Firecracker - Complicated Pregnancies Flashcards
What is the teratogenic risk of fluoroquinolones?
- Antibiotics that carry teratogenic risks include aminoglycosides, fluoruoquinolones, sulfonamides and tetracyclines.
- Aminoglycosides cause vestibulocochlear damage, skeletal abnormalities and renal defects
- Fluroquinolines cause abnormalities in cartilage development
- Sulfonamides cause kernicterus which is bile infiltration in the brain
- Tetracyclines cause:
- Skeletal abnormalities
- Limb abnormalities
- Teeth discolouration
What are the fetal risks of cocaine use during pregnancy?
- Cocaine use during pregnancy carries the fetal risks of:
- Abruptio placentae
- Intrauterine growth restriction
- Facial abnormalities
- Delayed intellectual development
- Fetal demise
- Maternal risks of cocaine use during pregnancy include:
- Arrythmia
- Myocardial infarction
- Subarachnoid haemorrhage
- Seizures
- Stroke
What are the causes of abruptio placentae?
- Abruptio placentae is a premature separation of the placenta caused by a retroplacental clot, which leads to significant maternal haemorrhage.
- Risk factors include:
- Hypertension
- Smoking
- Cocaine use
- Previous amputation
- Older mother
Maternal trauma, especially motor vehicle accidents, can lead to placental abruption as a result of deceleration forces.
How can maternal gonorrhea/chlamydia infection be diagnosed during pregnancy?
- Gonorrhea/chlamydia infection during pregnancy carries the risk of spontaneous abortion, neonatal sepsis and neonatal conjunctivitis
- Maternal infection can be diagnosed with cervical culture or with enzyme immunoassays, such as nucleic acid amplification tests (NAAT)
What is the teratogenic risk of sulfonamides?
Sulfonamides cause kernicterus, which is bile infiltration of the brain.
When is Rho(D) given in cases of placenta previa?
- In cases of minor bleeding, patients with placenta previa can be treated with bed rest.
- However, for active bleeding they require inpatient admission with maternal and fetal monitoring.
- Rho(D) immune globulin is given to any Rh-negative mothers that have bleeding in the third trimester
- Tocolytic agents (agents used to slow contractions) are used to delay delivery in cases of a preterm fetus with immature lungs, if mild maternal bleeding is present
- Patients with placenta previa should deliver by cesarean section.
In order of trimester what are the causes of oligohydramnios?
- Oligohydramnios is a deficiency of amniotic fluid in the gestational sac (amniotic fluid index <5cm)
- It is associated with:
- Intrauterine growth restriction
- Fetal stress
- Fetal renal abnormalities, such as in potter syndrome
- Poor fetal health
- FIRST TRIMESTER:
- Oligohydramnios frequently results in spontaneous abortion
- SECOND TRIMESTER
- Caused by fetal abnormalities or maternal causes such as:
- Pre-eclampsia
- Renal disease
- Hypertension
- Collagen vascular disease
- Placental thrombosis
- Caused by fetal abnormalities or maternal causes such as:
- THIRD TRIMESTER associated with:
- Premature rupture of the membranes
- Pre-eclampsia
- Abruptio placentae
- Idiopathic causes
Outline a brief treatment plan for mothers with pre-eclampsia?
- The definitive treatment of preeclampsia and eclampsia is delivery of the baby
- If the symptoms of preeclampsia are mild and the mother is far from term recommend:
- Restrcited activity
- Frequently maternal exams for worsening symptoms
- Growth scans, followed by maternal fetal medicine
- Fetal non-stress tests twice a week
- If symptoms of pre-eclampsia are severe and the mother is far from term:
- Admit the mother and closely monitor
- Maintain blood pressure below 155/105 with diastolic above 90 with antihypertensives like labetalol (do not use ACE-inhibitors anigotensin receptor blockers because of teratogenic effects
- Intravenous magnesium sulfate for seizure prophylaxis and neuroprotection
- Deliver as soon as the fetus is considered viable
- Antihypertensive medication and magnesium sulfate should be continued immediately postpartum while continuing observation for symptoms and lab abnormalities.
- Blood pressure is expected to return to normal within 6 weeks of postpartum
- If mother has pre-existing hypertension, labetalol or methyldopa should be used initially followed by a long acting calcium channel blocker (nifedipine and amlodipine) as a second agent if necessary.
What anticoagulants carry teratogenic risks?
- Anticoagulants that carry teratogenic risks include heparin and warfarin.
