Lecture 6: Complications of Pregnancy Flashcards
MC site of ectopic pregnancy
Ampulla
What is the classic triad for presentation of Ectopic preg?
What other d/o has these Sxs?
- Unilateral pelvic/abd pain
- Amenorrhea (missed LMP)
- Vaginal Bleeding
Also seen w/threatened abortion
Main Sx a/w Atypical presentation of Ectopic preg?
What does this cause?
Atypical presentation = shoulder pain –> fluid irritating diaphargm –> peritonitis
Pt comes in to ED and you find out she has an ectopic pregnancy. She is cool, tachycardic, HoTNsive, and has severe abd pain, N/V and is dizzy.on PE you find free fluid in her pelvis.
What type of ecotopic pregancy is this?
Ruptured Ecotopic Pregnancy
1500-2000 mIU/mL is called what for the b hCG? What does this level indicate?
Part 2:
What is suspected if b hCG > 1500-2000 and no intrauterine gestational sac is seen?
What does NOT occur w/b hCG levels in ectopic preg?
Discrimatory zone
- should see intrauterine sac on US w/b hCG levels 1500-2000
1500-2000 bh CG and no intrauterine gestational sac is seen –> suggests ectopic or noon-viable intrauterine preg
bhCG DONT double every 2 days in ectopic preg (will in norm preg)
2 signs a/w ectopic preg that are seen on PE?
note: +/- uterine enlargement
- Adenexal mass
2. CMT
if Dx of ecotopic pregnancy is unclear what 2 things should be repeated/when?
- Repeat b hCG in 48hrs
2. Repeat TVUS - once b hCG above discriminatory zone
How to distinguish ectopic preg from miscarriage?
heavy bleeding (miscarriage) –> declining b hCG
What medication is given for Tx of ectopic pregnancy?
MTX - Methotrexate
Medical Tx of Ecotopic pregnancy w/MTX:
- what days do you check b hCG levels
- how often do you follow them til?
- what do you do if this method fails (2 options)
- check b hCG levels on Day 1, 4, 7
- follow b hCG til < 5
- MTX fails –> 2nd dose or surgery
What are the 2 surgical options (Laparoscopic) for ectopic preg? How are they different?
Which is 1st line Tx?
Laparoscopic
- Salpingectomy = 1st line
- remove fallopian tube - Salpingostomy
- just remove preg
What is GTD (Gestational Trophoblastic Dz)
What is the MC type?
abn proliferation of placenta trophoblast
MC = Molar pregnancy
How does GTN differ from GTD
main example?
GTN = malignant neoplasm arising from GTN
main example = choriocarcinoma
Preg pt presents w/painless vaginal bleeding, severe N/V. Her labs reveal she is hyperthyroid. Her uterine size > dates, b h CG = 105,000 and on US there is a snowstorm appearance but not fetal parts present. Dx?
Dx = Complete Molar Pregnancy
Note: Partial Molar
- same Sxs
- fetal tissue present
- b hCG < 100,000
- and uterine size is small for dates
- less risk than Complete for progressing to GTN
How to definitely Dx GTD?
what is the mainstay of Tx for GTD? why done immed?
- what is the other Tx must be given
Pathology
- karyotype
Tx = D&C w/suction curettage to remove preg to avoid choriocarcinoma
- must give contraception –> cant get preg for 6 mo
When should you suspect GTD has progressed to GTN?
What is general Tx for GTN?
b hCG levels plateau, incr or stay (+)
Tx = chemo
Difference in chemo Tx for Low risk GTN vs high risk?
How do WHO scores differ?
Low risk –> single agent
- MTX or Actinomycin-D
- lower WHO score (< 6)
High risk dz –> multiple agents
- EMA-CO
- higher WHO score (> 6)
3 differences b/t monozygotic and dizygotic twins?
Monoxygotic
- 1 sperm, 1 egg
- ALWAYS same sex
- # of sacs/placenta varies
Dizygotic
- 2 sperms, 2 eggs
+/- same sex
- ALWAYS 2 placentas, 2 sacs
early split (0-4 days) –> how many placentas/sacs
late split (> 12 days) –> what?
early split –> 2 placentas, 2 sacs
late split –> conjoined twins
What can determine chronicity before 14 wks?
What sign a/w Monochorionic? Dichorionic?
US
- T sign = Monochorionic
- Lambda = Dichorionic
What 2 major increased risks for multiple gestation babies
Do twins ever make it to due date?
- stillbirth
- neonatal death
NO b/c risks –> deliver all twins early
Which type of twins can be delivered the latest?
Which type need inpt management at 24 wks?
