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R1 - OBGYN > Pregnancy Complications > Flashcards

Pregnancy Complications Flashcards

1
Q

Abortion

A
  • a pregnancy that ends spontaneously before the fetus has reached a viable gestational age (before 20 wks gestation or <500g)
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2
Q

Spontaneous Abortion etiology, RF, and sxs

A
  • most occur in first 12wks (80%)
  • fetal RF: chromosomal abnl (MC: trisomy, monosomy X), congenital anomalies
  • Maternal RF: Advanced age, previous SAB, smoking, infxn, uterine anomalies, maternal dz, gravidity, fever, prolonged ovulation to implantation interval, high or low BMI, celiac dz
  • Sxs: vaginal bleeding, pain, type of abortion determined by passage of POC and whether cervix is dilated or not
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3
Q

spontaneous abortion dx and tx

A
  • dx: quant B-hCG, CBC, blood type, ab screen US
  • tx:
    • >13wk: medical abortion (mifepristone - antiprogesterone) (misoprostol - prostaglandin)
    • D&C - first trimester
    • D&E - second trimester
    • Surgery required if ineffective or excessive blood loss
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4
Q

Complete abortion

A
  • known pregnancy with passage of all products of conception before 20wk gestation
  • passage of all products, no symptoms of preg, test (-)
  • consider ectopic
  • sxs: vaginal bleeding, cervical os closed, uterus firm, well contracted, small for dates, no CMT or adnexal tenderness
  • dx: US, empty uterus
  • tx: does NOT require evacuation of uterus, still needs monitoring
    • curettage nearly 100% successful in completing early preg losses
  • Health maintenance: vaginal rest to decrease risk of infxn
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5
Q

missed abortion

A
  • retention of nonviable preg for prolonged period (2+ menstrual cycles)
  • pt presents w/ smaller gest size by exam than by dates and no FHT
  • sxs: missed menses (persistent amen.), + preg test or inappropriately rising hCG levels, no bleeding, loss of earlier sxs of preg (nausea, breast tenderness)
    • no cramping, 2-3wk lag, cervical os CLOSED, uterus small for dates, no CMT or adnexal tenderness
  • dx: UCG, hCG, CBC, type and screen, fibrinogen weekly for coag, US - fetal demise, no cardiac activity, macerated
  • tx: Resuscitation, observation, serial exams, medical, surgical, or expectant management
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6
Q

threatened abortion

A
  • consider ectopic in ddx, vag bleeding before 20th wk w/o loss of fluid or tissue (normal preg with bleeding)
  • sxs: bleeding, cramping, cervical os closed, uterus sized for date, softer than normal, no CMT or adnexal tenderness
  • dx: + UPT, CBC, type and screen
  • tx: no intervention if no abnormality, 50% proceed to SAB, increased risk PTB and LBW
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7
Q

inevitable abortion

A
  • during first 20wks w/ bleeding, cramping, dilated cervix or gush of fluid WITHOUT passage of POC
  • dx: uCG, hCG, CBC, type and screen, transvag US, US shows IUP, slow cadiac activity, abnormal yolk sac, abnormal gestational sac
  • tx: resuscitation, observation, serial exams, send home to run natural course or may elect for surgical or medical managment
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8
Q

incomplete abortion

A
  • involves passage of products of conception, POC can be at the open os with partial expulsion, intermittent pain and continued bleeding
  • sxs: heavy bleeding (passage of POC), painful cramping (cervical dilation), cervical os open, POCs seen, uterus soft, tender, not well contracted, small for date
  • tx: UCG, hCG, CBC, type and screen, US - retained POCs, clot
  • dx: surgery but can be expectant management (surg not necessary for all women and is invasive), persistent, heavy bleeding with significant pain requires D and C
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9
Q