- heparin although safer than warfarin causes:
- Prematurity
- Intrauterine fetal demise
- warfarin causes:
- Spontaneous abortion
- IUGR
- CNS and facial abnormalities
- Dandy-walker malformation
- Mental retardation
- heparin although safer than warfarin causes:
What are the teratogenic risks of tetracyclines?
Tetracyclines cause:
Skeletal abnormalities
Limb abnormalities
Teeth discoloration
What tests should be performed on a pregnant woman to rule out pre-existing complications of hypertension?
- Chronic hypertension is defined as hypertension that existed prior to conception, developed before 20 weeks GA or persists 6 weeks postpartum
- A baseline ECG and 24 hour urine output should be obtained to rule out pre-existing complications of hypertension including heart and renal disease
- In woman already on antihypertensives or with blood pressure persistently elevated above 140/90, labetalol and nifedipine are the drugs of choice
- 1/3 of women with chronic hypertension will develop superimposed pre-eclampsia.
What steps can be taken to improve amniotic fluid volume?
- Oligohydramnios is treated with expectant management if the fetus responds well to tests of well being
- Induced delivery may be required if the fetus is viable and the risk of fetal demise is significant
- Hydration and best rest may improve amniotic fluid volume.
How is polydramnios diagnosed?
- The diagnosis of polydramnios is made with sonographic visualization of increased amniotic fluid volume
- The amniotic fluid index will be greater than 25 cm or will show one pocket of at least 8 cm
- The amniotic fluid index is an estimate of amniotic fluid volume.
- The uterus is divided into 4 imaginary quadrants
- The deepest part of these pockets are measured with ultrasound and added up to obtain the amniotic fluid index.
What are the drugs of choice for management of pregnant women with chronic hypertension that are already on antihypertensives or with blood pressure persistently above 140/90?
- In women already on antihypertensives or with blood pressures persistently elevated above 140/90, labetalol and nifedipiine are the drugs of choice.
- Which antihypertensive is teratogenic?
- ACE-inhibitors cause renal abnormalities and decreased skull ossification
What are some complications of placetnta previa?
- Complications from placenta previa include:
- Haemorrhage
- Premature rupture of membranes (PROM)
- IUGR
- Increased risk of hysterectomy with delivery because of catastrophic bleeding
- 1% of causes result in maternal death
What are the teratogenic risks of warfarin?
- Anticoagulants that carry teratogenic risks include heparin and warfarin
- Warfarin causes:
- Spontaneous abortion
- IUGR
- CNS and facial abnormalities
- Dandy-walker malformation
- Mental retardation
- Warfarin causes:
What four major classes of antibiotics carry teratogenic risks?
- Aminoglycosides cause vestibulocochlear nerve damage, skeletal abnormalities, and renal defects.
- Fluoroquinolones cause abnormalities in cartilage development.
- Sulfonamides cause kernicterus, which is bile infiltration of the brain.
- Tetracyclines cause:
- Skeletal abnormalities
- Limb abnormalities
- Teeth discoloration
What are the maternal risks of stimulant use during pregnancy?
Malnutrition from lack of appetite
Arrhythmia
Withdrawal depression
Hypertension
Describe rubella infections and how they can be diagnosed and prevented.
Rubella infections during pregnancy may result in congenital rubella syndrome, which may include:
Intrauterine growth restriction
Sensorineural deafness
Cardiovascular abnormalities (notably patent ductus arteriosus)
Vision abnormalities (notably cataracts and retinopathy)
CNS abnormalities
Hepatitis
In addition to congenital rubella syndrome, an infection during pregnancy may have the following effects on the fetus/neonate:
Increased risk of spontaneous abortion
A “blueberry muffin” rash due to extramedullary hematopoiesis
Diagnostic tests helpful in preventing congenital rubella syndrome is early prenatal IgG screening to detect immunity to rubella from prior infection or vaccination.
The mother should be immunized 1 month prior to attempting to become pregnant (in order to clear the virus) because there is no proven benefit from rubella immune globulin and there is no treatment if an infection develops during pregnancy. Note: non-immune pregnant patients should not be vaccinated because it is a live-attenuated virus.
How can intrauterine fetal demise be managed if the fetus is less than 24 weeks’ gestation?
Intrauterine fetal demise is managed by inducing labor and delivery to expel the nonviable fetus. Note: it is not an indication for a cesarean section.
