Complications of Pregnancy Flashcards
1
Q
Define ectopic pregnancy. Where do they usually occur?
A
- Implantation of pregnancy anywhere except the endometrium
A. > 95% occur in fallopian tubes
B. 55% occur in ampulla
C. Rare sites include cervix, ovary, abdominal or pelvic cavity
2
Q
What is the most common cause of an ectopic pregnancy?
A
occlusion of tube 2° to adhesions
3
Q
What are the risk factors for ectopic pregnancies?
A
- Prior ectopic pregnancy
- Hx of salpingitis / PID
- Hx of abdominal /pelvic surgery
- IUD use
4
Q
What are the classic sxs of an ectopic pregnancy?
A
- Adnexal pain/tenderness
- Amenorrhea or spotting
- +/- palpable adnexal mass
- Sometimes:
A. Dizziness
B. GI sxs
5
Q
What are the sxs for a ruptured ectopic pregnancy?
A
- Severe abd pain
- Shoulder pain (Kehr’s sign)
- Tachycardia
- Syncope
- Orthostatic hypotension
6
Q
What is the timeline for beta hCG level rise?
A
Normally beta-hCG levels double q 48 hrs
7
Q
How is an ectopic pregnancy diagnosed?
A
- Serial levels of beta-hCG are less than expected
- Transvaginal USN diagnostic in 90% of cases
A. Women with beta-hCG titer > 1500 mU/mL should show intrauterine pregnancy (IUP) on transvaginal USN
B. If not seen, ectopic pregnancy is clinical Dx
8
Q
How is an ectopic pregnancy treated medically?
A
- Methotrexate used if diagnosed early
- Criteria for methotrexate:
A. Serum hCG titer
9
Q
How is an ectopic pregnancy treated surgically?
A
- Laparoscopy preferred
A. Removal of ectopic pregnancy
10
Q
What is the f/u for an ectopic pregnancy?
A
Serum b-hCG’s &/or transvaginal USN to exclude any remaining evidence of pregnancy
11
Q
Define spontaneous abortion. How often does it occur?
A
- Spontaneous premature expulsion of products of conception
2. Occurs in 15-20% of pregnancies
12
Q
What are the types of spontaneous abortion?
A
- Threatened
- Inevitable
- Incomplete
- Complete
- Missed
13
Q
When do most spontaneous abortions occur?
A
80% occur in 1st trimester
14
Q
What are the most common causes of spontaneous abortion?
A
- 50% of these asst w/ chromosomal abnormalities
- Blighted ovum causes about one out of twomiscarriages
A. Fertilized egg implants in uterus but doesn’t develop into an embryo
15
Q
What are the characteristics of a threatened abortion?
A
- Vaginal bleeding: Yes
- Cervix Open: No
- Products of conception passed: No
16
Q
What are the characteristics of an inevitable abortion?
A
- Vaginal bleeding: Yes
- Cervix Open: Yes
- Products of conception passed: Not yet, but no way to maintain pregnancy
17
Q
What are the characteristics of an incomplete abortion?
A
- Vaginal bleeding: Yes
- Cervix Open: Yes
- Products of conception passed: Partial
18
Q
What are the characteristics of an complete abortion?
A
- Vaginal bleeding: Yes
- Cervix Open: Yes
- Products of conception passed: Yes
19
Q
What are the characteristics of a missed abortion?
A
- Vaginal bleeding: No
- Cervix Open: No
- Products of conception passed: No, fetal demise has occurred w/o sxs
20
Q
What are the risk factors for spontaneous abortion?
A
- Smoking
- Infection
- Maternal systemic disease
- Immunologic factors
- Drug Use
21
Q
What are the sxs of a spontaneous abortion?
