OBGYN: Pregnancy complications Flashcards
first 30 days of gestation, levels of HCG?
-afte 30 days what happens
doubles every 2.2 days
after 30 days– doubles every 3.5 days
If HCG levels rise by less than ____%= problem with pregnancy
53%
HCG level and what to see on TVUS for discrimatory zone
HCG level= 2500
TVUS= shuld see a intrauterine pregnancy
what do you see on TVUS with the following HCG levels:
- 1500
- 2500
- 5200*
- 17,500*
1500=gestational sac
2500=intrauterine pregnancy
5200=fetal pole aka spine
17,500=fetal cardiac monitoring
define early pregnancy loss
- nonviable
- intrauterine pregnancy with either:
- empty gestational sac OR *gestational sac with embryo or fetus w.o heart beat
- **first 12 weeks aka first trimester
T/F:
In the first trimester, the terms miscarriage, spontaneous abortion and early pregnancy loss are used interchangeably
true
% of women experience early preg loss
MCC?
MC during what trimester
10-15%
MCC=chromosomal abnormalities
MC (80%) in firs tri
which type of spontaneous abortion has the potential for a viable fetus
threatened abortion
early preg loss < ____ weeks
spontaneous abortion < _____ weeks
early preg loss < 12 weeks
spontaneous abortion < 20 weeks
management for early pregnancy loss
- EXPECTANT MANAGEMENT
- limited to first trimester
- 80% body does it on its own - MEDICAL MANAGEMENT
-mifepristone + misoprostol
200 mg Mifepristone PO—- 24 hours later take 800 mcg of vaginal misoprostol - SURGICAL MANAGEMENT
-for women who present with hemorrhage, hemodynamic instability or s/s infection
-or women who prefer a more immediate completeion of abortion
**surgical D&C (dilation and curettage) <16 weeks
OR
***Dilation and Evacauation (D&E) >16 weeks
work up + labs for diagnosis of early preg los (5)
CBC, blood type Rh screen Beta hCG titers Transvaginal ultrasound Pelvic exam
vaginal bleeding prior to the 20th week
+/- cramps/pain
cervix closed
products of conception are intact
Threatened abortion
-50%ish can continue to go on and survive
+pain/cramping
+bleeding
Cervix partially dilated
Products of conception are intact
Inevitable abortion
***membranes have ruptured
**mom is RH-, needs RhoGAM
how long can we wait for expectant abortion to occur
**up to how many weeks gestation can we allow for expectant abortion
6-8 weeks
up to 12 weeks gestation
+pain/cramps
+bleeding
completely dilated cervix
POC: some expelled
incomplete abortion
**some POC remain inside uterus
**mom is RH-, needs RhoGAM
-pain/cramps
-bleeding
-cervix closed
POC intact
missed abortion
- *fetus died— but body did not expel contents yet
- this is foud out when mom goes for routine sonogram and no fetal HB detected with not rising HCG levels
+pain, prior
+bleeding, prior
Cervix is now closed
POC all expelled from uterus
complete abortion
rh- mom needs RHOGAM
+/- Pain
Bleeding–foul smelling with brown discharge
cervix–closed with +CMT
POC some or all remain
septic abortion
-mom needs rhogam if rh-
tx for septic abortion
surgical D/C or D/E
AND
Broad spec ABX
in NYS– up to how many weeks can you do an elective abortion
24 weeks
up to how many weeks can you do an elective medical abortion
up to 10 weeks gestation
MOA for mifepristone and misoprostol
MIFE: progeterone anagonist—leads to dilation and softening of cervix + placental separation
MISO
*prostaglandin analog— stim uterine contractions
hydatidiform mole=?
tumor is benign–80%
list the types of benign/Hydatidiform molar pregnancies
which is MC?
which has highest risk for malignant development?
- Complete mole–MC–>empty egg with no DNA, it is fertilized by either 1 or 2 sperm (23 chromosomes)
- no fetal tissue develops
- carries highest risk of malignant development - partial mole–>egg is fertilized by 2 or 1 sperm— but it duplicated its own chromosomes (69 chromosomes)
- yes or no produces fetal tissue— but if it does—fetus is abnormal and not viable
define molar pregnancy
abnormal placental development that forms a tumor of trophoblastic tissue
-tumor is either bengin (Hydatidiform–MC) or malignant (Gestational trophoblstic neoplasia)
CM for molar pregnancy
-PE findings
painless vag bleeding
often preeclampsia B4 20 weeks
hyperemesis gravidarum
PE
*uterine size + date mismatch
*HcG abnormally high—- >100,000
US=snowstorm or cluster of grapes pattern
tx for molar pregnancy
-howlong can the PT not get pregnant again for?
- surgical D/C
- hysterectomy– only for cases where it spread and if wmoan does notwant to get preg again
tell pt to not get pregnant for one year*
HCG monitoring after tx for molar pregnancy
- weekly monitoring: levels subside within 12-16 weeks
- folloiwng 3 normal HCG levels– PT should be followed monhtly x1 yr
- tell pt to not get pregnant for one year*
what happens if HCG levels start to rise after tx for molar pregnancy
start PT on chemo
key to successufl management of ectopic preg?
early diagnosis
first step to diagnosing ectopic preg?
obtain HCG levels
(-)= NOT ectopic
RF for ectopic pregnancy
-bigest one?
