Complications of pregnancy before 26 weeks Flashcards
Initial workup for hyperemesis gravidarum
- Aggressive normal saline resuscitation (~2L)
- Ongoing assessment of electrolyte abnormalities
- NPO
- Administration of pregnancy-safe antiemeitcs (ondansetron or pyridoxine)
- Diagnostic evaluation:
- Pelvic ultrasound (r/o multiple gestations, molar pregnancy, choriocarcinoma)
- Urinalysis
- Lipase
- LFTs
- RUQUS
Note: Remember that hyperemesis gravidarum is a diagnosis of exclusion. You must rule out other causes of intractable N/V.
“Threatened abortion”
Any vaginal bleeding during pregnancy
10% of these cases turn out to be ectopic pregnancy
40% do turn out to be spontaneous abortion
The remaining ~50% are carried to term
Inevitable abortion vs cervical insufficiency
Inevitable abortion: Painful contractions + cervical dilation
Cervical insufficiency: Painless cervical dilation without contractions
Thus, pain is the key feature to distinguish between the two
Next best step when a pregnant patient presents with suspected asthma exacerbation
Spirometry with FEV1 would be the gold standard, but this is almost always impractical
So, peak expiratory flow rate (PEFR) is usually used in lieu of FEV1, as it can be measured with inexpensive dispostable flow meters at the bedside. This will confirm the diagnosis if improvement is seen with albuterol challenge.
A good response is characterized by PEFR > 80% of personal best and resolution of symptoms sustained for 4 hours.
You have diagnosed a pregnant patient with asthma exacerbation. How do you treat?
q3-4 albuterol inhalation for 24-48 hours with inhaled glucocorticoids
If the pt takes home nebulized glucocorticoids, the home dose should be doubled.
Pt may be managed with close outpatient follow-up unless there are any red flags.
Factors that contribute to premature rupture of membranes
- Intrauterine stretch/strain from polyhydramnios, multiple gestations
- Cervical insufficiency
- Ascending bacterial infection
1 most common complication of PROM
Chorioamnionitis
Exam findings that confirm ROM
Pooling of fluid in the posterior fornix on speculum exam
Leakage of fluid on Valsalva
Positive nitrizine paper test (indicates pH > 6.5. Amiotic fluid pH ~ 7.1, vaginal fluid pH ~ 5.0)
Ferning observed on microscope slide preparation of vaginal fluid
Ultrasound finding of oligohydramnios (given prior Hx of normal fluid)
What exam maneuvers should you not perform on a patient with PROM?
Digital cervical exam
Since this increases the risk of chorioamnionitis
Most patients with PPROM should be managed by. . .
. . . admission to the hospital, likely until delivery
Gestational age range where it is appropriate to administer prophylactic corticosteroids for lung maturity
24-34 weeks
Antibiotics for PPROM
Ampicillin 2g IV q6 for 48 hours followed by amoxicillin 500 mg q8 for 5 days
AND
Azithromycin 500 mg IV for 48 hours followed by azithromycin 250 mg PO BID for 5 days
Who gets supplemental progesterone for pregnancy?
When is it given?
- Patients with history of preterm birth, irrespective of cervical length
- Patients without history of preterm birth but with short cervix (< 20mm)
Progestone is given between 16-36 weeks gestation to reduce the risk of premature delivery.
Treating hyperthyroidism in pregnancy
Beta blockers and thioamides (PTU if 1st timester, methimazole if 2nd/3rd trimester)
However, beta blockers are contraindicated in asthmatic patients or patients with CHF, and are also contraindicated in the peri-delivery period (due to c/f neonatal bradycardia, hypoglycemia)
“bHCG > 1500 and no intruterine pregnancy”
Ectopic pregnancy
