OB Patients Flashcards
Barker hypothesis
Poor placental development has been linked to preeclampsia, preterm birth, and intrauterine growth restriction (IUGR), all of which are associated with low birth weight (<2500 grams), and may play a role in fetal programming of chronic diseases later in life. This is known as the Barker hypothesis
Importance of preconception care
By the time most pregnant women have their first prenatal visit, it is too late to address the risk of low birth weight and obesity, and to reduce the risk of some birth defects.
Elements of prenatal care
the three basic components of prenatal care are (1) early and continuing risk assessment, (2) health promotion, and (3) medical and psychosocial interventions and follow-up
prenatal diagnostic testing with amniocentesis or chorionic villus sampling (CVS) be offered to all pregnant women regardless of their age
Confirmation of pregnancy and viability
It is important to differentiate a normal pregnancy from a nonviable or ectopic gestation. In the first 30 days of a normal gestation, the level of hCG doubles every 2.2 days. In patients whose pregnancies are destined to abort, the level of hCG rises more slowly, plateaus, or declines.
It is important to differentiate a normal pregnancy from a nonviable or ectopic gestation. In the first 30 days of a normal gestation, the level of hCG doubles every 2.2 days. In patients whose pregnancies are destined to abort, the level of hCG rises more slowly, plateaus, or declines
If a live, appropriately growing fetus is present at 8 weeks’ gestation, the fetal loss rate over the next 20 weeks (up to 28 weeks) is in the order of 3%.
Incidence of early pregnancy loss
spontaneous abortion occurs in 10-15% of clinically recognizable pregnancies. The term biochemical pregnancy refers to the presence of hCG in the blood of a woman 7 to 10 days after ovulation but in whom menstruation occurs when expected.
Threatened abortion
Threatened abortion - vaginal bleeding before 20th week. Pain, such as dull ache, may occur. 25-50% of threatened abortions result in loss.
Inevitable abortion
a clinical pregnancy is complicated by both vaginal bleeding and cramp-like lower abdominal pain. The cervix is frequently partially dilated, contributing to the inevitability of the process.
Incomplete abortion
There is passage of some products of conception
Complete Abortion
Passage of all the products of conception and the bleeding and uterine contractions abate.
Missed Abortion
Fetus has died but is retained in the uterus for more than 6 weeks. Coagulation problems can occur, surgical intervention is needed.
Recurrent abortion
Three successive spontaneous abortions usually occur before a patient is considered to be a recurrent aborter. Referral to genetic counseling is needed.
Etiologies of early pregnancy loss
Infection (Toxoplasma, Listeria, Mycoplasma)
Smoking and alcohol
Psychosocial stress
Medical disorders (DM, HTN, Lupus, Hypothyroid)
Maternal age (10% risk at age 40)
Uterine abnormalaities
Fetal genetic abnormality (most common cause)
Placental factors
Cervical Incompetence
The diagnosis of cervical incompetence is usually made when a mid-trimester pregnancy is lost with a clinical picture of sudden unexpected rupture of the membranes, followed by painless expulsion of the products of conception.
Management of each type of early pregnancy loss
Threatened - if a live fetus is on ultrasound, reassurance and genetic testing of fetus for abnormalities
Incomplete - Pain management and stabilization, then refer to surgery
Missed - Confirm with ultrasound
Always send pathology samples and Rh study
Calculate gestational age / EDC
determined by adding 9 months and 7 days to the first day of the last menstrual period
Folic Acid
vitamins plus folic acid daily before conception. Because neural tube closure is complete by 28 days post-conception, initiating folic acid after the first 28 days has no prophylactic value.
