OB 4 Flashcards
- What is the MC type of multiple gestation?
- What 5 things increase the likelihood of multiple gestation?
- Dizygotic Twins (Fraternal) (70%)
- Fertility tx
- Advanced maternal age
- Increasing parity
- Fam hx (either parent)
- Obese (BMI >30) + Tall (>5’4”)
Describe Dizygotic “Fraternal Twins”
- How many oocytes are ovulated & fertilized?
- How many chorions & amniotic sacs?
- 2 oocytes are fertilized
- 2 chorions / 2 amniotic sacs
Describe Monozygotic “Identical Twins”
- Ovulation & fertilization of how many oocytes?
- What determines “placentation?”
- How many chorions & amniotic sacs?
- A single oocyte is ovulated/fertilized
- Timing of egg division determines placentation
- 1 chorion, 1 amniotic sac = monoamniotic
- 1 chorion, 2 amniotic sacs = diamniotic
- What is the ONLY method for DEFINITIVE dx of multiple gestation?
- What are the 2 different “signs” you can see?
-
Ultrasound
- Gives accurate gestational age
- Determines chorionicity/amnionicity
- Best if done in 1st trimester >7 weeks
- “Lamda Sign” = Dichorionic twins
- “T Sign” = Monochorionic twins
What is this?
Multiple Gestation
- US of intertwin membrane showing “Lambda Sign” = Dichorionic twins
- Fraternal Twins (Dizygotic)
- Diamniotic = 2 amniotic sacs
What is this?
Multiple Gestation
- US of intertwin membrane showing “T Sign” = Monochorionic twins
- Identical Twins (Monozygotic)
- Diamniotic (2 amniotic sacs)
Multiple Gestation
- What are the 7 complications?
- Which 2 complications are MC?
- Preterm delivery** (60% before 37 weeks)
- Low BW** (57% are <5.5 lbs)
- Gestational diabetes
- Pregnancy induced HTN
- Pre-eclampsia
- Post-partum hemorrhage
- Higher C-section rate
“PL - HHCG”
What is the MOST SERIOUS complication of multiple gestation?** (probably on exam)
Describe it…
Twin-Twin Transfusion Syndrome
- Only occurs w/ monochorionic gestation (fetuses share 1 placenta & blood supply is unevenly distributed)
- One fetus is small w/ little amniotic fluid
Definition of what? Dx criteria?
- Cervical shortening which can lead to preterm spontaneous delivery
Cervical Incompetence
- US to see cervical length in 2nd trimester
- 20mm or less in women w/ NO prior pre-term delivery
- 25mm or less in women WITH a prior pre-term delivery
What is the tx for cervical incompetence?
- Placement of cervical cerclage
- Removed at 37 weeks gestation or onset of rupture of membranes
Which type of HTN?
- >140/90 PRIOR to 20 weeks gestation
Chronic HTN
Which type of HTN?
- New HTN (>140/90) presenting AFTER 20 weeks gestation w/ NO proteinuria
Pregnancy-Induced HTN
Which type of HTN?
- New onset HTN & Proteinuria AFTER 20 weeks
- BP reading criteria for dx?
Pre-Eclampsia
- BP readings elevated on at least 2 occasions, at least 6 hours apart
- Systolic 140+ or Diastolic 90+
Which type of HTN?
- HTN, Proteinuria, & seizures in woman w/ pre-eclampsia
Eclampsia
What are some RFs for Pre-Eclampsia?
- Nulliparity
- Pre-eclampsia in prev pregnancy
- Advanced maternal age
- Multiple gestation
- Diabetes
- Chronic HTN
- Chronic renal dz
- Family hx of pre-eclampsia
- Obesity
- HTN
- Epigastric pain
- HA
- Visual sxs: blurred vision, flashing lights, sparks
- Edema
- Hyper-reflexia
- Oliguria
Dx?
Pre-eclampsia
Describe criteria for Mild Pre-eclampsia
- Systolic BP 140+ OR diastolic 90+
- AND proteinuria of 0.3g+ in 24-h urine specimen
Describe criteria for severe pre-eclampsia
- Systolic 160+ or Diastolic 110+
- Oliguria <500cc in 24 hrs
- 3+ proteinuria (5+ grams on 24 h urine)
- End organ damage
- Fetal compromise
- SBP 160+ or DBP 110+
- Severe HA “worse ever had”
- Pulmonary Edema
- AMS
- Photopsia, scotomata, retinal vasospasm
Dx?
Severe features/Complications of Pre-eclampsia
What are 3 possible findings in Pre-Eclampsia or Eclampsia?
HELLP
- Hemolysis
- Elevated Liver enzymes
- Low Platelet count
- What labs/imaging should be done for Pre-Eclampsia?
- How often?
