complications of pregnancy Flashcards
probs in 1st trimester
Hyperemesis gravidarum Spontaneous abortion Recurrent Abortion Ectopic pregnancy Gestational trophoblastic disease
Hyperemesis Gravidarum
Extreme end of nausea/vomiting of pregnancy Diagnosis of exclusion 0.3-3% of pregnancies Weight loss of more than 5%: Ketonuria Electrolyte abnormalities Liver abnormalities Thyroid Unknown cause: ?Psychogenic ?hCG ?Estrogen
Hyperemesis Gravidarum
Maternal Effects
Fetal Effects
Treatment: Pyridoxine (vit B6), Doxylamine, (Diclegis is combo of those 2) anti emetics: Ondansetron, Metoclopramide, Promethazine
Corticosteroids
IV fluids, parenteral nutrition, enteral tube feeding
Spontaneous abortion
less than 20 weeks gestation
Common – 20% of pregnancies
60% due to chromosomal defects
table slide 7
Spontaneous Abortion
Work up: Vitals, hCG, CBC, Blood type, Ultrasound Treatment: -Hemodynamically stable: Expectant Medical: misoprostone +/- mifepristone -Hemodynamically unstable: D&C -more than 12 weeks: D&E
recurrent abortions
3+ spontaneous abortion: Abnormalities can be found in more than 50%
- check for Karyotype
- Uterine assessment (septums)
- Anticardiolipin antibody, lupus anticoagulant
- Thombophilia assessment: (Factor V Leiden, Prothrombin gene mutaation, Antithrombin III, homocystine, protein S and C)
- Thyroid function
ectopic preg
Pregnancy outside the uterine cavity 98% tubal RF: infertility, PID, prior tubal surgery 10% risk of recurrence more slide 12, 13
ectopic preg
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ectopic preg
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Gestational Trophoblastic Disease
Hydatidiform mole: partial or complete
Invasive mole
Choriocarcinoma
Placental site trophoblastic tumor
Hydatidiform mole
1/1500 pregnancies
20% malignant sequelae
Aberrant fertilization
chart slide 15
hydatidiform mole dx
Bleeding
Large uterus
Hyperemesis
HTN
Extremely elevated hCG
can cause hyperthyroidism
Placental vesicles on ultrasound ("snow storm pattern")
biopsy: “grape-like clusters”hydatidiform mole tx
D&C
CXR
hydatitiform mole follow up
Birth control!! (don’t want them to get pregnant again and raise HCG)
Weekly hCG until 3 negatives
hCG q1-3 months x 6 months
(should decrease after D/C)
Post molar gestational trophoblastic disease:
hCG plateau x4 over 3 weeks
hCG increase more than 10% x3 over 2 weeks
Persistence of hCG after 6 moths
-methotrexate
Choriocarcinoma
1/20,000-40,000 pregnancies
50% after term pregnancies, 25% after molar pregnancies, 25% other
-Persistent bleeding or hCG after delivery/D&C
Metastasis – vagina, lung, liver, brain
-Chemotherapy: MTX or actinomycin
Second and Third Trimesters
Pre-eclampsia/eclampsia
Acute fatty liver of pregnancy
Gestational diabetes
Preterm labor/Preterm rupture of membranes
Oligo- or Poly-hydramnios
Bleeding: Placental abruption, Placenta previa, Vasa previa
Cholestasis of Pregnancy
Pre-eclampsia/eclampsia
Pre-eclampsia: Elevated blood pressure + proteinuria (if no proteinuria just gestational HTN)
Eclampsia: + seizures (5%)
-more than 20 weeks gestation to less than 6 weeks postpartum
-Treatment: delivery
-Incidence: 7%
Risk Factors: multiple gestations, CHTN, DM, kidney disease, collagen-vascular disorders, autoimmune disorders, GTN
Pre-eclampsia/Eclampsia: mild vs. severe
mild: BP: 140-160/90-110 proteinuria: 0.3-5g/24hrs severe: BP: more than 160/110 proteinuria: more than 5g/24hrs
Other indications of severe disease:
S/S: (ha, scotomas, hyperreflexia, clonus, low urine output)
Labs (listen)
Fetal findings
Pre-eclampsia/Eclampsia tx
Treatment:
** Delivery
Allow fetal lung maturity
Mild: 37 weeks at the LATEST
Severe: 34 weeks at the LATEST (Corticosteroids, aggressive fetal monitoring, serial labs and evaluation)
Prevent eclampsia: Mg sulfate (calcium gluconate if toxicity)
Treat blood pressure
Eclampsia: obstetric emergency!
HELLP
hemolysis, elevated liver enzymes, low platelets
tx: delivery
Acute Fatty Liver of Pregnancy (rare, but high mort. rate)
Acute hepatic failure
7-23% mortality
Poor placental mitochonrial function
Flu-like symptoms–>abd pain, jaundice, encephalopathy, DIC, death
-Elevated Alk Phos, PT, Bilirubin, mild elevation of AST/ALT
**Hypoglycemia
Treatment: immediate delivery, supportive care
Cholestasis of Pregnancy
Incomplete clearance of bile acids
Generalized pruritis – especially hands and feet
Elevated bile acids
Treatment: ursodeoxycholic acid
*Increased risk of stillbirth: Increased surveillance, early delivery
Gestational Diabetes*
Abnormal glucose tolerance
Human placental lactogen (HPL, chorionic somatomammotropin):
-Increase in # of pancreatic beta cells
-Natural “insulin resistant” state
-Glucose and amino acids–>fetus
-Increases between 24-30 weeks gestation (when screen)
When pancreatic function not sufficient–>Gestational Diabetes
50% of women with GDM will develop overt DM may change DM screening
Gestational diabetes: Pregnancy implications
Excessive fetal growth Shoulder dystocia Cesarean section Pre-eclampsia Fetal hypoglycemia
Gestational diabetes Testing – 2 steps
Screening – 50g glucose tolerance test (1 hour)
- between 24-48 weeks
- if greater than 140 do dx test
Diagnostic – 100g glucose tolerance test (3 hours) normal glucose levels: fasting: 95 or less 1 hr: 180 2 hr: 155 3 hr: 140
*if 2 abnormal, dx with GDM
Gestational diabetes Types:
Testing
A1: controlled with diet
A2: controlled with medication: *Insulin, glyburide, metformin
preterm labor
Labor before 37 weeks
RF: prior PTD, PPROM, multiple gestation, intrauterine infection, mullerian anomalies, smoking, substance abuse, BV (bac bag), low socioeconomic status
Testing: Tocometer (see if contracting), FHTs, Cervical exams, Fetal fibronectin