Antidepressant of choice in pregnancy
Fluoxetine
Normal lab values in pregnancy
Slight decrease in albumin
Gradual 10% decrease in calcium
Slight dip (2-4) in sodium
Gradual 10% decrease in glucose
Decrease in BUN 1st trimester
Amylase increases by 50-100%
Hgb/HCT decreases
WBC slight increase
Cortisol can double
Prolactin gradually increases by 100% or more
T4/T3 slight early increase
CV changes in pregnancy
Body water increases by 6-8 L
Blood volume increases by 40% (anemia of pregnancy results)
Systolic BP drops by week 24, then rises to normal
MAP slight decrease
Heart rate increases slightly
Stroke volume increases by 10-30%
Cardiac Output increases by 33-45%
Oxygen consumption is higher
Respiratory changes in pregnancy
Slow increase in tidal volume
Expiratory reserve decreases
Residual volume and capacity falls significantly
Vital capacity normal
Minute ventilation increases by 40%
Respiratory alkalosis is common
Dyspnea is common
Renal changes in pregnancy
Renal blood flow increases by 30%
GFR increases by 40-50%
Lower levels of creatinine and BUN
Enhanced renal elimination of bicarb due to the respiratory alkalosis
Homeostasis in pregnancy
insulin response to glucose stimulation is augmented. After early pregnancy, insulin resistance emerges, so glucose tolerance is impaired. The fall in serum glucose for a given dose of insulin is reduced compared with the response in earlier pregnancy.
Increased risk of ketoacidosis
Endocrine changes in pregnancy
the thyroid gland undergoes moderate enlargement during pregnancy as a result of placenta-derived hCG
Adrenocorticotropic hormone (ACTH) and plasma cortisol levels are both elevated from 3 months’ gestation to delivery
Weight changes in pregnancy
Should be 25-28 pounds.
Mechanisms of transfer from mother to fetus across placenta
The placenta receives 60% of the combined ventricular output
Process of fetal oxygenation and fetal circulation
The fetal circulation is a parallel circuit characterized by channels (ductus venosus, foramen ovale, and ductus arteriosus) and preferential streaming, which function to maximize the delivery of more highly oxygenated blood to the upper body and brain, less highly oxygenated blood to the lower body, and very low blood flow to the nonfunctional lungs.
Innate and adaptive immunity in pregnancy
Development of fetal immunity
Immature granulocytes can be found in the fetal spleen and liver by 8 weeks. NK cells are detected in the liver by 8 to 13 weeks and complements 2 and 4 by 8 weeks
Maternal IgG crosses the placenta as early as the late first trimester, but the efficiency of the transport is poor until 30 weeks. Significant passive immunity can be transferred to the fetus in this manner and for this reason premature infants are not as well protected by maternal antibodies. IgM, because of its larger molecular size, is unable to cross the placenta.
Immunological responses during pregnancy
he nonspecific (innate) mechanisms of the immunologic system (including phagocytosis and the inflammatory response) are not affected by pregnancy. The specific (adaptive) mechanisms of the immune response (humoral and cellular) are also not significantly affected
Pregnant women are at higher risk of severe infection and death from certain pathogens such as viruses (hepatitis, influenza, varicella, cytomegalovirus, polio), bacteria (listeria, streptococcus, gonorrhea, salmonella, leprosy), and parasites (malaria, coccidioidomycosis) compared with nonpregnant women. Vitamin D supplementation during pregnancy, therefore, may be important not only to reduce the risk of immunologic fetal rejection, but also to help prevent infection.
4 stages of parturition
Parturition means childbirth
Phase 0 - Quiescence - progesterone plays a role in maintaining
Phase 1 - Activation. Uterine stretch seems to trigger. ACTH expression and secretion of SP-A to start labor
Phase 2 - Stimulation. Cascade of events, increasing estrogen overrides progesterone, prostaglandins trigger cervical ripening.
Phase 3 - Involution. Maternal oxytocin and uterine contractions with eventual explusion
Elements of the fetoplacental unit and their role in endocrinology
The hormonal and nonhormonal changes that occur during pregnancy and parturition are regulated through a physiological mechanism referred to as the fetoplacental unit. A series of hormones and transmitters are produced by each of the components of this unit, and they have multiple effects within and between the fetus, the placenta and the mother.
Function of endocrine hormones during pregnancy
Oxytocin causes uterine contractions, but impairment of oxytocin production, as in diabetes insipidus, does not interfere with normal labor.
Relaxin is associated with the softening of the cervix, which is one of the anatomical signs of pregnancy. Its primary function appears to be in promoting implantation of the embryo by facilitating angiogenesis.
What patients should be referred for genetic counseling? When?
Ideally before they decide to conceive, should be offered to all couples regardless of age.
