DSA24 - Medical Disorders of Pregnancy

Molar Pregnancy

Define Condition:

Multisystem disorder unique to pregnancy; varying clinical presentations

-Hx: PRIOR to 20 WGA

-Sx/PE:

> CNS Sx

> Pulm Edema

-Dx:

> Thrombocytopenia

> DIC

> Elevated transaminases/other hepatic injury

> Elevated Cr

Preeclampsia/eclampsia

Define Condition:

Dx based on new-onset HTN in latter 1/2 of pregnancy + New-onset proteinuria and/or other evidence of organ dysfunction

-Hx:

> AFTER 20th Week of Pregnancy

> Affecting FIRST Pregnancy (determined by Father of Baby/FOB)

> Risk Factors

>> Maternal Vascular Dz (Chronic HTN, Advanced maternal age, Meth)

>> Primiparous (Immuno-mediated placental vascular damage)

>> Increased Metabolic Demand (Multiples. Macrosomia. Gestational Trophoblastic Dz = mole)

>> Genetic/Environmental

>> Familial Factors (risk of daughters of preeclamptic mothers)

-Path: Inadequate uteroplacental perfusion leading to placental ischemia, or hypoxia

> Failure of cytotrophoblasts to adequately invade the uterine spiral arteries and establish low-resistance uteroplacental circulation of a normal pregnancy --> endothelial dysfunction/disturbed PG production (more vasoconstrictors = PGF2a, TXA, endothelin; less vasodilators = PGE2, Prostacyclin, NO), vasoconstriction, activation of coagulation system

-Sx/PE:

> Rising Wt/Edema (leaky capillaries)

> Rising BPs

>> HTN > 160/110 mmHg on 2 occasions at least 4hrs apart

> Pulm/Generalized Edema

>> Renal Insufficiency (Cr > 1.1 or doubling baseline)

> CNS Sx

>> Severe HA (refractory to Tylenol)

>> Scotoma (spots in vision)

-Dx:

> Micro

>> Lack of decidualization of myometrial spiral arteries (MORE PLACENTAL INFARCTION)

>> Glom capillary endotheliosis

>> Ischemia, hemorrhage, necrosis in many organs (secondary to arteriolar constriction)

> New-onset Proteinuria:

>> 1+ dipstick

> Thrombocytopenia (< 100k)

> DIC

> Elevated transaminases/other hepatic injury

> Elevated Cr

-Tx:

> DELIVER PLACENTA + Expect Mgmt (Hospitalize if Severe)

> Seizure Prophylaxis (MgSO4) if severe

> HTN therapy (Prevent CNS Hemorrhage)

-Prog: A/w greater maternal/perinatal mortality

HELLP Syndrome

Define Condition:

Variant of Severe Pre-eclampsia w/ particularly high mortality

-Hx:

> MULTIPAROUS

> Age > 25 y/o

> <36 WGA

> 20% may not see HTN before

-Sx/PE:

> Rising Wt

> Rising BPs

>> HTN > 160/110 mmHg on 2 occasions at least 4hrs apart

> Pulm/Generalized Edema

>> Renal Insufficiency (Cr > 1.1 or doubling baseline)

> CNS Sx

>> Severe HA (refractory to Tylenol)

>> Scotoma (spots in vision)

-Dx:

> HEMOLYSIS

> New-onset Proteinuria:

>> > 0.3 g protein in 24 urine

>> Protein/Cr Ratio > 0.3 AFTER 20th Wk

>> 1+ dipstick

> Thrombocytopenia (< 100k)

> DIC

> Elevated transaminases/other hepatic injury

> Elevated Cr

-Tx: DELIVER PLACENTA

Eclampsia

Define Condition:

New-onset grand mal seizures in female w/ preeclampsia that cannot be attributed to other causes

-Hx: Preeclampsia +/- Neuro Sx

-Tx: DELIVER PLACENTA

Chronic Hypertension

Define Condition:

-Known HTN before pregnancy

-Development of HTN prior to 20 WGA

-Gestational HTN > 12 wks postpartum

-Hx:

