Wk 3: Comprehensive Notes on Pregnancy-Related Conditions and Care
Comprehensive Notes: Pregnancy-Related Conditions and Care
These notes synthesize key ideas from the transcript: risk factors for pregnancy, hypertensive disorders, diabetes and thyroid disease in pregnancy, cardiac considerations, bleeding disorders, placental pathologies, spontaneous abortion etiologies, ectopic and molar pregnancies, fetal monitoring, and clinical management strategies including medication safety and emergency responses.
Risk factors and baseline considerations in pregnancy
Pregnancy can complicate existing conditions; baseline health and preexisting conditions are important for risk assessment.
Genetic/chromosomal factors and multifetal pregnancies increase physiological stress on the body: multifetal pregnancy (e.g., twins) is high risk because of doubled maternal stress and placental burden.
ABO incompatibility and Rh incompatibility affect fetal red blood cells:
ABO incompatibility: Incompatible mother–fetus blood types can lead to fetal hemolysis. The transcript notes AB and O as incompatible types.
Fetal hemolytic disease can occur when maternal antibodies attack fetal cells.
Preexisting medical/psychosocial factors to consider early:
Genetic/chromosomal abnormalities; multifetal pregnancies.
ABO/Rh incompatibility; fetal erythrocyte destruction.
Preexisting chronic diseases (e.g., hypertension) and their risk contribution.
Psychosocial factors: smoking, caffeine intake, alcohol use, violence, inter partner violence, human trafficking; stress; poverty; lack of prenatal care; age; access to resources.
Environmental factors: poor living conditions, mold exposure, access to clean water/air, radiation exposure (e.g., occupational exposure for X-ray tech).
Secondhand smoke exposure.
Practical implication: questions in exams may ask you to identify risk factors from a list rather than asking you to name the factor directly.
Hypertensive disorders of pregnancy (overview and distinctions)
Chronic hypertension (preexisting):
Definition: Hypertension present before pregnancy or diagnosed up to week ~20 of gestation; can also be defined as persistent hypertension postpartum up to ~12 weeks after delivery. If hypertension is diagnosed after 20 weeks and classified as gestational, different management applies.
Risk factors for chronic hypertension: very high BMI/obesity, poor diet, smoking; fetal growth restriction risk; cardiovascular stress.
Management goals: blood pressure control with antihypertensives; monitor for fetal well-being; more frequent prenatal visits.
Routine monitoring: home blood pressure monitoring; fetal surveillance (e.g., NST).
Potential pregnancy complications due to chronic HTN: placental abruption risk, fetal growth restriction, preeclampsia progression.
Gestational hypertension:
Definition: New-onset hypertension after 20 weeks’ gestation without other organ involvement.
Risk of progression to preeclampsia with time; ongoing surveillance required.
Preeclampsia (with or without severe features):
Diagnostic criteria in the transcript (simplified): persistent BP ≥ 140/90 on two readings at least four hours apart after 20 weeks, plus evidence of organ involvement (e.g., proteinuria or end-organ dysfunction).
Common signs/symptoms described: edema, headaches, visual disturbances, epigastric/right upper quadrant (RUQ) pain, and epigastric pain; hyperreflexia; changes in vision; RUQ tenderness.
Laboratory indicators discussed: elevated AST/ALT (LFTs), proteinuria, and low platelets as part of severe features.
End-organ involvement may include liver involvement (elevated LFTs), kidney involvement (proteinuria), visual disturbances, headaches, RUQ pain, and neurological symptoms.
Management emphasis: maternal stabilization and fetal surveillance; anticipates possible escalation to magnesium sulfate for seizure prophylaxis; possible pregnancy termination if maternal status deteriorates or fetus cannot be supported.
Magnesium sulfate (MgSO4) in preeclampsia
Purpose: seizure prophylaxis (not just BP reduction).
Administration: slow IV drip; continuous monitoring; frequent intake/output monitoring due to renal involvement.
Monitoring indicators: deep tendon reflexes (DTR), respiratory rate, urine output, oxygen saturation, level of consciousness.
