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OB > medical complications in pregnancy > Flashcards

medical complications in pregnancy Flashcards

1
Q

Pregnancy induced HTN (PIH)

A

HTN that develops AFTER 20 wks of gestation in the absence of proteinuria & returns to nml postpartum.

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2
Q

Chronic HTN

A

HTN present before 20th wk of pregnancy or HTN present before pregnancy

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3
Q

mild HTN

A

systolic >/= 140-180 mmHg or
diastolic >/= 90-100 mmHg or
both

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4
Q

severe HTN

A

SBP >/= 180 mmHg or

DBP >/= 100 mmHg

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5
Q

what is the major risk factor w/ chronic HTN?

A

development of preeclampsia/ eclampsia later in pregnancy

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6
Q

preeclampsia

A

develop of HTN w/ proteinuria & edema fter 20wks gestation

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7
Q

BP in preeclampsia

A

SBP > 140 mmHg or DBP > 90 mmHg
2 occasions > 6 hrs but < 7 days apart
after 20 wks gestation w/ previously nml BP

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8
Q

Proteinuria in preeclampsia

A

urinary excretion of 0.3 g protein or higher in 24 hr urine or >/= 1+ protein on UA dipstick

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9
Q

severe preeclampsia

A 
SBP > 160 mmHg or DBP > 110 mmHg
marked proteinuria -> 5g/24 hr urine or 3+ on 2 dipstick of random urine samples collected at least 4 hrs apart
oliguria-> < 500 mL in 24 hrs
cerebral/visual distrubances (HA & scotomata)
pulmonary edema/cyanosis
epigastric/RUQ pain
evidence of hepatic dysfunction
thrombocytopenia
IUGR
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10
Q

eclampsia

A

presence of convulsions (grand mal seizures) in a woman w/ preeclampsia not explained by neuro d/o
most cases occur w/in 24 hrs of delivery but can also occur 2-10 days postpartum

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11
Q

risk factors for preeclampsia

A 
nulliparity
age  35 yo
new paternity
FH of preeclampsia
CRD, chronic HTN
prolonged interpregnancy interval
antiphospholipid syndrome
DM
multi-fetal gestation
high BMI
connective tissue d/o (RA, SLE)
vit D insufficiency?
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12
Q

what is the predominant pathophysiological finding in preeclampsia

A

maternal vasospasm

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13
Q

what are some potential causes of maternal vasospasm

A

vascular changes
hemostatic changes
changes in prostanoids
dysfunctional changes in endothelium-derived factors
lipid peroxide, free radicals & antioxidant release

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14
Q

vascular changes

A

theorized that a shallowly implanted placenta becomes hypoxic-> upregulates placental inflammatory mediators->acts on vascular endothelium

  • decreased musculature in spinal arterioles leads to development of low-resistance, low pressure, high-flow system
  • inadequate maternal vascular response
  • endothelial damage w/in vessels
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15
Q

Hemostatic changes

A
  • increased platelet activation w/ increased consumption in microvasculature
  • endothelial fibronectin levels are increased & anti-thrombin III 7 a2- antiplsmin levels are decreased (reflects endothelial damage)
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16
Q

changes in prostanoids

A

-prostacycline (PG12) & thromboxane (TXA2) increased during pregnancy

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17
Q

PG12 promotes what?

A

vasodilation

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18
Q

TXA2 promotes what?

A

vasoconstriction

platelet aggregation

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19
Q

during pregnancy, balance is in favor of PG12 or TXA2?

A

PG12

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20
Q

pts w/ preeclampsia, balance is in favor of PG12 or TXA2?

A

TXA2

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21
Q

dysfunctional changes in endothelium-derived factors (may be placental in origin)

A

nitric oxide (potent vasodilator) is decreased–may explain evolution of vasoconstriction

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22
Q

lipid peroxide, free radicals & antioxidant release

A

lipid peroxide & free radicals implicated in vascular injury & increased in women who develop preeclampsia
decreased antioxidant levels noted

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23
Q

proposed theories regarding preeclampsia

A 
endothelial cell injury
immune rejection of the placenta
compromised placental perfusion
imbalance bet. prostacyclin & thromboxane
decreased glomerular filtration rate w/ retention of salt & H2O
decreased intravascular vol.
increased CNS irritability
disseminated intravascular coagulation
uterine m. stretch (ischemia)
dietary factors, including vit. def.
genetics
air pollution
obesity
unfamiliar sperm theory
thyroid dysfunction
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24
Q

evaluation of preeclampsia

A

detailed H&P- hx of HTN, previous preeclampsia
review of OB records if applicable
BP (tends to decline 2nd trimester)
wt- rapid wt gain (2 lbs/wk)
edema
DTRs- hyperreflexia or clonus at ankle worrisome

