Pregnancy Complications Flashcards
Spontaneous abortion/miscarriage
a pregnancy loss occurring before 20 weeks gestation
different types of spontaneous abortion
threatened, inevitable, incomplete, missed, and complete abortion
RF spontaneous abortion
maternal disease (e.g., diabetes mellitus, thyroid disease, thrombophilia, lupus anticoagulant), being severely overweight or underweight, structural abnormalities of the uterus, and exposure to teratogens or infections
dx spontanenous abortion
Diagnosis is made by pelvic examination, serially decreasing human chorionic gonadotropin levels, and transvaginal ultrasound showing inappropriate development or fetal demise
threatened abortion
vaginal bleeding with or without uterine contractions in the presence of a closed cervical os
inevitable abortion
vaginal bleeding and a dilated cervical os without passage of any fetal tissue
Products of conception can be felt or visualized through the cervical os
incomplete abortion
vaginal bleeding and a dilated cervical os with the passage of some but not all of the products of conception
missed abortion
death of the fetus before 20 weeks gestation, retained products of conception, and a closed cervical os
there is no history of vaginal bleeding
complete abortion
complete passage of the products of conception out of the uterus and cervix. On physical examination, the cervical os is closed and the uterus is small
tx for specific types of abortion
inevitable, incomplete, or missed abortion is managed with surgical uterine evacuation (e.g., dilation and curettage), pharmacologic uterine evacuation (e.g., mifepristone followed by misoprostol or misoprostol only), or expectant management. Retained products of conception after administration of misoprostol may be treated with surgical evacuation or a second round of misoprostol
when is expectant management an option for spontaneous abortion
Expectant management is an option for patients at < 14 weeks gestation who are stable and have no signs of infection.
Retained products of conception after 4 weeks of expectant management should be treated with surgical evacuation
dose for Rh immune globulin
A 50 mcg dose is given if the abortion occurred before 13 weeks gestation.
Otherwise, the standard 300 mcg dose is given
when does serum hCG usually come back to normal
Serum human chorionic gonadotropin typically returns to normal within 6 weeks after a completed abortion and may be monitored serially after expectant management or pharmacologic evacuation
pelvic rest for abortion
Pelvic rest is recommended for 2 weeks following an abortion
what should always be offered to ppl w spontaneous abortion
counseling
The most common cause of spontaneous abortion
fetal chromosomal abnormalities
what suggests viability of pregnancy if threatened abortion
Incremental increases in serum hCG and elevated progesterone concentrations suggest viability of the pregnancy
Women with incomplete abortions should be monitored for
development of endometrial infections and complete expulsion of the products of conception
septic abortion
an infection of partially retained products of conception
diagnostic workup in all patients with first trimester bleeding
CBC, quantitative serum hCG, blood type, and transvaginal ultrasound.
Ectopic pregnancy
a pregnancy occurring outside of the uterus
where do most ectopic pregnancies occur
in the Fallopian tubes
RF ectopic pregnancy
previous ectopic pregnancy (most important), prior tubal surgery, pregnancy occurring with an intrauterine device in place, and prior pelvic inflammatory disease
sx ectopic pregnancy
Lower abdominal pain and vaginal bleeding are the most classic symptoms. The vaginal bleeding is usually heavy and painful
when do ectopic pregnancies MC occur
Ectopic pregnancies occur most frequently 6 to 8 weeks after the start of the last menstrual period
initial presentation in 50% of women w ectopic
tubal rupture is the initial presentation in 50% of women with ectopic pregnancy
sx tubal rupture for ectopic pregnancy
lightheadedness, syncope, orthostasis, hypotension, and tachycardia in addition to vaginal bleeding and abdominal pain
dx ectopic pregnancy
Ectopic pregnancy is diagnosed based on clinical findings, laboratory testing, and pelvic ultrasound
The presence of an adnexal mass in combination with the absence of an intrauterine gestational sac and hCG level above the discriminatory zone is diagnostic of an ectopic pregnancy
discriminatory zone
the hCG level at which an intrauterine gestational sac should be visible on transvaginal ultrasound in a normal intrauterine pregnancy. The most common discriminatory zone threshold used for transvaginal ultrasounds is 2,000 mIU/mL. However, sometimes 3,500 mIU/mL is used as the threshold, which decreases the false-positive rate
in regards to discriminatory zone, who is deemed at risk of ectopic pregnancy
