Complications of Pregnancy Flashcards
1
Q
Complications during first trimester
A
- Hyperemesis gravidarum
- Spontaneous abortion
- Recurrent Abortion
- Ectopic pregnancy
- Gestational trophoblastic disease
2
Q
Hyperemesis gravidarum
A
-Extreme end of nausea/vomiting of pregnancy
-Diagnosis of exclusion
-Weight loss of > 5%
(Ketonuria, Electrolyte abnormalities, Liver abnormalities, Thyroid)
-Unknown cause
(Psychogenic, hCG, Estrogen?)
*HCG is higher when pregnant with multiples (hyperemesis, think multiples possibly)
3
Q
Treatments for Hyperemesis gravidarum
A
- Pyridoxine (vit B6): WORKS WELL
- Doxylamine (antihistamine): WORKS WELL
- Ondansetron
- Metoclopramide
- Promethazine
- Corticosteroids
- IV fluids, parenteral nutrition, enteral tube feedings
4
Q
Complications of Hyperemesis gravidarum for mom
A
Hyperemesis gravidarum
5
Q
Spontaneous abortion may occur at _______
A
6
Q
KNOW CHART WITH TYPES OF SPONTANEOUS ABORTIONS FOR TEST AND BOARDS
A
slide 7
screen shot in exam folder
7
Q
Treatment for spontaneous abortion
A
- Hemodynamically stable: misoprostone +/- mifepristone
- Hemodynamically unstable: D&C (Dilation and curettage)
- If >12 weeks: D&E
8
Q
Recurrent abortion is defined as
A
3+ spontaneous abortions
-Abnormalities can be found in
9
Q
Things to check on a patient with recurrent abortions
A
- Karyotype
- Uterine assessment (look for septums, etc)
- Anticardiolipin antibody, lupus anticoagulant
- Thombophilia assessment: (Factor V Leiden, Prothrombin gene mutaation, Antithrombin III, homocystine, protein S and C)
- Thyroid function
10
Q
Ectopic pregnancy
A
- pregnancy outside the uterine cavity
- 98% tubal
- Risk factors to having this: infertility, PID, prior tubal surgery
- 10% risk of recurrence
11
Q
S/S of Ectopic pregnancy
A
-lower abdominal pain and bleeding
-Need to check hCG and CBC
-Need ultrasound
-May do Culdocentesis
or Laparoscopy
12
Q
Treatment for Ectopic Pregnancy
A
- Medical: Methotrexate
(ONLY IF emodynamically stable,
13
Q
Gestational Trophoblastic disease consists of
A
- Hydatidiform mole (partial or complete)
- Invasive mole
- Choriocarcinoma (cancer)
- Placental site trophoblastic tumor (cancer)
14
Q
Partial Hydatidiform mole facts
A
- Karyotype: 69XXY or 69 XYY or 69 XXX (less commonly)
- hCG elevated
- 2 sperm fertilize 1 egg
- Fetal tissue PRESENT
- Focal swelling of chorionic villi
- Focal trophoblastic hyperplasia
- Rarely see theca lutein cysts on ovaries
- rarely malignant sequelae
- rarely medical complications
15
Q
Complete Hydatidiform mole facts
A
- Karyotype: 46XX or 46 XY (all paternal, EMPTY OVUM)
- hCG VERY ELEVATED!
- ABSENT fetal tissue
- Diffuse swelling of chorionic villi
- Diffuse trophoblastic hyperplasia
- May see theca lutein cysts in ovaries (15-25%)
- May have malignant sequelae (6-23%)
- May have medical complications (
16
Q
S/S of hydatidiform mole
A
- Bleeding
- Large uterus (bc of swelling)
- Hyperemesis
- HTN
- Extremely elevated hCG
- Placental vesicles on ultrasound (“grape-like clusters”)
- Can get hyperthyroidism due to high hCG
17
Q
Ultrasound finding of complete mole
A
“Snow storm” pattern
18
Q
Ultrasound finding of partial mole
A
can see fetal pattern but also snowstorm pattern
19
Q
Treatment of hydatidiform mole
A
- D&C
- CXR
20
Q
ALWAYS order this if pt has hydatidiform mole
A
CXR- always get chest xray bc you CAN have metastasis to chest
21
Q
Medical follow up for hydatidiform mole
A
- Birth control!!
