unexplained fetal death Preclampsia Hydramnios Maternal & infant birth trauma Neonatal respiratory problems & metabolic problems (hypoglycemia, hyperbilirubinemia, hypocalcemia) Macrosomia very large babies Operative delivery
Glucose targets?
Fasting blood glucose < 95 mg/dl
One-hour postprandial blood glucose < 140 mg/dl
Two-hour postprandial blood glucose < 120 mg/dl
How do you treat gestational diabetes mellitus?
Diet Insulin Oral anti-hyperglycemic agents Glyburide Metformin
4 ways to manage gestational diabetes?
Good glucose control
Nonstress Tests
Biophyisical profile
Amniotic fluid index
Advantages of induction for gestational diabetes?
Avoidance of stillbirth
Avoidance of delivery related complications trauma or shoulder dyslocia
Disadvantages of induction for gestational diabetes?
Cesarean section
Neonatal morbidity if < 39 weeks
Based on the 2 types of gestational diabetes at what week would you deliver the baby?
A1 GDM
Deliver by 41 weeks
A2 GDM
Deliver @ 39 weeks
What should the levels be for patients at their postpartum follow up?
75 gram oral GTT Fasting < 140 impaired GTT > 140 DM 2 Hour 140 – 199 impaired GTT > 200 DM
Premature Rupture of Membranes
Refers to rupture of the fetal membranes prior to the onset of regular uterine contractions
It may occur at term > 37 weeks or preterm < 37 weeks
3% of pregnancies
Associated with 33% of preterm births
How to diagnose premature rupture of membranes
Sterile speculum exam Leaking of fluid Nitrazine test Fern test ROM Plus, AmniSure
What are 2 ways to manage premature rupture of membranes?
Induce labor
Expectant
4 risk factors of PROM
Previous PPROM (13.5%)
Genital tract infection
Antepartum bleeding
Cigarette smoking
PROM Management from 23-37 weeks
Antenatal corticosteroids– helps mature the lungs in 2 days
Antibiotics
Tocolytic drugs– stop the labor for at least 2 days so that you get better lung maturity
Placenta Previa
Placenta previa refers to the presence of placental tissue that extends over or lies proximate to the internal cervical os
Painless vaginal bleeding 3rd trimester****
Placenta Previa Risk factors
Previous placenta previa Previous cesarean section Multiple gestation Multiparity many babies Advanced maternal age Infertility treatment Previous abortion Previous intrauterine surgical procedure
Placenta Previa diagnosis
Suspect with painless vaginal bleeding
Do not do digital vaginal exam
Obtain ultrasound
Placenta Previa management
Follow with US
If uncomplicated deliver between 36-37.6 weeks
Unstable deliver by C/S
Abruptio Placentae
The separation of the placenta from its site of implantation before delivery of the fetus.
Also termed Placental Abruption
Abruptio Placentae patho
The immediate cause of the premature separation of the placenta is rupture of the maternal vessels in the decidua basalis, where it interferes with the anchoring villi of the placenta
unknown etiology
Abruptio Placentae signs and symptoms
Abrupt onset of vaginal bleeding with abdominal pain Bleeding can be mild or profuse Contractions Uterus is firm, may be rigid & tender Maternal hypotension Fetal distress DIC
Abruptio Placentae diagnosed by
U/S and clinically
Abruptio Placentae
Nonsevere abruption @ 34 – 36 weeks – deliver
Nonsevere abruption @ 36 weeks - deliver
**Most by C-section
Dystocia
difficult labor & is characterized by abnormally slow labor
Disproportion between the presenting part of the fetus and the birth canal
It is a consequence of 4 distinct abnormalities that may exist singly or in combination
What can cause dystocia?
abnormalities involving the cervix, uterus, fetus, maternal bony pelvis or other obstructions in the birth canal
ACOG simplified into 3 categories:
Abnormalities of the powers (uterine contractility & maternal expulsive effort)
Abnormalities involving the passenger (the fetus)
Abnormalities of the passage (the pelvis)
When does labor begin
contracting every 5 min
What are 2 types of uterine dysfunction?
Hypotonic uterine dysfunction mild contractions
Hypertonic uterine dysfunction uterus contracts and is “too contracted”
What are 3 causes of uterine dysfunction?
