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
*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
