Complications of Pregnancy Flashcards
1
Q
What is an ectopic pregnancy and where can it occur?
A
implantation of a fertilized egg outside the uterine cavity, can occur in the fallopian tubes, cervix, ovary, cornual region of the uterus, and abdominal cavity
2
Q
What are risk factors for an ectopic pregnancy?
A
- history of pelvic inflammatory disease
- previous ectopic pregnancy
- history of tubal surgery or tubal ligation
- fertility drugs or assisted reproduction technology
- IUD
3
Q
What are potential complications of an ectopic pregnancy?
A
- rupture of pelvic organ or structure
- massive hemorrhage
- infertility
- maternal death
4
Q
What is the treatment for an ectopic pregnancy?
A
- methotrexate therapy (fetus must be
5
Q
What is cervical incompetence?
A
women have multiple missed abortions and can’t carry child to term, treated by doing a cervical cerclage and sewing the cervix shut
6
Q
What is intrauterine growth restriction (IUGR)?
A
growth of the fetus is inhibited by a hostile intrauterine environment
7
Q
What are some maternal causes for IUGR?
A
- smoking
- protein malnutrition
- substance abuse
- chronic HTN
- pre-eclampsia
- diabetes
- hemoglobinopathies (sickle cell)
8
Q
What are placental and/or umbilical causes for IUGR?
A
- multiple gestation
- twin-to-twin transfusion
- placental or cord abnormalities
- chronic abruption
- placenta previa
9
Q
What are characteristics of an infant with IUGR?
A
- birth weight /= 3 cm from expected
10
Q
What is the pathophysiology behind IUGR?
A
- nutrition and gas exchange to the fetus is diminished
- nutritional stores are depleted
- blood flow is redistributed preferentially to develop vital organs and maintain the fetus (bone marrow, muscles, lungs, GI tract and kidneys have diminished blood flow)
11
Q
What are fetal complications of IUGR?
A
- intolerance of labor
- IUFD/stillbirth
- temperature instability
- necrotizing enterocolitis (NEC)
- renal failure
12
Q
Does the breech presentation increase or decrease with increasing gestational age?
A
decreases with increasing gestational age
25-28 weeks = 28%
29-32 weeks = 14%
37-40 weeks = 7%
13
Q
What are the 3 types of breech presentation?
A
frank (65%)
complete (10%)
incomplete (25%)
14
Q
What is the frank breech position?
A
hips flexed with legs straight up
15
Q
What is the complete breech position?
A
sitting “indian-style”
16
Q
What is the incomplete breech position?
A
feet or knees presenting
single vs double footling
17
Q
What are breech delivery options?
A
vaginal trial of labor
elective c-section
external cephalic version
18
Q
When might you do a vaginal trial of labor for a breech position?
A
- estimated fetal weight
19
Q
What are potential labor complications of breech presentation?
A
- failure to progress (fetal buttocks and feet do not provide an adequate wedge to block and dilate the cervix)
- umbilical cord prolapse (cervical opening is not uniformly occluded)
- fetal head entrapment (largest part of fetus comes last)
- increased maternal and fetal morbidity and mortality
20
Q
What are maternal risks with multiple gestation?
A
- anemia
- polyhydramnios
- HTN
- preterm labor
- post-partum uterine atony
- post-partum hemorrhage
- diabetes
- pre-eclampsia
- c-section
21
Q
What are fetal risks for multiple gestation?
A
- prematurity
- malpresentation
- placenta previa
- abruptio placenta
- PROM
- IUGR
- umbilical cord prolapse
- congenital anomalies
- increased morbidity and mortality
22
Q
When is vaginal delivery attempted for twins?
A
when twin A is vertex
23
Q
What is a relative indication for elective c-section for twins?
A
when twin B is not vertex
24
Q
What is the delivery mode of choice for triplets and quadruplets?
A
elective c-section
25
What are anesthesia implications for multiple gestation?
