Pregnancy Complications Flashcards
What is a spontaneous abortion?
an explosion of all or part of the products of conception before 20 weeks of gestation
What is the incidence of a spontaneous abortion?
incidence is 15-25% of pregnancies, first 12 wk (80%)
What is fetal RF?
chromosomal abnormalities (MC trisomy, monosomy X), congenital anomalies
What is maternal RF?
previous spontaneous abortion, smoking, maternal infection, anatomic anomalies (large uterine fibroids), Asherman syndrome, maternal disease, gravidity, fever, prolonged time achieving pregnancy, BMI <18.5 or >25, celiac disease
What are the symptoms of spontaneous abortion?
vaginal bleeding, or tissue passing from the vagina and pain in the belly or lower back
What are the labs for a spontaneous abortion?
quantitative beta-hCG, CBC, blood type, antibody screen, U/S to assess fetal viability and placentation
What is the tx for a spontaneous abortion?
- expectant management (<13 wk): allow complete abortion to occur
- > 13 weeks: medical abortin
- mifepristone (antiprogestin) or misopqrostol (prostaglandin) - 96% safe and effective
- D&C (first trimester)
- dilation and evacuation (2nd)
- surgery required if ineffective or excessive blood loss
What is a threatened abortion?
blood vaginal discharge before 20 weeks of gestation with or without uterine contractions in the presence of a closed cervix
What is an incomplete abortion?
dilated cervical os with the passage of some but not all products of conception before 20 weeks gestation
What is a missed abortion?
death of fetus before 20 weeks gestation, with products of conception remaining intrauterine
What is recurrent, spontaneous abortion?
three or more consecutive pregnancy losses
What is an ectopic pregnancy?
implantation of pregnancy somewhere other than the uterine cavity = 95% in the fallopian tube (55% in the ampulla of the tube)
What are the classic features of an ectopic pregnancy?
abdominal pain, bleeding, and adnexal mass in pregnant women
What is the MC cause of an ectopic pregnancy?
occlusion of tube secondary to adhesions
What are the characteristics of an ectopic pregnancy?
r/f: hx of previous ectopic, previous salpingitis (caused by PID), previous abdominal or tubal surgery, used of IUD, assisted reproduction, smoking
-ruptured ectopic pregnancy (medical emergency): severe abdominal or shoulder pain, peritonitis, tachycardia, syncope, orthostatic hypertension
How is an ectopic pregnancy dx?
- beta HCG is >1,500, but no fetus in utero
- serial increases of betaHCG are less than expected (should double every 2 days): get baseline BetaHCG and follow-up hormone levels in 48 hours - if they are sub-optimally rising (not doubling) then it is likely an ectopic pregnancy
- when BetaHCG is >1,500 = should show evidence of developing intrauterine gestation on ultrasound = if not, suspect ectopic, transvaginal US >90% sensitive (IUP visible by 5-6 weeks)
- ultrasound = ring of fire sing: the ring of fire sign also known as ring of vascularity signifies a hyper vascular lesion with peripheral vascularity on color or pulsed Doppler examination of the adnexa due to low impedance high diastolic flow
What is the tx of an ectopic pregnancy?
methotrexate - only if beta HCG <5,000, ectopic mass is <3.5 cm, no fetal heart tones, hemodynamically stable, no blood disorders, no pulmonary disease, no peptic ulcer, normal renal function, normal hepatic function, compliant pt that can return for follow up
-administration of methotrexate is the appropriate treatment for an ectopic pennant unless there are contraindications to the use of the drug
-these contraindications include current breastfeeding, active pulmonary disease, immunodeficiency, or hypersensitivity to methotrexate
-drug is a folic acid antagonist that inhibits DNA replication
the effectiveness of administration is similar to treatment without the risk of surgical complications
-indications for methotrexate therapy should include a hemodynamically stable patients, hCG levels below 5,000 IU/L, mass <3.5 cm, no fetal cardiac activity, and the ability to comply with post-treatment follow-up
-methotrexate can be administered intravenously, intramuscularly, or orally
-it can also be injected into the ectopic pregnancy directly, although this route of administration is not commonly used
-intramuscular administration is the route of administration that is most commonly used for the treatment of ectopic pregnancy
What is the surgical treatment of ectopic pregnancy?
laparoscopy salpingostomy = emergent situations (rupture) or patient not meeting methotrexate criteria
-follow up testing is crucial
What are the characteristics of gestational diabetes?
