Pregnancy Complications Flashcards
pregnancy complications to know
abortion
ectopic
GDM
trophoblastic dz
incompetent cervix
placenta abruption
placenta previa
preeclampsia/eclampsia
pregnancy induced HTN
Rh incompatability
5 types of abortion
spontaneous
threatened
incomplete
inevitable
missed
expulsionof all or part of products of conception before 20 weeks gestation
spontaneous abortion
-bloody vaginal d.c before 20 weeks gestation w. or w.o uterine contractions
-cervical os closed
threatened abortion
-dilated cervical os
-some passage of products of conception before 20 weeks
incomplete abortion
-dilated cervical os
-no passage of products of conception before 20 weeks gestation
inevitable abortion
-death of the fetus before 20 weeks gestation
-no products of conception passed
-cervical os closed
missed abortion
definition for reccurent spontaneous abortions
3 or more consecutive pregnancy losses
80% of spontaneous abortions occur during the first _ weeks of pregnancy
12
fetal RF for spontaneous abortion
chromosomal abnormalities
2 chromosomal abnormalities mc associated w. spontaneous abortion
trisomy
monosomy X
maternal rf for spontaneous abortion (lots!)
previous spontaneous abortion
smoking
infxn
anatomic anomalies (ex fibroids)
asherman syndrome
maternal dz
gravidity
fever
prolonged time to achieving pregnancy
BMI < 18.5 OR > 25
celiac
3 sx of spontaneous abortion
vaginal bleeding
abd pain
lbp
labs useful in spontaneous abortion (6)
b-hCG
CBC
blood type
abs screen
US
placentation
management of spontaneous abortion < 13
expectant management
management of spontaneous abortion > 13 weeks
medical abortion:
1. mifepristone (angioprogestin)
PLUS misoprostol (PG)
2. 1st trimester: D&C
3. 2nd trimester: dilation and evacuation
32 yo f w. sudden onset LLQ pain that radiates to the back/scapula and vaginal bleeding - LMP was 5 weeks ago - hx PID and unprotected sex
ectopic pregnancy
2 mc places for ectopic pregnancies
- fallopian tubes
- ampulla
3 classic sx of ectopic pregnancy
abd pain
bleeding
adnexal mass
mc cause of ectopic pregnancy
occlusion of tube 2/2 to adhesions
6 rf for ectopic pregnancy
-previous hx
-previous salpingitis (PID)
-previosu abd/tubal surgery
-use of IUD
-assisted reproduction
-smoking
5 sx of ruptured ectopic pregnancy
severe abd or shoulder pain
peritonitis
tachycardia
syncope
orthostatic HTN
labs for ectopic
- bHCG > 1,500 w.o fetus in utero
- serial bHCG increases less than expected
- get baseline bHCG and f/u hormones in 48 hr -> if not doubling -> probs ectopic
expected increase in bHCG
it should double q 2 days
at what bHCG level should you be able to see e/o developing intrauterine gestation on US
1,500
if not, suspect ectopic
imaging for ectopic
transvaginal US
IUP should be visible by 5-6 weeks
what is the ring of fire sign on US
hypervascular lesion w. peripheral vascularity -> ectopic
4 indications for MTX tx for ectopic
-hemodynamically stable
-hCG < 5,000
-ectopic mass < 3.5 cm
-no fetal cardiac activity
-ability to comply w. post tx/f.u
7 contraindications for MTX for ectopic
-current breastfeeding
-active pulmonary dz
-immunodeficiency
-blood disorder
-peptic ulcer
-impaired renal/hepatic fxn
-hypersensitivity to MTX
moa for MTX
folic acid antagonist -> inhibits DNA replication
surgical tx of ectopic
lparaoscopy salpingostomy
_ is crucial in consideration of tx for ectopic
ability of pt to f.u
t/f: GDM is a rf for T2DM post pregnancy
t!