Toxicity signs: respiratory rate < 12/min, urine output < 30 mL/hr, diminished/absent DTRs, altered mental status, decreased LOC.
Antidote for MgSO4 toxicity: calcium gluconate (often given as 2–3 doses or as directed by protocol).
If MgSO4 toxicity suspected or if magnesium dose too high: stop MgSO4, call for rapid assessment, and administer calcium gluconate as antidote per order.
Nursing priorities in MgSO4 toxicity: stop magnesium, ensure calcium gluconate is immediately available, monitor maternal and fetal status, escalate to rapid response or ICU as needed.
Eclampsia and HELLP syndrome
Eclampsia: seizure activity in the context of preeclampsia.
HELLP syndrome: a variant with Hemolysis (H), Elevated Liver enzymes (EL), and Low Platelets (LP). It can occur with or without severe hypertension.
Hemolysis: decreased Hb/Hgb, schistocytes on smear, fatigue, pallor.
Elevated liver enzymes: markedly increased AST/ALT; RUQ pain; sometimes extreme LFT elevations.
Low platelets: increased bleeding risk, easy bruising, petechiae.
Diagnostic approach: CBC (to assess Hb and platelets), CMP/metabolic panel (to assess liver enzymes), urinalysis for proteinuria; ultrasound may be used to assess fetal status and maternal organs.
Blood pressure target and monitoring around pregnancy
In OB practice, BP thresholds commonly referenced: sustained readings around or above 140/90 prompt investigation and potential treatment adjustments.
Two readings: require two elevated BP readings, four hours apart (or per local protocol).
Home BP monitoring and antenatal testing (NST) are used to monitor fetal well-being when hypertension is present.
Delivery and fluid management in hypertensive disorders
Definitive treatment for preeclampsia and/or HELLP is delivery when feasible, balancing maternal and fetal status.
Fluid management during labor and postpartum: avoid excess fluid to prevent volume overload in a stressed cardiovascular system.
Antihypertensive medications (general idea from transcript)
Goal is to maintain maternal perfusion and placental perfusion while minimizing maternal risk.
Specific drug choices aren’t enumerated in detail in the transcript, but common choices include labetalol, methyldopa, and nifedipine in practice; consult current guidelines for exact drug selection and dosing.
Prophylaxis and patient education in hypertensive disorders
Regular prenatal visits, home BP monitoring, and antithrombotic or aspirin prophylaxis in select high-risk cases (second trimester onward) as per provider guidance.
Symptoms to monitor at home: headaches, vision changes, RUQ pain, swelling beyond normal edema, sudden weight gain, reduced fetal movement, vaginal bleeding.
Early recognition and timely escalation of care are critical to prevent progression to severe disease or maternal/fetal complications.
Diabetes in pregnancy (overview, with emphasis on type 1 vs type 2 and gestational diabetes)
Type 1 diabetes in pregnancy
Pathophysiology: autoimmune destruction of pancreatic beta cells; little to no endogenous insulin production.
Treatment: insulin is required for glycemic control; monitoring includes finger-stick glucose checks and/or continuous glucose monitoring (Dexcom or similar).
Insulin management in pregnancy: insulin needs may change throughout gestation; first trimester may have relative hypoglycemia risk; second/third trimesters typically require more insulin due to increased insulin resistance from placental hormones.
Assessments: glycated hemoglobin (A1C) and daily glucose monitoring; increased maternal and fetal surveillance.
Type 2 diabetes in pregnancy
Pathophysiology: resistance to insulin with inadequate insulin production to meet higher metabolic demands.
Initial management: diet and exercise; goal is to achieve glycemic control with the least risk to the fetus.
If lifestyle measures fail, pharmacotherapy may be used; metformin is mentioned in the transcript as an agent used in pregnancy (note: metformin is commonly used for type 2 diabetes and gestational diabetes in many settings; it reduces hepatic glucose production and improves insulin sensitivity; insulin therapy is also used when needed in pregnancy).
