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Women's Health > Lecture 4: Complications of Pregnancy > Flashcards

Lecture 4: Complications of Pregnancy Flashcards

1
Q

What is an ectopic pregnancy and where is it MC?

A
  • Any pregnancy in which the embryo implants outside the uterine cavity.
  • MC in the ampulla of the fallopian tube.
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2
Q

Risk factors for ectopic pregnancy

A
  • Prior ectopic
  • STD
  • PID
  • Assisted Reproductive Technology (ART)
  • IUD
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3
Q

Dx of Ectopic pregnancy

A
  • Vaginal bleeding
  • Lower Abd Pain
  • Adnexal Mass
  • Tenderness on pelvic exam
  • If ruptured: hypotension, unresponsive, peritoneal irritation up to R shoulder referral
  • b-hCG does not 2x every 48h as it does normally
  • U/S: Empty uterus or donut sign
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4
Q

What is the pathognomonic sign on U/S for an ectopic pregnancy?

A

Donut sign

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5
Q

What risk factor is worrisome for heterotopic pregnancy?

A

ART patients

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6
Q

What is methotrexate’s MOA in regards to pregnancy?

A

Prevents proliferation of tissue such as trophoblasts. It is a folic acid antagonist.

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7
Q

Indications for methotrexate

A
  • Asymptomatic, motivated, compliant
  • Low initial b-hCG (< 5000)
  • Small ectopic size (< 3.5cm)
  • Absent fetal cardiac activity
  • No evidence of intraabdominal bleeding
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8
Q

What should you check prior to administering MTX? During?

A
  • Prior: CMP/CBC
  • During: b-hCG, which should decline starting day 4
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9
Q

What are the SEs associated with MTX use?

A
  • Separation pain (mild and relievable with analgesics)
  • Liver
  • Stomatitis
  • Gastroenteritis
  • Bone Marrow Depression

Immunosuppressant

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10
Q

Tx for ectopic pregnancy

A
  • MTX (first)
  • Surgery: Salpingostomy to salvage tubes
  • Salpingectomy: Tubal resection (MC done)

Surgery used if MTX fails

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11
Q

Define abortion/miscarriage

A

A pregnancy ending prior to 20 weeks gestation

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12
Q

What is a complete abortion?

A

Complete expulsion of all POC (products of conception) prior to week 20.

If no POC found make sure its not ectopic

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13
Q

How does an incomplete abortion present?

A
  • Vaginal bleeding and abd cramping
  • POC protruding thru dilated os or active vag bleeding
  • US shows nonviable intrauterine pregnancy
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14
Q

Management of an incomplete abortion

A
  • Curettage
  • PGE
  • Expectant management
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15
Q

How does an inevitable abortion present?

A
  • No expulsion of POC
  • Vag bleeding and dilation of cervix
  • nonviable pregnancy

Its gunna come out bc cervix is dilated?

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16
Q

Tx of inevitable abortion

A
  • PGE
  • Expectant management

PGE to help dilate and get it out sooner?

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17
Q

How does a missed abortion present?

A
  • Closed cervical os
  • Absence of uterine growth
  • U/S: nonviable pregnancy

Death prior to 20 weeks with complete retnetion of POC

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18
Q

Tx of missed abortion

A
  • Curettage
  • PGE
  • Expectant management

It already died so you gotta scoop it out and keep the cervix open :(

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19
Q

How does a threatened abortion present?

A
  • Vaginal bleeding before 20 weeks without dilation of cervix or expulsion of POC
  • Cervical os closed
  • Vaginal spotting
  • U/S: Viable pregnancy
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20
Q

Tx of threatened abortion

A
  • Pelvic rest
  • Expectant management
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21
Q

What Rh females should always get RhoGAM?

A

RH neg

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22
Q

What is a molar pregnancy?

