Pregnancy complications 2 Flashcards
Cervical insufficiency (incompetent cervix)
the inability of the uterine cervix to retain a pregnancy in the second trimester in the absence of clinical contractions or labor
common causes of cervical insufficiency
history of cervical trauma or procedures, collagen disorders, and congenital anomalies of the cervix.
Cervical trauma may include prior cone biopsies, prior deep cervical lacerations, and use of instruments during labor
dx cervical insufficiency
The diagnosis of cervical insufficiency is preferably made based on obstetric history and the cervical length on transvaginal ultrasound, but the diagnosis can be made based on obstetric history alone. The diagnosis is often made based on obstetric history in women with at least two consecutive second-trimester pregnancy losses or extremely early preterm births (prior to 28 weeks) associated with minimal or mild symptoms (usually painless). or at least three preterm births prior to 34 weeks gestation in which other causes have been excluded
The diagnosis of cervical insufficiency is often made based on obstetric history and exam or ultrasound in women with at least one prior preterm birth and advanced changes on physical examination before 24 weeks of gestation or cervical length ≤ 25 mm on transvaginal ultrasound examination
Exam findings cervical insufficiency
dilated and effaced cervix in a woman without contractions or with minimal contractions inconsistent with the amount of cervical change
tx cervical insufficiency
cervical cerclage and progesterone supplementation beginning at 16 weeks gestation
at what point in pregnancy is a cervical cerclage recommended
A cervical cerclage is recommended beginning at 12–14 weeks of pregnancy for women who meet the obstetric history criteria for a diagnosis of cervical insufficiency
management of Women with suspected cervical insufficiency who do not meet the obstetric history criteria
monitored with frequent surveillance via transvaginal ultrasound. This monitoring should be started at 14–16 weeks gestation
who else should be given supplemental progesterone in regards to cervical insufficiency
Women who meet the ultrasound criteria for a cervical cerclage with a prior history of a spontaneous preterm birth are also treated with progesterone supplementation beginning at 16 weeks gestation
The diagnosis of cervical insufficiency is limited to what type of pregnancies
singleton gestation pregnancies
At which gestational age in the pregnancy are cervical cerclages typically removed?
36–37 weeks gestation or with the onset of preterm labor
Placental abruption is also known as
abruptio placentae
placental abruption
a condition in which there is partial or complete placental detachment from the uterine wall prior to delivery of the fetus. Severe cases are associated with increased maternal and fetal morbidity
strongest RF for placental abruption
history of a previous placental abruption
Other RF placental abruption
Abdominal trauma, cocaine use, and eclampsia
polyhydramnios, chronic hypertension, preeclampsia, prelabor rupture of membranes, chorioamnionitis, and smoking
sx placental abruption
acute onset of painful vaginal bleeding (dark red blood) accompanied by uterine contractions and abdominal or back pain. Bleeding may be mild or profuse and life-threatening
PE placental abruption
a firm, rigid, or tender uterus
Findings that are concerning for increased maternal and fetal morbidity in placental abruption
abdominal pain, hypotension, and fetal heart rate abnormalities
dx placental abruption
primarily clinical
classic TVUS placental abruption
Retroplacental hematoma
placental abruption and risk of DIC
A placental abruption of > 50% significantly increases the risk for acute disseminated intravascular coagulation (DIC) and fetal death
Complications of placental abruption
DIC
fetal death
excessive blood loss resulting in hypovolemic shock, kidney failure, respiratory distress syndrome, multiorgan failure, and death
tx for life threatening placental abruption
Emergency cesarean section or peripartum hysterectomy
Grade 1 placental abruption
Mild bleeding with a normal fetal heart rate
Grade 2 placental abruption
mild to moderate vaginal bleeding, significant uterine contractions, and fetal heart rate abnormalities
Grade 3 placental abruption
mild to severe bleeding, severe abdominal pain, and evidence of fetal demise
what should be avoided with placental abruption
A pelvic exam or other cervical stimulation
what should be obtained in all women w bleeding in the third trimester
