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
preterm labor: Interventions to improve neonatal outcome
-Between 24-34 weeks: corticosteroids
-less than 32 weeks: magnesium sulfate (prevent CP)
Antibiotics
Tocolysis (stop labor): Terbutaline, Nifedipine, Indomethacin (stops contractions only use for about 48 hrs, dec. fluid around baby)
Prevention: IM progesterone?
Cervical insufficiency
-Cervical dilation without contractions
-Short cervical length
-Treatment:
Cervical cerclage
Vaginal progesterone
oligohydramnios
Too little amniotic fluid (less than 0.5L)
Measured by Amniotic Fluid Index: less than 5, DVP (deep pouch): less than 2
Fetal complications:
POTTER sequence: Pulmonary hypoplasia, Oligohydramnios (trigger), Twisted face, Twisted skin, Extremity defects, Renal failure (in utero)
NRFS
Causes: Placental insufficiency Bilateral renal agenesis Posterior urethral valves PPROM
Polyhydramnios
Too much amniotic fluid (more than 1.5-2L)
By AFI: greater than 24, DVP more than 8
Causes:
Fetal malformations:
Esophageal/duodenal atresia (can’t swallow it), Anencephaly
Maternal DM, Fetal anemia, Multiple gestation
Risk of: maternal respiratory issues, malpresentation, PTD/PPROM, cord prolapse, abruption, stretch of uterus, uterine atony (doesn’t contract down like it should–>bleeding–>hemorrhage)
Oligo- or Polyhydramnios Treatment
Oligohydramnios:
Amnioinfusion
Hydration
Polyhydramnios:
Indomethacin
Amnioreduction
Bleeding: placental causes
Placental abruption
Placenta previa
Placenta accreta
Vasa previa
Bleeding: non-placental causes
Labor/PTL/CI Infection Disorder of lower genital tract Cervical trauma Systemic disease
placenta abruption
Premature separation of the placenta RF: *HTN, *cocaine, multiparity, smoking, prior abruption, thrombophilias Symptoms: PAINFUL bleeding, frequent contractions Non-reassuring fetal status Severe hemorrhage slide 41: too many contractions?
Placenta previa
Placenta covers internal cervical os:
- Placenta accreta: Placental tissue invades through the endometrium
- Placenta increta: invasion to myometrium
- Placenta percreta: invasion through uterine serosa (“higher percentage”, may invade bladder)
RF: prior c-section**
Symptoms: PAINLESS vaginal bleeding
Delivery: C-section
Appropriate planning, can result in massive hemorrhage–>hysterectomy
(can only consider vaginal delivery with low lying
Uterine rupture
Uncommon Prior uterine scar (0.3-1%) C-section Myomectomy PAINFUL bleeding Non-reassuring fetal heart tones Management: immediate delivery
Vasa Previa
Portion of membranes cover the internal cervical os with fetal blood vessels:
- Velamentous umbilical cord
- Placental lobes with connection
Stillbirth/IUFD
Loss of pregnancy >20 weeks Similar work up as recurrent abortion Add syphilis testing, parvovirus B19 and maternal-fetal hemorrhage screen Possible fetal autopsy Delivery: Induction of labor Prior c-section not a contraindication Increased surveillance in subsequent pregnancies
Peripartum
Mastitis
Chorioamnionitis
Endometritis
Mastitis
Staph aureus more than 3 months after delivery Engourged breast Cellulitis Fever/chills Eval for abscess (esp with MRSA)
Tx: dicloxacillin or cephalosporin
Continue nursing
Abscess drainage
Uterine infections: Chorioamnionitis
Uterine infection diagnosed during pregnancy
Polymicrobial
RF: prolonged labor, c-section, internal monitors, mutliple exams, prolonged ROM, lower genital infection
Maternal sequelae: abnormal labor, hemorrhage
Fetal sequelae: sepsis, pneumonia, IVH, CP
Uterine infections: Endometritis
Uterine infection diagnosed after pregnancy
uterine infection dx and tx
dx: Fever One of the following: Maternal tachycardia Fetal tachycardia Foul smelling lochia Uterine tenderness \+/- amniocentesis -screen at 35 wks for GBS tx: Broad spectrum antibiotics: (during labor) Ampicillin/Gentamycin Ertapenem
Pre-Existing Medical Problems
Anemia Antiphospholipid Antibody Syndrome Thyroid disease Diabetes Mellitus Chronic Hypertension Heart DiseaseAsthma Seizure disorders
Antiphospholipid Antibody Syndrome
Arterial/venous thrombosis and adverse pregnancy outcomes + lab evidence of antiphospholipid antibodies
Treatment in pregnancy:
Heparin (LMWH) and low dose aspirin
APS
Diagnosis: Sydney crideria (Sapporo classification criteria)
Diagnosis = 1 clinical + 1 lab criteria
Clinical:
-1+ episode of venous, arterial, small vessel thrombosis
-Pregnancy morbidity:
Unexplained fetal death more than 10 wks gestation, 1+ PTD less than 34 wks 2/2 eclampsia, preeclampsia, placental insufficiency, 3+ fetal losses less than 10 wks gestation
-Lab: 2+ occasions, 12 wks apart: IgG or IgM anticardiolipin abs, Abs to beta2-glycoprotein I, Lupus anticoaculant activity
Hypothyroidism:
SAB, PTD, preeclampsia, placental abruption, impaired neuropyschological development
Treat with levothyroxine
Serial labs
Hyperthyroidism:
SAB, PTD, preeclampsia, maternal heart failure
Thyroid storm: life threatening
Propylthiouracil: hepatotoxicity, agranulocytosis
First trimester
Methimazole: congenital aplasia cutis, choanal/esophageal atresia
Second/third trimester
Beta blocker
NO radioiodine ablation
Pre-existing Diabetes Mellitus
SAB and IUFD
Fetal malformations:
Cardiac, skeletal and neural tube defects; caudal regression syndrome
Slow fetal growth
Inverse relationship with glucose control
chronic HTN
ddx from preeclampsia!
