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ANTEPARTUM lectures: SAB & PreEclampsia > SAB & Pre-Eclampsia > Flashcards

SAB & Pre-Eclampsia Flashcards

1
Q

first trimester bleeding etiology

A

often unknown

goal –> exclusion

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2
Q

differential diagnosis for FIRST TRIMESTER bleeding

A
  1. SAB
  2. Ectopic pregnancy
  3. Hydatidiform mole
  4. Normal/other
  5. Subchorionic hemorrhage
  6. Trauma
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3
Q

Normal Etiologies of FIRST TRIMESTER bleeding

A
  1. Polyps
  2. cervivitis
  3. vaginal infection
  4. STI
  5. implantation spotting
  6. increased vascularization of the cervix in pregnancy= increased friability
  7. post-coital spotting due to increase friability
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4
Q

implantation spotting

A

which is most often scant, 7-11 days after conception, lasting only a day or two; minority of pregnant women have this kind of spotting

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5
Q

how would you evaluate when first trimester bleeding present

A

History: severity, amount, associated s &sx, pain , and cramping
Past history: previous ectopic, prior SABs, medical disorders, risk factors, fibroids/

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6
Q

physical examination of first trimester bleeding

A

vital signs
abdominal exam (pain, FHTs)
SPECULUM EXAM- observe internal and external
bimanual exam: CMT, adnexal masses, uterine enlargement.

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7
Q

spontaneous abortion (SAB)

A

most common early pregnancy complication
80% are in the 1st 12th week of gestation
incidence varies 25-30% of all conceptions
Chromosomal errors most common reason

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8
Q

SAB risk factors

A

smoking
alcohol
immune factors (recurrent loss)
inherited blood dyscrasias (recurrent loss)
excessive caffeine >500mg daily
environmental exposures : pesticides arsenic, lead, formaldehyde, benzene.

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9
Q

threatened SAB

A

closed cervix, uterus appropriated sized

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10
Q

inevitable SAB

A

cervix dilated, increased bleeding with cramps, ctx, products of conception can be at os

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11
Q

completed SAB

A

small contracted uterus, open cervix, scant bleeding/cramping

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12
Q

incomplete SAB

A

placental tissue remaining, cervix open, POC can be at the os, uterus smaller than expected for gestational but not well contracted, variable bleeding/ cramping

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13
Q

missed SAB

A

in utero death of embryo prior to 20th week with retention of pregnancy for prolonged period of time. Cervix closed. +/- bleeding.

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14
Q

diagnosis SAB

A

Ultrasound KEY
may see abnormal yolk sac, slow or absent FHT, hematoma

Serial b-hCG adjunct to determine viability

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15
Q

serial b-hCG

A

adjunct to determine viability
double every 2-3 days
max levels at 8-10 weeks, then decline
serial measures.

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16
Q

management of SAB

A

type and screen

give Rhogam if Rh negative

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17
Q

management of threatened AB

A

expectant management if no infection present

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18
Q

inevitable & complete AB

A 
per MD (consult & referral) 
can be expectant or D&C
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19
Q

ectopic pregnancy

A

approximately 2% of pregnancies (or 20/1000)
increasing incidence
clinical manifestation commonly between 6-8 weeks, can occur later
many women asymptomatic when you see them.

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20
Q

ectopic pregnancy risk factors (HIGH)

A

tubal ligation
tubal pathology/surgery
prior ectopic
IUD- esp. mirena

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21
Q

ectopic pregnancy risk factors (moderate)

A

infertility
assisted reproduction technology
prior hx of genital tract infection (Chlamydia, GC, salpingitis)
multiple sex partner (secondary to increase risk for PID)
smoking (dose dependent)
african american

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22
Q

ectopic pregnancy risk factors( lower )

A

prior cesarean

douching

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23
Q

signs &symptoms of ectopic pregnancy

A

abdominal pain
amenorrhea - positive pregnancy test
bleeding (profuse if cervical pregnancy)

many women no symptoms
may have breast tenderness, nausea, other pregnancy signs.
signs of rupture : shoulder pain (blood irritating diaphragm)
Urge to defecate (blood pooling in the cul de sac)

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24
Q

evaluation of ectopic pregnancy

A

pregnancy test on all reproductive aged women with abdominal pain
pelvic exam for adnexal mass
assess cervical motion tenderness ( sometimes your first clue on routine 1st visit exam)

ultrasound - may or may not see extrauterine sac
serial B-hCG - may see slower rise, may be normal.

