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Flashcards in Complications of Pregnancy Deck (87)
1

What is the most common complication of early pregnancy?

Spontaneous abortion

2

1. What is a spontaneous abortion defined as?

2. What is considered a still birth?

3. 80% occur when?

1. Intrauterine pregnancy at less than 20 weeks

2, After 20 weeks considered still birth

3. About 80% occur in the first trimester

3

Etiology of Spontaneous Abortion
8

1. 60% result from chromosomal defects
15% associated with
2. Maternal trauma
3. Infections
4. Dietary deficiencies
5. Diabetes mellitus
6. Hypothyroidism
7. Anatomic malformations – incompetent cervix
8. 25% cannot be determined

4

Biggest Risk Factors For Spontaneous Abortion
3

1. Advanced maternal age

2. Previous spontaneous abortion

3. Maternal smoking

5

Symptoms of Spontaneous Abortion
5

1. Bleeding
(Bright red mostly, Heavy – saturating pads)

2. Midline cramping
3. Low back pain
4. Open or closed cervical os
5. Complete or partial expulsion of products of conception

6

Define the Subtypes of Spontaneous Abortion
1. Threatened?

2. Inevitable?

3. Incomplete?

4. Complete?

5. Missed?

1. Os closed, unpredictable outcome

2. Os open, products of conception have not passed, pregnancy cannot be saved

3. Os open, some products of conception have passed

4. Os may be open or closed, products of conception have passed

5. Pregnancy did not develop

7

Threatened Abortion
Signs
6

1. Slight bleeding
2. Abdominal cramping
3. Cervical os is CLOSED
4. Uterine size compatible with dates
5. No products of conception are passed
6. Prognosis is unpredictable

8

Treatment Measures
Threatened abortion?
9

1. Bed rest from 24 - 48 hours with gradual resumption of usual activities
2. No work, no child care responsibilities
3. Rest in horizontal position, except when bathing or using the toilet
4. No sexual intercourse
5. Antibiotics ONLY if there are signs of infection
6. Hormonal treatment is contraindicated
7. Hydration
8. Explicit instructions on when to report signs and symptoms
9. Definitive follow-up date

9

Inevitable Abortion
signs?
8

1. Moderate bleeding
2. Moderate to severe uterine cramping
3. Low back pain
4. Cervical os is DILATED
5. Membranes may or may not be ruptured
6. Uterine size is compatible with dates
7. Products of conception are not passed, but passage is inevitable
8. Prognosis is poor, pregnancy cannot be saved

10

Incomplete abortion signs?
7

1. Heavy bleeding
2. Moderate to severe abdominal cramping
3. Low back pain
4. Cervical os is DILATED
5. Uterine size is compatible with dates
6. Some portion of the productions of conception (usually the placenta) remain in the uterus
7. Pregnancy cannot be saved

11

Missed Abortion
signs?
6

1. Pregnancy ceased to develop, but products of conception have not been expelled
2. Symptoms of pregnancy disappear
3. Brownish vaginal discharge but no free bleeding
4. Pain does not develop
5. Cervix is semi-firm and slightly dilated
6. Uterus becomes smaller and irregularly softened

12

Treatment measures for Missed, Inevitable, or Incomplete abortion?
3

1. Counseling regarding fate of the pregnancy
2. Assess Rh factor and administer immunoglobulin to Rh negative, unsensitized woman
3. Planning for elective termination


13

Treatment measures for Missed, Inevitable, or Incomplete abortion:
How can we plan for elective termination?
3

1. Empty all products of conception to prevent infection and uterine hemorrhage with D&C
2. Insertion of laminaria to dilate the cervix followed by aspiration is the method of choice for missed abortion
3. Prostaglandin vaginal suppositories are an effective alternative

14

Complete Abortion
signs? 7

1. Bleeding may be heavy or minimal
2. Moderate to severe abdominal cramping
3. Low back pain
4. Fetus and placenta are completely expelled
5. Pain then ceases, but spotting may persist
6. Cervical os may be opened or closed
7. Uterus is normal pre-pregnancy size

