High Risk Multiple Pregnancies Lecture Powerpoint Flashcards
Abortion definition
Expulsion of fetus less than 16 weeks
Perinatal period
From 16 weeks to 28 days after birth
Risks for perinatal death not caused by congenital anomalies (7)
- breech position
- placental separation
- pre-eclampsia eclampsia
- pyelonephritis
- hydramnios
- placenta previa
- twins
Dizygotic (fraternal) twins
Originate from 2 zygotes, account for about 2/3 of twins, rates increase with age, can be same or different sex, and having one set increases likelihood of having it happen again
Thick seputm and 2 zygotes on ultrasound indicates…
….dizygotic twins
Dizygotic twins have __ amnion and chorions, the monozygotic varies based on when the zygotes divide during development
2
Monozygotic (identical) twins, when do they become conjoined?
one fertilized ovum, cleavage before 72 hours results in dichorionic diamniotic (best outcome) twins, between days 4-8 monochorionic diamnionic (2nd best) twins, and if 8-13 monochorionic and monoamnionic (worst) twins. Cleavage after day 13 will result in conjoined twins***
Vanishing twins
Occurs when ultrasound of first trimester finds twins 12% of all conceptions but only 1-2% of all births
Maternal risks of twins (6)
- physiologic changes occurring are exaggeration of what occurs in single
- preterm labor
- hypertension
- increased c section rate
- abruption
- anemia
- postpartum hemorrhage
Infant complications of twins (4)
- prematurity
- congenital anomalies increased 2-3x
- discordance (unequal weights due to altered surface area of placenta or twin to twin transfusion donation (smaller gives more to larger)
- typically larger twin does worse
Twin complications
- vanishing fetus
- locking twins (one breech and 2nd cephalic preventing chins from passing each other)
- dead fetus syndrome (
- delayed delivery of one twin
- cord intertwining (high risk for sudden stillbirth in monoamniotic monozygotic twins)
- abruption
- acardiac twin (parasitic growth but no actual 2nd twin present)
Maternal weight gain with twins or triplets
at least 30 lbs, at least 50 lbs in triplets
Prevention of preterm labor (3)
- bed rest NO longer advised
- early work leave okay at 36 weeks or so
- corticosteroids can help with lung maturity
Ultrasound cervix length
25mm or less at 24 weeks predicts preterm delivery
Any 12+ (adult) who has even 2 recurrent seizures unprovoked by proximate insult is considered ___, in children they can be due to ___ as well
epilepsy, fevers
Epilepsy and pregnancy
90% of women have a normal pregnancy, not a contraindication, however increased risk for perinatal complications
Perinatal epileptics are at increased risk for these conditions (6)
- maternal death
- need for c section
- antepartum hemorrhage
- preterm labor
- stillbirth
- SUPEP (sudden unexpected death in epilepsy) - most were taking lamotrigine!
Sudden unexpected death in epilepsy (SUPEP)
Sudden unexpected witnessed or unwitnessed non traumatic or non drowning death with or without evidence for seizure excluding status epilepticus which does not have autopsy reveal structural or toxicologic cause of death
__% of all pregnancies are unplanned
50%
Antiepileptic drug lower ___ putting developing infant at increased risk for ___
folic acid, neuro tube defects
All pregnant women should be on __ mg folic acid, epileptics should be on ___
.4-.8, 4mg
If pregnant and been 2 years since last seizure, should they withdraw?
No, wait till the pregnancy is over
Valproate and pregnancy
Antiepileptic contraindicated in pregnancy because of high teratogenicity unless already established pregnancy (don’t want to have seizure occur during change over)
Drug of choice for seizure abortion in delivery
Lorazepam
Lactation and antiepileptic drugs
Present in breast milk, not a concern to the newborn but avoid sedating ones such as phenobarbitol
Fetal hydantoin syndrome
Caused by phenytoin (antiepileptic )use in pregnancy can result in craniofacial anomalies, IUGR, developmental delay, cleft lip/palate, etc
Spinal bifida
a birth defect that occurs when the spine and spinal cord don’t form properly. It’s a type of neural tube defect. The neural tube is the structure in a developing embryo that eventually becomes the baby’s brain, spinal cord and the tissues that enclose them, treated thru surgery
Keppra (levetiracetam)
Antiepileptic drug that is the safest for women of reproductive age as it has the lowest incidence of birth defects (same as unexposed pregnancies)
Anticoagulants in pregnancy
Heparins are the safest choice, lovonox (lmw heparin) is used throughout with switch to unfractionated heparin in the last month of pregnancy since it is more quickly reversed, anticoagulated patients are not eligible for epidural analgesia,does not cross the placenta so no worry about harming the fetus
Goal aPTT range in pregnant woman
1.5-2.5x control (30-40 seconds is control, so like 45-120)
Warfarin in pregnancy
Embryopathic in first trimester, passes the placenta and fetus is anticoagulated may cause fetal hemorrhage, can switch to after birth
Pregnancy coagulability
Pregnancy is a hypercoaguable state with increased factor II, VII, VIII, X, and XII and decreased protein S
Most DVT occur in the __ leg in pregnancy
left
5 inherited autosomal thrombophilias
-factor v leidan
-prothrombin gene mutation
-hyperhomocystinemia
-protein C deficiency
Protein S deficiency
PE diagnostic studies (4)
- D dimer (nonspecific)
- pulmonary angiography
- spiral CT (gold standard in pregnancy)
- duplex scan/compression ultrasound
