Pregnancy Flashcards
Discuss the first symptoms and subsequent diagnosis of a pregnancy
Presentation - missed period - nausea, vomiting, bloating - food avrsion - breast enlargement and tenderness Investigations - urine bHCG - blood bHCG (normal is <5) - doubles every 36hrs in first 30 days of pregnancy
Discuss the methods to estimate the due date of pregnancy
Gestational Age:
- 1st day of womens last menstrual period
Naegele’s rule:
- 1st day of last menstrual period, minus 3 months and add 7 days
Ultrasound
- done after 6 weeks with crown-rump length to determine age
Discuss the risk factors for a complication in pregnancy
- Maternal age >35
- cardiac disease, hypertension
- diabetes
- thyroid disease
- anemia
- renal disease
- obesity or low body weight
- smoking or substance abuse
- multiple gestations
- grand multiparous
List some of the complications associated with advanced maternal age
- early miscarriage
- chromosomal abnormality
- placental problem
- low birth weight
- pre-term delivery
- fetal death
- multiple gestations
- C-section
Discuss some of the lifestyle changes required for pregnancy
- require extra 300 calories
- folic acid 1mg daily (if epileptic, insulin dependent, obese, or family history require 5mg daily for first 3 months before conception and then 1mg throughout)
- exercise 3-4 times per week
- live vaccines (MMVR, rotavirus) not recommended
Discuss timing of prenatal visits throughout pregnancy
- Every 4weeks between 0-28 weeks
- Every 2 weeks between 28-36 weeks
- Every 1 week from 36 to delivery
What is the fundal-symphysis height?
- uterus first palpbale at pubic symphysis at 12 weeks
- at umbilicus at 20 weeks
- from there should increase 1cm per week
List the 1st trimester screening tests
- Done once before 12 weeks
- IPS
- ultrasound for dating (after 6 weeks)
- CBC for hemoglobin and MCV for anemia (possible electropheresis)
- Blood type and Rh screen
- rubella, HBsAg, VDRL, HIV, urine culture and sensitivity, gonorrheae and chlamydia screen
- PAP test
List the 2nd trimester screening tests
- morphology ultrasound at 18-20 weeks
- gestational diabetes test with non-fasting 50g glucose load at 24-28 weeks
- if <7.8 then normal
- if 7.8-11 then 75g OGT test and measure fasting (>5.3), 1 hour (10.6) and 2 hour (9.0) post
- if >11.1 than positive
List the 3rd trimester screening tests
- Group B streptococcus at 35-37 weeks
Discuss the integrated prenatal screen
Two tests
- ultrasound to assess for nuchal translucency and low pregnancy associated plasma protein at 11-14 weeks to detect Down Syndrome
- maternal serum screening at 15-21 weeks for free beta HCG (high in T21), alpha fetoprotein (high in neural tube defects), and unconjugated estriol (low in T21 and T18
Discuss when you would move to invasive screening
- positive prior screening test
- family history of genetic disease
- maternal age >40
- specific ultrasound finding to follow up
Discuss a chorionic villous sampling
- done at 11-13 weeks from the plancetal villi (1% chance of miscarriage)
- test for genetic disorders
Discuss amniocentesis
- done at 15-22 weeks (<1% risk of miscarriage)
- rapid aneuploidy in 1 week and conventional chromosome analysis in 2-3 weeks
Discuss the placental circulation
- have 2 umbilical arteries where have exchange in the villi capillary (fetal blood) and the intervillous space (maternal blood)
- in maternal circulation there are spiral arteries in endometrium of uterus that drain into the intervillous space. Blood comes back through endometrial veins to the maternal circulation
Discuss the various functions of the placenta: Respiration Endocrine Immunity Nutrition Protection
Respiration
- transport of oxygen by high concentration in maternal blood, greater affinity of fetal hemoglobin, and oxygen dissociation curve pushed to right in maternal blood
Endocrine
- placenta synthesize and metabolize bHCG, estrogen, progesterone, thyroid, lactogen, relaxin, inhibin, GnRH, cortisol
Immunity
- placenta does not produce tissue antigens (except for HLA-G)
Nutrition
- transport nutrients and glucose into fetus