- Weekly hCG until 3 negatives
- hCG every 1-3 months for 6 months (monitor for at least 6 months to make sure hCG stays neg)
22
Q
Post molar gestational trophoblastic disease
A
- malignancy
- Ways to diagnose why hCG not going down properly:
- hCG plateau 4x over 3 weeks
- hCG increase >10%, 3x over 2 weeks
- Persistence of hCG after 6 months
23
Q
Treatment for Post molar gestational trophoblastic disease
A
Methotrexate chemo
24
Q
Choriocarcinoma
A
-Persistent bleeding or hCG after delivery/D&C
- Metastasis: vagina, lung, liver, brain
- Metastasis looks like black dots
- Chemotherapy: MTX (methotrexate) or actinomycin
25
Complications in 2nd and 3rd trimesters
1. Pre-eclampsia or eclampsia
2. Acute fatty liver of pregnancy
3. Gestational diabetes
4. Preterm labor/Preterm rupture of membranes
5. Oligo- or Poly-hydramnios
6. Bleeding (Placental abruption, Placenta previa, Vasa previa)
7. Cholestasis of Pregnancy
26
Pre-eclampsia
Elevated blood pressure + proteinuria
- Treatment: delivery
- Risk FActors: multiple gestations, CHTN, DM, kidney disease, collagen-vascular disorders, autoimmune disorders, GTN
27
Eclampsia
pre-eclampsia (HTN, proteinuria) PLUS seizures (5%)
**obstetric emergency**
28
Timeline to qualify as pre-eclampsia
Only after 20 weeks gestation to
29
Mild pre-eclampsia/eclampsia
140-160/ 90-110
| Proteinuria: 0.3-5g/24 hrs
30
Severe pre-eclampsia/eclampsia
>160/ >110
| Proteinuria: >5 g/24 hrs
31
HELLP (pre-eclampsia/eclampsia)
hemolysis, elevated liver enzymes, low platelets
32
S/S and labs during pre-eclampsia/eclampsia
May see RUQ pain, HA, blurred vision or scotoma, hyperreflexia or clonus, low urine output (kidneys not working right), check platelets and LFTs (liver function), high hemoblibin is red flag, should actually have a physiological anemia= ask about these if concerned about pre-eclampsia
33
Fetal findings during pre-eclampsia/eclampsia
growth restriction, oligohydramnios, fetal distress
34
Treatment for pre-eclampsia/eclampsia
*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
35
You can prevent eclampsia with
Magnesium sulfate
| Reverse mag toxicity with calcium gluconate
36
Acute Fatty Liver of Pregnancy
- Acute hepatic failure
- Poor placental mitochonrial function
- Flu-like symptoms (abd pain, jaundice, encephalopathy, DIC, death)
- Elevated Alk Phos, PT, Bilirubin, mild elevation of AST/ALT
- high mortality rate, rare disease
* *Hypoglycemia- SEE SEVERE HYPOGLYCEMIA
-Treatment: immediate delivery, supportive care
37
What to think of you see patient with severe hypoglycemia?
