High Risk Pregnancy & Early Pregnancy Complications Flashcards
Categories of High-Risk Pregnancies ?
Fetal
Maternal-Fetal
Maternal
High-Risk Pregnancies: Fetal ?
Structural or chromosomal abnormalities,
genetic syndromes,
multiple gestations,
infection
High-Risk Pregnancies: Maternal - Fetal ?
Preterm labor,
PROM,
cervical insufficiency,
intrauterine growth restriction (UGR),
abnormal placenta,
preeclampsia
High-Risk Pregnancies: Maternal ?
DM
HTN
cardiac or thyroid disease
infection
Maternal Leading Causes of Pregnancy-Related Deaths
Thromboembolic disease Hypertensive disease Hemorrhage Infection Ectopic pregnancy
____________ is leading cause of death of infants
Preterm birth
Defined as 28 weeks gestation through day 7 of life
Perinatal period
Prenatal Screening: Past OB Hx. ?
Recurrent AB (3+ losses)
Previous stillbirth
Previous preterm delivery
Rh or ABO incompatibility
Hx preeclampsia/eclampsia
Hx infant with genetic or
congenital d/o
Teratogen exposure – Drugs,
ETOH, infection, radiation
Half of all___________ are lost before pregnancy is even realized
conceptions
Another 15-20% of conceptions are lost in _______________ – half of these are due to abnormal karyotypes and cannot be saved
first trimester
Fetal Heart Rate Monitoring during labor options ?
Electronic vs. intermittent auscultation
Electronic use is increasing, but no trials to confirm it is better ( recording)
NL Fetal Heart Rates ?
110-160
FHR: below ____ is bradycardia and above _____ is tachy
110
160
Nonreassuring fetal status if either is seen
FHR: Accelerations weeks ?
32 weeks +
FHR: Accelerations - ↑ FHR of __ beats, lasting __ seconds
15
FHR: Accelerations - __ or more accelerations in a __ min period are reassuring
2
20
FHR: Accelerations - own notes ?
these are okay , good , variability to our HR
FHR: variability ?
Fluctuations in FHR of 2 cycles per minute
FHR: Decelerations - Early ?
mirror contractions, usually represent head compression
FHR: Decelerations - Late ?
Smooth ↓ in FHR, starting after contraction has started and ends after contraction is over.
Assoc with fetal hypoxemia, perinatal M&M
bad
contraction is starting and the FHR is going down
FHR: Decelerations - Variable ?
abrupt ↓ in FHR, return to baseline.
Usually represent cord compression.
Ominous when repetitive & severe
bad
**sudden drop after contraction has started = cord compression
these in a severe amount and repeatedly it is abd news **
FHR: Decelerations - Prolonged ?
↓ 15 beats below baseline, lasting 2-10 mins , decreased perfusion
bad
**FHR is staying down after many contractions **
FHR: Decelerations - Late is associated with ?
Assoc with fetal hypoxemia, perinatal M&M
FHR: Decelerations - Variable represents ?
cord compression
Early Pregnancy Complications ?
Hyperemesis Gravidarum Abortion Ectopic Pregnancy Gestational Diabetes Gestational Trophoblastic Diseases Hypertension Disorders in Pregnancy Preeclampsia Eclampsia HELLP syndrome Exposure to Fetotoxic Agents
Hyperemesis Gravidarum prevalence and etiology ?
0.3-2% of pregnancies
Etiology unknown
Hyperemesis Gravidarum sxs. ?
Severe N/V that may result in dehydration, weight loss
Psychological burden
Hyperemesis Gravidarum duration and timing ?
Usually starts at 3-5 weeks
resolves by 20 weeks
(some have symptoms until delivery)
Hyperemesis Gravidarum Tx. ?
Hydration, vitamin supplementation
Phenergan - makes you tired
Zofran? – off label use for severe cases
risk of cleft palate in fetus
Hyperemesis Gravidarum prognosis ?
80% will have it again in subsequent pregnancies
Spontaneous abortion: prevalence ?
15% of clinically evident pregnancies
50% of chemically evident pregnancies
urine based preggo tests
80% occur before 12 weeks
Spontaneous abortion increased risk with ?
Increased maternal age (30)
of previous spontaneous AB’s
Previous intrauterine fetal demise
Previous infant with malformations or genetic defects
Chromosomal abnormalities in mom or dad
Medical comorbidities
Spontaneous abortion less common causes ?
