High Risk Flashcards
Who would have a high risk pregnancy?
Multiple gestation, immune/nonimmune hydrops, maternal disease, AMA, hx of anomalies
What increases the risk for complications in multiple pregnancies?
- PEC
- bleeding
- prolapsed cord
- large for dates
- poly
- premature birth
- anomalies
How much greater is the risk for fetal death in multiple gestations?
five times greater
What percentage of twins end in a singleton pregnancy?
70%, many losses occur before it is known
What is monozygotic?
multiple gestations that occur from one fertilized ovum (zygote)- 1 ova, 1 sperm
What is dizygotic?
multiple gestations that occur from two fertilized ova- 2 ova, 2 sperm
What are dizygotic twins AKA?
fraternal, can be confirmed DI if opposite genders
How frequently do dizygotic twin pregnancies occur and what amount of twin pregnancies do they make up?
1 in 80 conceptions, 2/3 of all twins
How many chorions, amnions and placentas do dizygotic twins have?
2 of each
What are monozygotic twins AKA?
identical
If division occurs at the morula stage, what kind of pregnancy is it?
Dichorionic/diamniotic, 2 chorion, 2 amnion, 1-2 placentas
If division occurs at the blastocyst stage (1st week), what kind of pregnancy is it?
Mono/di, 1 chorion, 2 amnion, 1 placenta
If division occurs at the blastocyst stage (2nd week) what kind of pregnancy is it?
Mono/mono, 1 chorion, 1 amnion, 1 placenta
What happens if the embryonic disc divides after day 13?
conjoined twins
What are the clinical findings of multiples?
- increased hCG
- increased MSAFP
- increased uterine size (large for dates)
- embryonic or fetal reduction
What are maternal complications of multiples?
- HTN
- Preeclampsia/eclampsia
- placental abruption
- PP hemorrhage
- preterm labor
- anemia
What are fetal complications of multiple pregnancy?
- prolapse, entanglement, compression
- cord knots in mono/mono
- IUGR due to placental insufficiency
- hypoxia
- increased risk of fetal anomalies
What is vanishing twin?
Demise of twin in late 1st or early 2nd tri, embryo and sac are absorbed
What can vanishing twin have a similar appearance to?
SCH
What is TTTS?
twin to twin transfusion syndrome, occurs in mono twins (mo/di or mo/mo)
abnormal development of vascular supply in shared placenta
TTTS is a form of what?
AVM, shunts blood away from donor twin to recipient twin, potentially morbid for both twins
How does TTTS appear sonographically?
- 20% difference in fetal weights or AC
- recipient: poly, large for dates, edema, hydrops
- donor: oligo, small for dates, “stuck position”
What is twin embolization?
Blood clots or thromboplastic material from the demise of one fetus to the live fetus
How does twin embolization occur?
shared placental vascular supply
What are results of twin embolization?
Neurologic, GI, GU abnormalities
What is the sono app of twin embolization?
- demise of one twin
- hydrops
- poly
- intraplacental hemorrhage
- abnormal cranial contents
- enlarged, echogenic kidneys
What is acardiac twinning?
One twin has no vascular connection to placenta, umbilical arterial-arterial connection shunts blood from donor to “acardiac” twin
What is the result of acardiac twinning to the donor twin and the acardiac twin?
Donor: typically normal but with cardiomegaly, may develop heart failure & hydrops
Acardiac: multiple anomalies, no cardiac activity, may move and grow, anencephaly/microcephaly, cystic hygroma
What type of gestation does acardiac twinning occur in?
mono/mono only
What are conjoined twins?
incomplete division of embryonic disk after 13 days gestation
How are conjoined twins described?
- thoracopagus: thoracic MC
- omphalopagus: xiphoid to umbilicus
- pyopagus: sacrum
- ischiopagus: ischium/pelvis
- craniopagus: cranium
What are the 4 possible combinations of twin deliveries?
Both vertex: vaginal
A vertex, B breech: OB decision, version is possible
A breech, B vertex: c-section
Both breech: c-section
What is hydrops fetalis?
Serious condition where fluid accumulates in 2 or more fetal compartments, immune or nonimmune
Nonimmune hydrops constitutes what percentage of hydrops cases?
