Transcript Preterm Pregnancy - Medical Education Online

In the Name of God
Obstetrics Study Guide 3
Mitra Ahmad Soltani
2008
References
•
•
•
•
Iranian Council for graduate Medical Education. Board and pre-board Exam questions
for OBS and Gyn .2001-2006
Panda S . IUGR. Department of Obstetrics & Gynecology Medical College of India
2002
Pritchard JA, MacDonald PC, Gant NF. Williams Obstetrics. 22nd ed. New York,
NY: McGraw-Hill; 2005.
Tan T and Yeo G. IUGR. Current Opinion in Obstetrics and Gynecology 2005, 17: 135142
emedicine e-journal:
•
•
•
•
•
•
Butler J. postterm delivery. emedicine. June 19. 2006
Gaufberg S. Abruptio placenta. emedicine. Aug 29. 2006
Gibson P. HTN in Pregnancy. emedicine. DEC 13 2007
Hernandez E . GTN. emedicine. Jan 26, 2007
Marinnan G. Placenta Previa. emedicine. Aug 26. 2005
Ross M. preterm. emedicine. 31 may 2007
Pictures and material of multiple pregnancy are adapted
with permission from:
•
Zach T. multiple pregnancy.emedicine. Oct 2. 2007
HTN in Pregnancy
classification
• Hypertension is the most common medical problem
encountered during pregnancy, complicating 2-3% of
pregnancies.
• HTN is classified into 4 categories
1) chronic hypertension,
2) preeclampsia-eclampsia,
3) preeclampsia superimposed on chronic hypertension
4) gestational hypertension (transient hypertension of
pregnancy or chronic hypertension identified in the
latter half of pregnancy).
Chronic HTN
• blood pressure exceeding 140/90
mm Hg before pregnancy or before
20 weeks' gestation. It persists after
12 wks postpartum.
Gestational Age
–New-onset or worsening hypertension
after 20 weeks' gestation should lead
to a careful evaluation for
manifestations of preeclampsia.
–The diagnosis of severe hypertension
or preeclampsia in the first or early
second trimester necessitates
exclusion of GTD and/or molar
pregnancy.
Maternal Risk factors
• First pregnancy
• New partner/paternity
• Age younger than 18 or
older than 35 years
• History of preeclampsia
• Family history of
preeclampsia in a firstdegree relative
• Black race
• Obesity (BMI >35)
• Interpregnancy
interval less than 2 years
or more than 10 years
• Chronic hypertension
• Preexisting diabetes (type
1 or type 2)
• Renal disease
• SLE
• Obesity
• Thrombophilia
Placental Risk factor
– Multiple gestations
– Hydrops fetalis
– Gestational trophoblastic disease
– Triploidy
BP measurement
Blood pressure should be measured in the sitting
position, with the cuff at the level of the heart.
Women should be allowed to sit quietly for 5-10
minutes before each blood pressure
measurement.
Korotkoff sounds I (the first sound) and V (the
disappearance of sound) should be used to
denote the systolic blood pressure (SBP) and DBP,
respectively.
Indications of preg. termination
Mild
Severe
Diastolic blood pressure
<100mmhg
110 mmhg or higher
Proteinuria
Trace to 1+
Persistent 2+ or more
Headache
Absent
present
Visual disturbances
Absent
present
Upper abdominal pain
Absent
Present
Oliguria
Absent
Present
Convulsion
Absent
Present
Serum Cr
Normal
Elevated
thrombocytopenia
Absent
Present
Liver enzyme elevation
Minimal
Marked
IUGR
Absent
Present
Pulmonary edema
Absent
present
CBC
• Platelet counts less than 100,000/µL
suggest preeclampsia or ITP.
• Hemoglobin levels greater than 13
g/dL suggest hemoconcentration.
• Low Hbg levels may be due to
microangiopathic hemolysis or iron
deficiency.
Proteinurea
– Trace levels to +1 proteinuria are acceptable, but
levels of +2 or greater are abnormal and should be
quantified with a 24-hour urine collection or spot
urine protein:creatinine ratio.
– In a 24-hour urine collection, the reference range
for protein excretion in pregnancy is up to 300
mg/d.
Protein:Cr ratio
• Creatinine clearance increases approximately
50% during pregnancy, and levels less than
100 mL/min suggest renal dysfunction that is
either chronic or due to preeclampsia.
• protein:Cr ratios appear to be more accurate than
urinalysis, although an abnormal result should still be
confirmed with a 24-hour urine collection.
Coagulation tests
•
•
•
•
•
•
•
•
•
LDH,
bilirubin,
haptoglobin,
fibrinogen,
D-dimers
If:
PT/INR/aPTT results are abnormal,
thrombocytopenia is present,
the hemoglobin level is dropping
Fetal Monitoring
–Alternate a biophysical profile
with a fetal NST twice each
week.
– Ask for Serial fetal ultrasound
starting at 18 weeks.
Methyldopa (Aldomet)
Centrally acting antihypertensive agent widely considered the
first-line agent for treatment of hypertension during pregnancy.
250 mg PO bid/tid; increase q2d prn; not to exceed 3 g/d
Hydralazine (Apresoline)
Intravenous form is useful when treating severe
hypertension due to preeclampsia/eclampsia.
