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SFM5 > Pregnancy pathophys > Flashcards

Pregnancy pathophys Flashcards

1
Q

consequences of dysfunctional early placenta dev

A
  • prematurity
  • fetal growth restriction
  • stillbirth
  • preeclampsia
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2
Q

due date calc

A

LMP + 280 days ~40wk

EDD often corrected based on crown-rump length in 1st tri, more accurate indication of start of pregnancy

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3
Q

how long conception –> implantation

A

1 wk

“pregnancy” starts when egg implants

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4
Q

trophoblast differentiation and function

A

b//c placenta

syncytiotrophoblasts

  • produce hormones (hCG to maintain corpus lutem)
  • proteases to degrade endometrium

cytotrophoblasts

  • direct contact with maternal blood = uteroplacental circulation
  • during invasion extravillous trophoblasts seek sPIRal arteries
  • remodeling of spiral arteries
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5
Q

preeclampsia mx

A
  • high bp during pregnancy
  • risk of eclampsia
  • d/t inadequate placental invasion during early pregnancy

mx:

  • myometrial spiral arterioles undisturbed by trophoblasts = still responsive to maternal vasomotor
  • impaired blood supply to placenta –> increased maternal bp
  • sFLT –> endothelial dysfunction (anti-angiogenic)
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6
Q

signalling molecules in placentation

A

angiogenic:

  • support formation of new blood vessels
  • PIGF - placental growth factor
  • VEGF

anti-angiogenic

  • prevent maternal endothelial cells from resealing ends of spiral arteries
  • prevent maternal blood vessels from entering fetal compartment
  • prevent fetal vessels from growing out into uterus
  • sFLT-1
  • increased in preeclampsia
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7
Q

placenta accreta spectrum

A

excessive invasion of placenta into uterus
*hemorrhage risk

  • accreta = villi attached to myometrium
  • increta = villa invade myometrium
  • percreta = villi invade through myometrium
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8
Q

placental hemorrhage ddx

A
  • placenta accreta spectrum (accreta < increta < percreta)
  • placenta previa (covering cervix)
  • placental abruption (*trauma, smoking, hypertension, preeclampsia, cocaine)
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9
Q

fetal nutrition in pregnancy

A

first 10-12 weeks = diffusion/histiotrophic

then vascular circulation/hemotrophic

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10
Q

placental hormones

A

syncytiotrophoblast

  • influence maternal physiology
  • beta-hCG maintains corpus luteum
  • progesterone synthesized de novo from cholesterol, maintains endometrium and pregnancy
  • hPL ~ GH, decreases maternal insulin sensitivity and glucose
  • CRH –> fetal ACTH, onset of labor

cytotrophoblast
- prevent maternal hormones from entering fetal compartment

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11
Q

hCG testing

A
  • blood detection at 3 weeks (1 wk post-conception)
  • urine @ 4 wk
  • doubles every 48 hours in early pregnancy
  • peaks at 8-10 wk
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12
Q

thyroid hormones in preg

A

alpha-hCG is identical to TSH, stimulates T3/T4 production

  • T3/T4 increases throughout pregnancy and don’t fall much even after hCG has dropped
  • TSH inversely proportional to hCG, initial significant dip followed by recovery as hCG peaks and drops ~8-10 wk
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13
Q

progesterone in pregnancy

A
  • initially produced by corpus luteum
  • then directly by placenta via de novo synthesis from cholesterol

“pro-gestation”

  • immune tolerance to fetus
  • hair growth
  • inhibits prolactin
  • increases respiration (maternal)
  • smooth muscle relaxation –> vasodilation (important d/t increase in plasma volume)
  • inhibits uterine contraction

sfx:

  • GI: constipation, gallstones
  • possible orthostatic hypotension
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14
Q

CVD in preg - presentation

A

htn ≥ 140
HR ≥ 120
crackles, S3, gallop
O2 ≤ 90%

(some or all of above)

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15
Q

estrogens in pregnancy

A
  • increases across gestation
  • fetal DHEAs (fetal adrenal) –> estraDIol (E2) and *esTRIol (E3)
  • b/c placenta lacks 17alpha hydroxylase only DHEA pathway, no de novo synthesis

low estriol ~ poor outcome

fx

  • endometrial and uterine growth
  • placental angiogenesis
  • breast enlargement

sfx

  • nausea
  • hepatic clotting factors (increased clotting)
  • estriol –> contractions, labor onset
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16
Q

hPL

A 
human placental lactogen
similar to GH
shunts resources to baby
- decreases maternal insulin sensitivity
- decreases maternal glucose use
- increases maternal lipolysis
also mammogenesis
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17
Q

