Transcript Breeding Trouble Early & Late Pregnancy Complications

Breeding Trouble
Early Complications & Diabetes
Jennifer K. McDonald
Spontaneous Abortion
 Delivery
before the 20th completed
week of gestation
 Implies
fetus less than 500 grams
Incidence
 15%
clinically evident pregnancies
 60% chemically evident pregnancies
 80% occur prior to 12 weeks
gestation
Etiology
Trimester
% Abnormal
1st
> 50%
2nd
20-30%
3rd
5-10%
Genetic Abnormalities
Aneuploidy = abnormal number of chromosomes
 Autosomal
trimsomies 50% losses
 Trisomy 16 most common autosomal trisomy
 Monosomy X (Turners) = most common
aneuploidy (20%)
 Polyploidy found in 20% miscarriages
Typically results in blighted ovum
Terminology
 Complete
abortion
 Incomplete abortion
 Inevitable abortion
 Missed abortion
 Septic abortion
Threatened vs Inevitable
Threatened Abortion
20% pregnancies experience 1st trimester bleeding
Cervix remains closed
Inevitable Abortion
Abdominal or back pain and bleeding with an open cervix.
Abortion is inevitable when cervical dilation, effacement,
and/or rupture of membranes is present
Complete vs Incomplete
Complete Abortion
Passage of the entire conceptus. Bleeding continues
for short time and pain usually ceases.
Incomplete Abortion
Products of conception have partially passed from the
uterine cavity. Cramping usually present. Bleeding
can be severe.
Missed Abortion
Pregnancy has been retained after the death
of the fetus.
Blighted ovum
 Anembryonic
pregnancy
 Fertilization without subsequent
development of embryonic tissue
Maternal Factors
 Maternal
infection
 Congenital uterine defects (25-50% risk)
 Acquired uterine defects (fibroids)
 Immunologic disorders
 Severe malnutrition
 Toxic factors (radiation, alcohol,
antineoplastic drugs)
 Trauma
Diagnosis
 Vaginal
bleeding
 Abdominal pain
 Need to rule out ectopic pregnancy
 Decreased symptoms of pregnancy
 Abnormally rising hCG
 Abnormal ultrasound findings
Treatment
 Expectant
management
 D&C
 Important
to know blood type & Rh
 Rhogam for Rh - blood types
Recurrent Abortion
3
or more consecutive losses before
20 weeks gestation
 Incidence 0.4-1%
Recurrence risk higher if the embryo
has a normal karyotype
Ectopic Pregnancy
 Leading
cause of pregnancy related
death in the 1st trimester
 9% of all pregnancy related deaths
 1% of pregnancies
 Increasing over past 10 years
Sites of Ectopic Pregnancy
95% occur in the fallopian tube
Ampullary
Ampullary
• 80-90% of ectopics
• Tubal damage minimal since
usually growing outside lumen
• Can open tube to remove
contents (linear salpingostomy)
Isthmic
• 5-15% of ectopics
• Grow within tubal
lumen
• Usually tube needs
to be resected
(salpingectomy)
Fimbrial
• 5% of ectopics
• Partially extruded
ectopic that stays at
the end of the tube
Cornual/Interstitial
• 1-2% of ectopics
• Growing within
muscular wall of
uterus
• Removal very
difficult
Ovarian
• <1% of ectopics
• Abundant blood
supply
• Difficult to save
the ovary
Abdominal
Abdominal
• Ectopic that has
been extruded from
tube and implants in
the abdomen
• 20x higher
maternal mortality
• Often placental
tissue left in situ
Cervical
• <1% of ectopics
• Abundant blood
supply (uterine
vessels)
• Non-surgical
methods employed
Heterotopic Pregnancy
 An
ectopic in combination with an
intrauterine pregnancy
 1 in 15,000-40,000
 1% of patients undergoing IVF
Risk Factors
History of sexually transmitted diseases or PID
 Prior ectopic pregnancy
 Previous tubal surgery
 Prior pelvic or abdominal surgery resulting in
adhesions
 Endometriosis
 In vitro fertilization or other ART
 Congenital abnormalities of the fallopian tubes
 Use of an IUD