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25
management of ectopic pregnancy
refer surgery for rupture or failed medical therapy METHOTREXATE therapy: unrupture hcG < 500 !
26
Gestational trophoblastic disease
``` made up of interrelated lesions from trophoblastic epithelium of placenta Hydatidiform mole (80%) gestational trophoblastic neoplasia (GTN) ```
27
hydatidiform mole
complete - no fetal tissue- high incidence of becoming malignant partial-some fetal tissue
28
gestational trophoblastic neoplasia
invasive mole, choriocarcinoma characterized by persistent B-hCG, no tissue. incidence: 1-2/1000 pregnancies
29
gestational trophoblastic neoplasia risk factors
teens and age >35 prior molar pregnancy oral contraceptive use smoking
30
gestational trophoblastic neoplasia clinical manifestation
marked NAUSEA & VOMITING of pregnancy increase uterine size bleeding - occasional spotting to heavy bleeding.
31
diagnosis gestational trophoblastic neoplasia
USN | B-hCG ** may see abnormally high level, SLOWER rise
32
Management of gestational trophoblastic neoplasia
D & C hysterectomy post evacuation surveillance.
33
subchorionic hemorrhage
bleeding r/t separation of chorion from uterine lining see on USN outcomes usually good
34
midwifery care for FIRST TRIMESTER pregnancy
feeling of loss & grief, often more than women expect emotional healing takes longer than physical healing loss of future plans, dreams, and hope sensitive, caring language reassurance about what does not cause early loss to reduce blame
35
causes of late pregnancy bleeding
``` placenta previa abruption rupture vasa previa uterine scar dehiscence cervical polyp bloody show preterm labor/labor cervicitis or cervical ectropion vaginal trauma cervical cancer STIs ```
36
Placenta Previa
1/300 at 16-20 weeks gestations, low liine placenta is seen in 50% of the women, however 90% of those will be normal implantation by 30 weeks gestation. therefore, reassure women during normal ultrasound.
37
risk factors for placenta previa
``` maternal age >35 multiparity of 5 or greater smoking unexplained MSAFP frequent D & Cs Previous C/S Previous placenta previa ```
38
potential problem from placenta previa
Cesarean section preterm birth Third stage issues: placenta accreta, hemorrhage, hysterectomy
39
signs & symptoms of placenta previa
BRIGHT red PAINLESS BLEEDING often is intermittent may occur with : intercourse, vaginal exam, cervical dilation & no preceding event.
40
midwifery management of placenta previa
consider STERILE SPECULUM exam as a first line assessment no vaginal exam confirmation by ultrasound delivery by C/S for most
41
midwifery management for woman is stable & preterm
``` consult/collaborate bed rest or modified activity outpatient monitoring pad counts abstinence, nothing in vagina education & support ```
42
placenta abruption
partial separation or all of the placenta from the uterine wall. secondary to clot or hematoma . size of clot or hematoma determine the extend of seperation
43
prevalence & risk factors of placental abruption
1/200 a severe abruption leading to fetal death occurs in 1/830 hypertensive disorder cigarette smoking scar tissue abdominal trauma: blunt force cocaine use (vasocontriction) previous placental abruption advance maternal age and less than 20 years of age. poor nutritional status chorionitist hx thrombofibrin any that decrease the uterine volume such as rupture placental membrane elevated maternal placental protein which is associated with increase abruption
44
history : placental abruption
``` onset duration & severity color amount characteristic of discharge any precipitory event? any contraction? describe abdominal pain or not at all recent examination or intercourse trauma ? gestational age? when is the last ultrasound done ? gravid para blood type risk factors: multiparity, age greater than 35, previous placeta previa, uterine scar, multiple pregnancy ```
45
physical examination of placenta abruption
vital sign pain FHT abdominal exam --hard board like speculum exam: visualize dilation, check for erosion, polyps, STI ? bimanual exam to check for : dilation, effacement, station, presenting part, status of membrane
46
