Pregnancy Complications Flashcards
1
Q
If performing abortion in 1st trimester what can be given PO to complete abortion? (2)
- what is time frame for medical abortion w/pill?
- what lab value required to do this method
- dosing (days) for each?
What ABX ppx given or this type of abortion/length?
A
- 1st T Ab –> Mifepristone (Mifeprex) + Misoprostol (Cytotec)
- can be done up 9 wks gestation
- must have Hgb of > 10
day 1 = mifepristone (200-600 mg)
day 2-3 = misoprostol (400-800 mcg)
Ppx = doxycycline for 7 days
note: at PG they give 2 doses of Cytotec
2
Q
1st T Medical Ab
- What type of drug is Mifepristone/what does it cause?
- What about Misoprostol?
A
1st T Ab
- Mifepristone
- progesterone antag –> decr endometrial growth, cant maintain preg
Misoprostol (Cytotec)
- PGE1 analog –> causes uterine contractions–> expel fetus
3
Q
1st T Medical Ab:
2 main S/Es a/w Medical Ab in 1st T
A
1st T Ab: 2 main S/Es
- abd pain/cramping
- bleeding
4
Q
1st T Medical Ab w/injection
What is given for medical abortion injection occurring in 1st trimester? (2) - rarely used but more commonly used for _____ preg
A
1st T Ab w/injection
IM Methotrexate + Misoprostol (cytotect)
- rarely used but for Ab more commonly used for ectopic preg
5
Q
1st T Ab f/u: Medical
1+2. What are 2 options that can confirm the medical Ab is complete 2 wks later
- What is also given to Rh- mothers
A
1st T Ab f/u: 2 things confirm medical Ab is complete 2 wks later
- US
- bhCG level
- give Rh- moms Rhogam
6
Q
1st T Ab: Surgical
- 2 options
- What is given to cause cervical dilation? when?
Next step?
A
1st T Ab: Surgical
- 2 options
- D+C
- MVA (Manual Vacuum Aspiration) - For D+C –> misoprostol to cause cervical dilation at 13+ wks –> suction aspiration
7
Q
2nd T Ab: Surgical
Two types of surgical abortion performed in the 2nd trimester?
Which one can be performed later in preg? when?
Which has higher complication rate (so rarely done unless mom at risk)?
What do they both require prior the surgery? What is it made of?
A
- D & E (dilation & evacuation)
- D & X (dilation & extraction)
- done later –> 21+ wks
- higher complication rate (rarely done)
BOTH: require input of laminaria into vagina–> dilate cervix
- sterile, compressed seaweed
8
Q
6 complications of ALL surgical abortions
A
- Incomplete abortion
- Uterine perforation
- Cervical trauma/insuffic
- Infection (endometritis)
- Hemorrhage/Bleeding
- Adhesions (Asherman’s Syn)
Note: adhesions only affect ability to stay preg
9
Q
Other Option for 2nd T Ab
uses cervical ripening agents, aminotomy, high dose IV oxytocin (pitocin)
S/Es = retained placenta, uterine rupture, hemorrhage, infxn
Cons: longer process (days)
Pros: may have intact fetus –> postmortem eval
A
Other Option for 2nd T Ab = IOL
uses cervical ripening agents, aminotomy, high dose IV oxytocin (pitocin)
S/Es = retained placenta, uterine rupture, hemorrhage, infxn
Cons: longer process (days)
Pros: may have intact fetus –> postmortem eval
10
Q
What is the definition of SAB (spontaneous abortion)/ Miscarriage
- what is it often d/t
A
loss of preg < 20 wks gestation
often d/t chrom abnormalities
11
Q
4 major RFs for SAB?
A
- AMA
- previous SAB
- Smoking
- Meds/Substances
- EtOH, cocaine, NSAIDs
NSAIDs = PG inhib
12
Q
Complete abortion:
- how does cervical os look?
- POC expelled?
- what seen on sono?
- Tx?
A
Complete abortion:
- cervical os = CLOSED
- POC EXPELLED
- Sono –> empty uterus
- Tx = follow bhCG levels
13
Q
INcomplete abortion:
- definition
- how does cervical os look?
- POC expelled?
- what seen on sono?
- Tx?