10-20 mg/dose IV q4-6h prn initial; increase to 40 mg
per dose prn
BP >170/110 mm Hg: 0.1-0.2 mg/kg/dose IV q4-6h prn;
not to exceed 20 mg or 1.7-3.5 mg/kg/d IV divided q4-6h
Life-threatening complications in
preeclampsia
•
•
•
•
•
•
•
Seizures
Cerebral hemorrhage
Pulmonary edema
Acute renal failure
DIC
HELLP syndrome
Hepatic infarction/rupture and subcapsular
hematoma
IMP: mild preeclampsia
• General: condition/position/diet =low salt,high prot
• Lab: CBC ,BG, Rh, U/A,24hr urine (prot,cr,vol), BUN/Cr,
PT,PTT,Fib, ALT,AST,Al P, Bil (T, D)
• reserve of 2 units of PC
• IV :Ringer at heparin lock
• OTHER: Control of vital sign q4hrs, control of FHR, FAD chart ,
NST, sono OB, daily weight inform if BP>160/110, blurred
vision, head ache, epigastric pain, seizure
IMP: Severe preeclampsia
•
•
•
•
•
General: condition/position/diet =NPO
Lab: CBC ,BG, Rh, BUN/Cr, PT, PTT,Fib ,ALT,AST,Al P, Bil (T, D)
prep 2 units of PC
IV :Ringer 1000cc +10 u of oxytocin
if BP>160/110,blurred vision, head ache, epigastric pain, seizure then amp
hydralazine 5 mg iv prn
MgSO4 (4 gr) in 200cc DW5% in 20 min then 10 gr(1/2) im in
each buttock then 5 gr im q4h
If platelet is below 100000 then 20 gr in 1000cc infused in
100cc/hrs (check of I/O, RR, DTR, prep CPR set with 2 gr 20%
MgSO4 ready) +Amp Dexa 6 mg bid for 4 doses
OTHER: Control of vital sign q15 min , control of FHR, fix foley,
Preterm Pregnancy
Definition
• Preterm labor is defined as the presence of
uterine contractions of sufficient frequency
and intensity to effect progressive effacement
and dilation of the cervix prior to term
gestation (between 20 and 37 wk).
• It is the leading cause of neonatal mortality.
Causes of preterm Labor
• decidual hemorrhage, (eg, abruption, mechanical factors such
as uterine overdistension from multiple gestation or
polyhydramnios),
• cervical incompetence (eg, trauma, cone biopsy),
• uterine distortion (eg, müllerian duct abnormalities, fibroid
uterus),
• cervical inflammation (bacterial vaginosis [BV], trichomonas),
• maternal inflammation/fever (eg, urinary tract infection),
• hormonal changes (eg, mediated by maternal or fetal stress),
• Uteroplacental insufficiency (eg, hypertension, insulindependent diabetes, drug abuse, smoking, alcohol).
Risk factors of preterm birth
• Demographic factors for preterm labor include
nonwhite race, extremes of maternal age (<17 y
or >35 y), low socioeconomic status, and low
prepregnancy weight.
• Preterm labor and birth can be associated with
stressful life situations (eg, domestic violence;
close family death; insecurity over food, home, or
partner; work and home environment)
• Previous preterm delivery
Methods for predicting preterm birth
• home uterine activity monitoring (HUAM)
• salivary estriol : DHEA increases before the onset of labor. This
results in an increase of maternal estriol.
• FFN is a basement membrane protein that helps bind
placental membranes to the decidua. FFN has a predictive
value in identifying patients who will or will not deliver within
the subsequent 1-2 weeks.
• A short cervical length in the early or late second trimester
has been associated with a markedly increased risk of preterm
labor and delivery.
Contraindication to tocolysis
1-Fetal growth restriction
2-Oligohydramnios
3-Nonreactive NST,Positive CST
4-Absent or reversed diastolic flow upon
Doppler examination of umbilical blood
flow
5-Repetitive severe variable decelerations
6-Significant vaginal bleeding consistent with
abruption.
Definition of IAI
(Intra Amniotic Infection)
A temperature greater than 38.0°C (100.0°F) and
2 of the 5 following signs:
1-WBC > 15,000 cells/mm3
2-Maternal HR> 100 (bpm)
3- Fetal HR> 160 bpm
4-Tender uterus
5-Foul-smelling discharge
Chorioamnionitis Order
• General: condition/position/diet=NPO
• Lab: CBC diff, MP, WW, B/C X2, U/A , U/C,CXR,BUN/Cr
• IV : 1000cc Ringer +10 units of oxytocin start at
2 drops /min, add 2 drops every 15 min if FHR and
contractions are normal
Amp ampicillin 2gr iv qid +gentamicin im 80mg stat then 60
mg TDS
AMP clindamycin 900 mg iv TDS for allergic women to
penicillin(continue antibiotics after delivery until the
mother is a febrile
OTHER: Control of vital sign hourly
IMP:PLP before 37 weeks out patient:
(contractions 4 in 20 min or 8 in 60 min +progressive change in cervix
cervical dilation of more than one
cervical effacement of more than 80 % or greater)
if:
Check of contractions:+
U/A, U/C: Fern:Then: Hydrate and sedate
Stop of contractions: discharge
With:isoxsuprine 10 mg TDS for
10 days
Contractions persist: hospitalize
Next slide
IMP:PLP before 37 weeks, hospitalized
• General: condition/position/diet
• Lab: CBC, BG, Rh, U/A, U/C, fern, reserve of 2 units of PC
• IV :
1-1000cc Ringer free
2-MgSO4 (4 gr) in 200cc DW5% in 20 min then 20 gr in 1000cc infused in
100cc/hrs (check of I/O, RR,DTR, prep CPR set- I/O with measure)
3-Amp pethidine 25 mg iv 25 mg im
4-Amp ampicillin 2 gr IV qid
5-Amp erythromicin 400 mg QID
6- Amp betamethasone 12 mg im, repeat after 24 hrs for GA below 34 wks
• OTHER: Control of vital sign q4hrs, Inform if LP, leakage, VB, ab VS or FHR
Contraindication for beta mimetics
Maternal
• cardiac disease
• Diabetes
• Thyrotoxicosis
• HTN
Contraindication for MgSO4
• Hypocalcemia
• Myasthenia gravis
• Renal failure
Dosage of Ritodrine or Terbutaline for tocolysis
• 50-100 mcg/min increase by 50 mcg/min
every 10 min
• max dose:350mcg/min
If labor is arrested continue the infusion for at
least 12 hrs
• SC:
250 mcg q3-4 hrs
Length of GA with multiple fetuses
• Twin=36 wks
• Triplets=33.5 wks
• Quadruplets=31 wks
Postterm
Definition of postterm
• Postterm pregnancies define
pregnancies extending up to or after
42 weeks.
