PART 2222 Flashcards
time frame of childbirth considered premature
20
37 weeks
1 cause of neonatal morbidity and mortality
prematurity
cervical changes without uterine contractions are typically d/t
cervical insufficiency
cervical insufficiency definition
painless shortening or dilation of the cervix that occurs in the second or early 3rd trimester and results in preterm birth
cervical insufficiency is related to _____% of second trimester miscarriages
25%
cervical insufficiency is associated with what possible pathologies?
uterine anomalies DES exposure Cervical procedures (ie: conization)
what is cervical cerclage?
treatment for cervical insufficiency in which stitches are used to close the cervix during pregnancy in order to help prevent pregnancy loss or premature birth
When is cerclage done, removed, and who can’t get it?
done around weeks 14
16
removed around weeks 36
38
ineligible if the mother has cervicitis, dilation > 4 cm, or if the membranes have already ruptured
what are braxton hicks contractions?
contractions that occur without causing cervical changes painless contractions that are felt as tightening or pressure and last 10
20 minutes aka false labor usually get better with walking/activity
how many contractions are needed in order for cervical change to occur
> 4/hour
what are contractions felt as?
abdominal tightening, low back pain, or pelvic pressure
in order to be termed “preterm labor” what must be present?
contractions that are causing cervical effacement or dilation
what is the cause of preterm labor?
no idea
what are some risk factors for preterm labor?
Smoking
Cocaine
Uterine malformation
Cervical incompetence
Infection (STI, Group B Strep, UTI/Pyelo)
Low pre
pregnancy weight of mother
what are some complications of preterm labor for the mother and fetus?
Hypertension
Diabetes
Infection
PROM
Abruptio placentae
delivery of a baby
at a hospital with a NICU
cervical changes associated with preterm labor
Dilation of > 2 cm at presentation
Dilation of > 1 cm at serial exams
Effacement > 80% (2 cm)
what are some late symptoms of preterm labor?
Bloody mucus vaginal discharge (“bloody show”)
Contractions, pressure, cramps, and low back pain
what cervical length (found on US) increases the risk of preterm labor?
cervical length of 2 cm at 24 weeks
what is significant about Fetal Fibronectin found in cervical/vaginal secretions?
if present, the risk raises for delivery of the fetus within 2 weeks
If cervical length is less than 4 cm and FF is abnormal
50% chance of delivery before 34 weeks
If cervical length is 4 cm and Fetal Fibronectin is abnormal
11% chance of delivery before 34 weeks
3 reasons to obtain lung maturity via amniocentesis for diagnosis of preterm labor
If the estimated gestation date is uncertain, if you suspect chorioamnionitis, or if the fetus is > 34 weeks gestation
how is preterm labor managed?
Decisions are made based on estimated gestation date, estimated weight of the fetus, and existence of contraindications to suppressing preterm labor
antibiotics given for Group B Strep
Penicillin or Ampicillin (Cefazolin, clindamycin, erythromycin or vanco if PCN
Allergy)
when do you stop antibiotics for Group B Strep?
if the re
test in 5 weeks is negative
what do you give to help the fetus develop it’s lungs?
steroids
what are tocolytics?
drugs that stop contractions
what is the goal of using tocolytics in regards to preterm labor?
short term goal is to continue the pregnancy for 48 hours after steroid use to ensure lung maturity and viability
long term goal is to continue the pregnancy past 34
36 weeks when fetal morbidity and mortality decrease
who is considered for the use of tocolytics in preterm labor?
mother’s with cervical dilation
what is considered “successful” tocolytic use?
when contractions fall to less that 4 to 6 per hr
tocolytic: magnesium sulfate
side effects
signs of toxicity
treatment of toxicity
begin use when
Side effects: nausea, fatigue, muscle weakness
Signs of Magnesium toxicity: decreased reflexes, respiratory depression, cardiac collapse
Treat toxicity with calcium gluconate
Begin when preterm birth is expected within 2
24 hours, gestational age confirmed between 24
32 weeks, and when any contraindications to Magnesium have been ruled out
tocolytic: CCBs (Nifedipine)
how does it work?
side effects
inhibit calcium uptake into uterine muscle cells (via voltage
dependent channels) which reduces uterine contractility and relaxes uterine muscles
SEs: hypotension, tachycardia
tocolytic: beta
mimetic adrenergic agents
action
side effects
used only to
drug used and how
Direct action on _2 receptors to relax uterus
Severe side effects
dose related cardiovascular effects (pulmonary edema, adult RDS, elevated SBP, reduced DBP, tachycardia)
Used only to stabilize and triage until other tx determined
Terbutaline: Not FDA approved; Use subcutaneous boluses only in an inpatient setting for max of 48
72 hrs
tocolytic: prostaglandin synthase inhibitors
drug name
MOA
fetal side effects
requires you to check for
limited use for who
Indomethacin
Inhibits prostaglandin synthesis (prostaglandin is a mediator of uterine muscle contractility)
Serious fetal effects: Oligohydramnios, Premature closure of ductus arteriosus (PDA), Intracranial hemorrhage
Requires US every 48
72 hrs to check for oligohydramnios
Limited to
when is a cesarian used in preterm labor?