those who develop gestational diabetes are at higher risk of developing type II diabetes later in life
- in most cases, there are no symptoms
- a blood sugar test during pregnancy is used for diagnosis
- most common complications: macrosomia
How is gestational diabetes dx?
obtain a random glucose on all pregnant women during the first prenatal visit to check for preexisting diabetes, then conduct a repeat screening at 24 to 28 weeks
- *screening consists of administering a nonfasting 50-g glucose challenge test, followed by a serum glucose level 1 hour later
- if the 1-hour serum glucose value is greater than 130 mg/dL, a 3-hour glucose tolerance test is performed
- 3-hour glucose tolerance test: glucose concentration greater than or equal to these values at two or more time points are generally considered a positive test
- fasting: 95
- one hour>180
- two hour >155
- three hour>140
What is the tx of gestational diabetes?
patients with gestational diabetes must check their blood glucose levels daily after fasting overnight and after each meal
- at each office visit, the patient’s home glucose level should be reviewed, and if necessary, a fasting or a 2-hour postprandial blood glucose measurement should be done during the office visit
- patients who have fasting blood glucose measurements of greater than 105 mg/dL or 2-hour postprandial blood sugar measurements of greater than 120 mg/dL may require insulin
- insulin is the treatment of choice - the goal is fasting glucose <95
- NPH/Regular 2/3 in AM and 1/3 in PM
- glyburide (only oral hypoglycemic that doesn’t cross placenta but higher risk of eclampsia) initially if needed, higher risk of eclampsia
- early delivery by c-section at 38 weeks if the child macrocosmic
- good glucose control is described as a 2-hour glucose tolerance test <140 mg/dL
- if pregnancy is insulin-dependent do weekly fetal heart rate monitoring
- in baby worry about hypoglycemia, shoulder dystocia cardiac abnormalities, respiratory distress syndrome, IUGR
What does gestational trophoblastic disease include?
both benign and malignant proliferation of placental cells = signs: BetaHCG higher than expected, size-date discrepancy, hyperemesis
What are the risk factors for molar pregnancies?
include maternal age extremes - like younger than 20, or older than 35, and previous molar pregnancy
What is a benign gestational trophoblastic disease?
molar pregnancy (also called hydatidifrom moles) -Both complete and incomplete moles are premalignant conditions that can develop into invasive mole
What is a complete mole?
huge amounts of HCG, missed periods, positive pregnancy test, vaginal bleeding, symptoms of hyperthyroidism, uterus larger than expected for GA
-“grape-like” mass or “snow-storm” on transvaginal ultrasound
What is an incomplete mole?
secretes more HCG than normal (not as much as a complete mole), uterus NOT larger than expected, most result in spontaneous abortion
What is malignant gestational trophoblastic disease?
invasive moles, which derive from the benign moles, and choriocarcinoma - which is placental cancer that most frequently occurs in the absence of a molar pregnancy
- invasive moles always develop after a molar pregnancy
- choriocarcinoma can also develop after a normal pregnancy
How is gestational trophoblastic disease dx?
HCG >100,000 mlU/ml are diagnostic of molar pregnancy
- sometimes HCG levels may not reach that threshold = can also be diagnosed when a transvaginal ultrasound shows a “snowstorm” or “Swiss cheese” pattern
- this is a diffuse echogenic pattern resulting from the presence of abnormal placental villi and blood clots
- with complete moles, theca lutein cysts may be found on one or both ovaries
- with incomplete moles, fetal parts may be visible, and there’s often oligohydramnios
What are the characteristics of invasive moles and choriocarcinoma?
the diagnosis is made when HCG levels plateau, meaning they remain within 10% of the previous result, over a three week period, or when HCG levels increase more than 10% across three values recorded over two weeks, or when there is still detectable serum HCG up to 6 months after evacuation of a molar pregnancy
What are the characteristics of ultrasound of invasive moles and choriocarcinoma?
- invasive mole has anechoic areas with high vascular flow
- choriocarcinoma, on the other hand, looks like a single mass distending the uterus, and it looks heterogeneous because it has areas of necrosis and hemorrhage
What does the work up for both a persistent mole and choriocarcinoma include?