Induced abortion

A
  • medical or surgical termination of an intact pregnancy before the time of viability
  • mifepristone and methotrexate: increase uterine contractility by reversing the progesterone-induced inhibition of contraction
  • misoprostol: stimulates the myometrium directly
  • medical abortion up to 49d gestation
  • surgical abortion greater than 49d
  • tx:
    • first trimester: suction curettage
    • second trimester: mifepristone (RU 486) = antiprogestin
      • PLUS: methotrexate (antimetabolite), misoprostol (prostaglandin)
      • OR: suction or extraction forceps
    • last line: D&E (dilation and evacuation)
  • complications: uterine perforation, cervical laceration, hemorrhage, incomplete removal, infxn
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10
Q

septic abortion

A
  • Infected abortion, whether complete or incomplete
  • More common with illegal abortions under unsterile conditions by persons who have little or no knowledge of medicine or anatomy
  • sxs: bleeding, sanguinopurulent drainage (strawberry milkshake) +/- passage of POCs, fever, chills, abd pain, amenorrhea
    • tachycardia, tachypnea, fever, dilated os, uterus soft
  • dx: UCG, hCG, CBC, type and screen, blood and endometrial cx, US - retained POCs, clot, foreign body
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11
Q

Ectopic pregnancy etiology, RF, and sxs

A
  • MC site = ampulla
  • RF: An ECTOPIC
    • An: AMA
    • E: exposure to DES in utero
    • C: cigarette
    • T: tubal ligation
    • O: ovulation induction
    • P: prior PID/ectopic
    • I: infertility
    • C: contraceptive IUD
  • sxs: abd pain, bleeding
    • ominous findings: vertigo/syncope, shoulder pain worse with insp.
    • generalized unilateral tenderness, os closed, adnexal tenderness, CMT, uterus smaller than dates
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12
Q

ectopic pregnancy dx, tx

A
  • dx: UPT +, serum BhCG x3 q48h (inappropriately rising)
    • gestational sac on TVUS: 4-5wk after LMP
  • tx: methotrexate IM 50mg (check baseline kidney and liver fn)
    • need to follow up day 4 and 7, then weekly until neg for hCG
    • contraindications: breastfeeding, immunodef, liver dz, blood dyscrasias, pulm dz, PUD, renal dz
    • exploratory laparotomy or laparoscopy if ruptured ectopic
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13
Q

gestational trophoblastic dz

A
  • RF: asian, 2+ miscarriages
  • dx: FIGO criteria:
    • plateau of 4 hCGs over 3+ wks
    • rise of 3 weekly consecutive hCGs over 2+ wk (by at least 10%)
    • persistently elevated hCG >6mo after D&C
    • histologic dx of choriocarcinoma
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14
Q

Molar Pregnancy etiology, RF, and sxs

A
  • excessively edematous immature placentas, including: complete hydatidiform mole, partial hydatidiform mole, and malignant invasive mole
  • RF: hx previous mole, age extremes, vit A and carotene def, long term OCP use, presents during 11-25wk gest.
  • sxs: hx of 1-2mo amenorrhea, 50% vag bleeding (spotting to profuse hemorrhage), N/V significant
  • signs: large uterus for dates
  • complications: anemia, preeclampsia, hyperemesis, hyperthyroidism (tachycardia)
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15
Q

Partial mole

A
  • Partial mole: may contain fetal parts, placenta, triploid karyotype resulting from fert of egg by dispermy, marked villi welling, lower hCG levels, affects older patients, longer gestations, dx as missed or incomplete abortions
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16
Q

Complete mole

A
  • Complete mole: does not contain fetal or placental parts, diploid from fert of empty egg by single sperm or two sperm, trophoblastic prolif with hydrpic degen, larger uteri, pre-eclampsia, post-molar GTD
17
Q

molar pregnancy dx and tx

A
  • dx: CBC, SCr, AST, type and screen, PT/PTT, BhCG, TVUS shows snowstorm, elevated free T4 and decreased TSH
  • tx: CXR (lungs MC site of mets), suction dilatation and curettage or hysterectomy with ovarian preservation, repeat BhCG 48h after and repeat q1-2wk until hCG undetectable
18
Q

