Pregnancy complications Flashcards
1
Q
What is a spontaneous abortion? How many occur in first semester? Risk after 15 wks?
A
- intrauterine preg at less than 20 wks - after 20 wks considered a still birth
- about 80% occur in first trimester
- after 15 wks risk is 0.6%
- overally almost 20% of all cinincally recognized pregnancies terminate in spontaneous abortion
2
Q
Etiology of spontaneous abortion?
A
- 60% result from x’somal defects
- 15% assoc with:
maternal trauma
infections
dietary deficiencies
DM
hypothyroidism
anatomic malformations- incompetent cervix - 25% can’t be determined
3
Q
What are the biggest RFs for spontaneous abortion?
A
- advanced maternal age
- previous spontaneous abortion
- maternal smoking
4
Q
Sxs of a spontaneous abortion?
A
- bleeding: bright red mostly, heavy - saturating pads
- midline cramping
- low back pain
- open or closed cervical os
- complete or partial expulsion of products of conception
5
Q
Subtypes of spontaneous abortion?
A
- threatened: Os closed, unpredictable outcome (pregnancy may still be viable)
- inevitable: Os opened, products of conception have not passed, pregnancy can’t be saved
- incomplete: os open, some products of conception have passed
- complete: os may be open or closed, products of conception have passed
- missed: pregnancy didn’t develop
6
Q
Signs and sxs of threatened abortion?
A
- slight bleeding
- abdominal cramping
- cervical os is closed
- uterine size is compatible with dates
- no products of conception are passed
- prognosis is unpredictable
7
Q
Tx measures for threatened abortion?
A
- bed rest from 24-48 hrs with gradual resumption of usual activities
- no work, no child care responsibilities
- rest in horizontal postion except when bathing or using toilet
- no sex
- abx only if there are signs of infection
- hormonal tx is CI
- hydration
- explicit instructions on when to report signs and sxs
- definitive f/u date
8
Q
What ar the signs and sxs of an inevitable abortion?
A
- moderate bleeding
- moderate to severe uterine cramping
- low back pain
- cervical os is dilated
- membranes may or may not be ruptured
- uterine size is compatible with dates
- products of conception are not passed but passage is inevitable
- prognosis is poor, pregnancy can’t be saved
9
Q
Signs and sxs of an incomplete abortion?
A
- heavy bleeding
- moderate to severe abdominal cramping
- low back pain
- cervical os is dilated
- uterine size is compatible with dates
- some portion of productions of conception (usually placenta) remain in uterus
- pregnancy can’t be saved
10
Q
What is a missed abortion?
A
- pregnancy ceased to develop but products of conception haven’t been expelled
- sxs of pregnancy disappear
- brownish vaginal d/c but no free bleeding
- pain doesn’t develop develop
- cervix is semi-firm and slightly dilated
- uterus becomes smaller and irregularly softened
11
Q
Tx for missed, inevitable and incomplete abortions?
A
- counseling regarding fate of pregnancy
- assess Rh factor and admin immunoglobulin to Rh negative, unsensitized woman
- planning for elective termination:
empty all products of conception to prevent infection and uterine hemorrhage with DandC
insertion of laminaria to dilate cervix followed by aspiration is method of choice for missed abortion
prostaglandin vaginal supps are an effective alternative
12
Q
Signs and sxs of a complete abortion?
A
- bleeding may be heavy or minimal
- moderate to severe abdominal cramping
- low back pain
- fetus and placenta are completely expelled
- pain then ceases, but spotting may persist
- cervical os may be opened or closed
- uterus is normal pre-pregnancy size
13
Q
What are habitual abortions?
A
- considered recurrent pregnancy loss/habitual abortions if 3 previous pregnancies
- 3 previous pregnancies - 70-80% chance of carrying a fetus to viability
- 4 or more - 65-70% chance of carrying a fetus to viability
14
Q
Eval of suspected spontaneous abortion?
A
- hx
- PE including pelvic exam and visualization of cervix
- +/- fetal doppler
- +/- transvaginal US
- lab eval:
serum hCG (should double normally)
blood type and ab screen if suspected RH negative mother
15
Q
Workup for recurrent pregnancy loss?
A
- most useful tests:
assessment of uterine structure, rule out lupus (anticardiolipin ab, lupus anticoag), TSH - less useful tests:
blood glucose
genetic (only if other testing normal): maternal and paternal - day 3 FSH levels
- progesterone levels
16
Q
F/U for spontaneous abortion?