Special note on metformin: transcript describes it as a hyperglycemic agent, which is incorrect—metformin is an antihyperglycemic agent. In real clinical practice, metformin is used to improve glycemic control; clinicians may use metformin in select patients during pregnancy, depending on guidelines and physician judgment. Always verify current institutional protocols.
Insulin in pregnancy
Often required for type 1 diabetes and many with type 2 diabetes during pregnancy to maintain euglycemia and reduce fetal risk.
Administration: subcutaneous insulin with potential use of continuous glucose monitoring (Dexcom or similar).
Key concept: fetal glucose crosses the placenta; maternal hyperglycemia leads to fetal hyperglycemia, increased insulin production by the fetus, and risk of macrosomia (large baby).
Gestational diabetes (GDM)
Pathophysiology: pregnancy hormones (placental hormones) increase insulin resistance; if maternal pancreas cannot compensate by increasing insulin production, hyperglycemia results.
Fetal impact: excess glucose transfer to fetus leads to fetal hyperinsulinemia and macrosomia (macrosomia is the baby being larger than normal).
Signs of maternal imbalance: hypoglycemia and hyperglycemia symptoms—hypoglycemia: shakiness, sweating, lethargy; hyperglycemia: polyuria, polydipsia.
Assessment and monitoring: A1C and glucose monitoring; A1C target in the transcript is given as 6.5 or less for prediabetes context (note: A1C interpretation in pregnancy may differ; refer to current guidelines for appropriate targets in pregnancy).
Lifestyle management: diet and exercise as initial management for type 2 and gestational diabetes; 30 minutes of exercise on most days of the week is suggested in the transcript; carbohydrate moderation and balanced meals are emphasized.
Pharmacotherapy: if lifestyle changes fail, medications (metformin or insulin) may be used depending on patient and provider judgment; Dexcom and finger-stick checks help tailor therapy.
Pregnancy timing and glycemic control
In the first 20 weeks, insulin needs may not increase dramatically; later in pregnancy, insulin resistance rises and needs typically increase, requiring adjustment of medications or dosages.
Monitoring and fetal outcomes in diabetes
Fetal risks with maternal hyperglycemia: macrosomia, higher risk of birth complications.
Maternal risks: hypoglycemia episodes, poor perfusion, and related complications.
Routine fetal surveillance and delivery planning should account for maternal glucose control status and fetal well-being.
Practical education points for patients with diabetes in pregnancy
Regular glucose monitoring: finger sticks or continuous glucose monitoring.
Diet and exercise adherence: 30 minutes, 5 days per week; carbohydrate management; consistent caloric intake.
Hypoglycemia prevention: carry quick sources of sugar; recognize signs; carry glucose tablets or a sugary snack.
Signs of hyperglycemia to seek care: persistent polyuria, polydipsia, weight changes, fatigue, or dehydration.
Thyroid disease in pregnancy
Thyroid physiology and pregnancy
TSH is the pituitary signal for thyroid hormone production; T4 is the main circulating thyroid hormone relevant for metabolic effects.
If T4 is low (hypothyroidism), TSH tends to rise trying to stimulate more thyroid hormone production; if T4 is high (hyperthyroidism), TSH tends to be suppressed.
Hypothyroidism: increased TSH, low T4; Hyperthyroidism: low TSH, high T4.
Common clinical patterns and management
Hypothyroidism in pregnancy: commonly managed with thyroid hormone replacement (levothyroxine, brand names include Synthroid/Levothyroxine). Dose adjustments are often needed during pregnancy due to increased demand.
Hyperthyroidism in pregnancy: may require antithyroid medications or other management depending on severity; monitoring TSH and T4 is essential.
In pregnancy, the demand on the thyroid increases; clinicians may increase levothyroxine dosing to maintain euthyroid status.
Education and signs to monitor
Recognize symptoms associated with thyroid imbalance and know when to contact care providers for dose adjustments.
Cardiac disease in pregnancy
Cardiac systems in pregnancy are highly stressed due to increased blood volume and cardiac output.
Key concerns:
Cardiac decompensation and congestive heart failure (CHF) risk; signs include fatigue, shortness of breath, edema, and reduced perfusion.