Acute Fatty Liver of Pregnancy
38
Cholestasis of pregnancy
- usually 3rd trimester
- Incomplete clearance of bile acids
- Generalized pruritis – especially palms of hands and soles of feet
- Elevated bile acids
- Treatment: ursodeoxycholic acid
* Increased risk of stillbirth
- Increased surveillance, early delivery
39
Gestational Diabetes
- Abnormal glucose tolerance
- Human placental lactogen (chorionic somatomammotropin)
- Increase in # of pancreatic beta cells
- Natural “insulin resistant” state
- Glucose and amino acids are going to fetus
- Increases between 24-30 weeks gestation
- Usually increase glucose resistance in pregnancy (want baby to get glucose)
- When pancreatic function not sufficient --> Gestational Diabetes
* *50% of women with GDM will develop overt DM
40
Pregnancy implications
| of gestational diabetes
- Excessive fetal growth
- Shoulder dystocia
- Cesarean section
- Pre-eclampsia
- Fetal hypoglycemia
41
Testing for gestational diabetes
2 steps:
1. Screening: 50g glucose tolerance test (1 hour)
2. Diagnostic: 100g glucose tolerance test
(3 hours)
- Less than 140 is normal
- More that 140 means you need diagnostic test
42
Types of gestational diabetes
A1: controlled with diet (nutritional counseling)
A2: controlled with medication (Insulin, glyburide, metformin)
43
Preterm Labor
44
Testing for preterm labor
Tocometer
Fetal heart tones
Cervical exams
Fetal fibronectin
45
Preterm Labor: Interventions to improve neonatal outcome
-Between 24-34 weeks: corticosteroids
| -
46
Cervical Insufficiency (preterm labor)
- Cervical dilation without contractions
- Short cervical length (baby is closer to coming out)
- Treatment: Cervical cerclage (sew it), Vaginal progesterone
47
Oligohydraminos
-Too little amniotic fluid (
48
Fetal complications of Oligohydraminos
- Potter sequence: pulmonary hypoplasia, limb deformities, flattened facies
- NRFS (Nonreassuring fetal status is a medical term that is used when test results suggest that your baby may be having problems late in pregnancy)
49
Causes of Oligohydraminos
- Placental insufficiency
- Bilateral renal agenesis
- Posterior urethral valves
- PPROM
50
Polyhydramnios
Too much amniotic fluid (>1.5-2L)
By AFI: >24, DVP >8
-Baby can’t swallow amniotic fluid
Uterus is stretched more that usual, can lead to early labor
-Risks: maternal respiratory issues, malpresentation, PTD/PPROM, cord prolapse, abruption, uterine atony (bleeding)
51
Causes of Polyhydramnios
- Fetal malformations
- Esophageal/duodenal atresia
- Anencephaly
- Maternal diabetes
- Fetal anemia
- Multiple gestation
52
Treatment for Oligohydramnios
Amnioinfusion (Can infuse saline) and Hydration
53
Treatment for Polyhydramnios
- Indomethacin
| - Amnioreduction (remove with needle)
54
**Placental causes of bleeding**
- Placental abruption
- Placenta previa
- Placenta accreta
- Vasa previa
55
Non-placental causes of bleeding
- Labor/PTL/CI
- Infection
- Disorder of lower genital tract
- Cervical trauma
- Systemic disease
56
Placental 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
57
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
- RF: prior c-section**, multiparity, age, smoking
- Symptoms: PAINLESS vaginal bleeding
- Digital exam/internal exam can be very dangerous
-Delivery: c-section
(need appropriate planning, can result in massive hemorrhage, then pt needs hysterectomy)
58
Uterine Rupture
- Uncommon
- Prior uterine scar (from C-section or myomectomy)
- PAINFUL bleeding
- Non-reassuring fetal heart tones
- Management: immediate delivery
59
Vasa Previa
- Portion of membranes cover the internal cervical os with fetal blood vessels
- Velamentous umbilical cord
- Placental lobes with connection
60
Stillbirth/ IUFD (intrauterine fetal demise)
- 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
61
Peripartum conditions
- Mastitis
- Chorioamnionitis
- Endometritis
62
Mastitis
-Staph aureus
| -
63
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
64
Endometritis
Uterine infection diagnosed after pregnancy
65
S/S of uterine infections
-Fever
-One of the following:
1. Maternal tachycardia
2. Fetal tachycardia
3. Foul smelling lochia
4. Uterine tenderness
+/- amniocentesis
66
Treatment of uterine infections
Broad spectrum antibiotics:
Ampicillin/Gentamycin
Ertapenem
67
Antiphospholipid antibody syndrome
-Arterial/venous thrombosis and adverse pregnancy outcomes + lab evidence of antiphospholipid antibodies
-Treatment in pregnancy:
Heparin (LMWH) and low dose aspirin
68
Diagnosis of APS (Antiphospholipid antibody syndrome)
* Sydney crideria (Sapporo classification criteria)
- Diagnosis = 1 clinical + 1 lab criteria
-Clinical:
1. 1+ episode of venous, arterial, small vessel thrombosis
2. Pregnancy morbidity:
(Unexplained fetal death >10 wks gestation, 1+ PTD
69
Hypothyroidism
- SAB, PTD, preeclampsia, placental abruption, impaired neuropyschological development
- Treat with levothyroxine
- Serial labs
70
Hyperthyroidism
-SAB, PTD, preeclampsia, maternal heart failure
-Thyroid storm: life threatening
-Propylthiouracil: hepatotoxicity, agranulocytosis (in first trimester)
-Methimazole: congenital aplasia cutis, choanal/esophageal atresia
(Second/third trimester)
-Beta blocker
-NO radioiodine ablation
71
Pre-existing DM
-SAB and IUFD
-Fetal malformations:
Cardiac, skeletal and neural tube defects; caudal regression syndrome, Slow fetal growth,
Inverse relationship with glucose control
72
Chronic hypertension
- Differentiate from preeclampsia!
