Preconception Counseling-Paulson Flashcards
Prenatal Care
- 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
Preconception Counseling
- 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
Preconception Counseling:
-What supplement should all Pregnant Pts take?
- *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
Preconception Counseling:
-What should be checked?
- 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.
Preconception Counseling Video:
https://www.youtube.com/watch?v=k9GJEvPnmlQ
Infertility is defined as:
No pregnancy after trying for 12 months with normal sexual activity without contraception
What is Advanced Maternal age (AMA) defined as?
35yo and older (AMA) – infertility increases with age
Infertility:
-Male factor diagnosed in __% of infertile couples
25 - 40%
Infertility:
-majority of couples can be treated with?
- –>use of assisted reproductive technologies (ART):
- Ovulation induction
- Insemination with sperm
- In vitro fertilization
Factors leading to Infertility in females
- Anovulation
- Endometriosis
- Fibroids
- Tubal factor
- Cervical factor
-idiopathic
Infertility in Males
several causes
Male Infertility Work-up
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
Female Infertility Work-up
- History
- PE
- Monitoring of Ovulation
- Hormone Analysis
- Studies of anatomy – (fallopian tubes and uterine cavity) – hysterosalpingogram
- Chromosomal Studies
Maternal – Fetal Physiology:
-cardiac?
- 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
Maternal – Fetal Physiology:
-Heme
- Increase in plasma volume 50%
- RBCs only increase 20-30% (decreased HCT)
- WBCs increase
- Slight decrease in platelets
- Hypercoagulable state (increased fibrinogen)
Maternal – Fetal Physiology:
-GI?
- 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
Maternal – Fetal Physiology:
-endocrine?
- Increased estrogen -> increased thyroid binding globulin
- Increased metabolic demand -> increase T3/T4
Maternal – Fetal Physiology:
-Renal?
- Kidneys increase in size
- GFR increases by 40-65%
Maternal – Fetal Physiology:
-Pulmonary?
- Increase in tidal volume 35-50%
- Increase in inspiratory capacity and minute ventilation
Maternal – Fetal Physiology::
-Derm?
- Spider angiomas and palmar erythema (increased estrogen)
- Hyperpigmentation of nipples, umbilicus, abdominal midline (linea nigra), and face (melasma or cholasma)
Fetal Circulation:
-Describe
- 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
First Trimester Bleeding:
-Approx. ___% of pregnant women experience first trimester bleeding
25%
First Trimester Bleeding:
-etiology?
- Implantation into the endometrium
- Abortion
- Ectopic pregnancy
- Molar gestation
- Infection
Abortion: defined as?
Termination of pregnancy before 20 weeks
Abortion: 2 types
- Spontaneous abortion (SAB)
- Therapeutic abortion (TAB)
Abortion: Sx
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)
Complete Abortion
- 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
Inevitable abortion
- 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
Threatened Abortion
-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
Threatened Abortion
- 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
Incomplete Abortion:
- describe
- Sx?
- Only some products of conception are passed before 20 weeks
- Moderate to severe cramping
- Heavy bleeding
- Cervical os is dilated
Incomplete Abortion:
- prognosis?
- tx?
-Prognosis is poor
Treatment – options include surgical (D&C), medical, or expectant management
Missed Abortion:
- defined as ?
- sx?
- Embryo is not viable prior to 20 weeks
- Products of conception retained in uterus
- No cervical dilation
Sx: Cramping or bleeding may be present
Missed Abortion:
-tx?
options include surgical (D&C), medical, or expectant management
Septic Abortion=
- 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
Septic Abortion: dx?
CBC, UA, endocervical cultures, blood cultures, and abdominal x-ray to r/o uterine perforation. Ultrasound should be done to look for retained POCs.
Septic Abortion: tx?
Hospitalization and IV antibiotics with anaerobic and aerobic coverage. May need D&C for retained POCs.
Elective Abortion
- Complete social hx, medical hx, PE, including uterine size/position
- Missed period
- Medical abortion (using oral medication)
Elective Abortion:
-describe the Medications that can be used for medical abortions (hint: 3 M’s)
- 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
Elective abortion:
-surgery?
- Suction or surgical curettage
- Dilation and evacuation – More common for second trimester abortions, up to 18 weeks gestation in outpatient setting
Abortion:
Suction Curettage
=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
Recurrent Pregnancy Loss: defined as?
3 or more consecutive SABs before 20 weeks
Recurrent Pregnancy Loss:
-etiology?
