Women's Health: Prenatal Care / Pregnancy (Complications)

Abortion

A pregnancy that ends before 20 weeks gestation, with almost 80% occurring before 12 weeks

-MCC is chromosomal abnormalities

-Presentation: crampy abdominal pain and vaginal bleeding

-Dx: US, CBC, blood type and screen, serial b-hCG titers, progesterone levels

Septate Uterus, Factor V Leiden, Antiphospholipid syndrome

What maternal congenital abnormality, thrombophilia, and endocrine disorder are linked most commonly to abortion?

Threatened

What type of abortion is being described?

-Products of conception intact, cervical os is closed

-Tx: supportive observation at home, rest, watch beta-hCG

Inevitable

What type of abortion is being described?

-Products of conception intact, cervical os is open

-Tx: surgical evacuation (<16 weeks gets D&C), D&E if > 16 weeks, misoprostol

Incomplete

What type of abortion is being described?

-Some POC expelled from uterus, cervical os is open

-Tx: expectant, surgery, or misoprostol

Complete

What type of abortion is being described?

-All products of conception expelled from the uterus

-Cervical os is usually closed

-Tx: RhoGAM if indicated, follow-up beta-hCG

Missed

What type of abortion is being described?

-Products of conception are intact, cervical os is closed, no bleeding or cramping

-Tx: surgical evacuation or misoprostol

Septic

What type of abortion is being described?

-Some products of conception are retained

-Cervical os is closed, cervical motion tenderness

-Foul brown discharge, fever, chills

-Tx: D&E to remove POC + broad spectrum antibiotics

Levofloxacin + Metronidazole

What two antibiotics are used for a septic abortion?

Mifepristone, Misoprostol

For an elective medical abortion, what can be given up to 10 weeks gestation?

Mifepristone

Progesterone receptor antagonist that leads to dilation/softening of the cervix and placental separation

Misoprostol

Prostaglandin E1 analog, which causes uterine contractions

-Pt must return 7-14 days after to confirm complete termination

24 weeks

A surgical abortion can performed up to how many weeks from LMP?

-D&C during 4-12 weeks

-D&E after 12 weeks

Ectopic Pregnancy

Implantation of the fertilized ovum outside the uterine cavity, with the fallopian tube being the MC site of implantation

-RF: previous ectopic, hx of PID, IUD use

-Presentation: amenorrhea, unilateral pelvic/lower abdominal pain, vaginal bleeding, severe abdominal pain and left shoulder pain if ruptured

-Dx: beta-hCG, TVUS

-Tx: Methotrexate (early gestation), salpingectomy

Beginning

What part of a woman’s cycle would her progesterone be < 1 ng/mL?

Middle

What part of a woman’s cycle would her progesterone be 5-20 ng/mL?

First Trimester

What part of a woman’s pregnancy would her progesterone be in the range of 11.2-90?

RhoGAM

What should be administered to all Rh(-) women with an ectopic pregnancy or abortion?

Gestational Diabetes

Glucose intolerance or diabetes mellitus only present during pregnancy, subsiding during the postpartum phase

-RF: family history or prior hx of gestational diabetes, macrosomia, obesity, AA

-Patho: maternal insulin resistance in women with undiagnosed beta cell dysfunction exacerbated by placental release of human placental lactogen

-Presentation: polyuria, polyphagia, polydipsia, weight loss, ketoacidosis

-Fetal Complications: fetal macrosomia, preterm labor, hypoglycemia, hypocalcemia, jaundice, polyhydramnios

-Dx: glucose challenge at 24-28 weeks, 3 hr is gold standard

-Tx: lifestyle, metformin, insulin, induction at 38 weeks

130-140

At 24-28 weeks, pregnant patients should undergo the 50g 1 hr glucose challenge test. Any value higher than _____-______ mg/dL should prompt a 3hr test

OGTT

What is the gold standard diagnostic for gestational diabetes?

95, 180, 140

Gestational diabetes can be diagnosed if the patient has a positive OGTT plus 2 or more of the following:

-Fasting > ___ mg/dL

-1 hr > ____ mg/dL

-2 hr > 155 mg/dL

-3 hr > ____ mg/dL

Lifestyle Modifications

What is the initial treatment of choice for gestational diabetes?

Insulin

What is the treatment of choice for gestational diabetes if fasting glucose is > 95 and 1 hr postprandial is > 130-140?

C-section

What is the delivery method of choice in a child that is macrosomic?

