Pregnancy & Complications Flashcards
hPL and hPGH
- Human Placental Lactogen (hPL) and human Placental Growth Hormone (hPGH) both promote growth. Both induce insulin-resistance → glucose availability for the fetus.
- hPL increases maternal lipolysis → increased FFAs for maternal energy use, which frees glucose, AAs, and ketones to cross placenta for fetal use.
Placental steroidogenesis
Placenta lacks 17 alpha hydroxylase (converts progesterone to 17-hydroxyprogesterone). Mother produces cholesterol, converted to progesterone in placenta, then moves to fetus, which does have 17 alpha OH, so DHEA-S can be formed, which is subsequently converted to estrogen.
What type of estrogen is formed by placenta?
Estriol. Very weak.
3 natural functions of progesterone in pregnancy
2 therapeutic functions of progesterone in pregnancy
- Inhibits contractions, decreases vascular resistance (increases blood flow to baby), immune adaptation via T cell inhibition (so baby isn’t attacked).
- Used therapeutically to treat recurrent miscarriages and preterm labor.
Where is hCG made?
Synctiotrophoblast
What does abnormally high hCG indicate? (3)
Multiple gestation, molar pregnancy, hyperemesis gravidum
What does abnormally low hCG indicate? (2)
Spontaneous abortion, ectopic pregnancy
3 things that may present w/ vaginal bleeding and pelvic pain during pregnancy
Miscarriage, ectopic pregnancy, hydatiform mole
Spontaneous abortion timeline
Prior to 20 weeks
Preterm labor timeline
After 20 weeks
Threatened abortion
Uterine bleeding in a pregnancy prior to 20 weeks gestation with a closed cervix
Inevitable abortion
Uterine bleeding prior to 20 weeks gestation with an open cervix, or an ultrasound diagnosis of a non-viable pregnancy prior to 20 weeks
Missed abortion
Fetal or embryonic death prior to 20 weeks gestation without any expulsion of fetal or placental tissue.
Often refers to an ultrasound diagnosis before clinical signs of miscarriage in setting of an embryonic gestation or early embryonic demise.
Septic abortion
An infection associated w/ spontaneous or elective abortion, most often in the setting of an incomplete abortion.
Managing a threatened abortion
Pelvic rest and low physical activity
Managing intrauterine fetal demise
- Dilation and curettage (D&C) to clean out uterus after spontaneous abortion.
- Important to get blood type of mother after spontaneous abortion. If Rh-, give Rho Gham to prevent immune hemolysis in subsequent pregnancies.
Definition of recurrent pregnancy loss
Diagnosed after 3 consecutive miscarriages.
Etiology of recurrent pregnancy loss Anatomic Endocrine Genetic Immunologic 2 others
- 50% are idiopathic
- Anatomic factors: uterine anomalies (ex: septum), fibroids/polyps, intrauterine adhesions, cervical insufficiency (often present as a late second trimester loss).
- Endocrine factors: thyroid dysfunction, diabetes, PCOS, hyperprolactinemia, decreased ovarian reserve
- Genetic factors: translocations or aneuploidy of parental chromosomes (5%)
- Immunologic factors: Antiphospholipid syndrome, infection
- Environmental factors
- Thrombophilias
Managing recurrent pregnancy loss
Treat underlying disease, empiric progesterone supplement
Ectopic pregnancy risk factors (4)
- Tubal damage – infection (PID), previous ectopic, surgery (tubal ligation)
- Current IUD use
- Assisted reproductive technologies – ovulation induction or IVF
- Smoking
Diagnosing ectopic pregnancy (4)
- Presentation – pain / vaginal bleeding often at 6-8 weeks LMP
- No intrauterine pregnancy seen on US despite hCG > 1000-1500. May see ectopic on US.
- Pelvic mass
- If advanced, tubal rupture / intra-abdominal hemorrhage
Treating ectopic pregnancy (2)
•Methotrexate – inhibits DNA synthesis. If hCG is
Molar pregnancy presentation
- Presents very similar to missed abortion and ectopic pregnancy: vaginal bleeding, hyperemesis, preeclampsia, excessive hCG (>100,000), hydropic villi, possible hyperthyroidism, uterine enlargement greater than expected for gestational age.
- Absence of intrauterine gestational sac.
- Placenta grows but no fetus.
Complete mole
46 XX or rarely 46 XY. Occurs when an empty egg is fertilized by 2 sperm or 1 sperm that duplicates its genetic material
Partial mole
69 XXX, XYY, or XXY. Caused by 2 sperm entering the same egg → 69 chromosomes. US shows a fetus but it is very small compared to the placenta. Excess paternal genes lead to placental overgrowth.
Risk of molar pregnancy
3-5% progress to choriocarcinoma
Treating molar pregnancy (4)
- Surgical evacuation (D&C)+/- suction
- Hysterectomy may be indicated for bleeding or perforation
- Close follow-up of hCG
- Avoid pregnancy until hCG is undetectable b/c otherwise you can’t use it as a tumor marker.