A
- Uterine size does not correlate appropriately to LMP
- Fundus of uterus may be “boggy” or tender
A. Boggy uterus – more flaccid than expected
22
Q
How is a spontaneous abortion diagnosed?c
A
- Serum hCG (Quantitative & Qualitative)
- Serum progesterone
- Transvaginal USN
A. Nonviable pregnancy may include:
-Inappropriate development or interval growth
-Fetal demise - Blood type & Rh
A. R/O sensitization of Rh (-) mom
23
Q
How is a spontaneous abortion treated?
A
- Uterus must be emptied
A. D&C may be necessary - F/U pelvic USN, pelvic exam & serum hCG
- Rho-Gam administered to Rh (-) woman if spontaneous abortion
- Septic or infected abortion
A. D&C, medical support & antibiotics
24
Q
Define gestational trophoblastic disease (GTD)
A
Proliferation of trophoblastic tissue in pregnant or recently pregnant women
25
Define trophoblast
1. Outermost layer of cells of blastocyst that attaches the fertilized ovum to uterine wall
A. Becomes the placenta
26
What is the malignant form of gestational trophoblastic disease?
1. Choriocarcinoma (malignant)
A. A highly malignant tumor that arises from trophoblastic cells within the uterus.
B. Tends to be invasive and metastasize early and widely through both the venous and lymphatic systems.
27
What is the benign form of gestational trophoblastic disease?
1. Hydatidiform mole-most common (generally benign, but can turn malignant)
A. AKA molar pregnancy
2. Results from over-production of tissue that is supposed to develop into placenta, but develops into abnormal growth
3. Complete & incomplete (partial)
28
What are the characteristics of a complete hydatidiform mole?
1. More common
2. Characterized by empty egg & appearance of “grape like vesicles” or a “snowstorm pattern” on USN
3. 20% progress to malignancy
29
What are the characteristics of an incomplete hydatidiform mole?
1. Has a nonviable fetus present
| 2. 10% progress on to malignancy
30
What are the sxs of GTD?
1. (+) hCG
2. Vaginal bleeding
3. Severe vomiting / hyperemesis
4. No fetal movement, no fetal heart tones
5. May have HA/visual changes leading to early pre-eclampsia
6. Uterine size > dates
31
How is GTD diagnosed?
1. Serum hCG
2. Transvaginal USN
3. CXR: evaluate for metastasis
32
What are the hCG levels in GTD?
1. In complete molar pregnancy, often greater than 100,000 mU/mL
2. Persistently high levels may indicate gestational trophoblastic tumor
33
What are the usn results in GTD?
1. Characterized by empty egg & appearance of “grape like vesicles” or a “snowstorm pattern”
2. 20% progress to malignancy
34
How is GTD treated?
1. D & C always indicated
2. Effective contraception during f/u period
3. Follow hCG weekly until nl for 3-4 wks, then monthly x 6mo
A. Levels should drop consistently & never inc
B. If increase or plateau, need to R/O metastasis
C. Refer to GYN Oncology
D. Reach normal w/in 8-12 wks
4. Importance of F/U bc 20% molar pregnancies can develop malignancy afterwards
5. Instructions not to become pregnant for ≥ 6mo
6. Early USN in future pregnancies
35
True/false: multiple gestation is considered a high risk pregnancy
true
36
What is the phys for multiple gestation?
Division of single fertilized ovum or 2 ova & 2 sperms
37
What are the risk actors for multiple gestations?
1. Ovarian stimulation w/ clomiphene or gonadotropins
2. Assisted reproduction (in vitro fertilization)
3. Hx multifetal pregnancy
4. Advanced maternal age
38
What are the potential complications for multiple gestation?
1. Inc maternal morbidity & mortality
2. Premature Rupture Of Membranes (PROM),
3. Hemorrhage
4. UTI
5. Pregnancy induced HTN
6. Anemia
7. Spontaneous abortion
8. Preterm birth
9. Preeclampsia
39
What is the prevalence of identical vs. fraternal twins?
1. 2/3 of twins are dizygotic or fraternal
A. Formed by fertilization of 2 ova
2. Monozygotic twins occur randomly
a. Formed by fertilization of one ovum that splits
40
What are the characteristics of multiple gestation?