A
  • Hydatiform mole
  • Excessively edematous immature placentas
  • Villous stromal edema
  • Trophoblast proliferation
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23
Q

Risk factors for molar pregnancy

A
  • Extremes of reproductive age (young or old)
  • Hx of prior
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24
Q

What is a complete mole?

A
  • 46 XX or XY
  • Paternal in origin for both sets
  • Vag bleeding
  • Large for date
  • hCG > 100k
  • Theca lutein cyst
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25
Q

Pathology of a complete mole

A
  • No fetal parts
  • Edematous villi
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26
Q

What is a partial mole?

A
  • 69 XXX or XXY or XYY
  • Two paternal haploid and 1 maternal
  • Missed abortion + small for date
  • Fetal parts present
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27
Q

Dx of molar pregnancy

A
  • Serum hCG
  • U/S for complete: echogenic uterine mass with numerous anechoic cystic spaces without fetus or sac snowstorm appearance
  • U/S for partial: Thickened, multicystic placenta along with fetus or tissue
  • Pathology confirms
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28
Q

Common sequelae of molar pregnancies

A
  • Thyroid storm
  • Hyperemesis gravidarum
  • Preeclampsia/eclampsia
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29
Q

Management of molar pregnancy

A
  • Preop eval: thyroid, CBC, CMP, CXR, EKG, Type and screen
  • Suction dilation and curettage (pitocin)
  • RhoGAM if needed
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30
Q

What needs to be continuously monitored post evacuation of a molar pregnancy?

A
  1. b-hCG every 1-2wks until undetectable.
  2. Check monthly for 6 months afterwards
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31
Q

What is antepartum bleeding?

A

Bleeding occurring with a viable mature fetus (> 24 wks)

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32
Q

What is placental abruption?

A

Separation of placenta prior to delivery due to hemorrhage into decidua

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33
Q

How does placental abruption present early?

A
  • Considered chronic abruption if early
  • May be associated with elevated AFP
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34
Q

Risk factors for placental abruption

A
  • Trauma
  • Increasing age
  • HTN/preeclampsia (MC condition associated)
  • Preemie ruptured membranes
  • smoking
  • cocaine
  • Lupus
  • Thrombophilias
  • Uterine fibroids
  • Recurrent abruption
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35
Q

What are the clinical findings and dx of placental abruption?

A
  • Sudden onset abd pain
  • Vaginal bleeding
  • Uterine tenderness
  • DX of exclusion
  • U/S: generally limited in use.
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36
Q

Complications of placental abruption

A
  • Hypovolemic shock
  • Consumptive coagulopathy/DIC
  • AKI
  • Couvelaire Uterus (makes myometrium bluish purple)
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37
Q

Management of placental abruption

A
  • C-section for quicker sx but risk of DIC is higher
  • If fetus is dead already, do vaginal
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38
Q

What is placental previa?

A
  • Placenta implanted in lower uterine segment
  • Over/near internal cervical os

Blocking the cervix

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39
Q

What are the two types of placenta previa?

A
  • Placenta previa: internal os covered partially or fully by placenta
  • Low-lying placenta: Implantation in lower uterine segment but not reaching internal os; 2cm outside of os
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40
Q

Risk factors for placental previa

A
  • Increased age
  • Increased parity
  • Prior C-section
  • Smoking
  • Elevated MSAFP(same as AFP)
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41
Q

Clinical presentation of placenta previa

A

Painless vaginal bleeding occurring past 2nd trimester

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42
Q

Dx of placenta previa

A

TVUS is most accurate

DO NOT DO DIGITAL EXAM UNTI PREVIA IS RULED OUT

you might puncture the placenta doing a digital exam

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43
Q

What factors make a low-lying placenta likely to persist?

A

Hx of prior C-section or hysterotomy scar

Low chance up until 23 weeks, at which time it goes up in persistence.

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44
Q

Management of placenta previa

A
  • If persistent bleeding: Delivery for preemie
  • If non-persistent bleeding: watch if its preemie
  • If Term: Delivery via C-section
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45
Q

What are the placenta accrete syndromes?