A chest x-ray, and a head, abdomen, pelvis CT to look for metastases, and to stage the tumor
What is stage 1 of invasive moles and choriocarcinoma?
tumors are confined to the uterus, and there are no metastases
What is stage 2 of invasive moles and choriocarcinoma?
tumors extend to the Fallopian tubes, the ovaries, or the vagina
What is stage 3 of invasive moles and choriocarcinoma?
tumors have lung metastases, regardless of genital structure involvement
What is stage 4 of invasive moles and choriocarcinoma?
tumors ave metastases in any organs other than the lungs or the genital structures
What is the tx for complete and incomplete mole?
treatment for both complete and incomplete moles is uterine evacuation via suction curettage
- uterine contents should always be examined histologically
- follow up = measure serum HCG weekly, until it’s detectable for three consecutive weeks, and then once a month for 6 months
- this should be done while the female is on reliable contraception - like the barrier method or oral contraception
- if HCG levels rise or plateau, there may be a persistent, invasive mole or there may be a choriocarcinoma
What is the tx of choriocarcinoma?
resect, methotrexate chemotherapy
- a score between 0 and 6 means low risk, so treatment relies on a single chemotherapeutic agent like methotrexate
- a score higher than 6 means high risk, and combination chemotherapy regimen like EMA-CO
- remission is defined as three consecutive undetectable HCG levels during weekly monitoring
What is an incompetent cervix?
spontaneous, premature dilation or shortening of the cervix during the second or early third trimester (up to 28 weeks) of pregnancy
What does an incompetent cervix present?
with recurrent 2nd-semester miscarriages
What are the risks of an incompetent cervix?
h/o cervical insufficiency, hx of injury, surgery, colonization, DES exposure in utero, anatomic abnormalities
What does the exam of an incompetent cervix show?
painless dilation and effacement
- significant cervical dilation of >2 cm
- minimal contraction until 4 cm
- bleeding or vaginal discharge (especially in the 2nd trimester)
How is an incompetent cervix dx?
diagnosis with transvaginal ultrasound - will see funneling of the cervix
- between weeks 18 and 22 weeks, the ultrasound focuses on detecting fetal abnormalities
- normally, the cervix should be at least 30 mm in length
- cervical weakness is variably defined
- however, a common definition is a cervical length <25 mm before 24 weeks
What is the tx of an incompetent cervix?
cervical cerclage placed at 12-16 weeks and removed at 36-38 weeks to allow for delivery
- culture for G/C and GBS before placement
- confirm viable intrauterine pregnancy before placement
- a cervical pessary is being studied as an alternative to cervical cerclage since there are fewer potential complications
What is placenta abruption?
premature separation of all/section of otherwise normally implanted placenta from the uterine wall after 20 weeks of gestation resulting in hemorrhage
When is the MC cause of placenta abruption?
third trimester bleeding
What are the risk factors for placental abruption?
include trauma, smoking, hypertension, preeclampsia, and cocaine abuse
What is the primary cause of placenta abruption?
unknown - maternal HTN, prior history of abruption, maternal cocaine use, external maternal trauma, rapid decompression of over distended uterus
How does placenta abruption presents?
heavy painful vaginal bleeding in the 3rd trimester with severe abdominal pain and/or frequent strong contractions (30% have no symptoms)
What are the physical exam findings of placenta abruption?
vaginal bleeding and firm tender uterus with small frequent contractions, 20% present with no bleeding (concealed hemorrhage)
How is placenta abruption dx?
the diagnosis is always clinical, ultrasound is minimally helpful but is usually ordered
- ultrasound may show retroplacental blood collection
- blood-stained amniotic fluid in the vagina
- abruption signs evidenced by fetal heart rate, uterine activity
- decelerations may indicate fetal hypoxia, bradycardiai
What is the tx of placenta abruption?
delivery of the fetus and placenta is the definitive treatment, blood type, crossmatch, and coag studies as well as placement of large-bore IV line
- emergent delivery = vaginal/cesarean, as indicated
- corticosteroids as indicated to enhance fetal lung maturity
- expectant management for small abruptions
What is placenta previa?
a condition in which the placenta lies very low in the uterus and covers all or part of the cervix
-placenta prevue happens in about 1 in 200 pregnancies
What is a complete previa?
placenta completely covers the internal os
What is a partial previa?
placenta covers a portion of the internal os
What is marginal previa?
the edge of placenta reaches the margin of the os
What is a low-lying placenta?
implanted in the lower uterine segment in close proximity but not extending to the internal os
What is vasa previa?
fetal vessel may lie over the cervix
What is the presentation of placenta previa?
