Pregnancy Complications Flashcards
Complications of Pregnancy
Spontaneous abortion Ectopic pregnancy Gestational trophoblastic disease Placental abnormalities Hyperemesis gravidarum Premature rupture of membranes DM Thyroid disease
Define Spontaneous Abortion
Loss of a fetus at less than 20 weeks gestation
“Miscarriage”
Etiology of Spontaneous Abortion
Chromosomal defects (60%) Maternal trauma Infections Dietary deficiencies DM Hypothyroidism Anatomic malformations: incompetent cervix Undetermined (25%)
Risk Factors for Spontaneous Abortion
Advanced maternal age
Previous spontaneous abortion
Maternal smoking
Symptoms of Spontaneous Abortion
Bleeding: bright red, heavy Midline cramping Low back pain Open or close cervical os Complete or partial expulsion of products of conception
Subtypes of Spontaneous Abortion
Threatened Inevitable Incomplete Complete Missed
Define Threatened Spontaneous Abortion
Os close
Unpredictable outcome: can have a viable pregnancy
Define Inevitable Spontaneous Abortion
Os open
Products of conception have not passed
Pregnancy can not be saved
Define Incomplete Spontaneous Abortion
Os open
Some products of conception have passed
Define Complete Spontaneous Abortion
Os open or closed
Products of conception have passed
Define Miss Spontaneous Abortion
Pregnancy didn’t develop
+ pregnancy test, then heavy period week later
Threatened Abortion
Slight bleeding Abdominal cramping Cervical os closed Uterine size compatible with dates No products of conception are passed Prognosis is unpredictable
Treatment Measures for Threatened Abortion
Best rest for 24-48 hours with gradual resumption of usual activities
No work, child care, or sexual intercourse
Rest in horizontal position except bathing & using toilet
Infection: antibiotics
Hydration
Explicit instructions when to report signs/symptoms
Definitive follow up date
Treatment Contraindications for Threatened Abortion
Hormonal therapy
Inevitable Abortion
Moderate bleeding Moderate/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 poor
Incomplete Abortion
Heavy bleeding Moderate/severe abdominal cramping Low back pain Cervical os is DILATED Uterine size is compatible with dates Some portion of the productions of conception remain in the uterus Pregnancy cannot be saved
Missed Abortion
Pregnancy ceased to develop, products of conception have not been expelled
Symptoms of pregnancy disappear
Brownish vaginal discharge but no free bleeding
Pain does not develop
Cervix is semi-firm & slightly dilated
Uterus becomes smaller & irregularly softened
Treatment for Missed, Inevitable, and Incomplete Abortions
Counseling regarding fate of pregnancy
Assess Rh factor & administer immunoglobulin
Planning for elective termination
Elective Termination Strategies
D&C: empty all products of conception; prevent infection & hemorrhage
Insertion of laminar to dilate cervix follow by aspiration (missed)
Prostaglandin vaginal suppositories (alternate)
Complete Abortion
Bleeding may be heavy or minimal Moderate/severe abdominal cramping Low back pain Fetus & placenta completely expelled Pain ceases but spotting may persist Cervical os open or closed Uterus is normal pre-pregnancy size
Define Habitual Abortions
Recurrent pregnancy loss/habitual abortions if 3 previous pregnancies
Evaluation of Suspected Spontaneous Abortion
H&P
+/- fetal doppler
+/- transvaginal US
+/- labs: serum hCG, blood type & Rh factor
Workup for Recurrent Pregnancy Loss
Assessment of uterine structure* Rule out lupus* TSH* Blood glucose Genetic: maternal & paternal Day 3 FSH levels Progesterone levels
Follow Up of Spontaneous Abortion
GYN exam 2-3 weeks later
Contraception for 3 months to allow complete healing & regeneration of endometrial lining
Define Ectopic Pregnancy
Implantation of fertilized ovum outside of the uterine cavity
Locations for Ectopic Pregnancy
Fallopian tube (98%) Cervix Ovary Abdominal cavity
Ectopic Pregnancy
Rupture inevitable
Potentially life-threatening
MAJOR CAUSE OF MATER DEATH DURING 1ST TRIMESTER
Risk Factors of Ectopic Pregnancy
History of genital infections* History of infertility* History of tubal pregnancy* History of any ectopic pregnancy* Intrauterine devices* Abdominal or pelvic surgery History of ruptured appendix Intrauterine exposure to DES Use of drugs that slow ovum transport
Natural History of Ectopic Pregnancy
Rupture: significant hemorrhage
Abortion: expulsion of products
Spontaneously resolve
Classic Presentation of Ectopic Pregnancy
