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Gyn/OB > Pregnancy complications > Flashcards

Pregnancy complications Flashcards

1
Q

What is ectopic pregnancy

A

A pregnancy that implants outside the uterine cavity. May occur in ovary, cervix, outside fallopian tube, abdominal wall, bowel. Most common site is ampulla (70%) then isthmus (12%) them fimbria (11%)

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2
Q

What is the danger with ectopic pregnancy?

A

Rupture, rapid hemorrhage, shock and death

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3
Q

RFs of ectopic pregnancy

A
  • Prior ectopic, the stronges risk
  • hx of STI or PID
  • Previous tubal surgery
  • Prior pelvic or abdominal surgery resulting in adhesions
  • endometriosis
  • current use of exogenous hormones
  • IVF and other assisted reproduction
  • DES-exposed pat w congenital abnormalities
  • Congenital abnormalities
  • IUD
  • Smoking
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4
Q

dx of ectopic pregnancy

A
  • Hx: unilateral/lower abdominal pain and vaginal bleed
  • PE: adnexal mass, tender uterus small for GA, bleed from cervix
  • Labs: bhCG low for GA, drop in Hct
  • US: adnexal mass or extrauterine pregnancy, IUP remember about multiple gestation, intraabdominal fluid,
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5
Q

how to tx edtopic pregnancy?

A
  • Unstable: IV fluids, blood, vasopressors, Exploratory laparotomy to stop bleed and remove pregnancy
  • If stable w rupture: exploratory laparoscopy, evacuate hemoperitoneum, coagulate bleed and resect. Resection: salpingostomy, salpingectomy, cornual resection.
  • Unruptured: Surgery as above, medically w methotrexate for smal fetus without heartbeat
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6
Q

What is definition of SAB

A

Spontaneous abortion is a pregnancy that ends before 20 weeks gestation. Happen to about 15-25% of pregnancies.

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7
Q

Abortus definition

A

Fetus lost before 20w or less than 500g

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8
Q

Complete abortion

A

Complete expulsion of all POC (products of conception) before 20w

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9
Q

Incomplete abortion

A

Partial expulsion of some but not all POC before 20w

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10
Q

Inevitable abortion

A

No expulsion of products, but vaginal bleed and dilatation of the cervix such that a viable pregnancy is unlikely

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11
Q

Threatened abortion

A

Any vaginal bleed before 20w without dilatation of cervix or expulsion of any POC

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12
Q

Miseed abortion

A

Death of the embryo or fetus before 20w w complete retention of all POC

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13
Q

What is the most common cause of 1st tm SAB

A

Abnormal chromosomes from errors in maternal gametogenesis. Autosomal trisomy is most common abnoraml chromosome.

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14
Q

What are causes of SAB in 1st tm

A
  • Chromosomal abn
  • Infection
  • Maternal anatomic defect
  • immunologic factors
  • environmental exposures
  • endocrine factors
  • idiopathic
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15
Q

sx of SAB

A
  • Bleed from vagina
  • Cramping
  • Abdominal pain
  • Decreased sx of pregnancy
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16
Q

dx of SAB

A
  • Quantitative hcg
  • CBC, blood type, antibody screen
  • US to assess fetal viability and placental bleed
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17
Q

tx of SAB

A

Stabilize. Send tissue to pathology. Incomplete: surgery of medical admin of prostaglandins. W threatened: placed on pelvic rest.

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18
Q

What are the associated causes of 2nd tm abortions

A

Infection , maternal cervical or uterine anatomic defects, maternal systemic disease, exposure to fetotoxic agents, and trauma. PTL and incompetent cervix.

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19
Q

What are often tx in 2nd tm missed or incomplete abortion

A

D&E

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20
Q

What is difference btw D&C and D&E?

A

Depends on age of fetus, , D&E is in second tm

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21
Q

What is cervical insufficiency

A

Incompetent cervix present with painless dilatation of the cervix, often in 2nd and 3rd tm. Common other findings are infection, vaginal discharge and rupture of membranes, short term cramping or contracting. Leading to advancing cervical dilation or pressure in vagina with chorionic and amniotic sac bulging out.

