Disease Of Pregnancy Flashcards
Def and Diff for Anemia in Pregnancy
Def = HgB < 10.5
Diff
- Iron Def - (microcytic) do iron trial then recheck in 3 wks - if no improvement then do iron studies and HgB electrophoresis
- Beta thalassemia minor (microcytic) - high A2 HgB; do not give iron
- HELLP - anemia + jaundice + thrombocytopenia; treatment is delivery of baby
- If also low WBCs and low platelets suspect BM problem - acute leukemia or TB of BM - biopsy
- Folate > Vit B12 def (macrocytic)
HSV in Pregnancy
- Can cause neonatal encephalitis
- Consider C sect if vesicles on cervix, vagina, uterus OR just if prodromal symptoms (burning, itching, tingling)
- Acyclovir @ 36 wks for any woman who had recurrence or first episode of HSV during pregnancy - dec viral shedding
2 Major Causes of Antepartum Bleeding (@ > 20 wks)
1- Placenta Previa
- Painless bleeding (often first time is mild), post-coital spotting
- US first then speculum then digital to avoid bleeding b/f US
- Not associated w/ sig coagulopathy
- C section at 34 wks
2- Placental Abruption
- Painful w/ uterine contractions
- Complications include coagulopathy, fetal to maternal hemorrhage, still birth
- US is not sensitive; blood looks like placenta
- Dx is by clinical picture, serial HgB, fetal erythrocytes in maternal blood, FHR tracings
- Deliver if > 34 wks
Risk Factors for Placenta Previa
- grand multiparity
- prior c section
- prior uterine curettage
- prior placenta previa
- mult gestations
Risk Factors for Placental Abruption
- cocaine or cig use
- short umbilical cord
- trauma
- uteroplacental insufficiency
- PPROM
- submucosal fibroid
- sudden uterine decompression (hydramnios)
Appendicitis in Pregnancy
- nausea, vomiting, anorexia, fever, leuks, superior and lateral to normal McBurney point
- Laproscopic or laparotomy if far along in pregnancy + abx
- Mimics location of pyelonephritis
Cholecystitis in Pregnancy
- inc sludge production predisposes to gallstones; if just stones then conservative but if cholecystitis, cholangitis, pancreatitis then surgery
- RUQ pain
- If just biliary colic switch to low fat diet and observe until post-partum
Ovarian Torsion in Pregnancy
- Unilateral colicky sudden ab or pelvic pain w/ nausea and vomiting
- Most common around 14 wks and immediately post-partum
- Surgery - untwist to see if blood flow returns; if not then remove ovary
- Can be complication of a benign ovarian cyst
Ectopic Pregnancy
- esp in 1st trimester; spotting; unilateral
- Diagnose by transvaginal US and beta hCG
- May have hemoperitoneum
Corpus Luteum Cyst Rupture
- Form from normal physiology or excess progesterone
- Rupture because hemorrhage into cyst itself; esp in pregnancy because friable luteum or if bleeding disorder (VWF) or on blood thinner –> hypovolemia and syncope
- If persistent then do lap; stop bleeding and remove cyst
- If b/f 10 wks the corpus luteum makes progesterone for baby so if removed you must replace w/ progesterone
Diff for Pruritus in Pregnancy
1- ICP - intrahepatic cholestasis of pregnancy; inc bile acids in blood; itching without rash; esp in third trimester; may cause fetal distress or preterm labor esp if jaundice
- Tx - cornstarch bath, antihistamine, cholestyramine or ursodeoxycholic acid
2- Herpes gestationis - IgG against BM and complement activation; diagnosed by immunofluroesence from biopsy; intense itching w/ erythema and vesicles/bullae on trunks more than abdomen; associated w/ stilbirth and growth restriction
- oral steroids
3- PUPPP - pruritic urticaria w/ papules and plaques of pregnancy (papules w/ pale halo); esp on abdomen and extremities
- Histo - normal epidermis but superficial leuk infiltrate
- No association w/ fetal problem
- Tx - topical antihistamine and topical steroids
DVT in Pregnancy (pathophysiology, diagnosis and treatment)
- Pathophysiology - venous stasis from pressure on vena cava and inc estrogen so more clotting factors like fibrinogen
- Diagnosis - CT or MRI angio; no D dimer because naturally elevated in pregnancy (esp if clear CXR)
- Tx - IV heparin for 5 to 7 days then subQ for 3 months (unfractionated or LMWH); no warfarin because teratogenic; cont “full heparinization” thru 6 wks postpartum
- Goal aPTT = 1.5 to 2.5