Which type must you do C-section for delivery?
Note: if vertex-breech –> can do vaginal or C-section
if vertex-vertex do vaginal
Dichorionic/Diamniotic
- delivered latest (38 wks)
Monochorionic/Monoamniotic
- need inpt management
- must do C-section
What is the name of the screening test done at 1st prenatal visit for DM?
GCT (1 hr Glucola)
What type of GDM needs medication as Tx?
- what med is preferred?
What can the other type be controlled with?
A2 GDM - Medication
- insulin preferred
A1 GDM - controlled w/diet
If a growth scan shows EFW > 4500 g why is a C section done
risk of shoulder dystocia
What test is done to screen the mother for pre-DM/DM postpartum at 6-12 wks?
75 OGTT Test
What are the 3 types of Pregnancy induced HTN?
What is difference b/t chronic HTN and pregnancy induced?
- Gestational HTN
- Pre-eclampsia
- Eclampsia
Chronic present < 20 wks GA
Pregnancy induced > 20 wks GA
When can pre-eclampsia occur (2 pds)
- Intrapartum
2. postpartum (6 wks after delivery)
Which type of HTN has BP > 160/110
Pre-eclampsia w/SEVERE Features
Which 2 types of HTN dont have proteinuria
Gestational HTN
Chronic HTN
What the nemonic for Liver Findings for Pre-eclampsia w/SEVERE Features? what does it stand for?
Other major sign = edema of vasculature, lungs, brain
HELLP
Hemolysis (incr LDH)
Elevated Liver enzymes
Low Platelets
How does the presentation of Eclampsia differ from Pre-eclampsia w/SEVERE Features?
Therefore what is the overall Tx for eclampsia? Med for seizures?
Eclampsia has same Sxs as Pre w/SEVERE Features + SEIZURES –> life threat
Tx= delivery ASAP
- med for seizures = Mag sulfate
Do any pts w/HTNsive d/o make it to their due date? why?
NO - incr risk of stillbirths
4 BP Meds used in pregnant women w/HTN?
- Labetalol
- Methyldopa
- Nifedipine
- Hydralazine
What is the Kleihauer-Betke Test?
Test that determines dose of Rhogam needed based on amt of exposure
What is considered preterm labor?
Definition of labor (2 things)
preterm labor: < 37 wks
Labor = regular contractions + progressive cervical changes (effacement and dilation)
Preg pt at 36 wks presents w/ cramping, back pain, pelvci pressure, vaginal d/c and uterine contractions. Her cervix is dilated 4 cm and is 85% effaced…Dx?
Preterm Labor
4 Tests used to Dx PTL
Note: Dx PTL –> admit
- BEDREST NOT INDICATED
- Nitrazine pH paper test (turns blue)
- Fern Test –> delicate crystallization
- Presence of Fetal Fibronectin
- L:S ratio < 2:1 (immature lungs)
What 2 meds should be given for PTL if 24-37 wks
- Antenatal Steroids
2. GBS ppx
What is the Med for Antenatal Steroids and GBS ppx
- Antenatal Steroids –> BMZ
2. GBS ppx –> PCN
What medication should be given for PTL if 24-34 wks?
Tocolytics
What type of Tocolytic is specifically given in 24-32 wk range?
Other 3 Tocolytics?
24-32 wks –> Mag sulfate + other Tocolytic
- Indomethacin
- Nifedipine
- Terbutaline
What type of Tocolytic is specifically given in 24-32 wk range?
Other 3 Tocolytics?
24-32 wks –> Mag sulfate + other Tocolytic
- Indomethacin
- Nifedipine
- Terbutaline
definition of PROM - Premature Rupture of Membranes
ROM before onset of labor
definition of PPROM - Premature Premature Rupture of Membranes
ROM before 37 wks AND onset of labor
Definition of Prolonged Rutupre of Membranes
ROM > 18 hrs
How to Dx PROM?
Sterile Speculum Exam
- pooling of secretions = water broke
3 parts of Sterile speculum exam
What does blue indicate on 2 of these tests?
- Nitrazine pH Paper Test
- Fern Test
- AFI
- blue = amnio fluid –> PRM likely
General Management of PROM (3 meds)
When do you usually deliver?
- BMZ
- Tocolytics
- Latency ABXs
- same rules for 1+2 as PTL
Deliver at 34 wks
Latency ABXs
- what 2 options of IV meds can be given for 1st 2 days
- what 2 PO meds given together for next 5 days
- IV Ampicillin/erythromycin for 2 days then..
2. PO Amoxicillin and Erythromycin for 5 days