CBC, blood type and cross, and fibrinogen level should be obtained
diagnostic test of choice for placental abruption
Transvaginal ultrasound demonstrating a hematoma in between the placenta and endometrium is a specific and safe test to evaluate for placental abruption and thus is the diagnostic test of choice
Indications for C section for placental abruption
if there are signs of fetal distress, deteriorating hemodynamic status of the mother, persistent vaginal bleeding, or active labo
IV steroids and tocolytics for placental abruption
Intravenous steroids and tocolytics are indicated for women with placental abruption who are < 34 weeks gestation to promote fetal lung maturity and prevent labor
on top of tocolytics and steroids, women less than 32 weeks with placental abruption should also receive
magnesium sulfate for neuroprotection
indications for expectant management placental abruption
Expectant management of a placental abruption is reasonable for women between 24–34 weeks gestation who are not in active labor and when both the fetus and the mother are hemodynamically stable
placenta previa
the placenta implants itself over the internal cervical os
RF placenta previa
previous placenta previa, previous cesarean delivery, multiparity, smoking, and increasing maternal age
dx placenta previa
US
sx placenta previa
painless bright red vaginal bleeding, which can range anywhere from light spotting to profuse hemorrhaging
occurs during the second half of pregnancy
management placenta previa
Initially, all women with placenta previa should be hospitalized for stabilization and bed rest. For pregnancies at 36 weeks gestation or earlier, if the bleeding and abdominal cramping have subsided, patients can be discharged and closely monitored. However, for pregnancies at 37 weeks or greater, a cesarean section delivery is indicated
when is placenta previa MC diagnosed
Placenta previa is also frequently diagnosed when it is identified on the fetal anatomic survey ultrasound performed between 16 and 20 weeks gestational age. However, 90% of placenta previa cases identified on an ultrasound before 20 weeks gestation resolve prior to delivery
when should you suspect placenta previa
The diagnosis of placenta previa should be suspected in all pregnant women presenting with vaginal bleeding at more than 20 weeks gestation
management asx women w placenta previa
Women who are asymptomatic with placenta previa should have an ultrasound repeated in the third trimester around 32 weeks. If the placenta previa has not resolved, then the patient should have a cesarean delivery between 36 and 38 weeks gestational age. Furthermore, these patients should be educated on lifestyle modifications to reduce the risk of bleeding, which include avoiding sexual intercourse and heavy lifting
management for women w placenta previa and resolved episode of bleeding
Women who have placenta previa and a resolved episode of bleeding can typically be treated outpatient as long as they are stable and able to return to the hospital if bleeding recurs. These women should have a cesarean delivery between 36 weeks and 37 6/7 weeks gestation
what should be given to all Rh negative women w bleeding from placenta previa
Anti-D immune globulin
indications for c section placenta previa
active labor (cervical dilation around 4–6 cm), refractory maternal hemorrhage, nonreassuring fetal status, and any significant bleeding after 34 weeks
Cesarean delivery is recommended between 36–38 weeks gestation in women with asymptomatic placenta previa
what should be avoided by providers in placenta previa
health care clinicians should avoid speculum examinations in women who are known to have placenta previa
Preeclampsia
emergency pregnancy condition that consists of hypertension with proteinuria or hypertension with signs of severe end-organ involvement
new-onset hypertension with proteinuria after the 20th week of gestation
systolic blood pressure ≥ 140 mm Hg or a diastolic blood pressure ≥ 90 mm Hg on at least two occasions at least 4 hours apart in a previously normotensive patient
RF preeclampsia
a prior history or family history of preeclampsia, preexisting medical conditions (e.g., pregestational diabetes, chronic hypertension, prepregnancy body mass index > 25 kg/m2 or body mass index > 30 kg/m2), nulliparity, and advanced maternal age
pre-hypertensive values
between 120 and 139 mm Hg systolic and 80 and 90 mm Hg diastolic
overt HTN for preeclampsia
≥ 140/90 mm Hg
when does preeclampsia MC manifest
37 weeks gestation
Preeclampsia with severe features
