Lecture 6 - Complications of Pregnancy Flashcards
What is the frequency of ectopic pregnancy?
1:100
Where are ectopic pregnancies MC?
in the tubes
70% in the ampullary
why? because this is where the sperm meets the egg
What are the risk factors of ectopic pregnancy?
H/o ectopic pregnancy
H/o tubal surgery
Endometriosis
H/o pelvic infection (Chlamydia is MC reason of tubal disorders and thus ectopic pregnancies)
H/o infertiity
IUD (if you are in the 1% that get pregnant while on IUD)
Smoking
What are the sxs of ectopic pregnancy?
Pelvic pain
Missed LMP
vaginal bleeding
What labs should you order for a pt who you suspect of ectopic pregnancy?
Bhcg
CBC (r/o anemia and possible internal bleed)
Type and Screen (Rh status –remember that even those this pt won’t be pregnant for long or deliver, we still don’t ever want the mom to produce antibodies to Rh+)
Pelvic US
Discriminatory Zone
when the Bhcg is 1500-2000 mIU/mL –you should be able to see something on US in the uterus
Does the Bhcg tell you anything about the gestational age of the fetus?
no
it tells you (when 1500-200) that you should see something on US and it should be doubling every 48 hours
but that is all it tells you
When should you expect to see fetal pole?
6 weeks
When should you expect to see FMH?
FMH - fetal heart motion
6.5 weeks
What do you need to be able to say the pregnancy is “viable”?
fetal pole and FMH
Heterotopic pregnancy
when you have both an ectopic pregnancy and a uterine pregnancy
these pts are NOT candidates for methotrexate for ectopic management since you would be harming the uterine fetus
How do you dx ectopic pregnancy?
adnexal mass c/w ectopic
free fluid in pelvis (ruptured ectopic)
hemodynamically unstable (HTN, tachy, diaphoretic)
Bhcg >1500-2000 with no intrauterine gestational sac
inappropriately rising Bhcg and no intrauterine gestation sac
What is the dx of ectopic pregnancy is unclear, what should you do?
have the pt come back in 2 days to retest the Bhcg and pelvic US
What is the treatment for ectopic pregnancy?
Surgery or medication
Methotrexate (MTX)
- IM injection
- check Bhcg on day 1, 4 and 7
if you see a 15% decrease between day 4 and 7 = SUCCESS
Who is not a candidate for methotrexate tx for ectopic pregnancy?
Evidence of rupture
Hemodynamically unstable
Absolute or relative contraindications to MTX
Heterotopic
These pts need to have surgery —salpingectomy/salpingostomy
Besides methotrexate, what other medication do you need to give pts with ectopic pregnancy?
Rhogam if they are Rh negative
What do you need to tell pts who were given Methotrexate to avoid?
Avoid the sun and NSAIDs and stop taking prenatal meds
What are the relative contraindications for methotrexate?
Showing that the pregnancy is “further along”:
-Bhcg >5000
-Gestational sac >35mm
-Fetal heart tones
Pt unwilling/unable to comply with follow up
Pt unwilling to accept blood transfusion
What are the absolute contraindications of methotrexate?
Hemodynamically unstable or clinical evidence of ruptured ectopic Liver disease or EtOHism Blood dyscrasias Renal dysfunction Immunodeficiency Active pulmonary disease Peptic ulcer disease Breastfeeding
Salpingectomy
Remove entire fallopian tube
Surgery for ectopic
Salpingostomy
Remove pregnancy only from fallopian tube
You have to follow up with these pts to make sure their Bhcg is below 5 d/t risk of pregnancy tissue being left in the tube
Why chose salpingectomy over salpingostomy?
Either way you are at the same risk of recurring ectopic and change in fertility is the same
GTD
Gestational trophoblastic disease
Lesions characterized by abnormal proliferation of placenta tophoblast
Molar pregnancy
This can progress to GTN which is cancer
What are the sxs of GTD?
Bhcg >100,000
Abnormal vaginal bleeding
Hyperthyroidism
Dx: pathology is definitive
US
How do you dx GTD?