A
- GYN exam 2-3 wks after termination
- use contraception for 3 months to allow complete maternal healing and regeneration of endometrial lining
- follow hCG (make sure it goes back down)
17
Q
What is an ectopic pregnancy? Sites?
A
- implantation of fertilized ovum outside of the uterine cavity: fallopian tube: MC site (98%) cervix ovary in abdominal cavity - rupture is inevitable - potentially life threatening condition - incidence: 1/80 pregnancies - Major cause of maternal death during 1st trimester
18
Q
RFs for ectopic pregnancy? Lower risk factors?
A
RFs:
- hx of genital infections (PID)
- hx of infertility
- hx of tubal pregnancy (ligation or reconstruction)
- hx of any ectopic pregnancy
- IUD
lower risk:
- abdominal or pelvic surgery
- hx of ruptured appendix
- intrauterine exposure to DES
- use of drugs that slow ovum transport (mini-pill)
19
Q
DES - shown to cause what?
A
- given to preg ladies from 1940-1970 b/c of the belief it would reduce complications and miscarriages
- cause rare vaginal tumor in girls and young women exposed to drug in utero
- daughters also have slightly increased risk of breast cancer after 40
20
Q
Natural hx of ectopic pregnancy?
A
- rupture: assoc with profound hemorrhage that can be fatal
- abortion: expulsion of products of conception through fimbria and absorption of tissue
- some can spontaneously resolve
21
Q
Classic presentation of ectopic pregnancy?
A
- 1-2 months of amenorrhea
- morning sickness
- breast tenderness
- diarrhea, urge to defecate
- malaise and syncope
- lower abdominal/pelvic pain: sudden and severe, especially adnexal (lateralizes to one side)
- referral of pain to shoulder
22
Q
Atypical presentation of ectopic pregnancy?
A
- vague or subacute sxs
- menstrual irregularity
- signs and sxs don’t always correlate with severity of condition
23
Q
PE - on pt with suspected ectopic pregnancy?
A
- vital signs may reveal orthostatic changes: tachycardia, hypotension
- adnexal, cervical motion and or abdominal tenderness on pelvic exam
- pelvic exam: normal appearing cervix, marked tenderness, vaginal vault may be bloody, usually brick red to brown in color
tender adnexal mass may be palpated - This can KILL your PT
- be vigilant about vital signs and maintaining IV access
- emergency surgery is only thing that can save them once rupture with hemorrhage has occurred: pt w/ tachycardia, hypotension and + pregnancy test needs surgery b/f they bleed out
24
Q
Differential once you have ruled out ectopic pregnancy?
A
- PID
- ovarian cyst
- ovarian tumor
- intruterine pregnancy
- recent spontaneous abortion
- early hydatidifrom degeneration
- acute appendicitis
- other bowel related disorders
25
Q
Labs for suspected ectopic pregnancy?
A
- b-hCG: will be lower than expected for normal pregnancies of sam duration
if followed over few days:
there may be slow rise or plateau rather than near doubling q 2 days assoc with normal PG or falling levels assoc with spontaneous abortion - CBC: may show anemia or slight leukocytosis
- Rh factor
26
Q
Imaging for suspected ectopic pregnancy? What is the correlation b/t US and hCG?
A
- transvaginal US: empty uterine cavity
- correlation b/t U/S and hCG - hCG level of 6500 U/ml with an empty uterine cavity by US virtually dx of ectopic pregnancy
27
Q
Dx and tx of ectopic pregnancy?
A
- laparoscopy is definitive
- depending on size of ectopic and whether or not it has ruptured, salpingostomy with removal of ectopic or partial or complete salpinectomy can be performed pelvicscopically
- may need laparotomy to manage if severe
28
Q
Indications for surgical management for ectopic pregnancy?
A
- hemodynamic instability
- impending or ongoing ectopic mass rupture
- not able or willing to comply with medical therapy post tx f/u
- lack of timely access for medical care in case tube rupture
- failed medical therapy
29
Q
Medical management of ectopic pregnancy?
A
- methotrexate given systemically as a single or multiple doses is acceptable medical therapy for early ectopic pregnancy who are:
- hemodynamically stable
- are willing and able to comply with post tx f/u
- have an hCG of less than or equal to 5000 miU/mL
- have no fetal cardiac activity
- size of ectopic is less than 3.5 cm with no active bleeding
- MTX: stops growth of cells and most times will absorb (still taking a risk - could rupture)
30
Q
F/U after tx of ectopic pregnancy?