1. Vaginal bleeding may signify single/multiple loss
2. More severe sx’s than in single gestation
A. Back pain
B. Nausea
C. Pelvic pressure
D. Constipation
E. Hemorrhoids
F. Abdominal distension
G. SOB
3. Preeclampsia risk
4. Excessive weight gain
41
What complications can affect the babies in multiple gestation?
1. Intrauterine growth restriction
2. Cord accidents
3. Death of one twin
4. Congenital anomalies
5. Abnormal or breech presentation
6. Placenta abruptio or placenta previa
42
How are multiple gestation managed?
1. USN to confirm
2. Early PN care
3. Close monitoring for complications
4. Increased risk of post partum hemorrhage due to uterine distension
5. Nearly all multiple gestations delivered via C-section
6. Importance of more frequent f/u, non-stress tests & biophysical profiles (BPP) near term
43
What are the risk factors for gestational diabetes?
1. Aging ( > 35 yr)
2. Overweight
3. PCOS
4. 1st degree relative w/ Type II DM
5. Hyperinsulinemia/insulin resistance
6. HTN before or in early pregnancy
7. Prior delivery of infant greater than 4000 g (8 lb 12.8 oz)
8. Higher rates in Mexican Americans, Native Americans, Pacific Islanders
44
What are the risks to the fetus if the mom has Gestational Diabetes?
1. Respiratory distress (due to delayed fetal lung maturity ~38.5 wks)
2. Hypoglycemia
3. Jaundice
4. Seizures or stillbirth if untreated
5. Macrosomia (large for gestational age) greater than 4000 g (8 lb 12.8 oz) increases risk of
:
A. Shoulder dystocia
B. Asphyxia
C. Brachial plexus injury
D. Transverse/breech
E. Cephalohematoma
F. Clavicle/humeral fx
45
How is gestational diabetes diagnosed?
1. Any degree of glucose intolerance w/ onset or 1st recognition during pregnancy
2. Glucose intolerance continues beyond 24–28 weeks of gestation
3. FBS > 126 mg/dL
OR
4. Random glucose > 200 mg/dL on any occasion & confirmed on a subsequent day
OR
5. Screening GTT done @ 24-28 weeks, >140 mg/dL→ GDM
46
How is gestational diabetes treated?
1. Diet
2. Insulin
3. May use metformin
4. Repeat GTT should be done @ 6 weeks postpartum
47
Define preterm L&D and how often it occurs
1. Delivery of viable infant before 36 weeks gestation
| 2. Occurs in 8-10% births
48
What is the most common cause of neonatal death not resulting from congenital malformations?
Preterm delivery
49
What are common characteristics of low birth weight preterm babies?
1. Visual & hearing impairments
2. Developmental delays
3. Cerebral palsy
4. Lung disease
50
What are the risk factors for preterm birth?
1. Smoking
2. Cocaine use
3. Uterine malformations
4. Cervical incompetence
5. Group B Strep vag infection or UTI
6. Low pre-pregnancy weight
51
What are the sxs of preterm labor?
```
1. Regular uterine contractions between 20-36 weeks gestation that are less than 5-8 min apart & 1 or more of the following:
A. Cervical dilation more than 2 cm
B. Cervical effacement more than 80%
2. Menstrual like cramps
3. Watery or bloody discharge
4. LBP
```
52
How is preterm labor diagnosed?
1. Examination of cervicovaginal secretions for fetal fibronectin (fFN)
2. Vaginal cultures
3. Urine culture
53
What is fetal fibronectin?
1. Marker for preterm labor
2. “Glue-like” protein that bonds developing fetus to uterus
3. Detectable in vaginal secretions in beginning & end of pregnancy
4. After 35th week of pregnancy, it begins to break down & is detectable
5. fFN may be detected before week 35 in pts in preterm labor
54
How is preterm labor treated?