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22
Q

What are rfs to cervical insufficiency?

A

Surgery, trauma is most common cause. Dvs D&C, LEEP or cervical conization. DEs exposure w congenital abnormality.

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23
Q

Dx of cervical insufficiency

A

Often found on routine US

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24
Q

Tx of cervical insufficiency

A
  • If previable: expectant and elective termination. Placement of emergent cerclage, McDonalds (cervical-vaginal) or Shirodkar(internal os)
  • Viable: betamethasone , tocolysis
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25
Q

What to do if cervical insufficiency was dx at previous pregnancy?

A

Elective cerclage usually at 12-14wg. Maintained until 36-38w. If fail, transabdominal cerglage, during laparotomy at internal os. Elective or at 12-14w. They need c-section.

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26
Q

What are the etiologies of recurrent SAB

A
  • Antiphospholipid syndrome 15%
  • Chromosonal abn
  • Maternal systemic disease
  • maternal anatomic defect
  • infection
  • Luteal phase defect
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27
Q

dx testing w recurrent abortions

A
  • Karyotype from parents and POC. Array complete genome hybridization for chr. abnormalities.
  • Hysterosalpingogram.
  • Test hypothyroidism, DM, APAsd, hypercoagulability and SLE. (lupus anticoagulant, factor V leiden, G2021A mutation, ANA, anticardiolipin antibody, Russel viper venom, antithrombin3, protein S & C. )
  • Serum progesteron in luteal phase
  • Cultures of vagina, cervix and endometrium
  • EMB
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28
Q

What are ass w elevated AFP

A

Open fetal cavities as NTD, gastrochisis osv

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29
Q

Which medications are ass w teratology?

A

ACEi, Androgens, AT2 blockers, carbamazepine, cumarins, cyclophosphamide, DES, isotretinoin, lithium (Ebstein), misoprostol, valproate(NTD)

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30
Q

What is placenta previa ?

A

Placenta lies in lower segment of uterus. Normally the placenta migrates upward during the course of pregnancy.

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31
Q

What are the types of placenta previa

A
  • Marginal: at lower segment but not at cervical os
  • Partial: Partially covers cervical os
  • Complete: completely covers os
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32
Q

What are RF of placenta previa?

A
  • Previous placenta previa
  • Multiple gestation
  • ART
  • Prior c-section and uterine surgery
  • Multiparity
  • Erythroblastosis
  • Smoking
  • Increasing maternal age
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33
Q

What are the presentation of placenta previa?

A

Painless bleed, dx on US

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34
Q

What are complications of placenta previa?

A
  • PTD
  • PPROM
  • IUGR
  • Malpresentation
  • Vasa previa
  • Congenital anomalies
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35
Q

What are the names of abnormal placentation ?

A

Complications of placenta previa in the presence of previous uterine scar

  • Placenta accreta: villi invade beyond Nitabuchs layer and into the deep layers of the decidua basalis. (superficial myometrium)
  • Increta: Villi partially invade into myometrium
  • Percreta: Completely through myometrium and occasionally to serosa or beyond bladder
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36
Q

Circumvallate placenta

A

When membranes doubleback over edge of placenta. Considered a variant of placental abruption. Cause of hemorrhage

37
Q

Velamentous placenta

A

Occurs when blood vessels insert btw the amnion and the chorion, away from the margin of the placenta, leaving vessels unprotected and vulnerable to compression and injury.

38
Q

Succenturiate placenta

A

Extra lobe of the placenta that is implanted at some distance from the rest of the placenta.

39
Q

mx of placenta previa

A
  • No vaginal exam
  • If maternal danger EM c-section
  • Term and marginal os >2cm = vaginal delivery
  • Preterm and stable = admit and observe, deliver at 36w
40
Q

What is abruptio placentae

A

Premature separation of placenta from the uterus. Nr.1 cause of late pregnancy bleed.

41
Q

What are rfs to placental abruption?