• The reported frequency is 3-12%.
Cause of postterm P.
• The most frequent cause of postterm
pregnancy is inaccurate dating criteria
• primiparity,
• prior postterm pregnancy,
• male gender of the fetus,
• genetic factors
Risks of postterm P
• Macrosomia complications like shoulder dystocia,
CPD and Maternal risks like an increase in labor
dystocia, perineal injuries, and cesarean
deliveries.
• dysmaturity syndrome: affects 20% of postterm
fetuses and is thought to be caused by chronic
uteroplacental insufficiency resulting in
oligohydramnios, meconium aspiration, and
reversible neonatal complications.
surveillance
• NST and AFI 2 times per week for pregnancies
continuing past 41 weeks.
Intra Uterine Growth Retardation
Definition
• Intrauterine growth restriction (IUGR)
occurs when the unborn baby is at or
below the 10th weight percentile for his or
her age (in weeks). The fetus is affected by
a pathologic restriction in its ability to grow.
•
Low birth weight (LBW) means a baby
with a birth weight of less than 2500Gms,
which could be due to IUGR or Prematurity
Classification
Symmetricl
the baby's head and body
are proportionately small.
may occur when the fetus
experiences a problem
during early development.
Asymmetrical
baby's brain is abnormally
large when compared to the
liver.
may occur when the fetus
experiences a problem
during later development
Etiology of IUGR
Idiopathic- In a majority of cases (40%)
•
•
•
•
•
•
•
Maternal Risk Factors
Has had a previous baby with IUGR
Extremes of age
Small mothers (Ht & Wt)
poor weight gain and malnutrition during preg.
socially deprived
Substance abuse (like tobacco,narcotics, alcohol)
low total blood volume during early pregnancy
•
•
•
•
•
•
•
Maternal Risk Factors
Multiple pregnancy
Living in High altitude locations
Drugs like anticoagulants, anticonvulsants
Cardio-vascular disease:preeclampsia, HTN,
cyanotic heart disease, cardiac disease Gr III &
IV, diabetic vascular lesions
Chronic kidney disease
Chronic infection- UTI, Malaria, TB, genital
infections
Antibody abnormality like antiphospholipid
antibody syndrome, SLE
Fetal Risk Factors
• Intrauterine infection:German measles (rubella),
cytomegalovirus, herpes simplex, tuberculosis, syphilis, or
toxoplasmosis, TB, Malaria, Parvo virus B19.
• Birth defect (cardiovascular, renal, anencephally,
limb defect, etc).
• Chromosome defect(trisomy-18 (Edwards’
syndrome),21(Down’s syndrome), 16, 13, xo (turner’s
syndrome.)
• Primary disorder of bone or cartilage.
• Chronic lack of oxygen during development
(hypoxia).
• Developed outside of the uterus.
• Placenta or umbilical cord defects.
Placental Factors
• Uteroplacental insufficiency:
– Improper / inadequate trophoblastic invasion and
placentation in the first trimester.
• Lateral insertion of placenta.
• Reduced maternal blood flow to the placental bed.
• Fetoplacetal insufficiency due to:
• Vascular anomalies of placenta and cord
• Decreased placental functioning mass:
• Small placenta, abruptio placenta, placenta previa,
post term pregnancy.
Screening:
• US fetal biometry: HC- BPD- AC
• Uterine Doppler studies (Doppler Velocimetry):
bilateral notches and a mean resistance index
of at least 0.55
Or
• Unilateral notches and a mean resistance index
of at least 0.65 at 20 weeks.
• Biochemistry: CRH level at 33 weeks
Neonatal Diagnosis
Low ponderal index (Wt./Fl).
Decreased subcutaneous fat.
Presence / appearance of –
Hypoglycemia,
Hyperbilirubinemia,
Necrotizing enterocolitis,
Hyper viscosity syndrome
Prevention
Strong evidence of benefit only for the following
interventions:
• balanced protein/energy supplementation,
• strategies to reduce maternal smoking,
• antibiotic administration to prevent urinary tract
infections
• antimalarial prophylaxis.
Surveillance
•
•
•
•
Non-Stress Test,
Amniotic Fluid Index,
Doppler of the Umbilical Artery
Biophysical Profile
Surveillance

Amniotic Fluid Index (AFI)
The current recommendations are
that if the AFI decreases below 5
after 35 weeks, then delivery should
occur.
Treatment
• Bed rest
• Aspirin before 20 wk GA
• Nutritional supplementation: zinc , fish oil,
hormones
• Oxygen therapy.
For cases termination is indicated:
• Corticosteroids with a delay in delivery for 2.4 days
• Mode of delivery depends on the bishop score and
IUGR severity
• For dichorionic twins : injection of KCl into the heart
of the weaker fetus ( in most cases management is
expectant)
• For monochorionic twins photocoagulation of
anastomoses or diathermy in cases of TTTS and AAA
Short Term Risks of IUGR for the
neonate
•
•
•
•
•
Meconium Aspiration Syndrome,
infection,
hypoglycemia,
hypothermia,
Sudden Infant Death Syndrome,
Long term Prognosis
• Fetal Death
• low blood sugar
• low body temperature
• abnormal development of the nervous system
Adulthood aftermath :
• CAD
• HTN
• Diabetes II
• Dyslipidemia
• Stroke
• Depression
• Suicide attempts
abruptio
Definition
• Abruptio placentae (ie, placental abruption)
refers to separation of the normally located
placenta after the 20th week of gestation.
• Abruptio placentae occurs in about 1% of all
pregnancies.