15

1. Habitual Abortions
defined as?

2. Three previous pregnancies – _____% chance of carrying a fetus to viability

3. Four or more – _____% chance of carrying a fetus to viability

1. Considered recurrent pregnancy loss/habitual abortions if 3 previous pregnancies

2. 70-80

3. 65-70

16

Evaluation of Suspected Spontaneous Abortion
5

1. History
2. Physical exam including pelvic exam and visualization of cervix
3. +/- Fetal doppler
4. +/- Transvaginal ultrasound
5. +/- Laboratory evaluation

17

What labs would you do for a spontaneous abortion?
2

1. Serum hCG
2. Blood type and antibody screen if suspected RH negative mother

18

Work-up For Recurrent Pregnancy Loss
1. Most useful tests? 3

2. Less useful tests? 4

1. Most useful tests
-Assessment of uterine structure
-Rule out lupus (anticardiolipin antibody, lupus anticoagulant)
-TSH

2. Less useful tests
-Blood glucose
-Genetic (only if other testing is normal)
-Maternal and paternal
-Day 3 FSH levels
Progesterone levels

19

Follow-up of Spontaneous Abortion
1. When?

2. Use contraception until when?

1. GYN exam 2-3 weeks after termination

2. Use contraception for 3 months to allow complete maternal healing and regeneration of endometrial lining

20

What is a major cause of maternal death in the first trimester??

Ectopic Pregnancy

21

Ectopic Pregnancy
1. What is it?
2. Where are the four most common spots?
3. What is inevitable?

-Potentially life-threatening condition
-Incidence is 1 in 80 pregnancies

1. Implantation of fertilized ovum outside of the uterine cavity

2.
-Fallopian tube – most common site (98%)
-Cervix
-Ovary
-In the abdominal cavity

3. Rupture is inevitable

22

Ectopic Pregnancy
1. High risk factors? 5
2. What lowers your risk? 4

1. Risk Factors
-History of genital infections
-History of infertility
-History of tubal pregnancy (ligation or reconstruction)
-History of any ectopic pregnancy
Intrauterine devices
-Lower risk

2. Lower Risk
-Abdominal or pelvic surgery
-History of ruptured appendix
-Intrauterine exposure to DES
-Use of drugs that slow ovum transport (mini-pill)

23

Dietheylstilbesterol (DES)
1. What is it?
2. What was it shown to cause?
3. Daughters of women who took DES during pregnancy may have a slightly increased risk of what?

1. A synthetic form of estrogen
-From about 1940 to 1970, DES was given to pregnant women under the mistaken belief it would reduce the risk of pregnancy complications and losses

2. In 1971, DES was shown to cause a rare vaginal tumor in girls and young women who had been exposed to this drug in utero


3. breast cancer after age 40

24

Natural History of Ectopic Pregnancy
3

1. Rupture - associated with profound hemorrhage that can be fatal

2. Abortion – expulsion of the products of conception through the fimbria and absorption of the tissue

3. Some can spontaneously resolve

25

Classic Presentation of ectopic pregnancy?
7

1. 1-2 months of amenorrhea
2. Morning sickness
3. Breast tenderness
4. Diarrhea, urge to defecate
5. Malaise and syncope
6. Lower abdominal/pelvic pain
(Sudden and severe and Especially adnexal (lateralizing to one side))
7. Referral of pain to shoulder

26

Atypical Presentation
of ectopic pregnancy?
2

1. Vague or subacute symptoms
2. Menstrual irregularity

Remember, signs and symptoms do not always correlate with severity of condition

27

Physical Exam of ectopic pregnancy?
5

1. Vital signs may reveal orthostatic changes

2. Adnexal, cervical motion and/or abdominal tenderness on pelvic exam

Pelvic exam
3. Normal appearing cervix, marked tenderness
4. Vaginal vault may be bloody, usually brick red to brown in color
5. Tender adnexal mass may be palpated

28

Physical Exam of ectopic pregnancy: Which vital signs are abnormal?
2

1. Tachycardia,
2. hypotension

29

Physical Exam
1. First and foremost remember what?