For borderline cases (23
24 wks and 500
600g wt)
regard the parents’ wishes
how is preterm labor prevented?
-Avoid risk factors
-Administer Progestin if mother has a prior history of preterm labor
• Weekly IM injections of 17-alpha hydroxyprogesterone caproate from 16-36 weeks decreases risk of recurrence by 30%
• Vaginal suppositories may reduce the risk of short cervix
what is a cesarian?
Delivery of fetus, placenta, and membranes through an abdominal and uterine incision
Indicated in cases where vaginal delivery is either not feasible or would impose undue risks to the mother or baby
risk of cesarian
Thromboembolus
Excessive bleeding
Infection
Fetal tachypnea
Fetal hemorrhage and hypoxia w/placenta transected
why are cesarian rates increasing?
Lower rates of vaginal births after C
section (VBAC) (1/3 of caesarians)
Lower operative vaginal delivery rates (vacuum, forceps, or suction) in regards to dystocia or failure to progress and fetal distress
Fewer vaginal breech deliveries
basically we’re getting wimpy, and when complications arise we find it easier just to cut the woman open
what are the 3 P’s that must be adequate in order for a vaginal delivery to occur?
power passenger pelvis
what is labor dystocia?
labor progresses and then either stops completely (arrests) or becomes prolonged (protracted)
the fetal head is too large to pass through the pelvis when (3 disproportions)
Inlet disproportion
in the primigravida patient begins labor with the fetal head unengaged
Midpelvic disproportion
if the anteroposterior diameter is short, the ischial spines are prominent, or the sacrospinous ligament is short
Outlet disproportion usually requires a trial of forceps or vacuum before a safe vaginal delivery is determined to be impossible
other reasons for cesarian
fetal heart rate abnormalities (decelerations are bad)
transverse lie or breech presentation
Placenta previa
Preeclampsia/eclampsia
Placental abruption
Multiple gestations
Fetal abnormalities
Cervical cancer
Active genital herpes infection
success of a vaginal birth after cesarian (VBAC) depends on
dystocia
malpresentation
uterine rupture
how many they’ve had before and why they needed them
Dystocia
lower rate of successful VBAC
Malpresentation
higher rate of VBAC success
Uterine rupture
rate (weakened wall) after low transverse incision is low, but can lead to death of fetus and morbidity/mortality of the mother
best candidates for VBAC
1 prior low
transverse caesarean section
Those who present in labor
Those with nonrecurring conditions (eg: no breech, abnormal fetal heart rate patterns, or placenta previa in prior pregnancy)
Those with a prior vaginal delivery
who cannot get a VBAC
Prior classical (vertical) uterine incision
Prior myomectomy
cesarian incision
A low transverse (Pfannenstiel) uterine incision is usually made in an effort to decrease blood loss, ease repair, and decrease the risk of rupture vs vertical incision (also better for cosmetic purposes)
complications of cesarian
postpartum hemorrhage
endometritis (prophylactic ABX often used to avoid this)
wound infection
incision healing
what is an episiotomy
laceration used to help ease of a vaginal delivery
what does an episiotomy increase the risk of?
postpartum incontinence
why are episiotomies recommended?
If extensive vaginal tearing appears likely
Infant is in an abnormal position
Infant is large (fetal macrosomia)
Infant needs to be delivered quickly
what are the 2 episiotomy incision options and their pros/cons?
Midline or median: done vertically; is the easiest to repair but has a higher risk of extending into the anal area
Mediolateral: done at an angle; offers the best protection from an extended tear affecting the anal area, but is often more painful and may be more difficult to repair
what can be done to decrease the need for an episiotomy?
Perineal massage, either antepartum or during the second stage of labor, can decrease muscular resistance and reduce the likelihood of laceration
Use of warm compresses on the perineum during pushing can reduce third
degree and fourth
degree lacerations
first degree laceration
Injury to perineal skin only
second degree laceration
Injury to perineum involving muscles but not the anal sphincter
third degree laceration
Injury to perineum involving the anal sphincter complex
IIIa degree laceration
Less than 50% of external sphincter torn
IIIb degree laceration
More than 50% of external sphincter torn
IIIc degree laceration
Both external sphincter and internal anal sphincter torn
fourth degree laceration
Injury to the perineum involving the anal sphincter complex (external and internal sphincters) and anal epithelium
natural labor pain management (3)
Lamaze
Hypnosis
Relaxation/meditation
things to think about when administering pharmacological pain relief to the mother during labor…
All analgesics cross the placenta
Systemic medications produce higher maternal and fetal blood levels than regionally administered drugs
Many drugs have central nervous system depressant effects
While they may have the desired effect on the mother, they also may exert a mild to severe depressant effect on the fetus or newborn
what class of drugs are commonly used in the first stage of labor because they produce both a state of analgesia and mood elevation?
