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Women's Health > Complications of Pregnancy - Exam 1 > Flashcards

Complications of Pregnancy - Exam 1 Flashcards

1
Q

If the pregnancy is ectopic, where is it most likely to implant? What are 5 risk factors?

A

ampulla of the fallopian tube

Prior ectopic pregnancy – scaring in the tube
STDs
PID
Assisted reproductive technology (ART)
IUD

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2
Q

What would a pt experiencing an ectopic pregnancy complain of? What would you find on PE?

A

Vaginal bleeding
Lower abdominal pain

Adnexal mass
Tenderness on pelvic exam

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3
Q

Based on hCG, how can you tell if a preg is ectopic or in the uterus?

A

ectopic preg: does NOT double every 48h as it does with a normal IUP

normal IUP: hCG WILL double every 48 hours

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4
Q

What level of hCG should you see of pregnancy in the uterus?

A

1500-2000mIU/mL (depends on facility)

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5
Q

What is a heterotopic pregnancy? ____ pts have an increased risk

A

have both an IUP and ectopic pregnancy

ART

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6
Q

_____ sign on US is pathoneumonic
for ectopic pregnancy

A

donut sign

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7
Q

What is the medical management tx for ectopic pregnancy? What drug class? What is the MOA?

A

Methotrexate

Folic acid antagonist

Highly effective against rapidly proliferating tissue

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8
Q

In order to qualify for methotrexate as tx an ectopic pregnancy, what 5 pt factors must be present?

A

Patient should be: Asymptomatic, Motivated, Compliant

Low initial β-hCG (<5000)

Small ectopic size (<3.5cm)

Absent fetal cardiac activity

No evidence of intraabdominal bleeding

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9
Q

What are the CI to methotrexate?

A

Sensitivity to MTX

Evidence of tubal rupture

Breast feeding

IUP

Hepatic, renal or hematologic dysfunction

Peptic ulcer disease

Active pulmonary disease

Evidence of immunodeficiency

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10
Q

What labs need to be drawn before methotrexate can be given? What is the monitoring requirements?

A

CMP, CBC

-Check β-hCG on Day 1 then 4 and 7
May not decline from Day 1 to 4 but should decrease by 15% from Day 4 to 7
-Can consider repeating dose of Methotrexate, if first dose is not effective

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11
Q

What are the SE of methotrexate?

A

Liver
Stomatitis
Gastroenteritis
Bone Marrow Depression

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12
Q

_____ is the surgical management for an ectopic pregnancy. What are the 2 options?

A

laparascopy

Salpinostomy -> tubal salvage

Salpingectomy -> tube resection

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13
Q

Why is a Salpinostomy not done as often as a Salpingectomy?

A

Higher rate of subsequent uterine pregnancy
Higher rate of persistently functioning trophoblast

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14
Q

What is the technical definition of an abortion?

A

Abortion or miscarriage is a pregnancy that ends before 20 weeks’ gestation

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15
Q

What are the 5 different types of abortion?

A

complete

incomplete

inevitable

missed

threatened

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16
Q

What is a complete abortion? What are 2 things to pt will complain of?

A

complete expulsion of all products of conception(POC) before 20 weeks

vaginal bleeding and passage of tissue

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17
Q

What is important to note regarding a complete abortion?

A

need to f/u if no evidence of POC because you CANNOT rule out an ectopic pregnancy

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18
Q

What is considered an incomplete abortion? What is the tx?

A

partial expulsion of some but not all POC before 20 weeks

Curettage
Prostaglandins
Expectant management

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19
Q

What is the cervical os doing in an complete and incomplete abortion?

A

complete: cervical os is closed

incomplete: cervical os is dilated or actively bleeding

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20
Q

Define inevitable abortion. What is the tx?

A

no expulsion of products, but vaginal bleeding and dilation of the cervix such that a viable pregnancy is unlikely. Has ruptured membranes/ vaginal bleeding

Prostaglandins
Expectant management

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21
Q

Define missed abortion. What is the tx?

A

death of the embryo or fetus before 20 weeks with complete retention of all POC

Curettage
Prostaglandins
Expectant Management

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22
Q

Define threatened abortion. What will you see on PE? What is the tx?

A

any vaginal bleeding before 20 weeks without dilation of the cervix or expulsion of any POC

Cervical os closed
Vaginal spotting
US: viable intrauterine pregnancy

pelvic rest and monitoring closely

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23
Q

What is the MOA for RhoGAM?