Cervical Insufficiency

Inability to maintain pregnancy secondary to premature cervical dilation

-Common cause for recurrent pregnancy loss in the 2nd trimester, with previous trauma or LEEP procedure as a risk factor

-Presentation: usually asx, may develop pressure, bleeding, vaginal discharge, or Braxton-Hix-like contractions in the 2nd trimester. Will have painless dilation and effacement of the cervix on physical exam

-Dx: TVUS shows length <25mm before 24 weeks

Cerclage

What is the treatment of choice for cervical insufficiency?

Chorioamnionitis

Acute inflammation of the membranes of the chorion of the placenta, usually occurring in association with ruptured membranes (prolonged length of labor or PROM)

-Presentation: fever, uterine tenderness, purulent or malodorous amniotic fluid, maternal tachycardia, fetal tachycardia

-Dx: presumptive with fever > 102.2 plus purulent fluid from cervical os, leukocytosis, and fetal tachycardia. Dx is confirmed with gram staining, culture, or low glucose in amniotic fluid

-Tx: Ampicillin/Gent + induction of labor, add metro or clinda if c-section

-Complications: endometritis, uterine atony, perinatal death, asphyxia, sepsis

Delivery + Abx

What is the treatment of choice for chorioamnionitis?

Placenta Abruption

Partial or complete premature separation of the placenta from the uterine wall, which may be concealed or external

-Patho: rupture of maternal vessels in the decidua basalis, leading to bleeding into the separated space

-RF: prior abruption, HTN, cocaine use, trauma

-Presentation: sudden onset of painful 3rd trimester vaginal bleeding and severe abdominal pain. Rigid uterus and fetal bradycardia on exam

-Dx: DO NOT PERFORM A PELVIC EXAM, TVUS may show a clot, DIC is biggest complication

-Tx: delivery

Abruption

What diagnosis should come to mind in a 3rd trimester patient with painful vaginal bleeding?

Placenta Previa

Abnormal placenta placement over or close to the internal cervical os, which can be complete, partial, or marginal

-RF: previous placenta previa, previous c-sections, multiple gestations, smoking

-Presentation: sudden onset of painless vaginal bleeding in the 3rd trimester, absence of abdominal pain or uterine tenderness

-Dx: TA US followed by TVUS

-Tx: stabilize with premature fetus, deliver when stable

Vasa Previa

Fetal vessels are present over the cervical os

-Presentation: rupture of membranes followed by painless vaginal bleeding and fetal bradycardia

-Dx: may be seen prior to delivery as the vessels crossing the os

-Tx: immediate c-section

Placenta Accreta

The placenta abnormally invades the uterine wall and attaches to the myometrium, which is a cause of postpartum hemorrhage

-Tx: hysterectomy is often required but curettage can be tried to preserve fertility

Placenta Increta

The placenta abnormally invades the uterine wall and penetrates the myometrium, which is a cause of postpartum hemorrhage

-Tx: hysterectomy is often required but curettage can be tried to preserve fertility

Placenta Percreta

The placenta abnormally invades the uterine wall and penetrates through the myometrium to the uterine serosa or adjacent organs

-Tx: hysterectomy is often required but curettage can be tried to preserve fertility

Uterine Rupture

Rupture of the uterus slightly before, during, or after labor

-MC in women with previous c-section

-Presentation: fetal bradycardia, variable or late decelerations, loss of fetal station, abdominal pain, cessation of contractions, vaginal bleeding

-Dx: clinical

-Tx: emergent cesarean, maternal resuscitation, uterine repair vs hysterectomy

Morning Sickness

Nausea and vomiting up until 16 weeks gestation

-Tx: lifestyle modifications, vitamin B6`

Hyperemesis Gravidarum

Severe, excessive form of morning sickness associated with weight loss and electrolyte imbalance that persists beyond 16 weeks of pregnancy

-RF: primigravida, previous hyperemesis, multiple gestations, molar pregnancy

-Patho: vomiting center oversensitivity to beta-hCG

-Dx: PUQE score, electrolyte imbalance

-Tx: Vitamin B6 + antinausea meds

Molar Pregnancy

Neoplasm due to abnormal placental development with trophoblastic tissue proliferation arising from gestational tissue. Seen most often in patients with prior molar pregnancy and Asian women

-Presentation: painless vaginal bleeding, preeclampsia before 20 weeks, hyperemesis gravidarum, tachycardia, weight loss. Discrepancies between uterine size and dating on US