Especially if family history of defects, previous child with defect, multiple fetal losses, teratogenic exposure, know carrier of genetic disorder
Types of chromosomal disorders
Fragile X - 2nd most common cause of developmental delay
Trisomy (Down syndrome)
Klinefelter syndrome
Sickle Cell
Cystic Fibrosis
Tay-Sachs disease
Thalassemia
Neural Tube Defects (multifactorial)
Multiple screening approaches for fetal aneuploidy in each trimester
1st - B-Hcg and plasma protein-A, ultrasound to visualize fetal facial nasal bone absence
2nd - MSAFP testing, if elevated then ultrasound or amniocentesis
Combined / Integrated - most cost effective and sensitive
Concept of teratology and teratogens that affect fetus
teratogens may be assigned to three broad categories: (1) drugs and chemical agents, (2) infectious agents, and (3) radiation.
The most vulnerable stage is between day 17 to day 56 postconception or from approximately 4 weeks to 10 weeks by gestational age
Common disorders of pregnancy
Heartburn - elevate head of bed at night, avoid supine after eating, calcium carbonate
Constipation - Increase fiber and water, stool softeners
Hemorrhoids - rest and leg elevation, avoid constipation
Leg Cramps - Massage and stretching, Increase vitamin D
Backaches - exercise, proper shoes, rest, heat, tylenol
N/V and Hyperemesis
protein snacks at night, saltine crackers at the bedside, and room-temperature sodas are nonpharmacologic approaches that may provide some relief. Where medication is deemed necessary, antihistamines appear to be the drug of choice, though no single product has been satisfactorily tested for efficacy and safety. Vitamin B6 (pyridoxine) and accupressure (“sea sickness arm bands”) may be effective.
Recommended weight gain for pregnancy
25-28 pounds
Interval of follow up during pregnancy
About 4-week intervals until 28 weeks
2-week intervals from 28 to 36 weeks
Weekly thereafter until delivery
What assessments are performed at each pregnancy visit?
Screening for disorders
Taking measures to reduce fetal and maternal risks
Counseling
Differentiate the types of assessment of fetal well being
fetal movement counts (kick count), the non-stress test, biophysical profile, modified biophysical profile, contraction stress test, and Doppler ultrasound exam of the umbilical artery.
Define Rh alloimmunization
hesus (Rh) alloimmunization is an immunologic disorder that occurs in a pregnant, Rh-negative woman who is carrying an Rh-positive fetus. The immunologic system in the mother is stimulated by fetal cells that cross the placental barrier into the maternal circulation to produce antibodies to the Rh antigen, which then cross the placenta into the fetal circulation and opsonize fetal Rh-positive red cells, resulting in their destruction in the spleen.
Pathophysiology and incidence / risks, management, prevention of Rh alloimmunization
Most immunizations occur at the time of delivery, and antibodies appear either during the postpartum period or following exposure to the antigen in the next pregnancy.
Because RhD immunization occurs in response to exposure of an RhD-negative mother to the RhD antigen, the mainstay for prevention is the avoidance of maternal exposure to the antigen. Rh immune globulin diminishes the availability of the RhD antigen to the maternal immune system
HTN criteria in pregnancy
140 systolic or more, and/or diastolic of 90 or more
Preeclampsia / eclampsia
new-onset hypertension in the latter half of gestation, accompanied by new-onset proteinuria and/or other evidence of organ dysfunction.
Eclampsia is the presence of new-onset grand mal seizures in a woman with preeclampsia that cannot be attributed to other causes.
Chronic hypertension
The diagnosis of chronic hypertension requires at least one of the following: known hypertension before pregnancy or the development of hypertension before 20 weeks’ gestation.