narcotics
narcotic: Codeine
60mg IM
narcotic: Meperidine
50
100mg IM (or 25
50mg IV titration)
narcotic: Fentanyl
PO or Epidural
narcotic: Sufentanil
Derivative of Fentanyl with increased potency and lipophilicity
Widely used for intrathecal and epidural analgesia during labor
narcotic: Remifentanil
Newer ultra
short
acting synthetic opioid with rapid onset (~1 min)
Rapidly metabolized by nonspecific blood and tissue (not renally or hepatically
so it does no accumulate in the fetus)
narcotic: Butorphanol (Stadol)
1
2 mg IV or IM every 3
4 hours
Onset of analgesia is within a few minutes
Less respiratory depression compared with an equivalent dose of Morphine
narcotic: Nalbuphine (Nubain)
Mixed agonist.antagonist opioid similar to Butorphanol but potency is equivalent to that of Morphine (mg:mg)
narcotic: Propofol
Ideal agent for induction of general anesthesia at a dose of 2 mg/kg
It also can be used in 10
to 20
mg increments during surgery under regional block to treat nausea and vomiting.
narcotic: Etomidate
Rapid onset of anesthesia with minimal cardiorespiratory effects makes it ideal for those who are hemodynamically unstable
Induction dose of 0.2
0.3 mg/kg
Undergoes a rapid hydrolysis that leads to quick recovery
narcotic: Ketamine
Stimulates the cardiovascular system to maintain heart rate, blood pressure, and cardiac output
Useful in the setting of major blood loss, when rapid induction of general anesthesia is required. However, it has significant hallucinogenic effects that limit its utility in obstetrics
Maternal cardiovascular status and uterine blood flow are well maintained. Effective low doses of 0.25
0.5 mg/kg but without loss of consciousness or protective reflexes
The margin of safety is narrow, so it should be used only by physicians able to easily secure and protect the airway if loss of consciousness occurs
For caesarean delivery, general anesthetic induction can be produced with 1
2 mg/kg IV
most commonly use inhalation anesthetics (3)
sevoflurane desflurane isoflurane
what is a regional/local anesthetic?
Injection of a local anesthetic around the nerves that pass from spinal segments to the peripheral nerves responsible for sensory innervation of a portion of the body
5 regional/local anesthetics
Tetracaine Lidocaine Bupivacaine Chloroprocaine Ropivacaine
when are regional/local anesthetics used?
labor analgesia, caesarean delivery, and other obstetric operative procedures (eg, postpartum tubal ligation, cervical cerclage) Patient is either awake or under anesthesia
when are regional/local anesthetics contraindicated?
valvular heart disease, infection, coagulopathy, hypovolemia, progressive neurologic disease, patient refusal
most side effects of spinal or epidural anesthesia are secondary to
blockage of the sympathetic nerve fibers
Physiologic regulating mechanisms are disturbed: BP, HR and contractility, vagal stimulations, shock
Lumbar epidural block should eradicate pain between (what 2 spinal levels) for the first stage of labor and between (what 2 spinal levels) for the second stage of labor.
between T10 and L1 for the first stage of labor
between T10 and S5 for the second stage of labor
what is the anesthetic (approach) of choice for cesarian delivery?
subarachnoid (spinal) anesthesia
what is a pudendal block?
One of the most popular of all nerve block techniques in obstetrics
The infant is not depressed, and blood loss is minimal
Simple technique d/t location of nerve: injection of 10 mL of 1% lidocaine on each side will achieve analgesia for 30
45 minutes approximately 50% of the time
what is the purpose of amniotic fluid?
acts as a cushion, protects the fetus from loss of body heat, helps lung development by breathing in fluid, allows proper bone and limb growth with movement
when does the amount of amniotic fluid increase? when does the amount peak?
increases until the beginning of the 3rd trimester peaks around 34-36 weeks of about 1 quart
how is the amount of amniotic fluid measured? (2 ways)
Vertical pocket measurement: measure the dimensions of the largest vertical pocket of amniotic fluid
AFI (Amniotic Fluid Index): divide the uterus up into 4 quadrants using the linea nigra as the vertical axis and the umbilicus as the horizontal axis. The pocket with the largest vertical dimension is measured in each quadrant. The sum of all 4 measurements = AFI
what is the definition of oligohydramnios? (amount based) when does it occur?
Decreased amniotic fluid:
a maximum vertical pocket of fluidluid less than 2 cm(BPP) or amniotic fluid index (AFI) less than 5 cm; cm; (usually less than 300mL)
Occurs any time, but more often in the 3rd trimester
what is an important sign of oligohydramnios?
vaginal fluid leakage
what are some causes of oligohydramnios?
IUGR
Maternal HTN/pre
eclampsia
Fetal birth defects, esp kidneys; and in multiple gestations
Maternal DM
longstanding
PROM
Uteroplacental insufficiency
Post
term pregnancy
what are some complications of oligohydramnios early in the pregnancy?
Premature birth
Birth defects
particularly MSK, IE clubfoot
Miscarriage or stillbirth
what are some complications of oligohydramnios in the third trimester?
growth deficits
umbilical cord prolapse and/or compression
how is oligohydramnios treated?
Not treated if at it occurs at the end of healthy pregnancy
Bed rest can help improve placental blood flow
side
lying is the best
If found early in pregnancy, check karyotype, look for amniotic bands
Amnioinfusion of isotonic fluid infused trans abdominally or through cervix especially helps umbilical cord compression and dilutes meconium
intensive biophysical profile surveillance
labor induction or c
section if severe
what is polyhydramnios? when is it detected? who is it more common in?
