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Clin Med Final Material- Semester 2 > Preconception Counseling-Paulson > Flashcards

Preconception Counseling-Paulson Flashcards

1
Q

Prenatal Care

A
  • Pregnancy is a normal process; however, complications that increase morbidity/mortality to mother and or fetus occur in 5-20% of pregnancies
  • Mothers receiving prenatal care have lower risk of complications
  • Identify and treat high-risk patients
  • Woman planning pregnancy ideally should have a medical evaluation before conception
  • Purpose of prenatal care is to ensure successful pregnancy outcome
  • ->Delivery of live, healthy fetus
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2
Q

Preconception Counseling

A
  • Consider likelihood of pregnancy in all reproductive age women
  • Discuss their desire to become pregnant and when
  • Discuss contraception
  • Quit smoking
  • Obesity (weight loss)
  • Eat Healthy and exercise
  • Limit alcohol use
  • Ask about drug use
  • ->*Marijuana is not safe to use in pregnancy
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3
Q

Preconception Counseling:

-What supplement should all Pregnant Pts take?

A
  • *Folic Acid supplement 400mcg – 800mcg daily
  • -Folic acid taken 3 months prior to conception may be beneficial in decreasing Neural Tube Defect (NTD) and cardiac anomalies
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4
Q

Preconception Counseling:

-What should be checked?

A
  • Check medication list
  • Chronic medical conditions optimally managed (Diabetes, SLE, HTN)
  • Infectious disease
  • -Immunizations -> no live vaccines (varicella/rubella)
  • -May offer pertussis, Hep B
  • -HIV and STD testing
  • Genetic screening options
  • Intimate partner violence
  • Travel History – Risk of Zika Virus, TB, etc.
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5
Q

Preconception Counseling Video:

A

https://www.youtube.com/watch?v=k9GJEvPnmlQ

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6
Q

Infertility is defined as:

A

No pregnancy after trying for 12 months with normal sexual activity without contraception

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7
Q

What is Advanced Maternal age (AMA) defined as?

A

35yo and older (AMA) – infertility increases with age

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8
Q

Infertility:

-Male factor diagnosed in __% of infertile couples

A

25 - 40%

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9
Q

Infertility:

-majority of couples can be treated with?

A
  • –>use of assisted reproductive technologies (ART):
  • Ovulation induction
  • Insemination with sperm
  • In vitro fertilization
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10
Q

Factors leading to Infertility in females

A
  • Anovulation
  • Endometriosis
  • Fibroids
  • Tubal factor
  • Cervical factor

-idiopathic

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11
Q

Infertility in Males

A

several causes

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12
Q

Male Infertility Work-up

A

History:

  • Sexual function/dysfunction
  • Excess alcohol or drug use
  • STDs
  • Cryptorchidisim/ orchidectomy/mumps

PE:

  • Varicocele
  • Diabetes
  • Neurologic disease
  • Absence of vas deferens
  • Systemic illness
  • Semen Analysis – sperm concentration, motility, and morphology
  • Chromosomal Studies
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13
Q

Female Infertility Work-up

A
  • History
  • PE
  • Monitoring of Ovulation
  • Hormone Analysis
  • Studies of anatomy – (fallopian tubes and uterine cavity) – hysterosalpingogram
  • Chromosomal Studies
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14
Q

Maternal – Fetal Physiology:

-cardiac?

A
  • Increased Cardiac Output, ~40% (may hear systolic ejection murmur)
  • Lower BP d/t hormones in pregnancy -> smooth muscle relaxation -> vasodilation
  • Resting heart rate increases by about 15 beats over course of pregnancy
  • Increased venous pressure in lower extremities from compression of inferior vena cava by uterus
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15
Q

Maternal – Fetal Physiology:

-Heme

A
  • Increase in plasma volume 50%
  • RBCs only increase 20-30% (decreased HCT)
  • WBCs increase
  • Slight decrease in platelets
  • Hypercoagulable state (increased fibrinogen)
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16
Q

Maternal – Fetal Physiology:

-GI?

A
  • Nausea and vomiting (increase in BhCG and progesterone)
  • GERD -> hormones causes relaxation of lower esophageal sphincter
  • Constipation (decreased intestinal motility)
  • Gallbladder emptying slowed -> increased risk for gallstones
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17
Q

Maternal – Fetal Physiology:

-endocrine?

A
  • Increased estrogen -> increased thyroid binding globulin

- Increased metabolic demand -> increase T3/T4

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18
Q

Maternal – Fetal Physiology:

-Renal?

A
  • Kidneys increase in size

- GFR increases by 40-65%

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19
Q

Maternal – Fetal Physiology:

-Pulmonary?