Bhcg >100,000
US - “snowstorm”
Pathology (definitive)
What do you see on US for GTD?
Snowstorm appearance
Complete mole - no fetal parts
Partial mole - +/- fetal parts, enlarged cystic placenta
What are the differences between partial and complete mole?
Complete mole - 46XX, XY P57 - negative (all paternal) No fetal tissue Bhcg >100,000 Uterus is large for date 6-32% risk of GTN
Partial mole - 69 XXX, XXY P57 - positive (positive when maternal is present) Fetal tissue present <100,000 mIU/mL Uterus is small for date <5% risk of GTN
What is the management of GTD?
Surgical evacuation (D and C)
Follow up - serial Bhcg
Weekly until <5
Can’t get pregnant for 6 months —> contraception
GTN
Progression from GTD (molar pregnancy)
This is cancer
Bhcg positive at 6 months
Tx: Chemotherapy
Single or multi agent based on risk factors
MTX (methotrexate) or actinomycin - D
WHO score <6
High risk disease WHO score >6
EMA-CO (etoposide, methotrexate, actinomycin - D, cyclophasphasmide, vincristine)
What is the treatment for GTN?
Tx: Chemotherapy
Single or multi agent based on risk factors
MTX (methotrexate) or actinomycin - D
WHO score <6
High risk disease WHO score >6
EMA-CO (etoposide, methotrexate, actinomycin - D, cyclophasphasmide, vincristine)
Monozygotic vs dizygotic
Mono is 1 sperm, 1 egg
Splits to identical twins
Dizygotic is 2 eggs and 2 sperms
Dichorionic diamniotic
2 placentas, 2 sacs
This occurs if the split happens 0 - 4 days
Monozygotic or dizygotic
Monochorinoic diamniotic
1 placenta
2 sacs
This occurs if the split happens 4-8 days
Monozygotic
Monochorionic monoamniotic
1 placenta
1 sac
This happens if the split occurs 8-12 days
Monozygotic
Conjoined twins
This occurs if the slit happens >12 days
Monozygotic
How do dizygotic twin pregnancies show in regards to sac and placenta?
Dichorionic diamniotic
2 placentas, 2 sacs
Lambda sign
Seen on US with Dichorionic —2 placentas
T sign
Sign on US for monochorionic
What are the risks of pregnancy for a women having twins?
Abortion Hyperemesis Preterm labor (PTL) Preterm rupture of membranes (PROM) Preterm birth (PTB) Placenta previa Placental abruption Pre-eclampsia Gestational DM (GDM) Postpartum hemorrhage (PPH)
What are the risks for the baby with a twin birth?
Growth restriction Prematurity Still birth (5X) Neonatal death (7X)
Monochorionic twins are at greater risk of what?
Increased risk of congenital anomalies (ex. Heart defects)
Monochrionic diamniotic twins are at increased risk of what?
Twin twin transfusion syndrome (TTTS)
Twin anemia polycythemia sequence (TAPS)
Twin reversed arterial perfusion (TRAP)
Monochorionic monamniotic twins are at an increased risk of what?
Cord entanglement/accident
Do multiple gestation (twins) make it to full term?
No
Dichorionic/Diamniotic (DCDA) go to delivery when?
38 weeks
Growth scan every 4 weeks
When do monochorionic/diamniotic (MC/DA) deliver?
34-37 weeks
Growth scan every 4 weeks
Fluid/bladder scan every 2 weeks starting at 16 weeks to screen for TTTS
MCA dopplers every 2 weeks starting at 20 weeks, screening for TAPS
Non-stress tests weekly starting at 32 weeks
When do monochorionic/monoacmniotic (MC/MA) delivery?
32-34 weeks
Inpt management at 24 weeks d/t risk of sudden cord entanglement
Vertex
When the babies head is down (ready for vaginal delivery)
What determines the mode of delivery for twin births?
The presentation of the presenting twin (twin A)
Both vertex? —> vaginal delivery
one vertex, one breech? —> vaginal or cesarean
Non-vertex twin a? —> cesarean section
ALL MC/MA get delivered by C section (probably d/t cord entanglement problems)
Who gets screened for GDM?
