Complications of Pregnancy Flashcards
What is the most common complication of early pregnancy?
Spontaneous abortion
- What is a spontaneous abortion defined as?
- What is considered a still birth?
- 80% occur when?
- Intrauterine pregnancy at less than 20 weeks
2, After 20 weeks considered still birth
- About 80% occur in the first trimester
Etiology of Spontaneous Abortion
8
1. 60% result from chromosomal defects 15% associated with 2. Maternal trauma 3. Infections 4. Dietary deficiencies 5. Diabetes mellitus 6. Hypothyroidism 7. Anatomic malformations – incompetent cervix 8. 25% cannot be determined
Biggest Risk Factors For Spontaneous Abortion
3
- Advanced maternal age
- Previous spontaneous abortion
- Maternal smoking
Symptoms of Spontaneous Abortion
5
- Bleeding
(Bright red mostly, Heavy – saturating pads) - Midline cramping
- Low back pain
- Open or closed cervical os
- Complete or partial expulsion of products of conception
Define the Subtypes of Spontaneous Abortion
1. Threatened?
- Inevitable?
- Incomplete?
- Complete?
- Missed?
- Os closed, unpredictable outcome
- Os open, products of conception have not passed, pregnancy cannot be saved
- Os open, some products of conception have passed
- Os may be open or closed, products of conception have passed
- Pregnancy did not develop
Threatened Abortion
Signs
6
- Slight bleeding
- Abdominal cramping
- Cervical os is CLOSED
- Uterine size compatible with dates
- No products of conception are passed
- Prognosis is unpredictable
Treatment Measures
Threatened abortion?
9
- Bed rest from 24 - 48 hours with gradual resumption of usual activities
- No work, no child care responsibilities
- Rest in horizontal position, except when bathing or using the toilet
- No sexual intercourse
- Antibiotics ONLY if there are signs of infection
- Hormonal treatment is contraindicated
- Hydration
- Explicit instructions on when to report signs and symptoms
- Definitive follow-up date
Inevitable Abortion
signs?
8
- Moderate bleeding
- Moderate to severe uterine cramping
- Low back pain
- Cervical os is DILATED
- Membranes may or may not be ruptured
- Uterine size is compatible with dates
- Products of conception are not passed, but passage is inevitable
- Prognosis is poor, pregnancy cannot be saved
Incomplete abortion signs?
7
- Heavy bleeding
- Moderate to severe abdominal cramping
- Low back pain
- Cervical os is DILATED
- Uterine size is compatible with dates
- Some portion of the productions of conception (usually the placenta) remain in the uterus
- Pregnancy cannot be saved
Missed Abortion
signs?
6
- Pregnancy ceased to develop, but products of conception have not been expelled
- Symptoms of pregnancy disappear
- Brownish vaginal discharge but no free bleeding
- Pain does not develop
- Cervix is semi-firm and slightly dilated
- Uterus becomes smaller and irregularly softened
Treatment measures for Missed, Inevitable, or Incomplete abortion?
3
- Counseling regarding fate of the pregnancy
- Assess Rh factor and administer immunoglobulin to Rh negative, unsensitized woman
- Planning for elective termination
Treatment measures for Missed, Inevitable, or Incomplete abortion:
How can we plan for elective termination?
3
- Empty all products of conception to prevent infection and uterine hemorrhage with D&C
- Insertion of laminaria to dilate the cervix followed by aspiration is the method of choice for missed abortion
- Prostaglandin vaginal suppositories are an effective alternative
Complete Abortion
signs? 7
- Bleeding may be heavy or minimal
- Moderate to severe abdominal cramping
- Low back pain
- Fetus and placenta are completely expelled
- Pain then ceases, but spotting may persist
- Cervical os may be opened or closed
- Uterus is normal pre-pregnancy size
- Habitual Abortions
defined as? - Three previous pregnancies – _____% chance of carrying a fetus to viability
- Four or more – _____% chance of carrying a fetus to viability
- Considered recurrent pregnancy loss/habitual abortions if 3 previous pregnancies
- 70-80
- 65-70
Evaluation of Suspected Spontaneous Abortion
5
- History
- Physical exam including pelvic exam and visualization of cervix
- +/- Fetal doppler
- +/- Transvaginal ultrasound
- +/- Laboratory evaluation
What labs would you do for a spontaneous abortion?
2
- Serum hCG
2. Blood type and antibody screen if suspected RH negative mother
Work-up For Recurrent Pregnancy Loss
1. Most useful tests? 3
- Less useful tests? 4
- Most useful tests
- Assessment of uterine structure
- Rule out lupus (anticardiolipin antibody, lupus anticoagulant)
- TSH - Less useful tests
-Blood glucose
-Genetic (only if other testing is normal)
-Maternal and paternal
-Day 3 FSH levels
Progesterone levels
Follow-up of Spontaneous Abortion
1. When?
- Use contraception until when?
