Complications of Pregnancy - Exam 1 Flashcards
If the pregnancy is ectopic, where is it most likely to implant? What are 5 risk factors?
ampulla of the fallopian tube
Prior ectopic pregnancy – scaring in the tube
STDs
PID
Assisted reproductive technology (ART)
IUD
What would a pt experiencing an ectopic pregnancy complain of? What would you find on PE?
Vaginal bleeding
Lower abdominal pain
Adnexal mass
Tenderness on pelvic exam
Based on hCG, how can you tell if a preg is ectopic or in the uterus?
ectopic preg: does NOT double every 48h as it does with a normal IUP
normal IUP: hCG WILL double every 48 hours
What level of hCG should you see of pregnancy in the uterus?
1500-2000mIU/mL (depends on facility)
What is a heterotopic pregnancy? ____ pts have an increased risk
have both an IUP and ectopic pregnancy
ART
_____ sign on US is pathoneumonic
for ectopic pregnancy
donut sign
What is the medical management tx for ectopic pregnancy? What drug class? What is the MOA?
Methotrexate
Folic acid antagonist
Highly effective against rapidly proliferating tissue
In order to qualify for methotrexate as tx an ectopic pregnancy, what 5 pt factors must be present?
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
What are the CI to methotrexate?
Sensitivity to MTX
Evidence of tubal rupture
Breast feeding
IUP
Hepatic, renal or hematologic dysfunction
Peptic ulcer disease
Active pulmonary disease
Evidence of immunodeficiency
What labs need to be drawn before methotrexate can be given? What is the monitoring requirements?
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
What are the SE of methotrexate?
Liver
Stomatitis
Gastroenteritis
Bone Marrow Depression
_____ is the surgical management for an ectopic pregnancy. What are the 2 options?
laparascopy
Salpinostomy -> tubal salvage
Salpingectomy -> tube resection
Why is a Salpinostomy not done as often as a Salpingectomy?
Higher rate of subsequent uterine pregnancy
Higher rate of persistently functioning trophoblast
What is the technical definition of an abortion?
Abortion or miscarriage is a pregnancy that ends before 20 weeks’ gestation
What are the 5 different types of abortion?
complete
incomplete
inevitable
missed
threatened
What is a complete abortion? What are 2 things to pt will complain of?
complete expulsion of all products of conception(POC) before 20 weeks
vaginal bleeding and passage of tissue
What is important to note regarding a complete abortion?
need to f/u if no evidence of POC because you CANNOT rule out an ectopic pregnancy
What is considered an incomplete abortion? What is the tx?
partial expulsion of some but not all POC before 20 weeks
Curettage
Prostaglandins
Expectant management
What is the cervical os doing in an complete and incomplete abortion?
complete: cervical os is closed
incomplete: cervical os is dilated or actively bleeding
Define inevitable abortion. What is the tx?
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
Define missed abortion. What is the tx?
death of the embryo or fetus before 20 weeks with complete retention of all POC
Curettage
Prostaglandins
Expectant Management
Define threatened abortion. What will you see on PE? What is the tx?
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
What is the MOA for RhoGAM?
Suppresses the immune response and antibody formation of Rh negative individuals to Rh positive red blood cells
When is RhoGAM recommended within if the choriodecidual space is breached?
within 72 hours
What is a molar pregnancy? What is another name for it? What is it caused by?
Excessively edematous immature placentas
Hydatiform Mole
chromosomally abnormal fertilizations
What are the risk factors for a molar pregnancy?
Age (extremes of reproductive age)- 12-20 or older than 30
History of prior mole
What is considered a complete mole? 15-20% have subsequent _______
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.
What is the clinical presentation of a molar pregnancy?
Vaginal bleeding
Large for date
Soft consistency of uterus
hCG >100,000
Theca Lutein Cysts
What is the underlying cause of Theca Lutein Cysts? What are they associated with?
Result from overstimulation of lutein elements by hCG
complete molar pregnancy
46, XX or XY (Diploid) is considered a ______ mole.