BMI >30 First degree relative with DM Hx GDM in prior pregnancy Hx macroscomic infant (>4000mg) Physical inactivity (subjective) HgbA1c >7.5%
How do you screen and dx GDM?
Start with the GCT (Glucose challenge test)
This is when give them 50gms of sugar and wait an hour to test their BG which should be below 140
If they fail the GCT then you move on to the 3 hour GTT
Give them 100 gm of sugar and test their blood sugar every hour on the hour
GCT
50 gm
1 hour wait
BG should be below 140
Used as first test for GDM
GTT
Used if the GCT test is failed
100gm sugar
Positive result if: Fasting BG >95 1hr >180 2hr > 155 3hr > 140
Fail if greater than 2 from those marks
What is the treatment for GDM?
Diet
Exercise - 3-5x/week 30 min
Blood sugar monitoring 4-5 times per day
In the morning before food (fasting), 2 hour post prandial, +/- night
Goals:
Fasting <95
1hr post prandial <140
2hr post prandial <120
What are the goals of blood glucose with GDM?
Fasting <95
1hr post prandial <140
2hr post prandial <120
A1 GDM vs A2 GDM
A1 - abnormal OGTT but normal fasting and post prandial blood glucose —diet control is enough to manage
A2 - abnormal OGTT with abnormal fasting and post prandial blood glucose - medication required
What is the preferred medication for GDM?
Insulin
What pregnancy risks are present with GDM?
PreEclampsia C section Indicated PTB Still birth Macrosomia Shoulder dystocia Neonatal: hypoglycemia, hyperbilirubinemia
What is the screening and delivery schedule for A1 GDM?
Growth scan every 4 weeks
Delivery by 41 weeks
What is the screening and delivery schedule for A2 GDM?
Growth scan every 4 weeks
NST (non-stress test) weekly between 28 and 32 weeks
Delivery depends on how well controlled the DM is
Well controlled - 40 weeks
Poorly controlled - 37-39 weeks
What is the postpartum GDM management?
Basically nothing
Just do a 75g OGTT at 6-12 weeks postpartum since 50% of women with GDM go on to develop DM during their lifetime
Then monitor their HgA1c every 3-5 years
Their OGTT should be <110 fasting and <140 2hr post prandial
What timing during pregnancy differentiates between chronic HTN and gestational HTN?
If HTN <20 weeks —chronic HTN
If HTN >20 weeks —Gestational HTN
What criteria needs to be met to be dx with gestational HTN?
BP >140/90 x2 >4hr apart >20 weeks GA
What is the HTN spectrum with gestation?
Gestational HTN | | PreEclampsia without severe features | | PreEclampsia with severe features | | Eclampsia
How does gestational HTN differ from preeclampsia?
No proteinuria with gestational HTN
What are the severe features than can be seen with preeclampsia?
HELLP Crt >1.1 Plt <100K Pulmonary edema HA Vision changes Oliguria (<500cc/day) Liver hematoma
What is the difference between preeclampsia and eclampsia?
Eclampsia has seizures d/t the increase in cerebral edema
What is the treatment of preeclampsia?
Delivery
What are the risk factors of preeclampsia?
Hx of preeclampsia First pregnancy Family hx of preeclampsia T1DM/T2DM Chronic HTN Lupus Antiphospholipid antibody syndrome CKD Multifetal pregnancy Advanced maternal age (>/=35)
HELLP
Might be seen with severe features of PreEclampsia
Hemolysis
Elevated Liver Enzymes
Low Platelets
What is the most common type of HA seen with preeclampsia?
Occipital HA
Why don’t gestational HTN pts make it to full term?
Increased risk of still birth
What are the common BP meds used in pregnancy?
Labetalol
Hydralazine
Nifedipine
Methyldopa (less common)
What additional meds are you giving for HTN for preeclampsia with severe features and eclampisa?
Magnesium sulfate to decrease seizure risk
How do you treat seizures from eclampsia?
Lorazepam
Immediate delivery
ABO vs Rh D?
ABO - IgM - does NOT cross placenta
Rh D - IgG - crosses placenta
What are the fetal consequences of Rh Incompatibility?