Infection
Anatomic defect of baby or mom
septate uterus
Endocrine factor in mother
Immunologic factor
Exposure to toxin
Trauma
Large percentage – unknown reason
Spontaneous abortion: maternal anatomic defect ?
septate - wedge of U tissue ( resect the wedge before she is preggo)
Ahermans syndrome - scarring interfere with implantation
Bicornate - 2 sepatete fundi, complete = 2 separate cervxi
Spontaneous abortion complications: development of ?
Severe or persistent bleeding
-not all products of conception are out
Infection
Intrauterine adhesions (Asherman’s syndrome) results and cause of a spontaneous abortion
Infertility
Subsequent D&C can:
- Perforate (0.5%) cause U wall is softened
- Cause cervical insufficiency
- incompetent cervix from dilation
50% of 1st trimester spontaneous AB’s, have ?
abnormal karyotype
Most common abnormality is trisomy
Threatened abortion: Defined as ? In a ?
1st trimester bleeding
- In a viable pregnancy
- Before 20 weeks gestation
- No cervical dilation - nothing has passed yet
- No passage of products of conception
TA: 25% of pregnant women have ?
1st trimester bleeding
TA: Usually caused by _____________ and it resolves
implantation
TA: At risk for subsequent ?
miscarriage,
PROM,
preterm labor
Inevitable abortion:
Uterine bleeding before 20 weeks
Dilated cervix
No expulsion of products of conception ( but going to happen cause it is dilated)
Complete abortion (CA) ?
Expulsion of all products of conception before 20 weeks
CA US ?
endometrial lining is thin, no products of conception in uterus
everything has left the building
CA Dx. ?
Complete abortion can only be diagnosed if a previous intrauterine gestation was documented on US and pathology specimen confirms products of conception
Otherwise, hCG levels must be followed to make sure it was not an ectopic
CA Tx. ?
observe for further bleeding. If none, no further tx needed.
Incomplete abortion (IA) ?
Before 20 weeks gestation
Passage of some, but not all, products of conception
Bleeding and cramping (sometimes severe) continue until complete ( or until D &C to get everything out )
Missed abortion ?
Embryonic or fetal demise
Nonviable pregnancy retained in the uterus
Requires D&C to remove it
Anembryonic pregnancy dx ?
US
Anembryonic pregnancy patho ?
Embryo fails to develop or non-viable embryo is resorbed (“blighted ovum”)
Anembryonic pregnancy management ?
like missed AB
Management of spontaneous abortion: CBC ?
evaluate for significant bleed
Management of spontaneous abortion: Cervical culture ?
see if it was infection that cause the AB
WBC is also elevated in pregnancy so this is why you need to get the culture
Management of spontaneous abortion: Pregnancy test ?
Serum ß-hCG,
monitor serial values
Management of spontaneous abortion TVUS ?
Can see gestational sac at 4-5 weeks
Fetal heart motions at 6-7 weeks
Measure endometrial thickness
and Blood type
SA tx: expectant ?
Risk of bleeding, pain
Higher rate of retained tissue – may require medical or surgical intervention
allow spontaneous passage
SA tx: medical ?
Misoprostol (prostaglandin) – induces uterine contractions
Bleeding and pain may result in need for surgical tx
SA tx: surgical ?
Dilation and curettage (D&C)
Formerly the 1st line of tx, but higher rates of infection
Risk of perforation, cervical insufficiency
Lower rates of retained tissue
Septic Abortion ?
Intrauterine fetal demise with intrauterine infection
Infection can be from normal vaginal flora or an STI
Septic Abortion: In countries where abortion is illegal, death rates from septic abortions are high, why ?
Nonsterile instruments – introduce bacteria
Poor surgical technique – incomplete removal of products of conception
Septic Abortion: spreading ?
Endometritis can spread to peritonitis, bacteremia, sepsis
Septic Abortion Tx ?
hospitalize,
IV ATB’s,
possible D&C
Recurrent Pregnancy Loss: definition ?
3+ losses before 20 weeks gestation
Recurrent Pregnancy Loss: what are the chances of viable pregnancy ?
Overall – 60% chance of a viable pregnancy
Recurrent Pregnancy Loss: idiopathic, but check ?
Genetic
Immunologic – antiphospholipid syndrome,
lupus
Endocrinologic
Anatomic
Microbiologic
Thrombophilic – arterial or venous
Ectopic Pregnancy pathology ?
Fertilized ovum implants outside the endometrial cavity
Ectopic Pregnancy prevalence ?