patients who present with systolic blood pressure values ≥ 160 mm Hg or diastolic values ≥ 110 mm Hg with proteinuria. This diagnosis is also used for patients with hypertensive values who have evidence of end-organ dysfunction as manifested by new-onset cerebral or visual disturbances (e.g., severe, persistent headache, blurred vision, scotomata, altered mental status), severe, persistent right upper quadrant or epigastric abdominal pain, thrombocytopenia (< 100,000 platelets/microL), progressive kidney insufficiency (serum creatinine > 1.1 mg/dL), or pulmonary edema
testing preeclampsia
complete blood count, serum creatinine level, liver studies, and urinary protein determination (protein to creatinine ratio)
Fetal status should be determined while evaluating the mother with a nonstress test or biophysical profile test
delivery for preeclampsia
Term pregnancies (≥ 37 weeks gestation) can be delivered at the time of presentation of preeclampsia without severe features, while preterm pregnancies should be treated via expectant management with delivery after 37 weeks gestation
tx preeclampsia w severe features
magnesium sulfate for seizure prophylaxis. It is administered intravenously as 4–6 g over 20–60 minutes initially, with maintenance dosing at 1–2 g/h with therapeutic drug levels ranging from 4.8 to 8.4 mg/dL
Patients with preeclampsia with severe features should be delivered regardless of gestational age due to the maternal risks
what should you test when you administer magnesium sulfate and how often
patellar reflex; testing every 6 hours to adjust the maintenance dosing as indicated
when does loss of patellar reflex, respiratory paralysis, and cardiac arrest occur in regards to magnesium sulfate
Loss of patellar reflexes occurs at levels ≥ 10 mg/dL, with respiratory paralysis occurring at levels ≥ 15 mg/dL and cardiac arrest possible with levels ≥ 25 mg/d
tx magnesium toxicity
Calcium gluconate
All patients with preeclampsia should be monitored for
fluid balance, with total intravenous fluid administration not to exceed 80 mL/h to avoid pulmonary edema
first line meds for HTN in preeclampsia
labetalol, nifedipine, and hydralazine
target BP preeclampsia
130 to 150 mm Hg systolic and 80 to 100 mm Hg diastolic
When can magnesium sulfate be discontinued?
At least 24 hours after delivery
Is proteinuria a requirement for dx of preeclampsia
no
Screening for preeclampsia
regular blood pressure measurements and urinalysis
All pregnant women should be screened with blood pressure measurements at all prenatal visits
what reduces risk of preeclampsia
low dose aspirin
definitive tx preeclampsia
delivery
when is continued monitoring an appropriate tx for preeclampsia
blood pressure is < 160/110 mm Hg, and no evidence of end-organ dysfunction
antihypertensives are recommended when >60/110 or evidence of end-organ dysfunction
Antihypertensive classes to avoid in pregnancy
angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, direct renin inhibitors, and mineralocorticoid receptor antagonists
True or false: cigarette smoking increases the risk of preeclampsia
False. Cigarette smoking is associated with a lower risk of preeclampsia
fetal risks for preeclampsia
preterm delivery and being born small for gestational age
maternal risks for preeclampsia
cerebral hemorrhage, cardiac failure, acute kidney injury, hepatic failure, and progression to eclampsia
how to confirm proteinuria in preeclampsia
24-hour urine collection or by a random urine protein to urine creatinine ratio
≥ 300 mg (0.3 g) per 24-hour urine collection, urine protein to creatinine ratio > 0.3, or urine dipstick reading of ≥ 2+
All patients with preeclampsia should be delivered at
37 weeks
is preeclampsia an indication for C section
Preeclampsia is not an indication for a cesarean delivery regardless of the presence of severe features
what should be administered to women with preeclampsia who are < 34 weeks pregnant
antenatal corticosteroids
What are some side effects of magnesium sulfate?
Depressed reflexes, hypotension, flushing, drowsiness, impaired cardiac function, diaphoresis, and vision changes
Development of grand mal seizures in a woman with preeclampsia
eclampsia
HELLP syndrome
hemolysis, elevated liver enzymes, low platelets; recognized as a subtype of preeclampsia in which these features may present with or without hypertension or proteinuria
What is the typical fetal response to maternal seizures in eclampsia?
Bradycardia during and immediately after the seizure
What disorder is associated with preeclampsia that presents prior to 20 weeks of gestation?
A molar pregnancy
