Pregnancy complications Flashcards
What is ectopic pregnancy
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%)
What is the danger with ectopic pregnancy?
Rupture, rapid hemorrhage, shock and death
RFs of ectopic pregnancy
- 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
dx of ectopic pregnancy
- 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,
how to tx edtopic pregnancy?
- 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
What is definition of SAB
Spontaneous abortion is a pregnancy that ends before 20 weeks gestation. Happen to about 15-25% of pregnancies.
Abortus definition
Fetus lost before 20w or less than 500g
Complete abortion
Complete expulsion of all POC (products of conception) before 20w
Incomplete abortion
Partial expulsion of some but not all POC before 20w
Inevitable abortion
No expulsion of products, but vaginal bleed and dilatation of the cervix such that a viable pregnancy is unlikely
Threatened abortion
Any vaginal bleed before 20w without dilatation of cervix or expulsion of any POC
Miseed abortion
Death of the embryo or fetus before 20w w complete retention of all POC
What is the most common cause of 1st tm SAB
Abnormal chromosomes from errors in maternal gametogenesis. Autosomal trisomy is most common abnoraml chromosome.
What are causes of SAB in 1st tm
- Chromosomal abn
- Infection
- Maternal anatomic defect
- immunologic factors
- environmental exposures
- endocrine factors
- idiopathic
sx of SAB
- Bleed from vagina
- Cramping
- Abdominal pain
- Decreased sx of pregnancy
dx of SAB
- Quantitative hcg
- CBC, blood type, antibody screen
- US to assess fetal viability and placental bleed
tx of SAB
Stabilize. Send tissue to pathology. Incomplete: surgery of medical admin of prostaglandins. W threatened: placed on pelvic rest.
What are the associated causes of 2nd tm abortions
Infection , maternal cervical or uterine anatomic defects, maternal systemic disease, exposure to fetotoxic agents, and trauma. PTL and incompetent cervix.
What are often tx in 2nd tm missed or incomplete abortion
D&E
What is difference btw D&C and D&E?
Depends on age of fetus, , D&E is in second tm
What is cervical insufficiency
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.
What are rfs to cervical insufficiency?
Surgery, trauma is most common cause. Dvs D&C, LEEP or cervical conization. DEs exposure w congenital abnormality.
Dx of cervical insufficiency
Often found on routine US
Tx of cervical insufficiency
- If previable: expectant and elective termination. Placement of emergent cerclage, McDonalds (cervical-vaginal) or Shirodkar(internal os)
- Viable: betamethasone , tocolysis
What to do if cervical insufficiency was dx at previous pregnancy?
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.
What are the etiologies of recurrent SAB
- Antiphospholipid syndrome 15%
- Chromosonal abn
- Maternal systemic disease
- maternal anatomic defect
- infection
- Luteal phase defect
dx testing w recurrent abortions
- 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
What are ass w elevated AFP
Open fetal cavities as NTD, gastrochisis osv
Which medications are ass w teratology?
ACEi, Androgens, AT2 blockers, carbamazepine, cumarins, cyclophosphamide, DES, isotretinoin, lithium (Ebstein), misoprostol, valproate(NTD)
What is placenta previa ?
Placenta lies in lower segment of uterus. Normally the placenta migrates upward during the course of pregnancy.
What are the types of placenta previa
- Marginal: at lower segment but not at cervical os
- Partial: Partially covers cervical os
- Complete: completely covers os
What are RF of placenta previa?
- Previous placenta previa
- Multiple gestation
- ART
- Prior c-section and uterine surgery
- Multiparity
- Erythroblastosis
- Smoking
- Increasing maternal age
What are the presentation of placenta previa?
Painless bleed, dx on US
What are complications of placenta previa?
- PTD
- PPROM
- IUGR
- Malpresentation
- Vasa previa
- Congenital anomalies
What are the names of abnormal placentation ?
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
Circumvallate placenta
When membranes doubleback over edge of placenta. Considered a variant of placental abruption. Cause of hemorrhage
Velamentous placenta
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.
Succenturiate placenta
Extra lobe of the placenta that is implanted at some distance from the rest of the placenta.
mx of placenta previa
- 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
What is abruptio placentae
Premature separation of placenta from the uterus. Nr.1 cause of late pregnancy bleed.
What are rfs to placental abruption?
- 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
What are sx of placental abruption
- Painful late bleed
- Firm and tender uterus, abd/back pain
- Pain btw contractions
- FHT: bradycardia, late deceleration
How to dx placenta abruption
Difficult to see on US but done to rule out vasa previa
How to mx placental abruption
- Maternal danger= sectio
- Term and stable = vaginal delivery
- Preterm and stable= admit and observe
rf to uterine rupture
- uterine scarring
- excessive uterine stimulation
- uterine anomalies
- hx of invasive mole
- hx of percreta, increta
- malpresentation
- fetal anomaly
- cocaine
sx of uterine rupture
- Tearing uterine pain
- popping sensation
- hemorrhage
- cessation or abnormalities of contraction
- loss of fetal station or distress
mx or uterine rupture
emergent sectio w repair or hysterectomy
vasa previa
Fetal placental vessels cross the internal cervical os
rfs to vasa previa
- Velamentous cord
- accessory (succenturiate) placental lobe
- Multiple gestation
dx og vasa previa
Easy w US and color dople
How does vasa previa present
AROM -> painless bright red bleed -> fetal bradycardia
how to mx vasa previa
Emergency sectio. May have fetal death as complication.
