Medical & Surgical Conditions of Pregnancy Flashcards
who is at risk of developing a pregnancy related HTN disorder
what are the fetal complications of HTN during pregnancy
affect 5-10% of pregnancies
- a major player in maternal morbidity and mortality
- this can include those with HTN getting pregnant & those who get HTN while pregnant
RIsk Factors: who is at risk for HTN during pregnancy
- first child (primiparity)
- prior pre-eclampsia
- Chronic HTN
- histor of thrombophilia
- multiple fetuses (multiples)
- IVF
- family history
- DM
- SLE
- AMA (advanced materal age)
- obesity
- AA race
Fetal Outcomes
- IUFD
- IUGR
- preterm delivery
when there is HTn during pregnancy, there is no way for the uterus to regulate the blood flow its receiving : thus if there is HTN; constricted vessel, decreased blood flow to the uterus and the uterus has no compensatory mechanisms for this
During Pregnancy; what are the normal BP changes one can expect
During Pregnancy
- BP naturally lowers in the 1st and 2nd trimester
- this is a result of increased progesterone which dilates the vessels, leading to a decrease in SVR
in 3rd Trimester: BP rises back to the pre-pregnancy levels
week 28: the lowest BP mom will have during pregnancy: then it will climb
progesterone = dilate: decrease SVR: drop pressure
- but also; increased pooling in the legs (edema) and swelling, light headed, etc. becuase they have lost that resistance force
Chronic HTN v Gestational HTN
how do you know which it is
how do these differ from pre-eclampsia
Chronic HTN
- HTN they had prior to becoming pregnant
- defined as HTN prior to 20 weeks gestation
- they should have lower BP during this time up to the 3rd trimester; so if high now, it was likely high before
- can also be diagnosed afte 12 weeks PP (since the preg. related HTN should be gone)
Gestational HTN
- HTN they had as a result of pregnancy (or we just didn’t know if they had it before)
- define as HTN after 20 weeks gestation
- no other abnormalities present, jsut straight up HTN (no end organ damage signs, etc.)
Preeclampsia
- HTN in pregnancy with the addition of other features: maininly proteinuria
Chronic HTN in pregnancy
what is it
what do you do
labs, fetal testing etc.
CHTN
- HTN before pregnancy: before 20 weeks or afte 12 weeks PP
- can be stage 1 or stage 2 HTN (in normal HTn numbers: 130-139/80-89 (Stage1))
Manage Meds
- if on meds: off ACE/ARB
- HCTZ: ok
- prefer labataolol, nicardipine
Testing
Labs
- want to get baselines: to see if it develops into pre-eclampsia, HELLP syndrome, etc.
- CMP/EKG/24hr. urine (or spot check protein:Cr ratio)/eye exam
Fetal Testing
- 3rd trimester: NST (1-2x weekly depending on severity) assesing placenta compromise too
- growth US (Q4wk.; serial US starting at 28wk.)
- delivery ideally between 38-39 weeks
Gestaional HTn
what is it
diagnosis criteria
management
Gestational HTN
- HTN After 20 weeks gestation
- or HTN which resolves after 12 weeks PP
Diagnosis
- requires two BP readings 4 hours apart
- NO proteinuria: proteinuria = preeclampsia
- 2+ readings elevated BP 4 hours apart
Management
- weekly NST for fetal monitoing
- serial growth US
- serial weekly labs: LFTs, CBC, urine protien:Cr ratio (r 24 hour) {monitoring for development into preeclampsia}
- anti-hypertensive management: carvadilol, labatolol
delivery: between 37 -38 weeks weighing risk benefits for mom/baby
Pre-Eclampsia
Etiology
Pathology
Preeclampsia
- a pregnancy specific syndrome: can effect virtually every organ system
Etiology
- poorly known
- thought to have something to do with placental inflammatory reaction to paternal chromosomal influence triggering an immune type reaction
- results in: capillary leakage & 3rd spacing
Pathology (what basically happens as a result)
cardiac: HTN, increasd preload, endothelial damange, vasoconstrction
hematologic: hemoconcentation, thrombocytopenia, DIC, hemolysis
Fluid changes: edema
Renal: decreased perfusion, decreased GFR, proteinuira, AKI, ARF
Liver: infarction, hepatic hemotoma, rupture, impaire liver function
brain: cerebral edema, CVA (increased CSF pressures)
Pre-Eclampsia
Diagnosis
Mild V Severe
Diagnosis
- evidence of HTN via BP readings (2+ in 4 hours)
- evidence of Proteinuria
- additional symptoms: visual disturbances, fluid in lungs, SOB, abd pain
Mild
- HTN: 140/90
- proteinuria
Severe
- 160/110
- proteinuria
- lab abnormalities including
- LFTs elevated (“2x baseline”)
- platlets low ( < 100k)
Pre-Eclampsia
treatment
what can you give to those at increasd risk in 1st trimester
Preeclampsia Treatment
- delivery is the only cure: we like to wait/get baby to at least 34weeks if severe, mild can try 37 weeks
- monitor LFTs, CBC, & labs
- monitor fetus via : growth US & NST
- magnesium sulfate to prevent seizures
- corticosteroids to help fetal lung development upon delivery
- manage inpt. v outpt. deoending on severity
Prevention
- daily asprin starting at 12 weeks in first trimester for those high risk
- High Risk: DM, HTN, family hx., older age, smoker, etc.