painless vaginal bleeding, usually occurs after 28 weeks of gestation
- bleeding from placenta previa results from small disruptions in placental attachment during normal development and thinning of the lower uterine segment during third-trimester = may stimulate further uterine contractions = further placental separation and bleeding
- fetal complications associated with Previa: preterm delivery and its complications, preterm PROM, intrauterine growth restriction, malpresentation, vasa previa, congenital abnormalities
What are the risk factors of placenta previa?
prior c-section, multiple gestations, multiple induced abortions, advanced maternal age
How is placenta previa dx?
ultrasound (transvaginal) - vaginal exam contraindicated = a digital exam can cause further separation
-sonography
What is the tx of placenta previa?
strict pelvic rest (no intercourse) and modified bed rest, no vigorous exercise
- blood transfusion may be necessary so get a type and screen if you discover previa via U/S
- c-section is preferred delivery
- give Rhogam if Rh-
- some studies show that delivery between 34-37 weeks may be optimal
What is preeclampsia?
classic triad of HTN, (+) proteinuria (+/-) edema (must have HTN and proteinuria) after 20 weeks GA
What are the characteristics of mild preeclampsia?
- BP 140/90-160/110
- proteinuria ->300 mg/24 hours or >+1 on dipstick
- edema of face hands and feet
- delivery is the only cure performed at 34-36 weeks - schedule for elective vaginal delivery - A c-section is not necessary unless complications develop
- steroids to mature lungs at 26 to 30 weeks
- daily weights, BP and dipstick weekly, bed rest
What are the characteristics of severe preeclampsia?
- BP >160/110
- proteinuria >5g in 24 hours or no urine or 3+ on dipstick
- cerebral visual changes
- pulmonary edema
- ***HELLP Syndorme - hemolysis, elevated liver enzymes, and low platelets
- delivery is only cure - performed at 34-36 weeks
- hospitalization and start magnesium sulfate to prevent eclampsia
- BP MEDS: started if BP >180/110 - hydralazine
What is eclampsia?
HTN, + proteinuria + seizures or coma
- patient meets all criteria for preeclampsia + seizures or coma this is life-threatening for mother and fetus
- same diagnostic criteria as pre-eclampsia
- treat with magnesium sulfate for seizures
- delivery of fetus once the patient is stabilized
- BP meds: Hydralazine
How is mild preeclampsia dx?
hypertension with proteinuria
- BP 140/90 - 160/110
- proteinuria ->300 mg/24 hour or >+1 on dipstick
How is severe preeclampsia dx?
- BP >160/110
- proteinuria >5 g in 24 hours or no urine or 3+ on dipstick
How is eclampsia dx?
patient meets all criteria for preeclampsia + seizures or coma this is life-threatening for mother and fetus
What is the tx of preeclampsia/eclampsia?
- delivery is the only cure for preeclampsia
- the decision to induce depends on the stage of pregnancy and the severity of the disease
- patients with preeclampsia without severe symptoms are generally induced into labor after 37 weeks gestation in severe preeclampsia delivery is performed at 24-26 weeks
- if less than 34 weeks antenatal steroids promote fetal lung development
- intravenous magnesium sulfate as seizure prophylaxis
What is gestational hypertension?
BP >150/90 after 20 weeks into the pregnancy that resolves 12 weeks postpartum
- clinically asymptomatic
- elevated BP and NO PROTEIN
- may withhold medications, hydralazine or labetalol are considered safe if treatment is warranted
What is chronic hypertension?
BP >140/90 prior to 20 weeks of gestation that persist for >6 weeks postpartum
- symptoms of HTN include headache and visual symptoms if severe
- mild BP >140/90, severe 180/110 with no proteinuria
- monitor every 2-4 weeks, then weekly at 34-36 weeks gestational age and deliver at 39-40 weeks
- severe -meds if BP >150/100 - alpha methyldopa is the drug of choice, avoid ACEI and diuretics, labetalol or nifedipine are safe alternatives
What is RH incompatibility?
if the mother is Rh- and baby is Rh+, then the mother may develop antibodies against the infant’s blood
-the 1st pregnancy is always unaffected
What is the tx of Rh incompatibility?
give Rhogam at 28 weeks, within 72 hours of delivery and during any uterine bleeding throughout pregnancy
- given if Rh-negative mother and father Rh-positive or unknown
- risk of hydrops fetalis