Increased amniotic fluid
vertical pocket > 8 cm or AFI > 25 cm; (usually over 2000mL)
Can be detected by 20th week, most often found at 30th week
more common with multiple gestations
what causes polyhydramnios and what symptoms might the mother present with?
Uterus grows more rapidly than it should causing unusual abdominal discomfort, increased back pain, SOB, severe feet and ankle swelling, vulvar swelling, decreased urine production
what are some causes of polyhydramnios?
Usually from pressure exerted in the uterus and on nearby organs
Birth defect in fetal GI tract or CNS
Maternal DM
Twin
twin transfusion
Fetal anemia
Blood incompatibilities
what complications is polyhydramnios associated with?
Premature birth
PROM
Macrosomia
Placental abruption
Umbilical cord prolapse
Hemorrhaging after delivery (atony)
Stillbirth
what is the treatment for polyhydramnios?
Amniocentesis for genetic evaluation or to drain excess fluid
Indomethacin which reduces fetal urine production but it isn’t recommended after 30 weeks gestation due to the risk of cardiac problems (early DA closure)
what is Intrauterine Growth Retardation (IUGR)?
Estimated fetal weight less than the 10th percentile for gestational age found on US
what is small for gestational age (SGA)?
applies to the infant that is less than the 10th percentile at birth
what causes 1/3 of IUGR and is the single most preventable cause in the US?
SMOKING
women who smoke have a 3
4x increased risk of IUGR of the fetus
if the mother stops smoking before ____ weeks gestation the fetus is not at an increased risk for IUGR
16 weeks
genetic disorders account for _____ of IUGR
3-Jan
IUGR: symmetric smallness
what % of IUGR cases
what is it
small brain due to
20%
all organs are decreased proportionally
small brain due to decreased number of cells
IUGR: asymmetric smallness
what % of IUGR cases
what is it
likely caused by
decreased brain due to
80%
Organs are decreased disproportionately (abdominal circumference is affected to a greater degree than is head circumference)
Likely is caused by intrauterine deprivation that results in an increase in flow to the brain and heart at the expense of less important organs
Slightly decreased brain d/t decreased size of cells
what is macrosomia
Macrosomia represents a subset of LGA fetuses weighing >4500 g; they are >95th percentile at any gestational age
Large for Gestational Age (LGA) have EFW > 90th percentile
what does macrosomia increase the risk of?
fetal morbidity
what are some maternal and fetal causes of macrosomia?
Maternal
Diabetes (gestational, chemical, or insulin
dependent), obesity, postdatism, multiparity, advanced age, previous LGA infant, large stature
Fetal
genetic or congenital disorders, male gender
what are some complications of macrosomia?
C
section, post
partum hemorrhage, shoulder dystocia, perineal trauma, operative vaginal delivery, stillbirth, low apgar score, neonatal hypoglycemia, jaundice, or feeding difficulties
how is macrosomia treated/prevented?
Early detection of RFs
Monitor postprandial glucose levels
Regular aerobic exercise
what is a prolapsed umbilical cord? what can it cause?
Descent of the umbilical cord into the lower uterine segment; most occur during labor as the cervix dilates
Exposes the cord to intermittent compression between the presenting part and the pelvic inlet, cervix, or vaginal canal.
Compromises fetal circulation and, depending on the duration and intensity, may lead to fetal hypoxia, brain damage, and death
cord prolapse is considered an obstetric _____
emergency
what are some causes of cord prolapse?
Prematurity (
how is cord prolapse treated?
Considered a high risk pregnancy
Continuous FHR monitoring during labor
Avoid artificial ROM until presenting part at/in cervix
At normal ROM, carefully check for prolapse
Amniotomy and slow release of fluid until presenting part engaged at cervix
Caesarian section is usual preferred route of delivery
what is overt cord prolapse?
associated with rupture of membranes and displacement of the umbilical cord into the vagina, often through the introitus
overt cord prolapse:
cord exposure causes:
perinatal mortality rate:
treatment:
exposure of the umbilical cord to air causes irritation and cooling of the cord, resulting in further vasospasm of the cord vessels
perinatal mortality rate approaches 20%. Prematurity, itself a contributor to prolapse, accounts for much of this perinatal loss
Abdominal delivery ASAP
what is occult cord prolapse?
cord may lie adjacent to the presenting part cannot be palpated during pelvic exam
occult cord prolapse:
may be indicated by what?
place patient in what position?
treatment options:
may be indicated by FHR decelerations during labor
place patient in lateral Sims or Trendelenburg
amnioinfusion may decrease incidence of decelerations
if cord compression persists C
section should be done
what is funic cord presentation?
cord lies below the presenting part; the cord often can be easily palpated through the membranes
treatment of funic cord presentation
at term
preterm
At term should be delivered by caesarean section prior to rupture of membranes
If premature, no consensus;
Conservative approach
hospitalize the patient on bed rest in the Sims or Trendelenburg position in an attempt to reposition the cord
Serial US examinations to ascertain cord position, presentation, and gestational age
what is the preferred method of delivery for a previable or dead fetus?