HELLP Syndrome in Pregnancy
what is it
when does it occur
HELLP Syndrome
H = hemolysis (evidence via LDH and haptoglobin. bilirubin,etc.)
E = elevated
L = Liver enzymes (AST/ALT)
L= low
P = Platelets
can be a more severe form of preeclampsia (so HTN + Proteinuria) + these symptoms
or
can be on its own, absenc of proteinuria and HTN (seems more rare)
Eclampsia
what is it
when does it happen
treatment
Eclampsia
- a generalize tonic-clonic seizure with convulsions which has not underlying, attributable cause
- pre-eclampsia symptoms (HTN, proteinuria) + seizure
When
- can happen up to 6 weeks PP
- highest risk is withint first week of delivery
Complications from eclampsia
- abruption of placenta
- neurological defictis
- aspiration PNA
- pulmonary edema
- acute renal failure
- cardiac arrest
- death
Managemnet
- first line is magensium sulfate
- then if seizure continuing: move to the benzos or phenytonin
- anti-hypertensives to drop pressure (labatalol, nicardipine)
- diuretics
- delivery of baby
Anemia In Preganancy
why does it occur & causes of the anemia
symptoms/signs
what supplementation is recommended
Anemia in Pregnancy
- there is a natural hemodilution in pregnancy; increase in plasma volume but not as much of an increase in RBC production via erythropoetin
- baby is taking all your iron and calcium
- post-partum: there is a decent hemoconcentration back (as fluid is lost)
Causes
- IDA: iron deficiency aneami
- anemia from acute blood loss: vaginala dn c-section losses
Supplementation Recommendations
- for all women
- iron (can be within the prenatal vitamin)
- iron is constipating: give stool softener
Symptoms & Signs of anemia
- lethargy
- SOB
- palpations, chest pain
- dizzy
- HA and fainting
- pallor
- tachycardic
- soft ejection systolic murmur
Anemia in Pregnancy: IDA
labs & treatment
Iron Deficiency Anemia (IDA)
- a result of lack of iron, because baby is taking it all from you & during pregnancy you need more!!!!!
Labs
- hypochromic (not holding as much HGB)
- microcytic (small because pumping them out asap to try to carry as much o2 as it can)
- Hgb < 11 in first trimester, or < 11.5 in second trimester : check hgb at 1st trimester & at 28weeks
- additional labs: iron/iron binding capacity, reticulocytosis
Treatment
- Iron supplementation (IV or oral)
Anemia in Pregnancy: Acute Blood Loss
when might you seen this
labs to obtain
treatment
Acute Blood Loss
First Trimester: ectopic, aborption, hydatiform mole
more commonly: due to obstertirc hemorrage
PPH : loss of >1000 mL in any delivery modality
Labs to obtain
- after delivery or in 1st tri: CBC
- 1day post devleiry: get CBC to see how they’re compensating
Treatment
- blood transfucion: no clear guide on when bu if symptomatic: transfuse (around 7 start thinkin)
- iron supplementation
Additional causaes for Anemia in Pregnancy
decide the cause of the anemia via a HgbElectrophoresis
Sickle cell
anemai of chronic disease (rare)
folate/B12
Thalassemia
CKD
Hypothyroidism
UTI in pregnancy
why are they common : patho
labs to obtain
bugs
UTI = most common infection in pregnancy
Patho
- progesterone relaxes the mucosal sphincters: leading to the ability for bacterial to easily backflow from utertra up to bladder and even to utereters and kidneys (pyleo)
Pregnant Changes
- increased kidney size, dilation of calyces and ureters
- increased GFR
- vesiculoureteral reflux
Labs to Obtain
- urinaylsis
- urine culutre
Bugs
- 90% of the time its e coli
- could be klebsiella
- GBS too
Asymptomatic Bacteruria in Pregnancy and Treatment
we want to treat asymptomatic UTIs
- bacteruria: bacteria in the urine in the absence of other symptoms
- cystitis/urethritis: bacteria in the bladder/urethra: infection (symptoms)
Who’s At Risk
- AA multiparous women with sickle cell MC
- DM pt. too
Treatment
- bacterial specific
- nitrofurantonin (macrobid)/cephalosporins/PCN are safe
- bactrum safe: in the 1/2 trimester: not 3rd
- Avoid florquinolones
Cystitis and urethritis in pregnacy
symptoms
treatment
Symptoms
- urgency, frequency, dysuria
- few to no systemic findings
- hematuria (microscopic)
- pyuria can indicate chalymida
Treatment
7day course = preg. = complicated
amoxicillin
mitrofurantonin
bactrium (specific trimesters)
Pyleonephritis in Pregnancy
risk factors
symptoms
bugs
Pyleno: kidney infection (asecnding UTI)
- affect renal calyces, pelvis and parynchma
Risk factors
- younger pt.