1-2 months of amenorrhea Morning sickness Breast tenderness Diarrhea, urge to defecate Malaise & syncope Lower abdominal/pelvic pain: sudden/severe, especially adnexal referral of pain to shoulder
Atypical Presentation of Ectopic Pregnancy
Vague or subacute symptoms
Menstrual irregularity
PE Findings with Ectopic Pregnancy
Tachycardia
Hypotension
Adnexal, cervical motion, and/or abdominal tenderness on pelvic exam
Pelvic: brick red to brown blood
Differential of Ectopic Pregnancy
PID Ovarian tyst Ovarian tumor Intrauterine pregnancy Recent spontaneous abortion Early hydatidiform degeneration Acute appendicitis Other bowel related disorders
Labs for Ectopic Pregnancy
B-hCG: lower than expected
CBC: anemia or leukocytosis
Rh factor
Imaging for Ectopic Pregnancy
Transvaginal US: empty uterus + hCG levels
Laparoscopy or laparotomy (severe)
Indications for Surgical Management of Ectopic Pregnancy
Hemodynamic instability
Impending or ongoing ectopic mass rupture
Not able or willing to comply with medical therapy & post treatment follow up
Lack of timely access for medical care in case of tube rupture
Failed medical therapy
Medical Management of Ectopic Pregnancies
Methotrexate
Indications for Methotrexate Use in Ectopic Pregnancy
Accept medical therapy early in ectopic pregnancy
Hemodynamically stable
Willing to comply with follow up
Have hCG
Follow Up for Ectopic Pregnancy
Rhogam
Contraception for 2+ months to allow adequate healing & repair
Pelvic rest until B-hCG negative
Follow up 2 weeks post surgery
Types of Gestation Trophoblastic Diseases
Hydatidiform Mole*
Choriocarcinoma*
Persistent/invasive gestational trophoblastic neoplasia
Placental site trophoblastic tumors
Define Hydatidiform Mole
Benign neoplasm of the chorion in which chorionic villi degenerate & become transparent vesicles containing clear, viscous fluid
When does a hydatidiform mole occur?
Single sperm fertilizes an egg without a nuclus
Define Partial Hydatidiform Mole
Fetus or evidence of an amniotic sac is present
Define Complete Hydatidiform Mole
No fetus or amnion is found
May become choriocarcinoma
Risk Factors for Hydatidiform Mole
Low socioeconomic status
History of mole
Clinical Presentation of Hydatidiform Mole
Vaginal bleeding Enlarged uterus Pelvic pressure or pain Theca lutein cysts Anemia Hyperemesis gravidarium Hyperthyroidism Pre-eclampsia before 20 weeks gestation Vaginal passable of hydraulic vesicles No fetal heart tones or activity
Labs & Imaging for Hydatidiform Mole
B-hCG: extremely high for age
Ultrasound
Chest x-ray
What are we looking for on ultrasound with a hydatidiform mole?
Absence of gestational sac
Characteristic multiple echogenic region “snowy” within uterus
What are we looking to rule out on chest x-ray with a hydatidiform mole?
Pulmonary metastases of trophoblast
Treatment of Hydatidiform Mole
D&C pathologic exam on curating Effective birth control Weekly quantitative B-hCG No pregnancy until hCG levels remain normal for 1 year
What can choriocarcinoma follow?
Hydatidiform mole Invasion mole Abortion Normal pregnancy Ectopic pregnancy
What does choriocarcinoma cause?
Ulcerating surfaces into the endometrial cavity
How do the malignant cells get transported to the lungs, brain, or elsewhere?
Malignant cells enter the circulation through open blood vessels in the endometrial cavity
Treatment of Choriocarcinoma
Highly sensitive to chemo
Surgery (if resistant to chemo)
4 Major Causes of Bleeding in the 1st Trimester
Physiologic: implantation
Ectopic pregnancy
Impending or complete abortion
Cervical, vaginal, or uterine pathology
Work up of 1st Trimester Bleeding
Assess stability of patient & degree of bleeding
Ultrasound
CBC
Serial B-hCG
Types of Placental Problems
Placenta previa
Abruptio placentae
Placenta Accretas
Define Placenta Previa
Placenta implanted in lower segment of the uterus & extends over or lies proximal to the internal cervical os
3 Types of Placenta Previa
Total or complete
Partial
Marginal or low-lying
Define Total or Complete Placent Previa
Entire os covered
Define Partial Placenta Previa
Internal os partially covered
Define Marginal or Low-Lying Placenta Previa
Edge of placenta at os but does not cause obstruction
Risk Factors for Placenta Previa
Previous placental previa Multiparity Multiple gestation Previous cesarean section Trauma Smoking Advanced maternal age Infertility treatment Previous intrauterine surgical procedure
Presentation of Placenta Previa
Painless bleeding in 3rd trimester Bright red blood May have shock symptoms if severe bleeding VS stable Fetal heart tones normal Fetal activity present
What should you not do if you suspect placenta previa?