A
  • Abnormally implanted, invasive, or adhered placenta
  • Abnormally firm adherence to myometrium due to lack/thin decidua basalis and imperfect fibrinoid layer.
  • Placenta Accreta: Attached to myometrium
  • Placenta Increta: Invading myometrium
  • Placenta Percreta: Penetrating myometrium and serosa
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46
Q

Risk factors for placenta accrete syndromes

A
  • Associated placenta previa
  • Prior C-section
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47
Q

Dx of placental accrete syndromes

A
  • TVUS
  • MRI can be adjunct
  • Pathology to confirm
48
Q

Management of placenta accrete syndromes

A
  • Planned delivery at 34-36 to avoid C-section
  • Consider pre-op uterine artery embolization
  • Consider leaving placenta in situ and do hysterectomy later
49
Q

What is cervical insufficiency?

A
  • Painless cervical dilatation in 2nd trimester
  • Followed by prolapsing and ballooning of membranes into vagina, leading to expulsion of immature fetus

your cervix cant keep it in

50
Q

Risk factors for cervical insufficiency?

A
  • Prior cervical trauma
  • DES exposure
51
Q

Dx of cervical insufficiency

A
  • TVUS to confirm fetus
  • Swab for infection
52
Q

Expectant management for cervical insufficiency

A
  • Trendelenberg position (tr = toes raised)
  • Pelvic rest
  • Cerclage? (stitch of uterus until 36wk)
53
Q

Tx of cervical insufficiency

A
  • Done for the subsequent pregnancy
  • Cerclage
54
Q

4 primary reasons to deliver a preterm baby

A
  1. Spontaneous unexplained preterm labor with intact membranes (including cervical insufficiency)
  2. Idiopathic preterm premature rupture of membranes (PPROM)
  3. Delivery for maternal or fetal indication (Pre-eclampsia)
  4. Twins and higher order births
55
Q

W/u for preterm labor

A
  • Fetal fibronectin (good negative predictive value)
  • Cervical length (check transvaginally, > 3cm = not in labor
  • Sterile vag exam
  • Sterile spec exam (cultures and nitrazine)
  • UA/UC
56
Q

Tx of preterm labor

A
  • Tocolysis (stopping contractions) for 48h or less
  • Mg sulfate (neuroprotection)
  • Nifedipine
  • PGE synthetase inhibitor prior to 2nd trimester (indomethacin)
  • Terbutaline (B-agonist)
  • Bedrest
  • Corticosteroids for lung maturation (beta/dexamethasone for 24-34 wks)

all the drugs are tocolytics

57
Q

Prevention of Preterm labor

A
  • Cervical cerclage (length < 25mm at high risk)
  • IM progesterone for hx of prior preemie birth
  • Vaginal progesterone for shortened cervix
58
Q

What is PPROM?

A

Membrane rupture before contraction onset and before 37 wks

59
Q

PPROM risk factors

A
  • Genital tract infection
  • History of PPROM
  • Antepartum bleeding
  • Smoking
60
Q

Dx of PPROM

A
  • Speculum exam showing pooling or nitrazine weirdness or ferning pattern
  • US showing low AFI
61
Q

Management of PPROM

A
  • Hospitalize for rest of pregnancy
  • Corticosteroids
  • Tocolysis
  • ABX for latency (ampicillin then amoxicillin/erythro IV then PO or azithro)
62
Q

Management of PPROM

A
  • Expectant management for delivery until 34wks
  • If clinical chorioamnionitis: deliver
63
Q

Most dangerous complication of PPROM

A

Cord prolapse

64
Q

What is IUGR?

A

Intrauterine growth restriction

65
Q

Dx of IUGR

A
  • Abd palpation (eh)
  • U/S: abd circumference + estimated fetal wt

< 10th percentile

66
Q

Management of IUGR

A
  • Antepartum: AF volume measurement
  • Umbilical artery doppler velocimetry
  • Growth U/S
  • Plan for 38wk delivery
67
Q

When do most fetal deaths occur?