A

Suppresses the immune response and antibody formation of Rh negative individuals to Rh positive red blood cells

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24
Q

When is RhoGAM recommended within if the choriodecidual space is breached?

A

within 72 hours

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25
Q

What is a molar pregnancy? What is another name for it? What is it caused by?

A

Excessively edematous immature placentas

Hydatiform Mole

chromosomally abnormal fertilizations

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26
Q

What are the risk factors for a molar pregnancy?

A

Age (extremes of reproductive age)- 12-20 or older than 30

History of prior mole

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27
Q

What is considered a complete mole? 15-20% have subsequent _______

A

Both sets of chromosomes are paternal in origin. Chromosomes of ovum either absent or inactivated. No fetal parts present just edematous placenta villi

Gestational Trophoblastic Neoplasia: a rare group of cancers that develop in the placenta during or after pregnancy. GTN occurs when trophoblast cells, which normally develop into the placenta, instead form abnormal tumors.

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28
Q

What is the clinical presentation of a molar pregnancy?

A

Vaginal bleeding

Large for date

Soft consistency of uterus

hCG >100,000

Theca Lutein Cysts

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29
Q

What is the underlying cause of Theca Lutein Cysts? What are they associated with?

A

Result from overstimulation of lutein elements by hCG

complete molar pregnancy

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30
Q

46, XX or XY (Diploid) is considered a ______ mole.

69 XXX or XXY occasionally XYY (triploid)
is considered a _____mole

A

complete mole

partial mole

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31
Q

What is the underlying cause of a partial mole? What is the clinical presentation?

A

Two paternal haploid sets of chromosomes and one maternal haploid set

missed abortion and small for date

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32
Q

Will a complete mole or partial mole have evidence of fetal parts? Be small for date or large for date? Level of hCG?

A

complete mole: NO fetal parts, LARGE for date, greater than 100,000

partial mole: some fetal parts present, small for date, less than 100,000

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33
Q

What will a complete molar pregnancy look like on US? **What is the pearl associated with it?

A

echogenic uterine mass with numerous anechoic cystic spaces but without fetus or amnionic sac

“Snowstorm” appearance

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34
Q

What will a partial mole look like on US? How do you confirm?

A

thickened, multicystic placenta along with a fetus or fetal tissue

pathology

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35
Q

What are three common sequelae that result of molar pregnancies?

A

thyroid storm
Hyperemesis gravidarum
Preeclampsia/Eclampsia

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36
Q

Why do you see a thyroid storm with molar pregnancies?

A

Elevated hCG leads to elevated TSH which elevates fT4
fT4 normalizes after uterine evacuation

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37
Q

What am I?

A

“snowstorm” appearance

complete mole

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38
Q

What is the preop management needed for a molar pregnancy?

A

Thyroid studies
CBC
CMP
CXR – if it were to become cancer (arrhythmias)
EKG – if it were to become cancer (mets to lung common)
Type and screen

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39
Q

What is the tx for a molar pregnancy?

A

Suction dilation and curettage

Pitocin should be given as evacuation is begun – because these patients bleed a lot

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40
Q

**What is the monitoring requirement after a pt has had a molar pregnancy evacuation?

A

β-hCG levels

Check 48h postevacuation then check every 1-2 weeks until undetectable

Then check monthly for at least 6 months

If remains undetectable thru the 6 month period, it is ok to allow pregnancy again
Should have reliable contraception for this time period

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41
Q

Define antepartum bleeding

A

Bleeding that occurs with a viable mature fetus (typically considered >24 weeks)

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42
Q

What is a placental abruption? What are the different variations? What are the s/s?

A

Separation of the placenta either partially or totally from its implantation site before delivery

complete or partial

concealed or revealed

active vaginal bleeding, sudden onset abdominal pain, uterine tenderness

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43
Q

What is the difference between a concealed and revealed placental abruption?

A
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44
Q

What are the risk factors for placental abruption? Which one is the most common?

A

Trauma
Increasing maternal age
Hypertension/Preeclampsia MC
Preterm premature ruptured membranes
Cigarette smoking
Cocaine
Lupus anticoagulant and thrombophilias
Uterine fibroids
Recurrent abrutpion

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45
Q

placental abruption is a _________. What will it present like on US?

A

Diagnosis of Exclusion

Limited use because negative findings do NOT exclude abruption.

aka very hard to find on US and a normal US does not rule out placental abruption

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46
Q

What are 5 complications of placental abruption?

