Pregnancy Complications Flashcards
Causes of third trimester bleeding
Labor Placental abruption Placenta previa Vasa previa (velamentous cord insertion where some of the fetal vessels in the membrane cross over the cervical os) Non-obstetric: -vaginal lacerations -cervical lacerations -genital lacerations -postcoital spotting
Placental abruption Path: Risk Factors: Sx: Dx: Complications: Tx:
Path: Separation of placenta from its site of implantation before delivery of the fetus
Apparent or Concealed
Risk Factors: Prior abruption, Increased age, Increased parity, Chronic hypertension, Preterm rupture of membranes, Multifetal gestation, Trauma , Hydramnios , Cigarette smoking , Lateral thrombophilias , Cocaine use, Uterine fibroids, Race
Sx: Vaginal bleeding, Uterine tenderness or back pain, Fetal distress, Preterm labor, High-frequency contractions, Hypertonus (inc resting tone), Dead fetus
Dx: Clx
Complications:
- Consumptive coagulopathy -> DIC
- Renal failure
- Fetal demise
- Couvelaire uterus: widespread extravasation of blood into the uterine musculature beneath uterine serosa
Tx:
Maternal resuscitation w/ blood and crystalloid
Delivery :
-For viable fetus: cesarean section if vaginal delivery is not imminent
-For abruption demise: start induction when mother is stabilized
Placenta previa Path: Risk factors: Sx: Dx: Tx:
Path: placenta is located over/very near internal os
- Complete previa: covers entire os
- Incomplete previa: placenta at the edge of/partially covers os
- Low-lying: placenta is within 2cm of internal os
Risk factors:
- Prior cesarean delivery
- Advanced lateral age
- Multiparity
- Smoking
Sx: Painless hemorrhage occurring at end of 2nd trimester or later in pregnancy
Dx:
- Doppler TV U/S @20w (early in pregnancy may resolve by term from placental migration)
- Speculum exam visualize bleeding is from above the os
Tx:
- Ideal: term fetus or fetus w. Documented lung maturity can be scheduled for routine cesarean
- Less ideal: pt w. Known previa presents in labor and receives emergent cesarean
- Least ideal: severe hemorrhage preterm mandating stat cesarean
Preeclampsia and Eclampsia
Path
Maternal vasospasm
Preeclampsia: HTN + proteinuria +/- edema AFTER 20w gestation (earlier in multiple gestation or molar pregnancy)
Eclampsia: Seizures or coma in pts who meet preeclampsia criteria
Preeclampsia without severe features:
Pt:
Dx:
Tx:
Pt: asx
Dx:
- BP >/=140 / >/=90 sustained, starting after 20w
- Urine: 300mg/dL proteinuria (1+ dip stick)
Tx:
>37w deliver urgently (induce)
<37w bed rest
Preeclampsia with severe features:
Pt:
Dx:
Tx:
Pt:
- Sx of HTN: HA, visual sx
- Fetal growth restriction
- Edema caused by proteinuria (dec oncotic pressure)
Dx:
- BP >160 / >110 sustained, starting after 20w
- Proteinuria 5g/24h (3+ dip stick)
- Oliguria (<500ml/24h)
- Thrombocytopenia, +/- DIC
- HELLP syndrome: Hemolytic anemia, Elevated liver enzymes, Low Platelets
Tx:
- Prompt delivery (induce)
- Magnesium sulfate (seizure prevention)
- BP meds in acute severe HTN: Hydralazine, Labetalol, Nifedipine
Eclampsia:
Pt:
Dx:
Tx:
Pt:
- Abrupt tonic-clonic seizures
- HA, visual changes, cardiorespiratory arrest
Dx:
- Same at preeclampsia + seizures
- Hyperreflexia
Tx:
- ABCD’s 1st
- Magnesium sulfate for seizures (lorazepam if refractory)
- Delivery of fetus once mom is stabilized
- BP meds: hydralazine, labetalol
Pregnancy induced HTN: Path: Pt: Dx: Tx:
Path: HTN no proteinuria after 20w gestation
Resolves 12w postpartum
Thought to be due to arteriolar vasoconstriction
Pt: asx
Dx:
BP >/=140 / >/=90
No proteinuria
Tx:
May withhold meds
+/- hydralazine, labetalol
Monitor for preeclampsia
Ectopic pregnancy Path: Pt: Dx: Tx:
Path:
Zygote implants not in uterus
- Ampulla (MC)
- Stricture
Pt:
- Abdominal pain
- Bleeding
- UPT +
Dx: TV U/S B-Quant * >/=1500 w/ negative TV U/S * <1500 -Too soon to tell -If B-HCG doubles in 48 hours-> normal pregnancy
Tx: Salpingostomy: no rupture Salpingectomy: + rupture Methotrexate (+/- leucovorin) ok if: -B-HCG <5000 -Gestation sac <3.5cm -No heart tones
Threatened Spontaneous abortion Path: Pt: Dx: Tx:
Path:
- Pregnancy may be viable or abortion may follow
- MC cause of 1st trimester bleeding
Pt:
Bloody vaginal discharge: spotting -> profuse
+/- contractions
Uterus size compatible w/ dates
Dx:
- Products of conception: No POC expelled from uterus
- Cervical OS: Closed
Tx:
- Supportive: rest @ home, return to ER if sx persist or passage of POC
- Serial B-HCG to see if doubling
- RhoGAM if indicated
Inevitable Spontaneous abortion Path: Pt: Dx: Tx:
Path: Pregnancy not salvageable
Pt:
- Moderate bleeding >7d
- Mod-severe uterus cramping
- Uterus size compatible w/ dates
Dx: Products of conception: No POC expelled Cervical OS: * Progressive cervix dilation: >3cm, effaced * +/- rupture of membranes
Tx:
- 2nd trimester: D&E
- 1st trimester: suction curettage
- RhoGAM if indicated
Incomplete Spontaneous abortion Path: Pt: Dx: Tx:
Path: Pregnancy not salvageable
Pt:
- Heavy bleeding
- Mod-severe cramping
- Retained tissue
- Boggy uterus
Dx:
- Products of conception: some POC expelled, some still retained
- Cervical OS: Dilated
Tx: May be allowed to finished D&E after 1st trimester D&C in 1st trimester Pitocin RhoGAM if indicated
Complete Spontaneous abortion Path: Pt: Dx: Tx:
Path: Complete passage of all products
Pt:
- Pain, cramps and bleeding usually subsides
- Pre-pregnancy size of uterus
Dx:
- Products of conception: All POC expelled from uterus
- Cervical OS: usually closed
Tx: RhoGAM if indicated
Missed Spontaneous abortion Path: Pt: Dx: Tx:
Path: Fetal demise but still retained in uterus
Pt:
- Loss of pregnancy sx
- Brown discharge
Dx:
- Products of conception: no POC expelled
- Cervical OS: closed
Tx:
- D&E 2nd trimester
- D&C 1st trimester
- Misoprostol
Septic Spontaneous abortion Path: Pt: Dx: Tx:
Path: The retained POC becomes infected -> infection of uterus and organs
Pt:
- Foul brownish discharge, fever, chills
- Uterine tenderness
- Spotting -> heavy bleed
Dx: Products of conception: Some POC retained Cervical OS: -Closed -CMT
Tx:
-D&E to remove POC + broad spectrum abx
+/- hysterectomy if refractory