- Superimposed preeclampsia: 20-50%
- Antihypertensives when BP is over 150/100 or end organ damage
* No ACE-I or ARB
Diuretics: don’t start in pregnancy, but may continue
73
Asthma
- Treat similarly in pregnancy
- Pulmonary function tests
- Beta 2 agonists
- Inhaled corticosteroids
- Systemic corticosteroids
**Minimize hypoxic episodes to fetus
74
Seizure disorders
- Discontinuation of meds if seizure free 2-5 years
- Consider teratogenicity of medications
- Discontinue valproic acid
- Newer anti epileptic drugs (Lamotrigine, Topiramate, Oxcarbazepine, Levetiracetam)
- Give mom folic acid
75
UTI in pregnancy
-Treat asymptomatic UTIs!!
-risk for preterm delivery
-Very common in pregnancy
(Predisposition to urinary stasis, Pressure exerted by gravid uterus on ureters and bladder cause hypotonia and congestion)
-20-40% develop pyelonephritis
76
Treatment for UTIs
- Nitrofurantoin, *ampicillin*, cephalexin
- NO sulfonamides in 3rd trimester (may cause neonatal hyperilirubinemia)
- NO flouroquinolones (causes fetal carilage and bone defects)
**Always do test of cure
77
GBS
-test all moms
-can cause neonatal sepsis:
(20-30% mortality in premature infants, mental retardation, neurologic disability)
-treat with ampicillin
78
Who gets treated for GBS?
- Anyone with + vaginal/rectal culture
- Anyone with + urine culture
- Prior infant with invasive GBS disease
- Mom who has unknown culture with elevated temperature, ruptured membranes >18 hours, preterm (
79
Congenital Varicella S/S
- Skin lesions
- Limb/digit abnormalities: hypoplasia
- Microcephaly
- Ocular defects: cataracts, microphthalmos
80
Varicella during 2nd, 3rd trimesters
- Protected by maternal IgG
- Risk: maternal infection 5 days before – 2 days after delivery
- Give VZIG within 96 hrs of exposure (up to 10 days)
- Theres a maternal risk of pneumonia
81
Tuberculosis
-Latent disease: treatment postpartum
-Active disease:
1. Isoniazid and ethambutol
2. Isoniazid and rifampun
V3. itamin B6
- Good prognosis if appropriately treated
- Postpartum treatment doesn’t effect breastfeeding
82
HIV/AIDS
-High neonatal transmission rate (66%) in the past- NOW ONLY 2%
- CD4 count, viral load
- Continue current antiretroviral regimen
- 3 drug therapy regardless of viral load and CD4 count (2nd trimester and after)
- IV zidovudine before delivery when viral load >400
- Cesarean delivery if viral load >1000
83
Hep B
- Vertical transmission blocked by hep B IG and hep B vaccine
- Repeat vaccine at 1 month and 6 months
84
Hep C
5-6% transmission rate
| 14% when also HIV+
85
Genital Herpes- Primary infection late in pregnancy
- High risk of transmission
| - Acyclovir 400mg 3x/day
86
Genital Herpes- Recurrent infection
- Lower neonatal attack rate
- Asymptomatic shedding is common
- Cesarean if active lesion or prodromal symptoms
- Acyclovir prophylaxis at 36 weeks
87
Syphilis
| *KNOW*
- May cause: Abortion, IUFD (intrauterine fetal demise), transplacental infection, congenital syphilis
- Early: Hepatomegaly, rhinitis, rash, nonimmune fetal hydrops, myocarditis, pneumonia, etc.
- Late: frontal bossing, saddle nose, hutchinson teeth, mulberry molars, saber shins, etc.
88
Gonorrhea
- Large joint arthritis, ophthalmia neonatorum
- Ulceration, scarring, visual impairment
- eyes crusted shut
89
Chlamydia
- inclusion conjunctivitis, pneumonia
| - eyes crusted shut