Choriocarcinoma

A
  • MC type trophoblastic neoplasm following term preg or miscarriage
  • placental tumors, aggressive invasion into myometrium and propensity to metastasize
  • sxs: irreg bleeding (continuous, intermittent, sudden or massive hemorrhage or after any pregnancy)
  • dx: serum B-hCG + w/ hx recent preg, hemogram, TVUS, CXR, DO NOT BX
  • tx: chemo
    • MC mets are lungs and vagina
19
Q

general characteristics and clinical features of gestational diabetes

A
  • carbohydrate intolerance only present during pregnancy
  • lifetime risk of developing it is 50% (vs 5% in gen pop)
    • if insulin required during preg, 50% risk developing DM w/in 5 yrs from preg
  • recurrence is common in subsequent preg
  • maternal complications: preeclampsia, hyperacceleration of diabetic complicaitons, traumatic birth including shoulder dystocia
  • fetal complications: macrosomia, prematurity, fetal demise, delayed fetal lung maturity
  • sxs: usually asx
  • RF: hx previous LGA infant, obesity, >25yo, glucosuria, Fhx DM, AA, asian, hispanic, american indian
20
Q

dx and tx of gestational diabetes

A
  • dx: screening recommendations
    • obtain random glucose on all preg women in first prenatal visit, then conduct repeat at 24-28wk
    • HgbA1C not recommended as screening method in gest DM
    • nonfasting 50g glucose challenge, check serum level 1 hr later. If >130, perform 3hr gtt
    • 3hr gtt: 100g fasting glucose, levels taken at 1, 2, and 3hrs. if two or more values meet or exceed cutoff values, pt dx w/ GDM
      • fasting: 95
      • 1hr: 180
      • 2hr: 155
      • 3hr: 140
  • tx: diet and exercise, check blood glucose after fasting and after each meal
    • pts with fasting glucose >105 or 2hr postprandial >120 may need insulin
    • oral hypoglycemics not used in USA
    • if pt well controlled and no macrosomia, labor induced at 40wks. If glucose poorly controlled or macrosomia, induction at 38wks
21
Q

Incompetent cervix etiology, RF and sxs

A
  • inability of uterine cervix to retain preg in second trimester in absence of contractions
  • RF: previous cervical trauma
  • sxs: hx of midtrimester preg loss
    • painless cervical dilation in second trim.
    • absence of contractions, infxn, abruption, or uterine anomaly
    • pelvic pressure, cramping, back pain, increased d/c
    • PPROM
    • can be followed by prolapse, and ballooning of membranes into vagina and expulsion
22
Q

incompetent cervix dx and tx

A
  • dx: sonogram (decreased cervical length <30mm), fetal fibronectin (fFN) testing +, CBC, amnio, evaluate for placental abruption
  • tx: cerclage placement: reinforces weak cervix
    • used if hx of cervical insuff with cerclage placement, hx of spontaneous PTB and short cervical length <25mm prior to 24wk
  • contraindications to cerclage: bleeding, uterine contractions, ruptured membrane
23
Q

placential abruption etiology, RF, and sxs

A
  • separation of placenta from implantation site before delivery of baby
  • RF: preeclampsia, chronic HTN, smoking, cocaine, thrombophilia, prior abruption, AMA, multiparity, multifetal gestation, prior uterine surgery, polyhydraminos, fibroid, PPROM
  • sxs: painful vaginal bleeding, uterine tenderness, frequent contractions
  • signs: uterine tenderness (“woody”), fetal distress, shock, dilated cervix
24
Q

placential abruption dx and tx

A
  • dx: clinical dx - US, CBC, coags, fibrinogen, type and screen BUN/Cr, tocodynamometry (FHR monitoring), urine output
  • tx: immediate delivery due to high risk of fetal death
    • preterm/no distress (34-37): induce labor
    • term/no distress: vaginal delivery
    • fetal distress: emergent CS regarless of age
    • fetal demise: vaginal delivery, induction, D&E if 2nd trim.
  • complications: life-threatening PPH and increased need for emergent hysterectomy
25
Q

Placenta previa etiology, RF, and sxs

A
  • placenta implants over internal cervical os
  • most common abnormality of placental implantation
  • RF: AMPS (AMA, multiparity, multiple gestation, prior previa, c-section, D&C, smoking)
  • sxs: painless vaginal bleeding, nontender uterus, breech/transverse lie common
  • consequences: PPH, required C-section, placenta accreta, increta, or percreta, abruption, and growth restriction
26
Q

placenta previa dx and tx

A
  • dx: if dx in first or second trim., repeat US
    • on TVUS, placenta is low\
    • CBC, coags, type and screen
    • fetal HR monitoring
    • DO NOT PERFORM DIGITAL EXAM
  • tx: hospitalization for evaluation, if 37+ wks - delivery, if <36wks - expectant management (asx or preterm = close observation and steroids; mature fetus+/- contractions = base on fetal testing, document lung maturity, schedule 36-38wk)
    • delivery regardless of gest age if: severe fetal status, life threatening hemorrhage, bleeding after 34wk
27
Q

mild gestational HTN

A
  • considered mild until following thresholds are exceeded:
    • SBP = 160
    • DBP = 110
  • must make at least 2 readings at least 4hr apart
  • tx: tx of mild gest HTN does NOT alter course of preeclampsia or diminish perinatal morbidity/mortality and should be avoided
28
Q