A
  • Increase in tidal volume 35-50%

- Increase in inspiratory capacity and minute ventilation

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20
Q

Maternal – Fetal Physiology::

-Derm?

A
  • Spider angiomas and palmar erythema (increased estrogen)

- Hyperpigmentation of nipples, umbilicus, abdominal midline (linea nigra), and face (melasma or cholasma)

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21
Q

Fetal Circulation:

-Describe

A
  • Umbilical cord -> 2 umbilical arteries, 1 umbilical vein (vein is what carries oxygen rich blood, umbilical arteries allow exchange with the maternal blood across placenta)
  • Oxygen rich blood carried from the placenta via the umbilical vein
  • 50% of blood bypasses liver through ductus venosus -> IVC
  • O2 rich blood mixes with O2 poor blood returning from fetal tissues and enters right atrium
  • Pressure in RA > LA due to collapsed lungs, 80% of oxygenated blood is directly shunted to LA through the foramen ovale -> left ventricle->ascending aorta -> brain and fetal upper body
  • Remainder of blood pumped (20%) that does not go to LA, pumped into RV -> pulmonary artery
  • Blood from pulmonary artery -> ductus arteriosus down the descending aorta -> systemic circulation (bypass nonfunctioning lungs) -> lower body
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22
Q

First Trimester Bleeding:

-Approx. ___% of pregnant women experience first trimester bleeding

A

25%

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23
Q

First Trimester Bleeding:

-etiology?

A
  • Implantation into the endometrium
  • Abortion
  • Ectopic pregnancy
  • Molar gestation
  • Infection
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24
Q

Abortion: defined as?

A

Termination of pregnancy before 20 weeks

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25
Q

Abortion: 2 types

A
  • Spontaneous abortion (SAB)

- Therapeutic abortion (TAB)

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26
Q

Abortion: Sx

A

Symptoms include: vaginal bleeding (usually bright red), low back pain, abdominal pain/cramping, cervical dilation, passage of products of conception, bHCG levels falling or not adequately rising, abnormal ultrasound findings (empty gestational sac, lack of fetal growth or cardiac activity)

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27
Q

Complete Abortion

A
  • All products of conception expelled before 20 weeks
  • Cervical is closed
  • Observe patient for further bleeding
  • If bleeding minimal, no further treatment necessary
  • Can follow serial HCG levels
  • Products of conception should be examined and sent for path exam
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28
Q

Inevitable abortion

A
  • Pregnancy can not be saved
  • Bleeding
  • Moderate to severe uterine cramping
  • Cervical os is dilated
  • Products of conception not yet passed
  • Prognosis is poor
  • Treatment – D&C, blood type and crossmatch, Rh status
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29
Q

Threatened Abortion

A

-Possible pregnancy loss
-Pregnancy can continue without further problems
No products of conception passed
Bleeding before 20 weeks
May or may not have abdominal cramping/pain
Uterine size compatible with dates
Cervical os closed
Unknown prognosis, better if bleeding and cramping resolve
Treatment – recommend pelvic rest

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30
Q

Threatened Abortion

A
  • Possible pregnancy loss
  • Pregnancy can continue without further problems
  • No products of conception passed
  • Bleeding before 20 weeks
  • May or may not have abdominal cramping/pain
  • Uterine size compatible with dates
  • Cervical os closed
  • Unknown prognosis, better if bleeding and cramping resolve

-Treatment – recommend pelvic rest

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31
Q

Incomplete Abortion:

  • describe
  • Sx?
A
  • Only some products of conception are passed before 20 weeks
  • Moderate to severe cramping
  • Heavy bleeding
  • Cervical os is dilated
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32
Q

Incomplete Abortion:

  • prognosis?
  • tx?
A

-Prognosis is poor

Treatment – options include surgical (D&C), medical, or expectant management

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33
Q

Missed Abortion:

  • defined as ?
  • sx?
A
  • Embryo is not viable prior to 20 weeks
  • Products of conception retained in uterus
  • No cervical dilation

Sx: Cramping or bleeding may be present

34
Q

Missed Abortion:

-tx?

A

options include surgical (D&C), medical, or expectant management

35
Q

Septic Abortion=

A
  • Any embryonic or fetal demise with uterine infection
  • -Uterine bleeding, fever, increased leukocytes, abdominal pain, cervical motion tenderness, foul smelling discharge
  • -Usually from retained products of conception or ascending infection, polymicrobial
36
Q

Septic Abortion: dx?

A

CBC, UA, endocervical cultures, blood cultures, and abdominal x-ray to r/o uterine perforation. Ultrasound should be done to look for retained POCs.

37
Q

Septic Abortion: tx?

A

Hospitalization and IV antibiotics with anaerobic and aerobic coverage. May need D&C for retained POCs.