A

Prior to week 20

68
Q

MCC of fetal death

A

Obstretical complications: abruption, multifetal gestation, PPROM

69
Q

What is HTN in pregnancy?

A

BP >= 140 and/or 90 on 2 occasions at least 6 hours apart

70
Q

What is pre-existing HTN?

A

> 140/90 prior to week 20 or longer than week 12 postpartum

71
Q

What anti-HTNs cant be used in pregnancy?

A

ACEis and ARBs

72
Q

Prenatal labs for chronic HTN

A
  • EKG
  • Echo if long-term
  • Baselines of CBC, BMP, LFTs, Coags, Urine dipstick
73
Q

Tx of chronic HTN

A
  • Taper/D/C if BP < 120/80 in 1st trimester, restart if 150 or 95
  • Primarily ASA to reduce risk of superimposed preeclampsia
  • Labetalol
  • CCBs
74
Q

Management of chronic HTN

A
  1. Observational management
  2. NSTs, BPPs, Growth US
  3. Without complications: 37-39 wk delivery
75
Q

What is gestational HTN?

A
  • BP > 140/90 after 20 wks in normotensive women
  • Develops late and usually resolves 12 weeks postpartum

Tx same as chronic HTN

76
Q

What is preeclampsia?

A

New onset HTN + proteinuria after 20 wks

> 140/90
0.3g (2+) on urine dipstick

77
Q

Risk factors for Preeclampsia

A
  • First preg
  • Young
  • Multifetal gestation
  • DM, SLE, renal disease
  • Obesity
  • African-American
  • Chronic HTN
78
Q

What other conditions can occur in place of proteinuria to qualify for preeclampsia?

A
  • Thrombocytopenia
  • Renal insufficiency
  • Impaired liver function
  • Pulmonary edema
  • New onset HA unresponsive to therapy
79
Q

What is eclampsia?

A

Seizure/coma with preeclampsia with no other neurological condition

80
Q

When is pre-existing HTN superimposed by pre-eclampsia?

A
  • New onset proteinuria
  • Sudden increase in BP
  • Development of HELLP or symptoms of severe preeclampsia
81
Q

What is HELLP?

A

Hemolysis, Elevated Liver enzymes and Low Platelets

RUQ pain

Indicates severe preeclampsia

82
Q

Tx of preeclampsia

A
  • Definitive: Deliver
  • AntiHTN therapy to prevent CV hemorrhage or HTN encephalopathy (IV labetalol, hydralazine, PO nifedipine)
  • MgSO4: Prevent CNS depression
  • Corticosteroids for fetal lung maturation
83
Q

Dx of pregestational DM

A
  • High plasma glucose, glucosuria, ketoacidosis
  • Random plasma glucose > 200 mg/dL + polydipsia/polyuria/unexplained wt loss
  • Fasting glucose > 125
84
Q

Pregestational diabetes thresholds

A
  • FBG > 125
  • HbA1c > 6.5%
  • Random BG > 200 + confirmation
85
Q

What HbA1c level or FBG is bad juju for pregnancy?

A
  • HbA1c > 12
  • FBG > 120
86
Q

Complications of neonates born to pregestational DM

A
  • RDS
  • Hypoglycemia (glucose crosses placenta, insulin does not)
  • Hypocalcemia
  • Hyperbilirubinemia and polycythemia
  • Cardiomyopathy
  • Long term cognitive defects

Infant overproduces insulin

87
Q

Fetal effects due to pregestational DM

A
  • Spontaneous abortion
  • Preterm delivery
  • Malformations (esp with T1)
  • IUGR or macrosomia
  • Fetal demise
  • Hydramnios
88
Q

What supplement needs to be increased in pregestational DM?