A
  • HT, DM, CTD,
  • Blunt force trauma
  • Cocaine use, methamphetamine, smoking, alcohol
  • Previous abruption
  • high maternal age
  • multiparity
  • uterine distention
  • Polyhydramnios
  • vascular deficiency
  • circumvallate placenta
  • short umbilical cord
42
Q

What are sx of placental abruption

A
  • Painful late bleed
  • Firm and tender uterus, abd/back pain
  • Pain btw contractions
  • FHT: bradycardia, late deceleration
43
Q

How to dx placenta abruption

A

Difficult to see on US but done to rule out vasa previa

44
Q

How to mx placental abruption

A
  • Maternal danger= sectio
  • Term and stable = vaginal delivery
  • Preterm and stable= admit and observe
45
Q

rf to uterine rupture

A
  • uterine scarring
  • excessive uterine stimulation
  • uterine anomalies
  • hx of invasive mole
  • hx of percreta, increta
  • malpresentation
  • fetal anomaly
  • cocaine
46
Q

sx of uterine rupture

A
  • Tearing uterine pain
  • popping sensation
  • hemorrhage
  • cessation or abnormalities of contraction
  • loss of fetal station or distress
47
Q

mx or uterine rupture

A

emergent sectio w repair or hysterectomy

48
Q

vasa previa

A

Fetal placental vessels cross the internal cervical os

49
Q

rfs to vasa previa

A
  • Velamentous cord
  • accessory (succenturiate) placental lobe
  • Multiple gestation
50
Q

dx og vasa previa

A

Easy w US and color dople

51
Q

How does vasa previa present

A

AROM -> painless bright red bleed -> fetal bradycardia

52
Q

how to mx vasa previa

A

Emergency sectio. May have fetal death as complication.

53
Q

What does sinosoidal pattern on fetal monitoring suggest

A

Fetal anemia, is non-reassuring. Indication of emergency sectio

54
Q

What is tocolysis

A

Attempt to prevent contractions and progression to labor. Ritodrine, a beta-mimetic agent. Increased hydration. Terbutaline. Magnesium Sulfate. CCB - nifedipine. Indomethacin. Atosiban (oxytocin antagonist)

55
Q

Shoulder dystocia

A

Impaction of the anterior shoulder behind the maternal synphysis

56
Q

Risk factors of shoulder dystocia

A
  • Fetal macrosomia
  • Maternal DM
  • Post term pregnancy
  • Prolonged 2nd stage
  • Operative vaginal delivery
  • Hx of shoulder dystocia
57
Q

Sign of shoulder dystocia

A

Turtle sign

58
Q

What is mx of shoulder dystocia

A
  • Suprapubic pressure
  • McRoberts maneuver
  • Rudin maneuver
  • Woods Corkscrew maneuver
  • Others: Episiotomy, attempt to deliver post shoulder, break clavicle, emergent c-section
59
Q

What are complication of shoulder dystocia

A

Erbs palsy and fractures. Compression of cord

60
Q

Asymmetric IUGR

A

Insult after 20w. Caused by creased nutrition and oxygen transmitted from placenta. Shunted to fetal brain. Increased head to abdominal ratio

61
Q

Cause of decreased growth potential

A
  • Chr/genetic abnormalities
  • Intrauterine infection
  • teratogenic exposure
  • substance abuse
  • radiation
  • small maternal stature
  • pregnancy at high altitude
  • female fetus
62
Q

IUGR causes

A
  • HT
  • Anemia
  • Chronic renal disease
  • Malnutrition
  • Severe DM
  • Placenta previa
  • chronic abruption
  • placental infarction
  • multiple gestation
63
Q

RF for macrosomic infant

A
  • DM
  • Maternal obesity
  • postterm
  • previous LGA or macrosomic infant
  • maternal stature
  • multiparity
  • AMA (advanced maternal age)
  • Male infant
  • Beckwith Wiedemann sd
64
Q

What defines oligo and polyhydramnios

A 
Oligo= AFI <5
Poly = >20, or 25
65
Q

What is Erythroblastosis fetalis

A

Anemia cause by hemolysis leads to increased extramedullary production of fetal red cells. Same ad fetal hydrops. Hyperdynamic state, heart failure and diffuse edema, pericardial effusion. Extracellular fluid accumulation in two body compartments.

66
Q

When should we give RhoGAM?