potential problems with placental abruption
``` hemorrhage shock coagulopathies/DIC hysterectomy stillbirth hypoxia preterm delivery fetal death ```
47
signs & symptoms of ABRUPTION
``` PAIN (hallmark symptom) - mild to severe bleeding -may or may not (conceal? ) backache- posterior abruption ? contractions may report decreased fetal movement ```
48
frequency of symptoms with abruption
vaginal bleeding : 80% Abdominal or back pain and uterine tenderness: 70 % fetal distress: 60% abnormal uterine contractions (hypertonic, high frequencty): 35% idiopathic premature labor: 25%
49
complications associated with placental abruption --FETAL
growth restriction (chronic abruption) preterm birth and associated morbidity perinatal mortality fetal hypoxemia or asphyxia
50
complications associated with placental abruption- MATERNAL
``` Hypovolumia (secondary to blood loss) blood transfusion DIC cesarean section renal failure ARDS multisystem organ failure death ```
51
midwifery management for placental abruption
call for USN call for consultant NST Labs per consultant: CBC PTT fibrinogen BUN type & Rh
52
emergency management of placental abruption
mask O2 at 10L/min assess uterine tone, any relaxation, contractions pain monitoring and management-dont want to mask pain that may be diagnostic IV fluids-volum support, replacement and venous assess foley cath-output monitoring, expect decreased amount, increased concentration
53
pathophysiology of preeclampsia
increase BP is most common presentation, pathologic process starts well before maternal signs & symptoms Pathologic process originated with placental development, early in 1st trimester characterized by widespread maternal endothelial cell dysfunction result in mild-severe microangiopathy of target organs such as brain, liver, kidney, placenta
54
causes preeclampsia
placental or maternal response to placenta development - -> SHALLOW PLACENTATION: invasion of fetal trophoblasts into the maternal spiral arteries incomplete - -> this causes the SPIRAL ARTERIES to REMAIN SMALLER, FIRM and RESISTANT, instead of remodeling to relaxed and less resistant (pseudovascularization)
55
why pseudovascularization is incomplete
genetic factors immunologic factors early hypoxic episode to differentiating cells
56
causes of late pregnancy bleeding
``` placenta previa abruption rupture vasa previa uterine scar dehiscence cervical polyp bloody show preterm labor/labor cervicitis or cervical ectropion vaginal trauma cervical cancer STIs ```
57
Placenta Previa
1/300 at 16-20 weeks gestations, low liine placenta is seen in 50% of the women, however 90% of those will be normal implantation by 30 weeks gestation. therefore, reassure women during normal ultrasound.
58
risk factors for placenta previa
``` maternal age >35 multiparity of 5 or greater smoking unexplained MSAFP frequent D & Cs Previous C/S Previous placenta previa ```
59
potential problem from placenta previa
Cesarean section preterm birth Third stage issues: placenta accreta, hemorrhage, hysterectomy
60
signs & symptoms of placenta previa
BRIGHT red PAINLESS BLEEDING often is intermittent may occur with : intercourse, vaginal exam, cervical dilation & no preceding event.
61
midwifery management of placenta previa
consider STERILE SPECULUM exam as a first line assessment no vaginal exam confirmation by ultrasound delivery by C/S for most
62
midwifery management for woman is stable & preterm
``` consult/collaborate bed rest or modified activity outpatient monitoring pad counts abstinence, nothing in vagina education & support ```
63
placenta abruption
partial separation or all of the placenta from the uterine wall. secondary to clot or hematoma . size of clot or hematoma determine the extend of seperation
64
prevalence & risk factors of placental abruption
1/200 a severe abruption leading to fetal death occurs in 1/830 hypertensive disorder cigarette smoking scar tissue abdominal trauma: blunt force cocaine use (vasocontriction) previous placental abruption advance maternal age and less than 20 years of age. poor nutritional status chorionitist hx thrombofibrin any that decrease the uterine volume such as rupture placental membrane elevated maternal placental protein which is associated with increase abruption
