Pregnancy Complications Flashcards
hypertensive disorders of pregnancy - subtypes
*chronic HTN
*gestational HTN
*preeclampsia
*preeclampsia with severe features
*eclampsia
*HELLP
hypertensive disorder of pregnancy: chronic HTN
*SBP 140+ and/or DBP 90+ (2 readings at least 4 hours apart or more) in one of the following settings:
1. pre-existing hypertension (diagnosed before pregnancy) OR
2. HTN diagnosed PRIOR TO 20 wks gestation OR
3. HTN persisting > 6 weeks postpartum
chronic hypertension in pregnancy - treatment
*treat to goal BP: SBP < 140 and < 90 DPB
*continue or switch to medications safe in pregnancy: LABETALOL, nifedipine, hydralazine, methyldopa
*should NOT take ACE inhibitors or thiazides
*monitor for progression to preeclampsia
*depending on treatment / control, delivery between 37-40 weeks
hypertensive disorder of pregnancy: gestational hypertension
*NEW ONSET hypertension (SBP 140+ and/or DBP 90+) AFTER 20 weeks gestation
*cannot have pre-existing hypertension
*no proteinuria or end-organ damage
gestational hypertension - treatment
*recommended delivery by 37th week of pregnancy
*monitor for evidence of preeclampsia
*do NOT treat BP unless becomes severe range (160/110 or higher)
preeclampsia (w/o severe features) - defined
*new onset HTN with proteinuria AFTER 20 weeks gestation
*at least 2 elevated BP 4+ hours apart (SBP 140+ and/or DBP 90+) AND elevated protein:creatinine ratio (300+ or 0.3+)
*treatment: deliver by 37th week
preeclampsia with severe features - defined
*new onset HTN with end-organ dysfunction AFTER 20 weeks gestation
*at least 2 elevated BP 4+ hours apart (SBP 140+ and/or DBP 90+) AND end-organ damage or symptoms
preeclampsia with severe features - symptoms of end-organ damage
*neuro: scitomas (or vision changes), severe unresponsive HA
*resp: SOB (outside of normal pregnancy SOB)
*cardio: chest pain
*liver: RUQ pain, persistent N/V/epigastric pain without cause
preeclampsia with severe features - signs of end-organ damage
*resp: flash pulmonary edema (CXR); hypoxia
*cardio: EKG changes (i.e. acute MI); severe range BP (160/110+)
*liver: 2x ULN LFTs; low platelets (<100)
*kidneys: creatinine 1.1+ or 2x baseline
preeclampsia with severe features - etiology
abnormal placental spiral arteries → endothelial dysfunction → vasoconstriction → ischemia
preeclampsia with severe features - risk factors
*pre-existing HTN
*diabetes
*chronic renal disease
*autoimmune disorders (thrombophilias, anti-cardiolipin antibodies, SLE, etc)
*previous pregnancy with preeclampsia (especially early)
preeclampsia with severe features - complications
*placental abruption
*coagulopathy
*renal failure
*uteroplacental insufficiency
*may lead to eclampsia and/or HELLP
preeclampsia with severe features - treatment
*IV magnesium sulfate
*anti-hypertensives (labetalol, nifedipine, hydralazine, methyldopa)
*move toward delivery (if 34w0d or later)
eclampsia - overview
*preeclampsia (new onset HTN after 20 weeks gestation with proteinuria and/or end-organ dysfunction) + SEIZURES; a medical emergency
*maternal death occurs due to: stroke, intracranial hemorrhage, ARDS
eclampsia - treatment
1) IV magnesium sulfate
2) antihypertensive medications
3) immediate delivery
*consider protecting airway
HELLP syndrome - overview
*type of severe preeclampsia: preeclampsia with thrombotic microangiopathy of the liver
*can lead to hepatic subcapsular hematomas → rupture → severe hypotension
*HELLP acronym:
H - Hemolysis
EL - Elevated Liver enzymes
LP - Low Platelets (blood smear → schistocytes)
HELLP syndrome - treatment
*immediate delivery
hydatidiform mole - overview
*cystic swelling of chorionic villi & proliferation of chorionic epithelium (trophoblast)