- first child
- increasing gestation (as time goes on)
Symptoms
- fever,chiils
- CVA tenderness
- N/V
- decrease appetitie
- elevated whites on labs
Bugs
- e. coli, klebsiella, enterobacter (gram -)
- GBS, streptococcus, staph. (gram +)
risk for preterm labor and contractions due to endotoxins
Risk of urosepsis!!!
Pyleonephritis in Pregnancy
Treament
Risk of urosepsis so high = admit pregnant pt.
LAbs
- urine and blood culutres
Treatment
- monitor VS for deterioration
- IV hydration
- IV abx: ampucillin + gentamycin; cefazolin;ceftriaxone
D/C when afebrile for 24 hours
Continnue PO abx. 7-10 days (total treatmetn 10-14 days)
repeat UC for clearnace of the infection 1-2 weeks
Gestaional Diabetes
Etiology
Risk Factors
Maternal and Fetal Complications
Gestational DM
Etiology
- normally, there is some degree of decreased insulin sensitivity in pregnancy: thus blood sugars during pregnancy tend to remain higher for a bit longer
- this is because the baby needs the glucose for energy: so mom needs to provide to baby
- placenta: releases prolactin, progesterone and human placental lactogene (which all impact insulin sensitivity; resistant) as placenta grows: increased resistance
- in the case of GDM: there is impaired insulin sensitivity to the point which hyperglycemia results and prolongs: the pancreas isnt able to overcome/moutn the need for higher glucose and higher insulin release in pregnancy - DM results
Risk Factors
- obestiy
- older age
- mutliples
- race
- prior GDM
- family hx.
Materal Complcations
- can result in DM after pregnancy
- increased weight gain
- shoulder dyscrocia (bigger baby) & c seciond
Fetal Effects
- hyperinsulinemia
- increased fetal fat cells
- hypoglycemia at birth: been pumping so much insulin themselves to fight off moms high glucose load
- stillbirth risk
- macrosomia (larger baby)
Gestational DM
Symptoms
when to test: early v normal
what type of test is done
GDM
Symptoms
- asymptomatic usually
- polydipsia, polyuria
- glucosuria
When to test
those at higher risk: test early on: within 1st trimester
everyone else: test at 24-28 weeks
What Test
- nonfasting: 1 hour glucose tolerance test postive = > 135 {considered the screening test}
- fasting: 3hours gluocse tolerance test postiive = 2+ elevations of the 4 levels pulled at 0,1,2,&3 hours {considered the diagnostic test}
so if you fail the screen (test postive) you move on and do the fasting 3 hour test for diagnosis of GDM
Gestaional Dm
Treatment and management
Management
- dietician: lifestyl choices are first
- increase exercise
- glucose screenings: continuously (about 4 daily)
- if still abnormal after diet and exercise changes: medication
- metformin
- insulin
- GLPs
First Trimester Bleeding
what is it
DDX.
First trimester bleeding: any vaginal bleeding before 14 weeks
- can be normal, very common
- management depends on the signs, symptoms and the exam
DDX.
threatened abortion: bleeding without loss of tissue (can still be a viable preg.)