69 XXX or XXY occasionally XYY (triploid)
is considered a _____mole
complete mole
partial mole
What is the underlying cause of a partial mole? What is the clinical presentation?
Two paternal haploid sets of chromosomes and one maternal haploid set
missed abortion and small for date
Will a complete mole or partial mole have evidence of fetal parts? Be small for date or large for date? Level of hCG?
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
What will a complete molar pregnancy look like on US? **What is the pearl associated with it?
echogenic uterine mass with numerous anechoic cystic spaces but without fetus or amnionic sac
“Snowstorm” appearance
What will a partial mole look like on US? How do you confirm?
thickened, multicystic placenta along with a fetus or fetal tissue
pathology
What are three common sequelae that result of molar pregnancies?
thyroid storm
Hyperemesis gravidarum
Preeclampsia/Eclampsia
Why do you see a thyroid storm with molar pregnancies?
Elevated hCG leads to elevated TSH which elevates fT4
fT4 normalizes after uterine evacuation
What am I?
“snowstorm” appearance
complete mole
What is the preop management needed for a molar pregnancy?
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
What is the tx for a molar pregnancy?
Suction dilation and curettage
Pitocin should be given as evacuation is begun – because these patients bleed a lot
**What is the monitoring requirement after a pt has had a molar pregnancy evacuation?
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
Define antepartum bleeding
Bleeding that occurs with a viable mature fetus (typically considered >24 weeks)
What is a placental abruption? What are the different variations? What are the s/s?
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
What is the difference between a concealed and revealed placental abruption?
What are the risk factors for placental abruption? Which one is the most common?
Trauma
Increasing maternal age
Hypertension/Preeclampsia MC
Preterm premature ruptured membranes
Cigarette smoking
Cocaine
Lupus anticoagulant and thrombophilias
Uterine fibroids
Recurrent abrutpion
placental abruption is a _________. What will it present like on US?
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
What are 5 complications of placental abruption?
hypovolemic shock
Consumptive coagulopathy (or DIC)
Acute kidney injury
Couvelaire Uterus
Intrauterine fetal demise
What is the tx for hypovolemic shock?
baby needs to be delivered ASAP due to maternal blood loss
Requires prompt treatment with crystalloid and blood infusion
______ is the MC obstetric cause of DIC. What is it?
Abruption
Consumptive coagulopathy: Intravascular activation of clotting
acute kidney injury as a result of placental abruption is caused by ______
hypovolemia
What is couvelair uterus? What is it associated with?
Wide spread extravasation of blood into the uterine musculature and beneath the serosa
placental abruption
What is this?
Couvelaire Uterus due to placenta abruption
When considered delivery options for a placental abruption, what should you be thinking? If the baby is deceased, ____ delivery is preferred.
Cesarean delivery is quicker but risk of consumptive coagulopathy causing increased bleeding should be considered
vaginal delivery
What is placenta previa? What is a low-lying placenta?
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
How common is placental previa? What are the 5 risk factors?
0.3%
Increasing maternal age
Increasing parity
Prior cesarean delivery
Cigarette smoking
Elevated MSAFP
How does a placental previa present? When?
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
How do you dx placenta previa? When does it need to be excluded?
using transvaginal US
Previa should be excluded in any patient who presents with vaginal bleeding after 2nd trimester
**What should you NOT perform until placenta previa is ruled out? Why?
DIGITAL EXAM SHOULD NOT BE PERFORMED UNTIL PREVIA IS RULED OUT
can cause severe hemorrhage
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
patient has history of prior cesarean or hysterotomy scar
LOW
> 50%
What is placenta migration? What does greater upper uterine blood flow lead to?
Used to describe the apparent movement of the placenta AWAY from the internal os
to placental growth towards the fundus
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?
observe and consider outpt vs inpt management
deliver
deliver by c- section
risking maternal and fetal demise with increased bleeding
What are placenta accrete syndromes? what are the 3 different options?
