OBGYN_2_Placental abnormalities, Eclampsia, Abortion

Question 1

What is the strongest predisposing factor for placenta previa?

Answer 1

Uterine scarring, most commonly secondary to Cesarean sections or uterine surgeries.

Other risk factors for placenta previa:
- Advanced maternal age
- Multiparity
- Smoking
- Multiple gestations

Question 2

What is the first step in evaluating third-trimester painless vaginal bleeding?

Answer 2

Transabdominal ultrasound to evaluate placental position and rule out placenta previa.

Question 3

Why is vaginal examination contraindicated in suspected placenta previa?

Answer 3

Vaginal examinations can worsen bleeding and cause complications due to disruption of placental vessels.

Question 4

What defines chronic hypertension in pregnancy?

Answer 4

Systolic ≥140 mm Hg or diastolic ≥90 mm Hg diagnosed before conception or before 20 weeks of gestation.

Question 5

What defines gestational hypertension?

Answer 5

New-onset hypertension (systolic ≥140 mm Hg or diastolic ≥90 mm Hg) after 20 weeks of gestation without proteinuria or signs of end-organ damage.

Question 6

What defines preeclampsia?

Answer 6

New-onset hypertension after 20 weeks of gestation with proteinuria (≥300 mg/24 hours) or signs of end-organ damage.

Question 7

What is the general pathophysiology of preeclampsia?

Answer 7

Preeclampsia results from abnormal development of the uteroplacental circulation, causing systemic vasoconstriction, ischemia of organs, and endothelial dysfunction.

Question 8

What is the recommended prophylaxis for high-risk patients to prevent preeclampsia?

Answer 8

Low-dose aspirin starting at 12-28 weeks until delivery.

Question 9

When is the onset of preeclampsia?

Answer 9

Generally 20 weeks

Can occur earlier.

Question 10

What are the maternal complications of preeclampsia?

Answer 10

Seizures (eclampsia)
Disseminated intravascular coagulation (DIC)
Pulmonary edema
Intracerebral hemorrhage

Question 11

What are the obstetric complications of preeclampsia?

Answer 11

Uteroplacental insufficiency
Placental abruption
Fetal growth restriction
Oligohydramnios

Question 12

What defines eclampsia?

Answer 12

Preeclampsia with new-onset tonic-clonic seizures.

Question 13

What are the highest risk factors for preeclampsia?

Answer 13

History of preeclampsia
Advanced maternal age (>40 years old)
Young maternal age (<20 years old)
Multiple gestation
Black race
Vascular disease
Chronic hypertension, diabetes, kidney disease, obesity, or autoimmune disease

Question 14

What are the risk factors that make for a moderate risk for preeclampsia?

Answer 14

Nulliparity
Obesity
Advanced age

Question 15

What are the diagnostic criteria for preeclampsia?

Answer 15

Systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg

PLUS one of the following:

1) Proteinuria (≥300 mg/24 hours or ≥2+ on dipstick)

2) Evidence of end-organ damage
Elevated liver enzymes
Renal dysfunction
pulmonary edema
thrombocytopenia
CNS symptoms like headaches or visual changes

Question 16

What is the gold standard for diagnosing proteinuria in preeclampsia?

Answer 16

24-hour urine collection for total protein.

Question 17

Why is urinalysis not definitive for diagnosing preeclampsia?

Answer 17

Urinalysis has a high rate of false negatives due to the small urine sample size compared to daily total urine output.

Question 18

What is the management of preeclampsia without severe features at term?

Answer 18

Deliver at ≥37 weeks
IV magnesium sulfate for seizure prophylaxis at time of delivery
Antihypertensives for BP control

Question 19

What distinguishes preeclampsia with severe features?

Answer 19

Systolic BP ≥160 mmHg or diastolic BP ≥110 mmHg

New end-organ damage, such as:
CNS: Severe headache, scotomata
Renal: Creatinine >1.1 mg/dL or 2x baseline
GI: Elevated AST/ALT >2x normal
Platelets <100,000/mm³
Pulmonary edema

Question 20

What is the management of preeclampsia with severe features?