Symptoms and signs
– Vaginal bleeding - 80%
– Abdominal or back pain and uterine tenderness 70%
– Fetal distress - 60%
– Abnormal uterine contractions (eg, hypertonic,
high frequency) - 35%
– Idiopathic premature labor - 25%
– Fetal death - 15%
Classification of abruptio
• extent of separation (ie, partial vs
complete)
• location of separation (ie, marginal
vs central)
• Clinical
classification
Class
VB
Uterus
BP-HR coagulopathy
tenderness
0
1
2(I=27%)
mild
mild
Mild-mod
--------mild
Modsevere
NL
NL
Tilt +
3(I=24%)
Mildsevere
tetanic
shock Fib<150 mg/dl
Fetal
distress
--------------------------------------Hypofibrinogene present
mia (ie, 50-250
mg/dL)
death
Causes1
•
•
•
•
•
•
Maternal HTN(44% of all cases)
Maternal trauma
Cigarette smoking
Alcohol consumption
Cocaine use
Advanced maternal age
causes2
• Short umbilical cord
• Sudden decompression of the uterus (eg,
PROM, delivery of first twin)
• Retroplacental fibromyoma
• postamniocentesis
• Idiopathic (probable abnormalities of uterine
blood vessels and decidua)
Imaging Studies
• Ultrasonography is not very useful in
diagnosing placental abruption.
– Retroplacental hematoma may be recognized in 225% of all abruptions.
– Recognition of retroplacental hematoma depends
on the degree of hematoma and on the operator's
skill level.
IMP: R/O abruption
•
•
•
•
•
•
Condition/position/diet:NPO
Lab: CBD-BG-Rh-U/A-U/C-PT-PTT-Fib-FDP-D-DimerPrep 4 units of crossmatched packed red blood cells
Prep 5 units of platelets, prep 10 units of FFP
Continuous high-flow supplemental oxygen
One or 2 large-bore IV lines with normal saline (NS) or
lactated Ringer (LR) solution+10 units of oxytocin in 1 lit of
ringer start at 2 drops/min add 2 drops every 15 min if fetal
heart rate and uterine contractions are favorable.
• perform amniotomy
• Closely observe the patient. Monitor vital signs and urine
output, fetal heart rate and uterine height measurement.
• Prepare OR for emergent C/S
Placenta Previa
subtypes
• (1) complete or total: the placenta covers 360° of
the internal cervical os;
• (2) incomplete or partial: 0°-360° of the internal
cervical os is covered by placental tissue;
• (3) marginal: the placental tissue does not cover
the internal cervical os;
• (4) low lying: the edge of the placenta lies
abnormally close to but does not abut the
internal cervical os.
Risk factors
•
•
•
•
prior placenta previa,
prior cesarean delivery,
increased maternal age,
large placentae (eg, multiple gestations or
erythroblastosis),
• maternal history of smoking.
Frequency
• 1 in 200 deliveries
Vaginal Bleeding
• painless vaginal bleeding during the second
half of pregnancy (70%).
• It can occur without an inciting cause,
although pelvic examination, intercourse, or
labor may provoke it.
• The average gestational age at presentation is
32 weeks.
• Hemorrhage recurs, and, in nearly all cases, it
is more severe the second time.
management
•
•
•
•
•
•
Patients are treated expectantly, with:
volume replacement,
transfusions,
tocolytics,
emergent cesarean delivery
Without endangering the life of the mother,
all attempts are made to delay delivery until
the fetal lungs mature.
Preferred Examination
• Physical examination should be performed
only with a fetus that has achieved pulmonary
maturity and only in a fully staffed operating
room.
Preferred examination
• TA sonography is the test of choice to confirm
placenta previa.
• When the internal cervical os cannot be
visualized or when the results are
inconclusive, transperineal or transvaginal
sonography is recommended as an adjunct.
• No increased risk of hemorrhage has been
associated with transvaginal or transperineal
sonography in this clinical setting.
Blood loss classifications
Class 1
Class 2
Class 3
Class 4
Blood Loss
Volume (mls) in
adult
750mls
800 - 1500mls
1500 - 2000mls
>2000mls
Blood Loss
% Circ. blood
volume
<15%
15 - 30%
30 - 40%
>40%
Systolic Blood
Pressure
No change
Normal
Reduced
Very low
Diastolic Blood
Pressure
No change
Raised
Reduced
Very low /
Unrecordable
Pulse (beats /min)
Slight tachycardia
100 - 120
120 (thready)
>120 (very thready)
Capillary Refill
Normal
Slow (>2s)
Slow (>2s)
Undetectable
Respiratory Rate
Normal
Normal
Raised (>20/min)
Raised (>20/min)
Urine Flow
(mls/hr)
>30
10 - 20
0 - 10
20 med-ed-online
- 30
2007
Estimated
blood loss
Suitable fluid regimes
1000 mls
3000 mls crystalloid
o
r
1000 mls colloid
1500 mls
1500 mls crystalloid & 1000mls
colloid
o
r
4500 mls crystalloid
2000 mls
1000 mls crystalloid, 1000mls colloid
& 2 units blood
o
r
3000 mls crystalloid & 2
units blood
med-ed-online 2007
Multiple pregnancy
Pictures and material of multiple pregnancy are adapted from:
Zach T. multiple pregnancy. emedicine. Oct 2. 2007
with permission
pathophysiology1
• Dizygotic twins(fraternal) are produced when 2
sperm fertilize 2 ova. Separate amnions, chorions,
and placentas are formed in dizygotic twins. The
placentas in dizygotic twins may fuse if the
implantation sites are proximate. The fused
placentas can be easily separated after birth.
• Monozygotic twins (Identical)develop when a single
fertilized ovum splits during the first 2 weeks after
conception. An early splitting (ie, within the first 2 d
after fertilization-30%) of monozygotic twins
produces separate chorions and amnions. These
dichorionic twins have different placentas that can
be separate or fused.