Chronic hypertension with superimposed preeclampsia
women with chronic hypertension who develop new-onset proteinuria (≥0.3g in a 24-hour collection) after the 20th week of gestation. In pregnant women with preexisting hypertension and proteinuria, the diagnosis of superimposed preeclampsia should be considered if they experience sudden significant increases in blood pressure or proteinuria or the new onset of any of the other signs and symptoms of severe preeclampsia
Gestational hypertension
The diagnosis of gestational hypertension is made if hypertension without proteinuria or other signs of organ dysfunction first appears after 20 weeks’ gestation or within 48 to 72 hours of delivery and resolves by 12 weeks postpartum. It is extremely difficult to differentiate this condition from the early stages of preeclampsia. These women must be followed closely because a significant percentage go on to develop proteinuria and the full preeclamptic syndrome at a later stage in pregnancy. Others will have previously unrecognized chronic hypertension. The diagnosis of gestational hypertension can only be made in retrospect
Managing Gestational HTN
The ACOG Task Force recommends starting antihypertensive therapy if the systolic blood pressure is ≥160mmHg or the diastolic blood pressure is ≥105mmHg. There is little evidence that lowering blood pressure below the 140/90mmHg range benefits the pregnancy.
Methyldopa is considered to be the safest antihypertensive medication in pregnancy, but calcium channel blockers and labetalol are also considered to be safe.
ACE-I / ARBs must be avoided!
Incidence and definition of gestational diabetes
glucose intolerance with onset or first recognition during pregnancy. 80-90% of diabetes in pregnant women is gestational, and about 10% is pregestational
Screen at first prenatal visit, repeat at 24-28 weeks. OGCT >130 is positive, follow with a 3 hour OGTT after overnight fast - two or more abnormal values during the 3 hour tests is confirmation. If the OGCT is >200, the 3 hour test is not needed that is confirmatory.
Complications of gestational diabetes
lucose crosses the placenta easily by facilitated diffusion, causing fetal hyperglycemia that stimulates pancreatic β-cells, and results in fetal hyperinsulinism. Fetal hyperglycemia during the period of embryogenesis is teratogenic. Results in IUGR, prematurity
Goal is fasting level 95, postprandial <140.
Dose insulin to maintain 80-120 BGL
Thyroid disorders during pregnancy
Increased GFR can result in iodine excretion deficiency and goiter, consider supplementation
TSH may slightly rise during 1st and 2nd trimester
Maternal hyperthyroidism
An elevated serum free T4 level and a suppressed TSH level establish the diagnosis of hyperthyroidism. Other symptoms may be hard to differentiate from OB changes.
PTU should be used to treat overt hyperthyroidism in the first trimester, and methimazole should be used in the second and third trimesters. Importantly, antithyroid drugs should be reduced to the lowest dose that results in free T4 levels within the upper range of normal
Thyroid storm
Human chorionic gonadotropin (hCG) levels peak in the first trimester and can cause transient, subclinical hyperthyroidism. In the setting of a molar pregnancy, the extremely high hCG levels can result in thyrotoxicosis.
It is not uncommon to mistakenly attribute the signs and symptoms of severe hyperthyroidism to preeclampsia. Lack of proteinuria may be an indicator of thyroid storm. Treat with propranolol and PTU
Neonatal thyrotoxicosis
bout 5% of pregnant women with a history of Graves disease give birth to children with thyrotoxicosis due to transplacental transfer of TSH receptor antibodies. It is transient and lasts less than 2 to 3 months, but if clinically significant and untreated, it is associated with neonatal morbidity and mortality. Fetal thyrotoxicosis can be suspected if the baseline fetal heart rate consistently exceeds 160 beats per minute.
Hypothyroidism
The most important laboratory finding of hypothyroidism is an elevated TSH level. If the TSH level is elevated, the diagnosis of overt vs. subclinical hypothyroidism can be made based on whether free T4 levels are supressed.
levothyroxine should be started, and serum TSH levels should be measured monthly with appropriate adjustments in levothyroxine dosage.
untreated maternal hypothyroidism has been associated with an increased risk of spontaneous abortion, preeclampsia, abruption, low-birth-weight or stillborn infants, and lower cognitive function in offspring.
Congenital hypothyroidism
Thyroid hormone deficiency during the fetal and early neonatal periods leads to generalized cognitive impairment. This should be identified in routine neonatal screening.