- anticipate large blood loss (adequate IV access, type and crossmatch, have pitocin, methergine, and hemabate available)
- anticipate emergency c-section for twin b (anesthesia may be required to be on stand-by)
26
What is premature rupture of the membranes?
rupture of membranes prior to 37 weeks gestation
27
What are complications of PROM?
chorioamnionitis
pre-term labor
fetal pulmonary hypoplasia
umbilical cord prolapse
28
What is the treatment for PROM?
- dependent upon gestational age, fetal lung maturity, presence of infection, and maternal/fetal well-being
- delivery always indicated in presence of infection or maternal/fetal compromise
- in absence of infection or compromise, delivery is dependent upon fetal viability and fetal lung maturity
- tocolysis controversial
- steroids may be administered to accelerate fetal lung maturity
29
What is the purpose of an amniocentesis?
determine fetal lung maturity and fetal abnormalities
30
What is the definition of preterm labor?
contractions with cervical dilatation/effacement at 20-37 weeks gestation
31
What are associated factors with preterm labor?
- infection (chorioamnionitis, STDs, UTIs)
- uterine distention (multiple gestation, polyhydramnios)
- uterine anomalies (fibroids, bicornuate uterus)
- cervical compromise (incompetent cervix, previous bone biopsy or LEEP procedure)
- placental abruption
- uteroplacental insufficiency (HTN, IDDM, smoking, drug abuse, alcohol consumption)
32
What are the 2 treatment options for preterm labor?
delivery (IUGR, abruption, bleeding, infection, +CST, oligohydramnios, repetitive variable decels)
tocolysis
33
What a tocolytic agents used for preterm labor?
MgSO4 (Ca channel blocker)
Indomethacin (PGE inhibitor)
Ritodrine and Terbutaline (beta sympathemomimetics)
Nifedipine (Ca channel blocker)
34
What are complications of MgSO4 for tocolysis?
respiratory or CNS depression, cardiac conduction block
35
What are complications of Indomethacin for tocolysis?
bronchospasm, bleeding, fetal NEC, fetal IVH
36
What are complications of ritodrine or terbutaline for tocolysis?
cardiac arrhythmias or ischemia, CHF
37
What do you do for fetal therapy in preterm labor?
- acceleration in fetal lung maturity occurs with stress
| - glucocorticoids also accelerate fetal lung maturity (delivery must be delayed for >/= 12 hours to be effective)
38
What glucocorticoids and doses can be given for fetal lung maturity during preterm labor?
Betamethasone 12.5 mg q24 hours x 2 doses
| Dexamethasone 6 mg q6 hours x 4 doses
39
What is abruptio placenta?
premature separation of the placenta from the uterus, significant cause of 3rd trimester bleeding, associated with both maternal and fetal morbidity and mortality
40
What is the clinical presentation of placental abruption?
- moderate to severe abdominal pain
- vaginal bleeding 80% (concealed hemorrhage possible)
- uterine contractions or hypertonus/tenderness
- fetal distress
41
What differentiates placental abruption from placenta previa?
abdominal pain
42
What are some causes of placental abruption?
- cigarette smoking
- cocaine abuse
- trauma (seat belt across the abdomen, domestic violence)
- other (chorioamnionitis, prolonged ROM >24 hours, pre-eclampsia, HTN)
43
What is the medical treatment for placental abruption?
- 2 large bore PIVs
- fluid resuscitation
- type and crossmatch
- correction of anemia and coagulopathy
- tocolysis is controversial
44
What is the surgical treatment for placental abruption?
emergency delivery
45
When is vaginal delivery done for placental abruption?
- if mom hemodynamically stable
- rapid labor
- preferred route with IUFD
46
When is c-section done for placental abruption?