CRH

A

increases fetal ACTH
involved in immunosuppression
involved in onset of labor

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18
Q

blood changes in pregnancy

A

increased blood volume by ~50%

  • protection from blood loss at delivery
  • circulation to baby
  • starts at 6-8 wk
  • possibly triggered by estrogen stim of RAAS

increased red cell mass by ~20-30%

  • EPOesis d/t progesterone, hPL, prolactin
  • increase iron demand
  • lower blood viscosity – intervillous circulation, protect VTE

dilution anemia (more increase in blood volume than red cell mass)

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19
Q

CV changes in pregnancy

A

increase ventricular muscle mass and contractility

  • dilated heart but no reduction in EF
  • starts in 1st trimester
  • EDV increases in late pregnancy

CO increase by ~30-50%

  • most in first 8 wk
  • SV declines somewhat at term
  • postural - drops ~25% when supine, postural hypotension in ~8%
  • distribution mainly to uterus, kidneys, breast, and skin
  • no change in flow to brain, liver

SVR decreases ~35-40%

  • starting as early as 5 wk
  • ? why, progesterone, NO, low resistance placental circulation

BP decreases 5-10/10-15 mmHg

  • ~24 wk
  • affected by posture
  • except in preeclampsia
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20
Q

CV changes intrapartum (during labor) and postpartum

A

further increase in CO

  • E/NE rise d/t pain
  • autotransfusion d/t contractions
  • less affected if +epidural, left lateral position

CO increases another ~80% in first 15 min postpartum

  • autotransfusion d/t contractions
  • relief of aortocaval compression

CO returns to pre-labor ~1 h post-delivery

CO, SV, SVR do not return to pre-pregnancy until 12+ wk PP

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21
Q

PE CV findings in preg

A

normal:

  • 3rd heart sound
  • flow murmurs
  • up/lateral heart displacement CXR

abnormal:

  • systolic murmur >2/4
  • chronic hypertension

expected but abnormal:
- decompensation of underlying CVD

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22
Q

respiratory changes in pregnancy

A
  • O2 demand +20-40%
  • tidal volume +40%
  • minute ventilation +30-50%
  • no change in RR
  • decreased functional residual capacity d/t shmooshing ~20%
  • less reserve but no change in VC
  • no change in FEV1

why?

  • progesterone is a respiratory stimulant
  • increased sensitivity of medulla to CO2
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23
Q

acid-base changes in pregnancy

A

normal:

  • mild respiratory alkalosis
  • hyperventilation –> hypOcapnia
  • facilitates CO2 fetus –> mom
  • partial compensation +bicarb

abnormal:

  • mild CO2 elevation PaCO2 >35 is respiratory failure
  • requires intubation at that point
  • e.g. acute asthma attack
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24
Q

renal changes in pregnancy

A

structure:

  • larger +1-1.5cm
  • dilated calyces and pelvis
  • dilated ureters
  • right > left d/t dextrorotation of uterus
  • persists 3-4 mo PP

fx:

  • flow +50-85%
  • GFR +50% all in 1st tri
  • vasodilation of pre and post glomerular vessels w/o change in pressure
  • fall in serum creatinine
  • saturation of glucose reabsorption –> glucosuria
  • no hematuria
  • protein loss <300mg/24 h
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25
Q

bladder changes in pregnancy

A
  • upward displacement
  • flattening
  • urinary frequency
  • mechanical + hormonal
  • increased bladder capacity by ~1 L
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26
Q

normal renal/urinary lab changes in preg

A
  • low serum Cr (threshold of suspicion for disease also lower)
  • more rapid drug ecertion
  • glycosuria
  • asymptomatic bacteriuria
  • – strep B can be problem during cb
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27
Q

GI changes in pregnancy

A

gastric reflux more likely

  • delayed gastric emptying
  • relaxation of lower esophageal sphincter
  • increase in gastric acid

constipation more likely
- slower transit

also

  • stomach displaced upward
  • increased mucus
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28
Q

gallbladder changes in pregnancy

A

stasis –> gallstones

  • progesterone inhibits contractions
  • decreased contractility = slow emptying
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29
Q