A
- Rh immunoglobulin for Rh-negative women
- contraception for at least 2 months to allow for adequate tissue healing and repair
- pelvic rest until b-hCG is negative
- F/U appt w/in 2 wks of surgery
31
Q
What are the 4 types of gestational trophoblastic disease?
A
- hydatidiform mole
- persistent/invasive gestational trophoblastic neoplasia
- choriocarcinoma
- placental site trophoblastic tumors
32
Q
What is a hydatidiform mole? Diff b/t partial and complete?
A
- MC type of trophoblastic disease
- BENIGN neoplasm of the chorion in which chorionic villi degenerate and become transparent vesicles containing clear, viscous fluid
- occurs when single sperm fertilizes an egg w/o a nucleus
- partial: a fetus or evidence of an amniotic sac is present
- complete: no fetus or amnion is found (have a tendency to become choriocarcinoma)
33
Q
RFs for hydatidiform mole?
A
- low socioeconomic status
- hx of mole
- age below 18
- age over 40
34
Q
Clinical presentation of hydatidiform mole?
A
- vaginal bleeding
- enlarged uterus
- pelvic pressur or pain
- theca lutein cysts
- hyperemesis gravidarium
- hyperthyroidism (about 5%)
- preeclampsia b/f 20 wks gestation
- vaginal passable of hydropic vesicles
- no fetal heart tones or fetal activity
- N/V
35
Q
Labs and imaging for suspected hydatidifrom mole?
A
- b-hCG: extremely high for gestational age, above 40,000 mU/ml
- U/S: absence of gestational sac, characteristic multiple echogenic region “snowy” w/in the uterus
- CXR to rule out pulmonary mets of trophoblast
36
Q
Tx of hydatidiform mole?
A
- DandC immediately
- pathologic exam on curettings - if malignant=chemo
- effective birth control
- weekly quantitative B-hCG: after 2 decreasing weekly tests, interval is increased to monthlyx6 mos, then q 2 months for total of one year, no further investigation if hCG levels decrease to normal
If levels plateau or begins to rise, should be evaluated with CXR, then DandC and chemo - no pregnancy until hCG levels remain normal for min. of 1 yr
37
Q
How common are choriocarcinomas? What may they follow? PP?
A
- rare, highly malignant GTTD
- may follow HM, invasion mole, abortion, normal pregnancy, ectopic pregnany
- causes ulcerating surfaces into endometrial cavity
- malignant tumor cells enter circulation through open blood vessels in the endometrial cavity and are transported to lungs, brain or to other distant sites
38
Q
Tx for choriocarcinoma?
A
- highly sensitive to chemo, which is TOC
- surgery - little place (high vascularity and effectiveness of chemo) - it is indicated for tumor resistant to chemo and single mets persisting despite chemo
39
Q
4 major causes of 1st trimester bleeding?
A
- physiologic: implantation
- ectopic pregnancy
- impending or complete abortion
- cervical, vaginal or uterine path: polyps, inflammation, infection, trophoblastic disease
40
Q
W/U of 1st trimester bleeding?
A
- assess stability of pt and degree of bleeding
- US
- CBC
- serial B-hCG if threatened abortion
41
Q
What is placenta previa? 3 diff types?
A
- placenta implanted in lower segment of uterus and extends over or lies proximal to the internal cervical os
- 3 types:
total or complete: entire os covered
partial: internal os partially covered
marginal or low-lying: edge of placenta at os but doesn’t cause obstruction
42
Q
RFs for placenta previa?
A
- previous placenta previa
- multiparity
- multiple gestation
- previous C-section
- trauma
- smoking
- advanced maternal age
- infertility tx
- previous intruterine surgical procedure (myomectomy)
43
Q
Presentation of placenta previous? What should not be done? Dx made by?
A
- painless bleeding in 3rd trimester
- bright red blood
- may have shock sxs if bleeding is severe
- VS stable
- FHT normal
- fetal activity present
- NO vaginal or speculum exam should be done
- dx best made with transvaginal US
44
Q
Tx of placenta previa if acutely bleeding?
A
- dx: US
acute bleeding episode: - supportive care to maintain hemodynamic stability
- FHR monitor
- IV NS or LR
- Mg sulfate and corticosteroids if in labor and less than 34 wks
- about half respond to conservative management
45
Q
Tx of placenta previa - indications for a c-section and conservative management postbleed?