> MCC = Essential HTN

> Secondary HTN (renal, vascular, endo, behavioral (cocaine, meth) causes)

> Need to r/o HypERthyroidism

-Tx: Control HTN + Detect Superimposed Preeclampsia in Pree mom/IUGR in fetus

> Early detect (r/o other causes + Labs/EKG)

> Review Meds

>> If > 160/105 --> Start Meds (Goal = 140/90; lower too much --> uteroplacental hypoperfusion --> IUGR) = Methyldopa, CCBs, Labetalol (may cause IUGR)

Gestational HTN

Define Condition:

HTN w/o proteinuria/other signs of organ dysfunction after 20 WGA, or within 24-48hrs of delivery and resolves by 12wks postpartum

-Hx: Dx made RETROSPECTIVELY (pregnancy completed w/o proteinuria or other evidence of preeclampsia and normotensive by 12wks PP)

-Prog: May progress to preeclampsia or chronic HTN that was previously undiagnosed

Chronic hypertension w/superimposed preeclampsia

Define Condition:

Chronic HTN + New-Onset Proteinuria AFTER 20 WGA

-Hx:

> Preexisting HTN w/ Proteinura

-Sx/PE/Dx:

> SUDDEN BP CHANGES

> Worsening Proteinuria

> Severe Features (Thrombocytopenia, LFT, etc)

Gestational Diabetes Mellitus (GDM)

Define Condition:

Glucose intolerance with onset/first recognition during pregnancy

-Hx:

> Previous Occurence

> PCOS

> Obesity

-Path: Rising levels of HPL (stimulates insulin production AND increases insulin resistance), progesterone, prolactin, and cortisol in pregnancy --> progressive insulin resistance during pregnancy + maternal pancreatic function CANNOT overcome resistance

-Tx:

> OB + MFM + Nutrition

> Diet

> Exercise (walking after dinner)

> Pharm

>> Glyburide if diet/exercise doesn't help

>> Insulin

> Stages

>> Antepartum = achieve euglycemia

>> Intrapartum = maternal euglycemia + monitor fetus

>> Postpartum = Insulin requirements drop (monitor BS) + OGTT Test (AVOID Estrogen OCP if DM w/ vascular Dz)

-Prog: D/t Maternal HYPERglycemia or Vascular Dz + Placenta allows for fetal hyperglycemia (glucose passes via facilitated diffusion) --> fetal hyperinsulinemia

> T2DM later in life

> NTDs

> Polyhydraminos

> Fetal hyperinsulinemia = Teratogenic during embryogenesis OR Macrosomia/Shoulder dystocia during 3rd Tri

Rhesus Alloimmunization

Define Condition:

Immunologic disorder in pregnant Rh-negative woman carrying Rh- positive fetus

-Hx:

> Most occur AT Delivery

> Sensitization may also occur if Rh-neg is exposed to to Rh-pos blood via Transfusion

-Path:

1. Fetal cells enter maternal circulation at placental barrier during 1st pregnancy

2. Anti-D IgM Abs made (can't cross placenta) for short time --> Maternal immune system produces Abs (anti-D IgG) to the Rh antigen

3. Post-partum/Subsequent pregnancy: Maternal anti-D IgG crosses placenta into fetal circulation and opsonizes/attacks fetal Rh-positive RBCs (TYPE II HYPERSENSITIVITY RXN), if Fetus has RhD antigen --> resulting in their destruction in fetal spleen (hemolytic disease in fetus/newborn)

-Sx/PE: HDF/N

> Mild = Fetal compensation by increased rate of erythropoiesis

> Severe = PROFOUND FETAL ANEMIA

>> Extramedullary hematopoiesis

>> Portal HTN

>> Hypoalbuminemia

>> Hyperbilirubinemia

>> Heart Failure (Hydrops fetalis)

>> Intrauterine fetal demise (IUFD)

>> Neonatal encephalopathy + Kernicterus (High bilirubin --> CNS damage)