90%
What causes nonimmune hydrops?
Disease or condition that affects body’s ability to manage fluid levels
What are the main causes of nonimmune hydrops?
- anything other than Rh sensitivity
- cardiac anomalies
- infection
- chromosomal abnormalities
- TTTS
What is the sono appearance of nonimmune hydrops?
- pericardial effusion (earliest sign), pleural effusion
- ascites, poly
- fetal skin thickening (anasarca) >5 mm
- placental thickening
- hepatosplenomegaly
- enlarged umbilical vein
What is immune hydrops caused by?
Rh incompatibility
- Rh- mom, Rh+ dad= Rh+ fetus
- Destruction of RBC= erythroblastosis fetalis + anemia= hydrops
How is immune hydrops treated?
- Fetal RBC only enter maternal circulation at delivery
- RhoGam is given after each pregnancy to prevent antibody formation
How can immune hydrops be determined sonographically?
MCA doppler is used to help determine fetal anemia & IUGR, high resistance waveform
What are the causes of infertility for a minimum of 1 year?
Both: 5-10%
Unexplained: 5-10%
Male: 40%
Female: 40%
What are female factors that can cause infertility?
- abnormal ovulation & tubal transportation
- endometriosis
- myomas & uterine anomalies
- PCOS
- cervical factors
What is IVF?
ovarian stimulation, needle aspiration or oocytes, incubation with sperm, catheter delivery of 2-4 embryos into uterus
What is ZIFT?
zygote intrafallopian tube transfer, embryo (zygote) is placed into fallopian tube
What is GIFT?
Gamete intrafallopian tube transfer, sperm and ova are placed into fallopian tube
What is IUI?
intrauterine insemination, cases of male infertility, catheter guidance of sperm into fundal uterus
What are complications of assisted reproductive technologies?
ovarian hyperstimulation syndrome and multiple gestations
What is ovarian hyperstimulation syndrome?
- results from excessive hormonal stimulation
- mild cases: resolves with next cycle
- severe: fluid/electrolyte imbalance, resulting in 50% mortality rate
- large ovarian cysts, ascites, pleural effusion
What is hyperemesis gravidarum?
Dehydration & electrolyte imbalance due to excessive vomiting, IV administration is necessary, more common with multiple fetuses
What is supine hypovolemic syndrome? What does it cause?
- IVC syndrome
- large, heavy gravid uterus compresses IVC when pt is supine & decreases blood pressure
- causes faintness, nausea, lightheadedness, sweating
How do you counteract supine hypovolemic syndrome?
turn patient on side
How does diabetes affect pregnancy?
insulin dependent diabetes = increased risk of complications, glucose drives fetal growth
What is the result of high uncontrolled glucose levels?
macrosomia, fetal weight > 90th percentile or 4000g, too large for vaginal birth
What can diabetes cause?
Poly- PROM & caudal regression syndrome
What is gestational diabetes?
glucose intolerance during pregnancy, pathologically different than DM
What causes GD?
hormone & metabolic changes, typically 3rd trimester occurrence associated with macrosomia
What is hypertension in pregnancy associated with?
Associated with small placentas due to effects on blood vessels, restricts blood supply to fetus = growth restriction
What is PIH?
Pregnancy-induced hypertension: Preeclampsia and chronic HTN
What is preeclampsia?
High blood pressure develops with proteinuria or edema
What is eclampsia?
seizures or coma
What is HELLP syndrome?
hemolysis, elevated liver enzymes, low platelets
What are infections affecting pregnancy?
TORCH:
- toxoplasmosis
- other (syphilis)
- rubella
- cytomegalovirus
- herpes (genital)
What is Rh incompatibility?
Presence of Rh factor in blood, mother and fetus have different factors = maternal antibodies attack fetal blood
What can be done to prevent Rh incompatibility?
Screening and preventative treatments
What is erythroblastosis fetalis?
destruction of fetal RBCs by antibodies
What causes erythroblastosis fetalis?
- Rh incompatibility
- ABO incompatibility
- isoimmune disease
- additional blood disorders
What is IUGR?
spectrum of fetal weight below 10th percentile for GA, asymmetric & symmetric
What are the most common causes of IUGR?