Answer 20

Delivery if ≥34 weeks
IV magnesium sulfate
Antihypertensives to control BP to <160/110

If <34 weeks: Administer glucocorticoids and consider delivery

Question 21

What evaluations are required for new-onset hypertension at ≥20 weeks gestation?

Answer 21

• Serial blood pressure measurements
• Evaluate for clinical signs of end-organ damage
• Laboratory evaluations (urinalysis, creatinine, transaminases, platelet count)
• Fetal well-being assessment (e.g., nonstress test).

Question 22

Why is outpatient bed rest not recommended for gestational hypertension or preeclampsia?

Answer 22

It increases the risk of venous thromboembolism without preventing progression to preeclampsia.

Question 23

What antihypertensives are used to treat severe hypertension in preeclampsia?

Answer 23

IV labetalol, IV hydralazine, or oral nifedipine.

Question 24

What is eclampsia?

Answer 24

Eclampsia is defined as generalized tonic-clonic seizures in a patient with underlying preeclampsia.

It can lead to complications such as abruption, DIC, or cardiac arrest.

Question 25

What is the management of eclampsia?

Answer 25

Initial steps: Ensure airway protection and maintain oxygenation. Place the patient in the lateral decubitus position to prevent aspiration and improve venous return.

Seizure control: Administer IV magnesium sulfate for seizure prophylaxis and control.
If seizures persist, give additional magnesium sulfate or second-line agents (e.g., lorazepam or phenytoin).

Blood pressure control: Use IV labetalol, IV hydralazine, or oral nifedipine to maintain BP <160/110 mmHg.

Delivery: Expedite delivery once the mother is stabilized. Delivery is the definitive treatment, regardless of gestational age.

Post-delivery monitoring: Continue magnesium sulfate for 24 hours postpartum for seizure prophylaxis. Monitor for signs of magnesium toxicity (e.g., loss of reflexes, respiratory depression, magnesium toxicity management involves use of IV calcium gluconate).

Question 26

When is magnesium sulfate indicated in hypertensive disorders of pregnancy?

Answer 26

For seizure prophylaxis in preeclampsia with severe features and for fetal neuroprotection before 32 weeks if imminent delivery is expected.

Question 27

What is the therapeutic range for magnesium sulfate in eclampsia prophylaxis?

Answer 27

4-8 mEq/L.

Question 28

At what magnesium levels do toxicities occur?

Answer 28

7-10 mEq/L: Loss of deep tendon reflexes

10-15 mEq/L: Respiratory paralysis, altered cardiac conduction

> 25 mEq/L: Cardiac arrest

Question 29

What is the immediate treatment for magnesium toxicity?

Answer 29

IV calcium gluconate to stabilize cardiac membranes and reverse symptoms.

Question 30

What is the most common method used for induced abortion before 13 weeks’ gestation?

Answer 30

Dilation and curettage (D&C)

Complications include endometritis (which may require outpatient antibiotic treatment) and retained products of conception (which may require repeat curettage).

Question 31

What are the complications associated with dilation and curettage (D&C)?

Answer 31

Endometritis and retained products of conception

Endometritis may require outpatient antibiotic treatment. Retained products of conception may necessitate repeat curettage.

Question 32

What are the medical abortion methods used within the first 63 days of amenorrhea?

Answer 32

Mifepristone and misoprostol

Mifepristone is a progesterone antagonist that blocks progesterone, leading to uterine contraction, while misoprostol is a prostaglandin E1 analog that further induces uterine contractions.

Question 33

What is the rare complication of medical abortion with mifepristone and misoprostol?

Answer 33

Incomplete abortion

Incomplete abortion may require dilation and curettage (D&C) to complete the abortion process.

Question 34

What serious infection is associated with medical abortion?

Answer 34

Clostridium sordellii sepsis

Clostridium sordellii sepsis is associated with rapid onset of shock, organ failure, and death, requiring immediate medical attention.