- if necessary for maternal and fetal stabilization
- complications from coagulopathy
- classic vertical uterine incision often performed
- c-section-hysterectomy may be required
47
What is placenta previa?
placental implantation over the cervical os
48
What are the types of placenta previa?
complete
partial
marginal
low-lying
49
What is complete placenta previa?
placental implantation completely covers cervical os
50
What is partial placenta previa?
placental edge partially covers os
51
What is marginal placenta previa?
placental edge approaches os
52
What is low-lying placenta previa?
placental edge located at lower 1/2 or 1/3 of uterus
53
What are risk factors for placenta previa?
```
previous c-section
multiparity
hx of D&C
advanced maternal age
smoking
cocaine use
```
54
What is the hallmark symptom of placenta previa?
painless vaginal bleeding in the 2nd or 3rd trimester, first episode of bleeding is uaully a non-morbid heralding event
55
What is the medical treatment for placental previa?
- strict bedrest
- pelvic rest
- fluid resuscitation and transfusion prn
- tocolysis (allows for fetal lung maturity)
56
When would vaginal delivery be done for placental previa?
may be considered in marginal or partial previa with minimal bleeding, anesthesia may attend double set-up exam in delivery room
57
When would c-section be done for placental previa?
- safest mode of delivery
| - regional anesthesia preferred because decreases blood loss
58
What is placenta accreta?
placental attachment directly to myometrium
59
What is placenta increta?
placental attachment invades the myometrium
60
What is placenta percreta?
placental attachment penetrates the myometrium (worst)
61
What can cause uterine rupture?
previous myomectomy
VBAC
complication of forceps delivery or inappropriate use of pitocin
multiparas
62
What c-section incision has a higher change of uterine rupture?
classic vertical incision (1-2%), usually ruptures suddenly
63
What are the chances of a horizontal c-section incision causing uterine rupture?
0.5-1%, usually ruptures incompletely and slowly, often found on repeat c-section
64
What are intrapartum clinical findings of uterine rupture?
- may be hard to distinguish from abruption
- pain may be mild or severe
- may have mild to severe bleeding
- labor may stop
- may be loss of fetal movement and FHTs
- tetanic contractions can occur
65
What is the treatment for uterine rupture?
- emergent c-section
- surgical repair of defect (laparotomy if post-partum)
- hemodynamic support
66
What are the new definitions of post-partum hemorrhage?
- any bleeding that can or does result in hemodynamic instability
- EBL>1000 mL with vaginal delivery
- >10% decrease in Hct from prenatal value
67
What are some causes of postpartum hemorrhage?
```
uterine atony (most common)
cervical and/or vaginal lacerations
retained placenta
coagulopathy and thrombocytopenia
perineal or pelvic hematomas
uterine inversion
bicornuate uterus
uterine rupture
```
68
What is uterine atony?
uterus does not contract and blood loss continues from placental detachment site (normally contraction of the uterus compresses the severed spiral arteries and venous sinuses at the placental detachment site)
69
What is the treatment of uterine atony?
1. uterine massage
2. empty bladder
3. pitocin infusion (add 10-40 units/L IVF)
4. Methergine 0.2 mg IM
5. Hemabate 250 mcg IM q 15-30 mins
6. uterine curettage
7. internal iliac, hypogastric or uterine artery embolization
8. surgical exploration to repair lacerations or ligate arteries
9. hysterectomy
70
Why should you never give Pitocin IVP?
can cause peripheral vasodilation, tachycardia and hypotension
71
What are side effects of methergine and what route must it be delivered?
IM, causes HTN, vasoconstriction and increased PA pressures
72
What are some adverse effects of hemabate?
bronchospasm, VQ mismatch, hypoxemia
73
What is the incidence of uterine inversion and what can cause it?
1/25,000 deliveries
most common in multiparous patients
usually due to iatrogenic cause (when OB is trying to deliver the placenta)
74
What are the signs and symptoms of uterine inversion?