Epidural analgesia slow labor down
Chorioamnionitis
infection
What is Fetopelvic Disproportion
Contracted pelvis
Excessive fetal size small pelvis
What are second stage disorders of dystocia?
women is not pushing forcefully
Causes of inadequate expulsive forces
Heavy sedation
Conduction analgesia
Maternal-Fetal Effects of Dystocia
Intrapartum infection
Uterine rupture rare
Fistula formation due to pushing for long periods and the baby is larger causing lacerations to the vagina + rectum
Pelvic floor injury
What is fetal acidemia classified as
is an umbilical arterial blood pH of <7.00
What is the rationale for monitoring fetal heart rate?
FHR patterns are indirect markers of the fetal cardiac and medullary responses to blood volume changes, acidemia and hypoxemia, since the brain modulates heart rate
FHR Patterns based on category?
Category I Observation
Category II Intervention, no improvement deliver
Category III Deliver
Change the position of the patient with category II
Cesarean section
Refers to the delivery of a baby through surgical incisions in the abdomen and uterus.
Categorized as either primary or repeat
C/S rate in the U.S. is about 33%
3 most common indications account for about 80% of these deliveries
Failure to progress during labor (35%) dystocia
Nonreassuring fetal status (24%)
Fetal malpresentation (19%) breach or a face presentation
What are some less common causes for C-Section
Abnormal placentation (eg. placenta previa)
Maternal infection (eg. Genital HSV active)
Multiple gestation
Cord prolapse cord comes out first
Fetal bleeding diathesis
Suspected macrosomia (5000 gms in woman without DM, 4500 gms in woman with DM)
Mechanical obstruction to vaginal birth
What is used for anesthesia during C-Section?
Anesthesia
Spinal(best cause immediate) or epidural 30 min to go into effect
General
What are the 2 types of incisions for C-Section
External incision
Low transverse
Vertical— only time is if she already had this
Internal incision
Low transverse
Vertical (This is the incision that matters for subsequent pregnancies)
Vaginal Birth After Cesarean (VBAC) requirements?
Vertex Only one prior C/S Previous C/S > 18 months Full consent of patient Available OR for emergency C/S Blood available No pitocin
Postpartum Hemorrhage
Obstetrical emergency that can follow a vaginal delivery or cesarean section
Major cause of maternal morbidity
Top 3 causes of maternal mortality
excessive bleeding that makes the patient symptomatic
Occurs in 1-5% of deliveries
2 types of postpartum hemorrhage
Primary (first 24 hours after delivery)
Secondary or delayed (24 hours to 12 weeks after delivery)
What are some of the causes of postpartum hemorrhage
Overdistension of uterus Uterine infection Uterine relexants Uterine fatigue Uterine inversion Retained placenta trauma coag deficiencys
What are some risk factors for postpartum hemorrhage?
Retained placenta Failure to progress during second stage of labor Placenta accreta Lacerations Instrumental delivery Large for gestational age Hypertensive disorders Induction & augmentation of labor
What is the goal of postpartum hemorrhage?
Restore or maintain adequate circulatory volume
Restore or maintain adequate tissue oxygenation
Reverse or prevent coagulopathy
Eliminate the obstetric cause of PPH
Management of postpartum hemorrhage
Check for lacerations Retained placenta Treat uterine atony Intrauterine balloon tamponade Laparotomy Hysterectomy
Complications of postpartum hemorrhage
Hypovolemic shock & organ failure (renal failure, stroke, MI, Sheehan syndrome) Fluid overload (pulmonary edema) Anemia Abdominal compartment syndrome Transfusion related complications (ie: electolyte imbalance) Acute respiratory distress syndrome Anesthesia-related complications sepsis death
secondary hemorrhage for Postpartum Hemorrhage
Secondary postpartum hemorrhage (occurring 24 hours to 12 weeks postpartum)
Occurs 0.5-2%
Pathogenesis
Diffuse uterine atony
Subinvolution of placental site (retained products of conception, infection)
Bleeding diathesis
Choriocarcinoma
What is the recurrence rate of postpartum hemorrhage?
10-15% risk of recurrence in a subsequent pregnancy