Impact of cardiac disease during pregnancy
important cause of maternal mortality. The cardiovascular adaptations to pregnancy, delivery, and the early puerperium can trigger acute cardiovascular decompensation in women with high-risk lesions
Rhuematic heart disease
Mitral stenosis is common in Rheumatic heart disease. Asymptomatic patients may develop symptoms of cardiac decompensation or pulmonary edema as pregnancy progresses. Atrial fibrillation is more common in patients with severe mitral stenosis, and nearly all women who develop atrial fibrillation during pregnancy experience congestive heart failure
Congenital heart disease
patients with primary pulmonary hypertension or cyanotic heart disease with residual pulmonary hypertension are in danger of experiencing decompensation during pregnancy
In general, significant pulmonary hypertension with Eisenmenger syndrome is a contraindication to pregnancy due to the high maternal mortality that accompanies this condition.
Cardiac arrhythmias
Atrial premature beats are common, but usually benign and do not require therapy
A-Fib and A-Flutter are more concerning for underlying issue.
Ischemic heart disease
Most concerning issues are the medications used for treatment such as ACE-I/ARBs and fetal toxicity
Peripartum cardiomyopathy
Pregnant women particularly at risk of developing cardiomyopathy are those with a history of preeclampsia or hypertension and those who are poorly nourished. It appears to be a dilatational cardiomyopathy with a decreased left ventricular ejection fraction (LVEF < 45%).
Immune thrombocytopenia
In the absence of bleeding, therapy for ITP is usually not initiated unless platelet counts are less than 50,000/µL. Oral prednisone at a dose of 1mg/kg per day is given initially, and once platelet counts improve, it is tapered off over several weeks. Severe cases may need platelet transfusion.
The fetus / neonate must be monitored for thrombocytopenia
Lupus
SLE can flare up during any trimester or in the postpartum period. There is good evidence that the best pregnancy outcomes occur if the disease has been quiescent or under good control for at least 6 months before conception and there is no evidence of active lupus nephritis. A lupus flare, if it occurs, can be life-threatening, but it is often difficult to differentiate from superimposed preeclampsia, and both may coexist
Flares and active disease are generally managed with steroids and hydroxychloroquine, drugs that have less fetal toxicity than other immunosuppressive agents
Antiphospholipid syndrome
The antiphospholipid syndrome is defined as the presence of at least one of these antibodies in association with arterial or venous thrombosis and/or one or more obstetric complications. These complications include an unexplained fetal demise after 10 weeks’ gestation, a history of preterm delivery before 34 weeks’ gestation due to severe preeclampsia or placental insufficiency, or three or more unexplained miscarriages before 10 weeks’ gestation
LMW Heparin and aspirin are treatments.
GI disorders during pregnancy
about 50-80% of pregnant women complain of nausea and vomiting during the first trimester.
Hyperemesis gravidarum
Persistent N/V associated with ketosis and 5% weight loss. Symptomatic treatment and IV fluid, B6, antihistamines are used. Promethazine or Metoclopramide may be used, but stop them at once if signs of tardive dyskinesia appear
GERD
patients are instructed to eliminate dietary triggers; refrain from eating large and late meals; avoid the recumbent position, especially after meals; and use an extra pillow to elevate the head when sleeping. Antacids can be helpful, H2 or PPI may be considered.
PUD
Pregnancy conveys relative protection against the development of peptic ulceration and may ameliorate an already-present ulcer. Treatment may be needed (H2/PPI)
Mendelson syndrome
Acid Aspiration Syndrome
delayed gastric emptying and increased intrabdominal pressure increases the risk and can result in ARDS. Risk increases when sedatives or analgesia is used (why women in labor need to be NPO)
Chronic IBD
he best pregnancy outcomes occur in those patients who are in remission at the time of conception and whose disease activity can be controlled with medication that has minimal fetal toxicity. Major teratogens such as methotrexate must be discontinued before conception.
Sulfasalazine does not appear to be associated with fetal toxicity. Prednisone is metabolized by placental enzymes and relatively little crosses the placenta. However, first trimester use has been associated with cleft lip and palate, and high doses can inhibit fetal growth
Hepatic disorders of pregnancy
lthough the pathogenesis of intrahepatic cholestasis of pregnancy (ICP) is not known, some distinctive features are (1) cholestasis and pruritus in the second half of pregnancy without other major liver dysfunction, (2) a tendency for recurrence with each pregnancy, (3) an association with oral contraceptives and multiple gestations, (4) a benign course in that there are usually no maternal hepatic sequelae, and (5) an increased rate of meconium-stained amniotic fluid and fetal demise
Intrahepatic cholestasis of pregnancy
The main symptom of ICP is itching (most intense on the palms and soles), without abdominal pain or a rash, which may occur as early as 20 weeks’ gestation. Jaundice is rarely observed. Laboratory tests show elevated levels of serum bile acids.