WBC changes in preg

A

pre-preg ~4500
preg ~5000-12000
labor ~20000-25000
predominant rise in PMNs

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30
Q

platelet and clotting changes in preg

A

VTE risk 6x

platelets

  • increased production
  • increased consumption
  • sometimes a fall in 3rd tri d/t increase in peripheral consumption

clotting factors

  • increase
  • fibrinogen, V, VIII, IX, X –> thrombin
  • d/t estrogen
  • decreased fibrinolysis, protein S activity

venous stasis and deep vein capacitance also increase VTE risk

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31
Q

skin changes pregnancy

A
  • +blood flow
  • +pigmentation
  • melasma
  • darker nevi (rapid changes –> excision)
  • less hair loss during preg
  • more hair loss pp, regrowth by 6-12 mo
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32
Q

breast changes pregnancy

A

early

  • tenderness
  • tingling
  • heavyness
  • enlargement d/t
  • – vascular engorgement
  • – estrogen –> ductal growth
  • – progesterone –> alveolar hypertrophy

later

  • enlargement and pigmentation of areollae
  • colostrum late in preg
  • milk production
  • – estrogen
  • – progesterone
  • – prolactin
  • – hPL
  • – cortisol
  • – insulin
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33
Q

lactation

A
  • drop in E and P pp
    • progesterone inhibits lactation
  • maternal prolactin decreases pp, but not as much as progesterone –> lactation
  • pulsatile prolactin d/t suckling –> milk

“let down”
- suckling –> oxytocin –> release by myoepithelial cells

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34
Q

thyroid changes in preg

A
  • increased
  • alpha hCG = TSH
  • thyroid enlargement d/t hyperplasia and vascularity
  • TBG (binding globulin) +2-3x d/t estrogen

clinically:

  • don’t check total T4 or T3, check ratio FT3/FT4
  • low TSH common in 1st tri
  • transient hyper-T4 in first tri
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35
Q

metabolism and nutritional requirement in preg

A
  • increased metabolic demands
  • 300-400 cal/day in 2nd and 3rd tri
  • protein recommendations increase
  • carb recommendations increase
  • no rec for fat d/t optimal not known
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36
Q

weight gain rec in preg

A

BMI <18.5

  • total +30-40 lb
  • 1-4 lb 1st tri
  • 1-1.5lb/wk 2nd and 3rd

BMI 18.5-24.9

  • total +25-35 lb
  • 1-4 lb 1st tri
  • 1lb/wk 2nd and 3rd

BMI 25-29.9

  • total +15-25 lb
  • 1-4 lb 1st tri
  • 0.5 lb/wk 2nd and 3rd

BMI ≥30

  • total +10-20 lb
  • 1-4 lb 1st tri
  • > 0.5 lb/wk therafter
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37
Q

miscarriage/spontaneous abortion vs. stillbirth

A

SAB <20wk or fetus <500g

stillbirth thereafter

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38
Q

G&P

A

gravida = number of pregnancies, including the current one

para = delivery after 20 wk, abortion prior to 20 wk, living children

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39
Q

SAB incidence

A

15-20%

80% of which <12 wk

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40
Q

categories of SAB

A
  • threatened
  • inevitable
  • complete
  • incomplete
  • missed
  • septic
  • anembryonic/blighted ovum
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41
Q

threatened SAB

A
  • bleeding
  • closed cervical os
  • no tissue passage
  • watch and wait
  • bedrest no longer indicated as no clinical benefit
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42
Q

inevitable SAB

A
  • bleeding or leaking fluids
  • dilated cervical os
  • imminent fetal loss
  • POC not yet passed
  • ± fever, pain
  • may require medical or surgical intervention
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43
Q

complete SAB

A
  • all POC (products of conception) expelled
  • hx of heavy vaginal bleeding
  • closed cervical os (b/c already closed again)
  • generally no further treatment or f/u needed
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44
Q

incomplete SAB

A
  • some POC expelled
  • bleeding, cramping
  • open cervical os
  • watch and wait
  • may need medical or surgical mgmt
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45
Q

missed SAB

A
  • POC retained after demise
  • asymptomatic
  • pt reports “not feeling pregnant”
  • closed cervical os
  • requires evacuation
46
Q

septic SAB

A
  • infection post-demise
  • d/t retained POC + ascending bacteria
  • possible sepsis
  • uterine evacuation + abx
47
Q

anembryonic preg/blighted ovum

A
  • embryo fails to develop
  • empty gestational sac, no fetal pole
  • similar presentation to missed or threatened ab (bleeding or asymptomatic, generally no pain, fever, cramping, heavy bleeding)
  • d/t aneuploidy (± chromosome)
48
Q

fetal risk fx for SAB

A

chromosomal abnormalities, usually aneuploidy (± chromosome) ~75% of 1st tri SA, ~50% overall