A
INcomplete abortion:
- incomplete = misscarriage in process
- cervical os = OPEN/DILATED
- Some POC retained/visible
- Sono –> no IUP, debris in uterine cavity
- Tx = intervention to complete the abortion
14
Q
Missed abortion:
- definition/bhCG levels
- how does cervical os look?
- POC expelled?
- what seen on sono?
- Tx?
only difference seen w/blighted ovum on sono?
A
missed abortion
- NON-VIABLE preg (bhCG decreasing), hasnt been expelled yet
- Cervical os = closed
- No POC expelled
- sono–> no cardiac activity
Tx: give something to expel POC
blight ovum
- large GS + yolk sac but NO EMBRYO
15
Q
What is the only type of abortion that may be viable/continue
A
Threatened abortion
16
Q
Threatened abortion
- cervical os?
- what is seen on sono that is different from all other abortions
- sxs?
- tx?
A
Threatened abortion
- cervical os = closed (preg still may be viable)
- Sono - VIABLE IUP (heartbeat)
- Sx = spotting
- Tx = expectantly manage
17
Q
Inevitable Ab
- how does cervical os look?
- POC expelled?
- what seen on sono but why cant preg continue?
- Tx?
A
Inevitable Ab
- os = open
- POC not expelled
- sono = viable IUP but preg
cant continue b/c os is open - Tx = expectantly or surgical procedure to expel fetus
18
Q
23 y/o F underwent D+C 3 days ago. C/o continued vaginal bleeding, lower abd cramping, and recently noted fever/chills x1 day. PE - temp = 102, BP = 90/48, HR = 120. Abd/Pelvic exam reveals open os, uterine tenderness and CMT. Labs show elevated WBCs.
Dx?
Tx - what 2 ABXs best and what procedure should be done 4 hrs after ABX start
A
Dx = Septic Abortion
Tx = Broad spectrum ABX w/ Gentamicin + Clindamycin
- after 4 hrs –> D+C to remove POC
note: also give IVF for HoTN
19
Q
Septic Abortion
- what type of infxn
- what type of vaginal d/c is it a/w it
- What is tx if refractory to ABX and D+C
A
Septic Abortion
- ascending infxn
- foul smelling, purulent vaginal d/c
- refractory to ABX and D+C = Hysterectomy
20
Q
Confirming preg w/lab tests:
- Which type of pregnancy test is qualitative?
- Which type of pregnancy test is quantitative?
- what levels are definitive (+)?
- how do the levels change in a norm preg
Other method than lab testing to confirm preg?
A
Confirming preg w/lab tests:
- urine pregnancy test (UPT) = qualitative
- B-hCG = quantitative (blood test)
- > 25 = definitive confirmation of preg
- double every 2-3 days in norm preg
Other method to conifrm preg = TVUS
21
Q
TVUS & preg confirmation:
- What should be present at 4-5 wks?
- at 5 wks
- at 6 wks
- at 6.5 wks
- At what level of b-hCG is normal IUP visualized?
- will bhCG double q48hrs w/ectopic
A
TVUS & preg confirmation:
- 4-5 wks –> gestational sac
- 5 wks –> yolk sac
- 6 wk –> fetal pole
- 6.5 wks –> FHM (fetal heart motion)
- norm IUP visualized at b-hCG > 1500-2000
- No, bhCG wont double q48 hrs w/ectopic preg
22
Q
MC site of ectopic pregnancy
A
Ampulla
23
Q
Pt pts w/ unilateral pelvic/abd pain, amenorrhea, and vaginal bleeding. Pt has h/o endometriosis, PID and smoking. She currently uses IUD for contraception. On PE pt has an adenexal mass and CMT w/mild uterine enlargement. bhCG level is 2500 but no intrauterine gestational sac seen on US.
Dx?
Tx?
A
Dx = Ectopic Pregnancy
Tx = MTX
24
Q
Main Sx a/w Atypical presentation of Ectopic preg?
What does this cause?
Type of Ecotopic?
A
Atypical presentation = shoulder pain –> fluid irritating diaphargm –> peritonitis
Ruptured Ectopic
25
Pt comes in to ED and you find out she has an ectopic pregnancy. She is cool, tachycardic, HoTNsive, and has severe abd pain, N/V and is dizzy. On PE you find free fluid in her pelvis.
What type of ecotopic pregancy is this?
