Pregnancy complications Flashcards
What is an ectopic pregnancy
pregnancy implantation that occurs at another site other than the endometrium
Where are tubal pregnancies located
Most are located in the distal 2/3 of tube
What population is at highest risk of ectopic pregnancies
Black, non-hispanic
What is the biggest risk factor for ectopic pregnancies
50% have no risk factors
What are the risk factors for ectopic pregnancies
Prior ectopic
assisted reproduction
damaged fallopian tube
advanced maternal age
smoking
congenital tube defect
How do ectopic pregnancies present
abdominal pain and vaginal bleeding roughly 7 weeks after LMP
-can dx with TVUS and + serum HcG
Gestational sac can be seen by TVUS at what HcG level
> 1500
Gestational sac can be seen by trans abdominal US at what HcG level
> 3500
What is the medical management of an ectopic pregnancy
Methotrexate
*comparable to surgery
What is a tube saving surgical procedure for ectopic pregnancies
linear salpingostomy
What is a spontaneous pregnancy loss
non-viable intrauterine pregnancy with either an empty gestational sac OR gestational sac w/ embryo w/ no heart beat
When do most pregnancy losses occur
first trimester
What is the most common cause of spontaneous pregnancy loss
fetal chromosome abnormalities
If a mother is RH negative, what should be given
Rhogam
What is expectant management
Just wait things out and see what happens with the pregnancy
generally takes its course within 8 weeks
What HcG level is indicative of no pregnancy
<5
What is medical management of pregnancy loss
Intravaginal misoprostol
Which patients cannot have medical management of pregnancy loss
> 10weeks along
hemodynamically unstable
allergies to prostaglandins / NSAIDS
Anticoagulated patiens
infection
What is surgical management of pregnancy loss
Surgical evacuation preformed in the Office or operating room
What is gestational trophoblastic disease
Vaginal bleeding and enlarged uterus
How will gestational trophoblastic disease appear on US
Cluster of grapes
What rare complication can be evident by gestational trophoblastic disease
thyroid disease
What are the 2 types of gestational trophoblastic disease
Hydatidiform mole (molar preg)
Gestational trophoblastic neoplasia
What are the risk factors for gestational trophoblastic disease
extremes of age
hx of prior molar preg
hx os spontaneous preg loss
Can people have a normal pregnancy after a gestational trophoblastic disease
yes
What is a molar pregnancy
tumor that develops in the uterus as a result of a nonviable pregnancy
*generally non-cancerous
*can be complete or partial
What is gestational trophoblastic neoplasia
rare form of cancer
-choriocarcinoma
*placental-site trophoblastic tumor
What is the treatment for a molar pregnancy
surgical evaluation with D&C procedure (even if its a partial)
*if older = hysterectomy
also chemi/radiation
How long to woman have to wait to become pregnanct after a molar pregnancy
1 year
How long should HcG levels be monitored after a molar pregnancy
6 months
What are hypertensive disorders of pregnancy
gestational hypertension
preeclampsia
eclampsia
chronic HTN
chronic HTN w/ preeclampsia
How do you manage HTN in pregnancy if > 160/110
Mehtyldopa
labetolol
hydralazine
nifedipine
Which pregnant patients should labetalol not be used in
those with asthma or CHF
Which BP meds are contraindicated in pregnancy and why
ACEi
*Cause renal injury in 2nd/3rd trimester
What can be used for antenatal fetal surveillance
Non-stress test
US for fetal growth restriction
Biophysical profile
What is considered proteinuria in pregnancy
24 hour urine protein >300mg
Urine protein/creatinine >.3
What are severe feature of hypertension in pregnancy
severe HTN
Renal insufficiency
pulmonary edema
new onset HA**
visual disturbance
epigastric pain
impaired liver function
TTP>100,000
What is chronic HTN
Gestational BP elevated before the 20th week of gestation
*dx first time during pregnancy and doesn’t resolve postpartum
What is the most common cause of intrauterine growth restriction (IUGR)
Chronic HTN
What is gestational HTN
transient
*returns to normal by 12 weeks into post party period
HTN w/o proteinuria or severe features that develop after 20weeks