Symptomatic treatment with cold baths, emollients, and antihistamines such as hydroxyzine may be of some help. The best results have been obtained with ursodeoxycholic acid. It significantly ameliorates the pruritus and reduces serum levels of bile acids, aminotransferases, and bilirubin
Acute fatty liver disease of pregnancy
Acute fatty liver of pregnancy is a rare but extremely serious complication that can occur in the third trimester of pregnancy. It is associated with diffuse microvesicular fatty infiltration of the liver, resulting in hepatic failure.
Hypertension and proteinuria are present in approximately 50% of patients, raising the issue of coexisting preeclampsia. Patients can develop coagulopathy with intraabdominal hemorrhage, hepatic coma, and renal failure.
VTE in pregnancy
Pregnancy is a hypercoaguable state and lack of mobility or reduced activity increases risk.
Houman sign (pain in calf with foot dorsiflexion) and dull ache when walking along with a size difference in calf may be indicative of DVT. Most DVT in pregnancy are in left leg.
Heparin to treat, stop it 24 hours before delivery.
Asthma in pregnancy
During pregnancy, condition improves in about one-third of patients and deteriorates in about one-third, and about one-third have no significant change. Most exacerbations occur before the third trimester
Labor and delivery are usually not triggers of acute asthma attacks.
Seizure disorder in pregnancy
In patients who have had no seizure activity for at least 2 years, AED therapy can be discontinued before conception. All AEDs are teratogens but valproic acid may be the most dangerous. If taking an AED, increase folic acid supplements before conception.
regnant patients with epilepsy have a twofold increase in maternal complications such as preeclampsia, abruption, hyperemesis, and premature labor. Fetal hypoxia is a potential consequence of maternal seizures, and there is a high incidence of intrauterine fetal demise
General guidelines for surgery in pregnancy
Elective surgery should be avoided in pregnancy. When surgery must be done, but not emergently (e.g., an ovarian neoplasm), the second trimester is the safest time. During this period, the risks of teratogenesis and miscarriage are much lower than in the first trimester, and the risk of preterm labor is lower than in the third trimester. Regional analgesia is preferred because it is associated with lower mortality and morbidity than general anesthesia
Anemia
Iron deficiency anemia (IDA) is very common in pregnancy
iron replacement therapy with 60 to 120 mg of elemental iron daily is indicated if hemoglobin is less than 11 g/dL, along with an increase in iron-rich food intake.
UTI in pregnancy
Do a urine culture at 12-16 weeks to look for asymptomatic UTI
Nitrofurantoin and sulfonamides are the first line agents for treatment and prevention of UTI in the second and third trimesters while Amoxicillin/Augmentin is preferred in first.
Do a test-of-cure after treatment and repeat culture every 6-12 weeks
Group B Strep
GBS may not be significant to the woman but there is a chance of passing it to the baby during birth. Universal screening for GBS should occur at 35-37 weeks with treatment during labor if positive.
