Lecture 73, 74 - Disease of Pregnancy Flashcards
Where is the most common location for an ectopic pregnancy
Ampulla of the Fallopian tube (region of first narrowing)
Risk Factors for Ectopic Pregnancy
prior PID (salpingitis, endometritis)
Previous Tubal Ligation
Previous ectopic
Smoking
what is the classic triad of symptoms for ectopic pregnancy
amenorrhea, vaginal bleeding, sudden abdominal pain
Dx of Ectopic Pregnancy:
Requisite labs:
Gold standard Dx Procedure
Other dx procedures
hCG levels usually rise at a much slower rate based on dates
Gold standard: Laproscopy – direct visualization
D&C - absence of chorionic villi
Ultrasound -
Treatment of Ectopic Pregnancy:
Medical vs Surgical
who gets which method?
Medical: Methotrexate (anti folic acid), but has lots of side effects and pt must be followed by HCG tracking to make sure the treatment worked
Surgical – Conservatinve mangement (don;t take out anything) vs Salingectomy
Hemodynamically unstable patients need surgery
Chronic HTN during Pregnancy
outcomes?
patient has kind of HTN before pregnancy
25% develop chronic HTN or Pre-eclampsia
usually no complications
Gestational HTN
what is it?
how is it dx?
BP > 140/90 after 20th week of gestation (no pre-existing HTN). No proteinuria.
BPs measures at least twice, at least 4 hours apart
Blood pressures should be normalized 6 weeks after delivery
Pre-eclampsia
new onset HTN after 20th week of gestation + Proteinura and/or end organ damage (TTP, Kidney damage, Liver damage, Pulm Edema, Visual symptoms; cerebral swelling)
RF for preeclampsia
Nulliparty, extremities of age, African american, chronic HTN, Chronic renal disease, DM, Multifetal gestation
Prevention of progression of pre-eclmapsia to eclampsia
Mg Sulfate
Eclampsia
Pre-eclampsia + seizures
HELLP Syndrome
Hemolysis, Elevated Liver Enzymes, Low Platelets
describe what happens to a woman’s blood pressure normally during pregnancy ?
drops in BP due to increased volume and drop in vascular resistance, and continues to drop until 32 weeks, until it starts to climb back up
Maternal blood volume almost doubles in pregnancy
pathophysiology of pre-eclampsia in pregnancy
what is the organ at fault?
what are the meditators of a healthy endothelium ?
what are the mediators which inhibit healthy endothelium?
Placental Dysfunction – not enough syntiotrophoblasts invasion, therefore the vessels of materanal fetal exchange are not compliant enough. Incomplete invasion of the myometrium
TGFB1 and VEGF = healthy endothelial function
sEng and SFLT1 - bind and deactivate TGFB1 and SFLT1
what organs can be damaged due to poor endothelial funciton during pre-eclampsia?
what is a fatal complication?
Kidney – Proteinuria, Increased Cr, and BUN
Brain - HA, , Sz, Stroke
Liver - RUQ Pain, increased LFTs, TTP
Liver Rupture = Fatal
Vessels = Vasocontstriction – Microvascular hemolysis
Edema
what is the only resolution for pre-eclampsia
i. The only resolution is delivery bc the source of the problem is the placenta
Pre-eclampisa –
mother is at term: what is the treatment?
wmother is preterm: what is the treatment protocol ?
If Term –> Mg Sulfate to prevent sz and proceed with delivery
Pre term –>
With severe features: mg sulfate and deliver
Without severe features: expectant management until term or severe
PRETERM LABOR –
definition?
uterine contractions between 20 and 36 weeks
what normally induces contraction in the uterus? describe the cascade
what is inhibiting this cascade?
CRH – activates fetal pituitary and adrenal glands –> ACHT and Cortisol —> estrogen and prostaglandins —> Positive feedback with CRH –> other substances that lead to contractions of the myometrium
Inhibitng the cascade;
Progesterone inhibits CRH
CRH BP decreases free CRH
what else can induce the contraction process?