What is preeclampsia
New onset HTN and proteinuria dx after 20wks
OR
new onset HTN dx after 20 weeks with 1+ severe features
What are signs and symptoms of preeclampsia
LUQ / epigastric pain
persistent headache
hyperreflexia+/- clonus
occipital lobe blindness
What can be used to prevent preeclampsia
Low dose aspirin after 12 weeks gestation if at high risk for preeclampsia
What are the complications of preeclampsia
Seizure
hepatic dysfunction
DIC
Renal dysfunction
pulmonary edema
premature delivery
What is the only cure for preeclampsia
delivery… need to get placenta out
what is HELLP
Hemolysis
Elevated
Liver enzyme
Low
Platelets
When does HELLP present
antepartum or post partum
*preeclampsia variant
What is HELLP associated with
poor birthing person outcomes
*increased risk for pulmonary edema and acute renal failure
What is Eclampsia
New onset of grand Mal seizures in a patient with preeclampsia
What do you need to rule out before dx with eclampsia
hx of seizure disorder
head trauma
ruptured aneurysm
AVM
Who is at greatest risk for developing eclampsia
preeclampsia with severe features
How do you control convulsions in someone with eclampsia
magnesium sulfate
What are the indications for delivery with eclampsia
indicated for unstable birthing
fetal condition
What determines the mode of delivery with eclampsia
fetal gestational age
fetal presentation
cervical status
mom/fetal condition
Why is magnesium sulfate given to someone with eclampsia that is seizing
muscle relaxant to prevent uterine contractions
Which patients are more likely to have persistent HTN post partum
higher urinary protein
serum uric acid
BUN
What are some causes of vaginal bleeding in late pregnancy
placental abruption
placenta previa
cervical trauma
vaginal infections
“bloody show”
What is PPROM
preterm premature rupture of membranes
What is placental abruption
premature separation of normally implanted placenta from uterus
What will be seen on US with placenta abruption
adherent retro-placental clot with depression / disruption in underlying tissue
What is the triad of clinical finding for placental abruption
External/occult bleeding (dark)
Uterine pain/ hypertonus
fetal distress/death
When does placental abruption typically occur
Before onset of labor
What increases someones risk for placental abruption
Advanced birthing age
gestational HTN
Blunt external trauma
Abruption in prior preg
What is the hallmark presentation for placental abruption
3rd trimester bleeding
What management precautions are used with placental abruption
2 large bore IV
4 unit PRBCs
Coat studies
continuous fetal monitoring
When is a C-section done with placental abruption
If birthing person and fetus are deteriorating
What is placenta previa
Implantation of placenta over cervical os
What is the leading cause of painless 3rd trimester bright red bleeding
placenta previa
What are the kinds of placenta Previa
Total
partial
marginal
What are the risk factors for placenta previa
Previa in prior pregnancy
advanced maternal age
minority race
prior csection
cocaine/tobacco
When is placenta previa typically diagnosed
2nd trimester during the anatomy scan
If mom is >37 weeks along with placenta previa, how should baby be delivered
C section
What is monozygotic
single fertilized ovum splits
*same sex, genetically identical
What is dizygotic
Two separate ova are fertilized
*same OR opposite sex
What increases chances of multiple gestation
advancement in assisted reproductive technology
advanced maternal age
What is monochorionic- monochorionic
one placenta, one sac, always monozygotic.
*increased risk for twin to twin transfusion syndrome (TTS)
What is monochorionic-diamnionic
one placenta, two sacs
blood vessels communicate btw fetal circulation
What is dichorionic-diamnionic
two sacs, two placentas
occurs in most dizygotic twins
*lowest mortality rate
What will be seen on physical exam with multiple gestation
uterus is larger than date
pollyhydramnios
auscultation of multiple HR
Twins grow at the same rate as singletons until what gestational age
30-32 weeks
How often should growth ultrasounds be completed with twins
monthly
Are all twin pregnancies considered high risk?