- placenta appears at introitus attached to a mass (inversion may be partial or complete)
- shock (bradycardia due to vagal response)
- excessive hemorrhage
75
What is the treatment of uterine inversion?
- treat blood loss and shock
- give uterine relaxants (inhalation anesthetics, NTG 50-200 mcg IV, terbutaline 0.25 mcg subq)
- immediate uterine replacement (Johnson maneuver: last part out = first part in)
- consider exploratory laparotomy
76
What is amniotic fluid embolism?
rare OB emergency in which amniotic fluid, fetal cells, hair, or other debris enter the maternal circulation causing cardiopulmonary collapse
77
When does an amniotic fluid embolism usually occur?
during labor, but has occurred during abortion, abdominal trauma, and amnioinfusion
78
What are the classic symptoms of amniotic fluid embolism?
acute SOB +/- cough
| severe hypotension
79
What are other possible symptoms of amniotic fluid embolism?
```
agitation
seizures
cyanosis
cardiac arrest
fetal bradycardia from hypoxia
pulmonary edema
uterine atony
```
80
What is the pathophysiology behind amniotic fluid embolism?
- amniotic fluid and fetal cells enter the maternal circulation via endocervical or uterine tears
- pulmonary vessels are obstructed resulting in vasospasm, pulmonary HTN, and hypoxia
- hypoxia causes myocardial and pulmonary capillary damage
- left heart failure occurs, decreasing CO
- ARDS develops
81
What is the treatment for amniotic fluid embolism?
supportive
- oxygen
- hemodynamic support (fluids, blood products, pressors, possible swan)
- coagulopathy treatment (FFP, cryo, platelets)
- consider steroids (process may be immune-mediated)
- CPR PRN (if unsuccessful perimortem c-section)
82
What is the maternal morbidity and mortality for amniotic fluid embolism?
80% mortality rate
50% die in 1st hour
coagulopathy develops in 50% who survive the 1st hour
permanent neurologic impairment occurs in most women that survive
83
What is the neonatal survival for amniotic fluid embolism?
70%
84
What causes DIC during pregnancy?
secondary to another disease process such as shock, infection, abruptio placenta, amniotic fluid embolism, IUFD, pre-eclampsia and eclampsia
85
What is the pathophysiology behind DIC?
- imbalance between clot-forming and clot-lysing systems in the blood
- starts with clotting due to endothelial or tissue damage (production of fibrin, consumption of clotting factors and platelets, activation of the fibrinolytic system)
86
What are clinical findings of DIC?
- thrombocytopenia
- prolonged bleeding time
- prolonged PT/pTT due to decrease in factors I, II, V, and VIII
- decreased fibrinogen
- elevated D-dimer and FDP/FSP
87
What is involved with the management of DIC?
- treatment of underlying condition
- invasive monitoring as indicated
- replacement of blood and clotting factors
- maintenance of tissue perfusion
- correction of acidosis
88
What are maternal complications of DIC?
organ infarction
limb ischemia
renal and pulmonary failure
death
89
What is hydatidiform mole?
- placental hyperproliferation without fetal tissue
- occurs in 1/1500 pregnancies
- 4-20% develop into choriocarcinoma
90
What are signs and symptoms of hydatidiform mole?
- vaginal bleeding
- hyperemesis (due to severely elevated Hcg levels)
- hyperthyroidism
- absence of fetal heart tones
- pre-eclampsia
- ovarian cysts
91
What are lab/clinical findings of hydatidiform mole?
- Hcg levels >10,000
- anemia
- "snow storm" image on ultrasound
- possible coagulopathy
- possible lung mets on CXR
92
What is the treatment for hydatidiform mole?
D&E
| start oxytocin at beginning of procedure
93
What are potential complications of hydatidiform mole?
- uterine perforation (uterus large and boggy)
- hemorrhage (have methergine and hemabate available)
- iatrogenic pulmonary edema
- DIC
- trophoblastic embolism (uterus>16 weeks size)
