Pregnancy Complications

complicated pregnancy risk factors

maternal health, obstetric abnormalities, and fetal disease

leading causes of maternal death

thromboembolic disease, hypertensive disease, hemorrhage, infection, and ectopic pregnancy

leading causes of infant (birth-one year old) mortality

congenital malformations and prematurity-related conditions

triage of pregnant patients

1. vitals

2. symptoms

3. gestational age

4. red flags

spontaneous abortion

passing of a pregnancy at < 20 weeks of gestation

80% occur before 12 weeks’ gestation

what are first trimester abortions normally related to?

chromosomal abnormalities

what are second trimester abortions normally related to?

infections, uterine/cervix problems, exposure to toxins or trauma

threatening abortion

any intrauterine bleeding before 20 weeks without cervical dilation or POC passing

*this is the only one that is potentially viable

no expulsion of products, but bleeding and open os

inevitable abortion

partial POC passing before 20 weeks

incomplete abortion

complete expulsion of all POC before 20 weeks

complete abortion

death of the fetus before 20 weeks; complete retention of products, os closed

missed abortion

POC

products of conception

during which abortions is the os open?

inevitable and incomplete

during which abortion is the bleeding very heavy with cramping present?

incomplete

during which abortion is bleeding slight, continuing for weeks with no pain?

complete

spontaneous abortions occur < ________ weeks

<20

diagnostic tests for spontaneous abortion

- pregnancy test

- pelvic exam

- US

complications of spontaneous abortion

- medical risks (bleeding, infection)

- psychological impact

- future fertility concerns

prevention strategies spontaneous abortion

- preconception counseling (ID risk factors)

- folic acid supplementation

- maternal health management

- genetic counseling

pregnancy implanted outside of the endometrial cavity

ectopic pregnancy

IUD, STI/PID, prior ectopic pregnancy, previous abdominal or tubal surgery, endometriosis

risk factors for?

ectopic pregnancy

symptoms of ectopic pregnancy

unilateral or bilateral, localized or general abdominal pain and vaginal bleeding

2 largest risk factors for ectopic pregnancy

STI/PID

physical exam ectopic pregnancy

tender adnexal mass, uterus small for gestational age, vaginal bleeding

adnexal mass

growth relating to the ovary

diagnosis of ectopic pregnancy

beta HCG levels low for gestational age, does not double every 48 hours early in pregnancy

treatment ectopic pregnancy

stabilize, methotrexate in uncomplicated ex-lap (stable ectopic pregnancy)

surgical removal

qualitative HCG

Urine results are positive or negative - are they pregnant

quantitative HCG

measures the AMOUNT of hCG actually present in the blood - how far along are they

how does methotrexate treat stable ectopic pregnancy?

inhibits the action of dihydrofolate reductase, thereby inhibiting DNA synthesis

when is methotrexate contraindicated in treatment of ectopic pregnancy?

•Breastfeeding

•Overt or laboratory evidence of immunodeficiency

•Alcoholism, alcoholic liver disease, or other chronic liver disease

•Preexisting blood dyscrasias, such as bone marrow hypoplasia, leukopenia, thrombocytopenia, or significant anemia

•Known sensitivity to methotrexate

•Active pulmonary disease

•Peptic ulcer disease

•Hepatic, renal, or hematologic dysfunction

group of interrelated diseases resulting from an abnormal fertilization event resulting in abnormal proliferation of trophoblastic tissue

gestational trophoblastic disease

what trimester does gestational trophoblastic disease occur?

first

cells forming the outer layer of a blastocyst, which provides nutrients to the embryo and develops into a large part of the placenta

trophoblasts

types of gestational trophoblastic disease

Hydatidiform Mole (Benign) (also the MC)

Invasive Mole (Benign but invasive) in which the molar villi and trophoblasts penetrate the myometrium)

Choriocarcinoma (Malignant)

•fast-growing cancer that occurs in a woman's uterus

•The abnormal cells start in the tissue that would normally become the placenta

Placental site trophoblastic tumor (Malignant)

•Very rare

•This tumor represents a neoplastic transformation of intermediate trophoblastic cells that normally play a critical role in implantation

complete mole HCG

a complete mole results when there is fertilization of an empty ovum by one or two sperms

NO EMBRYO DEVELOPS and all chorionic villi are edematous

serum levels are very high

incomplete mole

Fetal parts, triploid, fertilization of ovum by 2 sperm.