Zika exposure
Mother-fetus spread
Avoid travel to outbreak / prone areas
Test
Ultrasounds if exposed to find fetal anatomy problems
Vaginitis
the most appropriate first-line treatment for vaginal yeast infections in pregnancy is a 7-day topical vaginal azole cream
BV/Trich has higher risks of complications and should be treated with metrondiazole
Bleeding in pregnancy
Twenty percent to 25% of women will experience bleeding during the first trimester
Rule out threatened abortion, ectopic, infection, molar, hormonal imbalance, substance use, trauma, implant bleeding
Monitor hCG
Preterm labor
reterm labor, defined as spontaneous rupture of membranes and/or uterine contractions that cause cervical change and dilation before 37 weeks of gestation, is a serious pregnancy complication that often (45% of the time) leads to premature delivery. Approximately 70% of neonatal deaths are related to prematurity
Tocolytics can buy 48 hours for corticosteroids for the fetal lung and antibiotics for GBS
Post Partum Bleeding Stages
0 - all women in labor. Oxytocin, fundal massage, assess
1 - >500 (vaginal) ot >1000 (C-section) - Type and crossmatch 2 units, increase oxytocin, give methergine and fundal massage
2 - Total loss 1000-1500 - Rapid Response Team, give carboprost, transfuse 2 units, place intrauterine balloon or embolization procedure
3 - Total loss >1500 - Coag studies, more blood transfuion, surgical ligation or hysterectomy
Accreta
Placenta accreta implies an abnormal attachment of the placenta through the uterine myometrium as a result of defective decidual formation
Ectopic pregnancy
Most in the fallopian tube
hCG levels that are slow to rise along with Ultrasound is diagnostic (no presence in uterus). Common to have significant abdominal pain.
classic triad of symptoms is (1) missed menses, (2) vaginal bleeding (usually spotting), and (3) lower abdominal pain.
Surgical emergency but some may be treated with methotrexate
Placenta previa
Painless bleeding later in pregnancy, placenta covers part (or all) the cervical opening
Abruptio placenta
Placenta detaches, abdominal pain with bleeding (but may be hidden), uterine hyperactivity
Medications to stop during pregnancy
ACE-I/ARBs, Warfarin, known teratogens, most antideprassants except fluoxetine (prozac)
Mastitis
Usually manifests with fever, generalized malaise, influenza-like symptoms, local erythema, and breast warmth and tenderness
Treatment of mastitis includes the application of warm packs to the breast and frequent breastfeeding or pumping.
Antibiotics such as amoxicillin-clavulanate, dicloxacillin, or a broad-spectrum cephalosporin to cover a probable staphylococcal or streptococcal infection.
Jaundice
Most newborns become mildly jaundiced during the third to fifth days of life. Breastfed babies commonly appear jaundiced into the third or fourth week of life and less commonly for 8 to 12 weeks
Poor latching
If the baby is having difficulty latching on, positioning strategies can improve comfort for the mother and milk transfer for the baby. Mothers should be taught how to bring the baby to the breast to prevent the infant from sucking on the nipple tip. Shallow latch causes pain and poor let-down
Engorgement
Breast engorgement may occur on the third or fourth postpartum day in first-time mothers and sooner in women who have had previous births. It can usually be minimized by feeding the infant 8 to 12 times each day in the days leading up to the milk coming in.
Deep asymmetric latch-on and sustained suckling will resolve most engorgement. If engorgement persists, ice packs may be applied to the breasts
Delayed let down
Stress, pain, and alcohol inhibit let-down. The let-down response is enhanced through thoughts about the infant, breast massage, and relaxation
Low milk production
Low milk production usually results from inadequate suckling and breast emptying, low prolactin levels, inadequate mammary glandular tissue, delayed or inadequate lactogenesis, or undetermined causes. Uniformly low prolactin levels suggest an endocrine basis for low milk supply. Inadequate mammary glandular tissue can result in low milk production despite normal prolactin levels
Try double pumping and consult with lactation specialist
Low infant weight gain
to assess an infant with low weight gain, providers must observe a breastfeeding session. Strategies to increase success include breast pumping to increase the milk supply and increased feeding frequency
Supplemental nutrition / formula may be needed
Cracked nipples
Cracked nipples are usually caused by attachment or latch-on problems. The nipple becomes abraded when the infant latches only to the tip of the nipple, instead of to the underside of the breast followed by the nipple. Mothers should be taught the asymmetric latch-on technique. Treatment of cracked nipples includes correcting the attachment and supporting milk extraction.
Use of medical lanolin, nipple shields, avoid over-drying of nipples, warm/moist compresses after feeding.
Postpartum depression
Normal depressed mood for first 10-14 days after delivery due to stress, lack of sleep, feeding schedule.
PPD persists beyond that and requires intervention
Inevitable abortion
a clinical pregnancy is complicated by both vaginal bleeding and cramp-like lower abdominal pain. The cervix is frequently partially dilated, contributing to the inevitability of the process.