Ruptured Ecotopic Pregnancy
26
How to distinguish ectopic preg from miscarriage?
heavy bleeding (miscarriage) --> declining b hCG
27
Medical Tx of Ecotopic pregnancy w/MTX:
- what days do you check b hCG levels
- how often do you follow them til?
- what do you do if this method fails (2 options)
Medical Tx of Ecotopic pregnancy w/MTX:
- check b hCG levels on Day 1, 4, 7
- follow b hCG til < 5
- MTX fails --> 2nd dose MTX or surgery
28
Surgical Tx of Ectopic Preg
2 surgical options (Laparoscopic)
How are they different?
Which is 1st line Tx?
which is not good for pts who want to get preg later on?
which type must you follow bhCG levels < 5
Laparoscopic
1. Salpingectomy = 1st line
- remove fallopian tube
- not good if want to get preg later on
2. Salpingostomy
- just remove pregnancy --> must follow bhCG
29
If you cant definitively determine if ectopic or rule it out then what 2 things should be repeated/when?
1. Repeat b hCG in 48hrs
| 2. Repeat TVUS - once b hCG above discriminatory zone
30
Inability to maintain pregnancy d/t premature dilation
MC in what trimester
Incompentent Cervix/ Cervical Insuffic
Inability to maintain pregnancy d/t premature dilation
MC in 2nd Trimester
31
biggest RF for Incompentent Cervix/ Cervical Insuffic
biggest RF for Incompentent Cervix/ Cervical Insuffic
| h/o cervical trauma/surgery
cone bx, cervical lac
32
G2P1 Pt who is 20 wks gestation presents c/o vaginal bleeding and d/c but no pain. on PE you notice dilated cervix that is somewhat effaced. Pt had h/o cervical lac w/ prior delivery and had cone Bx done to r/o cervical CA.
Dx?
Tx?
Dx = Incompentent Cervix/ Cervical Insuffic
Tx = Cerclage
33
What is GTD (Gestational Trophoblastic Dz)
What is the MC type? (usu benign or malig)
abn proliferation of placental/ trophoblastic tissues (fetal tissue)
MC type = molar preg (usu benign)
34
How does GTN differ from GTD
main example?
GTN = malignant neoplasm arising from GTD
main example = choriocarcinoma
35
37 y/o Asian preg pt presents w/painless vaginal bleeding, severe N/V. She has a h/o infertility and OCP use. Her labs reveal she is hyperthyroid. Her uterine size > dates, bhCG = 105,000 and on US there is a snowstorm appearance but no fetal parts present. Karyotype is 46 XX
Dx?
Tx?
Dx = Complete Molar Pregnancy
Tx = D+C
36
15 y/o Asian preg pt presents w/painless vaginal bleeding.She is nulliparous and smokes. PE is normal. on US uterine size < dates and IUGR present, and fetal parts present. bhCG levels normal and Karyotype is 69 XXY.
Dx?
Tx?
Dx = Partial Molar Pregnancy
Tx = D+C
37
What gives definitive Dx of GTD/molar pregnancy?
Definitive Dx of GTD
pathology of placenta after D+C
38
GTD: Complete vs Partial Mole
1. a/w norm egg fertilized by 2 sperm
2. a/w Absent fetal tissue
3. a/w all paternal chrom
4. Uterine size small for dates
5. extremely high bhCG level
6. Theca lutein cysts common
7. Chorionic villi: hydrophic/ swollen and US show snowstorm/cluster of grapes
8. higher malig potential
GTD: Complete vs Partial Mole
1. a/w norm egg fertilized by 2 sperm = Partial
2. a/w Absent fetal tissue = Complete
3. a/w all paternal chrom = Complete
4. Uterine size small for dates = Partial
5. extremely high bhCG level = Complete
6. Theca lutein cysts common
7. Chorionic villi: hydrophic/ swollen and US show snowstorm/cluster of grapes = Complete
8. higher malig potential = Complete
39
Complete Molar Pregnancy
high hCG levels --> mole can can act as homolog to:
1. FSH + LH -->
2. TSH -->
3. high levels --> 2 conditions
Complete Molar Pregnancy
high hCG levels --> mole can can act as homolog to:
1. FSH + LH --> theca lutein cysts
2. TSH --> hyperthyroid
3. high levels --> hyperemesis gravidarum, preeclampsia
40
Complete Molar preg
1. pts has signs of preeclampsia what med is given
2. pt has signs of hyperthroid what med given to prev thyroid storm
Complete Molar preg
1. pts has signs of preeclampsia what med is given
2. pt has signs of hyperthroid what med given to prev thyroid storm
41
Tx of GTN/Choriangiocarcinoma
1. Main form of Tx
2. low risk/non-metastatic -->
3. high risk/metastatic -->
4. other surgical option (not common)
Tx of GTN/Choriangiocarcinoma
1. Main form of Tx = CHEMO
2. low risk/non-metastatic --> single agent chemo (MTX)
3. high risk/metastatic --> multi-agent chemo
4. other surgical option (not common) = hysterectomy
42
F/u for GTD
1. what must be done serially (look for progression to GTN)
2. what must pts be on after D+C
F/u for GTD
1. Do serial bhCG levels (look for progression to GTN)
2. After D+C --> contraception
43
Screening for GDM
1. normal time to screen (no RFs)
2. if pt has RFs for GDM when are they screened
3. What is the screening test
4. What is the confirmation test (done if screening test +)
which is fasting, which is non fasting
Screening for GDM
1. normal time to screen = 24-28 wks
2. RFs for GDM --> screened at 1st prenatal visit
3. screening = 1 hr, 50g Oral glucose challenge Test (GCT)
- NON-fasting
4. Confirmatory test = 3hr, 100g Oral Glucose Tolerance Test (GTT)
- fasting
44
GDM Management:
1. What type of GDM needs medication as Tx?
- what med is preferred?
2. What can the other type be controlled with?
GDM Management:
1. A2 GDM - needs Medication
- insulin preferred
2. A1 GDM - controlled w/diet
45
Pathophysiology of GDM
Placental rel of what hormone antagonizes insulin --> insulin resis during preg
Pathophysiology of GDM
Placental rel of HPL (human placental lactogen) antagonizes insulin --> insulin resis during preg
46
Pt has poorly controlled GDM and macrosomia. What range should the baby be delivered
poorly controlled GDM and macrosomia --> deliver 37-39 wks
47
Growth scan at 34-37 wks shows EFW > 4500g what procedure is indicated?
- what is there a risk of
Growth scan at 34-37 wks shows EFW > 4500g
- C section indicated b/c risk of shoulder dystocia
48
Why are women w/GDM screened again postpartum (75g OGTT) and yearly afterwards
women w/GDM screened again postpartum (75g OGTT) and yearly afterwards b/c high risk of developing DM
49
5 Types of Hypertensive D/o in Pregnancy
5 Types of Hypertensive D/o in Pregnancy
1. Chronic HTN
2. Gestational HTN/PIH
3. Preeclampsia
4. Preeclampsia w/severe features
5. Eclampsia
50
How does chronic HTN differ from all other types of Hypertensive D/o in Pregnancy
Chronic HTN occurs BEFORE 20 wks
all the others occur AFTER 20 wks
51
Pt presents for routine prenatal visit at 24 wks w/ elevated BP 150/95 x2. 24 hr urine protein = 200 mg.
Dx?
Tx (gen)
Dx = Gestational HTN/PIH
- GA > 20 wks w/incr BP but preeclampsia ruled out w/ 24 hr urine protein
Tx = expectantly manage/monitor closely
52
Pathophysiology of Preeclampsia
What is responsible for uteroplacental insuffic in preeclampsia (2 steps)
Pathophysiology of Preeclampsia
vasoconstriction --> decr blood flow to placenta --> uteroplacental insuffic
53
Epidemiology of Preeclampsia
1. when is it MC
2. how long after deliv are concerned about it
Epidemiology of Preeclampsia
1. MC in 3rd T
2. also occurs postpartum (6 wks)
54
G1P0 35 y/o F pregnant w/twins w/ h/o GDM and CKD presents for routine prenatal visits at 24 wks w/ incr BP of 150/95 x2. 24 hr urine protein = 350 mg.
Dx?