2. What is the only thing that can save them once rupture with hemorrhage has occurred?

3. Pt with what things needs surgery before they bleed out? 3

1. Remember…this can kill your patient

2. Emergency surgery is the only thing that can save them once rupture with hemorrhage has occurred

3. Pt with
-tachycardia,
-hypotension and
-+ pregnancy test needs surgery before they bleed out

30

Differential for ectopic preg?
8

1. PID
2. Ovarian Cyst
3. Ovarian Tumor
4. Intrauterine Pregnancy
5. Recent spontaneous abortion
6. Early hydatidiform degeneration
7. Acute appendicitis
8. Other bowel related disorders

31

Labs for ectopic:
1. B-hCG will be lower or higher?

2. What will the pattern be if you follow it over a few days? 2

3. What will the CBC show?

B-hCG
1. Will be lower than expected for normal pregnancies of the same duration

2. If followed over a few days:
-There may be a slow rise or a plateau rather than the near doubling every 2 days associated with normal PG
-Or falling levels associated with spontaneous abortion.

3. CBC
-May show anemia or slight leukocytosis

Also get an Rh factor

32

1. Imaging for ectopic pregnancy?

2. What will it show?

1. Transvaginal Ultrasound

2. Empty uterine cavity

33

Correlation between U/S and hCG:
An hCG level of 1._____mU/ml with an 2.___________ by U/S virtually diagnostic of an ectopic pregnancy

1. 6,500

2. empty uterine cavity

34

Diagnosis & Treatment
1. What is definitive?

2. Depending on the size of the ectopic and whether or not it has ruptured, what can be performed pelvicscopically? 2

3. May need _________ to manage if severe

1. Laparoscopy is definitive

2.
-salpingostomy with removal of the ectopic or partial or
-complete salpinectomy

3. laparotomy

35

Surgical management
Indications for surgery?
5

1. Hemodynamic instability
2. Impending or ongoing ectopic mass rupture
3. Not able or willing to comply with medical therapy post treatment follow up
4. Lack of timely access for medical care in case of tube rupture
5. Failed medical therapy

36

1. Medical Management of ectopic pregnancy?

2. This is acceptable medical therapy for EARLY ectopic pregnancy who are what? 5

1. Methotrexate given systemically as a single dose or multiple doses

2.
-Hemodynamically stable
-Are willing and able to comply with post treatment follow-up
-Have an hCG ≤ to 5000 mIU/mL
-Have no fetal cardiac activity
-Size of ectopic is

37

Follow-up
for ectopic?
4

1. Rh immunoglobulin for Rh-negative women

2. Contraception for at least 2 months to allow for adequate tissue healing and repair

3. Pelvic rest until b-hcg is negative

4. F/U appointment within 2 weeks of surgery

38

Gestational Trophblastic Disease include what? 4
(what are the two main types?)


Whats the most common type?

1. Hydatidiform mole**
2. Persistent/invasive gestational trophoblastic neoplasia
3. Choriocarcinoma**
4. Placental site trophoblastic tumors


Hydatidiform mole

39

1. Hydatidiform mole is what?

2. Occurs when a single sperm fertilizes an egg without?

3. Partial is what?

4. Complete is what?

1. Benign neoplasm of the chorion in which chorionic villi degenerate and become transparent vesicles containing clear, viscous fluid

2. Occurs when a single sperm fertilizes an egg without a nucleus

3. Partial – a fetus or evidence of an amniotic sac is present

4. Complete – no fetus or amnion is found
-Have a tendency to become choriocarcinoma

40

Hydatidiform Mole
risk factors? 4

1. Low socioeconomic status
2. History of mole
3. Age below 18
4. Age over 40

41

Clinical Presentation
Hydatidiform Mole
10

1. Vaginal bleeding
2. Enlarged uterus
3. Pelvic pressure or pain
4. Theca lutein cysts
5. Anemia
6. Hyperemesis gravidarium
7. Hyperthyroidism (about 5%)
8. Preeclampsia before 20 weeks gestation
9. Vaginal passable of hydropic vesicles
10. No fetal heart tones or fetal activity