-Dx: Genetics

> Rh-D neg + Sensitized --> RhD of FOB determined

> Rh-D (-) FOB --> Fetus Rh-D neg

> Rh-D (+) FOB --> Rh genotype using PCR

>> HOMO for D Ag = Rh-D+ Fetus

>> HETERO for D Ag = 50% Rh-D+ chance --> Genotype via cell-free fetal DNA in maternal plasma

-Tx: PROPHYLACTIC Rh IMMUNE GLOBULIN at 28 WGA/RHOGAM (if RhD-negative) Or if experiencing bleeds

> Prevents maternal anti-D IgG production

> Used Postpartum, Antepartum event w/ risk of fetomaternal hemorrhage

-Prog:

> 1st Tri Bleed = MCC of Fetomaternal Hemorrhage (SABs, EABs)

> 2nd/3rd Tri Bleed = After Amnio/CVS, trauma, external cephalic

Hydrops fetalis (fka Erythroblastosis fetalis)

Define Condition:

Form of in-utero heart failure d/t Rhesus Alloimmunization

-Path: Most are d/t Abs to the D antigen of Rh

-Sx/PE:

> Fetal Ascites

> Pericardial effusion

> Pleural effusion

> Subcuticular edema (scalp)

> Polyhydramnios

Polyhydramnios

Define Condition:

Too much amniotic fluid

-Hx:

> MCC = IDIOPATHIC

> A/w fetal malformations that increase difficulty of swallowing fluid (ex: Esophageal/Duodenal Atresia, Anencephaly)

> Maternal Diabetes

> Fetal Anemia

> Multiple Gestations

Oligohydramnios

Define Condition:

Too little amniotic fluid

-Hx: A/w...

> Placental insufficiency

> Bilateral renal agenesis

> Posterior urethral valves (males)

> Potter Sequence

>> Pulm Hypoplasia

>> Twisted face

>> Twisted skin

>> Extremity defects

>> Renal Failure

Endometritis

Define Condition:

Inflammation of the endometrium associated with retained products of conception following delivery, miscarriage, abortion, or foreign body (IUD)

-Path: Retained material is the nidus for bacteria from vagina/GI tract

-Sx/PE:

> Uterine TTP

> Foul-smelling uterine bleeding

> +/- Fever

-Dx: Histo (Chronic) = Plasma Cells

-Tx: Gentamicin + Clindamycin +/- Ampicillin

Primary Infertility

Define Condition:

Unsuccessful conception after attempting to achieve pregnancy x 1yr

-Hx:

> Stress

> Increased age (reduced embryo quality/reduced coital frequency)

> Male vs Female Coital Factors

-Path: NO PRIOR PREGNANCIES

> Recurrent Spontaneous Abortions (SABs) = Even when fertilization occurs, >70% embryos are abnormal and fail to develop/become nonviable shortly after implantation

> Major deficiency (tubal occlusion) or Multiple minor deficiencies

-Dx: First 6-8 mo

> Noninvasive = Hysterosalpinogram (may be therapeutic)

> Operative Laparoscopy (only if needed)

Secondary Infertility

Define Condition:

Unsuccessful conception after attempting to achieve pregnancy x 1yr

-Hx:

> Stress

> Increased age (reduced embryo quality/reduced coital frequency)

> Male vs Female Coital Factors

-Path: Follows previous conception

> Recurrent Spontaneous Abortions (SABs) = Even when fertilization occurs, >70% embryos are abnormal and fail to develop/become nonviable shortly after implantation

> Major deficiency (tubal occlusion) or Multiple minor deficiencies

-Dx: First 6-8 mo

> Noninvasive = Hysterosalpinogram (may be therapeutic)

> Operative Laparoscopy (only if needed)

Male Coital Factors

Define Cause of Infertility:

FIRST to be evaluated (cheaper & easier/less invasive)

-Hx:

> Previous pregnancies

> Genital Tract Infex (Prostatitis, Mumps, Orchitis)

> Surgery/Trauma to inguinal or genital region

> Exposure to lead/cadmium/radiation/chemo

> Excessive EtOH

> Tobacco

> Environmental heat

> Varicocele (d/t increased temperature)

> Use of Furantoins + CCBs (reduce sperm quality/function)

