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OB/GYN > Pregnancy Complications > Flashcards

Pregnancy Complications Flashcards

1
Q

Complications of Pregnancy

A 
Spontaneous abortion
Ectopic pregnancy
Gestational trophoblastic disease
Placental abnormalities
Hyperemesis gravidarum
Premature rupture of membranes
DM
Thyroid disease
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2
Q

Define Spontaneous Abortion

A

Loss of a fetus at less than 20 weeks gestation

“Miscarriage”

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3
Q

Etiology of Spontaneous Abortion

A 
Chromosomal defects (60%)
Maternal trauma
Infections
Dietary deficiencies
DM
Hypothyroidism
Anatomic malformations: incompetent cervix
Undetermined (25%)
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4
Q

Risk Factors for Spontaneous Abortion

A

Advanced maternal age
Previous spontaneous abortion
Maternal smoking

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5
Q

Symptoms of Spontaneous Abortion

A 
Bleeding: bright red, heavy
Midline cramping
Low back pain
Open or close cervical os
Complete or partial expulsion of products of conception
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6
Q

Subtypes of Spontaneous Abortion

A 
Threatened
Inevitable
Incomplete
Complete
Missed
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7
Q

Define Threatened Spontaneous Abortion

A

Os close

Unpredictable outcome: can have a viable pregnancy

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8
Q

Define Inevitable Spontaneous Abortion

A

Os open
Products of conception have not passed
Pregnancy can not be saved

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9
Q

Define Incomplete Spontaneous Abortion

A

Os open

Some products of conception have passed

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10
Q

Define Complete Spontaneous Abortion

A

Os open or closed

Products of conception have passed

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11
Q

Define Miss Spontaneous Abortion

A

Pregnancy didn’t develop

+ pregnancy test, then heavy period week later

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12
Q

Threatened Abortion

A 
Slight bleeding
Abdominal cramping
Cervical os closed
Uterine size compatible with dates
No products of conception are passed
Prognosis is unpredictable
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13
Q

Treatment Measures for Threatened Abortion

A

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

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14
Q

Treatment Contraindications for Threatened Abortion

A

Hormonal therapy

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15
Q

Inevitable Abortion

A 
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
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16
Q

Incomplete Abortion

A 
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
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17
Q

Missed Abortion

A

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

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18
Q

Treatment for Missed, Inevitable, and Incomplete Abortions

A

Counseling regarding fate of pregnancy
Assess Rh factor & administer immunoglobulin
Planning for elective termination

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19
Q

Elective Termination Strategies

A

D&C: empty all products of conception; prevent infection & hemorrhage
Insertion of laminar to dilate cervix follow by aspiration (missed)
Prostaglandin vaginal suppositories (alternate)

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20
Q

Complete Abortion

A 
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
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21
Q

Define Habitual Abortions

A

Recurrent pregnancy loss/habitual abortions if 3 previous pregnancies

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22
Q

Evaluation of Suspected Spontaneous Abortion

A

H&P
+/- fetal doppler
+/- transvaginal US
+/- labs: serum hCG, blood type & Rh factor

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23
Q

Workup for Recurrent Pregnancy Loss

A 
Assessment of uterine structure*
Rule out lupus*
TSH*
Blood glucose
Genetic: maternal & paternal
Day 3 FSH levels
Progesterone levels
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24
Q

Follow Up of Spontaneous Abortion

A

GYN exam 2-3 weeks later

Contraception for 3 months to allow complete healing & regeneration of endometrial lining

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25
Q

Define Ectopic Pregnancy

A

Implantation of fertilized ovum outside of the uterine cavity

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26
Q

Locations for Ectopic Pregnancy

A 
Fallopian tube (98%)
Cervix
Ovary
Abdominal cavity
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27
Q

Ectopic Pregnancy

A

Rupture inevitable
Potentially life-threatening
MAJOR CAUSE OF MATER DEATH DURING 1ST TRIMESTER

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28
Q

Risk Factors of Ectopic Pregnancy

A 
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
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29
Q

Natural History of Ectopic Pregnancy

A

Rupture: significant hemorrhage
Abortion: expulsion of products
Spontaneously resolve

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30
Q

Classic Presentation of Ectopic Pregnancy

A 
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
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31
Q

Atypical Presentation of Ectopic Pregnancy

A

Vague or subacute symptoms

Menstrual irregularity

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32
Q

PE Findings with Ectopic Pregnancy

A

Tachycardia
Hypotension
Adnexal, cervical motion, and/or abdominal tenderness on pelvic exam
Pelvic: brick red to brown blood

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33
Q

Differential of Ectopic Pregnancy

A 
PID
Ovarian tyst
Ovarian tumor
Intrauterine pregnancy
Recent spontaneous abortion
Early hydatidiform degeneration
Acute appendicitis
Other bowel related disorders
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34
Q

