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Patient Evaluation > Late Pregnancy Complications > Flashcards

Late Pregnancy Complications Flashcards

1
Q

Late Pregnancy Complications examples ?

A

Preterm Labor

Premature Rupture of

Membranes

Amniotic Fluid Issues

Oligohydramnios

Polyhydramnios

Post-term Pregnancy

RH Alloimmunization & Blood

Group Incompatibilities

Stillbirth

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2
Q

Preterm Labor: Labor occurring after __ weeks and before __weeks gestation

A

20

37

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3
Q

Preterm Labor: Contractions are ?

A

regular and frequent

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4
Q

Preterm Labor: Cervical effacement ( thinning) or dilation is _______.

A

present

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5
Q

Preterm Labor: Preterm birth occurs in___ of US pregnancies

A

12%

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6
Q

1 cause of neonatal M&M ?

A

Preterm birth

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7
Q

Preterm Labor: Many causes of preterm labor, but 50% are __________.

A

idiopathic

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8
Q

Preterm Labor RF: Obstetric Complications ?

A

In previous or current pregnancy

  • Placental abnormality
  • Amniotic fluid ↓ or ↑
  • Maternal age
  • Socioeconomic status
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9
Q

Preterm Labor RF: Medical Complications ?

A

Pulm, heart or kidney disease

Smoking, alcohol use

Anemia, malnutrition, infection

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10
Q

Preterm Labor RF: Surgical Complications ?

A

Hx of intra-abdominal procedure, cervical conization (LEEP)?, c-section

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11
Q

Preterm Labor RF: Genital Tract Anomalies ?

A

Bicornuate or septate uterus

Cervical incompetence

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12
Q

Preterm Labor prevention ?

A

Not much prevention can be done but prolong as much as possible

For women with a history of prior preterm birth, some evidence that vaginal suppositories or IM injections of progesterone help reduce risk by 30%

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13
Q

Preterm Labor signs and sxs. ?

A

Uterine contractions

Dilation and effacement of cx

+/- bloody mucous vaginal discharge, mucus plug

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14
Q

Preterm Labor evaluation ?

A

Calculate gestational age –by FDLMP or sono estimation

Fetal monitoring
-2 belts around abd.

Tocodynamometry – confirm contractions

PE – check for cervical dilation, ROM, fundal tenderness ( sing of infection - endometritis) , vaginal bleeding, fever

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15
Q

Preterm Labor labs ?

A

CBC with diff

U/A with C&S

US

  • Fetal weight estimation
  • Presenting part – abnormal presentation more common
  • Placenta location
  • -make sure it is not over the oss

Amniocentesis – for fetal lung maturity, if indicated

Speculum exam – cervical culture, wet mount, GBS culture, check any vaginal fluid for amniotic fluid (nitrazine test

  • *blue means amniotic fluid in the vag - rupture of membranes and a sign hat we cant prolong the pregnancy and evacuation is needed!
  • *
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16
Q

about 100% survival rate of a preterm birth ?

A

> 34 weeks

1750-2000g

~100% survival

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17
Q

about 60% survival rate of a preterm birth ?

A

24-25 weeks

500-750 g

60% survival

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18
Q

Fetal Lung Maturity Testing done before ?

A

Elective deliveries

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19
Q

Fetal Lung Maturity Testing by ?

A

Fluorescence polarization

Lecithin/sphingomyelin ration (L/S ratio)

Phosphatidylglycerol (PG)

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20
Q

*Fluorescence polarization ?

A

polarized light in amniotic fluid measured by TDx-FLM analyzer

Moderate cost

Simple to run

Most widely used test

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21
Q

Lecithin/sphingomyelin ration (L/S ratio) ?

A

Large lab variation

Not the test of choice any longer

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22
Q

Phosphatidylglycerol ?

A

part of surfactant

Expensive

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23
Q

Maternal cases in which preterm labor should NOT be suppressed - DELIVER IT!

A

Severe HTN, eclampsia

Pulmonary or cardiac disease

Cervical dilation >4 cms

Maternal hemorrhage

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24
Q

Fetal cases in which preterm labor should NOT be suppressed - DELIVER IT!

A

Fetal death or lethal anomaly

Fetal distress
decelerations on fetal monitoring

Chorioamnionitis

Fetal weight < 2500g - viable - get it out!

Erythroblastosis fetalis

Severe IUGR

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25
Q

Preterm Labor: If no contraindication to suppress labor: ___________ management
versus
__________________.

A

Expectant

Intervention to induce

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26
Q

Expectant Management: If ________ weeks or fetal weight _____ – generally not viable

A

20-23

<550g

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27
Q

Expectant Management: Once _______ weeks, nearly same survival rate as __ weeks
NO steroids needed

A

34-37

37

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28
Q

Suppression of Preterm Labor-
24-34 weeks examples ?