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25
Q

S&S’s of preeclampsia

A 
visual disturbances
severe/persistant HA
RUQ pain
hx of LOC/seizures
dizziness
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26
Q

edema in preeclampsia

A

unresponsive to rest in supine position esp. in upper extremities, sacral egion & face

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27
Q

evaluation of the mother

A 
CBC, esp. Hct
platelet count- thrombocytopenia
coag profile (PT, PTT)- coagulopathy
LFTs- hepatocellular dysfunction
SCr- decreased renal function
uric acid
24 hr urine
CrCl
total urinary protein
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28
Q

Hct in preeclampsia

A

Hct signals worsening vasoconstriction & intravascular volume or hemolysis

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29
Q

lab studies of fetus

A

ULS for fetal wt, growth, amniotic fluid vol.

NST &/or biophysical profile- indirect assessment of placental status

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30
Q

Biophysical profile (BPP)

A

BPP has 5 components: 4 ULS assessments & a nonstress test (NST). The NST evaluates fetal HR & response to fetal mvnt. The 5 discrete biophysical variables:

  1. fetal mvnt
  2. fetal tone
  3. fetal breathing
  4. amniotic fluid volume
  5. fetal HR
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31
Q

NST/ Reactive FHR

A 
nml= at least 2 accelerations in 30 min
abnml= <2 accel. to satisfy the test in 30 min
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32
Q

ULS: fetal breathing mvnt

A

nml= at least 1 episode of breathing that lasts >30 seconds or >20s in 30 mins
abnml: none or < than 30s or 20s

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33
Q

ULS: fetal activity/ gross body mvnts

A

@ least 2 movnts of the torso or limbs

abnml: < 3 or 2 mvnts

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34
Q

ULS: fetal muscle tone

A

@ least 1 episode of active bendign & straightening of the limb/trunk
abnml: no mvnts or mvnts slow & incomplete

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35
Q

ULS: qualitative AFV/AFI

A

@ least 1 vertical pocket > 2cm or more in the vertical axis

abnml: largest vertical pocket </= 2 cm

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36
Q

BPP <2

A

labor induction

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37
Q

BPP 4

A

labor induction if gestational age >32 wks, repeating test same day if < 32 wks, then delivery if BPP <6

38
Q

BPP 6

A

labor induction if >36 wks if favorable cervix & nml AFI, repeating test in 24 hrs if 6

39
Q

BPP 8

A

labor induction if presence of oligohydramnios

40
Q

BPP is not usually performed before what?

A

the 2nd half of a pregnancy, since fetal breathing mvnts do not occur in the 1st half

41
Q

the presence of these biophysical variables implies absence of significant what?

A

CNS hypoxemia/acidemia @ the time of testing

42
Q

a compromised fetus typically exhibits what?

A

loss of accelerations of the fetal heart rate (FHR)
decreased body mvnts & breathing
hypotonia
decreased amniotic fluid volume

43
Q

mgnt of chronic HTN

A

goal: balance the mngt of both fetus & mother & to optimize outcome for mom & baby
- close monitoring of maternal BP
- watching for superimposition of preeclampsia/eclampsia
- following fetus for appropriate growth & fetal well being
- antiHTN meds if SBP is 150-160 or DBP 100-110
- purpose of med to to reduce likelihood of maternal stroke

44
Q

mgnt of preeclampsia

A

care is individualized
mainstay of mgnt is rest & freq. monitoring of mother & fetus
2x weekly NST, BPP or both
ULS 1 3 wks for fetal growth & amniotic fluid assessment
daily kick counts
hospitalized initially for new onset

45
Q

mgnt of severe preeclampsia

A

-best in tertiary care setting
-daily lab tests & fetal surveillance
-antiHTN therapy if repeated SBP > 160 or DBP > 105-110
-stabilize w/ magnesium sulfate
delivery via either induction or c-section

46
Q

what type of BP med is given in severe preeclampsia

A

hydralazine

47
Q

how is hydralazine given

A

in 5-10 mg incements until acceptable BP response
10-15 min response time is usual
goal of therapy is to reduce DBP to 90-100
further reduction may impair uterine blood flow

