Pregnancy Complications Flashcards
Secondary exposure to D antigen results in production of IgG antibodies that freely cross the placenta, enter the fetal circulation, and bind to fetal RBCs
RBCs that are highly bound undergo hemolysis
Large amounts of antibody may result in destruction of large numbers of fetal RBC and fetus may be unable to sufficiently replace the red cells which will cause anemia
Rh Incompability
Fluid accumulation in at least two extravascular compartments (pericardial effusion, pleural effusion, ascites, or subcutaneous edema)
Hydrops Fetalis
Which antigen is the biggest culprit in Rh compatability?
D antigen
Occurs most commonly in a subsequent pregnancy
Destruction of the fetal RBC by maternal antibodies leads to hemolysis, bilirubin release, and anemia
Rh Incompability
What is the amount of Rh positive fetal blood required to cause isoimmunization?
only 0.1mL
What is the only antigen that can cross the placenta?
IgG
What may occur when Rh negative woman is pregnant with Rh positive fetus?
Isoimmunization
Any event associated with fetomaternal bleeding can lead to maternal exposure to fetal RBC, which can trigger what?
maternal immune response
What is the most common minor antigen associated with hemolytic disease of the fetus?
Kell antigen
When anemia is significant in Rh incompatibility, hematopoiesis increases, including alternate sites for RBC production. What is the largest site for alternative RBC production?
Key alternate site is liver
List some examples of precipitating events that can result in Rh compatibility
Childbirth
Delivery of placenta
Abortion (Threatened, spontaneous, elective, or therapeutic)
Ectopic pregnancy
Bleeding associated with placenta previa or abruption
Amniocentesis
Abdominal trauma
External cephalic version
What is the treatment for Rh incompatibility?
RhoGam
What is RhoGam?
RhoGam is anti-D immune globulin
When is RhoGam administered?
RhoGam is administered at 28 weeks gestation or after complications
and within 72 hours of delivery
If bleeding occurs then will need which test?
Kleihauer-Betke test
The Kleihauer-Betke test figures out what?
Determines the amount of blood loss per mL of fetal blood into maternal circulation > 30mL
Why is the Kleihauer-Betke test important?
This will help to dictate the amount of RhoGam to be used
Pregnancy implants outside of the uterine cavity
Ectopic Pregnancy
What is the most common implantation location for ectopic pregnancy?
Most common location is the fallopian tubes
Second leading cause of maternal mortality
Ectopic Pregnancy
What is the largest risk factor for ectopic pregnancy?
PID largest risk factor
What are the risk factors for ectopic pregnancy?
History of STDs - PID largest risk factor
Prior ectopic pregnancy!!
IVF and assisted reproductive technology
IUD
Previous tubal surgery or pelvic surgery (Can happen after bilateral tubal ligation)
Endometriosis
Antiretroviral therapy
Rh- mothers with ectopic should be given what?
Rh immunoglobulin
What is the recurrent risk for an ectopic pregnancy?
25%
What is the risk of infertility for an ectopic pregnancy?
25-30%
Loss of fetus <20 weeks
1st trimester: typically genetic cause
2nd trimester: structural (incompetent cervix)
Spontaneous abortion
What type of abortion is described below?
Complete expulsion of products of conception
No gestational sac in uterus
Os closed
Complete abortion
What type of abortion is described below?
Incomplete expulsion
Some portion of the products of conception remain left behind in the uterus
Os is open
Incomplete abortion
What type of abortion is described below?
NO expulsion of sac
Bleeding with or without cramping
Os is open
Inevitable abortion
What type of abortion is described below?
Vaginal bleeding
With or without cramping
NO tissue has passed
Os is closed
Threatened abortion
What type of abortion is described below?
Embryo or fetus dies but the products of conception are retained
Brownish discharge
NO fetal heart tones
Missed abortion
What type of abortion is described below?
Termination of pregnancy before viability intentionally
Inducted abortion
3 or more SABs, 2+ SAB in women over 35 need to assess for what?
look into underlying disorder/problem
During pregnancy, as the baby grows and gets heavier, it presses on
the cervix
This pressure may cause the cervix to start to open before the baby is
ready to be born
Incompetent Cervix
What is the biggest concern with an incompetent cervix?
may lead to miscarriage or premature delivery
High risk for second trimester abortions
What are some risk factors for an incompetent cervix?