Diamniotic/dichorionic placentation
pathophysiology2
• Later splitting (ie, 3-8 d after fertilization)
results in monochorionic/diamniotic
placentation .
• Approximately 70% of monozygotic twins are
monochorionic/diamniotic.
Diamniotic/monochorionic placentation
pathophysiology3
• If splitting occurs even later (ie, during 9-12 d
after fertilization),
monochorionic/monoamniotic placentation
occurs .
• Monochorionic/monoamniotic twins are rare;
only 1% of monozygotic twins have this form
of placentation.
Monoamniotic/monoamniotic placentation
pathophysiology4
• Monochorionic/monoamniotic twins have a
common placenta with vascular
communications between the 2 circulations.
pathophysiology5
• Trizygotic triplets occur when 3 sperm fertilize
3 ova.
• Dizygotic triplets develop from one set of
monozygotic cotriplets and a third cotriplet
derived from a different zygote.
• Finally, 2 consecutive zygotic splittings with
one split results in a vanished fetus and
monozygotic triplets.
Frequency
• The birth rate of monozygotic twins
is constant worldwide
(approximately 4 per 1000 births).
• Birth rates of dizygotic twins vary by
race. (Highest in Africans and
lowerest in Asians)
mortality
• low birth weight infants( due to prematurity and
(IUGR)
• congenital anomalies,
• placenta previa, abruptio placenta,
• preeclampsia,
• cord accidents,
• malpresentations,
• asphyxia/perinatal depression,
• group B streptococcal (GBS) infections,
• hyaline membrane disease (HMD),
• TTTS.
History
•
•
•
•
•
excessive weight gain,
hyperemesis gravidarum,
sensation of more than one moving fetus
use of ovulation-inducing drugs
family history of dizygotic twins
Neonatal Lab Studies
• CBC count: In TTTS, the donor twin is frequently
anemic at birth. The recipient twin is
polycythemic at birth.
• Calcium level: Hypocalcemia is common in
premature infants, especially the donor twin in
TTTS.
• Glucose level: Hypoglycemia is common in
premature infants, especially if TTTS is present.
• Bilirubin level: Hyperbilirubinemia due to TTTS
may develop in polycythemic infants.
TRAP
• Twin reversed arterial perfusion (TRAP)
sequence occurs when an acardiac twin
receives all of the blood supply from the
normal "pump" twin. This only occurs in
monochorionic twins.
TTTS
• Occurs in monochorionic/monoamniotic or
monochorionic/diamniotic twins. Vascular
anastomoses in the monochorionic placenta
result in transfusion of blood from one twin
(ie, donor) to the other twin (ie, recipient).
Polyhydramnios develops in the sac of the
recipient twin and oligohydramnios develops
in the sac of the donor twin.
Conjoined twins
– Incomplete late division of monozygotic twins
produces conjoined twins.
– Classification:
•
•
•
•
•
Thoracopagus - Joined at chest (40%)
Xiphopagus/omphalopagus - Joined at abdomen (34%)
Pygopagus - Joined at buttocks (18%)
Ischiopagus - Joined at ischium (6%)
Craniopagus - Joined at head (2%)
Discordant
. Birth weight discrepancies of more
than 20-25% are considered
discordant. Discordant birth weights
occur in 10% of twins.
Gestational Trophoblastic Neoplasia
classification
• hydatidiform mole : is the most common form
of gestational trophoblastic neoplasia it can
behave in a malignant or benign fashion,
• invasive mole (chorioadenoma destruens),
• choriocarcinoma,
• and placental site trophoblastic tumor (PSTT).
Clinical course
• In 80% of patients with a benign hydatidiform
mole, serum HCG titers steadily drop to
normal within 8-12 weeks after evacuation of
the molar pregnancy.
• In the other 20% of patients with a malignant
hydatidiform mole, serum HCG titers either
rise or plateau.
staging
•
•
•
•
Stage I – Confined to the uterus
Stage II – Limited to the genital structures
Stage III – Lung metastases
Stage IV – Other metastases
WHO prognostic criteria1
•
•
•
•
Age 40 years or older = 1 point
Antecedent pregnancy terminated in abortion = 1 point
Antecedent full-term pregnancy = 2 points
Interval of 4 months to less than 7 months between
antecedent pregnancy and start of chemotherapy = 1 point
• Interval of 7-12 months between antecedent pregnancy and
start of chemotherapy = 2 points
• Interval of more than 12 months between antecedent
pregnancy and start of chemotherapy = 4 points
WHO prognostic criteria 2
• Beta-HCG level in serum is 1000 mIU/mL but less
than 10,000 mIU/mL = 1 point
• Beta-HCG level in serum is 10,000 mIU/mL but
less than 100,000 mIU/mL = 2 points
• Beta-HCG level in serum is 100,000 mIU/mL or
greater = 4 points
• Largest tumor is 3 cm but less than 5 cm = 1 point
• Largest tumor is 5 cm or greater = 2 points
• Site of metastases is spleen or kidney = 1 point
WHO prognostic criteria3
•
•
•
•
•
•
•
Site of metastases is gastrointestinal tract = 2 points
Site of metastases is brain or liver = 4 points
Number of metastases is 1-4 = 1 point
Number of metastases is 5-8 = 2 points
Number of metastases is more than 8 = 4 points
Prior chemotherapy with single drug = 2 points
Prior chemotherapy with multiple drugs = 4 points
Sign and Symptoms
• Patients with a hydatidiform mole present
with signs and symptoms of pregnancy.
– The most frequent symptom of gestational
trophoblastic neoplasia (GTN) is abnormal uterine
bleeding.
– Patients have a history of amenorrhea.
Occasionally, the typical hydatid vesicles
(edematous villi) are passed through the vagina.