In labor and postpartum, careful fluid management is essential to prevent fluid overload on an already stressed heart.
Practical implication: patients with cardiac conditions require close surveillance and may need specialized care plans for intrapartum and postpartum periods.
Antenatal testing and fetal surveillance concepts
Kick counts (fetal movement monitoring):
Practice: aim for roughly 10 movements in a given monitoring window (the transcript references 10 movements in two hours; verify local protocol).
Purpose: fetal well-being cue; babies often signal distress before mother notices symptoms.
NST (non-stress test):
Used as a primary entry point for monitoring at-risk pregnancies (e.g., maternal hypertension, diabetes, or other risk factors).
Hydration and activity recommendations:
Increase fluid intake (example given: 8–12 eight-ounce glasses per day).
Regular exercise as tolerated; nutritional guidance tailored to condition.
Bleeding in pregnancy: trimester-specific considerations
First trimester bleeding:
Common causes: spontaneous abortion (miscarriage) and ectopic pregnancy.
Second and third trimester bleeding:
Major causes discussed: placenta previa, placental abruption, “bloody show.”
Bloody show refers to slight cervical bleeding associated with cervix dilation and mucus plug changes near labor; often pink-tinged discharge.
Spontaneous abortion (miscarriage): classifications and management
Definitions:
Complete abortion: pregnancy loss with all products of conception expelled; uterus empty.
Incomplete abortion: part of the products retained (often placenta); risk of hemorrhage if tissue remains; management may include pharmacologic expulsion (Cytotec/misoprostol) or surgical removal (D&C).
Threatened abortion: vaginal bleeding with vaginal bleeding but no cervical dilation and intact fetal heart activity; may progress or resolve.
Inevitable abortion: cervix dilated with abortion imminent; cannot be stopped.
Missed abortion: fetus has not progressed but no cervical dilation or membrane rupture; fetal demise without expulsion.
Recurrent abortion: two or more spontaneous abortions; raises concern for future reproductive risk.
Risk factors: stress, smoking, alcohol or substance use, prior abortions, uterine anomalies; overall risk profile is multifactorial.
Diagnostics and monitoring:
Pregnancy test (hCG) trends: should decline after miscarriage occurs.
Ultrasound: confirms presence/absence of products of conception and fetal viability.
Therapeutic procedures:
Dilation and Curettage (D&C) versus medical management with Cytotec/Misoprostol depending on tissue status and gestation.
Incomplete abortion may require tissue expulsion; proper follow-up to ensure complete abortion and screen for infection/hemodynamic stability.
Patient-centered care considerations:
Emotional support and counseling; grief and loss resources; discuss future fertility planning and timing of attempts when appropriate.
Ectopic pregnancy
Definition: implantation of the fertilized egg outside the uterus, most commonly in a fallopian tube.
Presentation: unilateral abdominal pain with spotting/blood, usually around 6–8 weeks after a missed period; positive pregnancy test.
Diagnostics: ultrasound to determine location of pregnancy; ongoing hCG measurements.
Management: surgical intervention is common if rupture risk or hemodynamic instability; medical management may be possible in selected stable cases (e.g., methotrexate) per guideline.
Key teaching: early recognition and prompt treatment are critical to prevent rupture and life-threatening hemorrhage.
Molar pregnancy and gestational trophoblastic disease
Molar pregnancy (gestational trophoblastic disease): abnormal fertilization leading to proliferation of placental tissue without a viable fetus in many cases.
Presentation clues: markedly elevated hCG levels (can be >10^5 or higher); grape-like vesicles; prune-juice vaginal bleeding is described.
Management: suction curettage to remove tissue; serial hCG monitoring; counsel on not becoming pregnant for a period after treatment (often about 12 months per typical practice).
Important clinical note from transcript: a molar pregnancy can be associated with a viable baby in rare cases (as in the case anecdote). Always verify with current case-specific data and guidelines.
Placental pathologies and related bleeding risks
Placenta previa:
Definition: placenta implants near or over the cervical os; can be marginal, partial, or complete depending on coverage.