vaginal delivery
cord compression
good prognosis if:
poor outcome if:
Good prognosis if the diagnosis is made early and the duration of complete cord occlusion is
trisomy
may occur with which chromosomes
3 most common
others occur with who
the larger the chromosome involved, the
may occur with any chromosome
3 most common: 13, 18, and 21
other trisomies occur in pregnancies associated with older women
the larger the chromosome involved, the more severe the syndrome
trisomies can be indicated on the triple screen which are what 3 tests?
maternal AFP, hCG, and unconjugated estriol (uE3)
most frequent trisomy
trisomy 21: Down Syndrome
trisomy 21
involves the smallest chromosome and so:
triple screen levels
often to born to what age mothers
characteristics
involves the smallest chromosome and so the problems are the least severe and moderate life expectancy is anticipated
low AFP, low uE3, and high hCG
often born to teenage mothers or mothers > 35
trisomy 18
aka
triple screen levels
characteristics
Trisomy E: the “E” syndrome, Edward’s syndrome
Low values across all of the triple screen serum markers (low maternal AFP, low uE3, and low hCG)
Characteristics: severe mental retardation, long narrow skull with prominent occiput, congenital heart disease, flexion deformities of fingers, narrow palpebral fissures, low
set ears, harelip and cleft palate. Low birth weight and characteristic dermatoglyphics (6
10 arches on fingertips and single transverse palmar creases in 30%)
trisomy 13
aka
characteristics
Trisomy D: the “D1” syndrome, Patau syndrome
Characteristics: severe mental retardation, congenital heart disease (77%), polydactyly, cerebral malformations (especially aplasia of olfactory bulbs), eye defects, low
set ears, cleft lip and palate, low birth weight. Characteristic dermatoglyphic pattern (Excess of arches on fingertips and single transverse palmar creases in 60%)
what are the 3 most common neural tube defects?
anencephaly spina bifida meningomyelocele
what lab detects ~85% of all open neural tube defects?
serum AFP level > 3 standard deviations above normal
what does serum AFP not detect in term of neural tube defects?
skin
covered or closed form neural tube defects
cystic fibrosis
caused by
dysfunction of ______ leading to what symptoms?
most common fatal hereditary disorder of who
diagnosis
deletion of phenylalanine at position 508 of the CFTR gene on chromosome 7
dysfunction of exocrine glands interferes with chloride transport and water movement across epithelial cells, causing buildup of thick secretions that obstruct glands and ducts in multiple organs (esp lungs and digestive), and subsequent damage to exocrine cells
most common fatal hereditary disorder of white in the US
Diagnosis requires positive “sweat test” (pilocarpine iontophoresis test) OR documented CF in sibling or first cousin OR positive newborn test
gestational trophoblastic disease
group of interrelated diseases resulting in
where do the tumor cells originate
benign or malignant
4 major groups
group of interrelated diseases resulting in abnormal proliferation of trophoblastic tissue inside the uterus
tumors start in the trophoblastic cells around an embryo, that would normally develop into the placenta
most are benign
4 major groups:
Hyaditaform mole (molar pregnancy)
Invasive mole
Choriocarcinoma
Placental site trophoblastic tumor
most common form of gestational trophoblastic disease?
hyaditaform molar pregnancy
hyaditaform molar pregnancy
complete
partial (incomplete)
manifestations
labs
diagnosis
complete: fertilization of an empty ovum by a normal sperm; 20% progress to malignancy
partial (incomplete): when 2 sperm fertilize a normal ovum at the same time; non
viable fetus is present; 5% progress to malignancy
manifestations: painless, irregular, or heavy bleeding early in the pregnancy; PE shows molar clusters (grape
like clusters) protruding into the vagina
labs: complete molar if hCG > 100,000
US: no fetal heart tones, cluster patterns
diagnosis: microscopically identified by 3 classic findings: edema of the villous stroma, avascular villi, and nests of proliferating trophoblastic elements surrounding the villi
what maternally expressed gene can be screened for and will help in determining complete from partial hyaditaform malor pregnancy?
p57 immunohistochemistry straining for PHLDA2
absent in complete moles, present in partial moles
how is a molar pregnancy treated?
Complete removal of uterine contents
Monitor beta
hCG levels for 1 year to ID invasive moles
Some treat empirically with chemo
Avoid pregnancy for 1 year after “full remission”
what is an invasive mole? who gets them? what can it cause?
Malignancy where molar villi and trophoblasts penetrate the myometrium
10
15% who had hyaditaform mole
Can cause subsequent uterine rupture and hemoperitoneum
has the ability to spontaneously regress
what is a choriocarcinoma? who gets them? how does it present? what must be examined?