Abnormally implanted, invasive or adhered placenta
Placenta Accreta
Placenta Increta
Placenta Percreta
What is Placenta Accreta?
Villi attached to myometrium
What is Placenta Increta?
Villi invade myometrium
What is placenta percreta?
Villi penetrate through the myometrium and to or through the serosa
What does each box color represent?
red: percreta
blue: increta
green: accreta
Why is the rate of placenta accrete syndrome increasing? What are the risk factors?
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
What is Asherman’s syndrome? What does it increase your risk for?
scarring of the uterus
placenta accrete syndromes
How do you dx placenta accrete syndromes? Confirm?
US
pathology: confirms dx and extent of invasion
What is the management for placenta accrete syndromes? What should be discussed with pt prior? _____ could be considered to reduce bleeding
Planned delivery at tertiary center around 34-36 weeks to avoid emergency C-section
Risk of hysterectomy
preop uterine artery embolization
What is cervical insufficiency? What usually happens next?
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
What are risk factors for cervical insufficiency?
Prior cervical trauma
Dilation and curettage
Conization
Cauterization of the cervix
What is the tx for cervical insufficiency?
Trendelenburg position
Pelvic rest
Delivery
Cerclage
What is a cerclage?
A stitch in the uterus that holds it closed that you keep in until week 36
What are the indications for a cerclage?
History of recurrent midtrimester losses and diagnosis of cervical insufficiency
Women identified by ultrasound to have a short cervix (<25mm)
What is the difference between a rescue and elective cerclage?
rescue: Performed emergently after the cervix is found to be dilated, effaced or both
elective: Performed 12-14 weeks gestation with next pregnancy
What am I?
McDonald’s cerclage
What am I?
Shirodkar Cerclage
uses tissue and anchoring suture
When is vaginal progesterone considered a tx option for cervical insufficiency?
Consider treatment for patients with a history of preterm birth, singleton gestation and a shortened cervix
only helpful if the pt has. shorten cervix
What is considered a preterm birth?
delivery of infant before 37 weeks
What are 4 reasons for preterm birth?
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
What are 9 reasons for preterm labor? **What is the highest risk factor?
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
______ is a glycoprotein that is detected vaginally in labor that reflects stromal remodeling of the cervix before labor. But is NOT used frequently anymore
fetal fibronection
By looking at the cervical length, how can you determine if the pt is in preterm labor?
Check transvaginally from 18-22 weeks
If >3cm, indicates patient not in labor
When would you check a nitrazine in preterm labor? What are the normal vaginal pH ranges? amniotic fluid?
if you suspect rupture of membranes
Normal vaginal pH 4.5-5.5
Amniotic fluid pH 7.0-7.5
What steps need to be included in the work-up of a pt in pre-term labor?
check cervical length
sterile vaginal exam
sterile speculum exam
check nitrazine
check UA and culture
What is the tx for preterm labor?
tocolysis
-magnesium sulfate
-nifedipine
-Indomethacin
-terbutaline
-betamethasone if between 24-34 weeks
What is the MOA of tocolysis? What is the associated timing?
stopping the contractions
May delay delivery 48hours to allow time for transfer/meds
Why is Indomethacin NOT used past the 2nd trimester?
because it can close the ductus arteriosis
What is the prevention for preterm labor?
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
______ is used as neuroprotection to prevent neonatal intracranial hemorrhage. What week gestation range?
Magnesium sulfate
given from 24-32 weeks gestation for at least 12 hours
What does PPROM stand for? What is it?
Preterm Premature Rupture of Membranes
Membrane rupture before the onset of contractions and before 37 weeks gestation
What are the risk factors for PPROM?
Genital tract infection
History of PPROM
Antepartum bleeding
Cigarette smoking
Short cervical length
Low BMI
Low socioeconomic status
Illicit drug use
How do you dx PPROM?
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
What are 4 things that can cause a false positive on a nitrazine swab?