Dx = Preeclampsia
55
What 2 Hypertensive D/o in Pregnancy arent a/w proteinuria
Hypertensive D/o in Pregnancy not a/w proteinuria
1. Gestational HTN
2. Chronic HTN
56
Hemolysis (incr LDH)
Elevated Liver enzymes
Low Platelets
are a/w what type of preeclampsia and what is the name of this syndrome
Hemolysis (incr LDH)
Elevated Liver enzymes (AST/ALT)
Low Platelets
a/w Pre-eclampsia w/SEVERE Features
called HELLP Syndrome
57
How does the presentation of Eclampsia differ from Pre-eclampsia w/SEVERE Features?
Tx?
Eclampsia has same Sxs as Pre w/SEVERE Features + SEIZURES --> life threat
Tx= delivery ASAP
58
Tx of Hypertensive D/o in Pregnancy
1. Do any pts make it 40 wks
2. Med given for seizure ppx
3. med given to enhance FLM
4. What BP meds safe in preg to prev eclampsia
Tx of Hypertensive D/o in Pregnancy
1. NO pt make it 40 wks (risk of still birth)
2. seizure ppx --> MgSO4
3. enhance FLM--> BMZ
4. BP meds safe in preg to prev eclampsia
- Labetalol
- Methyldopa
- Nifedipine (Procardia)
- Hydralazine
(LMN for HTN)
59
When to deliver pts w/ Hypertensive D/o
1. Eclampsia -->
2. Preeclampsia w/severe features --> ___ wks
3. Preeclampsia--> ___ wks
4. GHTN/PIH --> ___ wks
5. Chronic HTN --> ___ wks
When to deliver pts w/ Hypertensive D/o
1. Eclampsia --> IMMED after stabilized
2. Preeclampsia w/severe features --> 34 wks
3. Preeclampsia--> 37 wks
4. GHTN/PIH --> 37-39 wks
5. Chronic HTN --> 39 wks
60
When to deliver pts w/ Hypertensive D/o
1. Eclampsia -->
2. Preeclampsia w/severe features --> ___ wks
3. Preeclampsia--> ___ wks
4. GHTN/PIH --> ___ wks
5. Chronic HTN --> ___ wks
When to deliver pts w/ Hypertensive D/o
1. Eclampsia --> IMMED after stabilized
2. Preeclampsia w/severe features --> 34 wks
3. Preeclampsia--> 37 wks
4. GHTN/PIH --> 37-39 wks
5. Chronic HTN --> 39 wks
61
Rh Incompatibility in Preg
1. Rh D --> IgM or IgG, can it cross the placenta
Rh Incompatibility in Preg
1. Rh D
- IgG --> CAN cross the placenta -->
62
Rh Incompatibility
If a woman is Rh __ and her baby is Rh ___ then the mother may become sensitized to Rh antigen and develop IgG antibodies, which can cross the ______ and cause _____ of fetal RBCs
Rh Incompatibility
If a woman is Rh (-) and her baby is Rh (+) --> mother may become sensitized to Rh antigen and develop IgG antibodies, which can cross the placenta and cause hemolysis of fetal RBCs
63
3 Fetal Consequences of Rh Incompatibility
3 Fetal Consequences of Rh Incompatibility.. baby has:
1. Hemolytic Anemia
2. Hydrops Fetalis/ Erythroblastosis Fetalis
3. Fetal death
64
1. CVS or Aminocentesis
2. Miscarriage
3. Antepartum hemorrhage
4. Abd trauma
5. ECV (ext cephalic version)
6. Delivery
7. Placenta previa/abruption
Examples of
1. CVS or Aminocentesis
2. Miscarriage
3. Antepartum hemorrhage
4. Abd trauma
5. ECV (ext cephalic version)
6. Delivery
7. Placenta previa/abruption
Examples of sensitizing events that could cause maternal + fetal blood mixing
65
Dx of Rh Incompatibility
1. what test looks to see if mom is making Abs to the fetal RBCs
2. what test determines if maternal Abs are attaching/attacking fetal RBCs
3. What Ab titer levels are concerning for fetal hydrops
Dx of Rh Incompatibility
1. Indirect Coombs Test --> see if mom is making Abs to the fetal RBCs
2. Direct Coombs test --> determines if maternal Abs are attaching/attacking fetal RBCs
3. Ab titer levels 1:16 or greater = concerning for fetal hydrops
66
If Rh- mother has Rh+ fetus and maternal and fetal blood mix what pregnancy is at risk
If Rh- mother has Rh+ fetus and maternal and fetal blood mix --> all subsequent pregnancies are at risk
67
If Ab titer 1:16 or greater (1:4) how do you monitor the baby for anemia
If Ab titer 1:16 or greater (1:4) monitor for anemia in fetus by Fetal MCA doppler
(faster flow = thinner blood/anemia)