Labs for Ectopic Pregnancy

A

B-hCG: lower than expected
CBC: anemia or leukocytosis
Rh factor

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35
Q

Imaging for Ectopic Pregnancy

A

Transvaginal US: empty uterus + hCG levels

Laparoscopy or laparotomy (severe)

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36
Q

Indications for Surgical Management of Ectopic Pregnancy

A

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

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37
Q

Medical Management of Ectopic Pregnancies

A

Methotrexate

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38
Q

Indications for Methotrexate Use in Ectopic Pregnancy

A

Accept medical therapy early in ectopic pregnancy
Hemodynamically stable
Willing to comply with follow up
Have hCG

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39
Q

Follow Up for Ectopic Pregnancy

A

Rhogam
Contraception for 2+ months to allow adequate healing & repair
Pelvic rest until B-hCG negative
Follow up 2 weeks post surgery

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40
Q

Types of Gestation Trophoblastic Diseases

A

Hydatidiform Mole*
Choriocarcinoma*
Persistent/invasive gestational trophoblastic neoplasia
Placental site trophoblastic tumors

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41
Q

Define Hydatidiform Mole

A

Benign neoplasm of the chorion in which chorionic villi degenerate & become transparent vesicles containing clear, viscous fluid

42
Q

When does a hydatidiform mole occur?

A

Single sperm fertilizes an egg without a nuclus

43
Q

Define Partial Hydatidiform Mole

A

Fetus or evidence of an amniotic sac is present

44
Q

Define Complete Hydatidiform Mole

A

No fetus or amnion is found

May become choriocarcinoma

45
Q

Risk Factors for Hydatidiform Mole

A

Low socioeconomic status

History of mole

46
Q

Clinical Presentation of Hydatidiform Mole

A 
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
47
Q

Labs & Imaging for Hydatidiform Mole

A

B-hCG: extremely high for age
Ultrasound
Chest x-ray

48
Q

What are we looking for on ultrasound with a hydatidiform mole?

A

Absence of gestational sac

Characteristic multiple echogenic region “snowy” within uterus

49
Q

What are we looking to rule out on chest x-ray with a hydatidiform mole?

A

Pulmonary metastases of trophoblast

50
Q

Treatment of Hydatidiform Mole

A 
D&C
pathologic exam on curating
Effective birth control
Weekly quantitative B-hCG
No pregnancy until hCG levels remain normal for 1 year
51
Q

What can choriocarcinoma follow?

A 
Hydatidiform mole
Invasion mole
Abortion
Normal pregnancy
Ectopic pregnancy
52
Q

What does choriocarcinoma cause?

A

Ulcerating surfaces into the endometrial cavity

53
Q

How do the malignant cells get transported to the lungs, brain, or elsewhere?

A

Malignant cells enter the circulation through open blood vessels in the endometrial cavity

54
Q

Treatment of Choriocarcinoma

A

Highly sensitive to chemo

Surgery (if resistant to chemo)

55
Q

4 Major Causes of Bleeding in the 1st Trimester

A

Physiologic: implantation
Ectopic pregnancy
Impending or complete abortion
Cervical, vaginal, or uterine pathology

56
Q

Work up of 1st Trimester Bleeding

A

Assess stability of patient & degree of bleeding
Ultrasound
CBC
Serial B-hCG

57
Q

Types of Placental Problems

A

Placenta previa
Abruptio placentae
Placenta Accretas

58
Q

Define Placenta Previa

A

Placenta implanted in lower segment of the uterus & extends over or lies proximal to the internal cervical os

59
Q

3 Types of Placenta Previa

A

Total or complete
Partial
Marginal or low-lying

60
Q

Define Total or Complete Placent Previa

A

Entire os covered

61
Q

Define Partial Placenta Previa

A

Internal os partially covered

62
Q

Define Marginal or Low-Lying Placenta Previa

A

Edge of placenta at os but does not cause obstruction

63
Q

Risk Factors for Placenta Previa

A 
Previous placental previa
Multiparity
Multiple gestation
Previous cesarean section
Trauma
Smoking
Advanced maternal age
Infertility treatment
Previous intrauterine surgical procedure
64
Q

Presentation of Placenta Previa

A 
Painless bleeding in 3rd trimester
Bright red blood
May have shock symptoms if severe bleeding
VS stable
Fetal heart tones normal
Fetal activity present
65
Q

What should you not do if you suspect placenta previa?