A

Folic acid

89
Q

1st trimester management for pregestational DM

A
  1. Glucose monitoring
  2. Insulin preferred over orals
  3. Baby ASA
  4. EKG, Echo
  5. 24 hour urine
90
Q

How do insulin needs vary throughout pregnancy?

A

Increased as it progresses

91
Q

Risk factors for gestational DM

A
  • Hispanic/African American/Native American/AAPI
  • Obesity
  • Increased age
  • Sedentary
  • Hx of gestational
92
Q

2 step method for screening gestational DM

A
  1. 50g 1 hour oral glucose at 24-28wk
  2. If positive, 100g 3hour oral glucose 2x
93
Q

Ideal FBG and 2h PPBG for gestational DM

A
  • FBG < 95
  • 2h PPBG < 120
94
Q

Ideal nutrition balance for gestational DM

A
  • 40% carbs
  • 40% fat
  • 20% protein
95
Q

Pharm Management for gestational DM

A
  • Insulin (does not cross placenta)
  • Oral hypoglycemics: glyburide/metformin (outcome data eh)
96
Q

When is elective C-section recommended in gestational DM?

A

Baby heavier than 4500g is at risk for shoulder dystocia

97
Q

What postpartum test should all gestational DM get?

A

75g 2h glucose tolerance test 6-12 wks postpartum

98
Q

What is most closely associated with the rise of multifetal births?

A

Infertility tx

99
Q

MC type of twin gestation

A

Fertilization of 2 ova => dizygotic (non-identical)

100
Q

What are vanishing twins?

A

1 twin vanishes before 2nd trimester

incidence of a twin is higher in 1st trimester

101
Q

Dx of multifetal gestation

A
  • Uterine size larger than expected during 2nd trimester
  • U/S to check for multiple placentas and twin peak sign/lambda/delta sign
  • T sign suggests shared placenta
102
Q

U/S images of T sign and twin peak sign

103
Q

Complications of multifetal gestations

A
  • SPontaneous abortion
  • Congenital malformations
  • Low birthwt: often preterm delivery
  • HTN (baby asa at 12 wk)
  • Preterm birth
  • Size discordance (if baby A is smaller than B, vaginal delivery is likely to fail)

A = first to come out

104
Q

What complications are unique to monochorionic monoamnionic twins?

A
  • Cord entanglement
  • Twin twin transfusion syndrome (in monochorionic)
105
Q

What is twin twin transfusion syndrome?

A
  • One twin donates to the other
  • Recipient twin develops HF, polycythemia, and severe hypervolemia
  • Donor twin develops anemia and IUGR
  • Need laser ablation of anastomosis

In any monochorionic twins there is a risk of this occurring

106
Q

Usage of what mechanical thingie can help with preterm birth in multifetal gestations?

107
Q

What twin type needs earliest delivery?

A

Monochorionic monoamniotic

High risk of TTTS?

108
Q

When does the fetus make its own thyroid hormone?

109
Q

How does pregnancy affect thyroid hormone?

A
  • Increases in TBG
  • Stimulation of TSH by hCG
110
Q

MCC of hypothyroidism in pregnancy

A

Hashimoto’s thyroiditis, tx with levothyroxine

Increase levothyroxine during pregnancy

111
Q

What is subclinical hypothyroidism?

A
  • Elevated TSH
  • Normal FT4
  • Consider levothyroxine
112
Q

When should we screen pregnant women for depression?

A

Initial prenatal visit

113
Q

What is Zuranolone?

A
  • GABA A receptor + modulator
  • Adjunct to SSRI/SNRI for 14d daily
114
Q

What opioid crosses the placenta? What does not?

A
  • Subutex does not cross readily.
  • Methadone crosses the placenta
115
Q

When should UTI screening with a UC be performed?

A

Initial prenatal visit

116
Q

Tx of UTI in pregnant women

A

Macrobid or keflex

Will also suppress with macrobid BID if 2+ tx still persistent

Women's Health (15 decks)

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