Pure epithelial tumor
50% follow a molar pregnancy; 2
5% are malignant
Usually presents as late vaginal bleeding in the postpartum period. An enlarged uterus, enlarged ovaries, and vaginal lesions may be noted during exam
No villi in histologic exam; may have small, isolated areas in sample, so entire curettage must be examined
what is a placental site trophoblastic tumor? where is the tumor? what is secreted?
rare malignant tumor that may be found months to years following a molar or normal pregnancy tumor is usually confined to the uterus human placental lactogen is secreted and it’s level can be monitored to follow response to therapy
all gestational trophoblastic trophoblastic tumors have increased levels of what?
hCG
diagnosis of gestational trophoblastic tumors can be done by what imaging technique and lab level?
hCG is the tumor marker
US
how is gestational trophoblastic disease treated?
malignant = chemo
low
risk metastasis = chemo
high
risk metastasis = chemo +/
radiation; possible suction curettage and hysterectomy
what cardiac conditions in the mother predict a high
risk pregnancy and so you should advise against pregnancy?
pulmonary hypertension
cardiomyopathies with decrease ejection fractions
Marfan’s (dilated aorta)
Coarctation of the aorta
prognostic indicators to predict cardiac events in pregnancy
NOPE
New York Heart Association (NYHA) functional class _II (or cyanosis)
Outlet obstruction of the left heart
Prior cardiac event (heart failure, arrhythmia, stroke)
Ejection fraction
maternal valve disorders and pregnancy
Mitral stenosis
Mitral regurge
MVP
Aortic stenosis
Mitral stenosis
most common seen in pregnancy
Risk of heart failure increases progressively
Goals to prevent fluid overload, tachycardia and A
fib Mitral regurg
Generally well tolerated; watch for CHF, A
fib MVP
Generally well tolerated, unless mod
severe MR exist
Some should have valve repair before pregnancy
Anticoagulation a problem after prosthetic valves Aortic stenosis
Pregnancy may be contraindicated due to increased hemodynamic demands and limited CO and perfusion. Indications for valve replcmt after 20 wks possible.
Mild
mod dz w/o sxs can be managed expectantly, restricted activity
Watch for increased CP, syncope and CHF; decreased carotid pulse
what is peripartum cardiomyopathy
def?
diagnosed when?
what about the baby?
how long does it last?
A dilated cardiomyopathy of unknown cause
It usually is diagnosed during late pregnancy or in the 4
5 months after delivery with the finding of left ventricular systolic dysfunction in a woman with no history of cardiac disease
Babies should be delivered after stabilization of the mother
Cardiac function normalizes within 6 months of delivery in approximately half of patients
treatment of UTI and acute cystitis during pregnancy
Nitrofurantoin, or a cephalosporin for 5
14 days
Urine culture after treatment
Persistent bacteriuria after 2 or more courses of therapy = Nitrofurantoin (50
100 mg PO at bedtime) for the duration of the pregnancy
treatment of pyelonephritis during pregnancy
A first
generation cephalosporin such as cefazolin IV usually is effective
Ceftriaxone IV is effective for most Enterobacteriaceae
When the patient is afebrile for 48 hours, change IV ABX to PO ABX
total treatment of 14 days
If no clinical response is seen in 48
72 hours, a resistant organism can be treated by adding an aminoglycoside such as gentamicin
also do US exam of kidneys and urinary tract
Recurrent bacteriuria and pyelo can occur
suppressive therapy with nitrofurantoin 100 mg orally at bedtime, or a similar regimen, is continued during the pregnancy and during the puerperium, often for 6 weeks
hyperemesis gravidarum
what is it
symptom onset
treatment
maternal complications
Unexplained intractable nausea, retching, or vomiting beginning in the first trimester, resulting in dehydration, ketonuria, and typically a weight loss of more than 5% of prepregnancy weight
Symptoms typically start between 3 and 5 weeks of pregnancy and 80% resolve by 20 weeks
Treatment includes avoidance of noxious stimuli, medications to relieve nausea and vomiting, hydration, and possibly hospitalization
Maternal complication can include Wernicke’s encephalopathy, acute tubular necrosis, central pontine myelinolysis, Mallory
Weiss tear of the esophagus, pneumomediastinum, and splenic avulsion
PUD
incidence and severity during pregnancy as compared to not pregnant
testing
treatment
what if they have H pylori?
Incidence and severity decrease during pregnancy, whereas symptoms of dyspepsia may be increased
Esophagogastroduodenoscopy is generally considered as safe during pregnancy and is recommended for the evaluation of PUD when symptoms are severe and nonresponsive to medical therapy
Avoid symptom
provoking foods, using antacids and sucralfate.
For persistent sxs, an H2 antagonist (cimetidine or ranitidine) can be given.
With continued symptoms, a PPI such as lansoprazole can be added to the drug regimen.
Can treat for H. Pylori in pregnancy
acute fatty liver of pregnancy
when does it occur?
symptoms?
labs
lethal complication
treatment
Rare complication of the 3rd trimester of pregnancy involving acute hepatic failure (usually ~36 weeks)
Symptoms include malaise, anorexia, nausea, vomiting, epigastric pain, headache, or jaundice
Laboratory abnormalities include thrombocytopenia, elevated transaminases, hyperuricemia, and elevated creatinine. Additionally, hyperbilirubinemia, hypoglycemia, and hyperammonemia are found
Pancreatitis can be lethal complication
Stabilize mom, supportive therapy based on labs, hydration, blood needs; then deliver based on gestational age. Mother mortality 10%, fetal 23%.
atopic dermatitis (eczema)
better or worse with pregnancy?
why?
treatment?
commonly exacerbated in pregnancy
Estrogen and progesterone modulate immune and inflammatory cell functions, including mast cell secretion
treatment w/ topical corticosteroids or systemic antihistamines. Oral prednisone may be needed
what is granuloma gravidarum?
