SM_209b: Abnormal Pregnancy

Question 1

Abnormalities of pregnancy often result in ____ which is defined as ____

Answer 1

Abnormalities of pregnancy often result in preterm birth which is defined as delivery < 37 weeks gestation

Question 2

Describe preterm birth

Answer 2

Preterm birth

• Birth < 37 weeks of gestation
• Accounts for 85% of perinatal morbidity and mortality
• Neonatal outcome primarily dependent upon gestational age
• Etiologies: spontaneous (70-80%), iatrogenic (20-30%)

Question 3

Describe causes of spontaneous and iatrogenic preterm birth

Answer 3

Spontaneous and iatrogenic preterm birth

• Spontaneous preterm birth: preterm PROM, preterm contraction, cervical insufficiency
• Iatrogenic preterm birth: placental abnormalities (placenta previa, vasa previa, placental abruption), FGR, preeclampsia, isoimmunization

Question 4

Preterm labor is ____

Answer 4

Preterm labor is uterine contractions associated with cervical dilation at < 37 weeks gestation

• Potential contributing mechanisms: uterine overdistention, decline in progesterone action, cervical disease, breakdown of maternal - fetal tolerance, stress, unknown, infection, vascular disorders, decidual senescence

Question 5

Describe prevention of preterm birth

Answer 5

Prevention of preterm birth

• 17 OHP
• Contraception
• Smoking cessation
• Screening and treating asymptomatic bacteriuria
• Treat symptomatic BV
• Single embryo transfer
• Vaginal progesterone

Question 6

Management of preterm labor involves ____, ____, and ____

Answer 6

Management of preterm labor involves administering steroids for fetal benefits (consideration of tocolysis), administering PCN for GBS chemoprophylaxis, and administering magnesium for fetal neuroprotection

• Goals of diagnosis: diagnose and treat underlying cause, transfer to facility with appropriate NICU, medically optimize fetus for potential delivery

Question 7

Cervical insufficiency is an ____ defined as ____ usually occuring in ____

Answer 7

Cervical insufficiency is an incompetent cervix defined as painless cervical dilatation in the abscence of contractions usually occurring in the mid-trimester (16-24 weeks)

Question 8

Risk factors for cervical insufficiency are ____, ____, and ____

Answer 8

Risk factors for cervical insufficiency are prior history of cervical insufficiency, multiple gestation, and connective tissue disorders

Question 9

Describe stages of cervical distensibility

Answer 9

Stages of cervical distensibility

1. Softening
2. Ripening
3. Dilation
4. Repair

Question 10

___ is used to treat cervical insufficiency

Answer 10

Cerclage is used to treat cervical insufficiency

Question 11

Describe indications and contraindications for cerclage

Answer 11

Cerclage

Emergent: ultrasound or physical exam based

Prophylactic: done if history suggestive of diagnosis of cervical insufficiency

Contraindications: contractions / labor, PPROM, infection, fetal demise, and major fetal anomaly

Question 12

Premature rupture of membranes (PROM) is ____

Answer 12

Premature rupture of membranes (PROM) is rupture of membranes prior to the onset of labor at any gestational age

Question 13

Preterm premature rupture of membranes (PPROM) is ____

Answer 13

Preterm premature rupture of membranes (PPROM) is rupture of membranes prior to onset of labor and before 37 weeks gestational age

Question 14

Preterm premature rupture of membranes (PPROM) possible contributing mechanisms are ____ and ____

Answer 14

Preterm premature rupture of membranes (PPROM) possible contributing mechanisms are alteration in cervical stromal composition and induction of amniotic membrane matrix metalloproteinases

Question 15

Preterm premature rupture of membranes (PPROM) diagnosis involves ____

Answer 15

Preterm premature rupture of membranes (PPROM) diagnosis involves sterile speculum exam

• Vaginal pooling
• Basic pH of fluid
• Microscopic ferning pattern

Question 16

Describe expectant management and delivery of preterm premature rupture of membrane (PPROM)

Answer 16

Expectant management and delivery of preterm premature rupture of membrane (PPROM)

• Expectant management: preterm labor (2/3 within 7 days, 1/2 of these within 2 days), infection, placental abruption, IUFZG
• Delivery: prematurity

Question 17

Describe management of preterm premature rupture of membrane (PPROM)

Answer 17

Management of preterm premature rupture of membrane (PPROM)

• Confirm gestational age
• If < 34 weeks and no contraindications, expectant management w/ antibiotics ( 7 day course promotes gestational latency) and administration of steroids
• Initiate fetal surveillance
• Contraindications for expectant management: labor, significant vaginal bleeding, infection

Question 18

Placenta previa is ____ that presents with ____

Answer 18

Placenta previa is implantation of placenta in a location where it covers the cervical os that presents with painless bright red vaginal bleeding