1. Bed rest
2. Oral or IV hydration
3. Abx if infection
4. Steroids to enhance fetal lung maturity
5. Tocolytics: medications that can inhibit labor, slow down or halt the contractions of the uterus
55
What are examples of tocolytics?
1. MgSO4
A. Inhibits myometrial contractility mediated by Ca
B. Can lead to decreased reflexes, resp. depression, cardiac collapse
-Calcium gluconate is antidote for MgSO4 toxicity
2. Beta adrenergic agents
A. Terbutaline stimulates beta receptors to relax smooth muscle to decrease uterine contractions
3. Ca channel blockers inhibit smooth muscle contractility by decreasing intracellular Ca, which relaxes uterine muscle
A. Nifedipine
56
Define premature rupture of membranes
1. Rupture of membranes before the onset of labor
| 2. When occurs before 37 weeks’ gestation: preterm PROM
57
What are the risk factors for PROM?
1. UTI
2. Smoking
3. Low BMI
4. Hx pre-term labor
5. Hx vag bleeding w/ pregnancy
6. Cerclage
7. Amniocentesis
58
What can PROM lead to?
1. Leading cause of pre-term labor
2. Most common cause of neonatal morbidity & mortality due to prematurity
3. Occurrence 13-26 wk gestational age is asst with poor fetal prognosis
4. Maternal infection: chorioamnionitis & endometritis
5. Neonatal sepsis
A. Most common: Group B Strep, E. coli
6. Placental abruption
7. Fetal/neonatal death
59
How long does it take for labor to begin after PROM?
1. At term: labor w/in 24 hrs
| 2. 32-34 wk: labor w/in 4 days
60
What are the sxs of PROM?
1. Leakage or sudden gush of fluid from vagina
2. Fever, heavy vaginal d/c, abdominal pain, fetal tachycardia suggests chorioamnionitis
3. No contractions
4. Pooling of amniotic fluid in vagina or visible leakage from cervix or meconium in vagina
5. If cervical dilation visualized, avoid digital exam until labor
A. Decreases infection risk
61
How does assessment of amniotic fluid in the vagina help determine PROM?
1. Alkalin one nitrazine test (blue)
A. Intact membrane fluid is yellow to brown
B. Ruptured membrane is green to blue/black
2. Amniotic fluid evaluation for ferning
62
How is PROM managed after 37 wks?
1. Hospital admission
2. Careful monitoring of mom & fetus
3. Induction w/ prostaglandin cervical gel or misoprostol &/or oxytocin
4. Goal is to expedite delivery & decrease rate of infection
63
Define Preterm Premature rupture of Membranes
PROM at 20-36 weeks gestation
64
How is PPROM managed?
1. If there is no sign of infection or distress, patient should be put on strict bedrest
2. If
65
Define preeclampsia
1. Triad of HTN, edema & proteinuria after 20 weeks gestation
3. Most often occurs near term, but can occur up to 2 weeks post partum
66
Define eclampsia
Severe preeclampsia w/ seizures
67
How is preeclampsia/eclampsia managed?
1. Preterm delivery should take place in OR setting w/ NICU whenever possible
2. Emergency C-section for fetal stress, uterine rupture, placental abruption
3. Urgent C-section w/ severe preeclampsia or eclampsia
4. Manage hemorrhage/shock in placental abruption, uterine rupture
68
What is the etiology of preeclampsia/eclampsia?
poorly understood
69
What are the risk factors for preeclampsia/eclampsia?
1. Nulliparity – most common risk factor
2. Pre-existing HTN
DM, GDM
3. less than 17 yr or greater than 35 yr
4. Hx preeclampsia
5. Multifetal pregnancy
6. Obesity
70
What are the fetal complications of preeclampsia/eclampsia?
1. Intrauterine growth restriction (IUGR)
2. Hypoxia
3. Preterm delivery
4. Perinatal death
71
What are the maternal complications of preeclampsia/eclampsia?
1. HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets)
2, Series of sx’s that make up syndrome affecting pregnant women
3. Thought to be a variant of preeclampsia, but it may be an entity all on its own
4. Unknown cause
72
How is preeclampsia/eclampsia diagnosed?
1. UA/Urine dipstick: proteinuria
2. CBC w/ diff, platelet count
3. CMP
4. Creatinine clearance
5. Fetal assessment w/ non-stress test (NST) & biophysical profile (BPP)
73
What is the definitive treatment of preeclampsia/eclampsia?
1. Definitive management is delivery of fetus: maternal risk vs fetal prematurity
A. Favorable cervix: oxytocin induction & ROM
B. Active labor: ROM
C. Unfavorable cervix: delivery via C-section
74
How is mild preeclampsia treated?
1. Hospitalization or possible outpatient Tx
2. Strict bedrest w/ laying on L side
3. BP, reflexes, nonstress testing or biophysical profile & OB visit 2-3 x / wk
4. dec salt intake, inc fluid intake
75
How is eclampsia/preeclampsia treated medically?
1. MgSO4 to treat BP & CNS sx’s
A. Seizures refractory to MgSO4: diazepam or lorazepam IV
B. MgSO4 continued until 24 hr postpartum
2. IV LR/NS 125 ml/hr or fluid challenge followed by furosemide for oliguria
A. Severe may require pulmonary artery catheter, ICU admission, renal vasodilators or dialysis
76
What are the general guidelines for treating HTN in pregnancy?
Methyldopa (Aldomet) 250-500 mg po bid
77
What are the general characteristics for Rh incompatibility?
1. Sensitization occurs during first pregnancy
2. With subsequent pregnancies:
A. If the mom is Rh (-) & fetus is Rh (+), the mom’s immune system has Ab against the infant’s blood, leading to hemolysis
78
When is RhoGam administered?
1. At delivery to Rh (-) moms who have Rh (+) infants
2. Ectopic pregnancy
3. Spontaneous abortions
4. CVS (Chorionic Villi Sampling)
5. Amniocentesis
79
How is Rh factor diagnosed?
1. Routine PN blood work should include Type & Screen
| 2. In a sensitized mom, a combination of Coombs test, amniocentesis & USN used to follow the developing fetus
80
How is Rh factor incompatibility treated?
1. Routinely given (300 mg IM) to Rh (-) moms at 28 weeks gestation & w/in 72 hr of delivering an Rh (+) fetus
2. RhoGam is also given at amniocentesis, or any other instance when uterine bleeding is a possibility
81
Define abruptio placenta
1. Premature separation of placenta after 20 wk gestation
| 2. Most common cause of 3rd trimester bleeding
82
What are the sxs of abruptio placenta?
1. Bleeding, typically bright red
2. Uterine tenderness, painful contractions
3. Shock: hypotensive, tachycardic, altered level of consciousness, ↓ UO
4. DIC sx’s :
A. Clotting & bleeding, bleeding from multiple sites, cyanosis, petechiae
5. Fetal stress
A, Prolonged bradycardia
B. Multiple late decelerations
6. Rapid increase in fundal height
83
How is abruptio placenta diagnosed?
1. Clinical
2. USN done but insensitive
3. Fetal heart monitoring
4. CBC, Type & screen/cross 2 units, PT/PTT
5. Serum fibrinogen & split products
84
How is placenta abruptio managed medically?
1. Preterm w/ stable mom & fetus
A. Hospitalization & bedrest
B. Consider corticosteroids to accelerate fetal lung maturity less than 34 wks
C. Biophysical profile for monitoring
D. Tocolysis for contractions
2. Vaginal delivery for hemodynamically stable mom w/ fetal death
85
How is placenta abruptio managed surgically?
1. C-section indications
A. Near term
B. Late decelerations on fetal heart monitoring
C. Maternal hemodynamic instability
D. Pediatrician/neonatal intensive care specialist present at delivery