Blood
Semen
Antiseptics
Bacterial vaginosis
When fluid allowed to dry, amniotic fluid causes a ______
ferning pattern
a pt presents with PPROM, 50% of pt will delivery within _______. Can it be managed outpt? Why?
delivery within 1 weeks
NO! pt is hospitalized the remainder of her pregnancy
due to risk of cord prolapse
What is the tx for PPROM? When would you like to wait to deliver the baby until?
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!!
PPROM pt and she develops ______ proceed with delivery. What are some s/s?
clinical chorioamnionitis
Fever, Uterine tenderness, Malodorous vaginal discharge, Fetal or maternal tachycardia
What are some complications that can arise with PPROM?
premature delivery including: Respiratory distress, Sepsis, Intraventricular hemorrhage,
Necrotizing enterocolitis
Placental Abruption
Chorioamnionitis (15-35%)
Sepsis
Cord Prolapse
Intrauterine Growth Restriction (IUGR) increases fetal morbidity and mortality due to ______, ______ and ______
stilbirth
neonatal encephalopathy
cerebral palsy
How do you dx IUGR? What 2 things can limit accuracy?
Fundal height measurement with discrepancy of >3cm
Maternal obesity and fibroids can limit accuracy
______ and ______ are the 2 most accurate ultrasound biometrical parameters for IUGR. _______ or _________ indicates IUGR.
Abdominal circumference and estimated fetal weight
<10th percentile overall growth
OR
< 10th percentile Abdominal circumference
What 3 things are monitored closely once dx with IUGR? When should you plan for delivery?
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
_______ counts for 29% of fetals death and _______ and _____ are at 24% each
Obstetrical complications – 29%
Undetermined and placental abnormalities are at 24% each
What is the tx for fetal death? How is it found?
need to make a plan for delivery
usually incidental and found during fetal assessment
What options should you offer parents after fetal death?
Neonatal autopsy
Karyotyping
Examination of placenta, cord and membranes
Cultures to test for infection
parents can choose to do nothing
What is the management for future pregnancies once the mom has had one previous fetal death?
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
What is considered hypertension in pregnancy?
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
What does a natural BP do over the course of the pregnancy?
BP falls early in pregnancy then rises again in the 3rd trimester
**What HTN medications are CI in pregnancy?
ACE inhibitors and ARBs
______ and ______ should be obtained in women with long- standing HTN
EKG and echo
**_____ or ______ are preferred in pregnancy for HTN. **______ may reduce the risk of superimposed preeclampsia
Labetalol
CCB
ASA 81-162mg
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.
120/80
> 95 mmHg
> 150 mmHg
A preg pt with chronic HTN should deliver without complications between ____ and ____ weeks
37-39 weeks
What is considered gestational HTN? When does it resolve?
BP > 140/90 after 20 weeks in previously normotensive women AFTER 20 weeks gestation
resolves by 12 weeks postpartum
**What is considered pre-eclampsia?
New onset of hypertension AND proteinuria after 20 weeks gestation
What is the HTN cutoff for pre-eclampsia? What is the protein level?
Systolic blood pressure ≥140 mmHg OR diastolic blood pressure ≥90 mmHg
Proteinuria of 0.3 g (300 miligrams) or greater in a 24-hour urine specimen
OR
Or protein/creatinine ratio of 0.3 or more
What is the pathophys behind preeclampsia? What else is usually present?
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
What are the risk factors for preeclampsia?
First pregnancy
Young women
Multifetal gestations
Presence of certain vascular disorders: DM, SLE, renal disease, etc
Obesity
African American race
Chronic hypertension
What is preeclampsia with severe features?
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
What are the maternal complications of preeclampsia with severe features? When is delivery recommended?
Pulmonary edema
MI
Stroke
Renal failure
Retinal injury
preeclampsia with severe features: deliver at 34 weeks
What is eclampsia? When can it occur?
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)
How often do you see Preeclampsia superimposed on Chronic Hypertension? What qualifies as the diagnosis?
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
What is HELLP syndrome? Where will the pt complain of pain? What does it indicate?
