OB Misc, Lupus, placenta accreta, turners Flashcards
What is gastroschisis?
Paraumbilical abdominal wall defect associated with evisceration of bowel and other abdominal organs
How can gastroschisis affect pregnancy?
Intestinal abnormalities
IUGR
Preterm birth
Fetal demise
What causes gastroschisis?
Defective formation or disruption of the body wall in the embryonic period
Risk factors for gastroschisis?
Young age
smoking
What marker would be elevated in gastroschisis?
AFP level
How does gastroschisis appear on ultrasound?
Small 2-5cm paraumbilical abdominal wall defect to the right of the midline with visceral herniation
Where is the umbilical cord insertion site in gastroschisis?
Adjacent to but separate from the defect and is normal
What abdominal organs herniate through the defect with gastroschisis?
Mostly the intestines but the liver and stomach can also
In gastroschisis is the herniated viscera covered or unconvered?
Uncovered
What other abnormalities can gastroschisis be associated with?
Malrotation
Atresia
Stenosis
Perforation
Bladder herniation
What amniotic fluid abnormality is gastroschisis associated with?
Oligihydramnios or polyhydramniosis if obstruction is present
How do you manage a pregnancy with diagnosed gastroschisis?
- Offer genetic screening if it has not been done
- Assess for other structural anomalies
- Monitor fetal growth every 3-4 weeks after FAS
- Assess fetal bowel and stomach for dilation and thickening with growths
- Antepartum fetal surveillance at 32 weeks (if significant bowel dilation start testing at diagnosis)
- Delivery at 38 weeks
What is considered significant bowel dilation in gastroschisis?
> 25mm
What is lupus?
Inflammatory condition caused by your body attacking itself
Can affect brain, heart, lungs, kidneys, joints and skin
How does lupus affect pregnancy?
Increase risk of spontaneous abortion
Increase risk of Preeclampsia
Increase risk of IUGR
Increase risk of preterm birth
What are the maternal complications of lupus in pregnancy?
Preeclampsia
Eclampsia
Need for c-section
Infection
Thrombocytopenia
VTE
PPH
Death
What are the fetal complications of lupus in pregnancy?
Fetal demise
IUGR
Preterm birth
Neontal lupus
What affects the prognosis of the mother and fetus with lupus in pregnancy?
There is a better prognosis when lupus is quiescent for at least 6 months prior to pregnancy
What is the recommendation for lupus patients prior to conceiving?
Having lupus under controlling with medications that can be used in pregnancy for at least 6 months prior to conception
What is the preconception management for lupus?
- Assess lupus for active disease
- Assess presence of antibodies
- Assess hyper coagulability or concurrent medical conditions
- Assess medication compatible with pregnancy
- Recommend disease quiescence for 6 months prior to pregnancy and discuss risk of adverse pregnancy outcomes
What antibodies in lupus patients should be assessed prior to pregnancy because of risk of neonatal lupus?
Anti Ro/La antibodies
What are the laboratory test that should be assessed in lupus patient prior to conception?
CBC
CMP
Protein:creatine ratio
Anti-Ro/SSA and Anti-La/SSA
anti double stranded deoxyribonucleic antibodies
Antiphospholipid antibodies
Complement C3 and C4
What lupus medications are safe during pregnancy?
Hydroxychloriquine (most common)
Azithropine
Cyclosporine
Tacrolimus
Prednisone
NSAIDs
What lupus medications are contraindicated during pregnancy?
Cyclophosphamide
Methotrexate
Mycophenolate mofetil
Leflunomide
How can you assess for active disease in lupus patients?
Increase in disease activity scales
Increase in DsDNA levels
Decrease in complement levels
Does lupus typically get worse or better in pregnancy?
More flares are seen in pregnancy
What things can increase probability of lupus flares during pregnancy?
- Active disease during 6 months prior to pregnancy
- History of lupus nephritis
- Discontinuation of medication
- Primigravid
- Low complement level
What are risk factors for adverse outcomes in pregnancy for patients with lupus?
Active disease
Prior lupus nephritis
Presence of antiphospholipid Abs
Use of antihypertensives
Presence of thrombocytopenia
What is neonatal lupus?
congenital heart block
How do you manage a pregnancy with lupus?
First visit:
Comprehensive history
Physical exam with vitals
Lab workup with CBC, CMP, PCR, APLs, complement levels, DsDNA activity, anti Ro, Anti La
Follow care with rheumatologist and MFM
Q trimester testing
CBC, creatine, urinalysis with sediment rate, protein creatine ratio
FAS at 18-22 weeks
Growth ultrasounds q3-4 weeks
Antepartum fetal testing at 32 weeks
How does lupus nephritis present in pregnancy?
Hypertension
Proteinuria
Active urine sediment
thrombocytopenia
declining renal function
How can you differentiate lupus nephritis from preeclampsia?
Proteinuria with active urine sediment
Low complement levels or increasing titers of DsDNA antibodies
Thrombocytopenia with antiphospholipid antibodies
What are some ultrasound findings of turners syndrome?
Cystic hygroma
Thickened nuchal fold
Hydrops
Cardiac abnormalities
Short femur
What is turners syndrome?
Sex chromosome disorder caused by loss of all or part of X chromosome
What is clinical features of turners syndrome?
Short statue
Ovarian insufficiency
Web necked
Shielded chest widely space nipples
Streaked gonads
What is placenta previa?
Placenta covering the internal os or <2cm from the internal os
How is placenta previa managed?
- Repeat ultrasounds to assess location and possible resolution of previa at 32 and 36 weeks
- Assessment to rule out placenta accreta spectrum disorders
- Recommend pelvic rest after 20wks including activity that may cause orgasm
- Recommend no digital cervical exams
- Recommend no moderate or intense exercise, heavy lifting or standing for long periods
- Recommend delivery between 36w0d-37w6d
What can placenta previa increase your risk for?
Placenta accreta spectrum
Vasa previa
When is emergency c-section indicated for placenta previa?
Severe or persistent bleeding
significant bleeding at 34 weeks or greater
Category 3 FHR tracing
Active labor
When do you hospitalize a patient with bleeding with placenta previa?
3 or more acute episode of bleeding
What is placenta acretta?
Placenta villi attach to the myometrium
What is placenta increta?
Placenta villi penetrate into the myometrium
What is placenta percreta?
Placenta villi penetrate through the myometrium to the uterine serosa or adjacent organs
Risk factors for placenta acretta spectrum disorder?
Placenta previa with previous c-section
Prior uterine surgery
Manual removal of placenta
Age>35 y/o
Multiparty
postpartum edometritis
Infertility
History of pelvic radiation
Risk of placenta acretta spectrum with first c-section?
3%
Risk of placenta acretta spectrum with 2nd c-section?
11%
Risk of placenta acretta spectrum with 3rd c-section?
40%
Risk of placenta acretta spectrum with 4th c-section?
60%
What are ultrasound findings of placenta acretta spectrum disorder?
Multiple placenta lacunae
Disruption of the bladder line
Myometrial thinning
Abnormal vascularity
What is the cause of placenta acretta spectrum disorder?
Abnormal decidulization in an area of scarring from prior uterine surgery
What is the timing of delivery for placenta acretta spectrum disorder?
34w0d-35w6d