What does sinosoidal pattern on fetal monitoring suggest
Fetal anemia, is non-reassuring. Indication of emergency sectio
What is tocolysis
Attempt to prevent contractions and progression to labor. Ritodrine, a beta-mimetic agent. Increased hydration. Terbutaline. Magnesium Sulfate. CCB - nifedipine. Indomethacin. Atosiban (oxytocin antagonist)
Shoulder dystocia
Impaction of the anterior shoulder behind the maternal synphysis
Risk factors of shoulder dystocia
- Fetal macrosomia
- Maternal DM
- Post term pregnancy
- Prolonged 2nd stage
- Operative vaginal delivery
- Hx of shoulder dystocia
Sign of shoulder dystocia
Turtle sign
What is mx of shoulder dystocia
- Suprapubic pressure
- McRoberts maneuver
- Rudin maneuver
- Woods Corkscrew maneuver
- Others: Episiotomy, attempt to deliver post shoulder, break clavicle, emergent c-section
What are complication of shoulder dystocia
Erbs palsy and fractures. Compression of cord
Asymmetric IUGR
Insult after 20w. Caused by creased nutrition and oxygen transmitted from placenta. Shunted to fetal brain. Increased head to abdominal ratio
Cause of decreased growth potential
- Chr/genetic abnormalities
- Intrauterine infection
- teratogenic exposure
- substance abuse
- radiation
- small maternal stature
- pregnancy at high altitude
- female fetus
IUGR causes
- HT
- Anemia
- Chronic renal disease
- Malnutrition
- Severe DM
- Placenta previa
- chronic abruption
- placental infarction
- multiple gestation
RF for macrosomic infant
- DM
- Maternal obesity
- postterm
- previous LGA or macrosomic infant
- maternal stature
- multiparity
- AMA (advanced maternal age)
- Male infant
- Beckwith Wiedemann sd
What defines oligo and polyhydramnios
Oligo= AFI <5 Poly = >20, or 25
What is Erythroblastosis fetalis
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.
When should we give RhoGAM?
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)
rfs for multiple gestation
ART. Clomiphene. Human menopausal gonadotropin. African American race. Multiparity. FHx. obesity. Tall height. Geography.
Sx of multiple gestation
- increased incidence of hyperemesis gravidarum
- larger than expected fundal height
- quantitative cHG, AFP will be high relative to date
What are the fetal complications of multiple gestation
- Prematurity, CP, MR
- Abnormal/discordant growth
- Congenital anomalies
- Death
Maternal complications of multiple gestation
- Hyperemesis
- Iron def anemia
- Pre-eclampsia/eclampsia
- Intrahepatic cholestasis of pregnancy
- Thrombosis
- Uterine atony
What are the days the different type of multiple gestation
<4 d = dichorionic, diamniotic
4-8d = monochorionic, diamniotic
>9-12d = monochorionic, monoamniotic
didi twins..
25%, separation up to morulastage. Up to 72hrs. Separate choria and septate amniotic sac
US: Lambda sign
MoDi twins
60-70%. Separation during blastocyst stage 4-8d. Shared choriom, separate sac. Major complication: TTTS. US: T-sign
MoMo twin
1-2%. Separation of embryonic disk 9-12d. Shared chorion and sac. Complication: TTTS, umbilical cord entanglement
Mx of multiple gestation
- Folate 1g, 30mg iron
- 10-14w determine what type on sono
- 18-22w: fetal anatomic survey
- 28w: antenatal steroids for momo
When to deliver multiple gestation
- 34-37: monochorionic twins (possibly earlier for momo)
- 38w: didi
Complications for 2nd twin
- Lower BW
- Malpresentation
- Cord collapse
- Abruptio placentae
Siametic twin
Separation at days 15-16.
TTTS
Polyhydramnios-oligohydramnios (poly-oli). One small anemic twin and one large plethoric, polycytemic and occasionally hydropic twin.
tx of TTTS
Before serial amnioreduction. Now coagulating vessels fetoscopically w laser. Termination.
What makes 50g-1hr screening positive?
> 130 after 1 hr, should proceed to 100g3hr
What makes 100g3hr screen positive
- Fasting >95
- 1hr >180
- 2hr >155
- 3hr >140
2 postive values in one screen gives dx of gestational DM
what are obstetric complications of gestational DM
Polyhydramnios, preeclampsia, increased sectio risk, infection. Traumatic delivery w shoulder dystocia(macrosomia)
gest DM complications
Hyopglycemia, DKA, diabetic coma, nephropathy, neuropathy, retinopathy
What congenital malformations are child of gest.DM morther at risk for
CV-defect, NTD, caudal regression sd, situs inversus, duplex renal ureter, IUGR
What are reasons for low hcg?
- Ectopic
- Thretened abortion
- Missed abortion
What are reasons for high hcg?
- Molar pregnancy
- Multiple gestation
- Choriocarcinoma
- Embryoynal carcinoma
What are the most common reason for abdnormal hcg?
Innaccurate dating.
White classification
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