Anemia
Hydrops fetalis (skin edema, ascites, pericardial effusion, pleural effusion)
Death
What is the prevention for Rh incompatibility?
Rhogam (AntiD immunoglobulin)
Prevents Rh D alloimmunization
Given prophylactically to Rh negative mothers at 28 weeks, within 72 hours of delivery if Rh + fetus, and after any sensitizing event like CVS or ECV
What is the mom has antibodies against Rh -?
Check titers every 4 weeks If: >1:16 Then: Fetal MCA doppler every 2 weeks
PUBS - peri umbilical cord blood sample and fetal RBC transfusion
What is considered preterm labor?
<37 weeks
30% spontaneously resolve
50% deliver at term
What are the risk factors of preterm labor?
Hx of PTL Hx of cervical surgery Uterine malformations Multiple gestation Infection Substance abuse Smoking
What labs do you need to draw for a mom in preterm labor?
Gonorrhea Chlamydia Urinalysis Urine culture Group B strep
Inpt admission
When are preterm infants considered “viable”?
24 weeks
What medications should a preterm infant get?
Bethamethason - for fetal lung maturity - STOP @ 37 weeks
Magnesium Sulfate - for cerebral palsy prevention - STOP @ 32 weeks
GBS prophylaxis - PCN
PROM vs PPROM
Premature rupture of membranes
-ROM before onset of labor (contractions)
Preterm premature rupture of membranes
-ROM <37 weeks AND before onset of labor
What do you need to dx premature rupture of membrane?
Sterile speculum exam should show:
- Nitrazine
- Ferning
- Pooling
- Amniotic fluid index (AFI)
Latency period
Time between rupture (PROM) and delivery 40-50% deliver within 1 week
70-80% deliver within 2-5 weeks
Tocolysis
Short term drug given in preterm labor to suppress preterm labor
Only given if preterm by 24-32 weeks +/- 32-34 weeks
A women is coming in 30 weeks gestation for preterm labor, what do you do?
For all preterm labors 24-32 weeks
Bethamethsone for fetal lung maturity
Mag sulfate for cerebral palsy prevention
Tocolysis to suppress labor
GBS prophylaxis - PCN
A women is in preterm labor at 33 weeks, what do you do?
For all preterm 32-34 weeks
Betamethasone
+/- tocolysis
GBS prophylaxis (PCN)
What drugs can be used for tocolysis?
To suppress pre term labor
Nifedipine
Indomethacin
Terbutaline
Mag sulfate (weak)
A women comes in for premature rupture of membrane at 30 weeks, what do you do?
For all premature ruptures 24-32 weeks: Betamethasone Mag sulfate Tocolysis Latency ABX -IV ampicilin + erythromycin for 2 days -PO amoxicillin + erythromycin for 5 days
Delivery at 34 weeks
How does the management for a premature rupture of membrane differ between 33 weeks and 30 weeks?
24-32 weeks: Betamethasone Mag sulfate Tocolysis Latency ABX Delivery by 34 weeks
32-34 weeks: Betamethasone Tocolysis Latency ABX Delivery by 34 weeks
What is the management for rupture of membrane between 34 and 37 weeks?
Betamethasone
GBS prophylaxis (PCN)
Deliver!
For premature rupture of membrane, the goal is to deliver at 34 weeks, under what circumstances would you deliver sooner?
Fetal distress
Placental abruption
Infection
Molar pregnancy put you at risk of GTN, which cancers are these pts most at risk for?
Complete molar pts are more at risk of GTN than partial molar
Gestational trophoblastic neoplasia (GTN): Choriocarcinoma PSTT- placental site trophoblastic timor ETT - epitheloid trophoblastic tumor Invasive mole
If a pt had been treated for molar pregnancy with a D and C, and the BhCG had not gone down, what is your next move?
Remember that with molar pregnancy these BhCGs are super duper high
After a D and C we check their BhCG weekly until its less than 5 and then continue to check it monthly for 6 months (these pts need to go on contraception because they can not get pregnant for 6 months)
If the BhCG is not going down with the weekly checks, we should start on Methotrexate