Oxytocin, misoprostol (PGE1 analogue), and PGE2 can be used to induce labor and delivery.
If the fetus is less than 24 weeks’ gestation, dilation and evacuation may be performed to remove the fetus.
How is polyhydramnios treated after 32 weeks’ gestation?
Treatment of polyhydramnios is only administered if the mother is uncomfortable or if there is a threat of preterm labor.
Pregnancies at <32 weeks’ gestation can be treated with amnioreduction and indomethacin with tapered dosing and weekly amniotic fluid volume measurement.
Pregnancies at >32 weeks’ gestation are only treated with amnioreduction. Indomethacin should be avoided after 32 weeks because of the risk of premature closure of the ductus arteriosus.
Describe the different types of multiple gestation.
- Multiple gestation pregnancy describes any pregnancy in which more than one fetus develops simultaneously
- Dizygotic twins - ‘fraternal twins’ arise from two zygotes by different sperm and are dichorionic (2 placentas) and diamnionic (2 amniotic sacs)
- Monozygotic twins aka identical twins arise form one zygote and have several presentations
- Dichorionic diamniotic monozygotic twins occur if the clevage of the zygote occurs between 4 and 8 days of fertilization
- Monochorionic, monoamniotic monozygotic twins occur if the cleavage of the zygote occurs between 9-12 days of fertilization
- Conjoined monozygotic twins occur if the cleavage of the zygote occurs after 12 days of fertilization
- an increased incidence of multiple gestation pregnancies are seen in women with a family history and those who have received reproductive assistance with fertility drugs (such as clomiphene citrate).
- Fertility drugs may lead to the growth of more ovarian follices and multiple ovulations and is responsible in part for the increasing number of twin pregnancies.
What are some causes of severe polyhydramnios?
Polyhydramnios is an excess of amniotic fluid in the gestational sac (amniotic fluid index >25 cm) and is associated with an increased risk of various adverse pregnancy outcomes.
The most common cause of severe polyhydramnios are fetal anomalies, which can include:
- anything that decreases the amount of amniotic fluid that the fetus swallows (GI obstruction, neuromuscular disorders, chromosomal abnormalities)
- Fetal anemia
- Maternal diabetes
- Multiple gestation, which can result in twin-twin transfusion syndrome
What medications should be continued in patients with eclampsia for 48 hours after delivery and why?
Eclampsia should be managed with magnesium sulfate and intravenous diazepam to control seizures.
The patient should also be stabilized with sufficient oxygen and blood pressure control using labetalol or hydralazine.
Magnesium and antihypertensive medications should be continued for 48 hours after delivery because 25% of seizures occur within 24 hours after delivery.
What should not be performed if abruptio placentae is suspected?
Ultrasound inconsistently shows separation of the placenta from the uterus in abruptio placentae (i.e. it does not diagnose it). The diagnosis is clinical.
DO NOT perform pelvic exam.
What physical exam finding is suspicious of polyhydramnios?
A physical exam finding of a uterine size that is large for the gestational age is suspicious for polyhydramnios.
What is the general management of ectopic pregnancy?
Management:
If the ectopic pregnancy has ruptured, the first goal is to stabilize the patient with IV fluids, blood and pressors as needed before taking her to the operating room for exploratory laparotomy to stop bleeding and resect ectopic pregnancy.
If the woman has an unruptured ectopic and there is no fetal heartbeat, methotrexate is the treatment of choice.
What type of delivery is indicated in placenta previa?
Patients with placenta previa should deliver by cesarean section.
What two drugs of historical interest carry teratogenic risks?
Drugs of historical interest that carry teratogenic risks include diethylstilbestrol (DES) and thalidomide.
Thalidomide is notorious for causing limb abnormalities.
Diethylstilbestrol (DES) causes vaginal and cervical cancer later in life.
What is intrauterine fetal demise?
Intrauterine fetal demise is defined as fetal death after 20 weeks’ gestation and before the onset of labor. Contrast this with miscarriage which is death before 20 weeks.
Associated risk factors include:
Placental or cord abnormalities
Infection
Fetal congenital abnormalities
Maternal hypertension
Poor maternal health
What are the teratogenic risks of diazepam?
Sedative-hypnotic drugs that carry teratogenic risks include diazepam and phenobarbital.
Diazepam causes:
Cleft palate
Renal defects
Secondary neoplasms
Phenobarbital causes neonatal withdrawal.
What complications are associated with preeclampsia?