Sign and Symptoms
•
•
•
•
Prolonged hyperemesis gravidarum
preeclampsia
Hyperthyroidism
signs and symptoms associated with the metastatic
disease, such as hematuria, hemoptysis, abdominal
pain, and neurologic symptoms
Physical Exam
• a positive pregnancy test result occurs in the
absence of a fetus.
• vesicles in the vagina is diagnostic
• Enlarged ovaries secondary to theca lutein
cysts are found in up to 20% of cases.
– The cysts regress after evacuation of the
hydatidiform mole for 12 weeks.
Cause
• A hydatidiform mole occurs when a haploid
sperm fertilizes an egg that has no maternal
chromosomes and then duplicates its
chromosomal complement.
– Most complete hydatidiform moles are 46,XX, and all
the chromosomes come from the male.
– Of hydatidiform moles, 10-15% are 46,XY. This occurs
when 2 sperm, 1 carrying an X and the other carrying
a Y, fertilize an "empty" egg.
• Partial moles are 69,XXY, and 2 sets of
chromosomes are of paternal origin.
Medical care1
•
•
•
•
Emergency department care involves :
starting intravenous (IV) fluids (crystalloids)
sending blood for type and antibody screen
Rh-negative patients should receive anti–RhD
immune globulin, such as RhoGAM, if not
already immunized
Medical Care2
• Patients with benign do not require medical
therapy.
• observing patients with weekly serum HCG
titers.
• Only patients with rising or plateauing titers
should be treated with chemotherapy.
Medical care3
• Patients with malignant nonmetastatic or metastatic lowrisk GTN are treated with single-agent chemotherapy like
MTX or actinomycin D in patients with poor liver function
• During treatment, the serum HCG titers are monitored
every week.
• One additional course of chemotherapy is administered
after a normal serum HCG titer.
• After 3-4 normal serum HCG titers, the titers are followed
once per month for 1 year.
• A switch from MTX to actinomycin D is made if the patient
receiving MTX for nonmetastatic or metastatic low-risk GTN
develops rising or plateauing serum HCG titers.
Medical care4
• Patients with high-risk metastatic are
subdivided into 2 groups:
– In patients with a WHO score of less than 8, a
combination of MTX, actinomycin D, and
cyclophosphamide can be used. This is known as
the MAC regimen. This chemotherapeutic regimen
is administered every 19-21 days (from day 1 of
the previous chemotherapy cycle) until the serum
HCG titers normalize.
Medical Care5
– Patients with WHO scores of 8 or higher are
treated with a combination of etoposide, MTX,
and actinomycin D administered in the first week
of a 2-week cycle and cyclophosphamide and
vincristine (Oncovin) administered in the second
week. This is known as the EMA-CO regimen. Two
additional courses of EMA-CO or EMA-CE are
administered after a normal serum HCG titer in
very high-risk patients.
Medical care6
– Patients with metastasis to the brain receive
whole brain irradiation (3000 cGy) in combination
with chemotherapy. Corticosteroids (Decadron)
with systemic effect are administered to reduce
brain edema.
– Patients with liver metastasis are considered for
liver irradiation (2000 cGy).
Surgical care
• The treatment of a hydatidiform mole is
evacuation of the uterus by suction and sharp
curettage.
– To avoid excessive bleeding, oxytocin is
administered intravenously at the initiation of the
suctioning of the uterine contents.
– The largest possible suction curet is used, usually
a 10F or 12F.
Further Care
• Obtain follow-up serum HCG titers :
• once per week until 3-4 normal values are
obtained.
• Then, obtain them once per month for 6
months.
• Have patients use reliable contraception, such
as oral contraceptives or depot progesterone
injections, during the period of follow-up care.
Prognosis1
• Nonmetastatic GTN has a cure rate with chemotherapy of
close to 100%.
• Metastatic low-risk gestational trophoblastic neoplasia has a
cure rate with chemotherapy of close to 100%.
• Metastatic high-risk gestational trophoblastic neoplasia has a
cure rate with chemotherapy of approximately 75%.
• After 12 months of normal HCG titers, less than 1% of patients
with malignant gestational trophoblastic neoplasia have
recurrences.
Prognosis2
• The rate of occurrence of a repeat molar pregnancy is
approximately 1-2%.
• The rate of occurrence of a repeat molar pregnancy in
a patient with a history of 2 previous hydatidiform
moles is approximately 10-20%.
• The pregnancy rate after chemotherapy with MTX and
cyclophosphamide is 80%. Of women treated with
EMA-CO, 46% have had at least 1 live birth after
chemotherapy.
• Patients who become pregnant after treatment for
GTN should have a pelvic ultrasound early during the
pregnancy to confirm that the pregnancy is normal.