Presentation: painless vaginal bleeding in the third trimester is typical; not usually associated with cramping.
Risk factors: prior uterine surgery (cesarean section, myomectomy), IVF/assisted pregnancy.
Management: fetal monitoring; plan for delivery by cesarean if placenta previa persists near delivery; may involve bed rest and hospitalization depending on bleeding risk.
Practical prep: two IV lines, blood type O status checked, CBC to assess Hb/platelets, plan for potential blood products.
Placental abruption (abruptio placentae):
Definition: premature separation of placenta from the uterine wall; typically painful bleeding.
Major risk factors: hypertension, cocaine use, trauma (car accidents, falls).
Clinical presentation: sudden, severe abdominal pain with vaginal bleeding; signs of fetal distress may occur.
Management: stabilize mother and fetus; rapid assessment; may require emergent delivery depending on severity and gestational age.
Distinction from previa: previa is painless bleeding from low placenta; abruption is usually painful with a higher risk of fetal compromise.
Laboratory tests and diagnostics in obstetric care
Key labs in hypertensive disorders and preeclampsia:
Complete blood count (CBC) for Hb/Hct, platelets (risk of thrombocytopenia in HELLP and preeclampsia).
Liver function tests (AST, ALT) to monitor hepatic involvement.
Urinalysis for proteinuria.
Metabolic panel (CMP) for overall function and LFT assessment.
Interpreting labs in HELLP and preeclampsia:
Hemolysis: anemia with evidence on smear; low Hb/Hct.
Elevated liver enzymes: AST/ALT significantly elevated from baseline; in HELLP, LFT elevations can be extreme.
Low platelets: thrombocytopenia (e.g., platelets around or below 100{,}000/µL).
Diagnostic imaging:
Ultrasound is essential to identify placental location (previa vs abruption), fetal status, and uterine contents after abortion or molar pregnancy concerns.
Fetal surveillance:
NST (non-stress test) and kick counts to assess fetal well-being in hypertensive or high-risk pregnancies.
Case study: 36-week gestation with gestational hypertension leading to preeclampsia features
Patient: 36 weeks gestation with repeated high BP readings: 188/104 and 189/102.
Key assessment questions to rule in/out preeclampsia:
Headache, visual disturbances (e.g., floaters, blurred vision).
Epigastric or RUQ pain indicative of liver involvement.
Fatigue and general malaise.
Deep tendon reflexes (DTRs) status (hyperreflexia is common in preeclampsia).
Fetal well-being via fetal monitoring (NST or similar).
Lab results highlighted in the case:
Hemoglobin low (anemia).
Platelets 88,000/µL (thrombocytopenia; normal ~150,000–450,000/µL).
ALT and AST doubled from baseline (marked elevation in transaminases).
Clinical decision: admitted for preeclampsia with severe features; management includes magnesium sulfate for seizure prophylaxis and close maternal-fetal monitoring.
Education points for patient in case:
Explanation of preeclampsia and importance of monitoring BP and symptoms at home.
MgSO4 therapy and its effects: “slows everything down” including reflexes, respiration, and heart rate; sedation and possible warmth or flushing are common.
Potential need for delivery if maternal or fetal status worsens; discussion of aspirin prophylaxis in some pregnancies (second trimester) and potential withholding if magnesium therapy is initiated—this depends on provider protocol.
If magnesium toxicity occurs (e.g., respiratory depression, decreased urine output, decreased DTRs), stop magnesium and administer calcium gluconate as antidote; monitor vitals and labs.
Flowchart and clinical reasoning tools described:
Bow tie exercise: two actions to stop magnesium and administer calcium gluconate; monitor respiratory status and DTRs.
Rapid response activation if deterioration occurs (e.g., signs of respiratory decline, severe hypotension, ongoing bleeding).
Practical considerations in care:
Two IV lines and ongoing labs to track BP, platelets, liver function, and urine output.
Fluid management to prevent edema and pulmonary edema.
In the setting of severe preeclampsia with signs of HELLP or DIC, escalate care and consider ICU transfer as needed.