48
Q

stabilizing w/ magnesium sulfate

A

used to prevent & tx eclamptic seizures
IM/IV 4-6 mg/dL
caution of toxic consequences
freq. eval of pts patellar reflexes & respirations
maint. of urine output of at least 25 mL/hr will avoid accum. in kidneys
reversal of effects done w/ shlow IV of 10% calcium gluconate, along w/ O2 supplementation

49
Q

delivery by either induction or c-section

A

stabilize pt then focus on delivery of baby
closely monitor blood loss
obverse for min 24 hrs post delivery
further admin of Mg2+ sulfate
seizures can occur pre, during, post delivery

50
Q

mngt of eclampsia

A

seizure life-threatening to both mother & fetus
maternal risks include: ms injury, hypoxia, aspiration
-insert padded tongue blade, restrain gently PRN, maintain adequate airway, gain IV access.
usu. self limited
tx directed to initiation of Mg2+ sulfate to prevent further seizures

51
Q

if pt already receiving Mg2+ sulfate, an additional_________can be given slowly

A

2 g

get blood level

52
Q

transient uterine hyperactivity for approx. 15 min associated w/ what?

A

fetal heart changes: bradycardia, decreased variability & late decelerations
usu. self limited
not dangerous unless > 20 min
delivery during this time unnecessary & should be avoided
place foley cath to monitor urine output

53
Q

HELLP syndrome

A

Hemolytic anemia
Elevated Liver enzymes
Low Platelet count

considered a variant of preeclampsia

54
Q

the findings of HELLP syndrome, a multisystem dz, attributed to?

A

abnormal vascular tone
vasospasm
coagulation defects

55
Q

when does HELLP syndrome generally present?

A

3rd trimester
can occur < 27 wks
presents antepartum (69%), postpartum (31%)

56
Q

postpartum onset

A

typically w/in 1st 48 hrs after delivery
may not become apparent for as long as 7 days after
pts usually multiparous
BP usually lower than preeclamptic pts

57
Q

HELLP syndrome symptoms

A 
may be vague
n/v
viral like syndrome
generalized malaise
epigastric pain
HA
early dx is critical- any 3rd trimester woman coming in w/ viral like sx's should be evaluated w/ CBC, LFTs
58
Q

PE for HELLP syndrome pt

A

can reveal RUQ pain & tenderness
(rupture of liver capsule= hematomoa)
usually no proteinuria

59
Q

labs in HELLP syndrome

A

CBC
CMP
coag studies
fibrin degredation products

tx done in high-risk OB center

60
Q

Tx of HELLP syndrome

A

cardiovascular stabilization
correction of coagulation abnormalities & delivery
DIC (disseminated intravascular coagulation) occurs in 20% of HELLP pts
platelet perfusion indicated if platelet count < 20,000/mm3
may be advisable to perfuse when platelet count <50,000 before c-section

61
Q

prophylactic transfusion of platelets at delivery does not reduce the incidence of what?

A

postpartum hemorrhage or hasten normalization of the platelet count

62
Q

pts w/ DIC should be given what?

A

fressh frozen plasma & PRBCs

63
Q

lab abnormalities in HELLP syndrome typically worsen when? begin to resolve when?

A

after delivery

3-4 days postpartum

64
Q

HELLP syndrome summary

A 
tx= prompt delivery
Mg2+ sulfate- decreases risk of seizures
blood transfusions- anemia
DIC- fresh frozen plasma
AntiHTN- labetalol, hydralazin, nefedipine
65
Q

what does amniotic fluid protects against what

A

infxn
fetal trauma
umbilical cord compression

66
Q

amniotic fluid has a pH of

A

7.5

67
Q

approx. how much amniotic fluid at 20 ?wks? 28 wks?

A

400mL

800mL (plateaus here)

68
Q

amniotic fluid allows for fetal movement & fetal breathing, which permits what?

A

fetal lung, chest & skeletal development
cushioning
prevents heat loss

69
Q

polyhydramnios AFI (amniotic fluid index) >20 cm assoc. w/ what?

A

Down’s/Edwards

GDM

70
Q

oligohydramnios AFI <5 cm assoc. w/ what?

A 
UT abnormalities (bilateral renal agenesis- Potter's syndrome)
maternal dehydration
71
Q

PROM (premature rupture of membranes) overview

A

PROM is the rupture of chorioamniotic membranes BEFORE onset of labor
occurs in ~12% of pregnancies
assoc. w/ about 8% of term pregnancies
generally followed by onset of labor w/in 24 hrs

72
Q

major complication of PROM

A

intrauterine infxn
cord prolapse, compression
fetal malpresentation

73
Q

prolonged PROM defined as

A

> 18 hrs before onset of labor

74
Q

consequence of PROM depends on what?

