Pregnancy Complications Pt. 1

What occurs for inevitable spontaneous abortion?

vaginal bleeding-

open cervix-

products of conception passed-

management-

vaginal bleeding- yes

open cervix- yes

products of conception passed- not yet but no way to maintain

management- conservative

What occurs when the placenta attaches low in the uterus that can partially or completely cover the cervix?

placenta previa

What are the symptoms associated with placental previa?

•PAINLESS bright red vaginal bleeding

•Often no clear event that leads to bleeding

What are some placental previa complications?

•Hemorrhage

•Preterm Birth

What is the diagnostic tool for placenta previa?

•TVUS

What should a pt be educated on to avoid if diagnosed with placenta previa?

•Sexual intercourse or sexual activity that produces an orgasm

•Moderate or strenuous exercise

•Moderate or heavy lifting

•Standing for long periods of time

What is the management for placenta previa?

•More frequent ultrasounds

•Admission for monitoring & blood transfusion with severe bleeding episodes

•If resolves - may plan for vaginal delivery

•If not, scheduled C-section!

•Emergency C-section w/ extreme blood loss

What occurs when the placenta grows into or through the wall of the uterus?

placenta accreta spectrum (PAS)

What is the MC form of placenta accreta spectrum where the placenta is attached to the superficial layers of the myometrium?

accreta

What placenta accreta spectrum occurs when it penetrates deeper into the myometrium?

increta

What placenta accreta spectrum occurs when the placenta penetrates through the myometrium to uterine serosa or organs. Most severe w/ increased mortality/morbidity?

percreta

What is the greatest RF associated with placenta accreta spectrum?

•Placenta previa after a prior C-section

What is the management for placenta accreta spectrum?

Cesarean hysterectomy

What is the term for premature separation of the placenta from the decidua ≥ 20wks gestation where the maternal vessels rupture into the decidua basalis?

placental abruption

What are the symptoms associated with placental abruption?

1.PAINFUL vaginal bleeding– usually abrupt

2.Abdominal pain

3.Uterine contractions

4.Uterine tenderness

5.Non-reassuring FHR pattern

What is the MC placental abruption classification and how does it present?

marginal

the separation is limited to the edge of placenta

What type of placental abruption occurs when the placenta does NOT completely detach from uterine wall?

partial

What type of placental abruption occurs when the placenta completely detaches from uterine wall. More vaginal bleeding assoc.

*hemorrhage can be concealed or not concelead?

compete/total

What are the diagnostic tools for placental abruption?

clincial!

- can do US

What are the maternal and fetal complications associated with placental abruption?

Maternal Complications:

•Hemorrhage

•DIC

•Blood clotting issues

•Kidney failure

Fetal Complications:

•Premature birth

•Low birth weight

•Still birth

•Hypoxic brain injury

What occurs with spontaneous complete transection of uterus from endometrium to serosa?

uterine rupture

What are the Risks associated with uterine rupture?

hx c-section/abnormal labor, placenta accreta

What is the tx for uterine rupture?

surgery

What protects against infection/fetal trauma/umbilical cord compression and allows for fetal movement & breathing?

amniotic fluid

What occurs as a rupture of chorioamniotic fluid prior to onset of labor around ≥37 wks gestation or more?

premature rupture of membranes -PROM

What type of rupture occurs < 37wks gestation

and is the Leading cause of neonatal morbidity/mortality?

PPROM (preterm-premature rupture)

What are the sx associated with PROM/PPROM?

•Hx leaking fluid per vagina

What are the diagnostic tests for PROM/PPROM?

•Speculum exam – pooling of amniotic fluid in posterior vaginal vault

•**Pooling** Gold Standard

•Nitrazine Test- vaginal discharge pH

•Fern Test

•US

What are the RFs associated with PROM/PPROM?

•hx PPROM

•Short cervical length.

•2nd/3rd trimester bleeding

•Low BMI

•Smoking/drugs

•STIs/BV

What is the tx for PROM/PPROM?

•Risk of infection --> chorioamnionitis

•Abx prophylaxis

•≥34wks delivery

•<37 wks Corticosteroids given before delivery

•Depends on time of rupture & gestation

What is the term for a fetus whose weight or abdominal circumference is less than the 10th percentile?

Intrauterine Growth Restriction (IUGR)

How do we diagnose Intrauterine growth restriction?

•Estimated gestational age critical

•Serial fundal height (↑1cm/wk btw 24-38wks)

1. US (fetal biometry measurements)

2.Doppler Velocimetry (umbilical artery)

What are the RFs associated with intrauterine growth restriction/

•Uteroplacental insufficiency w/ poor fetal nutrition & hypoperfusion

•50% unknown

•TORCH

•Alcohol/Smoking

What is the management for intrauterine growth restriction?

•Serial evaluations of fetal biometry performed q3-4wks

•Fetal surveillance

•Possible delivery

What can occur with excessive growth due to •Shoulder dystocia

•C-section

•Long term obesity- or maternal obesity?

macrosomia

What are the diagnostic tests for macrosomia?

•Measurement of symphysis-fundal ht. combined w/ clinical palpation

•2-d US exam*

What is the tx for macrosomia?

