Pregnancy complications part 2 Flashcards
Partial hydatidiform mole
Develops when two sperm fertilize a normal egg
These contain some fetal tissue. But this tissue is often mixed in with the trophoblastic tissue and is nearly always a triploid karyotype
Tx of partial mole
Only a small percentage of pts with partial moles need further tx after initial surgery. Partial moles rarely develop into malignant GTD
Sx of molar pregnancy- general
Almost all women with complete hydatidiform moles have irregular vaginal bleeding during pregnancy
Typically starts during the first trimester, often between the 6th and 16th week of pregnancy
Can present as blood clots or watery brown d/c. Sometimes bunch of grapes
When are women with partial moles most frequently diagnosed?
After partial or missed miscarriage
How sx of molar pregnancy differentiate from typical pregnancy
Abdominal swelling: gets bigger faster
Vomiting: More frequent and severe episodes
Preeclampsia: Can occur during first or second trimester
Potential signs of metastasis: vaginal bleeding, cough, hemoptysis, HAs, syncope
Molar pregnancy workup
Quantitative hCG
TVUS: snowstorm appearance
GTD- tx
D&C or hysterectomy as indicated by staging
Monitoring of weekly serum hCG levels to make sure levels fall to 0 (may take 6 mos) and then monthly for at least a year
If pt has had chemo, check every 3 mos for 5 yrs
Chemo if levels plateau or rise after falling
Persistent (invasive) GTD
A locally invasive tumor of the muscle
Includes GTD that has not been cured by D&C
Many cases in this category are complete moles that persist
Pathogenesis of invasive GTD
This may occur because D&C removes only the topmost layer of the endometrium, it does not remove the tumor if it is deep in the muscular wall of the uterus
Dx of invasive mole
beta-hCG decreases but then levels off or starts to rise again
Reexamination, CXR, TVUS, and possibly CT of head, abdomen/pelvis, and liver
Risks for persistent GTD
There is a long time (>4 mos) between the time periods had stopped and tx is started
Uterus has become very large
Woman is >40 yoa
Woman has had GTD in the past
If the tumor grows through the full thickness of the myometrium, it may result in a hole in the uterus that can hemorrhage
Tx of persistent GTD
Chemo is ordered based on the hCG
Choriocarcionoma
A malignant form of GTD
CA in the cells of the lining or epithelium of the layer of the membrane that surrounds the fetus
When can choriocarcinoma develop?
From a complete hydatidiform mole
After a normal pregnancy
After a pregnancy when the fetus is lost early
Characteristics of choriocarcinoma
It is usually not diagnosed promptly
It can be anywhere in the body and is a very aggressive CA. It metastasizes widely and early.
Very invasive and destroys the tissue. It bleeds profusely. If in the brain, then signs of a CVA or seizure may occur. If in lung, then hemoptysis; if in the uterus, irregular bleeding can occur
Simple pregnancy test that is pos will indicate the dx
Out of control blood sugars are more likely to cause what in pregnant women?
If not that result, what else could occur?
Spontaneous abortion
Heart and limb defects
Diabetic mothers have a twofold increase in what?
Development of pregnancy induced HTN
Pregnant pts have an increased risk of what? (Has to do with diabetes)
DKA
Retinopathy. Should receive an ophthalmalogic exam before or early in pregnancy.
Risks associated with DM
Macrosomia Polyhydramnios Preterm labor Stillbirth Neonatal hypoglycemia and respiratory distress
Diet for mothers with DM in pregnancy
35 Kcal/kg of ideal body weight, with 45% complex carbs, 35% fat, 20% protein
How often should BGs be taken in a woman with DM?
A minimum of five times/day and logged
FBS
2 hrs postprandial after each meal
HS
Visit frequency if pt has DM
Typically every 2 wks in early pregnancy, IF BGs UNDER CONTROL, then weekly thereafter
Labor conditions of gestational DM
Because of the greatly increased risk of stillbirth, most well controlled diabetics are induced at term
Postpartum care for gestational DM
At 2 mo check, a GTT should be performed to pick up the women who have not returned to normal status
Prognosis of developing diabetes after pregnancy ends if pt had gestational DM
70% go on to develop it later in life
Women who require insulin during pregnancy have a 50% chance of acquiring diabetes within 5 yrs
Definition of gestational HTN
Sustained SBP at or above 140 and/or DBP of 90 or greater AFTER 20 wks gestation
-If before 20 wks is chronic HTN
When is gestational HTN considered severe?