*can be complete (CHM) or partial (PHM)
*CHM: 1-2 sperm fertilize EMPTY ovum
*PHM: 1-2 sperm fertilize a viable ovum
*results in a “pregnancy” composed of PATERNAL DNA only
*dx: morphologic, genetic, histopathologic features
hydatidiform mole - clinical presentation
*may present with:
-vaginal bleeding
-emesis
-uterine enlargement more than expected
-pelvic pressure/pain
complete hydatidiform mole
*karyotype: 46, XX (or 46, XY, less commonly)
*components: most commonly enucleated egg + single sperm (subsequently duplicates paternal DNA)
*fetal parts: NO
*uterine size: enlarged
*hCG: extremely high
*imaging: “honeycombed” uterus or “clusters of grapes”, “snowstorm” on ultrasound
*risk of malignancy (gestational trophoblastic neoplasia) and risk of choriocarcinoma
partial hydatidiform mole
*karyotype: 69, XXX; 69, XXY; or 69, XYY
*components: 2 sperm + 1 egg
*fetal parts: YES
*uterine size: normal
*hCG: high (not as high as complete mole)
*imaging: fetal parts
*risk of malignancy (gestational trophoblastic neoplasia) and risk of choriocarcinoma lower than in complete mole
hydatidiform mole - treatment
*D&C +/- methotrexate
*pertinent to trend b-hCG down to 0
*monitor monthly for 6 months (complete HM)
*can progress to choriocarcinoma
ectopic pregnancy - overview
*implantation of a fertilized ovum in a site other than the uterus (most often in ampulla of fallopian tube)
*amenorrhea + low rise of b-hCG for dates + sudden lower abdominal pain = ectopic until ruled out
*can be mistaken for appendicitis
*need to confirm pregnancy location with ultrasound
ectopic pregnancy - clinical presentation
*presents with:
-first trimester bleeding
-lower abdominal pain
(often mistaken for appendicitis)
*suspect if: lower-than-expected risk in hCG based on dates
ectopic pregnancy - risk factors
*prior ectopic pregnancy
*history of infertility
*salpingitis (PID)
*ruptured appendix
*prior tubal surgery
ectopic pregnancy - treatment
*methotrexate or surgical removal
*if unstable patient, medical emergency = prompt surgical intervention
spontaneous abortions - missed
*no vaginal bleeding
*closed cervical os
*no fetal cardiac activity or empty sac
spontaneous abortions - threatened
*vaginal bleeding & cramping
*closed cervix, soft
*fetal cardiac activity present
*does not mean that it will definitely resolve in a miscarriage, but may
spontaneous abortions - inevitable
*vaginal bleeding & cramping
*rupture of membranes
*dilated cervical os
*products of conception seen or felt at or above cervical os
spontaneous abortions - INCOMPLETE
*vaginal bleeding & cramping
*DILATED cervical os
*products of conception incompletely expelled
spontaneous abortions - COMPLETE
*vaginal bleeding
*CLOSED cervical os
*products of conception completely expelled
vasa previa - overview
*fetal vessels overlying or in close proximity of internal cervical os
*associated with velamentous umbilical cord insertion (inserts in chorioamniotic membrane rather than placenta → fetal vessels are NOT protected by Wharton jelly)
“VASA” = vessels
“PREVIA” = overlying cervical os
vasa previa - clinical presentation
*PAINLESS vaginal bleeding
*fetal bradycardia
*premature membrane rupture
first aid: presents with painless vaginal bleeding (fetal blood from injured vessels) upon rupture of membranes accompanied by fetal heart rate abnormalities (eg. bradycardia)
vasa previa - complications
*fetal heart rate decelerations
*vessel rupture
*exsanguination
*fetal death
vasa previa - treatment
*emergency cesarean section delivery
placental abruption - overview
*premature separation of placenta from uterine wall (partial or complete) BEFORE delivery of infant