Spontaneous abortion vs induced abortion and counseling considerations
Spontaneous abortion overview:
Early pregnancy loss includes various types (complete, incomplete, threatened, missed, inevitable, recurrent).
Diagnostic and treatment approaches depend on symptoms, ultrasound findings, and clinical stability.
Counseling and care considerations:
Discuss emotional impact, support needs, and future fertility planning.
Provide information about the importance of follow-up and potential need for D&C or medical management depending on tissue retention and bleeding risk.
Ectopic pregnancy: quick reference for clinical reasoning
Hallmarks: unilateral abdominal pain with spotting; positive pregnancy test; risk of rupture and hemorrhage if untreated.
Diagnostic approach: transvaginal ultrasound and serial hCG measurements.
Treatment options depend on stability and location; surgical management is common for ruptured or unstable cases; medical management is possible in stable, unruptured ectopic pregnancies under appropriate criteria.
Gestational trophoblastic disease and molar pregnancy
Description: gestational trophoblastic disease includes molar pregnancies with abnormal placental tissue growth and, in some cases, or rarely, a concurrent viable fetus.
Key diagnostic clue: markedly elevated hCG and ultrasound findings of grape-like vesicles.
Management: suction curettage to remove tissue; follow-up with serial hCG to ensure clearance and monitor for potential persistent GTN; counseling on contraception and timing to conceive again.
Key practical takeaways for exam and clinical practice
Always distinguish between chronic hypertension (preexisting or before 20 weeks) and gestational hypertension (after 20 weeks) and preeclampsia (hypertension with end-organ involvement).
Preeclampsia signs to watch for: headache, visual disturbances, RUQ pain, edema, hyperreflexia, lab changes (elevated LFTs, thrombocytopenia, proteinuria).
Magnesium sulfate is for seizure prophylaxis in preeclampsia/HELLP; monitor for toxicity and have calcium gluconate ready as antidote.
HELLP syndrome requires CBC and liver enzyme monitoring; treat emergently due to high maternal and fetal risk.
Placental pathologies (previa vs abruption) have distinct clinical features: previa—painless bleeding; abruption—painful bleeding with possible fetal distress.
Bleeding in pregnancy requires prompt assessment, imaging (ultrasound), and appropriate interventions to prevent hemorrhage and preserve maternal health.
Diabetes management in pregnancy emphasizes glycemic control, fetal surveillance, and patient education on lifestyle and medication choices; insulin is commonly used in type 1 and many type 2 cases, while metformin may be used in select scenarios per guidelines.
Thyroid disease requires careful dose adjustment during pregnancy to maintain euthyroid status and minimize fetal risk.
Cardiac disease demands careful assessment of decompensation risk, restricted fluid strategies during labor, and multidisciplinary management.
Fetal monitoring and patient education on activity, hydration, and signs of trouble are foundational to improving outcomes.
Risk factors and baseline considerations in pregnancy
Genetic/chromosomal factors & multifetal pregnancies: Increase physiological stress.
ABO/Rh incompatibility: Can lead to fetal hemolytic disease.
Preexisting chronic diseases: e.g., hypertension, diabetes.
Psychosocial factors: Smoking, alcohol, violence, stress, poverty, age.
Environmental factors: Poor living conditions, exposure to toxins/radiation.
Hypertensive disorders of pregnancy
Chronic Hypertension: Preexisting or diagnosed before 20 weeks.
Risks: Fetal growth restriction, preeclampsia.
Management: BP control, fetal surveillance.
Gestational Hypertension: New-onset HTN after 20 weeks without organ involvement.
Risk: Progression to preeclampsia.
Preeclampsia: HTN (BP \geq 140/90 on two readings \geq 4 hours apart after 20 weeks) plus organ involvement (e.g., proteinuria, elevated LFTs, low platelets, headaches, visual changes, RUQ pain).
Management: Maternal stabilization, fetal surveillance, MgSO4 for seizure prophylaxis, potential delivery.