38
Q

Elective Abortion

A
  • Complete social hx, medical hx, PE, including uterine size/position
  • Missed period
  • Medical abortion (using oral medication)
39
Q

Elective Abortion:

-describe the Medications that can be used for medical abortions (hint: 3 M’s)

A
  • Mifepristone (RU-486) – Inhibits progesterone receptors, progesterone needed for pregnancy
  • Misoprostol – Drug that induces uterine contractions and expulsion of POCs – can be used alone or in combination
  • Methotrexate – Stops fast growing cells, used in combo with misoprostol
40
Q

Elective abortion:

-surgery?

A
  • Suction or surgical curettage

- Dilation and evacuation – More common for second trimester abortions, up to 18 weeks gestation in outpatient setting

41
Q

Abortion:

Suction Curettage

A

=Safest and most effective method for terminating pregnancy of 12 weeks gestation or less

  • More than 90% of abortions in US done using this method
  • Dilation of cervix by instruments
  • Low failure rate
  • <1% risk for complications such as infection and uterine perforation
42
Q

Recurrent Pregnancy Loss: defined as?

A

3 or more consecutive SABs before 20 weeks

43
Q

Recurrent Pregnancy Loss:

-etiology?

A
  • May be genetic, auto-immune, anatomic, endocrine, thrombophilic (table 13-1 in Lange)
  • Affects up to 5% of couples
44
Q

Recurrent Pregnancy Loss:

Prognosis?

A

Prognosis after repeated losses is good with most couples having ~60% chance of viable pregnancy

45
Q

Anembryonic Pregnancy

A
  • Previously called “blighted ovum”
  • Embryo fails to develop or is resorbed after loss of viability
  • Diagnosed by ultrasound:
  • -Empty gestational sac seen w/o a fetal pole
  • Clinical presentation similar to missed or threatened abortion:
  • Mild pain/bleeding
  • Cervix closed
  • Retained non-viable pregnancy
46
Q

Gestational Disorders: list Ex’s

A
  • Ectopic Pregnancy

- Gestational Trophoblastic Disease/Diseases of Trophoblastic tissue

47
Q

List Ex’s of Gestational Trophoblastic Disease/Diseases of Trophoblastic tissue

A
  • Hydatidiform mole
    - Complete
    - Partial
  • Invasive Mole
  • Choriocarcinoma
48
Q

Ectopic Pregnancy: defined as?

A

Implantation of the fetus in any site other than the endometrial cavity (1.5-2% )of all pregnancies

49
Q

Ectopic pregnancy: MC site?

A

within the fallopian tubes (95%)

50
Q

Ectopic pregnancy: risk factors?

A

Prior ectopic, PID, smoking, anatomic abnormalities, IUD

51
Q

Ectopic pregnancy:

-Complications?

A

Tubal Rupture, Hemorrhagic shock, Death!

52
Q

What is the leading cause of pregnancy related death in first trimester?

A

**ectopic pregnancy

53
Q

Ectopic Symptoms:

A

Pain – pelvic or abdominal pain present in almost 100% of cases
Bleeding – Abnormal uterine bleeding occurs in ~ 75% of cases
Amenorrhea
Syncope

54
Q

Ectopic PE findings:

A
  • Adnexal Mass
  • Uterine changes
  • Hemodynamic instability – vital signs
55
Q

Ectopic Pregnancy Diagnosis

  • labs?
  • imaging study?
A
  • CBC
  • B-HCG
  • Blood Type/Rh status
  • Pelvic US
  • Transvaginal US should show intrauterine pregnancy at beta HCG level of 1500 - 2,000 “discriminatory zone”
  • Can also order progesterone level (if <5 not usually a viable pregnancy) does not tell you location of pregnancy
56
Q

Ectopic Pregnancy Treatment:

-first line tx?

A
  • Methotrexate= usually first treatment choice for ending early ectopic pregnancy
  • -50mg IM injection
  • -Need to monitor LFTs and serum Cr
  • -Will need close follow-up until B-HCG is zero

–Patient education – counsel patient on side effects – abdominal pain, bleeding, nausea, vomiting. Go to ED if severe pain, dizziness, syncope (tubal rupture)

57
Q

Ectopic pregnancy:

-surgical tx?

A

Surgical - Laparoscopy:

  • -Salpingostomy
  • -Salpingectomy
58
Q

Salpingostomy=

A

small incision in tube

59
Q

Salpingectomy=

A

part of tube removed

60
Q

Ectopic Pregnancy Treatment:

emergency tx?

A

-Surgery in ruptured ectopic, transfusion usually required

61
Q

Ectopic pregnancy:

make sure to tell the Pt ____

A

No intercourse!!