PREGNANT DIABETICS
ADAPTATION TO PREGNANCY
• In early pregnancy Estrogen and Progesterone
stimulate beta cell hyperplasia and increased
insulin secretion
• Glycogenolyis and peripheral utilization
increase
• The net result is relative hypoglycemia
GLUCOSE LEVELS IN NORMAL PREGNANCY
• Fasting levels decline by 10 – 11 mg/dl
• Postprandial levels rarely exceed 120-140
mg/dl
• Glucose excursions with meals 30 – 35 mg/dl
• Marked increase in insulin levels with feeding
CHO METABOLISM 20- 24 WEEKS
• Increased human placental lactogen –
diabetogenic
• Increased prolactin – insulin resistance
• Increased cortisol – decreased glycogen
storage
OTHER METABOLIC CHANGES
• Stable amounts of FFA
• Increased cholesterol and TG
• Reduced amino acid levels
MATERNAL COMPLICATIONS
•
•
•
•
Retinopathy
Nephropathy
Chronic hypertension
Preeclampsia
RETINOPATHY
• Remains the leading cause of blindness in
women ages 24-64
• Every patient with pre-gestational diabetes
should have a retinal examination in early
pregnancy
• Laser therapy is safe and effective during
pregnancy
• Has a variable course during pregnancy
NEPHROPATHY
• Accounts for 1/3 of the deaths in diabetics <
31
• Renal findings are present as early as 1-2 years
after diagnosis
• Creatinine clearance may improve in
pregnancy due to increased renal blood flow
• Proteinuria may increase substantially
CHRONIC RENAL FAILURE
• Pregnancy is possible even in patients
requiring hemodialysis
• Reliable contraception is advised
• Fertility and successful pregnancy outcomes
are reduced with serum Cr > 2.0
CHRONIC HYPERTENSION
• Should be aggressively controlled
• ACE inhibitors are contraindicated
• Calcium channel blockers are probably a
reasonable alternative and are safe during
pregnancy
• Increases the incidence of fetal growth
restriction and superimposed preeclampsia
PREECLAMPSIA
• BP > 140/90
• Proteinuria > 300 mg/24 hours or increase in
baseline
• May be difficult to diagnose in the presence of
renal disease and chronic HTN
• 25% incidence of superimposed disease with
CHTN
SEVERE PREECLAMPSIA
•
•
•
•
•
BP > 180/110
Proteinuria > 5 g/24 hours
Lab: elevated LFT’s. thrombocytopenia
Sxs: headache, epigastric pain, blurred vision
Oliguria, pulmonary edema, fetal growth
restriction
PREGNANCY COMPLICATIONS
•
•
•
•
•
•
Hydramnios
Spontaneous abortions
Congenital malformations
Macrosomia
Diabetic ketoacidosis
Neonatal metabolic complications
HYDRAMNIOS
• 1-2 % in normals and 18% of diabetics
• Fetal osmotic diuresis is etiologic
• May also be due to fetal cardiac CNS
malformations
• May be associated with preterm labor
• ?Associated with level of glycemic control
SPONTANEOUS ABORTIONS
• In well controlled patients the rate is similar to
the non-diabetic
• Glycosylated hemoglobin levels are higher in
women who have a SAB
• Higher rates of spontaneous abortion in
diabetics with vascular disease
CONGENITAL MALFORMATIONS
• Associated with periconceptual glucose
control
• In general the rate is 2-3 x that of the nondiabetic gravida
• No increase when the father is diabetic
• “Fuel mediated teratogenesis”
TYPES OF CONGENITAL MALFORMATIONS
•
•
•
•
Fetal cardiac anomalies may be complex
CNS – Spina Bifida, Anencephaly
Caudal regression syndrome
Must consider family history of other
malformations that are unrelated to DM
GLYCOSYLATED HGB AND MALFORMATIONS
• HBA1C <8.5% , 3.4% malformations
• HBA1C > 8.5% , 22.4 % malformations
• Reflects glucose control over the preceeding
60 – 90 days
MACROSOMIA
• Seen more frequently with GDM and IDDM
without vascular complications
• Related to level of 3rd trimester glucose
control
• May occur in up to 25% of diabetics
DIABETIC KETOACIDOSIS
• Seen in type I DM
• Infection, fever, beta – agonists are frequent
predisposing factors
• Suspected with +serum ketones and blood
glucose levels above 300
• Fetal distress is common
NEONATAL METABOLIC COMPLICATIONS
•
•
•
•
•
Hypoglycemia
Hypocalcemia
Hypothermia
Hypomagnesemia
Hyyperbilirubinemia
PRECONCEPTION COUNSELING
•
•
•
•
•
•
•
“Tight” periconceptual control is essential
The diabetes should be stable
Multidisciplinary team maybe helpful
Diabetic education
Dietary counseling
Assessment of renal function
Retinal exam
PRECONCEPTION GLUCOSE CONTROL
•
•
•
•
•
Fasting blood glucose < 100 mg/dl
Pre-meal levels <110 mg/dl
Post-meal levels <140 – 150 mg/dl
Avoid wide swings in control
Normalize hemoglobin A1C
PREVENTION OF MALFORMATIONS
• Normal glucose levels
• Folic acid supplementation
• Dose: 4 mg/day from 1 month pre-pregnancy
to 12 weeks
FOLIC ACID
• All women of reproductive age should
consume at least 0.4 mg of folic acid
• High risk women should consume 4 mg/day
• This reduces the risk of neural tube defects
• Newer evidence suggests a lower risk of facial
clefting and congenital heart disease as well
INDICATIONS FOR HOSPITALIZATION
•
•
•
•
•
Persistent nausea and vomiting
Significant maternal infection
DKA
Poor control/compliance
Preterm labor
ASSESSMENT OF FETAL
WELL-BEING
• Daily fetal movement counting
• Twice weekly NST by 32 weeks
• At least weekly assessment of AFV
OR
• Weekly biophysical profiles
• With more advanced disease, earlier testing is
recommended
FIRST PRENATAL VISIT
• Routine prenatal lab
• Baseline 24 hour UA for protein and Cr
Clearance
• Baseline retinal exam
• EKG
• Thyroid function tests in Type 1 Diabetics
• Hemoglobin A1C
• Schedule 10-12 week USN
EARLY PREGNANCY CARE
•
•
•
•
Diabetic education and dietary instruction
Multi-disciplinary care is helpful