A

hypovolemic shock

Consumptive coagulopathy (or DIC)

Acute kidney injury

Couvelaire Uterus

Intrauterine fetal demise

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47
Q

What is the tx for hypovolemic shock?

A

baby needs to be delivered ASAP due to maternal blood loss

Requires prompt treatment with crystalloid and blood infusion

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48
Q

______ is the MC obstetric cause of DIC. What is it?

A

Abruption

Consumptive coagulopathy: Intravascular activation of clotting

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49
Q

acute kidney injury as a result of placental abruption is caused by ______

A

hypovolemia

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50
Q

What is couvelair uterus? What is it associated with?

A

Wide spread extravasation of blood into the uterine musculature and beneath the serosa

placental abruption

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51
Q

What is this?

A

Couvelaire Uterus due to placenta abruption

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52
Q

When considered delivery options for a placental abruption, what should you be thinking? If the baby is deceased, ____ delivery is preferred.

A

Cesarean delivery is quicker but risk of consumptive coagulopathy causing increased bleeding should be considered

vaginal delivery

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53
Q

What is placenta previa? What is a low-lying placenta?

A

Internal os is covered partially or completely by placenta

Implantation in the lower uterine segment is such that the placental edge does not reach the internal os and remains outside a 2cm wide perimeter around the os

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54
Q

How common is placental previa? What are the 5 risk factors?

A

0.3%

Increasing maternal age
Increasing parity
Prior cesarean delivery
Cigarette smoking
Elevated MSAFP

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55
Q

How does a placental previa present? When?

A

Uterine body is remodeling to form the lower uterine segment
Internal os dilates and some of the placenta inevitably separates
Bleeding occurs and myometrium is unable to contract to stop

usually seen after the second trimester

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56
Q

How do you dx placenta previa? When does it need to be excluded?

A

using transvaginal US

Previa should be excluded in any patient who presents with vaginal bleeding after 2nd trimester

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57
Q

**What should you NOT perform until placenta previa is ruled out? Why?

A

DIGITAL EXAM SHOULD NOT BE PERFORMED UNTIL PREVIA IS RULED OUT

can cause severe hemorrhage

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58
Q

Under what conditions is a low lying placenta more likely to persist? Until 23 weeks, likelihood of previa persistence is (low/high). If previa present after 23 weeks, ____ chance will persist

A

patient has history of prior cesarean or hysterotomy scar

LOW

> 50%

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59
Q

What is placenta migration? What does greater upper uterine blood flow lead to?

A

Used to describe the apparent movement of the placenta AWAY from the internal os

to placental growth towards the fundus

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60
Q

placenta previa, preterm fetus, no persistent active vaginal bleeding, What do you do?

placenta previa, preterm fetus, persistent active vaginal bleeding, what do you do?

placenta previa, term fetus, what do you do?

what are you risking in each scenario?

A

observe and consider outpt vs inpt management

deliver

deliver by c- section

risking maternal and fetal demise with increased bleeding

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61
Q

What are placenta accrete syndromes? what are the 3 different options?

A

Abnormally implanted, invasive or adhered placenta

Placenta Accreta
Placenta Increta
Placenta Percreta

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62
Q

What is Placenta Accreta?

A

Villi attached to myometrium

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63
Q

What is Placenta Increta?

A

Villi invade myometrium

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64
Q

What is placenta percreta?

A

Villi penetrate through the myometrium and to or through the serosa

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65
Q

What does each box color represent?

A

red: percreta

blue: increta

green: accreta

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66
Q

Why is the rate of placenta accrete syndrome increasing? What are the risk factors?

A

Increasing incidence due to increasing number of cesarean deliveries performed, the more c-sections the greater the risk

risk factors: Anything that cause a defect or disruption of the endometrial-myometrial interface

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67
Q

What is Asherman’s syndrome? What does it increase your risk for?

A

scarring of the uterus

placenta accrete syndromes

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68
Q

How do you dx placenta accrete syndromes? Confirm?

A

US

pathology: confirms dx and extent of invasion

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69
Q

What is the management for placenta accrete syndromes? What should be discussed with pt prior? _____ could be considered to reduce bleeding

A

Planned delivery at tertiary center around 34-36 weeks to avoid emergency C-section

Risk of hysterectomy

preop uterine artery embolization

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70
Q

What is cervical insufficiency? What usually happens next?

