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Clin Med - Repro > Lecture 6 - Complications of Pregnancy > Flashcards

Lecture 6 - Complications of Pregnancy Flashcards

1
Q

What is the frequency of ectopic pregnancy?

A

1:100

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2
Q

Where are ectopic pregnancies MC?

A

in the tubes
70% in the ampullary

why? because this is where the sperm meets the egg

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3
Q

What are the risk factors of ectopic pregnancy?

A

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

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4
Q

What are the sxs of ectopic pregnancy?

A

Pelvic pain
Missed LMP
vaginal bleeding

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5
Q

What labs should you order for a pt who you suspect of ectopic pregnancy?

A

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

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6
Q

Discriminatory Zone

A

when the Bhcg is 1500-2000 mIU/mL –you should be able to see something on US in the uterus

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7
Q

Does the Bhcg tell you anything about the gestational age of the fetus?

A

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

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8
Q

When should you expect to see fetal pole?

A

6 weeks

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9
Q

When should you expect to see FMH?

A

FMH - fetal heart motion

6.5 weeks

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10
Q

What do you need to be able to say the pregnancy is “viable”?

A

fetal pole and FMH

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11
Q

Heterotopic pregnancy

A

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

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12
Q

How do you dx ectopic pregnancy?

A

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

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13
Q

What is the dx of ectopic pregnancy is unclear, what should you do?

A

have the pt come back in 2 days to retest the Bhcg and pelvic US

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14
Q

What is the treatment for ectopic pregnancy?

A

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

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15
Q

Who is not a candidate for methotrexate tx for ectopic pregnancy?

A

Evidence of rupture
Hemodynamically unstable
Absolute or relative contraindications to MTX
Heterotopic

These pts need to have surgery —salpingectomy/salpingostomy

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16
Q

Besides methotrexate, what other medication do you need to give pts with ectopic pregnancy?

A

Rhogam if they are Rh negative

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17
Q

What do you need to tell pts who were given Methotrexate to avoid?

A

Avoid the sun and NSAIDs and stop taking prenatal meds

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18
Q

What are the relative contraindications for methotrexate?

A

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

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19
Q

What are the absolute contraindications of methotrexate?

A 
Hemodynamically unstable or clinical evidence of ruptured ectopic 
Liver disease or EtOHism
Blood dyscrasias
Renal dysfunction 
Immunodeficiency 
Active pulmonary disease 
Peptic ulcer disease 
Breastfeeding
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20
Q

Salpingectomy

A

Remove entire fallopian tube

Surgery for ectopic

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21
Q

Salpingostomy

A

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

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22
Q

Why chose salpingectomy over salpingostomy?

A

Either way you are at the same risk of recurring ectopic and change in fertility is the same

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23
Q

GTD

A

Gestational trophoblastic disease
Lesions characterized by abnormal proliferation of placenta tophoblast

Molar pregnancy

This can progress to GTN which is cancer

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24
Q

What are the sxs of GTD?

A

Bhcg >100,000
Abnormal vaginal bleeding
Hyperthyroidism

Dx: pathology is definitive
US

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25
Q

How do you dx GTD?

A

Bhcg >100,000
US - “snowstorm”
Pathology (definitive)

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26
Q

What do you see on US for GTD?

A

Snowstorm appearance

Complete mole - no fetal parts

Partial mole - +/- fetal parts, enlarged cystic placenta

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27
Q

What are the differences between partial and complete mole?

A 
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
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28
Q

What is the management of GTD?

A

Surgical evacuation (D and C)

Follow up - serial Bhcg
Weekly until <5

Can’t get pregnant for 6 months —> contraception

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29
Q

GTN

A

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)

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30
Q

What is the treatment for GTN?

A

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)

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31
Q

Monozygotic vs dizygotic

A

Mono is 1 sperm, 1 egg
Splits to identical twins

Dizygotic is 2 eggs and 2 sperms

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32
Q

Dichorionic diamniotic

A

2 placentas, 2 sacs
This occurs if the split happens 0 - 4 days

Monozygotic or dizygotic

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33
Q

Monochorinoic diamniotic

A

1 placenta
2 sacs
This occurs if the split happens 4-8 days

Monozygotic

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34
Q

Monochorionic monoamniotic

A

1 placenta
1 sac
This happens if the split occurs 8-12 days

Monozygotic

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35
Q

Conjoined twins

A

This occurs if the slit happens >12 days

Monozygotic

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36
Q

How do dizygotic twin pregnancies show in regards to sac and placenta?