- May be genetic, auto-immune, anatomic, endocrine, thrombophilic (table 13-1 in Lange)
- Affects up to 5% of couples
Recurrent Pregnancy Loss:
Prognosis?
Prognosis after repeated losses is good with most couples having ~60% chance of viable pregnancy
Anembryonic Pregnancy
- 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
Gestational Disorders: list Ex’s
- Ectopic Pregnancy
- Gestational Trophoblastic Disease/Diseases of Trophoblastic tissue
List Ex’s of Gestational Trophoblastic Disease/Diseases of Trophoblastic tissue
- Hydatidiform mole
- Complete
- Partial - Invasive Mole
- Choriocarcinoma
Ectopic Pregnancy: defined as?
Implantation of the fetus in any site other than the endometrial cavity (1.5-2% )of all pregnancies
Ectopic pregnancy: MC site?
within the fallopian tubes (95%)
Ectopic pregnancy: risk factors?
Prior ectopic, PID, smoking, anatomic abnormalities, IUD
Ectopic pregnancy:
-Complications?
Tubal Rupture, Hemorrhagic shock, Death!
What is the leading cause of pregnancy related death in first trimester?
**ectopic pregnancy
Ectopic Symptoms:
Pain – pelvic or abdominal pain present in almost 100% of cases
Bleeding – Abnormal uterine bleeding occurs in ~ 75% of cases
Amenorrhea
Syncope
Ectopic PE findings:
- Adnexal Mass
- Uterine changes
- Hemodynamic instability – vital signs
Ectopic Pregnancy Diagnosis
- labs?
- imaging study?
- 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
Ectopic Pregnancy Treatment:
-first line tx?
- 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)
Ectopic pregnancy:
-surgical tx?
Surgical - Laparoscopy:
- -Salpingostomy
- -Salpingectomy
Salpingostomy=
small incision in tube
Salpingectomy=
part of tube removed
Ectopic Pregnancy Treatment:
emergency tx?
-Surgery in ruptured ectopic, transfusion usually required
Ectopic pregnancy:
make sure to tell the Pt ____
No intercourse!!
Gestational Trophoblastic Disease
- 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
Gestational Trophoblastic Disease:
______ pattern
snowstorm
Hydatidiform Mole=
Molar Pregnancy – Benign neoplasm derived almost entirely from abnormal placental (trophoblastic) proliferation
Hydatidiform Mole:
-Sx?
- Vaginal bleeding
- More common in early teens (younger than 20) or perimenopausal (40)
- May preceed choriocarcinoma
Hydatidiform Mole:
-Complete:
Contains no fetal tissue, diffuse trophoblastic proliferation, 46xx or 46XY, BHCG >50,000, HIGH
Hydatidiform Mole:
-Partial:
Contains some fetal tissue, focal trophoblastic proliferation, 69xxx, or 69xxy, BHCG <50,000, slight elevation
Hydatidiform Mole: Dx
- labs?
- imaging study?
- BHCG levels high because trophoblastic neoplasms produce HCG
- Ultrasound is diagnostic method of choice for molar pregnancy
Hydatidiform Mole: Dx
US findings for Complete mole?
**Characteristic hypoechoic areas described as “snowstorm” pattern, normal gestational sac or fetus is not present, theca lutein cysts may be seen on ovaries
Hydatidiform Mole: Dx
US findings for Partial mole?
*focal areas of trophoblastic changes and fetal tissue may be noted, focal cystic changes in the placenta are also a hallmark finding
Hydatidiform Mole: analysis of tissue is obtained from ______
dilation and evacuation for histology and DNA content
Hydatidiform Mole (Analysis of tissue)
- Characterized grossly by _____
- characterized microscopically by_______
- 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
Molar Pregnancy: tx?
- 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!!
Invasive Mole=
=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
Choriocarcinoma=
- Malignant tumor, usually of the placenta.
- Abnormal proliferation of cytotrophoblastic and syncytiotrophoblastic cells (produce beta HCG), no chorionic villi
Choriocarcinoma:
metastasis?
Capable of widespread metastasis
Choriocarcinoma: tx?
Very sensitive to chemotherapy with a high cure rate
Choriocarcinoma:
- 50% arise from?
- 25% from?
- 50% arise from pre-existing molar pregnancy
- 25% from retained placental cells after abortion
- 25% from normal placenta after completion of a normal pregnancy
Choriocarcinoma: dx?
- 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
Choriocarcinoma: tx?
chemotherapy