A

gestational age @ time of occurrence

can spontaneously heal

75
Q

term PROM

A

PROM occurring >/= 37 wks

76
Q

preterm PROM (PPROM)

A

PROM that occurs before 37 wks

77
Q

what is the leading cause of neonatal morbidity & mortality?

A

PPROM

assoc. w/ 30-40% of preterm deliveries, making it the leading cause of preterm delivery

78
Q

suggested etiology of PROM

A

STIs & other lower genital tract conditions (i.e. BV)

subclinical intraamniotic infxn may contribute to PROM

79
Q

risk factors for PROM

A 
smoking during pregnancy
prior PROM
short cervical length
prior preterm delivery
polyhydraminos
multiple gestations
bleeding in early pregnancy (threatened abortion)
80
Q

Dx of PROM basics

A

-fluid passing thru vagina must be presumed to be amniotic fluid UNTIL proven otherwise
-pt will usually describe “gush” of fluid/ give hx of steady leakage of small amts of fluid
VS, abdominal exam
AVOID DIGITAL EXAM!!!! or keep to a min d/t risk of infxn

81
Q

PROM Dx exams

A

sterile speculum exam
nitrazine test
fern test
ULS

82
Q

sterile speculum exam

A

ontain cervical/ vaginal cultures for N. gonorrhoeae, B-hemolytic strep, C. trachomatis
cervix visualized for degree of dilation & free flowing amniotic fluid
fluid obtained for nitrazine &/or fern testing

83
Q

Nitrazine test

A

-uses pH to distinguish amniotic fluid from urine & vaginal secretions
-amniotic fluid alkaline w/ pH >7.1
vaginal secretions pH 4.5 to 6.0
urine pH </= 6.0
sample of fluid obtained from vagina during speculum exam is placed on nitrazine paper
if pH is 7.1-7.3, paper = blue
cervical mucus, blood, semen, vaginitis are possible causes of false + results

84
Q

fern test

A

amniotic fluid placed on slide & allowed to dry looks like a fern
cervical mucus usually does not fern but when it does it is a thick pattern w/ less branching

85
Q

ULS for PROM

A

helpful in eval the possibility of rupture of membranes
looking for less than expected amt of fluid around fetus, then ddx of oligohydraminos is considered
labor & infxn less likely when adequate vol. of amniotic fluid remains w/ in uterus– 800cc @ 34 wks, 600 cc at term
also helpful w/ gestational age

86
Q

mngnt of term PROM

A

90% of pts will experience spontaneous labor w/in 24 hrs
waiting for onset of spontaneous labor for 12-24 hrs reasonable unless presence of risk factors (GBS status, vaginal infxn, multiple deigital pelvic exams)
serial eval for devlop. of intrauterine infxn
induction of labor at any time after PROM considered appropriate

87
Q

mngt of PPROM- latency period inversely related to gestational age
28 wks- term &24-28 wks

A

28 wks- term: 50% in labor w/in 24 hrs, 80% w/in 1 wk

24-28 wks: 50% in labor w/in 1 wk
amniocentesis- fetal LU maturity, eval for intra-amniotic infxn
suspicion of uterine infxn- delivery ASAP, regardless of gestational age

88
Q

PPROM mgnt <24 wks

A

pt counseling regarding outcomes
expectant mngt or induction of labor
group B strep prophylaxis not recommended
Abx (data incomplete on prolonging latency)

89
Q

PPROM mgnt 24 wks to 31 completed wks

A 
expectant mgnt
group B step prophylaxis recommended
single-course corticosteroid use rec.
Tocolytics- no consensus
abx recommended to prolong latency if no CI
90
Q

PPROM mgnt 23 wks- 33 completed wks

A

expectant mngt, unless fetal pulmonary maturity documented
group B strep prophylaxis recommended
corticosteroids- no consensus, but some experts recommend
Abx recommended to prolong latency, if no CI

91
Q

PPROM mgnt 34-36 completed wks

A

same as for term

92
Q

PPROM before 20-22 wks

A

risk of prematurity & infxn
additional risks 2/2 prolonged oligohydraminos: pulmonary hypoplasia, skeletal malformations, possible permanent deformities
these pts should be counseled regarding impact of immediate delivery & potential risks & benefits of expectant mngt
usually managed expectantly until viability

OB (13 decks)

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