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Women's Health EOR > Pregnancy Complications > Flashcards

Pregnancy Complications Flashcards

1
Q

What is a spontaneous abortion?

A

an explosion of all or part of the products of conception before 20 weeks of gestation

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2
Q

What is the incidence of a spontaneous abortion?

A

incidence is 15-25% of pregnancies, first 12 wk (80%)

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3
Q

What is fetal RF?

A

chromosomal abnormalities (MC trisomy, monosomy X), congenital anomalies

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4
Q

What is maternal RF?

A

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

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5
Q

What are the symptoms of spontaneous abortion?

A

vaginal bleeding, or tissue passing from the vagina and pain in the belly or lower back

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6
Q

What are the labs for a spontaneous abortion?

A

quantitative beta-hCG, CBC, blood type, antibody screen, U/S to assess fetal viability and placentation

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7
Q

What is the tx for a spontaneous abortion?

A
  • 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
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8
Q

What is a threatened abortion?

A

blood vaginal discharge before 20 weeks of gestation with or without uterine contractions in the presence of a closed cervix

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9
Q

What is an incomplete abortion?

A

dilated cervical os with the passage of some but not all products of conception before 20 weeks gestation

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10
Q

What is a missed abortion?

A

death of fetus before 20 weeks gestation, with products of conception remaining intrauterine

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11
Q

What is recurrent, spontaneous abortion?

A

three or more consecutive pregnancy losses

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12
Q

What is an ectopic pregnancy?

A

implantation of pregnancy somewhere other than the uterine cavity = 95% in the fallopian tube (55% in the ampulla of the tube)

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13
Q

What are the classic features of an ectopic pregnancy?

A

abdominal pain, bleeding, and adnexal mass in pregnant women

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14
Q

What is the MC cause of an ectopic pregnancy?

A

occlusion of tube secondary to adhesions

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15
Q

What are the characteristics of an ectopic pregnancy?

A

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

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16
Q

How is an ectopic pregnancy dx?

A
  • 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
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17
Q

What is the tx of an ectopic pregnancy?

A

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

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18
Q

What is the surgical treatment of ectopic pregnancy?

A

laparoscopy salpingostomy = emergent situations (rupture) or patient not meeting methotrexate criteria
-follow up testing is crucial

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19
Q

What are the characteristics of gestational diabetes?

A

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
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20
Q

How is gestational diabetes dx?

A

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
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21
Q

What is the tx of gestational diabetes?

A

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
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22
Q

What does gestational trophoblastic disease include?

A

both benign and malignant proliferation of placental cells = signs: BetaHCG higher than expected, size-date discrepancy, hyperemesis

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23
Q

What are the risk factors for molar pregnancies?

A

include maternal age extremes - like younger than 20, or older than 35, and previous molar pregnancy

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24
Q

What is a benign gestational trophoblastic disease?

A 
molar pregnancy (also called hydatidifrom moles)
-Both complete and incomplete moles are premalignant conditions that can develop into invasive mole
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25
Q

What is a complete mole?

A

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

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26
Q

What is an incomplete mole?

A

secretes more HCG than normal (not as much as a complete mole), uterus NOT larger than expected, most result in spontaneous abortion

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27
Q

What is malignant gestational trophoblastic disease?

A

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
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28
Q

How is gestational trophoblastic disease dx?

A

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
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29
Q

What are the characteristics of invasive moles and choriocarcinoma?

A

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

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30
Q

What are the characteristics of ultrasound of invasive moles and choriocarcinoma?

A
  • 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
31
Q

What does the work up for both a persistent mole and choriocarcinoma include?

A

A chest x-ray, and a head, abdomen, pelvis CT to look for metastases, and to stage the tumor

32
Q

What is stage 1 of invasive moles and choriocarcinoma?

A

tumors are confined to the uterus, and there are no metastases

33
Q

What is stage 2 of invasive moles and choriocarcinoma?

A

tumors extend to the Fallopian tubes, the ovaries, or the vagina

34
Q

What is stage 3 of invasive moles and choriocarcinoma?

A

tumors have lung metastases, regardless of genital structure involvement

35
Q

What is stage 4 of invasive moles and choriocarcinoma?