Patients whose hCG level is above the discriminatory zone and do not have evidence of an intrauterine gestational sac on transvaginal ultrasound are considered to be at risk for an ectopic pregnancy
how are pts with vaginal bleeding and lower abdominal pain during early pregnancy and hCG level below the discriminatory zone without signs of an intrauterine or ectopic pregnancy on ultrasound managed
These patients are often managed by rechecking the hCG level in 48–72 hours as long as they are hemodynamically stable without signs of an acute abdomen
tx options for ectopic
expectant management, methotrexate, and surgical intervention (laparoscopic salpingostomy)
in regards to ectopic, when is expectant management not recommended
Expectant management is not recommended for women with suspected ectopic pregnancy hCG of at least 200 mIU/mL
Indications for methotrexate in ectopic pregnancy
Methotrexate works best in patients with ectopic pregnancy who meet each of the following criteria: hemodynamically stable, normal kidney and liver function, able to comply with follow-up, pretreatment hCG < 5,000 mIU/mL, and no fetal cardiac activity on transvaginal ultrasound, adnexal mass is ≤ 3–4 cm. However, methotrexate is often attempted in patients with higher hCG levels who are hemodynamically stable and wish to avoid surgery
indications for surgery for ectopic
Patients who are hemodynamically unstable or fail methotrexate therapy require surgical treatment
Abdominal exam ectopic
sometimes within normal limits but may also reveal generalized or localized tenderness and rebound tenderness in the event of a ruptured ectopic pregnancy
pelvic exam ectopic
Pelvic exam may be normal or may reveal uterine bleeding, tenderness to palpation, or a palpable adnexal or extrauterine mass
hCGs in ectopic pregnancy
hCG values do not double as expected and may not be as high as expected for gestational age
TVUS ectopic
If there is an adnexal mass with a small amount of free fluid in the cul-de-sac, an ectopic pregnancy is likely
C/I methotrexate
if there is a large amount of fluid or findings suggestive of clot
Gestational diabetes
glucose intolerance during pregnancy because of increased insulin resistance
cause of gestational diabetes
likely caused by the presence of placenta-secreted hormones (i.e., growth hormone, corticotropin-releasing hormone, human placental lactogen) and the inability of pancreatic beta-cells to compensate for the increased level of insulin resistance
RF gestational diabetes
previous macrosomic birth, obesity, and age over 30 years, history of polycystic ovary syndrome
when is screening recommended for gestational diabetes
24-28 weeks
2 screening modalities for gestational diabetes
two-step oral glucose tolerance test (OGTT) and the one-step OGTT
MC used screening modality for gestational diabetes
two step oral glucose tolerance test
two step oral glucose tolerance test (OGTT)
it involves a first-step screening OGTT followed by a diagnostic OGTT. For the screening OGTT, a 50-gram dose of glucose is given without regard to fasting, and the patient’s serum glucose level is measured 1 hour after the oral glucose load. If serum glucose concentrations after 1 hour are > 130 mg/dL, the screen is positive and the patient should progress to the diagnostic OGTT step (step-two). The diagnostic step is done by administering 100 grams of oral glucose to the patient after fasting for at least 8 hours. Serum glucose concentrations are measured before the glucose load and at 1-hour increments for 3 hours after the glucose load
positive serum glucose concentrations for the second step in two step OGTT
The following serum glucose concentrations would be considered a positive test for gestational diabetes using the Carpenter/Coustan method: fasting glucose ≥ 95 mg/dL, 1-hour glucose ≥ 180 mg/dL, 2-hour glucose ≥ 155 mg/dL, and 3-hour glucose ≥ 140 mg/dL
one step OGTT
75-gram OGTT can be performed on a fasting patient instead of the two-step OGTT
gold standard for diagnosing gestational diabetes
3-hour 100 g oral glucose tolerance test
Complications associated with gestational diabetes
preeclampsia, gestational hypertension, polyhydramnios, large for gestational age infant, maternal and infant birth trauma, perinatal mortality, and neonatal complications (e.g., shoulder dystocia, hypertrophic cardiomyopathy, hypoglycemia, hyperbilirubinemia, hypocalcemia, polycythemia)
dx gestational diabetes
A diagnosis of gestational diabetes may be made if the patient has two or more abnormal values during the 100 gram glucose tolerance test
screening for diabetes postnatal if they had gestational diabetes
Patients should be screened for diabetes mellitus at 4–12 weeks postpartum and every 3 years afterward because they are at increased risk of developing diabetes
what meds can ppl w gestational diabetes use if can’t use insulin
metformin
glyburide
Which hormones secreted by the placenta lead to postprandial hyperglycemia, permitting more nutrients to flow to the fetus?