If SBP is greater than or equal to 160 DBP greater than or equal to 110 for at least 6 hours
What distinguishes gestational HTN from preeclampsia?
Lack of other findings
What percentage of gestational HTN progresses to preeclampsia?
50%
Preeclampsia definition
HTN accompanied by proteinuria after the 20th wk of pregnancy
How can edema manifest itself in preeclampsia?
HAs Visual disturbances RUQ pain N/V Edema in the face, hands, feet/legs
In what population is preeclampsia more common?
Nulligravida
`What is generally present in preeclampsia?
Hyperreflexia. If clonus is present, more worrisome.
What may preeclampsia also cause?
Hepatic dysfunction and pain
Pulm edema
Thrombocytopenia
Oliguria
Risks of preeclampsia
DIC
HELLP
IUGR
Placental abruption
Criteria needed to define severe preeclampsia (only needs one)
BP >160 systolic or >110 diastolic
Proteinuria of >5.0 g on a 24-hr collection (3-4+ on dipstick)
Oliguria of <500 mL/24 hrs and/or SCr >1.1
Thrombocytopenia
Thrombocytopenia along with elevated hepatic enzyme activities and/or evidence of microangiopathic hemolytic anemia, usually with epigastric pain
Cerebral or visual sx
Pulm edema
Severe RUQ pain
Fetal growth restriction
Management of severe preeclampsia
Requires delivery in order to be reversed
Antihypertensives if SBP greater than or equal to 160 and/or DBP greater than or equal to 110
-MC methyldopa, labetalol, thiazide diuretics, nifedipine
Corticosteroids for fetal lung maturity if baby premature
Eclampsia
Preeclampsia progresses to seizure activity in a pt with no hx of seizures
Management of eclampsia
Stop seizures and deliver baby
Look for DIC/HELLP
Mag sulfate is the drug of choice
What is common to see immediately after a seizure in eclamptic pts?
Non-reassuring fetal HR patterns
What form of delivery is preferred in pts with eclampsia?
Vaginal > C-section
What can be a side effect of mag sulfate?
Respiratory depression
Calcium gluconate is antidote
Placenta previa
Placenta is covering or partially covering the cervix
Presentation of placenta previa
Bleeding is bright red and painless. May be small or large amount
If placenta is low early in pregnancy it may migrate up, you need to recheck closer to term
Management of placenta previa
If close to the cervix you can do a trial of labor if there is the ability to do a stat C-section
When is placenta previa more common?
Multiples
Previous uterine surgeries
Abruptio placenta
Premature separation of the placenta from the uterine wall after 20 wks but before birth of baby
Risk factors for abruptio placenta
Maternal HTN Abdominal trauma Maternal smoking Substance abuse, particularly stimulants Maternal age >40 Sudden uterine decompression
Types of abruptio placenta
Marginal- an edge starts to come up
Partial- the placenta starts to come away from the uterus, bleeding and pain increases
Complete- the placenta comes entirely free from the uterine wall. Can be obvious or concealed
Manifestations of abruptio placenta
Abdominal pain- uterus VERY firm to the touch. Does not completely relax between contractions
Vaginal bleeding
Non-reassuring fetal HR: typically see deep, long decelerations of the fetal HR
How can a dx of abruptio placenta be confirmed?
Bedside u/s if baby’s condition permits
Tx of abruptio placenta
If the abruption is d/t trauma and is not enlarging, pt/baby can be observed
Abruption in labor general results in C-section unless the baby is nearly delivered and the abruption is very marginal
Risks associated with abruptio placenta
Close association with DIC
- Reduced fibrinogen
- Increased fibrin degradation products
- Decreased platelet count
- Increased PTT
PE of DIC
Petechiae
Epistaxis
Bleeding gums
Blood in Foley bag
Bleeding around IV site
Bleeding from C-section incision as well as vaginally
If vaginal delivery, marked vaginal bleed