  • – trisomies ~50%, esp 16
  • – monosomy X ~18%
  • – polyploidy e.g. 69XXY

other fetal anomalies such as genetic mutations not compatible with life

49
Q

maternal risk fx for SAB

A
  • advanced maternal age >35
  • previous SAB
  • smoking, alcohol, cocaine
  • maternal chronic disease: diabetes, thyroid, PCOS, etc
  • immune disease e.g. APLS (antiphospholipid syndrome)
  • TORCH infections
  • listeria
  • fever
  • severely over or underweight
  • balanced translocation carrier
50
Q

SAB > fertility rate at ~ ___ y/o

A

40

SAB almost 100% >45 y/o

51
Q

uterine risk fx for SAB

A
  • congenital anomolies
  • septet uterus
  • fibroids
  • IUD
  • polyps
  • scarring
  • cervical insufficiency/incompetence
  • conization, LEEP, other cervical procedures (e.g. cancer or biopsy)
52
Q

other risk fx for SAB

A
  • amniocentesis
  • chorionic villi sampling
  • direct or indirect trauma
  • ovary removal
  • subchhorionic hematoma

NOT

  • stress
  • heavy lifting
  • sex
53
Q

workup for SAB

A
  • H&P
  • bleeding, pain, cramping
  • UPT
  • pelvic US
  • ± beta-hCG, CBC, Rh, blood type
54
Q

management/workup for preg of uncertain viability

A
  • suspect if slow growth, slow hr, large or abnormal sac
  • expectant management
  • trend beta-hCG - declining, plateau ~ abnormal preg
  • repeat US
  • serum progesterone <5 ng/ml
  • Rhogam blood type and Ab screen
  • CBC if heavy bleeding, infection
55
Q

management of confirmed SAB

A
  • expectant

retained POC:

  • medical - prostaglandin E1 (misoprostol)
  • – pretreatment w/ mifepristone improves evacuation success
  • D&C
  • vacuum aspiration

complications

  • hemorrhage
  • retained POC
  • infection
  • perforation
  • asherman syndrome post-D&C
56
Q

post-SAB management

A
  • counseling
  • future pregnancy planning

optional:

  • f/u beta-hCG
  • confirmatory US
57
Q

recurrent pregnancy loss

A

2-3+ SAB
3+ <1% incidence
~50% unknown cause

w/u:

  • thyroid
  • HbA1c
  • anti-phospholipid Ab
  • uterine assessment
  • parental karyotype

tx:

  • limited options w/o identifiable cause
  • possible role for IVF w/ selection of normal embryo
58
Q

APLS

A

antiphospholipid syndrome
- 1 clinical and 1 lab indication to make dx

sx:

  • VTE
  • preg morbidity
  • – 1+ loss >10wk
  • – preterm <34 wk d/t preeclampsia or IUGR
  • – recurrent loss

labs:

  • IgG or IgM anticardiolipin
  • +lupus anticoagulant
  • IgG or IgM beta-2 glycoprotein

tx:

  • heparin
  • ASA
59
Q

ectopic pregnancy

A
  • implantation outside endometrial cavity
    ~98% Fallopian tube

sx:

  • pelvic pain
  • vaginal bleeding
  • +UPT
  • high index of suspicion

w/u:

  • PE
  • transvaginal US
  • beta-hCG
  • (laparoscopy)

tx:
- expectant

  • methotrexate IF hemodynamically stable, asymptomatic, able to comply w/ follow up, no fetal cardiac activity, normal labs
  • – folic acid antagonist vs trophoblast
  • – nausea, vomiting, diarrhea, dizziness, stomatitis
  • – abd pain for a few days
  • surgery = definitive
  • – laparoscopy
  • – laparotomy
  • – linear salpingostomy or salpingectomy

risk fx:

  • IUD
  • previous ectopic
  • tubal damage, surgery
  • prior tubal infection
  • STI
  • assisted reproductive technology
  • smoking
60
Q

heteroectopic pregnancy

A

multiple pregnancy w/ 1+ extrauterine and 1+ intrauterine

increasing incidence d/t assisted repro

61
Q

molar pregnancy

A
  • placental tumor
  • premalignant

complete mole

  • no fetus
  • vesicles only
  • all paternal chromosomes
  • bleeding
  • size > expected by LMP
  • very high beta-hCG
  • hyperemesis, PEC, hypERthyroid, theca lutein cysts
  • 15-20% risk of neoplasia

partial mole:

  • some fetal tissue
  • triploid karyotype (69XXY, 69XXX, 69XYY)
  • <5% neoplasia risk
  • high bleeding risk
  • tx: D&C w/ aspiration, f/u weekly beta-hCG monitoring

risk fx:

  • prior GTD
  • age extremes
62
Q

3 “P’s” of normal labor

A

Power - uterine contractions
Passenger - fetus, position, umbilicus
Passage - maternal pelvis

63
Q

Braxton-hicks

A

sporadic uterine muscle activity
vs true, synchronized
>37 wk normal

assessment:

  • sterile vag exam for dilation and effacement
  • fetal heart tones, doppler or electronic monitoring
  • fetal presentation, hand or US
  • possible contraction monitoring
64
Q

cervical changes labor

A

dilation –> 10cm
effacement –> 100%, essentially flattening of cervix as it b//c dilated
station –> -5 to +5, location/orientation, 0 is ischial spine
pliancy

65
Q

fetal orientations

A

lie:

  • longitudinal (normal)
  • transverse
  • oblique

presentation

  • cephalic (normal)
  • breech (butt)
  • shoulder/arm

attitude

  • flexed
  • extended

position
- occiput, sacrum, mentum, A/P

66
Q

leopards maneuvers

A

manually turning fetus from abdomen

67
Q

pelvis shapes & fetal passage

A

gynecoid - most common, best for passage

may recommend C section:
platypoid - oval, L/R
android - heart
arthoropid - oval, A/P

68
Q

indications for L&D admission

A

synchronized contractions every 5 min >1h
fluid leak
bleeding
decreased fetal movements

69
Q

stages of labor

A
  1. dilation and effacement
    - - latent = less than 6 cm, hours to days
    - - active, more than 6 cm, acceleration, less variable, 1 cm every 1-2 h
  2. complete dilation
    - - active pushing
    - - minutes to 4h
    - - longer in nulliparous, epidural
  3. delivery, baby and placenta
    - - delayed cord clamping 30-60s after placing on mom’s chest
    - - active mgmt of placenta to minimize pp hemorrhage
    - — fundal massage, gentle traction, oxytocin
    - signs of placental detachment, hemorrhage risk: gush of blood, umbilical cord lengthening
    - placental delivery is up to 30 min
    - examine placenta for completeness (no POC), umbilical cord insertion (3 normal vessels), and membranes
  4. postpartum to 6 wk
70
Q

pain mgmt labor

A

stage 1
- visceral T10-L1

stage 2
- somatic S2-S4

options

  • IV morphine
  • inhaled nitrous
  • epidural ~60% - continuous injection of local anesthetic (usually bupivacaine) into epidural space
  • pudendal nerve block
71
Q

fetal monitoring labor

A

intermittent

  • handheld doppler
  • – every 30 min in stage 1, 15 stage 2 in uncomplicated
  • – every 15 in stage 1, 5 stage 2 in complicated

continuous

  • electronic fetal heart rate monitoring (EFM) ~85%
  • – controversial d/t unreliable assessment of fetal oxygenation, increased use of c-section, no significant change to cerebral palsy (d/t large confidence intervalbut does decrease neonatal seizures), and inter and intra-observer variability
  • – no RTC
  • – always indicated for high risk pregnancies i.e. preeclampsia, T1DM, IUGR
72
Q

