High Risk Pregnancy & Early Pregnancy Complications Flashcards

1
Q

Categories of High-Risk Pregnancies ?

A

Fetal

Maternal-Fetal

Maternal

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2
Q

High-Risk Pregnancies: Fetal ?

A

Structural or chromosomal abnormalities,

genetic syndromes,

multiple gestations,

infection

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3
Q

High-Risk Pregnancies: Maternal - Fetal ?

A

Preterm labor,

PROM,

cervical insufficiency,

intrauterine growth restriction (UGR),

abnormal placenta,

preeclampsia

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4
Q

High-Risk Pregnancies: Maternal ?

A

DM

HTN

cardiac or thyroid disease

infection

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5
Q

Maternal Leading Causes of 
Pregnancy-Related Deaths

A
Thromboembolic disease 
Hypertensive disease
Hemorrhage
Infection
Ectopic pregnancy
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6
Q

____________ is leading cause of death of infants

A

Preterm birth

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7
Q

Defined as 28 weeks gestation through day 7 of life

A

Perinatal period

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8
Q

Prenatal Screening: Past OB Hx. ?

A

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

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9
Q

Half of all___________ are lost before pregnancy is even realized

A

conceptions

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10
Q

Another 15-20% of conceptions are lost in _______________ – half of these are due to abnormal karyotypes and cannot be saved

A

first trimester

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11
Q

Fetal Heart Rate Monitoring during labor options ?

A

Electronic vs. intermittent auscultation

Electronic use is increasing, but no trials to confirm it is better ( recording)

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12
Q

NL Fetal Heart Rates ?

A

110-160

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13
Q

FHR: below ____ is bradycardia and above _____ is tachy

A

110

160

Nonreassuring fetal status if either is seen

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14
Q

FHR: Accelerations weeks ?

A

32 weeks +

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15
Q

FHR: Accelerations - ↑ FHR of __ beats, lasting __ seconds

A

15

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16
Q

FHR: Accelerations - __ or more accelerations in a __ min period are reassuring

A

2

20

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17
Q

FHR: Accelerations - own notes ?

A

these are okay , good , variability to our HR

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18
Q

FHR: variability ?

A

Fluctuations in FHR of 2 cycles per minute

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19
Q

FHR: Decelerations - Early ?

A

mirror contractions, usually represent head compression

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20
Q

FHR: Decelerations - Late ?

A

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

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21
Q

FHR: Decelerations - Variable ?

A

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 **

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22
Q

FHR: Decelerations - Prolonged ?

A

↓ 15 beats below baseline, lasting 2-10 mins , decreased perfusion

bad

**FHR is staying down after many contractions **

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23
Q

FHR: Decelerations - Late is associated with ?

A

Assoc with fetal hypoxemia, perinatal M&M

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24
Q

FHR: Decelerations - Variable represents ?

A

cord compression

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25
Q

Early Pregnancy Complications ?

A
Hyperemesis Gravidarum
Abortion
Ectopic Pregnancy
Gestational Diabetes
Gestational Trophoblastic Diseases
Hypertension Disorders in Pregnancy
Preeclampsia
Eclampsia
HELLP syndrome
Exposure to Fetotoxic Agents
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26
Q

Hyperemesis Gravidarum prevalence and etiology ?

A

0.3-2% of pregnancies

Etiology unknown

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27
Q

Hyperemesis Gravidarum sxs. ?

A

Severe N/V that may result in dehydration, weight loss

Psychological burden

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28
Q

Hyperemesis Gravidarum duration and timing ?

A

Usually starts at 3-5 weeks

resolves by 20 weeks

(some have symptoms until delivery)

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29
Q

Hyperemesis Gravidarum Tx. ?

A

Hydration, vitamin supplementation

Phenergan - makes you tired

Zofran? – off label use for severe cases
risk of cleft palate in fetus

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30
Q

Hyperemesis Gravidarum prognosis ?

A

80% will have it again in subsequent pregnancies

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31
Q

Spontaneous abortion: prevalence ?

A

15% of clinically evident pregnancies

50% of chemically evident pregnancies
urine based preggo tests

80% occur before 12 weeks

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32
Q

Spontaneous abortion increased risk with ?

A

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

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33
Q

Spontaneous abortion less common causes ?

A

Infection

Anatomic defect of baby or mom
septate uterus

Endocrine factor in mother

Immunologic factor

Exposure to toxin

Trauma

Large percentage – unknown reason

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34
Q

Spontaneous abortion: maternal anatomic defect ?

A

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

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35
Q

Spontaneous abortion complications: development of ?

A

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
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36
Q

50% of 1st trimester spontaneous AB’s, have ?

A

abnormal karyotype

Most common abnormality is trisomy

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37
Q

Threatened abortion: Defined as ? In a ?