aka pyogenic granuloma: a vascular tumor that occurs in 2% of patients between the
PUPPP: Pruritic urticarial papules and plaques of pregnancy
most common cause of
symptoms
how long do they last?
treatment?
most common pruritic dermatosis unique to pregnancy
symptoms: Pruritic, erythematous papules that coalesce into plaques forming usually after the 34th week of gestation. A halo may surround plaques
They may disappear completely within 2 weeks after delivery
treatment with antihistamines, topical steroids, and antipruritic medications; oral corticosteroids for extreme pruritus unresponsive to initial treatment
intrahepatic cholestasis of pregnancy
results in
when does it arise?
who is it more prevalent in?
causes increased risk of?
testing
treatment/resolution
results in pruritis and secondary skin lesions
arises after 30 weeks gestation
more prevalent in south american and Scandinavian populations
causes increased risk of preterm birth and stillbirth
test with fetal surveillance twice/week with fetal non
stress test and/or a biophysical profile
treatment = deliver child at 37
38 weeks; resolves several days later
most common complication of pre
eclampsia
hyperthyroid
hyperthyroid when pregnant
treatment choices
who should remain on therapy throughout pregnancy?
propylthiouracil and methimazole
dose is gradually reduced as improvement occurs
Women with large goiters, long
standing hyperthyroidism, or significant eye involvement should remain on treatment throughout pregnancy
mild hyperthyroidism is associated with _____ and usually resolves by _____
treatment
mild hyperthyroidism is associated with transient hyperthyroidism of hyperemesis gravidarum usually resolves by 20 weeks’ gestation Tx is symptomatic; antithyroid medication is not recommended
hypothyroid:
symptoms:
sxs may be masked by:
which labs when?
treatment?
complications
elevated TSH and low free T4
sxs: modest weight gain, fatigue, sleepiness, lethargy, decreased exercise capacity, depression, and cold intolerance (very unusual in normal pregnancy)
sxs may be masked by hypermetabolic state of pregnancy
eval maternal TSH levels at every trimester
treatment: L
thyroxine early morning on an empty stomach
complications: 2x rate of spontaneous abortion, lower IQ, increased risk of pre
eclampsia, placental abruption, IUGR, and IU fetal demise
postpartum thyroiditis
diagnosed when?
who’s at high risk to develop this?
symptoms?
onset
treatment?
positive correlation between postpartum thyroiditis and ______
diagnosed when TSH is elevated or depressed in the YEAR AFTER delivery
high risk women = high thyroid antibodies or type 1 diabetics
symptoms: fatigue, palpitations, heat intolerance, nervousness
onset: abrupt; goiter may be present
treatment: limited to symptomatic patients only; Beta
Blockers if in hyperthyroid phase; Levothyroxine if in hypothyroid phase
positive correlation between postpartum thyroiditis and postpartum depression
carpal tunnel and pregnancy
Symptoms at night
Usually best treated conservatively with elevation of the affected wrist and splinting
Usually abates postpartum
compression of femoral or obturator nerve during pregnancy
Most commonly related to pressure of the fetus just before and during vaginal delivery
Can occur from retraction during caesarean delivery or hysterectomy
bell’s palsy during pregnancy
Approximately one
fifth of cases of Bell’s palsy occur during pregnancy or shortly after
Treatment with prednisone 40
60 mg/d and acyclovir is helpful if given within 1 week of onset
migraine headaches during pregnancy
Chronic migraine headaches decrease during pregnancy in 50
80% of affected patients
Women with classic migraine (migraine with aura) may experience their initial onset during pregnancy
Preferred abortive medications during pregnancy include APAP, APAP w/ codeine, or magnesium
NSAIDs should not be used for prolonged periods and should be avoided in the third trimester because of possible oligohydramnios or premature closure of the ductus arteriosus
Prophylactic medications should be used if abortive therapy is only partially effective and if disabling migraines are occurring more than once per week
Options include beta mimetic blockers, low
dose TCAs, CCBs, magnesium, riboflavin (Vit B2), and topiramate (Topamax)
Valproic acid or divalproate should be avoided in pregnancy
epilepsy during pregnancy
The onset of epilepsy is not increased during pregnancy
More than 95% of patients who have seizures during pregnancy have a history of epilepsy
Antiepileptic drugs and seizures can negatively affect a fetus
Seizures can cause maternal and fetal injury, spontaneous abortion, premature labor, and fetal bradycardia
Mothers with frequent seizures must be counseled on seizure and infant safety
anemia definition
A hemoglobin concentration of
pregnant women with a history of iron deficiency anemia should be prescribed
at least 60 mg/d of elemental iron
anemia during pregnancy most commonly results from
nutritional deficiency (iron or folate)
anemia treatment during pregnancy
Ferrous sulfate 300 mg given TID
hemoglobin levels should increase by at least 0.3g/dL/wk
administer with citrus juice to help absorption
complications due to anemia
IUGR Preterm birth Increased risk of Postpartum depression Angina CHF
venous thromboembolism
increased risk while pregnant bc
virchow’s triad
treatment
increased risk while pregnant because pregnancy and puerperium are hypercoagulable states
Virchow’s triad
circulatory stasis, vascular damage, and hypercoagulability of blood
treatment: anticoagulate (w/LMWH), bed rest, and ambulation with compression stockings
treatment of DVT
antepartum
postpartum
antepartum= anticoagulate for 6
12 weeks postpartum (and a total of 3
6 months)
postpartum= anticoagulate for 3
6 months
gestational thrombocytopenia
characterized by
occurs when
characterized by mild, asymptomatic thrombocytopenia with platelet levels usually >70,000/_L
usually occurs late in gestation and resolves spontaneously after delivery
what is puerperium?