A

Dichorionic diamniotic

2 placentas, 2 sacs

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37
Q

Lambda sign

A

Seen on US with Dichorionic —2 placentas

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38
Q

T sign

A

Sign on US for monochorionic

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39
Q

What are the risks of pregnancy for a women having twins?

A 
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)
40
Q

What are the risks for the baby with a twin birth?

A 
Growth restriction 
Prematurity 
Still birth (5X) 
Neonatal death (7X)
41
Q

Monochorionic twins are at greater risk of what?

A

Increased risk of congenital anomalies (ex. Heart defects)

42
Q

Monochrionic diamniotic twins are at increased risk of what?

A

Twin twin transfusion syndrome (TTTS)
Twin anemia polycythemia sequence (TAPS)
Twin reversed arterial perfusion (TRAP)

43
Q

Monochorionic monamniotic twins are at an increased risk of what?

A

Cord entanglement/accident

44
Q

Do multiple gestation (twins) make it to full term?

A

No

45
Q

Dichorionic/Diamniotic (DCDA) go to delivery when?

A

38 weeks

Growth scan every 4 weeks

46
Q

When do monochorionic/diamniotic (MC/DA) deliver?

A

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

47
Q

When do monochorionic/monoacmniotic (MC/MA) delivery?

A

32-34 weeks

Inpt management at 24 weeks d/t risk of sudden cord entanglement

48
Q

Vertex

A

When the babies head is down (ready for vaginal delivery)

49
Q

What determines the mode of delivery for twin births?

A

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)

50
Q

Who gets screened for GDM?

A 
BMI >30 
First degree relative with DM 
Hx GDM in prior pregnancy 
Hx macroscomic infant (>4000mg) 
Physical inactivity (subjective) 
HgbA1c >7.5%
51
Q

How do you screen and dx GDM?

A

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

52
Q

GCT

A

50 gm
1 hour wait
BG should be below 140

Used as first test for GDM

53
Q

GTT

A

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

54
Q

What is the treatment for GDM?

A

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

55
Q

What are the goals of blood glucose with GDM?

A

Fasting <95
1hr post prandial <140
2hr post prandial <120

56
Q

A1 GDM vs A2 GDM

A

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

57
Q

What is the preferred medication for GDM?

A

Insulin

58
Q

What pregnancy risks are present with GDM?

A 
PreEclampsia 
C section 
Indicated PTB 
Still birth 
Macrosomia
Shoulder dystocia
Neonatal: hypoglycemia, hyperbilirubinemia
59
Q

What is the screening and delivery schedule for A1 GDM?

A

Growth scan every 4 weeks

Delivery by 41 weeks

60
Q

What is the screening and delivery schedule for A2 GDM?

A

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

61
Q

What is the postpartum GDM management?

A

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

62
Q

What timing during pregnancy differentiates between chronic HTN and gestational HTN?

A

If HTN <20 weeks —chronic HTN

If HTN >20 weeks —Gestational HTN

63
Q

What criteria needs to be met to be dx with gestational HTN?

A

BP >140/90 x2 >4hr apart >20 weeks GA

64
Q

What is the HTN spectrum with gestation?

A 
Gestational HTN 
|
|
PreEclampsia without severe features 
|
|
PreEclampsia with severe features 
|
|
Eclampsia
65
Q

How does gestational HTN differ from preeclampsia?

A

No proteinuria with gestational HTN

66
Q

What are the severe features than can be seen with preeclampsia?

A 
HELLP 
Crt >1.1 
Plt <100K 
Pulmonary edema 
HA 
Vision changes 
Oliguria (<500cc/day) 
Liver hematoma
67
Q

What is the difference between preeclampsia and eclampsia?

A

Eclampsia has seizures d/t the increase in cerebral edema

68
Q

What is the treatment of preeclampsia?

A

Delivery

69
Q

What are the risk factors of preeclampsia?