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
What is the definitive tx of preeclampsia? What are you trying to prevent? What are the ACUTE drugs of choice?
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)
Is gestational diabetes type I or type II?
Diagnosis of Diabetes during pregnancy that is not clearly Type or Type 2 Diabetes
What are the diagnostic criteria for pregestational diabetes?
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%
Hemoglobin A1c ____ or preprandial glucose ______ are at increased risk and often have worsened _______ or ______
> 12
> 120 mg/dL
cardiovascular or renal disease
What are complications of pregestational diabetes on the fetus?
spontaneous abortion
preterm delivery
malformations
altered fetal growth (either small or large)
unexplained fetal demise
hydramnios
pregestational type I diabetes has a _____ and is present in approx. 5% of pts
higher incidence of MAJOR malformations
including 4X higher risk of cardiac defects
infants born to DM mothers are more likely to be _____ at birth because insulin (does/does not)
hypoglycemic at birth
insulin DOES cross placenta so the infant is overproducing insulin and there is no longer overproduction of glucose from the mother
What are some neonatal effects that can happen as a result of pregestational DM?
respiratory distress syndrome
hypoglycemia
hypocalcemia
Hyperbilirubinemia and Polycythemia
Cardiomyopathy
Long term cognitive defects
When DKA does effect pregnancies, more likely to be ______ and are associated with what 4 things?
more likely to be T1DM and vomiting!
Associated with Hyperemesis gravidarum, β-mimetic drugs for tocolysis, infection and corticosteroids
Before getting pregnant is it recommended to keep BS at what levels?
Preprandial 70-100mg/dL
Peak Postprandial 100-129mg/dL
Mean daily glucose concentrations <110mg/dL
Hemoglobin A1c <7
What is important to note about DM and pregnancy? What should the levels be?
first trimester glucose monitoring is CRUCIAL?
Fasting <95
1h postprandial <140 or 2h postprandial <120
Hemoglobin A1c <6 -> Associated with lowest risk for LGA
______ is the preferred BS management in pregnancy. Do their need increase or decrease throughout pregnancy?
insulin
Insulin needs increase throughout pregnancy
______ is high risk factor for development of preeclampsia and may require ______ throughout pregnancy.
Pregestational diabetes
more frequent visits throughout pregnancy
should also refer for high risk consultation
______ and ______ are needed during the second trimester for a mother who has pregestational DM.
Targeted Ultrasound between 18-20 weeks
Fetal Echocardiogram between 20-24 weeks
for pregestational DM, _____ may be needed during delivery and delivery should be planned for ______. If greater than ____ should consider c-section
insulin drip
36-40 weeks
If >4500g, consider cesarean delivery due to increased risk of shoulder dystocia
What is important to note about the insulin requirements POSTPARTUM? the risk of _____ is increased
Insulin may need to be DECREASED by half and monitored closely in the subsequent weeks
Risk of infection is increased
What are 4 risk factors for gestational diabetes?
ethnicity: Hispanic, African American, Native American, Asian or Pacific Islander women
obesity
increasing age
sedentary lifestyle
what is the screening for gestational DM? When should moms be screened?
50g 1hour oral glucose challenge test between 24-28 weeks
Not affected by fasting
ACOG recommends cut-off of 130-140mg/dL
If the first screening test for DM is positive, what is the next step?
proceed to 100g 3 hour glucose tolerance test
Must be fasting for this test
For the 3 hour glucose tolerance test, how do you make the dx of gestational DM?
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
_____ 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
insulin
metformin
______ is rarely used in preg DM management due to increased risks of macrosomia and neonatal hypoglycemia
glyburide
What is the required screening for gestational DM after delivery? What is the associated timeframe?
All women should receive 75g 2 hour glucose tolerance test at 6-12 weeks postpartum
What are the 4 maternal and fetal effects of gestational DM?
increased rate of stillbirth
fetal macrosomia
neonatal hypoglycemia
maternal obesity
What lifelong effect does gestational DM have on the baby?
childhood and adult onset obesity
What type of twins are the most common?