aka postpartum
the 6 weeks following delivery when physiologic and anatomic changes of pregnancy reverse
postpartum
immediate time frame
early time frame
late time frame
Immediate
first 24 hrs when acute postanesthetic or postdelivery complications may occur
Early
extends until the first week postpartum
Remote
includes the period of time required for involution of the genital organs and return of menses, usually ~ 6 weeks
uterus changes postpartum
Immediately after delivery, wt is 1 kg, and its size approximates that of a 20
week pregnancy
After 2 days, uterus begins to shrink
At the end of the first postpartum week, it normally will have decreased to the size of a 12
week gestation and is palpable at the symphysis pubis
After 2 weeks, uterus descends into pelvic cavity
average rate is 1cm/day
what are “afterpains” and what do they do?
worse in multi
or nulliparous?
accentuated when? why?
myometrial contractions that assist in involution (shrinking) of the uterus
pains are worse in multiparous women
accentuated during nursing as a result of oxytocin release
postpartum endometritis
most common after what?
occurs when? symptoms?
labs?
treatment?
most common after C
section or PROM
occurs 2
3 days postpartum
symptoms: fever, uterine tenderness, adnexal TTP, peritoneal irritation, decreased bowel sounds
labs: WBC > 20,000; also do UA
treatment: single dose of ABX at cord cutting usually reduces incidence; treat until afebrile for 24 hours Clindamycin + Gentamicin (first line; Metronidazole added if septic)
Lochia
lochia rubra
lochia serosa
lochia alba
cessation of lochia
Lochia rubra
normal d/c postpartum, with blood, shreds of tissue, and decidua
lasts 3
4 days
Lochia serosa
becomes serous to mucopurulent, paler, and often malodorous
Lochia alba
2nd
3rd week, becomes thicker, mucoid, and yellowish
white
Secretions cease around 5
6th week
Cervix and genitals postpartum
os dilation after 1 week
os converts into
ovulation
Os dilation after 1 week ~ 1 cm
Os converts into a transverse slit
ovulation occurs as early as 27 days postpartum (avg: 70
75 days if not breastfeeding, 6 months if breastfeeding); suppression due to high prolactin levels
bladder postpartum
Over distention and incomplete emptying of the bladder with the presence of residual urine are common
Catheterization every 6 hours after delivery if she is unable to void or empty her bladder completely
usually resolves within 3 days
weight postpartum
average decrease
women who gained more than recommended
Average decrease 10
13 lb occurs intrapartum and immediately postpartum
may lose an additional 9 lb during the puerperium
Women who gain more weight than the recommended range during pregnancy tend to be heavier at 3 years postpartum
activity postpartum
Most patients benefit from 2
4 days of hospitalization after delivery
Most women can return home safely 2 days after normal vaginal delivery
Early ambulation after delivery hastens involution of the uterus, improves uterine drainage, and lessens thromboembolic events
diet/GI postpartum
About 500 kcal per day more than the recommended level for non
pregnant and non
lactating women
Daily vitamin
mineral supplement during the early puerperium, esp if lactating
Lactating women are advised to maintain calcium intake of 1000 mg per day
Mild ileus and constipation
Hemorrhoids common
Bathing/perineal care
May shower, no douching, tampons okay
transient “maternity blues”
sxs
occur and cease when?
Tearfulness, anxiety, irritation, and restlessness
Depression, feelings of inadequacy, elation, mood swings, confusion, difficulty concentrating, headache, forgetfulness, insomnia, depersonalization, and negative feelings toward the baby
Occur within the first few days after delivery and usually cease by postpartum day 10; weeping may occur for weeks after delivery
postpartum depression
Pathologic grief is characterized by the inability to work through the sense of loss within 3
4 months, with subsequent feelings of low self
esteem
sexual activity postpartum
desire can be lower than normal
may resume by 3rd week, but not fully recovered until 6 weeks postpartum
family planning (contraceptives) post partum
Lactational amenorrhea in breastfeeding mothers provides 98% contraceptive protection for up to 6 months; concurrent use of progestin
only pill is still advisable
Barrier techniques until postpartum exam
Oral contraception should be deferred until 6 weeks postpartum because of concerns about the postpartum hypercoagulable state
if choosing IUD, it should be placed at the first postpartum visit; however, it may be placed as early as immediately postpartum, but may risk expulsion
postpartum visit exam
occurs when?
check what?
PE of what?
ask about what?
occurs 4
6 weeks after discharge
check weight, BP, blood cell counts, and blood glucose
PE of breasts, rectovaginal exam, cervix + Pap, bimanual exam, check episiotomy
ask about emotional well being, bonding, breastfeeding, and immunizations