A

PAIN-LESS cervical dilatation in the second trimester

Followed by prolapsing and ballooning of membranes into the vagina and ultimately expulsion of an immature fetus

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71
Q

What are risk factors for cervical insufficiency?

A

Prior cervical trauma
Dilation and curettage
Conization
Cauterization of the cervix

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72
Q

What is the tx for cervical insufficiency?

A

Trendelenburg position
Pelvic rest
Delivery
Cerclage

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73
Q

What is a cerclage?

A

A stitch in the uterus that holds it closed that you keep in until week 36

74
Q

What are the indications for a cerclage?

A

History of recurrent midtrimester losses and diagnosis of cervical insufficiency

Women identified by ultrasound to have a short cervix (<25mm)

75
Q

What is the difference between a rescue and elective cerclage?

A

rescue: Performed emergently after the cervix is found to be dilated, effaced or both

elective: Performed 12-14 weeks gestation with next pregnancy

76
Q

What am I?

A

McDonald’s cerclage

77
Q

What am I?

A

Shirodkar Cerclage

uses tissue and anchoring suture

78
Q

When is vaginal progesterone considered a tx option for cervical insufficiency?

A

Consider treatment for patients with a history of preterm birth, singleton gestation and a shortened cervix

only helpful if the pt has. shorten cervix

79
Q

What is considered a preterm birth?

A

delivery of infant before 37 weeks

80
Q

What are 4 reasons for preterm birth?

A

Spontaneous unexplained preterm labor with intact membranes

Idiopathic preterm premature rupture of membranes (PPROM

Delivery for maternal or fetal indication

Twins and higher order multifetal births

81
Q

What are 9 reasons for preterm labor? **What is the highest risk factor?

A

Threatened Abortion during this pregnancy

Cigarette Smoking

Inadequate weight gain during pregnancy

Illicit drug use

Depression, anxiety, chronic stress

Short interval between pregnancies

Prior preterm birth-> highest risk factor

Periodontal disease

Infection

82
Q

______ is a glycoprotein that is detected vaginally in labor that reflects stromal remodeling of the cervix before labor. But is NOT used frequently anymore

A

fetal fibronection

83
Q

By looking at the cervical length, how can you determine if the pt is in preterm labor?

A

Check transvaginally from 18-22 weeks

If >3cm, indicates patient not in labor

84
Q

When would you check a nitrazine in preterm labor? What are the normal vaginal pH ranges? amniotic fluid?

A

if you suspect rupture of membranes

Normal vaginal pH 4.5-5.5
Amniotic fluid pH 7.0-7.5

85
Q

What steps need to be included in the work-up of a pt in pre-term labor?

A

check cervical length

sterile vaginal exam

sterile speculum exam

check nitrazine

check UA and culture

86
Q

What is the tx for preterm labor?

A

tocolysis

-magnesium sulfate
-nifedipine
-Indomethacin
-terbutaline
-betamethasone if between 24-34 weeks

87
Q

What is the MOA of tocolysis? What is the associated timing?

A

stopping the contractions

May delay delivery 48hours to allow time for transfer/meds

88
Q

Why is Indomethacin NOT used past the 2nd trimester?

A

because it can close the ductus arteriosis

89
Q

What is the prevention for preterm labor?

A

Cervical Cerclage: For women identified to have a cervical length <25mm who are at high risk for Preterm Birth

IM progesterone therapy: Weekly injections beginning at 16 weeks till 36 weeks

90
Q

______ is used as neuroprotection to prevent neonatal intracranial hemorrhage. What week gestation range?

A

Magnesium sulfate

given from 24-32 weeks gestation for at least 12 hours

91
Q

What does PPROM stand for? What is it?

A

Preterm Premature Rupture of Membranes

Membrane rupture before the onset of contractions and before 37 weeks gestation

92
Q

What are the risk factors for PPROM?

A

Genital tract infection
History of PPROM
Antepartum bleeding
Cigarette smoking
Short cervical length
Low BMI
Low socioeconomic status
Illicit drug use

93
Q

How do you dx PPROM?

A

speculum exam that will show:

pooling of amniotic fluid within the vagina

nitrazine swab will detect alkaline pH of amniotic fluid

ferning when fluid from posterior fornix is swabbed and placed on microscope slide

US: will show low amniotic fluid

94
Q

What are 4 things that can cause a false positive on a nitrazine swab?