Occurs in 1.5-2% of all pregnancies
Ectopic Pregnancy MC location ?
> 95% in fallopian tube
but dont forget to check other places
Ectopic Pregnancy incidence increases with ?
↑ rates of PID
↑ use of assistive reproductive technology (ART)
↑ rates of tubal ligation
and then getting it reversed ( scar tissue)
Ectopic Pregnancy: M&M is decreasing because ?
Earlier diagnosis and tx before rupture
Leading cause of pregnancy-related deaths in 1st trimester
Ectopic Pregnancy: RF - tubal damage ?
Hx of PID - damage to cilia or adhesions
Previous tubal surgery
Endometriosis
Uterine fibroids
DES exposure
Ectopic Pregnancy DDx of abdominal pain ?
Normal pregnancy Threatened or incomplete abortion Ovarian cyst rupture Ovarian torsion Gastroenteritis Appendicitis
So keep a high index of suspicion
Ectopic – Signs and Symptoms ?
Pelvic/abdominal PAIN
Abnormal uterine bleeding
-scant or huge
Amenorrhea
Syncope - dramatic blood loss
Abdominal tenderness
Adnexal mass/fullness – half of patients
Hemodynamic instability – VS changes
shoulder pain - the phrenic nerve
**~100% people have pain **
Ectopic - Labs ?
Hematocrit
beta-HcG - Quantitative
TVUS
MRI
Serum progesterone
Ectopic: Treatment- Expectant ?
if asymptomatic and hCG levels dropping. Risk of rupture and bleeding so monitor closely
Ectopic Pregnancy: RF ?
IUD use (uncommon)
Smoking – affects tubal cilia and smooth muscle function
Previous ectopic
1/3 of ectopics occur with no known risk factors
diethyl stidesterol **
Ectopic: Treatment- Medical ?
Methotrexate (inhibits DNA synthesis)
- Ineffective if too far along
- Not for women with blood dyscrasias, GI or resp disease
- make pregnancy unviable
- single or many doses but still monitor for rupture
Ectopic: Treatment- Surgical ?
when Expectant/Medical do not work or are contraindicated (tubal rupture)
Laparoscopy
Laparotomy
Ectopic: Treatment- Surgical - Laparoscopy ?
Linear salpingostomy
Salpingectomy
Linear salpingostomy ?
linear incision - esp. for women who desire future pregnancy
Salpingectomy ?
removal of tube ( unilateral) less risk of retaining trophoblastic tissue
Ectopic: Treatment- Surgical - Laparotomy ?
if unstable or adhesions, and many clots
-make a full incision in the abd to see what is going on
Gestational Diabetes Mellitus (GDM) general information ?
Any degree of glucose intolerance with onset (or first recognition) during pregnancy
Associated with increased risk of maternal and fetal/neonatal complications
7% of pregnancies
Hallmark is insulin resistance
50% will develop T2DM later in life`
GDM: Progressive insulin resistance normally occurs in __________, with increase in insulin release by the pancreas
pregnancy
GDM: But women with GDM exhibit more__________________, beta cells cannot overcome the decreased insulin sensitivity and hyperglycemia results
insulin resistance
GDM Risk Factors: Similar to T2DM ?
Obesity (BMI >30 prepregnant)
Family history of DM
Prior hx of GDM
Heavy glycosuria (>2+ on dipstick)
Hx of unexplained stillbirth
PCOS
Minority ethnicity
Older age (>35)
** Screen at first prenatal visit**
Women with positive risk factors undergo plasma screen
If plasma screen is negative, retest at 24-28 weeks
GDM: Two-step approach ?
ALL patients get 1-hour 50 g OGTT at 24-28 weeks
-Positive if >140
If positive, then a 3-hour 100g OGTT after overnight fast
-Positive if >95 fasting, >180 at 1 hour, >155 at 2 hours, >140 at 3 hours
GDM: One-step approach (outside US) ?
2-hour 75g OGTT
GDM – Potential Complications ?
Preeclampsia
Stillbirth
Macrosomia
Infant can have hypoglycemia, hyperbilirubinemia, hypocalcemia and RDS
Later in life, offspring at risk for obesity and impaired glucose tolerance
GDM – Treatment ?
1800-2400 kcal ADA diet
-educate them on weight gain
Home glucose monitoring
- Fasting 70-95
- 1 hour (<130-140) or 2 hour (<120) postprandial
- Nighttime
If not controlled with diet, add medication
-Metformin or glyburide may be tried, but typically insulin is first-line
Close monitoring during labor to avoid hyperglycemia
GDM: Postpartum ?