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
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38
Q

TA: 25% of pregnant women have ?

A

1st trimester bleeding

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39
Q

TA: Usually caused by _____________ and it resolves

A

implantation

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40
Q

TA: At risk for subsequent ?

A

miscarriage,

PROM,

preterm labor

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41
Q

Inevitable abortion:

A

Uterine bleeding before 20 weeks

Dilated cervix

No expulsion of products of conception ( but going to happen cause it is dilated)

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42
Q

Complete abortion (CA) ?

A

Expulsion of all products of conception before 20 weeks

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43
Q

CA US ?

A

endometrial lining is thin, no products of conception in uterus

everything has left the building

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44
Q

CA Dx. ?

A

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

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45
Q

CA Tx. ?

A

observe for further bleeding. If none, no further tx needed.

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46
Q

Incomplete abortion (IA) ?

A

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 )

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47
Q

Missed abortion ?

A

Embryonic or fetal demise

Nonviable pregnancy retained in the uterus

Requires D&C to remove it

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48
Q

Anembryonic pregnancy dx ?

A

US

49
Q

Anembryonic pregnancy patho ?

A

Embryo fails to develop or non-viable embryo is resorbed (“blighted ovum”)

50
Q

Anembryonic pregnancy management ?

A

like missed AB

51
Q

Management of spontaneous abortion: CBC ?

A

evaluate for significant bleed

52
Q

Management of spontaneous abortion: Cervical culture ?

A

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

53
Q

Management of spontaneous abortion: Pregnancy test ?

A

Serum ß-hCG,

monitor serial values

54
Q

Management of spontaneous abortion TVUS ?

A

Can see gestational sac at 4-5 weeks

Fetal heart motions at 6-7 weeks

Measure endometrial thickness

and Blood type

55
Q

SA tx: expectant ?

A

Risk of bleeding, pain

Higher rate of retained tissue – may require medical or surgical intervention

allow spontaneous passage

56
Q

SA tx: medical ?

A

Misoprostol (prostaglandin) – induces uterine contractions

Bleeding and pain may result in need for surgical tx

57
Q

SA tx: surgical ?

A

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

58
Q

Septic Abortion ?

A

Intrauterine fetal demise with intrauterine infection

Infection can be from normal vaginal flora or an STI

59
Q

Septic Abortion: In countries where abortion is illegal, death rates from septic abortions are high, why ?

A

Nonsterile instruments – introduce bacteria

Poor surgical technique – incomplete removal of products of conception

60
Q

Septic Abortion: spreading ?

A

Endometritis can spread to peritonitis, bacteremia, sepsis

61
Q

Septic Abortion Tx ?

A

hospitalize,

IV ATB’s,

possible D&C

62
Q

Recurrent Pregnancy Loss: definition ?

A

3+ losses before 20 weeks gestation

63
Q

Recurrent Pregnancy Loss: what are the chances of viable pregnancy ?

A

Overall – 60% chance of a viable pregnancy

64
Q

Recurrent Pregnancy Loss: idiopathic, but check ?

A

Genetic

Immunologic – antiphospholipid syndrome,
lupus

Endocrinologic

Anatomic

Microbiologic

Thrombophilic – arterial or venous

65
Q

Ectopic Pregnancy pathology ?

A

Fertilized ovum implants outside the endometrial cavity

66
Q

Ectopic Pregnancy prevalence ?

A

Occurs in 1.5-2% of all pregnancies

67
Q

Ectopic Pregnancy MC location ?

A

> 95% in fallopian tube

but dont forget to check other places

68
Q

Ectopic Pregnancy incidence increases with ?

A

↑ rates of PID

↑ use of assistive reproductive technology (ART)

↑ rates of tubal ligation
and then getting it reversed ( scar tissue)

69
Q

Ectopic Pregnancy: M&M is decreasing because ?

A

Earlier diagnosis and tx before rupture

Leading cause of pregnancy-related deaths in 1st trimester

70
Q

Ectopic Pregnancy: RF - tubal damage ?

A

Hx of PID - damage to cilia or adhesions

Previous tubal surgery

Endometriosis

Uterine fibroids

DES exposure

71
Q

Ectopic Pregnancy DDx of abdominal pain ?

A
Normal pregnancy
Threatened or incomplete abortion
Ovarian cyst rupture
Ovarian torsion
Gastroenteritis
Appendicitis

So keep a high index of suspicion

72
Q

Ectopic – Signs and Symptoms ?

A

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 **

73
Q

Ectopic - Labs ?

A

Hematocrit

beta-HcG - Quantitative

TVUS

MRI

Serum progesterone

74
Q

Ectopic: Treatment- Expectant ?