A

Blood

Semen

Antiseptics

Bacterial vaginosis

95
Q

When fluid allowed to dry, amniotic fluid causes a ______

A

ferning pattern

96
Q

a pt presents with PPROM, 50% of pt will delivery within _______. Can it be managed outpt? Why?

A

delivery within 1 weeks

NO! pt is hospitalized the remainder of her pregnancy

due to risk of cord prolapse

97
Q

What is the tx for PPROM? When would you like to wait to deliver the baby until?

A

hospitalized

corticosteroids for fetal lung maturity

tocolysis

abx: Amipicillin IV then Amoxicillin PO
or
Erythromycin IV then Erythromycin PO (could also used Azithromycin)

prefer 34 weeks!!

98
Q

PPROM pt and she develops ______ proceed with delivery. What are some s/s?

A

clinical chorioamnionitis

Fever, Uterine tenderness, Malodorous vaginal discharge, Fetal or maternal tachycardia

99
Q

What are some complications that can arise with PPROM?

A

premature delivery including: Respiratory distress, Sepsis, Intraventricular hemorrhage,
Necrotizing enterocolitis

Placental Abruption

Chorioamnionitis (15-35%)

Sepsis

Cord Prolapse

100
Q

Intrauterine Growth Restriction (IUGR) increases fetal morbidity and mortality due to ______, ______ and ______

A

stilbirth

neonatal encephalopathy

cerebral palsy

101
Q

How do you dx IUGR? What 2 things can limit accuracy?

A

Fundal height measurement with discrepancy of >3cm

Maternal obesity and fibroids can limit accuracy

102
Q

______ and ______ are the 2 most accurate ultrasound biometrical parameters for IUGR. _______ or _________ indicates IUGR.

A

Abdominal circumference and estimated fetal weight

<10th percentile overall growth
OR
< 10th percentile Abdominal circumference

103
Q

What 3 things are monitored closely once dx with IUGR? When should you plan for delivery?

A

Amniotic Fluid Volume measurement: weekly after 34 weeks

Umbilical Artery Doppler velocimetry: Begin around 28 weeks and repeat every 1-2weeks

Growth Ultrasound: Repeat growth measurements every 3-4 weeks after 18 weeks gestation

37-38 weeks unless s/s of fetal compromise

104
Q

_______ counts for 29% of fetals death and _______ and _____ are at 24% each

A

Obstetrical complications – 29%

Undetermined and placental abnormalities are at 24% each

105
Q

What is the tx for fetal death? How is it found?

A

need to make a plan for delivery

usually incidental and found during fetal assessment

106
Q

What options should you offer parents after fetal death?

A

Neonatal autopsy
Karyotyping
Examination of placenta, cord and membranes
Cultures to test for infection

parents can choose to do nothing

107
Q

What is the management for future pregnancies once the mom has had one previous fetal death?

A

Preconception counseling with Maternal Fetal Medicine

Control modifiable risk factors (ie Hypertension, etc)

Offer routine genetic testing

Obtain anatomy scan at 18 weeks and then serial growth ultrasounds beginning at 28 weeks

Begin antepartum surveillance at 32 weeks or 1-2 weeks prior to stillbirth

Elective induction or cesarean at 37 weeks

108
Q

What is considered hypertension in pregnancy?

A

Elevation of BP ≥140 mmHg systolic and/or ≥90 mmHg diastolic, on two occasions at least 4 hours apart AFTER 20 weeks OR

present after 12 weeks postpartum

109
Q

What does a natural BP do over the course of the pregnancy?

A

BP falls early in pregnancy then rises again in the 3rd trimester

110
Q

**What HTN medications are CI in pregnancy?

A

ACE inhibitors and ARBs

111
Q

______ and ______ should be obtained in women with long- standing HTN

A

EKG and echo

112
Q

**_____ or ______ are preferred in pregnancy for HTN. **______ may reduce the risk of superimposed preeclampsia

A

Labetalol

CCB

ASA 81-162mg

113
Q

May taper or discontinue meds for women with blood pressures less than _____ in 1st trimester. Reinstitute or initiate therapy for persistent diastolic pressures ______, systolic pressures >150 mmHg, or signs of hypertensive end-organ damage.

A

120/80

> 95 mmHg

> 150 mmHg

114
Q

A preg pt with chronic HTN should deliver without complications between ____ and ____ weeks

A

37-39 weeks

115
Q

What is considered gestational HTN? When does it resolve?