serum HCG levels not as high as complete

an empty ovum (with an absent or inactivated nucleus) is fertilized by a normal sperm

complete hydatidiform molar pregnancy

normal ovum is fertilized by 2 sperm

incomplete hydatidiform molar pregnancy

hydatidiform molar pregnancy symptoms

painless, irregular or heavy vaginal bleeding early in pregnancy, N/V

Vaginal bleeding MC presenting symptom (occurring in > 90% of patients)

______________ in the 1st trimester or early 2nd trimester—an unusual finding in normal pregnancies—has been said to be pathognomonic for a molar pregnancy

Preeclampsia

diagnosis hydatidiform molar pregnancy

hCG: markedly elevated related to that of a normal pregnancy

US: no fetal heart tones, “snowstorm pattern”

treatment hydatidiform molar pregnancy

immediate removal of uterine contents, serial hCG's for 1 year, pregnancy should be avoided during 1-year follow-up

considered a benign neoplasm, locally invasive and invades the myometrium and adjacent structures

invasive mole

half of ___________ cases, the antecedent gestational event is a hydatidiform mole; 25% follow a term pregnancy, and the remaining 25% occur after an abortion

•presents as late vaginal bleeding in the postpartum period

Choriocarcinoma

•May arise months to years after a hydatidiform mole or, less commonly, following a normal term pregnancy

•Generally confined to the uterus, but local invasion may occur into the myometrium, lymphatics, or vasculature

Placental-Site Trophoblastic Tumor

labor occurring after 20 weeks' but before 37 weeks' gestation with regularly frequent uterine contractions (>2 in one-half hour)

preterm labor

diagnosis preterm labor

cervical dilation 3 cm or greater and >80% effaced

or

•The presence of fetal fibronectin

•Signs of rupture of membranes

workup preterm labor

r/o UTI, STI, GBS

what guides treatment for preterm labor?

EGA

estimated weight of the fetus

existence of contraindications to suppressing preterm labor

treatment options for preterm labor

•Corticosteroids: accelerate fetal lung maturity, decrease incidence of neonatal respiratory distress

•Tocolytics: Nifedipine and Terbutaline, Magnesium sulfate

•Antibiotics: if the patient’s GBS status is positive or unknown

PCN, ampicillin

rupture of the chorioamniotic membrane before the onset of labor

premature rupture of membranes

if rupture of membranes occurs before _________of gestation = preterm PROM (PPROM)

37 weeks

the time from PROM to labor is called the ____________ period

latency

most important step in accurate diagnosis of premature rupture of membranes

sterile speculum exam

risk factors premature rupture of membranes

•Preterm birth in prior pregnancy

•Smoking

•STIs

•Lower genital tract infections (Bacterial vaginosis)

diagnosis PROM (3)

•Pooling- the collection of amniotic fluid in the posterior fornix

•Nitrazine test- Nitrazine paper turns blue in the presence of amniotic fluid, demonstrating an alkaline pH (7.0-7.25)

•Ferning- amniotic fluid place on slide, dries in fernlike pattern

Nitrazine test

this is a test of vaginal secretions if the client is uncertain whether the membranes have ruptured.

Color will indicate whether amniotic fluid is present.

Yellow = urine. Blue = Amniotic fluid.

yellow nitrazine test vs blue

Yellow = urine

Blue = Amniotic fluid (rupture of membranes)

Fluid passing through the vagina must be presumed _________ fluid until proven otherwise

amniotic

treatment PROM

•Expectant management: spontaneous labor will ensue in 90% of women within 24 hours

•Induction of labor: if + chorioamnionitis or does not progress into spontaneous labor

If ___________ is present in the patient with PROM, actively deliver regardless of gestational age

chorioamnionitis

6 symptoms of chorioamnionitis

1. maternal fever

2. maternal leukocytosis (>15,000)

3. uterine tenderness

4. maternal tachycardia >100 bpm

5. fetal tachycardia >160 bpm

6. foul smelling amniotic fluid

an acute inflammation of the membranes and fetal portion (chorion) of the placenta, typically due to ascending polymicrobial bacterial infection in patients whose membranes have ruptured

chorioamnionitis

once preterm PROM is confirmed what regime should be started initially? and after 48 hours if still undelivered?