42

Hydatidiform Mole
Labs and Imaging
3

1. B-hCG

2. Ultrasound

3. Chest xray

43

What will the following show for Hydatidiform Mole:
1. B-hCG

2. Ultrasound

3. CXR rules out what?

1. Extremely high for gestational age (Above 40,000mU/ml)

2. Absence of gestational sac
Characteristic multiple echogenic region “snowy” within the uterus

3. to rule out pulmonary metastases of trophoblast

44

Treatment of Hydatidiform Mole?
5

1. D & C immediately
2. Pathologic exam on curettings
3. Effective birth control
4. Weekly quantitative B-hCG
5. No pregnancy until hCG levels remain normal for a minimum of 1 year

45

1. If the Hydatidiform Mole is malignant how should we treat?

2. How should we schedule the b-hCG monitoring? 2

3. If levels plateau or begins to rise, should be evaluated with what? 3

1. If malignant = chemotherapy

2.
-After two decreasing weekly tests, interval is increased to monthly x 6 months, then every 2 months for a total of one year
-No further investigation if hCG levels decrease to normal

3.
-chest xray,
-then D&C and
-chemo

46

Choriocarcinoma
1. How common?
2. Prognosis?
3. May follow what? 5
4. What does it cause?

1. Rare
2. Highly malignant GTTD
3. May follow
-HM,
-invasion mole,
-abortion,
-normal pregnancy,
-ectopic pregnancy

4. Causes ulcerating surfaces into the endometrial cavity

47

Choriocarcinoma Treatment
1. TOC?

2. What has little place in treatment for this?
-but when is it indicated?

1. Highly sensitive to chemotherapy, which is the treatment choice

2. Surgery has little place (because of the high vascularity and the effectiveness of chemotherapy)
-It is indicated for tumor resistant to chemotherapy and single metastases persisting despite chemotherapy

48

Summary of First Trimester Bleeding
4 major causes of bleeding?

1. Physiologic
-implantation
2. Ectopic pregnancy
3. Impending or complete abortion
4. Cervical, vaginal or uterine pathology
-Polyps, inflammation, infection, trophoblastic disease

49

Work up for 1st trimester bleeding?
4

1. Assess stability of the patient and degree of bleeding
2. Ultrasound
3. CBC
4. Serial B-hCG if threatened abortion

50

What are the placental problems? 3

1. Placenta Previa,
2. Abruptio Placentae
3. Placenta Accretas

51

1. What is placenta previa?

2. What are the 3 types?

1. Placenta implanted in lower segment of the uterus and extends over or lies proximal to the internal cervical os

2. 3 types
-Total or complete – entire os covered
-Partial – internal os partially covered
-Marginal or low-lying – edge of placenta at os but does not cause obstruction.

52

Risk Factors for Placenta Previa
9

1. Previous placenta previa
2. Multiparity
3. Multiple gestation
4. Previous cesarean section
5. Trauma
6. Smoking
7. Advanced maternal age
8. Infertility treatment
9. Previous intrauterine surgical procedure (myomectomy)

53

Presentation of placenta previa

8

1. Painless bleeding in 3rd trimester
2. Bright red blood
3. May have shock symptoms if bleeding severe
4. VS stable
5. FHT (fetal heart tones) normal
6. Fetal activity present
7. NO vaginal or speculum exam should be done*****
8. Diagnosis best made with ultrasound

54

1. Diagnosis of Placenta Previa?

2. Treatment of Placenta Previa: Acute bleeding episode?
5

1. Diagnosis: ultrasound

2. Acute bleeding episode
-Supportive care to maintain hemodynamic stability
-Fetal heart rate monitor
-IV NS or lactated ringers
-Magnesium sulfate and corticosteroids if in labor and less than 34 weeks
-About half respond to conservative management