A

BP > 140/90 after 20 weeks in previously normotensive women AFTER 20 weeks gestation

resolves by 12 weeks postpartum

116
Q

**What is considered pre-eclampsia?

A

New onset of hypertension AND proteinuria after 20 weeks gestation

117
Q

What is the HTN cutoff for pre-eclampsia? What is the protein level?

A

Systolic blood pressure ≥140 mmHg OR diastolic blood pressure ≥90 mmHg

Proteinuria of 0.3 g (300 grams) or greater in a 24-hour urine specimen
OR
Or protein/creatinine ratio of 0.3 or more

118
Q

What is the pathophys behind preeclampsia? What else is usually present?

A

Abnormal trophoblastic invasion
Endothelial cell activation
Genetic factors

aka the cause is still unknown, why it happens

Thrombocytopenia
Renal insufficiency
Liver involvement
Cerebral symptoms
Pulmonary edema

aka lots of other things can present with it

119
Q

What are the risk factors for preeclampsia?

A

First pregnancy

Young women

Multifetal gestations

Presence of certain vascular disorders: DM, SLE, renal disease, etc

Obesity

African American race

Chronic hypertension

120
Q

What is preeclampsia with severe features?

A

160/110 on more than 2 occasions at least 4 hours apart

thrombocytopenia: platelet less than 100K

impaired liver function

renal insufficiency: serum creatinine concentration more than 1.1mg/dl or double of serum creatinine concentration

pulmonary edema

new onset HA

visual disturbances

121
Q

What are the maternal complications of preeclampsia with severe features? When is delivery recommended?

A

Pulmonary edema
MI
Stroke
Renal failure
Retinal injury

preeclampsia with severe features: deliver at 34 weeks

122
Q

What is eclampsia? When can it occur?

A

Occurrence of generalized convulsion and/or coma in the setting of preeclampsia, with no other neurological condition

May occur before, during or after labor (up to 48 hours postpartum)

123
Q
A
123
Q

How often do you see Preeclampsia superimposed on Chronic Hypertension? What qualifies as the diagnosis?

A

Affects 20% of patients with chronic HTN

Preexisting Hypertension with the following additional signs/symptoms:

New onset proteinuria
A sudden increase in blood pressure.
Development of any component of HELLP Syndrome or symptoms of Severe Preeclampsia

124
Q

What is HELLP syndrome? Where will the pt complain of pain? What does it indicate?

A

Hemolysis, Elevated Liver enzymes and Low Platelet Count

Patients have RUQ pain because the liver bleeds and it distends the capsule

Indicator of severe preeclampsia and associated with WORSE outcomes

125
Q

What is the definitive tx of preeclampsia? What are you trying to prevent? What are the ACUTE drugs of choice?

A

DELIVERY!!

prevent cerebrovascular hemorrhage and hypertensive encephalopathy especially when BP is greater to or equal to 160/100

IV labetalol, IV hydralazine, PO nifedipine
AND
Magnesium sulfate: aiming at controlling anticonvulsant as to not have any central nervous system depression
+/- corticosteroids if needed for fetal lung maturation (between 24-34 weeks)

126
Q

Is gestational diabetes type I or type II?

A

Diagnosis of Diabetes during pregnancy that is not clearly Type or Type 2 Diabetes

127
Q

What are the diagnostic criteria for pregestational diabetes?

A

High plasma glucose levels, glucosuria, ketoacidosis

Random plasma glucose >200 mg/dL plus classic symptoms such as polydipsia, polyuria and unexplained weight loss

Fasting glucose >125 mg/dL

HgbA1c ≥ 6.5%

128
Q

Hemoglobin A1c ____ or preprandial glucose ______ are at increased risk and often have worsened _______ or ______

A

> 12

> 120 mg/dL

cardiovascular or renal disease

129
Q

What are complications of pregestational diabetes on the fetus?

A

spontaneous abortion

preterm delivery

malformations

altered fetal growth (either small or large)

unexplained fetal demise

hydramnios

130
Q

pregestational type I diabetes has a _____ and is present in approx. 5% of pts

A

higher incidence of MAJOR malformations

including 4X higher risk of cardiac defects

131
Q

infants born to DM mothers are more likely to be _____ at birth because insulin (does/does not)

A

hypoglycemic at birth

insulin DOES cross placenta so the infant is overproducing insulin and there is no longer overproduction of glucose from the mother

132
Q

What are some neonatal effects that can happen as a result of pregestational DM?