Growth hormone, corticotropin-releasing hormone, human placental lactogen, and progesterone
Gestational trophoblastic disease occurs due to
errors during conception, which lead to abnormal proliferation of trophoblastic (placental) tissue
Trophoblastic tissue normally leads to the formation of the
placenta
thus gestational trophoblastic diseases are often considered diseases of placental tissue
The most common clinical manifestations of gestational trophoblastic disease
molar pregnancy
Partial (triploid) molar pregnancy
an egg is fertilized by two sperm and produces abnormal cells with 69 chromosomes (46 paternal chromosomes and 23 maternal chromosomes) and possible fetal tissue. Partial molar pregnancies usually result in a miscarriage during the late first trimester or early second trimester
complete (diploid) molar pregnancy
egg without genetic material (empty egg) is fertilized by a sperm. The genetic material then duplicates to produce a zygote with 46 paternal chromosome
do complete molar pregnancies contain fetal tissue
no
which type of molar pregnancy has a higher risk for malignant transformation
complete molar pregnancy
histologic findings in partial molar pregnancies
trophoblastic proliferation consisting predominantly of cytotrophoblast cells (inner layer of the trophoblast) with focal hydropic (swollen) villi
RF for gestational trophoblastic disease
extremes of gestational age (younger than 20 years or older than 40 years) and prior molar pregnancies
sx gestational trophoblastic dz
related to high hCG levels
N/V
hyperthyroidism
AUB
elevated hCG levels can cause
N/V
hyperthyroidism
bilateral theca lutein cysts
characteristic TVUS molar pregnancy
snowstorm appearance due to swollen villi
definitive dx molar pregnancy
biopsy
tx molar pregnancy
dilation and curettage and close monitoring to ensure hCG levels return to normal following treatment
hysterectomy if fertility not desired
The types of malignant transformation for gestational trophoblastic disease
invasive mole, choriocarcinoma, placental-site trophoblastic tumor, and epithelioid trophoblastic tumor
MC type of malignant transformation for gestational trophoblastic disease
Invasive mole
Invasive mole
Invasive mole is the most common type and is defined by invasion into the myometrium of the uterus
Choriocarcinoma and when may it occur
rare and aggressive tumor that spreads hematogenously. Distant metastasis is common
Choriocarcinoma may occur following a molar pregnancy, miscarriage or abortion, or following a preterm or term intrauterine pregnancy. Furthermore, choriocarcinoma can sometimes be part of germ cell tumors that are not related to gestation
characteristic pathology for choriocarcinoma
sheets of trophoblastic tissue consisting of syncytiotrophoblasts and cytotrophoblasts without villi
Molar pregnancy is also called
Hydatidiform mole
which type of molar pregnancy has higher beta hCG levels
complete molar pregnancy
An hCG level > 100,000 mIU/mL is more commonly associated with a complete molar pregnancy
a high hCG should prompt
TVUS
If there’s a super high hCG, but TVUS reveals no abnormalities, what should you do next
If the ultrasound reveals a normal single intrauterine gestation, the ultrasound and hCG should be repeated in 1 week to evaluate for the possibility of a twin conception or coexistent molar pregnancy
TVUS complete molar pregnancy
the absence of an embryo or fetus, the absence of amniotic fluid, a snowstorm pattern characterized by a central heterogeneous mass with multiple discrete, anechoic spaces, or the presence of ovarian theca lutein cysts
TVUS partial molar pregnancy
a viable but growth-restricted fetus, oligohydramnios, a snowstorm pattern similar to that seen in a complete molar pregnancy, or an increased transverse diameter of the gestational sac. Theca lutein cysts are not typically seen on ultrasound with a partial molar pregnancy
are theca lutein cysts commonly seen on TVUS for partial molar pregnancy
no - usually only complete molar pregnancy
Follow up after surgery for molar pregnancy
Following surgical treatment, serum hCG levels should be obtained every week. If the hCG level has progressively decreased > 10% across four measurements taken during the first 21 days, weekly measurements are taken until the hCG level is < 5 mIU/mL. At this point, if the patient had a complete molar pregnancy, hCG levels are obtained monthly for 3 months and then discontinued if undetectable. If the patient had a partial molar pregnancy, an hCG level is obtained at 1 month and then discontinued if undetectable
Bimanual exam for molar pregnancy
Bimanual exam may reveal bilateral large adnexal masses consistent with ovarian theca lutein cysts secondary to marked enlargement of the ovaries from human chorionic gonadotropin stimulation
How early can molar pregnancy be detected on US
8 weeks
What is considered an acceptable decrease in human chorionic gonadotropin levels after treatment for gestational trophoblastic disease?
A decrease > 10% demonstrated by four values taken weekly for 3 consecutive weeks
