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Patient Evaluation > High Risk Pregnancy & Early Pregnancy Complications > Flashcards

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

Patient Evaluation (29 decks)

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