Complicated Pregnancy - Clin Med

What does this refer to

• before birth; during or relating to pregnancy

Prenatal/antenatal

What does this refer to

• relating to the time, usually a number of weeks, immediately before and after birth

Perinatal/peripartum

What does this refer to

• of, relating to, characteristic of, or denoting the period after childbirth

Postnatal

What does this refer to

• Usually refers to the 6 weeks following birth

Postpartum

What does this refer to

• Infants born very early are not considered to be viable until after 24 weeks gestation.

Viable pregnancy

What does this refer to

• Transient increases in FHR

Fetal accelerations

What does this refer to

• Temporary, but distinct, decreases in FHR

Fetal decelerations

What position is the fetus facing

• toward the woman's back— face down when the woman lies on her back

Rearward

What position is the fetus facing

• Face up

Forward

What does this refer to

• _______ refers to the part of the fetus's body that leads the way out through the birth canal (called the presenting part).

Presentation

What does this refer to

• Single egg cell is fertilized by a single sperm cell = zygote

• Zygote splits into two = 2 separate embryos

• Same gender

• Most cases are not caused by genetic factors

• Share the exact same DNA

Monozygotic (MZ) twins (identical twins)

What does this refer to

• 2 egg cells are each fertilized by a different sperm cell in the same menstrual cycle

• twice as common as MZ twins

• More likely to “run in families”

  • Genetic component is hyperovulation

• Other influences

  • Mother’s age

  • Ethnic background

  • Diet

  • Body composition

  • Number of other children

Dizygotic (DZ) twins (fraternal twins)

What does this refer to

• The average length of a pregnancy for triplets is 32 weeks.

• For quadruplets, the average length is 30 weeks.

• Continuing a multiple pregnancy past 36 weeks can be risky for you and your babies.

Multiple gestation

What does this refer to

• Sign that the baby is not doing well

• Baby isn't receiving enough O2 through the placenta.

• Untreated —> baby breathing in amniotic fluid containing meconium (poo)

• In utero

  • Decreased fetal movement

  • Decreased fetal heart rate

• During labor

  • Tachycardia

  • Bradycardia

  • Variable decelerations

  • Late decelerations

Non-reassuring fetal status (NRFS)

What does this refer to

• Biophysical profile

  • Type of US

    • Assesses

      • Fetal movement

      • Detal tone

      • Fetal breathing

      • Amniotic fluid volume

• Non-stress test

• Contraction stress test

NRFS detected prior to labor

What does this refer to

Fetal monitoring in labor

What does this refer to

• Monitor identifies periods of fetal stress

  • Throughout the contraction

  • Recovering in the break periods

  • Only at the end of the contraction

  • Both during and after contractions

Fetal monitoring

What does this refer to

• Unborn baby's umbilical cord slips through the cervix and into the vagina after a mother's water breaks and before the baby descends into the birth canal.

• During delivery, the prolapsed cord can become compressed by baby's body.

Cord Prolapse

What does this refer to

• both of the baby's knees are bent and the feet and bottom are closest to the birth canal.

Complete breech

What does this refer to

• one of the baby's knees is bent and the foot and bottom are closest to the birth canal.

Incomplete breech

What does this refer to

• the baby's legs are folded flat up against the head and his bottom is closest to the birth canal.

Frank breech

What does this refer to

• where one or both feet are presenting.

Footling breech

What does this refer to

• Surgical procedure by which one or more babies are delivered through an incision in the mother's abdomen

(Cesarean section) C-section

What does this refer to

• The most common indications (in order of frequency)

  • Labor dystocia

  • Abnormal or indeterminate (formerly, non-reassuring) fetal heart rate tracing

  • Fetal malpresentation

  • Multiple gestation

  • Suspected fetal macrosomia

• Distress in the mother is also a consideration of vaginal v c-section delivery

C-section

What does this refer to

• Also called a cervical insufficiency

• Occurs when weak cervical tissue causes or contributes to premature birth or the loss of an otherwise healthy pregnancy

Incompetent cervix

What does this refer to

• Difficult birth

• Caused by

  • Large or awkwardly positioned fetus

  • Smallness of the maternal pelvis

  • Failure of the uterus and cervix to contract and expand normally

Dystocia

What does this refer to

• A 25-year-old primigravida is pregnant with twins at 11 weeks of gestation.

• She is experiencing daily nausea and vomiting of moderate intensity that is worse in the morning.

• She has tried nonpharmacologic therapies with limited success.

• She has also tried drinking and eating small amounts at a time and staying away from odors that make her feel nauseous.

• Labs reveal a hypochloremic metabolic alkalosis.