A

Do not perform a vaginal or speculum exam

66
Q

Diagnostic Test for Placenta Previa

A

Ultrasound

67
Q

Treatment of Placenta Previa in an Acute Bleeding Episode

A

Supportive care to maintain hemodynamic stability
Fetal HR monitor
IV NS or LR
Magnesium sulfate & corticosteroids if

68
Q

Treatment of Placenta Previa with Indications for Delivery (C-section)r

A

Non-reassuring fetal HR
Life threatening maternal hemorrhage
Significant vaginal bleeding after 34 weeks

69
Q

Conservative Management of Placenta Previa Post Bleed

A

Sometimes need to be hospitalized until delivery
High risk for re-bleeding & premature rupture of membranes
Stable: deliver at 36-37 weeks

70
Q

Define Abruptio Placentae

A

Partial or complete detachment of a normally implanted placenta at any time prior to delivery

71
Q

Epidemiology of Abruptio Placentae

A

More frequent during 3rd trimester
Anytime after 20 weeks
Significant cause of maternal & fetal morbidity & mortality

72
Q

Risk Factors for Placental Abruption

A 
Previous abruption
Abdominal trauma
Cocaine
Smoking
Eclampsia
Pregnancy induced HTN
73
Q

Presentation of Placental Abruption

A 
Mild to severe vaginal bleeding
Abdominal pain or back pain
Uterine contractions
Uterine tenderness
Non-reassuring fetal HR pattern
74
Q

Maternal Complications of Placental Abruption

A 
Hemorrhagic shock
Coagulopathy/DIC
Uterine rupture
Renal failure
Ischemic necrosis of distal organs
75
Q

Fetal Complications of Placental Abruption

A 
Hypoxia
Anemia
Growth retardation
CNS anomalies
Fetal death
76
Q

Diagnostic Evaluation of Placental Abruption

A 
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
77
Q

Treatment of Placental Abruption

A 
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
78
Q

Define Placenta Accretas

A

Placenta attaches too deeply into the wall of the uterus

79
Q

What is placenta accretas associated with a history of?

A

Prior c-section
Hx of uterine instrumentation or surgery
Placenta previa

80
Q

Risks Associated with Placenta Accretas

A

Preterm delivery

Severe postpartum hemorrhage

81
Q

Treatment of Placenta Accreta

A

Little can be done
Monitor pregnancy
Schedule a delivery & using surgery to spare uterus
Hysterectomy: severe cases

82
Q

Define Hyperemesis Gravidarium

A

Persistant, severe, intractable vomiting during pregnancy

Weight loss of 5+% of pre-pregnancy weight

83
Q

Evaluation of Excessive Nausea & Vomiting During Pregnancy

A 
Weight
Orthostatic VS
Electrolytes
UA
Obstetrical ultrasound to rule out gestational trophoblastic disease or multiple gestation
84
Q

Treatment of Hyperemesis Gravidarium

A 
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
85
Q

First Line Medical Therapy For Hyperemesis Gravidarium

A

Vitamin B6 TID to QID

Doxylamine (Unisom)

86
Q

Second Line Medical Therapy for Hyperemesis Gravidarium

A

DC doxylamine

+ prochloperazine (Compazine) or metaclpramide (Reglan)

87
Q

Third Line Medical therapy for Hyperemesis Gravidarium

A

Odansetron (Zofran)

88
Q

Diagnosing Preterm Premature Rupture of the Membranes (PPROM)

A

Visualization of fluid in the vagina of a pregnancy woman who presents with a history of leaking fluid

89
Q

Testing for Preterm Premature Rupture of the Membranes (PPROM)

A

pH paper
Ferning
Ultrasound
Instillation of indigo carmine into amniotic fluid
Placental alpha microglobulin-1 protein assay
Placental fibronectin

90
Q

Ferning: Amniotic Fluid

A

Delicate fern pattern

91
Q

Ferning: Cervical Mucous

A

Dense & thick ferm pattern

92
Q

Ultrasound

A

Check for volume of amniotic fluid

93
Q

Injection of Indigo Carmine into Amniotic Fluid

A

Place tampon in vagina for 20 minutes

Blue = leak

94
Q

Management of Preterm Premature Rupture of the Membranes (PPROM)

A

Patient & fetus stable or unstable
Unstable: deliver
Stable: hospitalize until delivery; antibiotics, corticosteroids & monitor for stability

95
Q

DM & Pregnancy

A

2 times risk of pregnancy induced HTN or pre-eclampsia

Worsening nephropathy & retinopathy

96
Q

DM and Risks to the Fetus

A

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

97
Q

Neonatal Risks of DM

A

Hypoglycemia
Hyperbilirubinemia
Hypocalcemia
Polycythemia

98
Q

Management of DM in Pregnancy

A

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

99
Q

Screening for Gestational DM

A

24-28 weeks: oral glucose challenge

Fail?: 3 hour glucose tolerance test

100
Q

Management of Gestational DM

A

Diet

Blood sugar goals: fasting

101
Q

DM During Pregnancy

A

Increased risk for UTI & pyelonephritis
Induce labor at 39 weeks
Macrosomia: shoulder dystocia

102
Q

Thyroid Disease & Pregnancy

A

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

OB/GYN (12 decks)

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