initial: Ampicillin + Erythromycin

after 48 hours: Amoxicillin + Erythromycin

Occurs when weak or “short” cervical tissue causes or contributes to painless cervical dilation

cervical insufficiency

risk factors cervical insufficiency

- Congenital uterine anomalies

- Structural abnormalities of cervix

- Previous cervical surgical trauma or procedures (i.e. dilate the cervix/D&C), loop electrosurgical excision procedure/LEEP or cold-knife conization

first trimester

1-13 weeks

second trimester

14-26 weeks

third trimester

27-40 weeks

•Painless dilation and effacement of the cervix

•When the cervix dilates 4 cm or more, active uterine contractions or rupture of the membranes may occur secondary to the degree of cervical dilation

signs of?

cervical dilation

diagnosis cervical insufficiency

TVUS is most accurate and predictive to measure cervical length

insufficiency is present if cervical length is 2.5 cm or less before 24 weeks

treatment cervical insufficiency

•Cerclage (suturing of cervical os) and bed rest

•Weekly injection of 17-alpha-hydroxyprogesterone might be added if w/ preterm birth hx (this is a naturally occurring hormone produced by the adrenal glands)

when the placenta implants such that the placental tissue is overlying the internal cervical os

placenta previa

leading cause of third-trimester bleeding, complicating 4 in 1000 pregnancies over 20 weeks

placenta previa

if the placenta is within 2 cm of the internal os, but not overlying it, the placenta is described as ___________

low-lying

risk factors placenta previa

multiparity

increasing maternal age

history of prior cesarean section or uterine surgery multiple gestation (twins, triplets)

symptoms placenta previa

painless vaginal bleeding, usually in the third trimester

Placenta accreta/increta/percreta

Accreta: placenta adhered to the myometrium

Increta: placenta invading myometrium

Percreta: invasion through myometrium and possibly other pelvic structures (bladder)

Most common indication for OB hysterectomy

Risks increase with increasing number of C-sections

high index of suspicion for ___________ in all patients who present with bleeding after 24 weeks

placenta previa

diagnosis placenta previa

transvaginal ultrasound

when is conservative treatment indicated for placenta previa?

between 24-36 weeks

treatment between 24-36 weeks placenta previa

if maternal and fetal stability and well-being are assured, conservative expectant management may be indicated

fluids

iron

rest

vitamin C

steroids

when is delivery/C-section the management of choice in placenta previa?

•Nonreassuring fetal heart rate pattern despite resuscitation efforts, including maternal supplemental oxygen, left-side positioning, or intravascular volume replacement

•If there is life-threatening maternal hemorrhage

•If the gestational age is > 34 weeks and there is known fetal lung maturity

•Fetus is ≥ 37 weeks of gestational age and there is persistent bleeding or persistent uterine activity

treatment placenta previa if bleeding is significant or the placenta covers the cervix completely

C-section

premature separation of the normally implanted placenta from the uterine wall after 20 weeks of gestation but prior to the delivery of the infant

placenta abruption

One-third of all antepartum bleeding in the third trimester is due to ___________

placental abruption

there is a well-known association between ________ abuse and placental abruption

cocaine

80% will present with the complaint of vaginal bleeding

tetanic uterine activity (ie, contractions), abdominal pain, uterine tenderness, increased uterine tone, fetal distress

symptoms of?

placental abruption

causes of placental abruption

the end of a chronic vascular pathologic process or may be due to trauma

placental abruption diagnosis

ultrasound

risk factors placental abruption

cocaine

maternal HTN

smoking

carrying multiples (twins) or multiple pregnancies

thrombophilias

partial placental abruption

placenta does not completely detach from the uterine wall

marginal placental abruption

blood passes between the fetal membranes and the uterine wall and escapes vaginally

what finding indicates a worse prognosis in terms of placental abruption?

a large hematoma

Asymptomatic

No symptoms; diagnosed retrospectively by finding a clot behind the placenta after delivery

grade abruption?

0

Moderate

Vaginal bleeding, moderate to severe uterine tenderness, significant abdominal pain, uterine contractions

grade abruption?

2

Severe

Heavy vaginal bleeding (may be concealed), severe uterine tenderness, continuous abdominal pain, shock

grade abruption?

3

Mild

Vaginal bleeding, mild uterine tenderness, and mild abdominal pain

grade abruption?

1