Cervical surgeries (LEEPs, Cone biopsies)
Cervical lacerations with previous deliveries
Uterine abnormalities
Family history
Procedure that sews the cervix closed to reinforce the weak cervix
Usually performed between week 14-16 of pregnancy and sutures removed between 36-38 weeks
Cerclage
Patients are not eligible for cerclage if they have these factors?
There is increased irritation of the cervix
The cervix has dilated 4cm
Membranes have ruptured
What are some complications with the cerclage?
Uterine rupture
Maternal hemorrhage
Bladder rupture
Cervical laceration
Preterm labor and delivery
Preterm rupture of the membranes
Abnormal premature separation of placenta
Abruptio Placentae
What are the types of abruptio placentae?
Partial separation (concealed hemorrhage)
Partial separation (apparent hemorrhage)
Complete separation (concealed hemorrhage)
Marginal
Abruptio placentae is associated with the use of which illegal drugs?
cocaine and meth
What are some signs and symptoms in abruptio placentae?
Sudden, PAINFUL bleeding with uterine pain and contractions
50% fetal distress as well
May have GI symptoms as well
Rigid, hard belly
Which type of abruptio placentae is described below?
Entire placenta separates
Concealed hemorrhage
Complete
Which type of abruptio placentae is described below?
Part of the placenta separates
Partial separation (concealed hemorrhage)
Partial separation (apparent hemorrhage)
Which type of abruptio placentae is described below?
Separation limited to ledge of placenta
Marginal
What are some risk factors for abruptio placentae?
Chronic HTN
Multiple gestations
Pre-eclampsia
AMA
Multiparity
Smoking
Chorioamnionitis
trauma
What is is the most common cause of coagulopathy in pregnancy?
Abruption
A rare complication of abruptio placentae where the uterine serosa is purple/blue due to blood penetration
Couvelaire uterus
Placenta location close or over internal cervical os
Placenta Previa
What are the types of placenta previa?
Complete
Partial
Marginal
Low lying
Placenta previa is associated with what?
Associated with an increase in preterm birth and perinatal mortality and morbidity
What is the signs/symptoms of placenta previa?
PAINLESS vaginal bleeding in third trimester
What are some complications of placenta previa?
Concomitant placenta accretia, incretia, percreta
bleeding
What must be avoided in patients with placenta previa?
pelvic/cervical digital exam
Intercourse
Vigorous exercise
Glucose intolerance during pregnancy
Impairment of carb metabolism that manifests during pregnancy
Gestational Diabetes
anti-insulin, produced by placenta
Human placental lactogen
degrades insulin, produced by placenta
Insulinase
More than what percentage of mothers return to normal after delivery, and what percentage go on to develop DM later in life?
95%
50%
Glucose tolerance screening for mothers with gestational diabetes needs to be done when post partum?
2-4 months
Glucosuria in pregnancy OK, what is the normal amount in pregnancy?
Normal: about 300mg/day
When is screening and diagnosing gestational diabetes done?
24-28 weeks
What is the mainstay of treatment in gestational diabetes?
Diet
High A1c can put a baby at high risk for which birth defects?
CV malformations
hypoplastic LE
sacralagenesis
Pre-Gestational DM puts patient at higher risk for what complication?
Increased risk for pre-eclampsia
List some complications of gestational diabetes
Macrosomia
IUGR
Excessive weight gain
Pre-eclampsia
Shoulder dystocia
Placental abruption
Pre-term labor
C-section
High risk of stillbirths
What is the most common birth defect with a mother with high A1c?
Cardiovascular
List some reasons of fetal morbidity and mortality of gestational diabetes
Higher risk for congenital anomalies
Macrosomia (>4000g)
Neonatal hypoglycemia
Increased frequency of respiratory distress syndrome
Polyhydraminios (amniotic fluid > 2000mL)
Underdeveloped/damage to Isles of Langerhans
hypertension that develops for the first time after 20 weeks
140/90 or higher
No proteinuria
Pregnancy-Induced Hypertension
What percentage of pregnancy-induced HTN patients go on to develop pre-eclampsia?