SAB: spontanous = pregnancy loss prior to 20 weeks
inevitable abortion = bleed or gross rupture of membranes accompanied by cervical dilation (can still have reg. preg.)
ectopic
subchorionic hematoma
cervical bleeding
implantation bleeding
SAB
Spontaneous Abortion
- 80% occur during first trimester (didnt even know they were preg. sometimes)
- half due to chromosomal abnormalites triggering the spotaneous loss
- second trimester: commonly due to materal disease, abnormal placenta or anatomic issues
- half are anembryonic (sac but no embryo)
assosiacted with
- periodontal disease
- chalymida infections
- smoking
Complete abortion
a documented pregnancy
complete loss of products of conception (POC)
cervic opened and now is closed
Management
- expectanat
- Rh factor
- bleed precautions
- follow up
Incomplete Abortion
Incomplete Abortion
- retained fragements of placental or product of conception
- they’re body isnt SAB-ing : so usually continue bleeding and intervention is indicated
Management
- expectant
- medical abortion: Mifepristone or misoprostol (for those with minila bleeding) : these will help uterus contract and push out remainin contents
- Surgical: Dilation and suction curettage with vacuum in OR or outpt. (for those with heavy bleeding, low hgb or unstable)
- ring forceps ca be used to remove early losses
Threatened Abortions
bleeding int eh first trimester without the loss of tissue
- cervix remains CLOSED
need to differentiate this from ectopic
Management
- pain management
- Rh factor
- serial bhcg
- TVUS
Inevitable Abortion
bleeding or gross rupture of the membranes accomplaited by cervical dilation
no tissue has left yet, but cervix is open
usually infection or contraction related
Management
- expectance
- bleeding precautions & Rh
- follow up
Missed Abortion
Cessation of fetal cardiac activity without passage of tissue (POC)
also known as retained pergnancy
Management
- expectant: most terminate spontaneously without intervention
- medical: misopristone
- Surgical: MVA/CVS (vacuum) or D&C
Ectopic Pregnancy
etiology
Risk Factors
outcomes of ectopic
Etiology
- defined as a pregnancy that is implanted anywhere outside the endometrium
- most commonly fallopian tubes
- risk of bleed and death if rupture
Risk Factors
- PID
- abnormal tubal anatomy
- prior ectopic
- tube ligation
- IUD
- ART therapy
Outcomes of Ectopic
- tubal rupture (bleeding)
- tubal abortion: pushed out the fibrae and leads to pain,bleeding and abortion
- pregnancy failure with complete reoslution
Ectopic
Symptoms
Diagnosis
Treatment
Symptoms
- many women = asymptomatic
- classic triad = pain, absense menses, vaginal bleeding
- severe sharp/tearing lower abd. pain and pelvic pain can occur with tubal rupture: CMT on exam
alwasy ensure and confirm pregnancy before you rule in/our ectopic
Diagnosis
- urine preg. test
- beta HCG: can chekc serum and recheck
- serum preogesterone (not specific)
- TVUS to ensure
Treatment: this is nonviable
- expectant: limited uesfullness through reasonable in stable or those with falling hcg levels: could be expectnat on own
- medical: methotrexate
- Surgical: laproscopic with salpingostomy/salpigectomy (preferred: remove tube)
Third Trimester Bleeding
due to what
Third Trimester Bleeding
Due to
- sex! irritation = easily friable cervix
- recent pelvic exam = easilyfriable
- trichamonas infection
- placenta previa (painless bleeding)
- placenta abruption (painful)
Work Up
- do NOT do a bimanual exam until placenta location is confirmed via US
Placenta Previa
waht is it
symptoms
risk factors
management
Placenta Previa
- placental location is close to or overlying the cervix
Symptoms
- painless vaginal bleeding in 3rd tri.
Risk Factors: those at increased risk
- prior placenta previa
- prior c section or uterine surg.
- AMA
- smoking
- cocaine use
Dx.
- TVUS
Managemnet
- IVfluids, BP measurements, bed rest & steroids
- heavy bleeding = need to deliver
- delivery via c section at 36-37 weeks prior to labor starting and rupture
Placental Abruption (Abruptio Placentae)
etiology
Risk Factors
Symptoms & Dx.
management
Etiology
- abnormal premature separation of the otehrwise normally implanted placenta
- can be partial, complete or margina
Risk Factors: whos more likely
- chronic HTN
- mutiples
- preeclampsia
- AMA
- mulipartity
- smoking and cocaine use
- chorioamnionitis
- any aburpt change in BP can increase risk of placental abruption
Symptoms
- painful bleeding
- painful contractions
- IUFD (rapid, within minutes if not devliered)
- feat HR abnormalities becuase flow is compromised
Dx.
- clincal + US
Managemnet
- Iv fluids
- monitor VS
- deliver if severe hemorrhage
- expectant management may be needed for some preterm pt.
- devliery often c seciont; occationally a vaginal is possibel
