Pregnancy complications Flashcards
A spontaneous abortion occurs within how many weeks of pregnancy?
20 weeks
What are some fetal risk factors for spontaneous abortion?
Chromosomal abnormalities i.e trisomy, monosomy X
What are some maternal risk factors for spontaneous abortion?
- previous abortion
- smoking
- infection
- BMI <18.5 or >25
What lab should you draw if you suspect spontaneous abortion?
Bhcg
Tx for spontaneous abortion?
if less than 13weeks than just expectant management
If greater than 13 weeks then medication abortion with Misoprostol
When can you do a dilation and curretage for an abortion?
within the first trimester
When would you do a dilation and evacuation for an abortion tx?
2nd trimester
What are the five types of miscarriages?
- Spontaneous
- Threatened
- incomplete
- inevitable
- missed
Which types of miscarriages have dilated cervical OS?
- incomplete
2. Inevitable
Death of a fetus before 20 weeks of gestation with the products of conception remaining intrauterine is what kind of miscarriage?
missed
Describe a threatened abortion?
bloody vaginal discharge before 20 weeks with or without uterine contractions in the presence of a closed OS
How many consecutive pregnancy losses do you need to make it recurrent spontaneous abortions?
3
Where do 95% of ectopic pregnancies occur?
in the fallopian tubes
55% in the ampulla
What are the classic features of ectopic pregnancy?
- abdominal pain
- bleeding
- Adnexal mass
what is the MCC for ectopic pregnancy?
occlusion of tube secondary to adhesions
What level of Beta Hcg do you need to for it to be ectopic?
greater than 1500 without a intrauterine fetus
If you were to get serial B-Hcgs, how much would you expect them to increase in two days given it was a normal pregnancy?
should double if they arent you should be worried
What imaging is preferred for dx ectopic pregnancy?
Transvaginal U/S
What is the finding on ultrasound called when evaluating an ectopic pregnancy?
Ring of Fire- hypervascular lesion with peripheral vascularity on color or pulsed Doppler examination of the adnexa due to low impedance high diastolic flow
When can you use methotrexate for an ectopic pregnancy?
Only if beta HCG < 5,000, ectopic mass is < 3.5 cm, no fetal heart tones, hemodynamically stable, no blood disorders, no pulmonary disease, no peptic ulcer, normal renal function, normal hepatic function, compliant pt that can return for follow up
How does methotrexate work?
it is a folic acid antagonist that inhibits DNA replication.
Again what are the indications for methotrexate in the setting of an ectopic pregnancy?
- hemodynamically stable
- B-Hcg >5,000
- no fetal heart tones
- ability to comply with post-treament f/u
What is the most common complication of gestational diabetes on the child?
Macrosomia
How do you screen for gestational diabetes?
- administer non-fasting 50-g glucose challenge test
2. obtain serum glucose level 1-hour later. If greater than 130 administer a 3 hour glucose challenge test
describe a 3-hour glucose challenge test?
you give 100-gram glucose load given to a patient i the morning who has fasted over night for at least 8 hours you then check serum glucose levels
what serum glucose levels for the 3-hour glucose challenge test indicate diabetes?
- fasting greater than 95
- 1 hour 180 or above
- two hours 155 and above
- 3 hours 140 and above
How often should people with gestational diabetes check their glucose levels?
daily
in the morning after fasting overnight
and after each meal.
What level of glucose may need insulin?
patients who have a fasting blood glucose level of greater than 105 or a 2 hour postprandial blood sugar greater than 120.
What is the goal fasting blood glucose for gestational diabetes and on insulin?
less than 95
What types of insulin is recommended for gestation diabetes?
NPH/regular
2/3 in the am
1/3 in pm
What PO form of diabetic medication can be used for preggos?
Glyburide because it doesnt cross the placenta but it does have a higher risk of preeclampsia
What do we want the serum glucose level to be at 2hour post prandial?
Less than 140 indicates good glucose control
What do you need to do weekly if the preggo needs to be on insulin?
need to have weekly fetal heart rate monitoring
What are some signs that someone is having a molar pregnancy?
ßHCG higher than expected, size-date discrepancy, hyperemesis
What is another name for a benign molar pregnancy?
hydatidiform moles
If you have a huge value for B-hcg and see a grape-like mass or snow-storm on transvaginal ultrasound do you think it is a complete or incomplete mole?
complete
what type of cancer can develop in pregnancy related to molar pregnancy?
Choriocarcinoma
What B-Hcg value is diagnostic of molar pregnancy?
HCG > 100,000
What form of imaging is the go to for dx molar pregnancy?
transvaginal ultrasound
How is the diagnoses of invasive moles/choriocarcinoma made?
- when HCG levels plateau, meaning they remain within 10% of the previous result, over a three week period,
- or when HCG levels increase more than 10% across three values recorded over two weeks,
- or when there is still detectable serum HCG up to 6 months after evacuation of a molar pregnancy
What is the workup for persistent mole and choriocarcinoma?
- CXR
2. Head/abdomen and pelvis CT /contrast
Describe the stages of the tumor involved in persistent mole and choriocarcinoma?