-Dx:

> Accurate appraisal of abnormal semen requires at least 3 samples

> Endocrine eval: hypothyroidism, hypothalamic-pituitary failure, prolactinoma, elevated FSH (parenchymal damage to testes)

-Tx: Scheduled intercourse w/nontoxic lubricant (Pre-Seed)

> Limit tobacco, EtOH (or stop all together)

> Avoid sauna, hot tub, tight undergarments

> Sperm abnormalities --> sperm washing and Intrauterine Insemination (IUI)

> Meds for H-P failure (FSH, LH) or hyperprolactinemia (bromocriptine, cabergoline – dopamine agonists)

> Ligation of venous plexus if varicocele causing low semen quality

> IVF: Intracytoplasmic sperm injection (ICSI)--> only 1 motile sperm required for each egg

Refractory cases: donor sperm

Primary Ovarian Insufficiency (fka Premature Ovarian Failure)

Define Cause of Infertility:

Premature atresia of ovarian follicles in women of reproductive age

-Hx:

> MCC = IDIOPATHIC

> Injury during surgery

> Radiation/chemo

> Fragile X carrier status

> Autoimmune disorders (Screen for Diabetes, Hypothyroidism, Hypocortisolism)

-Path: Before the age of 40 (if occurs before age 30, likely caused by chromosomal disorder à karyotype; If Y-chromosome is present, gonadectomy needed to prevent malignancy)

-Dx: Labs

> Low Estrogen

> Increased LH & FSH

-Tx: Replacement of hormone therapy to prevent effects of early menopause (i.e. osteoporosis)

Ovulation Issues

Define Cause of Infertility:

Irregular cycles and/or Advanced age --> reduced egg quality/number + less fecundity

-Tx: Fertility Rxs

> Clomiphene citrate or gonadotropins: will correct any luteal insufficiency

> If oligomenorrhea, induce more frequent ovulation

>> Following workup for thyroid disease, hyperprolactinemia, PCOS

> Pituitary insuffiency/hypothalamic amenorrhea: FSH/LH injections

> Hyperprolactinemia: bromocriptine or cabergoline (dopamine agonists)

> PCOS: clomiphene- inhibits neg feedback of endogenous estrogen --> rise in FSH and stimulates follicular maturation

> Metformin

> Ovarian "drilling" - old, rare, laparoscopic procedure

-Prog:

> Ovarian HyperStimulation Syndrome (OHSS) = marked ovarian enlargement + exudation of fluid and protein into peritoneal cavity --> Need to monitor to prevent

> Multiple fetal gestation

>> 8-10% clomiphene conceptions

>> 20-30% FSH/LH

Tubal Occlusion

Define Cause of Infertility:

-Hx:

> Salpingitis (Untreated/Undertreated GC/CT/PID --> Tubal scarring & infertility ==> Risk of Ectopic Pregnancy)

> Endometriosis

> Tubal Adenomyosis

> Tubal Surgery

> TB

-Path: Locations of Occlusion

> 1st MC = Fimbrial end

> 2nd MC = Mid-Segment

> 3rd MC = Isthmus-cornu

-Dx: HSG or Laparoscopy w/ chromotubation

-Tx: Microsurgical tuboplasty

> 60-80% pregnancy thereafter

>> 10% are ectopic

> Hydrosalpinx reduces IVF success by 50% -- repair or remove

Unexplained Infertility

Define Cause of Infertility:

No cause found in 10-15% patients with normal ovulation, Semen analysis, & HSG

-Hx/Path:

> Problem w/sperm transport?

>> IUI with washed sperm increases rate of conception

> Defect in ability of sperm to fertilize egg?

>> Lower fertilization rates during IVF

> Presence of antisperm antibodies?

> Minimal endometriosis?

> Mildly reduced ovarian reserve?

>> Reduced # of normal oocytes w/o hormonal abnormalities

-Tx: IUI Controlled w/ Ovarian Stimulation (Clomiphene or Letrozole and/or FSH/LH) --> IVF/IVF w/ embryo transfer (coception in about 80-85% infertile couples)