- produce hPL to reduce insulin in maternal system so as to favor transport to fetus
Protection
- act as barrier to prevent toxins from crossing
Discuss when the placenta should be examined following delivery
- maternal fever, bleeding, diabetes, hypertension or prior infertility
- placental anomaly
- fetal prematurity, growth restriction, congenital anomaly, poor APGAR score
List points of examination of the placenta
Umbilical cord: - short or long umbilical cord - small diameter - color (yellow suggest infection) - insertion of cord into membrane or margin - number of vessels - vessel patency (thrombosis) Placental size - normal is 500g Fetal Surface of Placenta - chorion and amnion surface Maternal surface - completeness - color
Discuss the ultrasound findings of the placenta
- can visualize placenta by 8 weeks, but usually not examined until morphological scan
Placental Thickness - normal is 2-4cm in 1st and 2nd trimester and then 4-5cm in 3rd trimester
- small placenta due to insufficiency
- thick placenta due to diabetes, anemia, hydrops, hemorrhage, infection, genetic syndrome
Placental Volume - normal is 16mL at 10 weeks and 200mL at 23 weeks
Placental Implantation - determines the adequacy of the implantation to the endometrium
- acreta (invasion to myometrium)
- increta (invasion penetrating myometrium)
- percreta (invasion through uterus)
Discuss some placental anomalies discovered on ultrasound
Placenta previa - placenta within 2cm of internal cervical os Placental abruption - seperation of placenta from myometrium - hyperechoic fluid inbetween Placental Insufficiency - intra-uterine growth restriction - oligohydramios - abnormal doppler utlrasound Circumvallate and Succenturiate Placenta - abnormal placenta
List the differential for 3rd trimester bleeding
Pregnancy Related - placental abruption - placental previa - vase previa - uterine rupture - cervical insufficiency Non-Pregnancy Related (PALM CE) - polyps - adenomyosis - leiomyoma - malignancy - coagulopathy - endometrial dysfunction (infection)
Discuss the presentation and management of placenta abruption
Risk Factors - age >35 - prior placental abruption - C-section - multi-parity - hypertension - cocaine - trauma Pathophysiology - marginal seperation - partial separation - complete separation Presentation - bleeding per vagina with pain uterine contractions - tenderness and hard uterus - fetal distress Management - stabilize - delivery (vaginal only if not in distress and fetus is mature)
Discuss the presentation and management of placenta previa
Risk factors - advanced maternal age - previous previa - multi-parity - previous surgery of uterus - multiple gestation Pathophysiology - grade 1: low lying where it is within 5cm of os - grade 2: marginal, where reaches os but does not cover - grade 3: partial coverage - grade 4: complete coverage Presentation - painless bright red vaginal bleeding during 2nd half of pregnancy - no pelvic exam due to risk of sudden, massive bleeding Management - C-section
Discuss the presentation and management of vasa previa
Risk Factors
- IVF pregnancy
- resolved previa, bilobed or succinturiate placenta
Pathophysiology
- fetal vessels unsupported by umbilical cord and lie over the cervix
Presentation
- triad of membrane rupture leading to painless vaginal bleeding and fetal bradycardia
- pulsating vessel in membrane
Management
- C-section
Differentiate between
- Pre-existing hypertension with pre-eclampsia
- Gestational hypertension
Pre-existing - hypertension that was present before pregnancy or before 20 weeks gestation with >=1 of the following after 20 weeks - resistant hypertension - new or worsening proteinuria - >=1 adverse condition - >=1 serious complication Gestational - hypertension with evidence of >=1 of the following after 20 weeks gestation - new proteinuria - >=1 adverse condition - >=1 serious complication
Discuss the definition and adverse events of pre-eclampsia