68
Rh Incompatibility
Fetal MCA Doppler shows increased flow (> 1.5 MoM) --> what does that mean
Rh Incompatibility
Fetal MCA Doppler shows increased flow (> 1.5 MoM) -->
faster flow = thinner blood --> anemia
69
What is indicated if MCA doppler flow is increased
what is also considered
MCA doppler flow is increased --> PUBS (Periumbilical Blood Sampling)
also consider Intrauterine transfusion
70
What test is used to determine the Rh type of the fetus
Cell free DNA --> determines the Rh type of the fetus
71
Rh Incompatibility + Rhogam
1. What test determines the dose of Rhogam
2. When is rhogam given (3 times)
Rh Incompatibility + Rhogam
1. KB (Kleihauer-Betke) test determines the dose of Rhogam
- give 300 mcg for every 15-30 mL blood mixed
2. Rhogam given
- at 28 wks
- w/in 72 hrs of deliv (if fetus Rh+)
- after any sensitizing event
72
abn implantation of the placenta over the internal cervical os
Placenta Previa =
| abn implantation of the placenta over the internal cervical os
73
Abn placental invasion into the uterine wall
Placenta accreta = abn placental invasion into the uterine wall
74
3 types of placenta accreta
1. which is superficial invasion into myometrium
2. which a/w placenta invading the myometrium
3. which goes thru myometrium --> uterine serosa
3 types of placenta accreta
1. accreta = superficial invasion into myometrium
2. increta = placenta invades the myometrium
3. percreta = goes thru myometrium --> uterine serosa
75
2 major RFs for placenta accreta
RFs for placenta accreta
1. H/o placenta previa
2. incr risk w/ incr # of C sections
76
Types of placenta previa
1. name of type when edge of placenta reaches margin of the os
2. name of type when placenta implants in lower uterine segment, close to os but not covering it
Types of placenta previa
1. edge of placenta reaches margin of the os --> Marginal previa
2. placenta implants in lower uterine segment, close to os but not covering it --> low lying previa
77
36 y/o pt who is G5P4 at 32 wks presents to clinic c/o acute onset of painless vaginal bleeding. She had post coital spotting after having sex few wks ago. Pt has h/o myomectomy, multiple gestations and smoking. You obtain an transabdominal US w/ empty bladder that confirms your suspicion.
Dx?
should pt be admitted/what should be done (2 things)
Dx = placenta previa
YES admit any pt w/previa --> continuous fetal monitoring + obtain IV access
78
Tx of Placenta Previa
1. what meds given if < 34 wks for FLM and to prolong preg/avoid PTL
2. What test done for Rh - pts
3. How/when is earliest pts delivered
Prep for hemorrhage + PTB --> get blood type and cross matched ready
Tx of Placenta Previa
1. If < 34 wks --> BMZ for FLM + Tocolytics to prolong preg/avoid PTL
2. KB test done for Rh - pts
3. Pt delivered by C/S and earliest at 34 wks
Prep for hemorrhage + PTB --> get blood type and cross matched ready
79
Why should pts w/ placenta previa NOT undergo vaginal delivery
No vag delivery for pts w/previa b/c lower uterine seg has decr conractility --> risk of PPH
80
35 y/o G5P4 at 39 wks had vag deliv. H/o myomectomy and 1 prior LTCS. Placenta doesnt deliver after 30 min --> attempt to manually extract it, but placenta noted to be firmly adherent to uterus.
Dx?
Next step in management?
Dx = Placenta
Tx = Hysterectomy
- trying to remove it manually --> hemorrhage
81
Premature separation of the placenta from the uterine wall
placental abruption = Premature separation of the placenta from the uterine wall
82
22 y/o G2P1 at 35 wks with PMH of cocaine use, HTN c/o of abd pain and vaginal bleeding. No leakage of fluid or h/o trauma. US norm. Fundus is tender and moderate amt of blood in vaginal vault. Cervix 1 cm dilated. FHR 160-170. BP 150/90
Dx?
Tx?
Dx = placental abruption
Tx = Deliver (anytime > 34 wks)