- CBC, Creatinine, Liver enzymes
- 24hr urine & Urine dipstick
- Fetal NST
- US (amniotic fluid volume / fetal weight)
Repeat weekly IF NO SIGNS of severe features
- Obese pregnant women 36 y/o w/ DM and HTN presents w/ blurred vision, flashing lights, HTN, epigastric pain, oliguria, proteinuria 5g, and “worse HA she’s ever had.”
- BP is 162/112
Dx & Tx?
Severe Pre-Eclampsia
- Tx is ALWAYS indicated if severe (to ↓ maternal stroke)
- Use Beta Blockers (IV Labetalol)
- AVOID: ACE, ARB, diuretics
T/F
- All antihypertensive meds cross the placenta
True!
Use Beta Blockers (=
DO NOT USE: ACE, ARB, diuretics )=
What are the 3 causes of mortality for the mother w/ pre-eclampsia?
- Acute MI
- Stroke
- Cardiac failure
What are the 6 causes of mortality in newborn when mom has pre-eclampsia?
- Poor oxygen transfer
- Fetal growth restriction
- Pre-term birth
- Placental abruption
- Stillbirth
- Neonatal death
G1P0 37 y/o pregnant female at 19 weeks gestation w/ hx of chronic renal dz presents w/ BP of 162/110.
Dx and Tx?
Chronic HTN / Severe Pre-eclampsia
Chronic bc: <20 weeks, nulliparity
Tx bc/ above 160/105!!
1st line: Labetalol
(Do not tx if below 160/105 w/ no evidence of end organ damage)
New HTN (162/112) in a 37 y/o female at 21 weeks gestation. She has no proteinuria.
Dx and Tx?
Pregnancy Induced HTN - Severe Pre-eclampsia
Preg-induced bc: >20 weeks w/ no proteinuria
Tx bc/ SBP 160+ or DBP 110+
1st line: Labetalol
37 y/o female w/ new onset HTN (140/90) w/ proteinuria of 0.3g in a 24 hr urine, at 24 weeks gestation. BP measured on 2 occasions 6 hours apart.
Dx and Tx?
Mild Pre-Eclampsia
- Antihypertensives ARE NOT indicated if BP is consistently <150/100.
- Tx: Expectant management / ambulatory BP measurements
40 y/o pregnant woman at 25 weeks gestation, w/ BP (162/112), oliguria <500cc, 5g proteinuria on 24 hr urine, signs of end organ damage.
Dx and tx? (3)
Severe Pre-eclampsia
- Admit for BP monitoring
- IV labetalol or hydralazine
- Prompt delivery for failed medical management
40 y/o pregnant woman at 25 weeks gestation, w/ BP (162/112), oliguria <500cc, 5g proteinuria on 24 hr urine, signs of end organ damage. Patient was admitted and tx w/ IV labetalol which failed.
What is dx and next steps (3) in therapy?
Severe Pre-Eclampsia
- Add Betamethasone bc/ under 34 weeks gestation (used to enhance fetal lung capacity)
- Add MgSO4 (magnesium sulfate) (6g, then 2g/hour)
- AND a PROMPT delivery
What 2 things does pregnancy cause which leads to Gestational Diabetes?
- Hyperinsulinemia
- Insulin resistance
6 RF of GDM (Gestational Diabetes Mellitus)
- Obesity
- +FH of DM
- >25 y/o
- Glucosuria
- Prev hx of GDM
- Hx of macrosomia (BW of 8lb 13oz = large baby)
What is the #1 “medical complication” in pregnancy?
GDM
How is GDM diagnosed?
- 50g 1 hour glucose challenge test administered at 24-28 w gestation. Positive/Failed test = >130
- 100g 3 hour OGTT, blood glucose measured at fasting, 1hr, 2hr, 3hr. (2/4 + values = GDM dx)
What are 2 major complications of GDM?
- Congenital anomalies (3-4 fold ↑)
- Pregnancy induced HTN (2 fold ↑)
- Others: macrosomia, placental abruption, prematurity, fetal demise, delayed fetal lung maturity, pre-eclampsia)
Patient has blood glucose of 140 at 1 hour and 3 hour post 100mg OGTT.
What is dx and tx?
Blood monitoring goals?
GDM
- 1st line: Insulin
- Monitor capillary blood glucose at fasting & 2 hours post meal (4x/day)
- Goal of fasting is <95-105
- Goal of 2hr postprandial is <120
Patient has blood glucose of 120 w/ 3 hour OGTT at fasting and 3 hour.
What is dx?
None. Patient does not have GDM bc/ glucose is not >130…
Besides insulin and monitoring blood gucose, what is the treatment for GDM? (5)
- ADA diet (diabetic diet)
- Moderate exercise program
- Nutrition cosult (usually has poor diet)
- Fetal monitoring w/ NST and BPP (US)
- Perform 2-hour glucose tolerance test at 6 weeks postpartum*** (this visit is to make sure GDM has resolved, incase pt entered pregnancy w/ undiagnosed DM2)