- pre-eclampsia is new proteinuria >300mg over 24hrs, or >1 adverse condition or >1 severe complication associated with SBP >140 and DBP >90 Adverse Condition - thrombocytopenia - headache, visual symptoms - chest pain - abnormal fetal heart rate - IUGR Severe Complication - eclampsia (seizure) - acute kidney injury - placental abruption - HELLP syndrome (hemolysis, elevated Liver Enzymes, Low Platelets)
Discuss the Risk Factors for pre-eclampsia
Maternal - age >40 - previous pre-eclampsia - previous miscarriage with same partner - pre-existing hypertension Current pregnancy - multiple gestations - maternal obesity - new partner - IVF
Discuss the pathophysiology of pre-eclampsia
- decidual immune cells and extravillous trophoblast interact and cause invasion and uteroplacental artery remodelling
- lead to inadequate placentation leading to release of mediators
- mediators result in endothelial cell activation and dysfunction within vulnerable organ systems
List preventative strategies for pre-eclampsia
Low Risk
- supplement with calcium and folic acid
- exercise
- abstinence from alcohol and smoking
High Risk
- low dose aspirin before 16 weeks until delivery
- L-arginine and increased rest at home within 3rd trimester
Discuss the management of pre-eclampsia
Lifestyle - exercise - salt reduction Blood Pressure Control - Methyldopa 250-500mg Q6-12H - labetalol 100-400mg Q8-12H - Nifedipine XL 20-60mg PO daily - no ACE or ARB
Discuss the Management of non-severe pre-eclampsia
<24 Weeks - deliver within days 24-34 Weeks - expectant management (IV access, administration of anti-hypertensives, corticosteroids for fetal lungs, and daily fetal and maternal labs and assessments) - possible delivery 34-37 weeks - expectant management or possible immediate delivery >37 Weeks - Immediate delivery
Discuss the management of severe pre-eclampsia (>160/110 or serious complication)
- maternal and fetal continuous checks
- blood pressure control with first-line agents (nifedepine 5-10mg Q30, labetalol 20mg Q30, hydrazine 5mg Q30)
- prophylaxis against eclampsia with MgSO4 4g IV
- HELLP treatment with fresh frozen plasma
- C section
Discuss the Post-Partum Management of Pre-Eclampsia
Early Management (6 weeks)
- control blood pressure with anti-hypertensive (<140/90)
- same as above with possible captopril and enalapril with breast feeding
Long Management (>6 weeks)
- screening of electrolytes, creatinine, fasting glucose, fasting lipids, urinalysis, ECG
- lifestyle changes
Discuss the presentation and management of ectopic pregnancy
Risk Factors
- older women, African women
- uterine abnormality: fibroids, adhesions
- prior ectopic
- IUD
- PID
- surgery of fallopian tube
Pathophysiology
- 70% are located in the ampulla of the fallopian tube (next are ampulla and fimbrae)
Presentation
- abdominal pain
- vaginal bleeding
- peritoneal signs
- tenderness to bimanual examination
Investigations
- bHCG (normally doubles ever 2 days, in non-viable will have slower, plateau or decrease)
- abdominal ultrasound (bHCG greater than 6000), transvaginal (>1500) to visualize pregnancy
Management
- stabilize
- surgical abortion (>3.5cm, fetal HR present, bHCG >5000, liver or renal disease, poor follow up)
- medical abortion (<3.5cm, fetal HR absent, bHCG <5000, good follow up) - methotrexate 500mg/m2
Discuss the presentation and management of spontaneous abortion
- 10-15% of all pregnancies
Presentation - abdominal cramping
- vaginal bleeding
- rupture of membranes
- passage of tissue or clots
- open cervix in incomplete, complete and missed, closed in threatended, inevitable and missed
Investigation - bHCG and ultrasound
Management - Rh negative then RhoGram
- septic abortion require broad-spectrum Abx
- Threatened: watch and wait
- Inevitable: retained products so require misprostol and possible dilatation and curretage
- Incomplete: retained products so require misprostol and possible dilatation and curretage
- Complete: no management required
- Missed: possible retained products so require misprostol and possible dilatation and curretage
List the differential for 1st trimester bleeding
- physiologic from spotting due to implantation of placenta
- abortion
- abnormal pregnancy
- trauma
- genital lesion