- Same for DVT
- Main side effect is osteoporosis
Blood Gas in Pregnancy
- Inc tidal volume and minute ventilation - so respiratory alkalosis; higher O2 and lower CO2 in arteries
- Higher pH (7.45)
- Lower bicarbonate because try to partially compensate for respiratory alkalosis thru inc bicarbonate excretion; this makes pregnant women more prone to metabolic acidosis (less buffer)
- Give oxygen if PaO2 < 80 in pregnant women
Chlamydia
- No inc risks of preterm birth
- Chlamydia eye infection and pneumonia in neonate; not protected by erythromycin eye ointment; give baby 14 days oral erythromycin if conjunctivitis
- Also late postpartum endometritis in mom
- Tx for mom - erythromycin or amox for 7 days, azithromycin 1X (no doxy because yellow fetal teeth)
Gonorrhea
- Can cause preterm birth, stillbirth, PPROM, chorioamnionitis, postpartum infection, neonatal sepsis
- Erythromycin eye cream protects baby
- More likely to become disseminated in pregnant women
- Tx for mom - IM ceftriaxone w/ treatment of Chlamydia too
HIV
- Transplacental or vertical transmission during delivery; risk transmission related to viral load
- Goal = < 1000 RNA copies per millimeter
- Polytherapy during pregancy; monitor LFTs and CBC for toxicity
- Consider C section; if vaginal delivery give mom IV ZDV at time of delivery
- If already ROM or in labor then C section is pointless; at that point give IV ZDV and minimize trauma (scalp electrode, IUPC, forceps, etc)
- ZDV oral syrup for baby and avoid breastfeeding
Parvovirus in Fetus
- suppression of bone marrow erythrocytes production –> anemia (mild or severe) –> hydrops fetalis (excess fluid in 2+ body cavities)
- Hydramnios (uterus size> gestational age; hard to palpate fetal parts)
- Skin edema
- Ascites
- Pericardial effusion
- Pleural effusion
Parvovirus Serology
- serology (IgM and IgG)
- If pos IgM and neg IgG then acute infection
- If neg IgM and pos IgG then prior infection so now immune (may be false negative so repeat in 1-2 wks)
- If both neg … think about incubation period; if < 20 wks since exposure then can still be infected so repeat test in 1-2 wks; if > 20 days sine exposure then not infected
Mgt of Mom w/ Parvovirus Exposure
- f/u for 10 wks w/ weekly US; refer to MFM if signs; observation if mild and transfusion if severe
- Can also use MCA Doppler; inc velocity suggests compensatory mechanism from anemia to maintain brain flow
Eclampsia Terms
- Chronic HTN - >140/90 before pregnant or before 20 wks
- Superimposed pre-eclampsia - pre-eclampsia in setting of chronic HTN; diagnosed by sudden inc BP or proteinuria
- Gestation HTN - >140/90 after 20 wks w/o proteinuria
- Pre-eclampsia - BP >140/90 after 20 wks + proteinuria > 300 mg in 24 hrs
- Eclampsia - w/ seizure
- Severe Pre-eclampsia - w/ end organ damage OR 160/110; requires immediate delivery
Risk Factors for Pre-eclampsia
Nulliparous, black, extremes of age, personal or family history, chronic HTN, renal disease, antiphospholipid, multifetal gestation, obesity, DM
H&P for Pre-eclampsia
LOOK FOR SIGNS OF END ORGAN DAMAGE
- Non-dependent edema
- Headache, vision changes, seizure, blindness, hyper-reflexes
- Oligouria, proteinuria, dec GFR
- Pulmonary edema
- Thrombocytopenia, microangiopathic anemia, coagulopathy
- Fetal - IUGR, oligohydramnios, late decelerations
- Inc liver enzymes, subcapsular hematoma, hepatic rupture; RUQ pain from liver ischemia
Pathophysiology and Main Cause of Death in Pre-eclampsia
- Pathophysiology - vasospasm and leaky vessels
* Seizure –> death due to intracerebral hemorrhage
Pre-Eclampsia Mgt
- If severe or > 37 wks then deliver; give magnesium at time of delivery and 24 hrs after (greatest risk seizure)
- If not severe and < 37 wks close monitoring then deliver once at term
- Look for signs of Mg toxicity - urine output, dyspnea/ resp depression, dec in deep tendon reflexes is first sign
- F/u in 1-2 wks to recheck BP and urine protein
- Must also treat BP itself - labetolol or hydralazine
Thyroid Changes in Pregnancy
- High estrogen –> inc thyroid binding globulin (so takes more levothyroxine therpy to saturate globulin and get same free/active T4)
- Inc levothyroxine dose once know pt is pregnant
- Inc in total T4 but unbound/active T4 and TSH stay unchanged