A

tumors ave metastases in any organs other than the lungs or the genital structures

36
Q

What is the tx for complete and incomplete mole?

A

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
37
Q

What is the tx of choriocarcinoma?

A

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
38
Q

What is an incompetent cervix?

A

spontaneous, premature dilation or shortening of the cervix during the second or early third trimester (up to 28 weeks) of pregnancy

39
Q

What does an incompetent cervix present?

A

with recurrent 2nd-semester miscarriages

40
Q

What are the risks of an incompetent cervix?

A

h/o cervical insufficiency, hx of injury, surgery, colonization, DES exposure in utero, anatomic abnormalities

41
Q

What does the exam of an incompetent cervix show?

A

painless dilation and effacement

  • significant cervical dilation of >2 cm
  • minimal contraction until 4 cm
  • bleeding or vaginal discharge (especially in the 2nd trimester)
42
Q

How is an incompetent cervix dx?

A

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
43
Q

What is the tx of an incompetent cervix?

A

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
44
Q

What is placenta abruption?

A

premature separation of all/section of otherwise normally implanted placenta from the uterine wall after 20 weeks of gestation resulting in hemorrhage

45
Q

When is the MC cause of placenta abruption?

A

third trimester bleeding

46
Q

What are the risk factors for placental abruption?

A

include trauma, smoking, hypertension, preeclampsia, and cocaine abuse

47
Q

What is the primary cause of placenta abruption?

A

unknown - maternal HTN, prior history of abruption, maternal cocaine use, external maternal trauma, rapid decompression of over distended uterus

48
Q

How does placenta abruption presents?

A

heavy painful vaginal bleeding in the 3rd trimester with severe abdominal pain and/or frequent strong contractions (30% have no symptoms)

49
Q

What are the physical exam findings of placenta abruption?

A

vaginal bleeding and firm tender uterus with small frequent contractions, 20% present with no bleeding (concealed hemorrhage)

50
Q

How is placenta abruption dx?

A

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
51
Q

What is the tx of placenta abruption?

A

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
52
Q

What is placenta previa?

A

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

53
Q

What is a complete previa?

A

placenta completely covers the internal os

54
Q

What is a partial previa?

A

placenta covers a portion of the internal os

55
Q

What is marginal previa?

A

the edge of placenta reaches the margin of the os

56
Q

What is a low-lying placenta?

A

implanted in the lower uterine segment in close proximity but not extending to the internal os

57
Q

What is vasa previa?

A

fetal vessel may lie over the cervix

58
Q

What is the presentation of placenta previa?

A

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
59
Q

What are the risk factors of placenta previa?

A

prior c-section, multiple gestations, multiple induced abortions, advanced maternal age

60
Q

How is placenta previa dx?

A

ultrasound (transvaginal) - vaginal exam contraindicated = a digital exam can cause further separation
-sonography

61
Q

What is the tx of placenta previa?

A

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
62
Q

What is preeclampsia?

A

classic triad of HTN, (+) proteinuria (+/-) edema (must have HTN and proteinuria) after 20 weeks GA

63
Q

What are the characteristics of mild preeclampsia?

A
  • 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
64
Q

What are the characteristics of severe preeclampsia?

A
  • 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
65
Q

What is eclampsia?

A

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
66
Q

How is mild preeclampsia dx?

A

hypertension with proteinuria

  • BP 140/90 - 160/110
  • proteinuria ->300 mg/24 hour or >+1 on dipstick
67
Q

How is severe preeclampsia dx?

A
  • BP >160/110

- proteinuria >5 g in 24 hours or no urine or 3+ on dipstick

68
Q

How is eclampsia dx?

A

patient meets all criteria for preeclampsia + seizures or coma this is life-threatening for mother and fetus

69
Q

What is the tx of preeclampsia/eclampsia?

A
  • 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
70
Q

What is gestational hypertension?

A

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
71
Q

What is chronic hypertension?

A

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
72
Q

What is RH incompatibility?

A

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

73
Q

What is the tx of Rh incompatibility?

A

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

Women's Health EOR (10 decks)

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