operative vaginal delivery

A
  • vacuum assisted
  • forceps assisted

indications

  • prolonged phase II
  • FHR requiring expedited delivery
  • maternal benefit

requirements

  • ≥+2 station
  • ≥34 weeks
  • no maternal/fetal c/i

benefits

  • avoid cesarean
  • fetus already in canal

risks
- F/M trauma

73
Q

indications for primary cesarean

A
  • labor arrest
  • abnormal FHR
  • fetal malpresentation
  • multiple gestations
  • F/M risk
  • large fetal size
  • non-gynecoid pelvis or small pelvic outlet
  • maternal request
74
Q

prevention of primary cesarean

A
  • allow prolonged latent labor
  • allow prolonged active labor
  • allow prolonged pushing
  • use operative vaginal delivery
  • avoid excessive maternal weight gain
  • encourage labor support such as doulas
  • leopards maneuver (external cephalic version)
  • trial of labor w/ twins
75
Q

pre-op cesarean mgmt

A
  • counseling
  • consent
  • IV - labs and fluids
  • foley
  • mom vitals, fetal EFM
  • prep abx - 2 gm Ancef
  • anesthesia consult
76
Q

pp management

A
  • uterine size and maternal physiology returns to normal by 6 wks
  • > 50% maternal deaths are pp
  • suicide and self harm among leading causes
  • ongoing, not single encounter
77
Q

preterm birth causes

A 
<37wk
#1 cause fetal mortality

F/M stress

  • activation of HPA
  • physical stress, depression
  • fetal stress e.g. inadequate arterial supply

inflammation

  • infection of placental membranes OR general e.g. UTI, dental
  • autoimmune or inflammatory conditions

abruption
- d/t abnormal placentation in early pregnancy

uterine distension

  • multiple gestation
  • polyhydroamnosis (too much amniotic fluid)

cervical insufficiency
- short cervical length by TVUS is a strong indicator of preterm labor

78
Q

management of preterm labor

A

<34 wk

  • betamethasone (steroid) injection –> surfactant
  • tocolytic agent –> relaxes uterus, delays continuation of labor

<32 wk
- + mag sulfate to protect against seizures, cerebral palsy

hx of preterm labor
- progesterone supplementation throughout preg

general recommendations
- lifestyle changes, e.g. smoking, cocaine use

79
Q

when to initiate prenatal care

A

ideally preconception

  • risk assessment
  • control underlying disease
  • smoking cessation
  • prenatal vitamins/folic acid

definitely recommended in 1st tri (~60% ww)

no prenatal care ~1% in US, 5x mortality

80
Q

frequency prenatal care

A
  • 1x/mo through 28 weeks
  • 2x/mo 28-36 wek
  • weekly >36 wk
81
Q

h&p 1st prenatal visit

A
  • LMP
  • Gs&Ps, outcome specifics
  • PMHx
  • risk assessment: genetic disease, teratogens
  • EtOH, drugs, smoking
  • DV
  • STI hx
  • viral illness since LMP
  • religion/cultural considerations
  • allergies
  • complete physical exam
  • US - TV
82
Q

Gs&Ps

A 
G = gravitas # of current preg
P = parity, outcomes by TPAL
- term ≥37wk
- preterm 20-36w6d (36 weeks 6 days)
- abortion, intentional or spontaneous, <20wk
- living children at encounter

examples:

G1P0 = first pregnancy
G3P0020 = 3rd pregnancy, 2 prior SAB or AB
G6P3106 = 6th pregnancy, 4 term births, 1 preterm twin delivery
G2P0100 = 2nd pregnancy, 1 preterm delivery of a now-deceased child
may be abridged in certain settings (e.g. G3P2, G6P4, G2P1 in above examples) but OB will generally use full TPAL

83
Q

calc gestational age

A

fastest way - LMP -3 mo, +1y3d
e.g. LMP 3/3/22, EDD 12/31/22

  • <9wk US, adjust EDD if >5 days discordant from LMP
  • 9-14wk US, adjust EDD if >7 days discordant
  • 14+ wk dating by biometry
  • after 22 wk dating accuracy drops significantly
84
Q

genetic carrier screening

A
  • expanded vs targeted
  • minimum: CF carrier, SMA carrier
  • others if FHx, ethnicity risk fx
  • pt counseling
85
Q

aneuploidy screening

A

1st tri:

  • nuchal translucency
  • PAPP-A
  • hCG

2nd tri:

  • hCG
  • AFP
  • UE3
  • inhibin

T21 (Down’s)