50% go on to develop pre-eclampsia
Predominant physical findings in pregnancy-induced hypertension is what?
maternal vasospasm
What are some risk factors for developing pregnancy-induced HTN?
First pregnancy
Obesity
Age >40
African American
Personal or family history of gestational HTN or pre-eclampsia
DM
Chronic renal failure
You are carrying twins or higher multiples
In pregnancy-induced HTN, BP of what we treat with medications because of the high risk of placenta abruption?
160/100 or higher
What is the diagnostic criteria for pregnancy-induced HTN?
Blood pressure of 140/90 or higher
Blood pressure highest when sitting down
NO PROTEIN IN URINE
Only safe blood pressure medication in pregnancy is what?
Methyldopa
In pregnancy-induced HTN, what class of antihypertensives must absolutely be avoided?
Absolutely NO ACE INHIBITORS
Most common form of hypertension in pregnancy
Pre-Eclampsia
In pregnancy-induced HTN, what other factor with the high readings is an indication for delivery?
IUGR and HTN = deliver
What pregnancy complication is 2x more common in AA females than whites?
Pre-Eclampsia
What are some risk factors for pre-eclampsia?
Family history
Primiparity
Previous preeclampsia
Multiple gestations
Advanced maternal age
Diabetes
Obesity
SLE
Chronic HTN
What pregnancy complication is hardest thing to control and hard to diagnose?
Pre-Eclampsia
What is the diagnostic criteria for diagnosing pre-eclampsia?
Development of HTN after 20 weeks
Can occur exclusively post-partum
New onset proteinuria, or thormbodcytopenia, impaired liver
function, renal insufficiency, pulmonary edema, cerebral or vascular
disturbances
Progressive
What is a normal 24hr protein?
100-300mg
What is the fetal surveillance in a mother with pre-eclampsia?
Ultrasound with amniotic fluid index
NST (non-stress test)
Biophysical profile
What maternal labs are drawn to evaluate pre-clampsia?
CBC with platelets
BUN/creatinine
LFTs
24 hour urine protein
What is the mainstay of treatment in mild to moderate pre-eclampsia?
bed rest
What is the treatment in severe pre-eclampsia?
In most cases, indication for delivery regardless of gestational age or
maturity if this pregnancy
In severe pre-eclampsia, initiate what but only if delivery within 24 hours? And why?
MgSO4
98% of convulsions will be prevented with MgSO4 (Protects CNS – prevents tonic-clonic seizures)
What is the initial drug of choice in managing blood pressure in severe pre-eclampsia?
hydralazine
BP >160/110 mmHg on 2 occasions at least 6 hours apart while patient is on bed rest
Marked proteinuria usually >5g per 24 hr period, or 3+ or more on two random dips 4 hours apart
-OR-
Diagnostic criteria of pre-eclampsia and one of the following:
Oliguria (<500mL in 24 hour period)
Visual disturbances or HA
Pulmonary edema or cyanosis
RUQ pain
Evidence of hepatic dysfunction
Thrombocytopenia
IUGR
Clonus >3, hyperreflexia
Severe pre-eclampsia
New onset grand mal seizures before, during, or immediately post-partum
Occurs in a small percentage of patients with pre-eclampsia
Life threatening
Can cause intracellular hemorrhage
Eclampsia
What are some signs and symptoms of eclampsia?
Severe headache
Hyperreflexia
Blurred vision
Photophobia
RUQ or epigastric pain
Altered mental status
What is the diagnostic criteria for eclampsia?
Hypertension + proteinuria + edema + SEIZURES after 20 weeks
What is the treatment of eclampsia?
Emergent delivery
Do NOT deliver during seizures, but delivery is the only cure!
When initiating MgSO4,, watch for this sign which signals toxicity
loss of DTRs
Form of severe pre-eclampsia that occurs in 10% of pre-eclampsia patients
Watch out for 🡪 life threatening
HELLP Syndrome
HELLP Syndrome - what are the factors/signs present?
Hemolysis
Elevated LFTs
Low platelets
RUQ pain (don’t assume gallbladder)
What form of severe pre-eclampsia has a high mortality and morbidity rate?