- ****previous ectopic pregnancy
- pregnancy after tubal ligation of with IUD
- hx PID
- Smoking
- use of assisted reproductive technology
ruptured ectopic preg MC results in?
tubal rupture– since MC are in FTs
AND
Intraperitoneal hemorrhage
LIFE THREATENING MEDICAL EMERGENCY
s/s of acutely ruptured ectopic preg
- severe abd pain— with abd distention, guarding and rebound tenderness
- dizziness
- referred shoulder pain–phrenic nerve irritation from blood in peritoneum
- hemodynamic instability with tachycardia, diaphoresis, hypotension, loss of consciousness
tx prior to surgery for ruptured ectopic preg
Insert a large bore (18 gauge) IV and start fluid resuscitation
Order a blood type and cross for imminent transfusion
classic triad for probable ectopic preg
prior missed menses \+ vaginal bleeding \+ lower abd pain
diagnosis for probable ectopi preg
HCG level
—- if above 2,500—->then get TVUS–>since it is above 2,500 we would see a intrauterine pregnancy– but if HCG is 2500 and there is nothing in uterus=ECTOPIC
tx for probable ectopic preg
- IM methotrexate
- PT returns on day 4 and 7 for HCG tests— should fall at lest 15% b/w these days– then PT is followed weekly until HCG not detected
* ***if HCG is plateuing or not falling fast enough—- second dose of IM Methotrexate
possible ectopic pregnancy
- usally occurs when
- CM
- diagnosis
MC clinical presentation
MC occurs during early prergnancy
CM= non specific and mild—- abd pain, abnormal vaginal bleeding–spotting to equivalent of a normal menses
Diagnosis=HCG test —- most likely below discriminatory zone—- so diagnosis cannot be confirmed yet—
how long should pregnancy be avoided after ectopic pregnancy
at least 3 MO
incompetent cervix— what is placed and when is it removed
cerclage (cervical stich) b/w 12-14 weeks and removed after 34 weeks
abrupto placentae
- define
- RF
- CM
- diagnosis
- mortality rate
premature partial or complete separation of the normally implanted placenta
RF– MC=maternal HTN
CM
- Third Tri: PAINFUL vaginal bleeding with cramps/ abd pain, back pain, hemodynamic instability VERY quickly.
- ***lots of bleeding
DIagnosis—- clinical
management=immediate delivery
Mortality rate is 35%
fetal and neonatal complications from maternal HTN disorders
- growth restriction
- prematurity
- death
SBP > than ______ or a DBP > _____ =HTN
SBP greater than or equal to 140
DBP greater than or equal to 90
define preeclampsia
new onset of HTN during pregnancy with proteinuria in the latter half of gestation
two essential criteria for diagnosis of preeclampsia
- develop of HTN (SBP >140 or DBP >90) in a woman whose BP were previously normal—– after the 20th week gestation
- development of new onset proteinuria after 20th week of pregnancy
* proteinuria= more than or equal to 0.3g protein in a timed 24 hour collection
what is preeclampsia preceded or associated with?
generalized edema— esp HANDS, FACE
varient of preeclampsia?
-what is it
HELLP SYNDROME–high morbidity
Hemolysis
Elevated LIver enzymes
Low Platelets
prodromal s/s of eclampsia
severe HA and sustained clonus aka seizures
define eclampsia
tonic-clonic seizures in woman with preeclampsia that cannot be atrributed to other causes
MC time for eclamptic seizures to occur
50% occur prior to labor
Preeclampsia/HELLP tx
- bed rest
- blood transfuision to tx anemia
- continuous monitoring of baby + fetus
- BP meds
- Mag Sulfate–prev seizures
- Corticosteroids for fetal lung developments (BETAMETHASONE)
definitive cure for preeclampsia?
delivery of fetus
tx for woman with preeclampsia without evidence of fetal compromise
-when should she deliver
bed rest
observation
*deliver b4 reaching 38 weeks
tx for preeclampsia that is severe
-when should she deliver
hospitalized for remainder of pregnancy
after 32-34 weeks—>delivery
5 serious s/s of preeclampsia
- SBP >140/90
- swelling face/hands
- visin changes
- migraine like HA
- sudden weight gain over 2 pounds/week
two most imp maternal issues to manage during delivery with preeclamptic mom?
- seizure prophylaxis——mag
- control of HTN—methyldopa
how long is mag given for seizure prophylaxis
during delivery and up to 24 hours after
what is the one antihypertensive medicaiton we can give during pregnancy
methyldopa
management of eclampsia
INITIAL=protect pt from injury–clear airway, give oxygen,
PHARMACOLOGIC= control BP, prophylaxis for seizures
*once mom is stabilized– we want to delivery— VAGINALLY IS IDEAL
define GD
glucose intolerance with onset or first recognition during pregnancy
what point during pregnancy is fetal hyperglycemia teratogenic
embryogenesis
when is every preg woman screened for GD and how screened
24-28 weeks via glucose challenge test
next step if glucose challenge screening test is +
diagnostic oral glucose tolerance test—- to confirm
gold standard tx for GD?
insulin
***PO hypoglycemic agents not recc in pregnancy
depressed mood 2-4 days PP, can last up to 10 days with NO thoughts of harming baby
PP blues
define puerperium
first 6 weeks PP
major depression, possibly including thoughts of harming baby, starting 2 weeks-2MO PP
PP depression
tx for PP depression
antidepressants and CBT
*resolves around 3-14 MO