-Dx: markedly elevated beta-hCG, “cluster of grapes” appearance on US

-Tx: surgical evacuation and following beta-hCG levels

Choriocarcinoma

Malignant transformation of trophoblastic tumor, which has a red, granular appearance on cut section

-Presentation: Abnormal bleeding for 6 weeks after any pregnancy

-Tx: chemotherapy, methotrexate if nonmetastatic

Eclampsia

Preeclampsia + seizures or coma

-Presentation: headache, blurred vision, photophobia, epigastric/RUQ pain, AMS, abrupt onset of tonic-clonic seizures

-Tx: IV magnesium sulfate for seizures + labetalol for hypertension, delivery of fetus after stabilized

Patellar Reflexes, EKG

What two things are monitored when checking for magnesium sulfate toxicity?

Calcium Gluconate

What should be administered to a patient on a magnesium sulfate drip that has developed widened QRS, loss of patellar reflexes, respiratory paralysis, or cardiac arrest?

Gestational HTN

New onset of HTN > 140/90 mmHg occurring after 20 weeks, without proteinuria, edema, or end-organ dysfunction

-Presentation: asymptomatic

-Risks: stroke, MI, CVD, renal disease, IUGR, preterm delivery

-Dx: preeclampsia workup

-Tx: monitoring, low dose aspirin in second trimester to reduce risk of developing preeclampsia

Rh Incompatibility

When a Rh(-) mother is exposed to Rh(+) fetus blood

-Patho: mother creates anti-Rh IgG antibodies which bind to fetal RBCs of a subsequent pregnancy, which can cause jaundice, fetal hydrops, anemia, and death in subsequent pregnancies

-Dx: indirect Coombs test for Rh typing and antibody screening at initial prenatal visit

-Tx: RhoGam 300mcg at 28 weeks

1:16

What is the critical value for RhD antibody titers?

50%

If the mother is Rh(-) and father is Rh(+), what is the chance that the fetus will be Rh(+)?

HELLP Syndrome

A severe progression of preeclampsia characterized by hemolysis, elevated liver enzymes, and a low platelet count

-Tx: delivery after stabilization in patients > 37 weeks, delivery before 37 weeks if the patient has signs of DIC/liver infarct/renal failure/pulmonary edema/placental abruption/fetal distress

Cholestasis of Pregnancy

Condition characterized by pruritus and an elevation in serum bile acid concentrations, typically in the late second or third trimester and rapidly resolving after delivery

-Presentation: pruritus on the palms and soles that is worse at night, RUQ pain, nausea, poor appetite, sleep deprivation, and steatorrhea. May see excoriations and nodules on the palms and soles.

-Dx: elevated bile acids, Alk phos, AST/ALT, and GGT

-Tx: UDCA for maternal pruritus, delivery if > 37 weeks

Preeclampsia

New onset of HTN occurring after 20 weeks gestation + proteinuria or end-organ dysfunction in a previously normotensive female, with 2 confirmatory BP measures taken at least 4 hours apart

-RF: HTN, nulliparity, maternal age < 20 years or > 35 years, diabetes, chronic renal disease

-Patho: defective remodeling of the spiral arteries, causing the patient to develop placental hypoperfusion that releases proinflammatory proteins and causes vasoconstriction

-Presentation: BP > 140/90 on > 2 occasions > 4 hours apart plus proteinuria > 300mg or protein:Cr >0.3

-Dx: CBC, Cr, liver enzymes, protein:Cr, NST or BPP

-Tx: delivery if > 37 weeks / expectant (mild), severe should be delivered

Preeclampsia with Severe Features

The presence of any one of the following in a patient with preeclampsia:

-BP > 160/110

-Platelets < 100,000

-SCr > 1.1 or 2x baseline

-ALT/AST 2x normal or persistent epigastric/RUQ pain

-Pulmonary edema

-Cerebral/visual changes (HA, blurred vision, flashing lights)

Labetalol

What is the first line IV/IM agent for hypertension in pregnancy?

ACE/ARB

What class of antihypertensives are contraindicated due to their association with fetal anomalies?

Cervical Insufficiency

A 24 y/o G3P0 woman presents at 20 weeks gestation with pelvic pressure and watery discharge. She denies contractions. On physical exam, her cervix is dilated with bulging membranes. TVUS shows a cervical length of < 25 mm.

Cerclage

What is the treatment of choice for cervical insufficiency?