Magnesium Sulfate (MgSO4): Seizure prophylaxis in preeclampsia.
Monitoring: DTRs, respiratory rate, urine output, O2 sat, LOC.
Toxicity: Respiratory depression, decreased DTRs. Antidote: calcium gluconate.
Diabetes in pregnancy
Type 1 Diabetes: Autoimmune destruction of beta cells; absolute insulin requirement.
Insulin needs: Fluctuate; increase in 2nd/3rd trimesters.
Type 2 Diabetes: Insulin resistance with inadequate production.
Management: Diet, exercise; metformin or insulin if lifestyle fails.
Gestational Diabetes (GDM): Pregnancy hormones cause insulin resistance; insufficient compensation by pancreas.
Fetal impact: Macrosomia due to fetal hyperinsulinemia.
Management: Diet, exercise (30 min/5 days/week), carb moderation; metformin or insulin as needed.
Key concept: Maternal hyperglycemia
\rightarrow fetal hyperglycemia
\rightarrow fetal hyperinsulinemia
\rightarrow macrosomia.
Thyroid disease in pregnancy
Demand for thyroid hormone increases.
Hypothyroidism: High TSH, low T4. Managed with levothyroxine; dose adjustments common.
Hyperthyroidism: Low TSH, high T4. May require antithyroid medications.
Cardiac disease in pregnancy
Increased blood volume/cardiac output places stress on heart.
Concerns: Cardiac decompensation, CHF risk.
Management: Careful fluid management, especially in labor/postpartum.
Antenatal testing and fetal surveillance
Kick counts: Approx. 10 movements in 2 hours (verify protocol).
Non-Stress Test (NST): Primary monitoring for at-risk pregnancies.
Bleeding in pregnancy
First Trimester: Spontaneous abortion, ectopic pregnancy.
Second/Third Trimester: Placenta previa, placental abruption, "bloody show" (cervical dilation).
Spontaneous abortion (miscarriage)
Complete: All products expelled.
Incomplete: Some products retained; hemorrhage risk.
Threatened: Bleeding, no cervical dilation, intact fetal heart activity.
Inevitable: Cervix dilated, abortion imminent.
Missed: Fetal demise without expulsion.
Recurrent:
\geq 2 abortions.Management: hCG trends, ultrasound; D&C or medical management (Cytotec).
Ectopic pregnancy
Definition: Implantation outside uterus (usually fallopian tube).
Presentation: Unilateral abdominal pain, spotting, positive pregnancy test (6-8 weeks).
Management: Surgical (rupture/instability) or medical (methotrexate for stable cases).
Molar pregnancy / Gestational trophoblastic disease
Definition: Abnormal placental tissue proliferation.
Presentation: Markedly elevated hCG (e.g.,
>10^5), grape-like vesicles, "prune-juice" vaginal bleeding.Management: Suction curettage, serial hCG monitoring, contraception for ~12 months.
Placental pathologies
Placenta Previa: Placenta implants near/over cervical os.
Presentation: Painless vaginal bleeding in 3rd trimester.
Management: Close monitoring, C-section planned if persists.
Placental Abruption: Premature separation of placenta from uterine wall.
Presentation: Sudden, severe abdominal pain with vaginal bleeding, fetal distress.
Risk factors: HTN, cocaine, trauma.
Management: Emergent delivery possible.
Distinction: Previa is painless, abruption is painful.
Laboratory tests and diagnostics
Preeclampsia/HELLP Labs: CBC (platelets, Hb/Hct), LFTs (AST, ALT), urinalysis (proteinuria).
HELLP: Hemolysis, Elevated Liver enzymes, Low Platelets (e.g.,
\leq 100{,}000).
Imaging: Ultrasound for placental location, fetal status, uterine contents.
Key Practical Takeaways
Distinguish chronic HTN, gestational HTN, and preeclampsia.
Preeclampsia: Watch for headache, visual changes, RUQ pain, labs.
MgSO4 for seizure prophylaxis; calcium gluconate is the antidote for toxicity.
HELLP syndrome is an emergency; monitor CBC, LFTs.
Placenta