Superimposed preeclampsia: 20-50%
Antihypertensives when BP over 150/100 or end organ damage
*No ACE-I or ARB
Diuretics: don’t start in pregnancy, but may continue
asthma
Treat similarly in pregnancy Pulmonary function tests Beta 2 agonists Inhaled corticosteroids Systemic corticosteroids
**Minimize hypoxic episodes to fetus
seizure disorders
Discontinuation of meds if seizure free 2-5 years
Consider teratogenicity of medications: D/C valproic acid
-Newer antiepileptic drugs:Lamotrigine, Topiramate, Oxcarbazepine, Levetiracetam
-Folic acid
Infectious complications
UTI GBS Varicella Tuberculosis HIV/AIDS Hepatitis B/C Herpes Genitalis Syphilis, Gonorrhea, Chlamydia
UTI of preg
Very common in pregnancy Predisposition to urinary stasis 2-8% have asymptomatic bacteriuria TREAT Risk of PTD 20-40% develop pyelonephritis
how to tx UTI
Nitrofurantoin, ampicillin, cephalexin No sulfonamides in 3rd trimester Neonatal hyperilirubinemia No flouroquinolones Fetal carilage and bone defects Always do test of cure
GBS
Carriage rate 10-30%
30% spontaneous clearing
10% recolonization
Neonatal sepsis:
20-30% mortality in premature infants (2-3% in term)
Mental retardation
Neurologic disability
GBS tx
Anyone with + vaginal/rectal culture Anyone with + urine culture Prior infant with invasive GBS disease Unknown culture with Elevated temperature Ruptured membranes more than 18 hours Preterm (less than 37 weeks)
VZV
-Congential VZV syndrome: Skin lesions Limb/digit abnormalities Limb abnormalities: hypoplasia Microcephaly Ocular defects: cataracts, microphthalmos
-2nd, 3rd trimesters:
Protected by maternal IgG
Risk: maternal infection 5 days before – 2 days after delivery
-VZIG within 96 hrs of exposure (up to 10 days)
Maternal risk of pneumonia
TB
Latent disease: treatment postpartum Active disease: Isoniazid and ethambutol Isoniazid and rifampin Vitamin B6
Good prognosis if appropriately treated
HIV/AIDS
High neonatal transmission rate (66%) in the past
Now 2%
CD4 count, viral load
Continue current antiretroviral regimen
3 drug therapy regardless of viral load and CD4 count
Second trimester
IV zidovudine before delivery when viral load greater than 400
Cesarean delivery if viral load more than 1000
Hep B/C
Vertical transmission blocked by hep B IG and hep B vaccine
Repeat vaccine 1 month and 6 month
Hep C: 5-6% transmission rate
14% when also HIV+
Herpes Genitalis
Primary infection late in pregnancy
High risk of transmission
Acyclovir 400mg TID
Recurrent infection:
- Lower neonatal attack rate
- Asymptomatic shedding is common
- Cesarean if active lesion or prodromal symptoms
- Acyclovir prophylaxis at 36 weeks
-Neonatal infection: SEM, CNS, Disseminated disease
Herpes Genitalis
Neonatal infection
Skin, eye mouth
Central nervous system
Disseminated disease
Syphilis transmission
Abortion, IUFD, transplacental infection, congenital syphilis
early syphilis signs
Hepatomegaly, rhinitis, rash, nonimmune fetal hydrops, myocarditis, pneumonia, etc.
late syphilis signs
frontal bossing, saddle nose, hutchinson teeth, mulberry molars, saber shins, etc.
G/C
Gonorrhea:
Large joint arthritis, ophthalmia neonatorum (Ulceration, scarring, visual impairment)
Chlamydia:
inclusion conjunctivitis, pneumonia
Zika virus
- transmitted by mosquitos
- if pregnant: baby–>microencephaly, neurologic deficits
- may get late abortions