- GYN exam 2-3 weeks after termination
2. Use contraception for 3 months to allow complete maternal healing and regeneration of endometrial lining
What is a major cause of maternal death in the first trimester??
Ectopic Pregnancy
Ectopic Pregnancy
- What is it?
- Where are the four most common spots?
- What is inevitable?
- Potentially life-threatening condition
- Incidence is 1 in 80 pregnancies
- Implantation of fertilized ovum outside of the uterine cavity
- Fallopian tube – most common site (98%)
- Cervix
- Ovary
- In the abdominal cavity
- Rupture is inevitable
Ectopic Pregnancy
- High risk factors? 5
- What lowers your risk? 4
- Risk Factors
-History of genital infections
-History of infertility
-History of tubal pregnancy (ligation or reconstruction)
-History of any ectopic pregnancy
Intrauterine devices
-Lower risk - Lower Risk
- Abdominal or pelvic surgery
- History of ruptured appendix
- Intrauterine exposure to DES
- Use of drugs that slow ovum transport (mini-pill)
Dietheylstilbesterol (DES)
- What is it?
- What was it shown to cause?
- Daughters of women who took DES during pregnancy may have a slightly increased risk of what?
- A synthetic form of estrogen
- From about 1940 to 1970, DES was given to pregnant women under the mistaken belief it would reduce the risk of pregnancy complications and losses - In 1971, DES was shown to cause a rare vaginal tumor in girls and young women who had been exposed to this drug in utero
- breast cancer after age 40
Natural History of Ectopic Pregnancy
3
- Rupture - associated with profound hemorrhage that can be fatal
- Abortion – expulsion of the products of conception through the fimbria and absorption of the tissue
- Some can spontaneously resolve
Classic Presentation of ectopic pregnancy?
7
- 1-2 months of amenorrhea
- Morning sickness
- Breast tenderness
- Diarrhea, urge to defecate
- Malaise and syncope
- Lower abdominal/pelvic pain
(Sudden and severe and Especially adnexal (lateralizing to one side)) - Referral of pain to shoulder
Atypical Presentation
of ectopic pregnancy?
2
- Vague or subacute symptoms
- Menstrual irregularity
Remember, signs and symptoms do not always correlate with severity of condition
Physical Exam of ectopic pregnancy?
5
- Vital signs may reveal orthostatic changes
- Adnexal, cervical motion and/or abdominal tenderness on pelvic exam
Pelvic exam
- Normal appearing cervix, marked tenderness
- Vaginal vault may be bloody, usually brick red to brown in color
- Tender adnexal mass may be palpated
Physical Exam of ectopic pregnancy: Which vital signs are abnormal?
2
- Tachycardia,
2. hypotension
Physical Exam
1. First and foremost remember what?
- What is the only thing that can save them once rupture with hemorrhage has occurred?
- Pt with what things needs surgery before they bleed out? 3
- Remember…this can kill your patient
- Emergency surgery is the only thing that can save them once rupture with hemorrhage has occurred
- Pt with
- tachycardia,
- hypotension and
- + pregnancy test needs surgery before they bleed out
Differential for ectopic preg?
8
- PID
- Ovarian Cyst
- Ovarian Tumor
- Intrauterine Pregnancy
- Recent spontaneous abortion
- Early hydatidiform degeneration
- Acute appendicitis
- Other bowel related disorders
Labs for ectopic:
1. B-hCG will be lower or higher?
- What will the pattern be if you follow it over a few days? 2
- What will the CBC show?
B-hCG
1. Will be lower than expected for normal pregnancies of the same duration
- If followed over a few days:
- There may be a slow rise or a plateau rather than the near doubling every 2 days associated with normal PG
- Or falling levels associated with spontaneous abortion. - CBC
- May show anemia or slight leukocytosis
Also get an Rh factor
- Imaging for ectopic pregnancy?
2. What will it show?
- Transvaginal Ultrasound
2. Empty uterine cavity
Correlation between U/S and hCG:
An hCG level of 1._____mU/ml with an 2.___________ by U/S virtually diagnostic of an ectopic pregnancy
- 6,500
2. empty uterine cavity
Diagnosis & Treatment
1. What is definitive?
- Depending on the size of the ectopic and whether or not it has ruptured, what can be performed pelvicscopically? 2
- May need _________ to manage if severe
- Laparoscopy is definitive
- salpingostomy with removal of the ectopic or partial or
- complete salpinectomy
- laparotomy