Calibrate reflectance meters
Adjust caloric needs for pregnancy and
lactation
• Review benefits of physical activity
TIMING OF DELIVERY
• Well controlled IDDM: at term
• Poorly controlled: after documentation of fetal
lung maturity
• If fetal surveillance reassuring, delivery before
39 weeks should be unusual
INTRAPARTUM GLUCOSE CONTROL
• No breakfast the morning of induction
• Establish IV with D5/.45% NaCl at 125 cc/hour
• Capillary blood glucose levels every 1 – 2
hours
• Begin continuous infusion of insulin with
levels above 120 mg/dl
• Avoid fluid boluses with D5
SHOULDER DYSTOCIA
BW (g)
No diabetes(%)
Diabetes(%)
< 4000
0.1-1.1
0.6-3.7
4000-4499
1.1-10.0
4.9-23.1
> 4500
4.1-22.6
20.0-50.0
NERVE INJURY
• Rate varies from 4-40% following shoulder
dystocia
• Most (90%) resolve without sequelae
• Can occur with EFW < 4000 g
• Can occur in utero and therefore not
preventable by cesarean
POSTPARTUM GLUCOSE CONTROL
• Insulin requirements may fall 50% in the 1st 24
hours
• Little need for treatment if under 200 mg/dl
CONTRACEPTION
• Reliable contraception should be offered
• Low-dose combination OCP’s do not
significantly impair carbohydrate metabolism
• Progestin only oral contraceptives appear to
accelerate the development of Type 2 DM in
women with gestational diabetes
• Barrier methods and even IUD may be
acceptable
ACOG Low Risk
• Age < 25
• Not a member of an at risk ethnic group
(Hispanic, African, Native American, South or
East Asian, Pacific Islanders)
• BMI < 25 (non-obese)
• No history of abnormal glucose tolerance or
FH
• No adverse outcomes
Screening
• If FBS is 110-126:
• Then 1 hr 50 gr or 3 hrs 100 gr
• remember 105– 195—165---145
Summary
• Every practice should adopt a screening
strategy, either by historical or laboratory
means
• Screening best between 24-28 weeks
• Remember to screen post delivery
Some diabetic cases
Bita Hazrati
A PLP case complicated by HTN and GD
• 24 yrs old
• G2 P1 L0 D1/ first fetal loss due to preterm c/s
delivery
• ( because of placenta previa)
• GA on admission 32-33 w
• CC: LP ( contractions mild/20 seconds D/ 2 in a
• 10- minute interval)
• WB: Intact
• ROM: - ( detected by Fern test)
• Reduced fetal movement: -
• Ph E:
PR= 86/min RR:16/min T:36
BP= 140/90 mmHg
• BS:
FBS=112 /10am=134 /4pm=145 /8pm=163
20-30 units total : 2/3 intermediate
1/3 regular
Morning: 10 units of NPH- 4 units of regular
Afternoon: 4 units of NPH – 4 units of regular
FBS is used to adjust evening NPH
2-hr PP (10 am) is used to adjust morning
Regular
Afternon preprandial (4 pm) is used to adjust
morning NPH
2hr PP is used to adjust evening Regular
What is your management of this combined
case of :
1- preeclampsia
2- GD
3- PLP
Answer:
Mg so4
Ampicillin+ Erythro
Isoxsuprine
Sedation
FBS-BS
NST-FAD-OB US (AFI and GA)
Insulin
Which is true about gestational diabetes?
A-This happens during pregnancy with FBS less
than 105 mg/dl. Its treatment is insulin.
B-It is a kind of type 2 diabetes.
C- All cases will develop overt diabetes within 20
years.
D- It happens because of reduced pancreas b
cell function.
Ans:B
Which is an independent cause of IUFD in diabetes?
A-hydramnios
B-abruptio
C-oligohydramnios
D-oxygen and metabolites transportation
Ans:D
Which is not a good method of contraception in a
diabetic woman?
A-LD OCP
B-medroxy progesterone acetate
C- HD OCP
D-norplant
Ans:C
What is the test for a 30 year old 10 wk pregnant
woman whose FBS is 85/ 2hr PP is 125?
A- 3 hr GTT
B-Repeat of FBS and 2hr PP next week.
C-Repeat of FBS and 2hr PP in 24-28 wk.
D-Repeat of FBS and 2hr PP in 34 wk.
Ans: C
Which is not a cause of PIH for a diabetic pregnant
woman?
A-poor blood glucose control
B-albuminurea
C-high creatinine
D-chronic HTN
Ans: A
What is the most common cause of perinatal mortality
in diabetic pregnancies?
A- malformations
B- RDS
C-metabolic errors
D- IUFD
Ans:A
What is one stage screening test for diabetes in
pregnancy?
A-100 grs oral glucose in 24-28 wk.
B-50 grs oral glucose in 20-22 wk.
C-75 grs oral glucose in 18-20 wk.
D-25 grs oral glucose in 30-32 wk.
Ans:A
What is your plan for a 35 wk diabetic pregnant woman
whose BP is 140/90 mmHg/ is on 60 units of insulin
/FBS=120 mg/dl?
A-increasing the insulin dose
B- no treatment
C-hospitalization and adjusting insulin dose
D-termination of pregnancy
Ans:C
What is your management of a 30 yr old 35 wk
pregnant woman class R diabetic with severe
retinopathy?
A-termination of pregnancy
B-Laser photocoagulation
C- high dose steroids
D-No action is needed now.
Ans:B
Which is not among the complications of type A2
diabetes in pregnancy?
A- macrosomia
B-increased C/S
C- still birth
D-malformations
Ans:D
A woman with a history of gestation diabetes is asking
for follow-up management after her delivery. Her FBS is
108 mg/dl and 2hr PP 135 mg/dl. What do you
suggest?
A-repeat of FBS and 2hr PP a year after delivery.
B- repeat of FBS and 2hr PP 3 yrs after delivery.
C-GTT with 100 grs glucose.
D-HbA1C 6 months after delivery.
Ans:B
In a woman with overt diabetes , BS is reported to be
130 mg/dl . What do you suggest for her IV infusion?
A- RL and DW5%
B-RL and DW5% +insulin 1 unit/hr
C-NS +insulin 1.5 units/hr
D- NS+insulin 2 units/hr
Ans:B
Points to remember about diabetic labor:
•
•
•
•
•
BS below 100 mg/dl : no insulin is needed
100-140 mg/dl:1 unit insulin
140-180 mg/dl:1.5 units insulin
180-220 mg/dl:2 units insulin
More than 220 mg/dl:2.5 units insulin
• BS more than 140 mg/dl needs NS as IV
infusion