A
- indications for c-section delivery:
nonreassuring fetal HR, life threatening maternal hemorrhage, sig vaginal bleeding after 34 wks - conservative management post bleed:
sometimes need to be hospitalized until delivery, depends on clinical situation, at high risk for rebleeding as well as PROM, if stable will deliver by c-section at 36-37 wks old
46
Q
What is abruptio placentae?
A
- placental abruption
- partial or complete detachment of a normally implanted placenta at any time prior to delivery
- more frequent during 3rd trimester
- may occur anytime after 20 wks gestation
- sig cause of maternal and fetal morbidity and mortality
47
Q
MC RFs for placental abruption?
A
- previous abruption
- abdominal trauma
- cocaine
- smoking (risk increases by 40% for each pack/day smoked)
- eclampsia
- pregnancy induced HTN
48
Q
Presentation of placental abruption?
A
- vaginal bleeding: mild to severe (amt doesn’t correlate with degree of separation)
- abdominal pain or back pain
- uterine contractions
- uterine tenderness to palpation
- nonreassuring FHR pattern
- *all preg women with abdominal pain, uterine contractions and vaginal bleeding need to have this ruled out
49
Q
Complications of placental abruption: maternal and fetal?
A
- maternal: hemorrhagic shock coagulopathy/DIC uterine rupture renal failure ischemic necrosis of distal organs (hepatic, adrenal, pituitary) - fetal: hypoxia anemia growth retardation CNS anomalies fetal death: if 50% of placenta is separated
50
Q
Dx eval of placental abruption?
A
- early markers of ischemic disease during routine care: elevated AFP with no other explanation and elevated B-hCG
- fibrinogen to eval for DIC: decreased fibrinogen, elevated fibrin degradation products and elevated D-dimer
- imaging: classic finding in a retroplacental hematoma (US)
51
Q
Tx of placental abruption?
A
- *these pts can have sudden worsening abruption at any time so be prepared for the worst
- continous fetal monitoring
- IV access for mother
- maintain maternal O2 sats over 95%
- CBC, blood type (cross and screen), coag studies (eval for DIC)
- tx of DIC if indicated
- severe abruption may reqr delivery of baby regardless of gestational age: if 36 wks or more then tx is to deliver.
52
Q
What is placenta accrete? 3 forms?
A
- placenta attaches too deeply into the wall of the uterus
- 3 forms:
placenta accreta
placenta increta
placenta percreta - dist. by severity and deepness of placenta attachment
- approx 1/2500 pregancies experience placenta accreta, increta, or percreta
53
Q
RFs for placenta accreta?
A
- all 3 forms are assoc with hx of prior c-section, hx of uterine instrumentation or surgery or placenta previa
- rarely abdnormal attachment is seen in absence of prior surgery and in the absence of placenta previa
54
Q
Risks assoc with placenta accreta?
A
- preterm delivery
- severe PPH
55
Q
Tx of placenta accreta?
A
- little can be done for tx once placenta accreta has been dx
- monitor pregnancy with intent of scheduling a delivery and using a surgery that may spare the uterus
- unfortunately placenta accreta may be severe enough that a hysterectomy may be needed
56
Q
What needs to be ruled out b/f vaginal exam if pt has bleeding after 1st trimester? What is go to dx test for bleeding during this time?
A
- all vaginal bleeding needs an eval
- US is go to dx test
- need to r/o placenta previa b/f speculum or vaginal exam
- have to continually assess hemodynamic status of pt
57
Q
Diff b/t normal N/V of pregnancy and hyperemesis gravidarium?
A
- normal: peak incidence 8-12 wks, should resolve by 20 wks
- hyperemesis gravidarium: persistent, severe, intractable vomiting during pregnancy
wt loss of 5% or more of pre-pregnancy wt, + ketonuria not from other causes in 1st trimester
58
Q
Eval of excessive N/V during pregnancy?
A
- wt
- orthostatic VS
- electrolytes (BMP)
- UA: ketones
- obstetrical US to rule out gestational trophoblastic disease or multiple gestation
59
Q
Tx of hyperemesis gravidarium?
A
- hospitalization with bed rest
- NPO x 48 hrs
- maintain hydration and electrolyte balance and vitamins with parenteral IV fluids
- As soon as possible - place pt on dry diet consisting of six small feedings daily plus clear liquids
- after stabilization: pt can be maintained at home even if she reqrs IV fluids in addition to her oral intake
60
Q
Meds for hyperemesis gravidarium?