62
Q

Gestational Trophoblastic Disease

A
  • Rare
  • Cells are called trophoblasts and come from tissue that is used to form the placenta
  • Seen in women of child-bearing age
  • Abnormal Fertilization
  • Uterine bleeding in first trimester
  • Absence of fetal heart tones and structures
  • HCG titers greater than expected for gestational age
  • Rapid enlargement of uterus or uterine size greater than anticipated for gestational age
  • Preeclampsia in first trimester or early second trimester may be pathognomonic for molar pregnancy
63
Q

Gestational Trophoblastic Disease:

______ pattern

A

snowstorm

64
Q

Hydatidiform Mole=

A

Molar Pregnancy – Benign neoplasm derived almost entirely from abnormal placental (trophoblastic) proliferation

65
Q

Hydatidiform Mole:

-Sx?

A
  • Vaginal bleeding
  • More common in early teens (younger than 20) or perimenopausal (40)
  • May preceed choriocarcinoma
66
Q

Hydatidiform Mole:

-Complete:

A

Contains no fetal tissue, diffuse trophoblastic proliferation, 46xx or 46XY, BHCG >50,000, HIGH

67
Q

Hydatidiform Mole:

-Partial:

A

Contains some fetal tissue, focal trophoblastic proliferation, 69xxx, or 69xxy, BHCG <50,000, slight elevation

68
Q

Hydatidiform Mole: Dx

  • labs?
  • imaging study?
A
  • BHCG levels high because trophoblastic neoplasms produce HCG
  • Ultrasound is diagnostic method of choice for molar pregnancy
69
Q

Hydatidiform Mole: Dx

US findings for Complete mole?

A

**Characteristic hypoechoic areas described as “snowstorm” pattern, normal gestational sac or fetus is not present, theca lutein cysts may be seen on ovaries

70
Q

Hydatidiform Mole: Dx

US findings for Partial mole?

A

*focal areas of trophoblastic changes and fetal tissue may be noted, focal cystic changes in the placenta are also a hallmark finding

71
Q

Hydatidiform Mole: analysis of tissue is obtained from ______

A

dilation and evacuation for histology and DNA content

72
Q

Hydatidiform Mole (Analysis of tissue)

  • Characterized grossly by _____
  • characterized microscopically by_______
A
  • Characterized grossly by: multiple grapelike vesicles filling and distending the uterus
  • Characterized microscopically by: edema of the villous stroma, avascular villi, and nests of proliferating trophoblastic elements surrounding villi
73
Q

Molar Pregnancy: tx?

A
  • Diagnosis confirmed –
  • Termination of molar pregnancy - Evacuation with suction and curettage under general anesthesia
  • Submit tissue for pathologic evaluation
  • Prophylactic chemotherapy – controversial, further studies required
  • Surveillance – Risk of malignant gestational trophoblastic disease 20-30%
  • Close monitoring with serial HCG titers, begin 48 hours after evacuation and continuing weekly intervals until HCG level is undetectable <5. If rise noted within 14 weeks, will need further HCG monitoring for 6 months – 1 year. Avoid pregnancy!!
74
Q

Invasive Mole=

A

=Invasion and/or perforation of the myometrium

  • Locally destructive
  • May have emboli to distant sites (brain, lungs, etc.)
  • Vaginal bleeding
  • Persistent elevated HCG
  • Complication: uterine rupture from invasion of myometrium
  • Molar pregnancy may go on to become malignant choriocarcinoma
75
Q

Choriocarcinoma=

A
  • Malignant tumor, usually of the placenta.

- Abnormal proliferation of cytotrophoblastic and syncytiotrophoblastic cells (produce beta HCG), no chorionic villi

76
Q

Choriocarcinoma:

metastasis?

A

Capable of widespread metastasis

77
Q

Choriocarcinoma: tx?

A

Very sensitive to chemotherapy with a high cure rate

78
Q

Choriocarcinoma:

  • 50% arise from?
  • 25% from?
A
  • 50% arise from pre-existing molar pregnancy
  • 25% from retained placental cells after abortion
  • 25% from normal placenta after completion of a normal pregnancy
79
Q

Choriocarcinoma: dx?

A
  • According to the 2002 criteria established by the International Federation of Gynecology and Obstetrics, malignant gestational trophoblastic disease may be diagnosed in the setting of:
    1. Rise in HCG levels of 10% or greater for >/= 3 values over 2 weeks
    2. Plateau in >/= 4 hCG values over 3 successive weeks
    3. hCG levels elevated at 6 months post-evacuation or
    4. Tissue diagnosis of choriocarcinoma
80
Q

Choriocarcinoma: tx?

A

chemotherapy

Clin Med Final Material- Semester 2 (22 decks)

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