A

respiratory distress syndrome

hypoglycemia

hypocalcemia

Hyperbilirubinemia and Polycythemia

Cardiomyopathy

Long term cognitive defects

133
Q

When DKA does effect pregnancies, more likely to be ______ and are associated with what 4 things?

A

more likely to be T1DM and vomiting!

Associated with Hyperemesis gravidarum, β-mimetic drugs for tocolysis, infection and corticosteroids

134
Q

Before getting pregnant is it recommended to keep BS at what levels?

A

Preprandial 70-100mg/dL

Peak Postprandial 100-129mg/dL

Mean daily glucose concentrations <110mg/dL

Hemoglobin A1c <7

135
Q

What is important to note about DM and pregnancy? What should the levels be?

A

first trimester glucose monitoring is CRUCIAL?

Fasting <95
1h postprandial <140 or 2h postprandial <120
Hemoglobin A1c <6 -> Associated with lowest risk for LGA

136
Q

______ is the preferred BS management in pregnancy. Do their need increase or decrease throughout pregnancy?

A

insulin

Insulin needs increase throughout pregnancy

137
Q

______ is high risk factor for development of preeclampsia and may require ______ throughout pregnancy.

A

Pregestational diabetes

more frequent visits throughout pregnancy

should also refer for high risk consultation

138
Q

______ and ______ are needed during the second trimester for a mother who has pregestational DM.

A

Targeted Ultrasound between 18-20 weeks

Fetal Echocardiogram between 20-24 weeks

139
Q

for pregestational DM, _____ may be needed during delivery and delivery should be planned for ______. If greater than ____ should consider c-section

A

insulin drip

36-40 weeks

If >4500g, consider cesarean delivery due to increased risk of shoulder dystocia

140
Q

What is important to note about the insulin requirements POSTPARTUM? the risk of _____ is increased

A

Insulin may need to be DECREASED by half and monitored closely in the subsequent weeks

Risk of infection is increased

141
Q

What are 4 risk factors for gestational diabetes?

A

ethnicity: Hispanic, African American, Native American, Asian or Pacific Islander women

obesity

increasing age

sedentary lifestyle

142
Q

what is the screening for gestational DM? When should moms be screened?

A

50g 1hour oral glucose challenge test between 24-28 weeks

Not affected by fasting

ACOG recommends cut-off of 130-140mg/dL

143
Q

If the first screening test for DM is positive, what is the next step?

A

proceed to 100g 3 hour glucose tolerance test

Must be fasting for this test

143
Q

For the 3 hour glucose tolerance test, how do you make the dx of gestational DM?

A

Must have 2 abnormal results to receive diagnosis of gestational diabetes

Fasting  95mg/dL
1h  180 mg/dL
2h  155 mg/dL
3h  140mg/dL

144
Q

_____ is considered preferred standard therapy for DM medical management. _____ is also a viable option but does NOT have lots of evidence and long term follow up

A

insulin

metformin

145
Q

______ is rarely used in preg DM management due to increased risks of macrosomia and neonatal hypoglycemia

A

glyburide

146
Q

What is the required screening for gestational DM after delivery? What is the associated timeframe?

A

All women should receive 75g 2 hour glucose tolerance test at 6-12 weeks postpartum

147
Q

What are the 4 maternal and fetal effects of gestational DM?

A

increased rate of stillbirth

fetal macrosomia

neonatal hypoglycemia

maternal obesity

148
Q

What lifelong effect does gestational DM have on the baby?

A

childhood and adult onset obesity

149
Q

What type of twins are the most common?

A

Usually result from fertilization of two ova

dizygotic twins are much more common

150
Q

______ are twins that arose from a single fertilized ovum. What are vanishing twins? incidence is higher in the ______ trimester

A

monozygotic

Usually result from fertilization of two ova

higher in first trimester

151
Q

What does dichorionic mean? **What sign is associated with it?

A

they have 2 separate placentas

**Twin peak sign

152
Q

_______ -> triangular projection of placental tissue extending a short distance between the layers of the dividing membrane

A

twin peak sign

dichorionic placenta

153
Q

What is another name for a twin peak sign?

A

Lambda or Delta sign

154
Q

______ is a thin dividing membrane. What sign is associated with it?

A

monochorionic placenta

t sign

155
Q

______ is a right angle relationship between the membranes and placenta and no apparent extension of placenta between the dividing membranes

A

T sign

monochorionic placenta

156
Q

Name that sign? What does it tell you?

A

T sign

monochorionic shared placenta

157
Q

Name that sign. What does it suggest?