Usually result from fertilization of two ova
dizygotic twins are much more common
______ are twins that arose from a single fertilized ovum. What are vanishing twins? incidence is higher in the ______ trimester
monozygotic
Usually result from fertilization of two ova
higher in first trimester
What does dichorionic mean? **What sign is associated with it?
they have 2 separate placentas
**Twin peak sign
_______ -> triangular projection of placental tissue extending a short distance between the layers of the dividing membrane
twin peak sign
dichorionic placenta
What is another name for a twin peak sign?
Lambda or Delta sign
______ is a thin dividing membrane. What sign is associated with it?
monochorionic placenta
t sign
______ is a right angle relationship between the membranes and placenta and no apparent extension of placenta between the dividing membranes
T sign
monochorionic placenta
Name that sign? What does it tell you?
T sign
monochorionic shared placenta
Name that sign. What does it suggest?
Twin peak sign
fused dichorionic placenta
What is size discordance? Under what scenario do you see it?
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
What complications are monochorionic monoamnionic twins at increased risk for? What should you do?
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
What is twin twin transfusion syndrome? What is the tx?
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
What is the recommended weight gain for a multifetal gestation?
Recommend 37-54lb weight gain for women with normal BMI
What is proven to help multifetal gestations NOT have a preterm birth?
no evidence that anything helps (best rest, tocolysis, progesterone, cervical cerclage) but
pessary are showing good promising signs they might be helpful
What are pessarys? When are they used?
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
What is the ideal presentation for mulitfetal gestation? When should di di twins be delivered? mono di? mono mono?
Cephalic-cephalic presentation ideal
di di: 38 weeks
mono di: 34-37 weeks
mono mono: 32-34 weeks
When does the fetus start making thyroid hormone? During this time thyroid hormone is vital for _____
after 12 weeks gestation
anything before is provided by mom
brain development
What effect does pregnancy have on the thyroid?
What is the MC cause of hypothyroidism? How do you dx it? What is the tx of choice?
Hashimoto’s thyroiditis
Painless inflammation with progressive enlargement of the thyroid gland
labs: Elevated TSH/ Low Free T4
Levothyroxine is treatment of choice
preg pt with hypothyroidism will need to (decrease/increase) their levothyroxine during pregnancy
INCREASE
Should follow thyroid levels about every 6 weeks – because they may need more Levo during pregnancy
What is the recommendation for subclinical hypothyroidism? What will their labs show?
Studies suggest treating with Levothyroxine decreases risk of neurodevelopmental complications in offspring
Elevated TSH/ Normal Free T4
______ is one of the most common treatable causes of mental retardation in preg
Congenital Hypothyroidism
___ of women have MDD during pregnancy
10-14% and 25% will have an increase in symptoms
What are risk factors for MDD in pregnancy? When do preg pts need to be screened?
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
____ is first line tx for MDD. If mother is stable on her MDD meds and gets pregnant, what is the recommendation?
SSRIs and SNRIs
If mother is stable on her current medication and there is so no contraindication, then should continue treatment
______ is the first medication approved for postpartum depression. Should you use it in combo with SSRI/SNRI? What is the tx length?
Zuranolone
YES, good to use in adjunct
daily for 14 days
What opioid substitutions cross the placenta?
Methadone crosses the placenta
Subutex does not cross as readily
_______ is a positive urine culture in an asymptomatic patient. ____ should occur at initial prenatal visit
Asymptomatic Bacteruria
urine culture screening
What is the tx for Asymptomatic Bacteruria? _____ should be repeated a week after completion of treatment to ensure resolution.
Treatment -> Macrobid, Keflex
Urine Culture
______ should be considered for women with a persistent UIT after 2 courses of treatment. What is the tx?
suppressive therapy
Macrobid 100 PO daily
What should you do if a preg pt develops pyelonephritis?
hospitalization with IV antibiotics
suppression therapy for duration of pregnancy to prevent recurrence