HELLP Syndrome
Defined as neoplasms that derive from abnormal placental
(trophoblastic) proliferation
Empty egg is fertilized by sperm (no maternal DNA present)
AKA molar pregnancy
Rare variation of pregnancy
Gestational Trophoblastic Disease
This is the only female disease that is responsive to chemotherapy
every single time
Gestational Trophoblastic Disease
Molar pregnancy can develop where the placenta was and is called what?
Placental site tumor
What are the risk factors for gestational trophoblastic disease?
Women over age 35 or under age 20
Low dietary carotene
Vitamin A deficiency
What are the key factors/signs of gestational trophoblastic disease?
Clinical picture of pregnancy, but exaggerated (Severe HTN, hyperemesis)
Pathognomic ultrasound findings
Uterine size/date discrepancy
Lack of fetal heart tones at 12 weeks
Specific tumor marker – hCG (Markedly high for LMP)
Pre-eclampsia in first or second trimester pathognomic for molar
pregnancy
How does gestational trophoblastic disease typically present?
Exaggerated symptoms of pregnancy
Painless second trimester bleeding
Quantitative hCG levels are excessively elevated for gestational age (think 100,000 or greater)
What are the two types of gestational trophoblastic disease?
Complete Mole
Incomplete/Partial Mole
Which type of gestational trophoblastic disease is described below?
No fetal parts
46XX paternal genome
Marked trophoblastic proliferation
15% persistent GTN
More common than partial/incomplete
Snowstorm, cluster of grapes on ultrasound
Can become invasive 🡪 invades myometrium
Complete Mole
Which type of gestational trophoblastic disease is described below?
Some fetal parts are present
69,xxx or –xxy 1/3 maternal genome
Focal trophoblastic proliferation
<5% persistent GTN
Most often presents as missed abortion
Vaginal bleeding is less common
Uterine growth is less than expected
Incomplete/Partial Mole
A complete mole that invades myometrium is also referred to as what?
Known as persistent metastatic or non-metastatic gestational trophoblastic disease (malignant GTN)
What is the treatment for gestational trophoblastic disease?
Definitive treatment is prompt evacuation of the uterine contents
May consider hysterectomy if patient desires no more children
Rh- negative patients should be given RhoGam
Patient should be on what medication for the first year after treatment for trophoblastic disease?
OCP
How long should a patient who had trophoblastic disease avoid pregnancy?
NO PREGNANCY for one year
In a patient who was treated for gestational trophoblastic disease, how long should they be monitored for?
Monitor closely for 6-12 months due to predisposition of recurrence
What are the monitoring guidelines in a patient who was treated for gestational trophoblastic disease?
Quant hCG within 48 hours, then q 1-2 weeks while still elevated (Follow serial hCG weekly to zero); Make sure to go to zero, or else worry about cancer
Then q 4 weeks for one year
If hCG plateaus or rises, that’s an indication of persistent disease (make sure to rule out new pregnancy)
Periodic PE to evaluate for vaginal metastasis and uterine involvement
What are the complications of gestational trophoblastic disease?
At higher risk for uterine atony and Asherman’s
Choriocarcinoma
Placental Site Tumor
Metastasize to lung
Malignant transformation of trophoblastic tissue
1 in 40 molar pregnancies
Rapid myometrial and uterine-vessel invasion with systemic metastases from hematogenous spread
Choriocarcinoma
Choriocarcinomas are highly sensitive to what treatment?
Highly sensitive to chemotherapy!
What are the most common sites of metastases for choriocarcinomas?
Lung, vagina, CNS, kidney, and liver
Very rare form of trophoblastic disease
Placental Site Tumor
What is the treatment for placental site tumor?
Hysterectomy
This pregnancy complication results in small bodies, big heads
Brain/head is spared, so blood will be shunted towards it
Intrauterine Growth Restriction
Round ligament pain presents how in pregnant patients?
Sharp groin pain
In round ligament pain, which side is most common presentation?
Right side most common
What is the most common cause of post-term pregnancy?
Most common cause is inaccurate estimation of gestational age
42 weeks or more
Post-Term Pregnancy
What is the preferred management for post-term pregnancy?
Induction at 41 weeks is the preferred management
What are the complications of post-term pregnancy?
Higher risk for shoulder dystocia, Erb Duchenne palsy, Klumpe palsy,
paralysis, meconium aspiration syndrome (MAS)