mc complication of GDM
macrosomia
dx for GDM
- first prenatal visit: random BG on all pregnant women
- 24-48 weeks: non fasting 1 hr 50g OGTT serum glucose level 1 hr later
- if 1 hr serum BG > 130 -> 3 hour 100 g OGTT
what indicates positive on a 3 hr 100g OGTT
BG >/= the following values at two or more time points:
-fasting: 95
-one hour: > 180
-two hour: > 155
-4 hr: > 140
when should pt’s w. GDM check their BG
daily:
after fasting overnight
after each meal
indications for insulin w. GDM
-fasting BG > 105
-2 hr post prandial BG > 120
tx of choice for GDM
insulin
fasting BG goal for GDM
< 95
only oral DM med that is ok in pregnancy
glyburide
glyburide increases risk of
eclampsia
a macrosomic child should be delivered at _ weeks via _
38 weeks
c section
good control of GDM is described as 2 hr OGTT <
140
when should FHR be monitored in pt w. GDM
weekly
what complications are you worried about for baby in mom w. GDM (5)
hypoglycemia
shoulder dystocia
cardiac abnormalities
respiratory distress syndrome
IUGR (intrauterine growth restriction)
gestational trophoblastic dz includes (2)
molar pregnancy
choriocarcinoma
31 yo f, LMP 6 weeks ago - bHCG 100,000 - US has a snowstorm pattern
gestational trophoblastic dz
gestational trophoblastic dz includes both benign and malignant
proliferation of placental cells
3 signs of gestational trophoblastic dz
bHCG higher than expected
size/date discrepancy
hyperemesis
2 rf for molar pregnancy
maternal age extremes (<20, >35)
previous molar pregnancy
benign gestational trophoblastic dz
molar
aka hydatidiform moles
two types of molar pregnancy
complete
incomplete
6 signs of complete molar pregnancy
huge amounts of hCG
missed periods
positive pregnancy test
vaginal bleeding
hyperthyroidism sx
uterus larger than expected for GA
3 US findings of molar pregnancy
grape-like mass
snow storm
swiss cheese pattern
2 signs of incomplete molar pregnancy
-elevated hCG but not as much as complete
-uterus NOT larger than expected
most incomplete molar pregnancies result in
spontaneous abortion
t/f:both complete and incomplete molar pregnancies are premalignant conditions that can develop into invasive moles
t!
malignant trophoblastic pregnancy can develop from (2)
benign moles (complete and incomplete)
choriocarcinoma
malignant trophoblastic gestation is same-same
invasive moles
placental ca that mc occurs in absence of molar pregnancy
choriocarcinoma
invasive moles ALWAYS develop after _
choriocarcinoma may develop after _
invasive moles: molar pregnancy
choriocarcinoma: molar pregnancy OR regular pregnancy
hCG > _ are diagnostic of molar pregnancy
100,000
with complete molar pregnancies, _ may be seen on one or both ovaries
lutein cysts
with incomplete moles, fetal parts may be visible and there is often
oligohydraminos
dx of invasive moles and choriocarcinoma is made when (3)
-hCG levels plateau (remain w.in 10% of previous result x 3 weeks)
OR
-hCG levels increase > 10% across 3 values x 2 weeks
OR
-there is detectable serum hCG up to 6 months after evacuation of molar pregnancy
2 US findings of invasive mole
anechoic areas
high vascular flow
US findings of choriocarcinoma
-heterogeneous single mass distending from uterus
-areas of necrosis and hemorrhage
work up for persistent mole and choriocarcinoma
-CXR
-head/abd/pelvis CT
stages I-IV invasive moles/choriocarcinoma
I: tumors confined to uterus
II: tumors extend to fallopian tubes, ovaries, or vagina
III: tumors have lung metastases, regardless of genital structure metastases
IV: tumors have metastases in any organ other than lungs or genital structures
tx for complete and incomplete mole
- uterine evacuation via suction curretage
- histological analysis of contents
- hCG weekly until no longer detectable for 3 weeks; then monthly x 5 months
- if bHCG rises: consider persistent invasive mole vs choriocarcinoma
tx for choriocarcinoma
0-6: low risk -> MTX
> 6: high risk -> combo chemo
remission of choriocarcinoma is defined as
3 consecutive undetectable hCB levels during weekly monitoring
32 yo F, G7P0A3 in 13th week of pregnancy - hx of 3 consecutive fetuses before 20 weeks gestation and 3 spontaneous first trimester abortions
incompetent cervix
premature, dilation, or shortening of the cervix during the second or early third trimester of pregnancy
incompetent cervix
incompetent cervix mc presents with _ trimester miscarriages
second trimester
5 rf for incompetent cervix
prev hx
hx of injury/surgery
colonization
DES exposure in utero
anatomic abnormalities
PE findings of incompetent cervix
cervical dilation > 2 cm
minimal contractions until 4 cm
bleeding/d.c mc in 2nd trimester
dx for incompetent cervix
transvaginal US
US finding of incompetent cervix
funneling of the cervix
btw 18-22 weeks, the US focuses on
detecting fetal abnormalities
normal length cervix:
incompetent cervix length:
normal: 30 mm
incompetent: < 25 mm before 24 weeks
tx for incompetent cervix
-cervical cerclage placed at 12-16 weeks
-removed at 36-38 weeks for delivery
2 things that need to be done before placement of a cervical cerclage
-culture G/C and GBS
-comfirm viable intrauterine pregnancy
29 yo F, 36 weeks gestation w. sudden onset of back pain w. uterine contractions that are very close together - c/o painful bright red vaginal bleeding - pelvis is ttp - cervix is closed, no e/o rupture of membranes