Most Common Cause Post-Partum Hyperthyroidism
lymphocytic thyroiditis (autoimmune flare when cortisol suddenly dec after labor); detect antimicrosomal and antiperoxidase antibodies
NOT graves like normal population
IUGR (definition, assessment, mgt)
IUGR (< 10th percentile)
- Symmateric (early) - chromosome abnormality or early TORCH infection
- Assymetric (head circumference spared compared to body to maintain brain flow - late) - maternal HTN, smoking, cocaine, low BMI and low wt gain by mom
- Assessment
- If just measured fundal ht then do actual US wt meas
- Biophysical profile - 10 pt score based on 30 min US (tone, breathing, movements, amniotic fluid)
- Amniotic fluid index - IUGR associated w/ low index (oligohydramnios)
- Umbilical artery Doppler - look for inc resistance seen as inc flow index OR absence/reversal of diastolic flow
- Mgt
- Repeat measurement in 2-4 wks; if no change then confirms IUGR
- Deliver if > 37 wks because risk of prematurity less than risk of IUGR
Pyelonephritis (mgt and complications)
Mgt -
*Hospitalize to give IV abx (ceftriaxone or gentamicin/amp)
- Repeat cx to confirm eradications and use suppressive therapy rest of pregnancy
- Suppressive therapy rest of pregnancy to prevent recurrence (nitro w/ monthly urine cx)
- If no improvement in 48-72 hrs then suspect urinary obstruction or abscess (CT or US)
Complications -
*Endotoxins from gram neg bacteria –> ARDS (dyspnea, patchy infiltrate on CXR) –> give O2
- # 1 cause sepsis in pregnancy
Prevention - urine cx at first prenatal visit; only time you treat asymptomatic bacturia
Criteria and Tx for DKA in Pregnancy
CRITERIA
- PH < 7.35
- Serum Ketones > 5
- Serum glucose > 200
- Serum bicarb < 18 or ketonuria
- Tx - same as non-preg; IV normal saline + insulin + correct electrolyte abnormalities (mainly K+) and treat underlying cause
- DO NOT DO C SECT DUE TO FETAL LATE DECEK; wait until mom is stable and see if they correct on own
Gestational DM Testing
- Routine screen at 26-28 wks
- First … 50 g 1 hr test … pos if > 130- to 140
- Second (confirm) … 100 g 3 hr test (need 2/4 abnormal)
- fasting - 95 to 105
- 1 hr - 180 to 190
- 2 hr - 155 to 165
- 3 hr - 140 to 145
- Check 6 wks postpartum w/ 75 g test (pos if >126 fasting or >200 at 2 hr)
Which Rh antibodies are dangerous to fetus?
Kell & Duffy
NOT Lewis
Mgt of Abnormal Pap in Pregnancy
HSIL / LSIL - do colposcopy
If ASC-US - just re pap postpartum (will not change mgt)
At what values do you expect to see an IUP?
Expect intrauterine pregnancy at beta of 1500-2000 and progesterone >25
Work Up for Spotting in Pregnancy
- Are they symptomatic (aka hypovolemia and pelvic pain?)
- Yes - laproscopy
- No - get hCG level
- Beta hCG > 1500 - 2000 so do US, if IUP then just observe and if no IUP do laproscopy because ectopic very likely
- Beta -hCG < 1500- 2000 then its okay if no IUP on USm recheck beta in 48 hrs
- Should inc by 66% ib 48 hrs - normal; redo US once at 1500
- If not inc that much then non-viable but do not know location; do curettage to see if villi
- Villi = miscarriage
- No Villi = ectopic
Ectopic Triad
1- ab pain
2- vag spotting
3- amenorrhea
Medical and Surgical Tx of Ectopic
- Medical - methotrexate
- Surgical
- Salpingectomy - if rupture, large or do not care about fertility
- Conservative - salpingostomy (cut, remove tissue and let incision open to avoid strictures); only if no rupture and want fertility
Molar Pregnancy
- Trophoblastic tissue without fetus
- Presentation - spotting, no heart tones, size > dates, elevated hCG, snowstorm on US
- Tx - D&C then track beta-hCG; if persists then CHEMO
Septic Abortion (presentation, labs, tx)
- Retained products after D&C may act as nidus of infection /(esp ascending from vagina)
- Labs - CBC, electrolytes, UA + swab for gram stain from cervical d/c
- May also get blood cx, chest X-ray and coagulation labs if hypotensive
- Tx
- Stabilize; IV fluids
- Monitor BP, urine output and oxygenation
- Give broad antibiotics (including anaerobes); allow 4 hrs antibiotics before surgery; often gentamicin + clindamycin
- Redo curettage
- If see air bubbles / gas pockets may be necrotizing metrisis - need urgent hysterectomy (Clostridial species)