A

Bedrest- controversial

Corticosteroids

ABS

Tocolytics

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29
Q

Corticosteroids for labor supression ?

A

for fetal lung maturation

Peak effect at 48 hours, lasts 7 days

2nd course of IM injections if still pregnant after two weeks

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30
Q

ABS for labor supression ?

A

Does not delay birth but for prevention of GBS

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31
Q

Tocolytics for labor supression ?

A

If cervix <5 cms

Short term goal is 48 hours, so steroids can reach peak effect

Long term goal is to get to 34-36 weeks
Many agents, each with contraindications and SE’s

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32
Q

Tocolytics examples ?

A

**Magnesium sulfate

Beta-mimetic adrenergics (Sub cut) - Terbutaline

Calcium channel blockers - Nifedipine

Prostaglandin synthase inhibitors (indomethacin)

Mutliple agents – better effect, but ↑ SE’s

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33
Q

**Magnesium sulfate ?

A

Reduces uterine contractility

Better tolerated, watch for resp and card depression

Plus, neuroprotective - reduces risk of cerebral palsy

** calcium glutinate is the antidote to mag sulfate - if fetus becomes under distress **

34
Q

Terbutaline ?

A

Beta-mimetic adrenergics

Relaxes uterus, but CV side effects

Used only initially until other therapy started

  • *T and N used in triage in early labor but ideally it is mag sulfate to stop the contractions nd it is better tolerated and had neuroprotective effects on the baby
  • *
35
Q

Nifedipine ?

A

CCB

Reduces uterine contractility

Oral admin, less side effects

  • *T and N used in triage in early labor but ideally it is mag sulfate to stop the contractions nd it is better tolerated and had neuroprotective effects on the baby
  • *
36
Q

indomethacin ?

A

Prostaglandin synthase inhibitors

Serious fetal effects

37
Q

Tocolytics – when to stop ?

A

Adverse maternal or fetal response

Cervix reaches 5 cms dilation

Intrauterine infection
esp. if membranes has ruptured

Placental abruption (separation)

38
Q

PROm can occur when and what is it ?

A

Can occur at any point in pregnancy

Rupture before onset of labor

39
Q

Preterm PROM – ?

A

fetus is preterm

40
Q

Prolonged PROM – ?

A

term fetus, but delay of contractions by >24 hours

  • *risk for infections , open bag with bacterial being able to ascend into the U
  • *
41
Q

Is PROM common ?

A

Common – 10% of all pregnancies, usually at term

42
Q

PROM RF ?

A

Decidual hemorrhage

Hx of spontaneous preterm birth

Intrauterine bacterial infection

Amniocentesis

Cervical insufficiency

Multiple gestation

43
Q

PROM prevention ?

A

for women with hx of preterm birth, weekly progesterone (vaginally or IM) may help

44
Q

PROM signs and sxs. ?

A

Sudden gush of fluid or continued leaking

Possible flecks of vernix (white cheesy stuff on the baby) or meconium in the fluid

Reduced uterine size

Increased prominence of fetus

45
Q

PROM PE ?

A

STERILE SPECULUM

Pooling of amniotic fluid in posterior fornix

Nitrazine test - paper turns blue (alkaline)

Ferning – air-dried slide

46
Q

PROM PE inspect cervix exams ?

A

Sterile speculum

Dilation and effacement

Cord prolapse

Observe for leakage of amniotic fluid with valsalva

If enough fluid
Send for tests of fetal lung maturity and infection

NO digital cervical ?

47
Q

PROM - Labs ?

A

CBC with diff

U/A with C&S

US – fetal size and amniotic fluid index (Biophysical Profile)

48
Q

PROM - Treatment depends on ?

A

gestational age

presence or absence of chorioamnionitis

**meconium staining in the right - deliver it - baby is turing blue

49
Q

PROM and Chorioamnionitis pathology and S&S ?

A

Infection, usually due to bacteria ascending from vagina

ecoli, GBS, bacteriodes

Fever

Maternal leukocytosis

Uterine tenderness

Tachycardia

Foul-smelling amniotic fluid

50
Q

PROM and Chorioamnionitis In all cases ?

A

Safer for fetus to be delivered than to stay in utero.

Delivery ASAP, regardless of gestational age

51
Q

PROM in Term Pregnancy Without Chorioamnionitis (infection) What management is better ?

A

Expectant vs Active Management – active is preferred

52
Q

PROM in Term Pregnancy Without Chorioamnionitis (infection) Tx. ?

A

Induce labor

Reduces amount of time between PROM and delivery

Reduces risk of chorioamnionitis

53
Q

PROM -Preterm Pregnancy Without Chorioamnionitis Tx if 34 weeks ?

