Pregnancy & Complications

Question 1

hPL and hPGH

Answer 1

• 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.

Question 2

Placental steroidogenesis

Answer 2

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.

Question 3

What type of estrogen is formed by placenta?

Answer 3

Estriol. Very weak.

Question 4

3 natural functions of progesterone in pregnancy

2 therapeutic functions of progesterone in pregnancy

Answer 4

• 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.

Question 5

Where is hCG made?

Answer 5

Synctiotrophoblast

Question 6

What does abnormally high hCG indicate? (3)

Answer 6

Multiple gestation, molar pregnancy, hyperemesis gravidum

Question 7

What does abnormally low hCG indicate? (2)

Answer 7

Spontaneous abortion, ectopic pregnancy

Question 8

3 things that may present w/ vaginal bleeding and pelvic pain during pregnancy

Answer 8

Miscarriage, ectopic pregnancy, hydatiform mole

Question 9

Spontaneous abortion timeline

Answer 9

Prior to 20 weeks

Question 10

Preterm labor timeline

Answer 10

After 20 weeks

Question 11

Threatened abortion

Answer 11

Uterine bleeding in a pregnancy prior to 20 weeks gestation with a closed cervix

Question 12

Inevitable abortion

Answer 12

Uterine bleeding prior to 20 weeks gestation with an open cervix, or an ultrasound diagnosis of a non-viable pregnancy prior to 20 weeks

Question 13

Missed abortion

Answer 13

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.

Question 14

Septic abortion

Answer 14

An infection associated w/ spontaneous or elective abortion, most often in the setting of an incomplete abortion.

Question 15

Managing a threatened abortion

Answer 15

Pelvic rest and low physical activity

Question 16

Managing intrauterine fetal demise

Answer 16

• 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.

Question 17

Definition of recurrent pregnancy loss

Answer 17

Diagnosed after 3 consecutive miscarriages.

Question 18

Etiology of recurrent pregnancy loss
Anatomic
Endocrine
Genetic
Immunologic
2 others

Answer 18

• 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

Question 19

Managing recurrent pregnancy loss

Answer 19

Treat underlying disease, empiric progesterone supplement

Question 20

Ectopic pregnancy risk factors (4)

Answer 20

• Tubal damage – infection (PID), previous ectopic, surgery (tubal ligation)
• Current IUD use
• Assisted reproductive technologies – ovulation induction or IVF
• Smoking

Question 21

Diagnosing ectopic pregnancy (4)

Answer 21

• 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

Question 22

Treating ectopic pregnancy (2)

Answer 22

•Methotrexate – inhibits DNA synthesis. If hCG is

Question 23

Molar pregnancy presentation

Answer 23

• 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.

Question 24

Complete mole

Answer 24

46 XX or rarely 46 XY. Occurs when an empty egg is fertilized by 2 sperm or 1 sperm that duplicates its genetic material

Question 25

Partial mole

Answer 25

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.

Question 26

Risk of molar pregnancy

Answer 26

3-5% progress to choriocarcinoma

Question 27

Treating molar pregnancy (4)

Answer 27

• 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.