Do not perform a vaginal or speculum exam
Diagnostic Test for Placenta Previa
Ultrasound
Treatment of Placenta Previa in an Acute Bleeding Episode
Supportive care to maintain hemodynamic stability
Fetal HR monitor
IV NS or LR
Magnesium sulfate & corticosteroids if
Treatment of Placenta Previa with Indications for Delivery (C-section)r
Non-reassuring fetal HR
Life threatening maternal hemorrhage
Significant vaginal bleeding after 34 weeks
Conservative Management of Placenta Previa Post Bleed
Sometimes need to be hospitalized until delivery
High risk for re-bleeding & premature rupture of membranes
Stable: deliver at 36-37 weeks
Define Abruptio Placentae
Partial or complete detachment of a normally implanted placenta at any time prior to delivery
Epidemiology of Abruptio Placentae
More frequent during 3rd trimester
Anytime after 20 weeks
Significant cause of maternal & fetal morbidity & mortality
Risk Factors for Placental Abruption
Previous abruption Abdominal trauma Cocaine Smoking Eclampsia Pregnancy induced HTN
Presentation of Placental Abruption
Mild to severe vaginal bleeding Abdominal pain or back pain Uterine contractions Uterine tenderness Non-reassuring fetal HR pattern
Maternal Complications of Placental Abruption
Hemorrhagic shock Coagulopathy/DIC Uterine rupture Renal failure Ischemic necrosis of distal organs
Fetal Complications of Placental Abruption
Hypoxia Anemia Growth retardation CNS anomalies Fetal death
Diagnostic Evaluation of Placental Abruption
Early markers of ischemic placental disease during routine care Elevated AFP with no other explanation Elevated B-hCG Fibrinogen to evaluate for DIC Retroplacental hematoma on imaging
Treatment of Placental Abruption
Continuous fetal monitoring IV access for mom Maintain maternal O2 sats >95% CBC Blood type (cross & screen) Coagulation studies Treatment of DIC as indicated Severe abruption: delivery baby regardless of age
Define Placenta Accretas
Placenta attaches too deeply into the wall of the uterus
What is placenta accretas associated with a history of?
Prior c-section
Hx of uterine instrumentation or surgery
Placenta previa
Risks Associated with Placenta Accretas
Preterm delivery
Severe postpartum hemorrhage
Treatment of Placenta Accreta
Little can be done
Monitor pregnancy
Schedule a delivery & using surgery to spare uterus
Hysterectomy: severe cases
Define Hyperemesis Gravidarium
Persistant, severe, intractable vomiting during pregnancy
Weight loss of 5+% of pre-pregnancy weight
Evaluation of Excessive Nausea & Vomiting During Pregnancy
Weight Orthostatic VS Electrolytes UA Obstetrical ultrasound to rule out gestational trophoblastic disease or multiple gestation
Treatment of Hyperemesis Gravidarium
Hospitalization NPO x 48 hours Maintain hydration & electrolyte balance & vitamins Dry diet with 6 small feedings/day Clear liquids IV fluids with thiamine if dehydrated Steroids after 1st trimester TPN if can't keep anything down
First Line Medical Therapy For Hyperemesis Gravidarium
Vitamin B6 TID to QID
Doxylamine (Unisom)
Second Line Medical Therapy for Hyperemesis Gravidarium
DC doxylamine
+ prochloperazine (Compazine) or metaclpramide (Reglan)
Third Line Medical therapy for Hyperemesis Gravidarium
Odansetron (Zofran)
Diagnosing Preterm Premature Rupture of the Membranes (PPROM)
Visualization of fluid in the vagina of a pregnancy woman who presents with a history of leaking fluid
Testing for Preterm Premature Rupture of the Membranes (PPROM)
pH paper
Ferning
Ultrasound
Instillation of indigo carmine into amniotic fluid
Placental alpha microglobulin-1 protein assay
Placental fibronectin
Ferning: Amniotic Fluid
Delicate fern pattern
Ferning: Cervical Mucous
Dense & thick ferm pattern
Ultrasound
Check for volume of amniotic fluid
Injection of Indigo Carmine into Amniotic Fluid
Place tampon in vagina for 20 minutes
Blue = leak
Management of Preterm Premature Rupture of the Membranes (PPROM)
Patient & fetus stable or unstable
Unstable: deliver
Stable: hospitalize until delivery; antibiotics, corticosteroids & monitor for stability
DM & Pregnancy
2 times risk of pregnancy induced HTN or pre-eclampsia
Worsening nephropathy & retinopathy
DM and Risks to the Fetus
Congenital anomalies = 6x that of average
Cardiac, CNS, renal, limb deformity, sacral agenesis
Increased risk of spontaneous abortion & stillbirth
Macrosomia
Uteroplacental insufficiency
Intrauterine growth retardation
polydyramnios
Neonatal Risks of DM
Hypoglycemia
Hyperbilirubinemia
Hypocalcemia
Polycythemia
Management of DM in Pregnancy
Frequent blood glucose monitoring
Airm for optimal glucose control through diet, exercise, & insulin therapy
Insulin requirements increase throughout pregnancy
Requires follow up every 1-2 weeks through 2nd trimester; weekly in 3rd trimester
Screening for Gestational DM
24-28 weeks: oral glucose challenge
Fail?: 3 hour glucose tolerance test
Management of Gestational DM
Diet
Blood sugar goals: fasting
DM During Pregnancy
Increased risk for UTI & pyelonephritis
Induce labor at 39 weeks
Macrosomia: shoulder dystocia
Thyroid Disease & Pregnancy
Thyroxine requirements increase with hypothyroidism
Adjust dose at 4 week intervals as needed
Postpartum thyroiditis
Thyroid binding globulins increase
Increased free T4 in 1st trimester