65
history : placental abruption
``` onset duration & severity color amount characteristic of discharge any precipitory event? any contraction? describe abdominal pain or not at all recent examination or intercourse trauma ? gestational age? when is the last ultrasound done ? gravid para blood type risk factors: multiparity, age greater than 35, previous placeta previa, uterine scar, multiple pregnancy ```
66
physical examination of placenta abruption
vital sign pain FHT abdominal exam --hard board like speculum exam: visualize dilation, check for erosion, polyps, STI ? bimanual exam to check for : dilation, effacement, station, presenting part, status of membrane
67
potential problems with placental abruption
``` hemorrhage shock coagulopathies/DIC hysterectomy stillbirth hypoxia preterm delivery fetal death ```
68
signs & symptoms of ABRUPTION
``` PAIN (hallmark symptom) - mild to severe bleeding -may or may not (conceal? ) backache- posterior abruption ? contractions may report decreased fetal movement ```
69
frequency of symptoms with abruption
vaginal bleeding : 80% Abdominal or back pain and uterine tenderness: 70 % fetal distress: 60% abnormal uterine contractions (hypertonic, high frequencty): 35% idiopathic premature labor: 25%
70
complications associated with placental abruption --FETAL
growth restriction (chronic abruption) preterm birth and associated morbidity perinatal mortality fetal hypoxemia or asphyxia
71
complications associated with placental abruption- MATERNAL
``` Hypovolumia (secondary to blood loss) blood transfusion DIC cesarean section renal failure ARDS multisystem organ failure death ```
72
midwifery management for placental abruption
call for USN call for consultant NST Labs per consultant: CBC PTT fibrinogen BUN type & Rh
73
emergency management of placental abruption
mask O2 at 10L/min assess uterine tone, any relaxation, contractions pain monitoring and management-dont want to mask pain that may be diagnostic IV fluids-volum support, replacement and venous assess foley cath-output monitoring, expect decreased amount, increased concentration
74
pathophysiology of preeclampsia
increase BP is most common presentation, pathologic process starts well before maternal signs & symptoms Pathologic process originated with placental development, early in 1st trimester characterized by widespread maternal endothelial cell dysfunction result in mild-severe microangiopathy of target organs such as brain, liver, kidney, placenta
75
causes preeclampsia
placental or maternal response to placenta development - -> SHALLOW PLACENTATION: invasion of fetal trophoblasts into the maternal spiral arteries incomplete - -> this causes the SPIRAL ARTERIES to REMAIN SMALLER, FIRM and RESISTANT, instead of remodeling to relaxed and less resistant (pseudovascularization)
76
why pseudovascularization is incomplete
genetic factors immunologic factors early hypoxic episode to differentiating cells
77
inflammation and preeclampsia
maternal infection like UTI, periodontal disease, chlamydia, etc, are associated with increased rates of preeclampsia
78
endothelial dysfunction
endothelium regulates vascular elasticity, permeability and coagulation cascade
79
increase insulin resistance
linked to pathophysiology of preeclampsia - characterized by microvascular dysfunction - may be primary pathway for adverse fetal effects- like FGR- in severe preeclampsia - check this out for a deeper understating of relationship
80
how preeclampsia lead to high blood pressure
increased vascular resistance --> decrease cardiac output--> widespread vasoconstriction--> increase BP
81
Maternal effects from preeclampsia
kidney - capillary edema, glomerular cell dysfunction CNA- vasospasm= headaches, visual changes liver- fibrin deposits Blood- hemoconcentration - thrombocytopenia uterus- underperfusion, utero-placental insufficiency.
82
Fetal effects from preeclampsia
decreased utero-placental blood flow may cause: - placental infarctions - oligohydramnios - placental abruption - fetal growth restriction - non-reassuring fetal status

ANTEPARTUM lectures: SAB & PreEclampsia (1 decks)

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