yes
What is birthing person at increased risk for with twins
preeclampsia
GDM
hypertensive disorders
If twins are vertex/non-vertex position, how does mom deliver
case by case defendant
What is gestational diabetes
carbohydrate intolerance starting in pregnancy
When is screening done for gestational diabetes
24-28 weeks
how often does glucose have to be monitored with gestational diabetes
4x/day
How do you treat GDM with >4 abnormal glucose values
insulin
*metformin is secondary
When should babies be delivered with GDM and why
39 weeks because they are at risk for still birth
What dietary modifications are used with GDM
Small frequent meals and decrease simple carbs
What is the postpartum care for GDM
at 6-12wks PP: diabetes screen
encourage normal BMI range
breastfeeding
glucose testing Q3 years
What is an incompetent cervix
Inability of the uterine cervix to retain a pregnancy in the second trimester in the absence of uterine contractions
What are the risk factors for an incompetent cervix
Prior 2nd trimester preg loss
short cervix
fetal fibronectin testing
how will a person with an incompetent cervix and has had a previous second trimester pregnancy loss present
Buldging fetal membranes
premature membrane rupture
rapid delivery
rare/absent contraction
How will someone with an incompetent service and no 2nd trimester pregnancy loss present
painless cervical dilation on physical exam in second trimester
How do you manage cervical insufficiency
cerclage
*suturing crevice shut
What are the contraindications to cerclage
Lethal fetal anatomy
intrauterine infection
active bleeding
preterm labor
ruptured membranes
fetal demise
What is premature rupture of membranes (PROM)
spontaneous rupture of fetal membranes before the onset of labor
What is the most common presentation of premature membrane rupture
gush of fluid from vagina, followed by persistent uncontrolled leakage
What timeline is considered preterm premature rupture of membranes (PPROM)
spontaneous rupture prior to onset of labor prior to 37 weeks
What associated infection is seen with PPROM
bacterial vaginosis
What is ferning
When fluid allowed to dry on clean slide produces microscopic fern crystallization patter
How will fluid PH be in the amniotic sac
alkaline (7.15)
How do you manage PROM
Rule out immediate delivery
What is the principal indication for delivery with PROM
chrioamnionitis
What is the most dangerous risk with PROM
Umbilical cord prolapse
What test should be done with PPROM
US for amniotic fluid to determine fetal presentation, fetal weight/growth
What is shoulder Dystocia
Obstetrical emergency
Anterior shoulder is stuck
What will the presentation be with chorioamnionitis
Fever, uterine tenderness, tachycardia, and high WBC count)
When is shoulder dystocia diagnosed
When the shoulders do not deliver shortly after the fetal head
What are the risk factors for shoulder dystocia
obesity
long labor
IOL
Forceps / vacuum
What tools can be used to deliver shoulder dystocia
Prompt reduction of shoulder
suprapubic pressure
episiotomy
intentional fx (last resort)
What is the McRoberts maneuver
hip hyper flexion and suprapubic pressure
What is woods corkscrew
180 degree shoulder rotation of posterior shoulder and deliver that shoulder
What is the good and bad of maneuvers for shoulder dystocia
more maneuvers increases the chance of success but also increases risk for fetal injury
What is the danger of taking longer than 5 minutes to deliver the baby
increased risk for fetal acidosis and hypoxic ischemic encephalopathy
What are fetal complications with shoulder dystocia
brachial plexus injury
diaphragmatic paralysis
facial nerve injury
horners syndrome
clavicle fx
death
What are the complications for the mom with shoulder dystocia
lacerations
postpartum hemorrhage
pubic symphysis separation
uterine rupture
What defines a postpartum hemorrhage
> 1L blood loss or blood loss associated with s/sx of hypovolemia
What are the risk factors for postpartum hemorrhage
Prolonged labor / rapid labor
over distended uterus
operative delivery
preeclampsia
chorioamnionitis
How can you prevent post partum hemorrhage
correct anemia
avoid episiotomy
infant to breast post delivery
active mgmt of 3rd stage of labor
What are causes of early postpartum hemorrhage
Uterine atony
genital tract trauma
retained placental tissue
coagulation disorders
How to you manage uterine atony
deliver placenta
uterine massage
removal of clots
give uterotonics (oxytocin)
Bimanual compression
Possible D&C
inspect/repair lacerations