placental abruption - clinical presentation
*ABRUPT, PAINFUL vaginal bleeding, typically in 3rd trimester
*can result in DIC, maternal hypovolemic shock, or fetal distress
*life threatening to mother and fetus
placental abruption - risk factors
*trauma (MVA, fall, IPV)
*smoking
*maternal HTN
*preeclampsia
*cocaine abuse
placental abruption - treatment
*depending on gestational age & stability of mom and baby
*monitor (inpatient) vs. delivery
placenta previa - overview
*attachment of PLACENTA over internal cervical os
*can be associated with placenta accreta spectrum
note - low lying placenta = located < 2cm from, but not covering, internal os
“PLACENTAL” = placenta
“PREVIA” = overlying internal cervical os
placenta previa - clinical presentation
*PAINLESS vaginal bleeding in 3rd trimester
placenta previa - risk factors
*multiparity
*prior cesarean or uterine surgery
placenta previa - treatment
*monitor for resolution and/or bleeding
*delivery by cesarean if no resolution or significant bleeding episode
placenta accreta spectrum - overview
*abnormal invasion of trophoblastic tissue into uterine wall:
-defective decidual layer during embryology
-abnormal attachment of placenta, abnormal separation after delivery
*spectrum based on depth of trophoblast invasion (accreta < increta < percreta)
placenta accreta spectrum - risk factors
*prior cesarean (or other uterine surgery)
*inflammation
*placenta previa
placenta accreta spectrum - presentation
*detected on ultrasound prior to delivery
*presents with difficulty separating placenta from uterus after fetal delivery
*severe postpartum bleeding / hemorrhage after manual removal of placenta (can cause Sheehan syndrome)
placenta accreta spectrum: ACCRETA
*placenta ATTACHES to myometrium (instead of overlying decidua basalis)
*does NOT penetrate or invade myometrium
*most common and most mild type
placenta accreta spectrum: INCRETA
*placenta partially invades / penetrates INTO myometrium
*intermediate subtype
placenta accreta spectrum: PERCRETA
*placenta COMPLETELY PENETRATES or PERFORATES through myometrium and into uterine serosa
*can cause attachment into rectum/bowel, bladder
*most severe subtype
placenta accreta spectrum - treatment
*cesarean hysterectomy
polyhydramnios - overview
*too much amniotic fluid
*associated with fetal anomalies, maternal diabetes, fetal anemia, multiple gestations
*complications: preterm labor, PPROM, cord prolapse, unstable lie (breech), PPH/uterine atony
oligohydramnios - overview
*too little amniotic fluid
*associated with: placental insufficiency, bilateral renal agenesis, posterior urethral valves
*complications: fetal growth restriction, fetal death/stillbirth, deformities, preterm birth, infection, delayed lung maturity, Potter Sequence
low birth weight - overview
*infant born small for gestational age, usually <2500 g (~5.5 lbs)
*causes: prematurity, fetal growth restriction (formerly IUGR)
*risks: overall mortality, SIDS, poor thermoregulation, hypoglycemia, etc
*complications: infections, RDS, necrotizing enterocolitis, intraventricular hemorrhage, persistent fetal circulation
postpartum hemorrhage (PPH) - overview
*1000mL + of blood loss within 24 hours of delivery
*occurs post delivery (after delivery of infant AND placenta)
*risk factors: twins, multiple gestations, coagulation disorders, hx of PPH
postpartum hemorrhage (PPH) - causes
*4 T’s:
1. TONE (uterine atony)
2. TRAUMA (lacerations)
3. THROMBIN (DIC, etc)
4. TISSUE (retained placenta)
postpartum hemorrhage (PPH) - management
*3 components of active management:
1. oxytoxin
2. uterine massage
3. umbilical cord traction
*other options: urine catheterization, early ambulation/bathroom use, breastfeeding