•C-section fetal wt >5000g without maternal DM

•C-section fetal wt. >4500g w/ DM

•Pre-pregnancy wt. loss

•DM management w/ nutrition, insulin

What is the term for:

•37+0 to 38+6 weeks of gestation.

early term

What is the term for:

•39+0 to 40+6 weeks of gestation.

full term

What is the term for:

•41+0 to 41+6 weeks of gestation.

late term

What is the term for:

•≥42+0 weeks of gestation (ie, ≥14 days from the estimated day of delivery).

post term

What are the RFs associated with post-term pregnancy?

•Previous postterm

•Nulliparity

•Male fetus

•Obesity

•Advanced maternal age

What are the complications associated with post term pregnancy?

•Macrosomia

•Dysmaturity syndrome

•Oligohydramnios

•Meconium aspiration syndrome

What is a spectrum of disease derived from abnormal fertilization and abnormal placental (trophoblastic) proliferation?

gestational trophoblastic disease

What is the MC form of premalignant GTD?

hydatidiform mole

What are some malignant GTDs?

invasive moles, choriocarcinoma, placental site trophoblastic tumor (PSTT), and epithelioid trophoblastic tumor

What can occur after aberrant fertilization and present as tiny water filled sacs similar to a cluster of grapes where an embryo is not supported and the pregnancy ends?

hydatidiform mole

What is the tx for hydatidiform mole?

•D & C +/- Chemo (if complete mole à malignancy)

What type of molar pregnancy occurs with no fetal parts and placental tissue grows but is abnormal and the placental is secreting hcg-- higher risk of developing into malignancy?

complete

What type of molar pregnancy has fetal parts in addition to molar degeneration and occurs when abnormal placenta forms + an embryo with an extra set of chromosomes?

partial mole

What are these signs and sx likely associated with:

•+ pregnancy test

•↑ Uterine size

•Painless 2nd trimester bleeding

•Abnormal bleeding*

•Marked HTN

•Proteinuria

•Severe N/V

•Large adnexal mass?

•Partial : milder sxs.

molar pregnancy

What are the diagnostic findings for molar pregnancy?

Labs

•↑↑↑ hCG, Anemia

diagnosis

•Routine prenatal tests (1st trimester)

•US** = fluid filled sacs instead of a placenta/ “snowstorm”

What occurs with a malignant transformation of trophoblastic tissue that causes rapid myometrial and uterine vessel invasion and metastasis?

choriocarcinoma

These sx are likely what dx?

**Abnormal bleeding > 6wks after ANY pregnancy

choriocarcinoma

What are the diagnostic tests for choriocarcinoma?

hcg and US

What is the tx for choriocarcinoma?

•Chemotherapy – most highly sensitive which often results in a cure w/o mets

•Methotrexate or Actinomyin C

What is the MC site for ectopic pregnancy?

fallopian tubes

What occurs when blastocyte implants anywhere other than the uterine lining?

ectopic pregnancy

ANY sexually active women, who is of reproductive age, who presents w/ PAIN, IRREGULAR bleeding and/or amenorrhea- should be considered for what diagnosits?

ectopic pregnancy

What is the management for ectopic pregnancy?

•Medical - methotrexate

•Surgical – linear salpingostomy, segmental resection or salpingectomy

These are the classic findings associated with what?

1.Vaginal bleeding

2.+/- abdominal pain

3.+ pregnancy test

ectopic pregnancy

What diagnostic tests CONFIRM ectopic pregnancy?

•Transvaginal US extrauterine gestational sac with a yolk sac or embryo

•+ serum hCG & NO products of conception

What defines pregnancy loss aka miscarriage or spontaneous abortion?

•nonviable pregnancy up to 20wks gestation

What defines recurrent pregnancy loss?

≥ 2 intrauterine pregnancy losses.

What occurs for threatened spontaneous abortion?

vaginal bleeding-

open cervix-

products of conception passed-

management-

vaginal bleeding- yes

open cervix- no

products of conception passed- no

management- none

What occurs for incomplete spontaneous abortion?

vaginal bleeding-

open cervix-

products of conception passed-

management-

vaginal bleeding- yes

open cervix- yes

products of conception passed- partial

management-suction curettage

What occurs for complete spontaneous abortion?

vaginal bleeding-

open cervix-

products of conception passed-

management-

vaginal bleeding- yes

open cervix- no

products of conception passed- yes

management- expectant/medical/surgical

What occurs for missed spontaneous abortion?

vaginal bleeding-

open cervix-

products of conception passed-

management-

vaginal bleeding- no

open cervix- no

products of conception passed- no

management- expectant/medical/surgical

What is the term for any any spontaneous/induced abortion complicated by an infection?

septic aborption

What are some sx associated with septic abortion?

•abdominal pain , purulent discharge, fever. Severe à sepsis, shock/hemorrhage/renal failure

How is septic abortion treated?

•Broad spectrum IV antibiotics

•Supportive care

•Evacuation of uterus (D&C)

What is the primary induced medical abortion way in the US?

Misoprostol + Mifepristone