A 
Hx of preeclampsia 
First pregnancy 
Family hx of preeclampsia 
T1DM/T2DM
Chronic HTN
Lupus
Antiphospholipid antibody syndrome 
CKD 
Multifetal pregnancy 
Advanced maternal age (>/=35)
70
Q

HELLP

A

Might be seen with severe features of PreEclampsia

Hemolysis
Elevated Liver Enzymes
Low Platelets

71
Q

What is the most common type of HA seen with preeclampsia?

A

Occipital HA

72
Q

Why don’t gestational HTN pts make it to full term?

A

Increased risk of still birth

73
Q

What are the common BP meds used in pregnancy?

A

Labetalol
Hydralazine
Nifedipine
Methyldopa (less common)

74
Q

What additional meds are you giving for HTN for preeclampsia with severe features and eclampisa?

A

Magnesium sulfate to decrease seizure risk

75
Q

How do you treat seizures from eclampsia?

A

Lorazepam

Immediate delivery

76
Q

ABO vs Rh D?

A

ABO - IgM - does NOT cross placenta

Rh D - IgG - crosses placenta

77
Q

What are the fetal consequences of Rh Incompatibility?

A

Anemia
Hydrops fetalis (skin edema, ascites, pericardial effusion, pleural effusion)
Death

78
Q

What is the prevention for Rh incompatibility?

A

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

79
Q

What is the mom has antibodies against Rh -?

A 
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

80
Q

What is considered preterm labor?

A

<37 weeks

30% spontaneously resolve
50% deliver at term

81
Q

What are the risk factors of preterm labor?

A 
Hx of PTL 
Hx of cervical surgery 
Uterine malformations
Multiple gestation 
Infection 
Substance abuse 
Smoking
82
Q

What labs do you need to draw for a mom in preterm labor?

A 
Gonorrhea
Chlamydia
Urinalysis 
Urine culture
Group B strep

Inpt admission

83
Q

When are preterm infants considered “viable”?

A

24 weeks

84
Q

What medications should a preterm infant get?

A

Bethamethason - for fetal lung maturity - STOP @ 37 weeks

Magnesium Sulfate - for cerebral palsy prevention - STOP @ 32 weeks
GBS prophylaxis - PCN

85
Q

PROM vs PPROM

A

Premature rupture of membranes
-ROM before onset of labor (contractions)

Preterm premature rupture of membranes
-ROM <37 weeks AND before onset of labor

86
Q

What do you need to dx premature rupture of membrane?

A

Sterile speculum exam should show:

  • Nitrazine
  • Ferning
  • Pooling
  • Amniotic fluid index (AFI)
87
Q

Latency period

A

Time between rupture (PROM) and delivery 40-50% deliver within 1 week
70-80% deliver within 2-5 weeks

88
Q

Tocolysis

A

Short term drug given in preterm labor to suppress preterm labor
Only given if preterm by 24-32 weeks +/- 32-34 weeks

89
Q

A women is coming in 30 weeks gestation for preterm labor, what do you do?

A

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

90
Q

A women is in preterm labor at 33 weeks, what do you do?

A

For all preterm 32-34 weeks

Betamethasone
+/- tocolysis
GBS prophylaxis (PCN)

91
Q

What drugs can be used for tocolysis?

A

To suppress pre term labor

Nifedipine
Indomethacin
Terbutaline
Mag sulfate (weak)

92
Q

A women comes in for premature rupture of membrane at 30 weeks, what do you do?

A 
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

93
Q

How does the management for a premature rupture of membrane differ between 33 weeks and 30 weeks?

A 
24-32 weeks:
Betamethasone
Mag sulfate
Tocolysis
Latency ABX 
Delivery by 34 weeks
32-34 weeks:
Betamethasone 
Tocolysis 
Latency ABX
Delivery by 34 weeks
94
Q

What is the management for rupture of membrane between 34 and 37 weeks?

A

Betamethasone
GBS prophylaxis (PCN)
Deliver!

95
Q

For premature rupture of membrane, the goal is to deliver at 34 weeks, under what circumstances would you deliver sooner?

A

Fetal distress
Placental abruption
Infection

96
Q

Molar pregnancy put you at risk of GTN, which cancers are these pts most at risk for?

A

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
97
Q

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?

A

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

Clin Med - Repro (18 decks)

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