Hyperemesis gravidarum

What does this refer to

• Beyond morning sickness

• Nausea AND vomiting that

  • Can lead to dehydration

  • Can result in poor weight gain

• Possible maternal and fetal risks

Hyperemesis Gravidarum

What does this refer to

• Some degree of nausea without vomiting in 90% of pregnancies

• MC in western countries and urban areas

• Slightly MC in younger, primigravid women

• Less common in American Indians and Eskimos

• Decreased risks with older gestational age

EpidemiologyHyperemesis Gravidarum

What does this refer to

• Elevated serum concentrations of estrogen and progesterone

• Genetic and familial etiology

EtiologyHyperemesis Gravidarum

What does this refer to

• Physical exam

  • Weight loss

  • >5% of pre-pregnancy weight

• Signs of dehydration

  • Orthostatic hypotension

  • Tachycardia

  • Delayed capillary refill time

  • Dry mucous membranes

  • Decreased skin turgor

Physical examHyperemesis Gravidarum

What does this refer to

Differential diagnosis for Hyperemesis Gravidarum

What does this refer to

• CBC w/ diff

  • ↑ H/H

• CMP

• UA

  • High specific gravity (dehydration)

• Ketonuria/+ serum ketones

• +/- hypotension

  • 2° hypovolemia

WorkupHyperemesis Gravidarum

What does this refer to

• Behavioral

  • Lifestyle modifications

  • Eat small meals/snacks often

    • Eat as soon as hungry or even before feeling hungry

    • Aim for high protein/carbohydrate foods that are low in fat

• Avoid spicy, greasy, or acidic foods

• Drink cold, clear beverages and drink between meals rather than during meals

• Avoid lying down right after eating

• Medical

  • IVF for hypovolemia/dehydration

  • Up to 2L lactated ringers over 3-5 hours

Clinical interventionHyperemesis Gravidarum

What does this refer to

• Doxylamine-pyridoxine 1st line (H1 antagonist)

• Dimenhydrinate, Meclizine, Diphenhydramine

  • if doxylamine-pyridoxine ineffective

• Acid reducing agents

  • Antacids containing aluminum of calcium

Clinical pharmacotherapeuticsHyperemesis Gravidarum

What does this refer to

• Most cases resolve by end of 1st trimester

• Some persist up to 22 weeks and even up to delivery

• Low pregnancy weight gain

  • Neonate small for gestational age

  • Preterm delivery

  • 5-minute APGAR < 7

PrognosisHyperemesis Gravidarum

What does this refer to

• A 24-year-old woman presents to the emergency room with 6 hours of severe left lower quadrant abdominal pain and some moderate vaginal bleeding.

• She is sexually active with 1 male partner and uses condoms occasionally.

• She has a history of pelvic inflammatory disease.

• Her last period was 7 weeks ago.

• A transvaginal ultrasound is performed and shows a mass in the left adnexa.

Ectopic Pregnancy

What does this refer to

• Allows the conceptus to implant and mature outside the endometrial cavity

• Results in death of the fetus

Ectopic Pregnancy

What does this refer to

• 1-2 % of all pregnancies

  • 1/40 pregnancies

• 85-90% occur in multigravida women

• In U.S. more common in all races other than Caucasians

EpidemiologyEctopic Pregnancy

What does this refer to

• Implantation of the ovum outside of the uterine cavity

• Fallopian tube MC location

• Risk Factors

  • Previous ectopic greatest risk factor*

  • Hx of PID

  • IUD use

  • Previous abdominal or tubal surgery

  • Hx of tubal ligation

  • Advanced maternal age

EtiologyEctopic Pregnancy

What does this refer to

• Classic triad

  • Amenorrhea followed by

  • Pain —> Unilateral pelvic/ Lower abdominal pain

  • Vaginal bleeding

Clinical historyEctopic Pregnancy

What does this refer to

• Lower abdominal pain on palpation

• Pelvic Exam

  • Adnexal mass

    • May or may not be palpable

  • Cervical motion tenderness

• If ruptured

  • May have heavy vaginal bleeding

Clinical presentationEctopic Pregnancy

What does this refer to

• Severe abd pain

• Left shoulder pain (Kehr sign)

• Dizziness

• N/V

• Acute abd signs

• Signs of shock

• 4 symptoms independently contributed to the diagnosis of tubal rupture

  • Diffuse abdominal pain

  • Vomiting during pain

  • Flashing pain

  • Pain > 30 mins

Clinical historyRuptured Ectopic Pregnancy

What does this refer to

• Ruptured ovarian cyst

• Appendicitis

• Spontaneous or threatened abortion

• Ovarian torsion

• Salpingitis

• Urinary tract

Differential diagnosisEctopic Pregnancy

What does this refer to

WorkupEctopic Pregnancy

What does this refer to

• Methotrexate Indications

  • Early gestation

  • Gestational sac < 4cm

  • B-HCG < 5000

  • No FHT

• Compliant F/U (serial B-hCG )

• Must be immunocompetent

• Alternative tx

  • Laparoscopic salpingostomy if patient does not meet criteria for medical management OR

  • Salpingectomy

• Rhogam if Rh negative

Treatment Stable Unruptured Ectopic Pregnancy

What does this refer to

• IVF

• Laparoscopic Salpingectomy —> rupture

• May need procedure to repair reproductive organs

• Rhogam if Rh Neg

TreatmentRuptured Ectopic Pregnancy (Unstable)

What does this refer to

• Recurrent ectopic pregnancy (15%)

• Infertility (11-62%)

• Death (31/100,00)

  • Usually due to severe hemorrhage from intraperitoneal bleeding

Complications/prognosisEctopic Pregnancy

What does this refer to

Workup – imagingIntrauterine vs Ectopic Pregnancy

What does this refer to

• Intentional termination of pregnancy

• In 1973 Roe v Wade – Supreme court ruled in favor of an unwed pregnant woman who sought and was denied an abortion. It was determined that this was unconstitutional.

• In 2022 Roe v Wade was overturned by the Supreme court

  • This decision dismantled 50 years of legal protection and paved the way for individual states to curtail or outright ban abortion rights.

Induced Abortion

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