Stage I tumors are confined to the uterus, and there are no metastases
Stage II tumors extend to the fallopian tubes, the ovaries, or the vagina
Stage III tumors have lung metastases, regardless of genital structure involvement
Stage IV tumors have metastases in any organs other than the lungs or the genital structures
What is the treatment for complete and incomplete mole?
uterine evacuation via suction curettage
What lab value should you follow up on after a uterine evacuation via suction curettage for a complete or incomplete mole?
measure serum HCG weekly, until it’s undetectable for three consecutive weeks, and then once a month for 6 months
Tx for choriocarcinoma?
resect, methotrexate, chemotherapy based on the score.
A score between 0 and 6 means low risk, so treatment relies on a single chemotherapeutic agent like methotrexate
A score higher than 6 means high risk, and combination chemotherapy regimen like EMA-CO
Remission is defined as three consecutive undetectable HCG levels during weekly monitoring
describe what an incompetent cervix is?
spontaneous, premature dilation or shortening of the cervix during the second or early third trimester (up to 28 weeks)
What would you see on PE of the cervix in someone with incompetent cervix?
cervical dilation >2cm
Less than 25mm at or before 24 weeks
What are some risk factors for incompetent cervix?
h/o cervical insufficiency
hx of injury
surgery
DES exposure in utero
How do you diagnose incompetent cervix?
transvaginal ultrasound
What will you see on transvaginal ultrasound for someone with incompetent cervix?
funneling of the cervix
a common cervical length for someone with incompetent cervix is what?
length < 25 mm before 24 wks, normally a cervix will be at least 30mm
What is the tx for incompetent cervix?
cervical cerclage placed at 12-16 weeks and removed at 36-38 weeks
Which is painful placenta abruption or previa?
abruption
what is the MC cause of third trimester bleeding?
placenta abruption
what are some risk factors for placenta abruption?
- trauma
- smoking
- hypertension -MC risk factor
- preeclampsia
- cocaine abuse
How do you diagnose placenta abruption?
it is made clinically, ultrasound is minimally useful but is usually ordered
what might an ultrasound show during placenta abruption?
retroplacental blood collection
Tx for placenta abruption?
delivery of the fetus and placenta - via c-section always
do a blood type, crossmatch and coag studies along with large-bore IV line
Should you give corticosteroids for placenta abruption?
yes to help enhance fetal lung maturity
What are the different types of placenta previa?
- complete
- Partial
- Marginal
- Low-lying
- Vasa previa
Describe the different types of placenta previa?
Complete- placenta completely covers the internal os
Partial- only covers a portion of the os
Marginal- edge of the placenta reaches the margin of the os
low-lying- implanted in the lower uterine segment in close proximity but not extending to the internal OS.
Vasa previa- Fetal vessel may lie over the cervix
When does placenta previa usually occur?
it is painless vaginal bleeding usually occurs after 28 weeks of gestation
What are some fetal complications associated with placenta previa?
- preterm delivery
2. preterm PROM
How do you dx placenta previa?
transvaginal ultrasound
a vaginal exam is contraindicated
What is the difference between eclampsia and preeclampsia?
eclampsia is the development of seizure in the setting of someone with preeclampsia
what time period can preeclampsia occur?
between 20 weeks gestation and 6 weeks postpartum
What is the classic triad of preeclampsia?
- HTN
- Proteinuria
- edema
after 20 weeks gestation
You must have HTN and proteinuria
What is the classification of this preeclampsia? BP 140/90 - 160/110, Proteinuria >300mg/24hr or >1+ on dipstick, edema of face hands and feet
This is mild preeclampsia and delivery is the only treatment at 34-36 weeks
Can give steroids to help mature lungs
What would severe preeclampsia be classified as?
- BP 160/110
- proteinuria >5g in 24hr or dipstick of 3+
- pulmonary edema
- vision changes
- HEELP
What does HELLP stand for?
- Hemolysis
- Elevated liver enzymes
- Low platelets
What is the tx for severe preeclampsia? What medication do you want to administer?
- delivery at 34-36 weeks
2. Magnesium sulfate
If BP is 180/110 in a preggo what BP med should you give?
hydralizine
If patient meets all the requirements for preeclampsia and also has a seizure or coma what do they have?
eclampsia
Gestational hypertension is defined as?
BP >150/90 after 20 weeks into the pregnancy that resolves 12 weeks postpartum
Will you have proteinuria in gestational hypertension?
NO just elevated BP
Chronis hypertension in a preggo is defined as what?
BP >140/90 before 20 weeks gestation that resolves 6 weeks postpartum
How often should you monitor chronic hypertension?
every 2-4 weeks until weeks 34-36 then you should monitor it weekly.
What is the drug of choice in severe chronic hypertension?
Alpha Methyldopa is the drug of choice, avoid ACEI and diuretics, labetalol or nifedipine are safe alternatives
If mom is RH (-) and baby is Rh (+) can mom potentially kill baby?
yes mom may develop antibodies against babies blood.
is the first pregnancy always protected when in come to RHo?
yes
When should you give mom Rhogam?
Give Rhogam at first prenatal visit, 28 weeks, and within 72 hours of delivery and during any uterine bleeding throughout pregnancy