A
- 1st line: Vit B6 25 mg po TID to QID
- doxylamine (unisom) 25 mg-50 mg po q 4-6 hrs
- 2nd line: DC doxylamine and try prochlorperazine (compazine) or metaclopramide (reglan)
- 3rd line or if severe reqring hosp. due to dehydration: odansetron (zofran) - may be related to cardiac defects and cleft palate
- IV fluids with thiamine if dehydration is noted
- glucocorticoids after 1st trimester (decrease nausea)
- TPN if unable to keep anything down
61
Q
PPROM - dx can be?
A
- clinical
visualization of fluid in vagina of preg lady who presents with hx of leaking fluid
62
Q
Testing for PROM?
A
- pH paper (nitrazine test) - amniotic - 7-7.3, vaginal: 3.8
- ferning - sawb onto glass slide, air dry for 10 min
amniotic: delicate pattern
cervical: dense and thick - US - check amniotic fluid level
- instillation of indigo carmine into amniotic fluid: place tampon in vagina for 20 min - if turns blue - there is a leak
- placental alpha microglobulin 1 protein assay (amnisure): immunochromatography, sterile swab in vagina - spendy
- placental fibronectin - from vaginal secretions (if negative supports no membrane rupture)
63
Q
Management of PROM?
A
- once dx confirmed determine if pt and fetus are stable or unstable
- if unstable deliver
- if stable: keep in hosp until delivery - administer abx, corticosteroids and monitor for stability of mom and baby
and deliver at 34 wks
64
Q
How common is diabetes in pregnancy?
A
- occurs in 7% of preg (dx of DM prior to pregnancy and during)
- carries an increased risk of congenital abnormalities if HgBA1C is more than 9.5%
- mothers have increased risk for DKA
- 2x risk of PIH or pre-eclampsia
- worsening diabetic nephropathy and retinopathy
65
Q
Risks of maternal diabetes to fetus?
A
- risk of congenital anomalies is 6x that of average
- cardiac, CNS, renal, limb deformity, sacral agenesis
- increased risk of spontaneous abortion and stilbirth
- macrosomia (wt over 4000-4500 g)
- sometimes uteroplacental insufficiency and IUGR
- polyhydramnios: (amniotic fluid of more than 2 L) - increased risk for placental abruption, preterm labor, and post partum uterine atony
- neonatal period: at higher risk of neonatal hypoglycemia, hyperbilirubinemia, hypocalcemia, and polycythemia
66
Q
DM management?
A
- frequent BG monitoring
- aim for optimal glucose control through diet, exercise, and insulin therapy
- insulin requirements increase throughout the pregnancy, most markedly at 28-32 wks
- reqrs FU q 1-2 wks for first 2 trimesters then once weekly for 3rd
67
Q
Screening for gestational DM?
A
screen 24-28 wks with 50 g 1 hr oral glucose challenge: no need to fast
- if BG greater than 140 mg/dL then they need a 3 hr glucose tolerance test
68
Q
DM management during pregnancy?
A
- mainstay of Gestational DM tx is diet and to maintain 30kcal/kg of IBW/day
- blood sugar goals:
fasting less than 95
1 hr postprandial: 130-140
2 hr post: less than 120 - if unable to attain goals with diet then move to insulin therapy and now starting to use some oral hypoglycemics (glyburide and metformin)
69
Q
Risks of having diabetes during pregnancy?
A
- increased risk for UTI and pyelonephritis with DM
- often induce at 39 wks
- babies large due to increased insulin and other hormonal changes = shoulder dystocia
- mother may need an IV drip of 5% dextrose during labor to maintain BG of 100
- with GDM the blood sugar may return to normal within 2 hrs of delivering the placenta
70
Q
Tx of thyroid disease during pregnancy?
A
- tx of hypothyroidism is with levothyroxine
- maternal thyroxine requirements increase in women with hypothyroidism dx prior to pregnancy
- adjust dose at 4 wk intervals and once stable check a TSH once q trimester
- post partum thyroiditis can occur for up to a year post delivery (w/ or w/o prior hx of hypothyroidism)
71
Q
PP of thyroid disease during pregnancy?
A
- TBG increase during pregnancy
- free T4 may increase in 1st trimester
- TSH decreases in first 10 wks
- no routine screening needed just check TSH in those with known thyroid disease
- gestational trophoblastic disease and hyperemesis gravidarium may affect thyroid fxn
- if hyperthyroid pre-preg, likely will need to adjust meds during pregnancy