Chronic (pre-existing) HTN

A
  • HTN present <20wk gest or predating conception
  • Persistent >12wks postpartum
  • workup is same as primary or secondary HTN
  • tx:
    • uncomplicated/mild (140-150/90-100): no tx
    • peristent (>150/95-99) or organ damage: methyldopa or labetalol
29
Q

Gestational HTN

A
  • diagnosed >20wk, NO PROTEINURIA
  • RF: extremes of age, nulliparity, chronic HTN, underlying vasc. dz, multifetal gest., AA, gest age <34wk, mean SBP >135, high serum uric acid
  • sxs: BP >140/90, no proteinuria or end organ damage, normotensive by 12wk postpartum
  • dx: goal is to distinguish from preeclampsia
    • 24h urine (ro proteinuria), eval for: HA, visual changes, RUQ/epigastric pain, vag bleeding, dec fetal mvmts
    • CBC w/diff, LFTs, SCr, BPP
  • tx: BP <160/110 = bed rest, no HTN tx, no seizure prophylax.
    • BP >160/110 = antiHTN drugs and seizure prophylax.
    • no weight lifting, week/biweek visits, serial US q3-4wks
30
Q

Preeclampsia/eclampsia

A
  • sxs occur after 20wks gestation; most often occurs near term but can be up to 6 weeks postpartum
  • preeclampsia: HTN, edema, proteinuria (edemal no longer necessary for diagnosis)
  • HELLP: presence of severe preeclampsia with addition of Hemolysis, Elevated Liver enzymes, and Low Platelets
  • Eclampsia is severe preeclampsia with the addition of seizures
  • MC RF for preeclampsia is nulliparity. Other factors include extremes of age, multiple gest., DM, preexisting renal dz, chronic HTN
  • Complications of preeclampsia: HELLP syndorme, abruptio placentae, renal failure, cerebral hemorrhage, pulm edema, disseminated intravascular coagulation
31
Q

clinical features, dx and tx of preeclampsia/eclampsia

A
  • sxs: edema of face and hands, sudden weight gain, HA, visual disturbances, N/V, RUQ pain, decreased urine output, HTN, proteinuria, hyperreflexia
    • mild preeclampsia: >140/90
    • severe preeclampsia: >160/110
  • Dx: urine protein, 24hr urine protein, CBC, fibrinogen, PT/PT, chem panel (incl liver enzymes, Cr, uric acid leves)
  • tx: delivery is ultimate tx for HTN of preg
    • mild preeclampsia: if reliable, can be outpt. delivery through induction is indicated after 37wk
      • mag sulfate to dec risk of sz (continued until 24hr postpartum)
      • urine output monitored , hydralazine or labetalol for HTN can be given, betamethasone given before 34wk gest. to enhance fetal lung maturity
    • severe preeclampsia or eclampsia is indication for prompt delivery regardless of gest age
32
Q

Rh incompatibility

A
  • when mom is Rh neg and fetus is Rh pos
  • Rh immunoglobulin (RhoGam) administered at 28-29wks to all Rh neg moms. If baby found to be Rh pos after delivery, mother receives RhoGam again to protect for future preg.
  • RhoGam should be administered at any event in which mom and fetal blood can mix (ectopic, SAM or TAB, CVS, amnio, trauma)
  • If Ab develops in mom against baby, future baby risks severe anemia and death (fetal hydrops)
  • dx: routine prenatal blood work, in sensitized preg, combo of coombs test, amnio, and US used to follow fetus for distriss or fetal hydrops
  • tx: routine RhoGam admin. at 28wks and w/in 72hr of delivering Rh pos infant

R1 - OBGYN (10 decks)

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