placental abruption
premature separation of all/section of otherwise normally implanced placenta from the uterine wall after 20 weeks gestation resulting in hemorrhage
placental abruption
mc cause of third trimester bleeding
placental abruption
5 rf for placental abruption
prev hx
trauma
smoking
HTN
preeclampsia
cocaine
heavy painful vaginal bleeding in the 3rd trimester is _ until proven otherwise
placental abruption
dx for placental abruption
clinical…always
US finding of placental abruption even tho you don’t need it for dx
retroplacental blood collection
what might you find in the vagina w. placental abruption
blood stained amniotic fluid
2 fetal signs of placental abruption
decelerations -> fetal hypoxia
bradycardia
tx for placental abruption (5)
delivery of fetus and placenta
corticosteroids
type and screen
coag studies
large bore IV
why give corticosteroids for placental abruption
enhance fetal lung maturity
management of small placental abruptions
expectant management
32 yo f, G2P1 at 35 weeks gestation - c/o painless vaginal bleeding x 2 hr w. substantial amt of blood clot d/c - no cramping, fetal HR nl - last pregnancy was via emergency c section at 37 weeks due to breech
placenta previa
condition in which placenta lies very low in the uterus and covers all parts of the cervix
placenta previa
5 types of placenta previa
complete
partial
marginal
low-lying
vasa previa
placenta completely covers internal os
complete placenta previa
placenta covers a portion of the intenal os
partial previa
edge of the placenta reaches the margin of the os
marginal previa
placenta implanted in lower uterine segment in close proximity but not extending to the internal os
low-lying previa
fetal vessel may overlie the cervix
low lying previa
painless vaginal bleeding after 28 weeks is always
placenta previa
bleeding from placenta in placenta previa results from (2)
-small disruptions in placenta
-thinning of lower uterin segment during third trimester
5 fetal complications of placenta previa
preterm delivery
preterm PROM
intrauterine growth restriction
vasa previa
congenital abnormalities
4 rf for placenta previa
prior c section
multiple gestations
multiple induced abortions
advanced maternal age
dx for placenta previa
transvaginal US
what exam is contraindicated w. placenta previa
digital vaginal exam
tx for placenta previa
strict rest
no intercourse
no vigorous exercise
+/- transfusion
c-section
Rhogam if Rh-
delivery 34-37 weeks
what differentiates eclampsia from preeclampsia
eclampsia: development of sz in a woman w. preeclampsia
time period in which pre-eclampsia may occur
20 weeks gestation to 6 weeks postpartum
preeclampsia triad
HTN
proteinuria
+/- edema
after 20 weeks gestation
mild preeclampsia parameters
-140/90 - 160/10
-proteinuria: > 300 mg/24 hr OR > +1 on dipstick
-edema of face, hands, feet
only cure for preeclampsia
delivery ->
at 34-36 weeks
t/f: preeclampsia requires c section
f!
only if complications
management of moderate preeclampsia
-steroids to mature lungs at 26-30 weeks
-daily weights and BP
-weekly dipstick
-bed rest
severe preeclampsia parameters
-BP > 160/110
-proteinuria: > 5 g x 24 hr OR no urine OR 3+ on dipstick
-pulmonary edema
complication of severe preeclampsia
HELLP syndrome:
hemolysis
elevated LFTs
low platelets
management of severe pre eclampsia
-hospitalization
-Mg sulfate
+/- BP meds
indication for BP meds w. severe eclampsia
BP med of choice
BP > 180/110
hydralazine
HTN + proteinuria should make you think
pre eclampsia
pt’s w. preeclampsia w.o severe sx are generally induecd into labor after _ weeks
pt’s w. severe preeclampsia are generally induced at _ weeks
preeclampsia: 37 weeks
severe preeclampsia: 34-36 weeks
what drug should a pt with preeclampsia receive if less than 34 weeks gestation
antenatal steroids
medication for sz prophylaxis for preeclampsia pt
Mg sulfate
gestational HTN (pregnancy induced HTN) is BP > _ after 20 _ weeks into the pregnancy that resolves _ weeks postpartum
> 150/90
20 weeks
12 weeks
what differentiates pregnancy indcued HTN from preeclampsia
proteinuria w. preeclampsia
HTN w.o proteinuria in pregnant pt should make you think
gestational HTN
management of pregnancy induced HTN
+/- meds
if meds: hyralazine, labetalol
when is gestational HTN considered chronic HTN
BP > 140/90 prior to 20 weeks gestation
that persists > 6 weeks postpartum
management of chronic HTN in pregnant pt
-BP q 2-4 weeks, then weekly at 34-36 weeks
-delivery 39-40 weeks
when should meds be initiated in pt w. chronic HTN
what meds are safe?
> 150/100
labetalol
nifedipine
hydralazine
if the mother is Rh_
and the baby is Rh
then the mother may develop abs against the infant’s blood
mother: Rh-
baby: Rh+
t/f: first pregnancy can never be affected by Rh incompatability
t!
dx for Rh incompatability (4)
-ABO blood group
-RhD type
-indirect erythrocyte abs screen
-indirect coombs
-fetal monitoring 2nd trimester
tx for Rh incompatability
rhogam given at:
-28 weeks
-72 hr of delivery
-during any uterine bleeding throughout pregnancy
Rhogam should be given if the mother is Rh_,
the father is Rh_,
or if unknown
mother: Rh-
father: Rh+
consequence of Rh incompatability
hydrops fetalis