Inflammation, Over distention (twins), Hemorrhage
Risk factors for pre-term delivery:
what is #1
1) H/o prior pre term delivery
other: Infection, Placental abn, Smoking, Multiple gestastion, Bleeding during pregnancy
Dx of pre term delivery –
what visualization/recording modalitites?
What ultrasound finding?
what is a good serum marker and why?
Tocogram - record contractions
Cervical Change – advance in dilation
US; Shorter cervical length
Fetal Fibronectin – Found in the ECM of the amniotic sac; will be present in vaginal secretions in delivery and PTL
If negative == Powerful predictor of not being in pre-term labor
what three drugs are administered in the management of PTL,
what are the reasons for each?
Steroids – promote lung maturity
Tocolysis – stop contractions long enough to administer steroids
Antibiotics: Prophylaxis for GBS
what drugs are used for tocolysis:
mechanisms for each
MG Sulfate – competes with calcium
Nifedipien – ca channel blocker
Indomethacin – indomethacin
Preterm Premature Rupture of Membranes (PPROM)
what is it
Risks
rupture of amniotic membranes prior to onset of labor at < 37weeks
Infection
Cord Prolapse –
Placental abruption – loss of fluid around the baby;
Pulmonary Hypoplasia
how is the dx made?
what three things are found
pooling - of amniotic fluid in the vagina
Nitrazine positive – alkaline fluid (indicates amniotic fluid)
ferning – NaCl crystals indicating amniotic fluid
mangment of PPROM
contraindciations
managment:
- watchful waitng
- Abx for GBS
- STeroids for lung maturity
- Tocolysis until completion of steroids
Contraindications -
- infection already present
- pregnancy > 34 weeks
Placenta previa
common presenting symptom:
management:
placenta attachement over or in close proximity to the internal cervical os
painless bleeding in the third trimester
management:
watchful waiting until term
Then proceed with C -section
Placental Abruption
common prsenting symptom
what can cause it?
(classically, what behavior causes it in baltimore)
management:
Placenta Separates prematurely from the uterine wall before delivery of the infant
Abrupt Painful vaginal bleeding + abdominal discomfort and uterine contracttions in the third trimester
Abrupt Painful vaginal bleeding + abdominal discomfort and uterine contracttions in the third trimester
management:
IV Fluids, blood products
C -section
Morbidly Adherent Placenta:
what is it?
what are three subtypes?
most common RF:
Defective decidual layer – abnormal attachment and separation after delivery
Placenta Accreta, Increta, Percreta
RF: Previous C section; placenta previa, HTN, Smoking,
Placenta Accreta, Increta, Percreta
differences between the three
accreta – placenta attaches to myometrium but not penetrating
Increta – placenta penetrates into myometrium
Percreta – placenta penetrates through myometrium and into serosa
why is the incidnce of Morbidly Adherent Placenta increasing?
Increasing Rate due to increasing rate of C section deliveries
MULTIFETAL GESTATION
complications:
PTL -- (due to over distention) Spontaenous Abortion Gestational DM Preeclampsia Maternal Hemorrhage
time line for the following:
Monochorionic and monoamniotic
Dichorionic diamniotic
Conjoined twins
Monochorionic diamniotic
which is at risk for twin twin transufion syndrome
which is at risk for cord entaglement
4 day split: Dichorionic + Diamniotic
4-8 day split: Mono chorionic + Diamniotic
- Twin twin infusion
8-13 day split: Monochroic + Monoamniotic
- Cord entanglement
> 13 day split = Conjoined twins
Twin-Twin Transfusion Syndrome
what is it
how is it managed?
Monochorionic Diamniotioc twins
Vascular anastomoses between the two twins;
Donor: impaired growth, hypovolemia, anemia, etc
recipient: Hypervolemia, CHF, HTN,
Treat: laser separation of the anastamosis