A

Twin peak sign

fused dichorionic placenta

158
Q

What is size discordance? Under what scenario do you see it?

A

Weight discordance >20% most accurately predicts adverse outcomes

More likely to fail a vaginal delivery if baby A (the first twin that comes out) is smaller than baby B

in multifetal gestations

159
Q

What complications are monochorionic monoamnionic twins at increased risk for? What should you do?

A

Cord entanglement
Congenital anomalies
Preterm birth
Twin twin transfusion syndrome

LOTS more testing and have increased risk of congenital cardiac disease

including fetal echo, giving corticosteroids and are delivered via c section

160
Q

What is twin twin transfusion syndrome? What is the tx?

A

Occurs in monochorionic diamniotic twins

Blood transfused from a donor twin to its recipient sibling
Donor becomes anemic and growth restricted

aka bigger twins starts stealing nutrients and oxygen from the smaller twin

tx:
Laser ablation of anastomosis is preferred
Selective reduction can be considered

161
Q

What is the recommended weight gain for a multifetal gestation?

A

Recommend 37-54lb weight gain for women with normal BMI

162
Q

What is proven to help multifetal gestations NOT have a preterm birth?

A

no evidence that anything helps (best rest, tocolysis, progesterone, cervical cerclage) but

pessary are showing good promising signs they might be helpful

163
Q

What are pessarys? When are they used?

A

These are little donuts that can be put into the vagina behind the pubic symphysis in order to help support the area and keep the babies in for longer

multifetal gestations

164
Q

What is the ideal presentation for mulitfetal gestation? When should di di twins be delivered? mono di? mono mono?

A

Cephalic-cephalic presentation ideal

di di: 38 weeks

mono di: 34-37 weeks

mono mono: 32-34 weeks

165
Q

When does the fetus start making thyroid hormone? During this time thyroid hormone is vital for _____

A

after 12 weeks gestation

anything before is provided by mom

brain development

166
Q

What effect does pregnancy have on the thyroid?

A
167
Q

What is the MC cause of hypothyroidism? How do you dx it? What is the tx of choice?

A

Hashimoto’s thyroiditis

Painless inflammation with progressive enlargement of the thyroid gland

labs: Elevated TSH/ Low Free T4

Levothyroxine is treatment of choice

168
Q

preg pt with hypothyroidism will need to (decrease/increase) their levothyroxine during pregnancy

A

INCREASE

Should follow thyroid levels about every 6 weeks – because they may need more Levo during pregnancy

169
Q

What is the recommendation for subclinical hypothyroidism? What will their labs show?

A

Studies suggest treating with Levothyroxine decreases risk of neurodevelopmental complications in offspring

Elevated TSH/ Normal Free T4

170
Q

______ is one of the most common treatable causes of mental retardation in preg

A

Congenital Hypothyroidism

171
Q

___ of women have MDD during pregnancy

A

10-14% and 25% will have an increase in symptoms

172
Q

What are risk factors for MDD in pregnancy? When do preg pts need to be screened?

A

History of depressive disorders
Low social support
Financial disadvantage
Adolescence
Unmarried
Recent adverse life events
History of abuse

initial visit and at risk then every visit after

173
Q

____ is first line tx for MDD. If mother is stable on her MDD meds and gets pregnant, what is the recommendation?

A

SSRIs and SNRIs

If mother is stable on her current medication and there is so no contraindication, then should continue treatment

174
Q

______ is the first medication approved for postpartum depression. Should you use it in combo with SSRI/SNRI? What is the tx length?

A

Zuranolone

YES, good to use in adjunct

daily for 14 days

175
Q

What opioid substitutions cross the placenta?

A

Methadone crosses the placenta

Subutex does not cross as readily

176
Q

_______ is a positive urine culture in an asymptomatic patient. ____ should occur at initial prenatal visit

A

Asymptomatic Bacteruria

urine culture screening

177
Q

What is the tx for Asymptomatic Bacteruria? _____ should be repeated a week after completion of treatment to ensure resolution.

A

Treatment -> Macrobid, Keflex

Urine Culture

178
Q

______ should be considered for women with a persistent UIT after 2 courses of treatment. What is the tx?

A

suppressive therapy

Macrobid 100 PO daily

179
Q

What should you do if a preg pt develops pyelonephritis?

A

hospitalization with IV antibiotics

suppression therapy for duration of pregnancy to prevent recurrence

180
Q
A

Women's Health (6 decks)

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