55

Treatment of Placenta Previa
1. Indications for delivery (C-section)? 3

2. Conservative management post bleed? 3

1.
-Nonreassuring fetal heart rate
-Life threatening maternal hemorrhage
-Significant vaginal bleeding after 34 weeks

2.
-Sometimes need to be hospitalized until delivery This decision depends on the clinical situation
-At high risk for rebleeding as well as premature rupture of the membranes
-If stable will deliver by c-section at 36-37 weeks

56

1. Abruptio Placentae
(placental abruption)
is what?

2. More frequent when?
3. May occur when?
4. Significant cause of mortality in who? 2

1. Partial or complete detachment of a normally implanted placenta at any time prior to delivery

2. More frequent during 3rd trimester

3. May occur anytime after 20 weeks gestation

4. Significant cause of
-maternal and
-fetal morbidity and mortality

57

Most Common Risk Factors For Placental Abruption
6

1. Previous abruption
2. Abdominal trauma
3. Cocaine
4. Smoking (risk increases by 40% for each pack/day smoked)
5. Eclampsia
6. Pregnancy induced hypertension

58

Placental Abruption
Presentation?
5

1. Vaginal bleeding (Mild to severe (amount does not correlate with degree of separation))
2. Abdominal pain or back pain
3. Uterine contractions
4. Uterine tenderness
5. Nonreassuring fetal heart rate pattern

59

All pregnant women with what? do you have to rule out Placental abruption?
3

1. abdominal pain,
2. uterine contractions and
3. vaginal bleeding need to have this ruled out

60

Complications of Placental Abruption
1. Maternal complications? 5

2. Fetal complications? 5

1.
-Hemorrhagic shock
-Coagulopathy/DIC
-Uterine rupture
-Renal failure
-Ischemic necrosis of distal organs (eg, hepatic, adrenal, pituitary)

2.
-Hypoxia
-Anemia
-Growth retardation
-CNS anomalies
-Fetal death (if 50% of the placenta is separated)

61

Diagnostic Evaluation
of placental abruption? 5

Imaging?

Early markers of ischemic placental disease during routine care:
1. elevated AFP with no other explanation and
2. elevated B-hCG
3. Fibrinogen to evaluate for DIC
-Decreased fibrinogen,
4. elevated fibrin degradation products,
5. elevated D-dimer

Imaging: classic finding is a retroplacental hematoma

62

Tx for placental abruption? 4

What labs should we monitor? 3

Severe abruption may require what?



Note: These patients can have sudden worsening abruption at any time so be prepared for the worst

1. Continuous fetal monitoring
2. IV access for the mother
3. Maintain maternal O2 sats > 95%
4. Treatment of DIC as indicated


1. CBC,
2. Blood type (cross and screen),
3. Coagulation studies (evaluate for DIC)

1. delivery of the baby regardless of gestational age
-If 36 weeks or > then treatment is to deliver

63

Placenta Accretas
1. Definition?
2. 3 forms?
3. Distinguished by what?

1. Definition - the placenta attaches too deeply into the wall of the uterus

2. 3 forms:
placenta accreta
placenta increta
placenta percreta

3. Distinguished by the severity and deepness of the placenta attachment

64

Placenta Accretas
1. All three forms of abnormal placentation are associated with what? 4

2. Rarely, abnormal attachment is seen in the absence of what? 2

1.
-a history of prior cesarean section,
-history of uterine instrumentation
-surgery
-placenta previa


2. prior surgery and in the absence of placenta previa

65

Risks Associated With Placenta Accretas
2

1. Preterm delivery
2. Severe postpartum hemorrhage

66

Placenta Accreta - Treatment
-Little can be done for treatment once placenta accreta has been diagnosed
1. Monitor pregnancy with the intent of what?
2. Unfortunately, placenta accreta may be severe enough that a __________ may be needed

1. scheduling a delivery and using a surgery that may spare the uterus

2. hysterectomy

67

Summary of Bleeding in Pregnancy After The First Trimester
1. What is the go to diagnostic test?
2. Need to rule out what before speculum or vaginal exam?

