Obstetrical Complications of Pregnancy

Question 1

32 yo G2P1 at 28 weeks’ gestation presents to L&D.

cc: vaginal bleeding
vs: stable

+fetal movement

+contractions

u/s: placenta is located on anterior wall of uterus and completely covers internal cervical os

Which of the following would most inc. her risk for hysterectomy?

a. Desire for sterilization
b. Development of DIC
c. Placenta accreta
d. Prior vaginal delivery
e. Smoking

Answer 1

c. Placenta accreta

Prior section delivery and placenta previa, esp with anteriorly located placenta, inc. risk of PA, PI, PP… this typically requires tx with hysterectomy

Question 2

A pt at 17 weeks’ gestation is diagnosed with intrauterine fetal demise. She desires expectant mgmt. She returns to your office 5 weeks later, and her vs are stable. She has not had a miscarriage, although she has had some occasional spotting. Her cervix is closed on exam. This pt is at inc. risk for which of the following?

a. Septic abortion
b. Recurrent abortion
c. Consumptive coagulopathy
d. Future infertility
e. Ectopic pregnancies

Answer 2

c. Consumptive coagulopathy

In women with intrauterine fetal demise, labor usually occurs within 2 weeks. Women are typically offered expectant mgmt vs. active mgmt with surgical or medical evacuation of uterus. If the fetus is retained longer than 1 mo, 25% of women can develop coagulopathy, which is manifested by decreased fibrinogen, elevated fibrin degradation products, and decreased platelets.

Since her cervix is closed and no tissue has passed, septic abortion is unlikely. Intrauterine fetal demise has no impact on future fertility or association with ectopic pregnancies.

Question 3

A 24 G1P0 presents at 30 weeks’ gestation for a new OB visit. She provides you with the official report of a dating u/s performed at 12 weeks; however, shortly thereafter, she moved out of state and has not had prenatal care. She has no medical problems, and has a normal BMI. She reports some abdominal cramping and SOB. During her visit, you examine her cervix and it is closed. You measure her fundal height at 50 cm.

What is the next best step in mgmt?

Answer 3

Order U/S

This pt has an abnormally large fundal height. A fundal height should typically measure within 3 cm of the patient’s GA.

Question 4

What is polyhydramnios associated with?

Answer 4

Excessive quantity of amniotic fluid and occurs in 1-2% of pregnant women

Potential complications:

placental abruption, uterine dysfunction, PPH

Question 5

During routine u/s surveillance of a twin pregnancy, twin A weighs 1200 g and twin B weighs 750 g. Polyhydramnios is noted around twin A, while twin B has oligohydramnios. Which of the following statements correctly describes this syndrome?

a. The donor twin develops polyhydramnios more often than the recipient twin
b. Gross differences may be observed between donor and recipient placentas
c. The donor twin usually suffers from hemolytic anemia
d. The donor twin is more likely to develop widespread thromboses
e. The donor twin often develops polycythemia

Answer 5

b. Gross differences may be observed between donor and recipient placentas

In the twin-to-twin transfusion syndrome (TTTS), the donor twin is always anemic. This is not due to a hemolytic process, but rather to the direct transfer of blood to the recipient twin who becomes polycythemic. The recipient may suffer thromboses 2/2 hypertransfusion and subsequent hemoconcentration.

Although the donor placenta is usually pale and somewhat atrophied, that of the recipient is typically congested and enlarged.

Polyhydramnios can develop in either twin, but is more frequent in the recipient twin due to circulatory overload.

Question 6

What is cervical insufficiency (or incompetence)?

Answer 6

Inability of the cervix to retain a pregnancy in the absence of contractions (or labor) in the 2nd trimester

It is dx based on a hx of painless cervical dilation after the 1st trimester with delivery usually before 24 weeks, w/o contractions or other clear pathology (i.e., infection, ruptured membranes).

Cerclage is indicated in a pt with a hx of one or more second-trimester losses related to cervical incompetence.

Question 7

What type of abortion?

• Uterine bleeding at 12 weeks’ gestation + cervical dilation w/o passage of tissue
• Fetal death at 15 weeks’ gestation w/o expulsion of any fetal or maternal tissue for at least 8 weeks
• Uterine bleeding at 7 weeks’ gestation without any cervical dilation

Answer 7

• Uterine bleeding at 12 weeks’ gestation + cervical dilation w/o passage of tissue = Inevitable
• Fetal death at 15 weeks’ gestation w/o expulsion of any fetal or maternal tissue for at least 8 weeks = Missed
• Uterine bleeding at 7 weeks’ gestation without any cervical dilation = Threatened

Question 8

Hydatidiform mole

1. When is it usually diagnosed?
2. Most common symptom?
3. What will you see on u/s
4. Most common chromosomal makeup for partial mole and complete mole?
5. Treatment?
6. Imaging and f/u?