A

if asymptomatic and hCG levels dropping. Risk of rupture and bleeding so monitor closely

75
Q

Ectopic Pregnancy: RF ?

A

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 **

76
Q

Ectopic: Treatment- Medical ?

A

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
77
Q

Ectopic: Treatment- Surgical ?

A

when Expectant/Medical do not work or are contraindicated (tubal rupture)

Laparoscopy
Laparotomy

78
Q

Ectopic: Treatment- Surgical - Laparoscopy ?

A

Linear salpingostomy

Salpingectomy

79
Q

Linear salpingostomy ?

A

linear incision - esp. for women who desire future pregnancy

80
Q

Salpingectomy ?

A

removal of tube ( unilateral) less risk of retaining trophoblastic tissue

81
Q

Ectopic: Treatment- Surgical - Laparotomy ?

A

if unstable or adhesions, and many clots

-make a full incision in the abd to see what is going on

82
Q

Gestational Diabetes Mellitus (GDM) general information ?

A

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`

83
Q

GDM: Progressive insulin resistance normally occurs in __________, with increase in insulin release by the pancreas

A

pregnancy

84
Q

GDM: But women with GDM exhibit more__________________, beta cells cannot overcome the decreased insulin sensitivity and hyperglycemia results

A

insulin resistance

85
Q

GDM Risk Factors: Similar to T2DM ?

A

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

86
Q

GDM: Two-step approach ?

A

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

87
Q

GDM: One-step approach (outside US) ?

A

2-hour 75g OGTT

88
Q

GDM – Potential Complications ?

A

Preeclampsia

Stillbirth

Macrosomia

Infant can have hypoglycemia, hyperbilirubinemia, hypocalcemia and RDS

Later in life, offspring at risk for obesity and impaired glucose tolerance

89
Q

GDM – Treatment ?

A

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

90
Q

GDM: Postpartum ?

A

GDM resolves with delivery, meds can be discontinued

91
Q

GDM: Prognosis ?

A

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

92
Q

Gestational Trophoblastic Diseases aka ?

A

Molar pregnancies

93
Q

Gestational Trophoblastic Diseases: arise from

A

abnormal proliferation of trophoblast in the placenta - fetal tissue

94
Q

Gestational Trophoblastic Diseases: Types ?

A

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

95
Q

Most common form of gestational trophoblastic disease ?

A

Hydatidiform Mole

96
Q

Hydatidiform Mole is _______ but carry risk of neoplasia.

A

Benign

97
Q

Hydatidiform Mole higher incidence in ?

A

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

98
Q

Hydatidiform Mole: two types ?

A

complete

partials

99
Q

Complete Hydatidiform Mole are _________ meaning ?

A

euploid

empty ovum fertilized by two sperm

100
Q

Complete Hydatidiform Mole have a Higher risk of recurrence and of developing ?

A

persistent trophoblastic disease

101
Q

Partial Hydatidiform Mole are ________, meaning ?

A

triploid

empty ovum fertilized by a duplicated sperm

102
Q

Both Hydatidiform Mole result in ?

A

homozygous conception (all paternal) with altered growth

103
Q

Hydatidiform Mole causes production of ?

A

molar vesicles

104
Q

Hydatidiform Mole characteristics ?

A

multiple grapelike vesicles filling and distending the uterus, usually without an intact fetus

105
Q

Invasive Mole: 10-15% of patients have hx of ?

A

hydatidiform mole

106
Q

Invasive Mole: Considered ______, but is locally invasive to myometrium

A

benign

107
Q

Invasive Mole: Can spontaneously _______, or can penetrate wall and cause uterine rupture

A

regress

108
Q

Choriocarcinoma: is a rare type of ?

A

gestational trophoblastic neoplasia (1 in 40,000 US pregnancies)

109
Q

Choriocarcinoma can occur after a ______________ pregnancy or a NL pregnancy

A

hydatidiform

110
Q

Choriocarcinoma: _________ epithelial tumor of uterus

A

Malignant

111
Q

PSTT aka ?

A

Placental-Site Trophoblastic Tumor

112
Q

When does PSTT arise ?

A

Usually arises months to years after a hydatidiform pregnancy (though can follow a normal pregnancy)

and is RARE

113
Q

PSTT is usually confined to the ?

A

Uterus

114
Q

PSTT can _____________ late in the course

A

Mets

115
Q

Signs and Symptoms of Molar Pregnancies ?

A

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)

116
Q

Molar Pregnancies - Labs ?

A

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
117
Q

Molar Pregnancies - LabsMolar Pregnancies - Labs US results ?

A

Vesicles as “snowstorm” pattern

Ovarian cysts

No gestational sac or fetus

118
Q

Molar Pregnancies - Treatment

A

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
119
Q

Molar Pregnancy - Prognosis ?

A

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