3. Degree of bleeding in placental abruption does not correlate with what?

4. Continually assess the what of the patient?

1. Ultrasound

2. placenta previa

3. severity

4. hemodynamic status

68

Hyperemesis Gravidarium
1. Defined as?
2. Dx? 2

1. Persistant, severe, intractable vomiting during pregnancy

2.
-Wt loss of 5% or more of pre-pregnancy wt
-+ Ketonuria not from other causes in the 1st trimester

69

Normal nausea and vomiting of pregnancy:
1. Peak incidence of N/V of pregnancy is ___________?

2. Should resolve by when?

1. 8-12 weeks

2. 20 weeks

70

Evaluation of Excessive Nausea and Vomiting During Pregnancy
5

1. Weight
2. Orthostatic vital signs
3. Electrolytes (BMP)
4. Urinalysis (looking for ketones)
5. Obstetrical ultrasound to rule out gestational trophoblastic disease or multiple gestation

71

Hyperemesis Gravidarium Treatment

5

1. Hospitalization with bed rest
2. NPO x 48 hours
3. Maintain hydration and electrolyte balance and vitamins with parenteral IV fluids
4. As soon as possible, place patient on a dry diet consisting of six small feedings daily plus clear liquids
5. After stabilization, patient can be maintained at home even if she requires IV fluids in addition to her oral intake

72

Medical Therapy For Hyperemesis Gravidarium
1. First line? 2
2. Second line? 2
3. Third line or severe?

1. First line
-Vitamin B6 25 mg po TID to QID
-+ Doxylamine -Unisom (OTC) 25mg-50mg po Q4-6 hrs

2. Second line
DC Doxylamine and
-try prochlorperazine (Compazine)
-or metaclopramide (Reglan)

3. Third line or if severe requiring hospitalization due to dehydration
-Odansetron (Zofran)
May be related to cardiac defects and cleft palate

73

Hyperemesis Gravidarium Tx continued:
1. IV fluids with _________ if dehydration is noted
2. _____________ after the 1st trimester
3. What if unable to keep anything down?

1. thiamine

2. Glucocorticoids

3. Total Parenteral Nutrition (TPN)

74

Premature Rupture of The Membranes
1. Dx made how?
2. Specifically what?

1. Diagnosis can be clinical

2. Visualization of fluid in the vagina of a pregnant women who presents with a history of leaking fluid

75

Premature Rupture of The Membranes: Testing?
10

1. pH paper (nitrazine test)
2. Ferning
3. Ultrasound
4. Instillation of indigo carmine into amniotic fluid
5. Placental alpha microglobulin-1 protein assay (Amnisure)
6. Placental fibronectin
7. Injection of indigo carmine into the amniotic fluid
8. Placental alpha microglobulin-1 protein assay (Amnisure)
9. AFP of vaginal secretions
10. Fetal fibronectin (from vaginal secretions)

76

Premature Rupture of The Membranes

pH paper (nitrazine test)
1. Of amniotic fluid is what?
2. Normal vaginal pH?
3. Ferning is what?
4. With the ferning what will the amniotic fluid look like?
5. What will the cervical mucous look like?
6. US done why?

pH
1. of amniotic fluid is 7.0-7.3
2. normal vaginal pH is 3.8

Ferning
3. Fluid from posterior vagina swabbed onto a glass slide and allowed to air dry for 10 min
4. Amniotic fluid = delicate fern pattern
5. Cervical mucous = dense and thick fern pattern

Ultrasound
6. To check for amniotic fluid volume

77

Premature Rupture of The Membranes

Injection of indigo carmine into the amniotic fluid
1. What makes a positive test?
2. Placental alpha microglobulin-1 protein assay (Amnisure) is what?
3. Explain how its done?
4. Fetal fibronectin (from vaginal secretions) if negative it supports what?