A

In unsensitized Rh-negativ mother. At any time posibility for exposure: amniocentesis, miscarriage, vaginal bleed, abruption, delivery.
If neonate is Rh-positive= at 28w and post partum.
Dose= 0,3mg. Kleihauer-Betke test (amount of fetal blood)

67
Q

rfs for multiple gestation

A

ART. Clomiphene. Human menopausal gonadotropin. African American race. Multiparity. FHx. obesity. Tall height. Geography.

68
Q

Sx of multiple gestation

A
  • increased incidence of hyperemesis gravidarum
  • larger than expected fundal height
  • quantitative cHG, AFP will be high relative to date
69
Q

What are the fetal complications of multiple gestation

A
  • Prematurity, CP, MR
  • Abnormal/discordant growth
  • Congenital anomalies
  • Death
70
Q

Maternal complications of multiple gestation

A
  • Hyperemesis
  • Iron def anemia
  • Pre-eclampsia/eclampsia
  • Intrahepatic cholestasis of pregnancy
  • Thrombosis
  • Uterine atony
71
Q

What are the days the different type of multiple gestation

A

<4 d = dichorionic, diamniotic
4-8d = monochorionic, diamniotic
>9-12d = monochorionic, monoamniotic

72
Q

didi twins..

A

25%, separation up to morulastage. Up to 72hrs. Separate choria and septate amniotic sac
US: Lambda sign

73
Q

MoDi twins

A

60-70%. Separation during blastocyst stage 4-8d. Shared choriom, separate sac. Major complication: TTTS. US: T-sign

74
Q

MoMo twin

A

1-2%. Separation of embryonic disk 9-12d. Shared chorion and sac. Complication: TTTS, umbilical cord entanglement

75
Q

Mx of multiple gestation

A
  • Folate 1g, 30mg iron
  • 10-14w determine what type on sono
  • 18-22w: fetal anatomic survey
  • 28w: antenatal steroids for momo
76
Q

When to deliver multiple gestation

A
  • 34-37: monochorionic twins (possibly earlier for momo)

- 38w: didi

77
Q

Complications for 2nd twin

A
  • Lower BW
  • Malpresentation
  • Cord collapse
  • Abruptio placentae
78
Q

Siametic twin

A

Separation at days 15-16.

79
Q

TTTS

A

Polyhydramnios-oligohydramnios (poly-oli). One small anemic twin and one large plethoric, polycytemic and occasionally hydropic twin.

80
Q

tx of TTTS

A

Before serial amnioreduction. Now coagulating vessels fetoscopically w laser. Termination.

81
Q

What makes 50g-1hr screening positive?

A

> 130 after 1 hr, should proceed to 100g3hr

82
Q

What makes 100g3hr screen positive

A
  • Fasting >95
  • 1hr >180
  • 2hr >155
  • 3hr >140
    2 postive values in one screen gives dx of gestational DM
83
Q

what are obstetric complications of gestational DM

A

Polyhydramnios, preeclampsia, increased sectio risk, infection. Traumatic delivery w shoulder dystocia(macrosomia)

84
Q

gest DM complications

A

Hyopglycemia, DKA, diabetic coma, nephropathy, neuropathy, retinopathy

85
Q

What congenital malformations are child of gest.DM morther at risk for

A

CV-defect, NTD, caudal regression sd, situs inversus, duplex renal ureter, IUGR

86
Q

What are reasons for low hcg?

A
  • Ectopic
  • Thretened abortion
  • Missed abortion
87
Q

What are reasons for high hcg?

A
  • Molar pregnancy
  • Multiple gestation
  • Choriocarcinoma
  • Embryoynal carcinoma
88
Q

What are the most common reason for abdnormal hcg?

A

Innaccurate dating.

89
Q

White classification

A 
A1= gestDM tx w diet and exercise
A2= gestDm tx w insulin 
B= DM onset >20y, duration <10y
C= DM onset 10-19y, duration >10y
D= DM onset <10y, duration >20
F= nephropathy
R= retinopathy
RF= retinopathy + nephropathy
H = heart disease
T= undergone renal transplant

Gyn/OB (4 decks)

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