Answer 8

1. When is it usually diagnosed? first trimester
2. Most common symptom? vaginal bleeding
3. What will you see on u/s? diffuse, mixed echogenic pattern
4. Partial mole: 69, XXX or 69, XXY / Complete: 46, XX
5. Treatment? Hysterectomy
6. Imaging? CXR to assess for mets… f/u with routine hCG titers for 6 mo.

Question 9

How to manage an unruptured ectopic pregnancy in a patient who desires future fertility?

Answer 9

Laparoscopic salpingostomy

These pts have higher risk of persistent ectopic tissue and should be followed with serial hCGs. Not necessary to perform a laparotomy in a stable patient nor remove entire fallopian tube (salpingectomy)

MTX therapy would also be a reasonable option if the pt does not have C/I: immunodeficiency, renal or liver disease, or inability to comply with meds

Question 10

When you suspect chorioamnionitis, what is the next step in mgmt?

Answer 10

Administer abx: ampicillin

No role for tocolytics since delivery must happen

Question 11

A 34 yo G4P3003 at 31 weeks’ gestation with a known placenta previa presents to the hospital with vaginal bleeding. On assessment, she has normal vital signs, a reactive fetal heart tracing, and no uterine contractions. Heavy vaginal bleeding is noted.

Which of the following is a risk factor for placenta previa?

a. Multiparity
b. Nulliparity
c. Hx of D&C
d. Uterine fibroids
e. Age younger than 25

Answer 11

a. Multiparity

Question 12

What is the best test to determine whether there has been fetal-to-maternal hemorrhage?

a. Type and screen
b. Apt test
c. Kleihauer Betke (K-B) test
d. CBC
e. Hemoglobin electrophoresis

Answer 12

c. Kleihauer Betke (K-B) test

Fetal erythrocytes contain hemoglobin F, which is more resistant to acid elution than hemoglobin A. After exposure to acid, only fetal hemoglobin remains. Fetal red cells can then be identified by uptake of a special stain, and quantified on a peripheral smear.

An apt test is usually used to detect the presence or absence (qualitative test) of fetal blood in a vaginal discharge, often to r/o vasa previa in late pregnancy.

Question 13

What is chronic placenta hypoxia or uteroplacental insufficiency associated with?

Answer 13

Maternal conditions:

vascular disease, chronic renal insufficiency, pregestational diabetes, chronic HTN, smoking, pre-eclampsia

Question 14

A 38 yo G4P3 at 33 weeks’ gestation presents for a routine OB visit, and is noted to have a fundal height of 29 cm. An u/s is performed and demonstrates an EFW in the 5th percentile for the gestational age. The biparietal diameter and abdominal circumference are concordant in size.

Which of the following is associated with symmetric growth restriction?

a. Nutritional deficiencies
b. Chromosome abnormalities
c. HTN
d. Uteroplacental insufficiency
e. Gestational DM

Answer 14

b. Chromosome abnormalities

IUGR is diagnosed when the estimated weight of the fetus falls below the 10th percentile for a given age. By the use of u/s, IUGR can be classified as either symmetric or asymmetric.

In asymmetric IUGR, the abdominal circumference is low, but the biparietal diameter may be at or near normal. In cases of symmetric IUGR, all fetal structures (including both head and body size) are proportionately diminished in size. Fetal infections, xsome abnormalities, and congenital anomalies usually result in symmetric IUGR.

Asymmetric IUGR is seen in cases where fetal access to nutrients is compromised, such as with severe maternal nutritional deficiencies or HTN causing utero-placental insufficiency.

Question 15

A 26 yo G1 at 37 weeks presents to the hosp in active labor. She has no medical problems and has a normal prenatal course except for fetal growth restriction. She undergoes an uncomplicated vaginal delivery of a femal infant weighing 1950 g. The infant is at risk for which of the following complications?

a. Hyperglycemia
b. Fever
c. HTN
d. Anemia
e. Hypoxia

Answer 15

e. Hypoxia

Fetuses that are growth-restricted often have difficulty transitioning to the extrauterine environment. Therefore, it is critical that neonatologists be involved in such deliveries. Growth-restricted fetuses more commonly pass meconium, and are more likely to develop meconium aspiration syndrome. In addition, growth-restricted fetuses compensate for poor placental oxygen transfer by developing polycythemia, which can then result in multiorgan thrombosis at or after birth.

At the time of delivery, growth restricted infants may suffer from hypoxia caused by uteroplacental insufficiency.

Infants with IUGR have less subcutaneous fat deposition; therefore, hypothermia and hypoglycemia are a potential concern.