Complications of preeclampsia and eclampsia include:
Eclampsia
Stroke
Maternal organ dysfunction
Risk of maternal death
Intrauterine growth restriction, oligohydramnios, preterm delivery, or fetal death
HELLP syndrome (discussed separately)
Risk of preeclampsia and eclampsia in the following pregnancy
What is a major fetal risk of ethanol consumption during pregnancy?
Ethanol use during pregnancy carries the risk of fetal alcohol syndrome, which includes:
Mental retardation
Intrauterine growth restriction
Neuropathy
Facial Abnormalities
In addition to fetal alcohol syndrome, fetal effects of maternal alcohol use include spontaneous abortion and intrauterine fetal demise.
Maternal risks of alcohol consumption during pregnancy are minimal.
hat must be obtained before performing maternal HIV screening?
In patients with HIV, there is a 5% risk of in-utero infection, but there is a rapid progressionof HIV to AIDS.
Consent is required, but early prenatal blood screening for HIV should be performed.
The use of Zidovudine (AZT) significantly reduces the risk of vertical HIV transmission to the fetus. Note: mothers should continue their antiviral regimens, but sources say the use of efavirenz, didanosine, stavudine, or nevirapine should be avoided.
What are the most significant risk factors for an ectopic pregnancy?
Ectopic Pregnancy: Pregnancy occurring outside the uterus. Ectopic embryos will ultimately grow or invade underlying tissues, most commonly causing peritoneal rupture, leading to hemoperitoneum and acute abdomen.
Most often occurs in the ampulla of the fallopian tube. It can also occur in the ovary, peritoneal cavity, and cervix.
Risk factors:
Most common cause: Scarring from chronic salpingitis or PID
Other causes include: History of prior ectopic pregnancy and prior tubal surgery.
Heterotopic pregnancy: A multiple gestation with at least one intrauterine pregnancy and one ectopic pregnancy. The risk of this is small but increases with IVF if multiple embryos were used.
How are mothers with severe preeclampsia that are far from term managed?
If symptoms of preeclampsia are severe and the mother is farm from term:
Admit the mother and closely monitor
Maintain blood pressure below 155/105 with diastolic above 90 with antihypertensives like labetalol (do not use ACE-Inhibitors or angiotensin receptor blockers because of teratogenic effects)
Intravenous magnesium sulfate for seizure prophylaxis and neuroprotection
Deliver as soon as the fetus is considered viable
What are the teratogenic risks of valproic acid?
Valproic acid causes:
Neural tube defects in 1% of pregnancies
Facial abnormalities
Cardiovascular abnormalities
Skeletal abnormalities
How is oligohydramnios diagnosed?
The diagnosis of oligohydramnios is made with ultrasound, which will show amniotic fluid volume <5 cm with no pockets at least 2 cm in size.
What is a heterotopic pregnancy?
Heterotopic pregnancy: A multiple gestation with at least one intrauterine pregnancy and one ectopic pregnancy. The risk of this is small but increases with IVF if multiple embryos were used.
What etiologies can cause oligohydramnios?
It is associated with:
Intrauterine growth restriction
Fetal stress
Fetal renal abnormalities, such as in potter syndrome
Poor fetal health
How can transmission of HSV from mother to neonate be avoided?
HSV infection can be confirmed with viral culture or enzyme immunoassays. Mothers with active HSV lesions or a primary outbreak should deliver the baby via cesarean section to avoid transmission.
Describe HSV infection.
Herpes simplex virus (HSV) infection carries a high risk of neonatal death in addition to the following fetal/neonatal effects:
Intrauterine growth restriction
Microcephaly
Spontaneous abortion
Increased risk of prematurity
Mental retardation
Rather than transplacentally, HSV is more commonly transmitted as the neonate passes through the birth canal.
HSV infection can be confirmed with viral culture or enzyme immunoassays. Mothers with active HSV lesions or a primary outbreak should deliver the baby via cesarean section to avoid transmission.
Acyclovir may be beneficial in the neonate if transmission has occurred.
What are the teratogenic risks of heparin?
Heparin, although safer than warfarin, causes:
Prematurity
Intrauterine fetal demise
What are the maternal risks of opioid use during pregnancy?
Opioid use during pregnancy carries the fetal risks of:
Narcotic withdrawal
Prematurity
Intrauterine growth restriction
Meconium aspiration
Neonatal infections
Maternal risks of opioid use in pregnancy include:
Infection
Narcotic withdrawal
Premature rupture of membranes