  • PAPP-A, AFP, UE3 low
  • hCG, inhibin high

T18/T13
- all decreased

86
Q

information from CVS or amnio

A
  • karyotype
  • microarray
  • other studies
  • PCR for TORCH
  • (outdated) fetal lung maturity
87
Q

prenatal visits 1st tri

A
  • 1st visit: LMP, labs, diabetes screen
  • 9-10 wk - NIPT (maternal blood screen for certain genetic conditions), doppler
  • 11-14: CVS, nuchal translucency
  • 10-14 - 1st tri serum
  • teratogen avoidance
  • dietary counseling
  • – avoid unpasteurized dairy, unwashed raw produce, high mercury fish
  • toxoplasmosis avoidance
  • SAB signs/sx
  • symptoms and concerns
88
Q

prenatal visits 2nd tri

A
  • 15-20: MSAFP
  • 15+ wk: amnio
  • 18-22 wk: detailed US
  • 24-28 wk: gestational diabetes screen, CBC
  • symptoms and concerns
  • preterm labor/SAB signs/sx
  • fundal height
  • fetal movement
  • may begin to address birth plan, anesthesia, breastfeeding, future family planning etc but typically more in 3rd tri
89
Q

prenatal visits 3rd tri

A
  • 28 wk - Rhogam (if Rh-)
  • 27-36 wk - Tdap
  • flu - any
  • 3rd tri labs - CBC, RPR, HIV, GC/CT risk
  • 36-37w6d - group B strep
  • regular US
  • fundal height
  • fetal movement
  • birth plan
  • anesthesia plan
  • breastfeeding
  • family planning/pp bc
  • sterilization consent e.g. desired sterilization, hysterectomy in event of complications
  • circumcision
  • sx and concerns
90
Q

prenatal visits near dd

A
  • delivery timing
  • consider induction of labor
  • fetal surveillance
  • cesarean
91
Q

assess at every prenatal visit

A
  • bp
  • ±urine dip
  • FHR
  • weight
  • edema
  • labor complaints
  • ± cervical exam
  • sx and concerns

2nd tri on:

  • fundal height
  • fetal movement (could ask earlier but generally won’t be present until 2nd tri)
92
Q

cutoffs for htn and severe htn of preg

A

mild ≥140/90
severe≥160/110
(systolic, diastolic, or both)

93
Q

classes of htn in preg

A
  • chronic: <20 wk gestation
  • gestational: >20wk, mild (140-160)
  • preeclampsia: >20wk, mild w/ proteinuria >300
  • preeclampsia w/ severe features: >20wk, severe htn or any end-organ damage
  • eclampsia: preeclampsia w/ seizure
94
Q

preeclampsia etiology

A
  • shallow placental invasion
  • failure of spiral artery remodeling
  • decreased blood flow to fetus w/o reduction in CO
  • inflammatory protein release by hypoxic placenta –> vasoconstriction, endothelial dysfunction
  • endothelial dysfunction also results in salt retention by kidneys
95
Q

maternal endothelial cell d/t preeclampsia

A
  • vasospasm
  • capillary leak incl proteinuria and edema
  • hypercoag
96
Q

end organ damage d/t preeclampsia

A 
liver
renal
headache
seizure (tx w/ mag)
abruption, poor fetal growth
97
Q

tx for eclampsia

A

mag to reduce seizures and reduce contractions

immediate delivery

98
Q

consequences of severe preeclampsia

A
  • placental abruption
  • hemorrhagic stroke
  • HELLP ~10-20%
  • – hemolysis, elevated liver enzymes, low platelets
  • – d/t sheering of RBCs over thromocytic plaques
  • systemic, pulmonary, and cerebral edema
  • seizures caused by cerebral edema mark eclampsia
99
Q

postpartum hemorrhage defn and etiology

A

top reason for maternal mortality ww
>500 ml post vaginal, >1000 post-cesarean
internal bleeding signs: >10% change in Hct, hr, bp, o2 changes

4 T’s::

  • tone (atony)
  • trauma - uterine, cervical, vaginal, peroneal bleeding d/t childbirth trauma; tx: pressure + surgical repair
  • tissue - retained placental fragments e.g. placenta accreta, umbilical traction
  • thrombin - poor clotting d/t genetic disorder, eclampsia, abruption –> dic; tx underlying cause, administer platelets and coagulation factors

tx::
- specific to type
for all:
- IV fluids
- blood products

100
Q

uterine atony

A
  • primary cause of postpartum hemorrhage
  • soft, spongy, boggy uterus
  • slow, steady blood loss
  • little to no uterine contraction after birth = no self-clamping of uterine arteries
  • d/t uterine fatigue from prolonged labor, multiple births, multiparous, certain anesthetics, urinary retention

tx:

  • fundal massage
  • catheter (if d/t retention)
  • meds
  • surgery
101
Q

uterine hematoma

A
  • cause of delayed hemorrhage
  • can often go unnoticed
  • mass or collection of blood d/t trauma of childbirth
  • rupture

signs:

  • persistent bleeding
  • firm uterus
  • delayed bleeding
102
Q

maternal cardiac risk stratification

A

1- no mortality risk, no to mild morbidity risk
2- small mortality risk, moderate morbidity risk
3- significant risk of M&M, rq expert counseling
4- extreme risk, preg c/i, termination advised, continue as in 3 if continues

calculators:

  • mWHO
  • CARPREG II
  • ZAHARA for congenital
103
Q

preg termination risks in women w/ cardiac conditions

A

medical ab:

  • unpredictable bleeding, hemodynamic alteration
  • esp if mother on anticoags or prone to hemodynamic instability
  • monitor closely

surgical ab:
- perform in OR w/ skilled anesthesiologists

104
Q

contraception in cardiac conditions

A

risk level 3 and 4 mothers need good contraception so that preg, if desired, can be planned and cardiac conditions stabilized amap

estrogen not advised d/t alterations in coag profile, increased bp, fluid retention, potential prolonged QT (mostly in post-menopausal F)

progestin-only is preferred - *IUD best

  • – implant and injection have theoretic risk of hematoma in pt on anti-coags, definite c/i in pts on bosentan for pulm htn
  • – injection - use caution w/ A-fib, flutter, PHTN, MI
  • – pills, ring interferes w/ anticoag
  • – IUD lessens menses, less risk of excessive blood loss :)
  • – IUD use caution w/ severe htn, complex chd d/t vasovagal

copper implant not advised if on anti-coags d/t worsening of bleeding

105
Q

non-cardiac risk factors pregnancy

A
  • AMA ≥40 y/o
  • black (mainly structural)
  • pre-preg BMI ≥35
  • pre-preg diabetes
  • htn
  • substances
  • hx chemo
106
Q

WHO class 4 cardiac risk conditions

A
  • PAH
  • EF <30%
  • RV failure
  • severe mitral stenosis
  • severe symptomatic aortic stenosis
  • severe aortic dilation
  • vascular ehlers-danlos (other EDS types including hypermobile generally do not carry much risk)
  • severe recoarctation
  • complicated Fontan (surgical procedure rerouting blood to lungs)
107
Q

breast development

A
  • starts w/ proliferation of fat and glands @ puberty
  • glands not fully developed until pregnancy
  • delivery: ducts –> buds and alveoli; proliferation declines
  • breastfeeding: alveolar hypertrophy, accumulation of secretory products
108
Q

stages of lactogenesis

A

stage 1

  • colostrum
  • 16+ weeks pregnant, through pp day 3
  • high IgA, lymphocytes, plasma cells
  • poor nutritional content

stage 2

  • day ~3-10 pp
  • secretory activation
  • increased lactose
  • decreased lytes (Na+, Cl-, Mg++)

stage 3

  • mature
  • day 10+ pp through end of feeding

stage 4

  • breast involution following end of feeding
  • decreased milk production
  • apoptosis of milk-producing cells
109
Q

hypERprolactinemia

A
  • amenorrhea
  • infertility
  • osteoporosis
  • sx d/t GnRH inhibition

causes

  • prolactinoma = benign posterior pituitary tumor
  • dopamine inhibitors
110
Q

hormonal components in breastfeeding

A

during preg

  • high inhibitory estrogen, progesterone
  • high prolactin, but not sufficient to overcome inhibition

after placental delivery

  • diminished progesterone and estrogen
  • high prolactin –> milk production

suckling

  • prolactin release d/t neural reflex w/ nipple stim –> milk production
  • oxytocin release d/t seeing baby, baby crying, other nursing stimulation –> smooth muscle contraction in breast alveoli –> let-down

SFM5 (14 decks)

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