GDM resolves with delivery, meds can be discontinued
GDM: Prognosis ?
Increased risk of T2DM in future (50% in 10-15 years)
2-hour 75 g OGTT at 6 weeks postpartum
If normal, recheck in 3 years
Gestational Trophoblastic Diseases aka ?
Molar pregnancies
Gestational Trophoblastic Diseases: arise from
abnormal proliferation of trophoblast in the placenta - fetal tissue
Gestational Trophoblastic Diseases: Types ?
Hydatidiform mole (complete and partial)
Invasive mole
Choriocarcinoma
Placental-Site Trophoblastic
Tumor (PSTT)
Most produce beta hCG ( but they are not pregnant)
The only way to prevent them is abstinence from intercourse
Most common form of gestational trophoblastic disease ?
Hydatidiform Mole
Hydatidiform Mole is _______ but carry risk of neoplasia.
Benign
Hydatidiform Mole higher incidence in ?
Younger than 20
Older than 40
Nulliparous women
Low socioeconomic status
Diets deficient in protein, folic acid and carotene
Blood group AB have worse prognosis
Hydatidiform Mole: two types ?
complete
partials
Complete Hydatidiform Mole are _________ meaning ?
euploid
empty ovum fertilized by two sperm
Complete Hydatidiform Mole have a Higher risk of recurrence and of developing ?
persistent trophoblastic disease
Partial Hydatidiform Mole are ________, meaning ?
triploid
empty ovum fertilized by a duplicated sperm
Both Hydatidiform Mole result in ?
homozygous conception (all paternal) with altered growth
Hydatidiform Mole causes production of ?
molar vesicles
Hydatidiform Mole characteristics ?
multiple grapelike vesicles filling and distending the uterus, usually without an intact fetus
Invasive Mole: 10-15% of patients have hx of ?
hydatidiform mole
Invasive Mole: Considered ______, but is locally invasive to myometrium
benign
Invasive Mole: Can spontaneously _______, or can penetrate wall and cause uterine rupture
regress
Choriocarcinoma: is a rare type of ?
gestational trophoblastic neoplasia (1 in 40,000 US pregnancies)
Choriocarcinoma can occur after a ______________ pregnancy or a NL pregnancy
hydatidiform
Choriocarcinoma: _________ epithelial tumor of uterus
Malignant
PSTT aka ?
Placental-Site Trophoblastic Tumor
When does PSTT arise ?
Usually arises months to years after a hydatidiform pregnancy (though can follow a normal pregnancy)
and is RARE
PSTT is usually confined to the ?
Uterus
PSTT can _____________ late in the course
Mets
Signs and Symptoms of Molar Pregnancies ?
90% have abnormal uterine bleeding in 1st trimester
Some get N/V, occasionally severe
Half have an abnormally large uterine size for gestational age (though some are small for gestational age)
-measuring fundal heights and they are ahead of the curve
Some have enlarged, painful ovaries because of theca lutein cysts
Preeclampsia in 1st trimester (usually starts in third)
Molar Pregnancies - Labs ?
Monitor quantitative beta-hCG
After evacuation of the pregnancy, levels should decline
If they don’t, viable tumor persists
Ultrasound – in complete molar
- Vesicles as “snowstorm” pattern
- Ovarian cysts
- No gestational sac or fetus
Molar Pregnancies - LabsMolar Pregnancies - Labs US results ?
Vesicles as “snowstorm” pattern
Ovarian cysts
No gestational sac or fetus
Molar Pregnancies - Treatment
Hydatidiform
Evacuation – by suction curettage up to 28 weeks
Hysterectomy
- May be necessary if hemorrhage
- Preferred if not desirous of future pregnancy
Prophylactic chemo - controversial
Surveillance
-To monitor for development of malignancy
-Serial hCGs weekly, then monthly
make sure they are coming down
-OCs for a year
cause we dont want them to get preg. so we can still watch the HCG come down
Malignant Gestational Trophoblastic Neoplasia
- Chemo
- Hysterectomy if no future pregnancies desired
- Chest and brain CT for mets
Molar Pregnancy - Prognosis ?
Excellent prognosis when treated with evacuation
Malignancy without mets also has good prognosis
Poorer prognosis with nonpulmonary mets (liver, brain)
Carefully monitor future pregnancies with US and beta hCG