Diagnosis
 Abdominal
pain (90-100%)
 Vaginal bleeding (75%)
 No evidence of intra-uterine pregnancy on
ultrasound (hCG 1500-2000 mIU/mL)
 Abnormally rising hCG
 Abnormal hematocrit
Timing of Rupture
 Isthmic
pregnancies rupture earliest
6-8 weeks
 Ampullary 8-12 weeks
 Interstitial pregnancies 12-16 weeks
Treatment
Unstable
 Stabilize
with IV
fluids, blood
products
 Immediate
laparotomy
Stable
Laparoscopy
or
 Methotrexate
injection

Methotrexate
 Folate
antagonist
 Destroys proliferating trophoblastic tissue
 May be useful in small unruptured ectopics
 Relative contraindications
Adnexal mass > 3.5 cm
Fetus with cardiac activity


Teratogenesis
Effect of a teratogen is dependent on
when the drug is given during the
pregnancy
 Incidence of major structural anomalies
~6%

Pre-implantation = conception to week 20
Embryogenic period = week 3 to week 8
Fetal period = week 21 to term
Pregnancy Categories
A
B
Controlled studies fail to demonstrate risk
C
Studies in animals showed an adverse effect or no
controlled studies available in women. Use when benefit
justifies potential risk to the fetus
D
Positive evidence of human fetal risk. May be
acceptable in a life threatening situation if better
options not available
X
Studies have confirmed fetal abnormalities. Risk always
outweighs benefit
Animal reproductive studies failed to identify a risk but
there are no controlled studies in pregnant women or
animal studies showed an effect that was not confirmed
in human studies
Diabetes in Pregnancy
Chapter 18
Statistics
 Pre-gestational
 Gestational
diabetes 1-3/1000 births
diabetes = any degree of
glucose intolerance with first recognition
during pregnancy
 Complicates 4% of pregnancies
 Diabetic women 4x more likely to develop
pre-eclampsia
 Twice as likely to have an SAB
Metabolism
 HPL
and cortisol normally lower glucose
levels, promote fat deposition and
stimulate appetite
 Rising estrogen & progesterone increase
insulin production and tissue sensitivity
 Overall result is lowered glucose levels
 70-80 mg/dL by 10th week
 Also decrease in postprandial glucose levels
2nd Trimester
 Fasting
and post-prandial levels rise
 Facilitates transfer of glucose across the
placenta (facilitated diffusion)
 Fetal levels 80% of maternal levels
 HPL rises steadily through 2nd & 3rd
trimesters
 Cortisol levels rise stimulating endogenous
glucose production & glycogen storage
Type 1 Diabetes
Cellular mediated autoimmune destruction of the 
cells of the pancreas
 Incidence 0.1-0.4%
 One of most common maternal disorders resulting
in anomalous offspring
 6-10% (2-3x general population)
 Incidence of malformations directly related to
level of glucose over embryonic period

Anomalies
Initial HbA1C
% Major Anomalies
< 7.9
3.2%
8.9-9.9
8.1%
> 10
23.5%
Common Anomalies
 Caudal
regression
 Neural tube defects
 Transposition of the great vessels
 Ventricular septal defects
 Renal agenesis
 Duodenal atresia
Approach to Prenatal Care
 Ideally
pre-conceptual care
 Normalization of blood sugars
 Initiation of prenatal vitamins with 400 g
folic acid
 Dilated eye exam
 Baseline labs: HbA1C, thyroid studies, 24
hour urine
Glucose Goals
 Fasting
glucose 80-95 mg/dL
 One hour post-prandial < 130 mg/dL
 Two hour post-prandial < 120 mg/dL
Retinopathy
 Diabetic
retinopathy leading cause of
blindness between ages 24-64
 Some form in 100% of patients with
Type 1 DM for 25 years or more
 5% of patients with background
retinopathy experienced worsening
during pregnancy with improvements
following delivery
Nephropathy
 Peak
incidence of nephropathy after
16 years of DM
 Renal blood flow and GFR increase
30-50%
 3rd trimester mean arterial pressure
and PVR increase
 Women with microvascular disease
experience worsening renal function
Gestational Diabetes
Screening
 ~28
weeks
 50 gram glucose load followed by 1
hour glucose measurement
 > 130 requires diagnostic test
Diagnosis GDM
8 hour overnight fast
100 gram glucose load
O’Sullivan Carpenter
Need 2 or more
abnormal values
Fasting
90
95
1 hour
165
180
2 hour
145
155
3 hour
125
140
Risk Factors GDM
>
25 years of age
 Obesity
 Family history
 Previous infant > 4000 grams
 Previous stillborn
 Previous polyhydramnios
 History of recurrent SABs