Injection of indigo carmine into the amniotic fluid
1. Place tampon in vagina X 20 min – if it turns blue there is a leak

Placental alpha microglobulin-1 protein assay (Amnisure)
2. Immunochromatography
3. Sterile swab placed in vagina X 1 min then into the test vial $$$

Fetal fibronectin (from vaginal secretions)
4. If negative supports no membrane rupture

78

Premature Rupture of The Membranes: Management
1. Once the diagnosis is confirmed determine if the patient and fetus are what?

2. If unstable, manage how?

3. If stable, manage how?

4. Administer what?

5. Deliver when?

1. stable or unstable

2. deliver

3. keep in the hospital until delivery

4.
-antibiotics,
-corticosteroids and
-monitor for stability of mother and baby

5. Deliver at 34 weeks

79

DM
1. Carries an increased risk of congenital abnormalities if the HgBA1C is > ___%
2. Mothers have an increased risk for what?
3. 2X risk of pregnancy induced what? 2

4. Worsening diabetic what? 2

1. 9.5

2. DKA

3. hypertension or pre-eclampsia

4. nephropathy and retinopathy

80

Gestational DM risk to the fetus?
6

1. Risk of congenital anomalies is 6X that of average

2. Cardiac, CNS, renal, limb deformity, sacral agenesis

3. Increased risk of spontaneous abortion and stillbirth

4. Macrosomia (weight > 4000-4500 g)

5. Sometimes uteroplacental insufficiency and IUGR


6. Polyhydramnios (amniotic fluid > 2L)
-Increased risk for placental abruption, preterm labor and post partum uterine atony

81

Neonatal period
The newborn of a mother with DM is at higher risk of neonatal what? 4

1. hypoglycemia,
2. hyperbilirubinemia,
3. hypocalcemia and
4. polycythemia

82

DM management goals?

4

1. Frequent BG monitoring
2. Aim for optimal glucose control through diet, exercise and insulin therapy
3. Insulin requirements increase throughout the pregnancy, most markedly at 28-32 weeks
4. Requires FU every 1-2 weeks for the first 2 trimesters then once weekly for the 3rd

83

Gestational DM
1. Screening ___________ with a what challenge?
2. Fast for this test?

3. If BG > _____ mg/dL then they need a 3 hour glucose tolerance test

1. 24-28 weeks, 50 g one hour oral glucose
2. No need to fast for this test

3. 140

84

DM Management During Pregnancy
1. Mainstay of Gestational DM treatment is what?

Blood sugar goals
2. Fasting?
3. 1hr post prandial ?
4. 2hr post prandial ?
5. If unable to attain goals with diet then move to what? 2

1. diet and to maintain 30kcal/kg of IBW/day

2. less than 95

3. 130-140

4. less than 120

5.
-insulin therapy and now starting to use some
-oral hypoglycemics (glyburide or metformin)

85

Diabetes During Pregnancy
1. Increased risk for what? 2

2. Often induce labor at ___ weeks

3. Babies large due to what?

4. Mother may need an IV drip of ___________ during labor to maintain BG of ____?

5. With GDM the blood sugar may return to normal within ___ hours of delivering the placenta

1.
-UTI and
-pyelonephritis with DM

2. 39

3. increased insulin and other hormonal changes = shoulder dystocia

4. 5% dextrose, 100

5. 2

86

Thyroid Disease
1. Treatment of hypothyroidism is with what?

2. Maternal thyroxine requirements __________ in women with hypothyroidism diagnosed prior to pregnancy

3. Adjust dose at __ week intervals and once stable check a TSH once every _______?

4. Post partum thyroiditis can occur for up to a _______ post delivery (with or without prior hx of hypothyroidism)

1. levothyroxine

2. increase

3. 4, trimester

4. year

87

Thyroid disease:
1. Thyroid binding globulins ________ during pregnancy

2. _______ may increase in the first trimester

3. TSH ________ in the first 10 weeks

4. What disease processes may affect thyroid function? 2


If hyperthyroid pre-pregnancy, likely will need to adjust meds during pregnancy

No routine screening needed just check TSH in those with known thyroid disease

1. increase

2. Free T4

3. decreases

4.
-Gestational trophoblastic disease and
-hyperemesis gravidarium