• Accounts for 20% of third trimester bleeding

Question 19

Describe risk factors for placenta previa

Answer 19

Placenta previa risk factors

• Prior cesarean section
• Multiparity
• Advanced maternal age
• Prior placenta previa
• Smoking
• Multiple gestation

Question 20

Describe goals of diagnosis and possible complications of placenta previa

Answer 20

Diagnosis and possible complications of placenta previa

• Awareness: pelvic rest
• Expectant management: administration of antenatal corticosteroids if appropriate
• Planned c-section at 37 weeks gestation
• Possible complications: maternal hemorrhage, placenta accreta

Question 21

Placenta accreta is ____ that commonly results from ____

Answer 21

Placenta accreta is when the placenta grows too deeply into the uterine wall that commonly results from placenta previa

• May cause severe blood loss after delivery

Question 22

Vasa previa is ____ that presents with ____

Answer 22

Vasa previa is a fetal vessel transversing the cervical os that presents with vaginal bleeding that is arising from fetal vessels (i.e. fetal blood)

• Fetal blood volume: ~ 100 cc/kg

Question 23

Describe diagnosis of vasa previa

Answer 23

Vasa previa

• Apt test shows fetal Hb resistant to lysis by alkaline solution
• Crash c-section
• Improved prenatal diagnosis with ultrasound

Question 24

Apt test demonstrating fetal Hb resistant to lysis by alkaline solution is ____

Answer 24

Apt test demonstrating fetal Hb resistant to lysis by alkaline solution is vasa previa

Question 25

Placental abruption is ____ characterized by \_\_\_\_

Answer 25

Placental abruption is premature separation of placenta from uterine characterized by vaginal bleeding in the presence of uterine contraction

Question 26

Describe risk factors for placental abruption

Answer 26

Risk factors for placental abruption * HTN * Prior placental abruption * Abdominal trauma * Smoking * Cocaine * Submucosal fibrois * PPROM

Question 27

Placental abruption management involves ____ and \_\_\_\_

Answer 27

Placental abruption management involves administration of antenatal steroids if appropriate and delivery based upon maternal and fetal status

Question 28

Fetal growth restriction is \_\_\_\_

Answer 28

Fetal growth restriction is fetus \< 10% percentile for given gestational age

Question 29

Describe causes of fetal growth restriction

Answer 29

Fetal growth restriction causes * Fetal: aneuploidy, anomalies, infection (TORCH), multiple gestation * Placental: uteroplacental insufficiency * Maternal: malnutrition, illicit drug use, smoking, maternal medical conditions

Question 30

Describe diagnosis of fetal growth restriction

Answer 30

Fetal growth restriction diagnosis * Suspected size \< dates on fundal height measurement * Ultrasound * Goals of diagnosis: counseling patients regarding prognosis and if applicable options regarding pregnancy management, institution of appropriate antenatal surveillance, administration of steroids if appropriate

Question 31

Preeclampsia is \_\_\_\_

Answer 31

Preeclampsia is new-onset HTN accompanied by proteinuria

Question 32

Describe severe preeclampsia

Answer 32

Severe preeclampsia * BP \> 160/110 on two occassions at least 4 hours apart * Maternal symptoms: headache, visual changes, RUQ pain * Hepatic injury / failure * Renal dysfunction / failure * Pulmonary edema Coagulopathy * HELPP syndrome * Eclampsia

Question 33

Definitive therapy for preeclampsia is \_\_\_\_

Answer 33

Definitive therapy for preeclampsia is delivery * Need to balance risks of prematurity with risks to maternal and fetal health with expectant management * Control BPs * Prevent eclampsia -\> MgSO4

Question 34

Rh alloimmunization is \_\_\_\_

Answer 34

Rh alloimmunization is exposure of Rh negative mother to Rh positive fetal blood resulting in maternal production of antibodies against the D antigen

Question 35

Rh alloimmunization is prevented by \_\_\_\_

Answer 35

Rh alloimmunization is prevented by administration of Rh immune globulin to all pregnant women who are Rh negative (unless certain that father is Rh negative) * 28 weeks * After delivery * Concerns for breakage in feto-maternal barrier

Question 36

Describe Rh alloimmunization management strategies

Answer 36

Rh alloimmunization management strategies * Paternal phenotype / genotype * Fetal antigen status (amniocentesis, cell free DNA) * Serial antibody titers * Fetal MCA doppler peak systolic velocity indices * Periumbilical cord blood sampling with intrauterine transfusion

Question 37

Spontaneous abortion is ____ that presents as \_\_\_\_, \_\_\_\_, and \_\_\_\_

Answer 37

Spontaneous abortion is pregnancy loss \< 20 weeks gestation that presents as vaginal bleeding, pelvic pain, or as an incidental finding on ultrasound

Question 38

Stillbirth is \_\_\_\_, which is when \_\_\_\_

Answer 38

Stillbirth is intrauterine fetal demise, which is when pregnancy loss is at ≥ 20 weeks gestation