Week 3: Complicated pregnancies

Question 1

Placenta Previa

Answer 1

• complete previa: placenta completely covers internal os
• partial previa: portion of placenta covers os
• low lying placenta: implants in lower uterine segment close in proximity but not extending to the internal os
• presentation: 0.5% of deliveries, bright red bleeding ~27-32 weeks, painless
• findings: vaginal hemorrhage, hypotension, tachycardia, soft, non tender uterus. Don’t do vaginal/cervical exam, may cause bleeding
• risks: prior uterine surgery, prior placenta previa, multiparity, adv. maternal age, multiple gestation, smoking

Question 2

Placenta accreta/increta/percreta

Answer 2

• accreta: placenta attaches too deep in uterine wall but doesn’t penetrate myometrium. Most common.
• increta: penetrates myometrium
• percreta: penetrates through uterine wall and may attach to other organs
• risks: increases with hx of Cesarean births, placenta previa
• rx: cesarean hysterectomy

Question 3

Placental abruption

Answer 3

• premature separation of normal implanted placenta from uterine wall, resulting in hemorrhage between the uterine wall and placenta
• 0.5-1% of pregnancies, 15% fetal mortality
• risks: HTN, prior hx of abruption, adv. maternal age, smoking, cocaine, trauma, fibroids, preterm premature rupture of membranes
• presentation: may or may not have bleeding, uterine tenderness, hypotension, tachy, fetal distress, may lead to shock, DIC, fetal death

Question 4

Preeclampsia

Answer 4

• Dx: HTN, proteinuria, after 20 weeks of pregnancy
• cause: uncertain, assoc. with generalized arteriolar constriction and edema
• maternal complications: seizures, cerebral edema or hemorrhage, thrombocytopenia, renal failure, hepatic rupture
• fetal complications: oligohydramnios, intrauterine growth restriction, stillbirth, placental abruption, fetal distress, premature delivery

Question 5

Degrees of preeclampsia

Answer 5

1. Preeclampsia (previously “mild preeclampsia”)
   - BP ≥ 140/90
   - 300 mg of urine protein on 24 hour urine collection or protein/Cr ratio ≥ 0.3 mg/dL
2. Preeclampsia with severe features
   - BP ≥ 160/110 (on 2 occasions, 4 hours apart)
   - Any of the following: headache, visual changes, RUQ or epigastric pain, elevated liver enzymes (2x normal), pulmonary edema, renal failure (Cr >1.1, or 2x baseline), thrombocytopenia (<100K)

Question 6

Rx for preeclampsia

Answer 6

• magnesium sulfate for seizure prophylaxis

- delivery is ultimate treatment: 34 weeks for severe or 37 weeks for without severe features

Question 7

Diabetes during pregnancy

Answer 7

• 3-10% of pregnancies
  1. Gestational (90%)
• increased placental steroids and peptide hormones rise throughout pregnancy: promotes insulin resistance and leads to increased maternal glucose levels, fetal hyperglycemia, and fetal hyperinsulinemia
• risk: family hx of DM, obesity, sedentary lifestyle, hispanic, asians, hx of GDM, previous large baby, excessive weight gain in pregnancy
  2. Complications
• polyhydramnios, preeclamsia, miscarriage, infection, fetal congenital anomalies, unexplained fetal death, neonatal resp. distress, IUGR, macrosomnia (shoulder dystocia, brachial plexus injury)

Question 8

Rx of diabetes during exercise

Answer 8

• preconception counseling and glucose control
• exercise and diet
• insulin
• for large fetuses, Cesarian delivery should be offered

Question 9

Post partum hemorrhage

Answer 9

Definition: > 500 mL of blood after vaginal delivery. >100 mL after Cesarean section
-causes: uterine atony, retained placenta, cervical/vaginal lacerations, uterine inversion, coagulopathy

Question 10

Postpartum depression

Answer 10

• 10-15%
• low energy level, anorexia, insomnia, hyper somnolence, extreme sadness, lasts more than a few weeks, sometimes suicidal homicidal ideations
• Rx: supportive for blues. SSRI, support for depression.

Question 11

premature delivery

Answer 11

• delivery before 37 weeks gestation
• 12% of pregnancies in US
• risks: premature rupture of membranes, infection, multiple gestations, uterine anomalies, prior preterm birth, abruption, preeclampsia, low socioeconomic status, cervical insufficiency
• Rx: tocolysis (Mg sulfate, Nifedipine, indomethacin, terbutaline), corticosteroids to help prevent problems of prematurity in fetus

Question 12

Post term delivery

Answer 12

• after 42 weeks
• increased risk of complications: macrosomia, oligohydramnios, meconium aspiration, intrauterine fetal demise
• postmaturity syndrome: dry, peeling loose skin, long finger and toenails, appears emaciated, prone to hypoglycemia