A

induce labor

54
Q

PROM -Preterm Pregnancy Without Chorioamnionitis Tx. if 22-24 weeks ?

A

terminate pregnancy or expectant management

55
Q

PROM -Preterm Pregnancy Without Chorioamnionitis Tx. 24-34 weeks /

A

Amniotic sample to check lung maturity

Antibiotics – prolong delivery after PROM and ↓ infection

Corticosteroids – before 32 weeks and IF no infection.

Magnesium sulfate – neuroprotective

** NO tocolytics, or for 48 hours only, to allow for steroids and ATB’s**

56
Q

Amniotic Fluid Issues is measured by ?

A

amniotic fluid index (AFI) on ultrasound

Measure fluid pockets, correlate with gestational age

**measure 4 pockets of A fluid to see if it is to much or to little **

57
Q

Amniotic Fluid Issues: Oligohydramnios inhibits ?

A

NL fetal movement

58
Q

Amniotic Fluid Issues: Oligohydramnios can lead to ?

A

fetal deformation. umbilical cord compression, death

59
Q

Amniotic Fluid Issues: Oligohydramnios can be caused by ?

A

fetal renal dz, post-term status, maternal disorder, PROM or idiopathic

60
Q

Amniotic Fluid Issues: Oligohydramnios results in fetal death when ?

A

In 1st and 2nd trimester

not enough A fluid to support it

61
Q

Amniotic Fluid Issues: Oligohydramnios what helps evaluate the fetus ?

A

Saline infusion

62
Q

Amniotic Fluid Issues: Oligohydramnios Tx. ?

A

No long term treatment available

Trying maternal hydration and desmopressin (DDAVP

63
Q

Amniotic Fluid Issues: Polyhydramnios caused by ?

A

decreased fetal swallowing or increased fetal urination

64
Q

Amniotic Fluid Issues MC etiologies ?

A

Fetal malformations/genetic disorders

Maternal DM, multiple gestation, fetal anemia

65
Q

Amniotic Fluid Issues Tx. ?

A

Dependent on age, degree

Amnioreduction - remove fluid

Indomethacin, plus steroids
- Not given after 34 weeks as may cause premature closure of ductus arteriosus

66
Q

Postterm Pregnancy patho ?

A

+42 weeks from FDLMP

67
Q

Postterm Pregnancy risks of what ?

A

dysmaturity from impaired nutritional supply

Weight loss, ↓subcut tissue, parchment-like skin

68
Q

Postterm Pregnancy maternal risks ?

A

large fetal size (CPD)

  • *CEPHALOPELVIC DISPROPORTION
  • *
69
Q

Postterm Pregnancy fetal risks ?

A

birthing injury, aging placenta

70
Q

Postterm Pregnancy: Oligohydramnios risk ?

A

cord compression

71
Q

Postterm Pregnancy offer induction at ?

A

41 weeks

If declined, careful fetal monitoring

72
Q

Rh Alloimmunization 1 ?

A

Fetus gets half of genes from mom, half from dad

So, fetus may have RBC antigens different from mom

If enough fetal cells cross into maternal blood, can provoke an antibody response

If maternal antibodies cross the placenta, they can destroy fetal erythrocytes – hemolytic anemia ( in the next baby)

Fetus response – erythroblastosis fetalis (fetal hydrops). Death can result

Rh group causes the majority of cases
-Mom is Rh-negative, fetus is Rh-positive

73
Q

Rh Alloimmunization 2 ?

A

Rh-negative mothers need prophylaxis to prevent sensitization

Screen pregnant woman at first prenatal visit
-ABO and Rh(D), also known as (Rh-negative)

Administer RhIgG (RhoGAM)
-Prenatally, IM to mom  at 28 weeks and again within 72 hours of delivery if infant is Rh-positive
74
Q

Other times to administer RhoGAM ?

A

Abortion

Amniocentesis, Chorionic
Villus Sampling

Antepartum bleeding

Any time fetal blood mixes with maternal blood

75
Q

Stillbirth definition ?

A

Intrauterine fetal death at or beyond 20 weeks

<1% of pregnancies

50% of cases – difficult to identify cause

76
Q

Stillbirth RF ?

A

similar to risks for infertility and abortion

77
Q

Stillbirth is determined by ?

A

absence of cardiac activity on US

78
Q

Stillbirth sxs. ?

A

pain, bleeding or asymptomatic

79
Q

Stillbirth evaluation ?

A

Thrombophilia

Maternal toxicology

Testing for diabetes

Placental pathology

Karyotyping (best done through amniotic fluid)

80
Q

Stillbirth Tx. ?

A

Induction of labor

D&E – intact delivery up to
26-28 weeks with cervical dilation

81
Q

Stillbirth prognosis ?

A

If no etiology found, risk for repeat stillbirth is 1-2%

Patient Evaluation (29 decks)

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