- uterus
- placenta & transfer rate
- AFI
What is symmetric IUGR?
- 25% of cases
- restriction affects entire fetus
- genetic or maternal infection
- occurs earlier
What is the sono appearance of symmetric IUGR?
- all measurements more than 2 weeks below GA
- oligo
- early mature placenta
- low BPP score
What is asymmetric IUGR?
- 75% of cases
- occurs in last 8-10 weeks
- fetus attempts to protect the brain, receive nutrient blood first
What is the sono appearance of asymmetric IUGR?
- asymmetry between HC & AC >2 SD
- AC > 2 wks behind HC
- oligo
- early mature placenta
What are maternal causes of IUGR (3rd tri/asymm)?
- poor nutrition
- smoking, drug, alcohol abuse
- multiple gest
- severe anemia
- diabetes
- CKD
- Rh sensitization
- asthma
- under 17, over 35
- heart disease
- high altitude
What are placental causes of IUGR (3rd tri/asymm)?
- infarcts & hemangiomas
- small size
- SUA
- abruption
- insufficiency
What are fetal causes of IUGR (2nd tri/symm)?
- genetic/chromosomal defects
- intrauterine infections
What can occur as a result of erythroblastosis fetalis?
CHF, hydrops, death
What is amniotic band syndrome?
Early disruption of amnion, bands of non-stretchable tissue free floats in amniotic fluid and entrap fetal body parts
What does amniotic band syndrome cause?
- Limb defects: amputation, clubfeet, constriction ring/band, syndactyly
- Craniofacial defects: asymmetric anencephaly, encephalocele, facial cleft, severe facial dysmorphia
- Visceral defects: gastroschisis, ectopia cordis
What is uterine rupture?
Spontaneous tearing of uterus caused by labor pressure & previous c scar, fetus is expelled into peritoneal cavity
results in hemorrhaging & mat-fetal death
What is PROM?
spontaneous rupture of membranes prior to labor
What is pre-term labor? What are risk factors for it?
Onset of labor prior to 37 wks
- previous uterine sx/ut anomalies
- multiple gestations
- smoking
- stress
- infection
What are signs of fetal death within days of it occuring?
- subcutaneous edema
- unnatural position: extreme flexion/extension
- Spaulding’s sign: overlapping of skull bones
- loss of definition of fetal abdominal structures
- Robert’s sign: gas within abdomen
- Maceration: skin breaks down and appears as echoes within amniotic fluid
What is the puerperal period?
Biochemical and physical changes beginning with expulsion of placenta and ending with maternal anatomy returning to non-gravid state
How long does the puerperal period last?
4-6 wks after delivery
What is the size of the PP uterus and how does it appear?
14x7x7cm, large, hypoechoic, fluid in endo, open internal os
What is the most lethal complication of the puerperal period?
hemorrhage
What constitutes hemorrhaging?
blood loss over 500 ml following vaginal delivery, over 1000 ml for c-section
How can hemorrhaging be controlled?
Medication, manual compression of uterus, surg
What are clinical signs of hemorrhage?
Shock, heavy bleeding, decreased hematocrit
What is hemorrhage associated with?
RPOC, uterine atony, uterine overdistention, uterine manipulation
What is the sonographic appearance of hemorrhage?
normal ut, expanded endo cavity
When should an infection be questioned?
Fever over 100.4 any 2 out of first 10 days PP
What causes PP infection and what is it associated with?
Pathogens introduced by vagina
Assoc. with:
- poor hygiene & nutrition
- anemia
- vaginitis/cervicitis
- invasive fetal monitoring devices
- c-section
- prolonged labor
What is abscess and what causes it?
Localized collection of pus, serous fluid anywhere in abdominal or pelvic cavities, causes by predisposing factors of infection
What is the sonographic appearance of abscess?
- complex/anechoic fluid collection
- internal debris
- shadowing when gas is present
What is hematoma? What is the most common location?
Occurs from excessive bleeding, post-op for c-section
Bladder flap hematoma is MC, located between uterus & posterior bladder wall
What is ovarian vein thrombosis and what is it caused by?
Clotting of ovarian/iliac vein PP caused by injury during labor to vessels & vascular changes due to pregnancy
