Breeding TroubleBreeding TroubleEarly Complications & Diabetes Early Complications & Diabetes

Jennifer K. McDonald

Spontaneous AbortionSpontaneous Abortion

Delivery before the 20th completed week of gestation

Implies fetus less than 500 grams

IncidenceIncidence

15% clinically evident pregnancies 60% chemically evident pregnancies

80% occur prior to 12 weeks gestation

EtiologyEtiology

Trimester % Abnormal

1st > 50%

2nd 20-30%

3rd 5-10%

Genetic AbnormalitiesGenetic 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

TerminologyTerminology

Complete abortion Incomplete abortion Inevitable abortion

Missed abortion Septic abortion

Threatened vs InevitableThreatened vs Inevitable

Threatened Abortion20% pregnancies experience 1st trimester bleeding

Cervix remains closed

Inevitable AbortionAbdominal 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 IncompleteComplete vs Incomplete

Complete AbortionPassage of the entire conceptus. Bleeding continues

for short time and pain usually ceases.

Incomplete AbortionProducts of conception have partially passed from theuterine cavity. Cramping usually present. Bleeding

can be severe.

Missed AbortionPregnancy has been retained after the death

of the fetus.

Blighted ovumBlighted ovum

Anembryonic pregnancy Fertilization without subsequent development of embryonic tissue

Maternal FactorsMaternal Factors

Maternal infection Congenital uterine defects (25-50% risk)

Acquired uterine defects (fibroids) Immunologic disorders

Severe malnutrition Toxic factors (radiation, alcohol,

antineoplastic drugs) Trauma

DiagnosisDiagnosis

Vaginal bleeding Abdominal pain

Need to rule out ectopic pregnancy Decreased symptoms of pregnancy

Abnormally rising hCG Abnormal ultrasound findings

TreatmentTreatment

Expectant management D&C

Important to know blood type & Rh Rhogam for Rh - blood types

Recurrent AbortionRecurrent 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 PregnancyEctopic 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 PregnancySites of Ectopic Pregnancy

95% occur in the fallopian tube

AmpullaryAmpullary

AmpullaryAmpullary

• 80-90% of ectopics• Tubal damage minimal

since usually growing outside

lumen• Can open tube to remove

contents (linear salpingostomy)

IsthmicIsthmic

• 5-15% of ectopics

• Grow within tubal lumen

• Usually tube needs to be

resected (salpingectomy)

FimbrialFimbrial

• 5% of ectopics• Partially

extruded ectopic that stays at the end of the tube

Cornual/InterstitialCornual/Interstitial

• 1-2% of ectopics• Growing within muscular wall of

uterus• Removal very

difficult

OvarianOvarian

• <1% of ectopics• Abundant blood

supply• Difficult to save

the ovary

AbdominalAbdominal

AbdominalAbdominal

• Ectopic that has been extruded from tube and implants in the

abdomen• 20x higher

maternal mortality• Often placental tissue left in situ

CervicalCervical

• <1% of ectopics• Abundant blood

supply (uterine vessels)

• Non-surgical methods employed

Heterotopic PregnancyHeterotopic Pregnancy

An ectopic in combination with an intrauterine pregnancy 1 in 15,000-40,000

1% of patients undergoing IVF

Risk FactorsRisk 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

DiagnosisDiagnosis

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 RuptureTiming of Rupture

Isthmic pregnancies rupture earliest 6-8 weeks

Ampullary 8-12 weeks Interstitial pregnancies 12-16

weeks

TreatmentTreatment

Unstable

Stabilize with IV fluids, blood

products Immediate

laparotomy

Stable

Laparoscopyor

Methotrexate injection

MethotrexateMethotrexate

Folate antagonist Destroys proliferating trophoblastic

tissue May be useful in small unruptured

ectopics Relative contraindications

Adnexal mass > 3.5 cm Fetus with cardiac activity

TeratogenesisTeratogenesis

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 20Embryogenic period = week 3 to week 8Fetal period = week 21 to term

Pregnancy CategoriesPregnancy CategoriesA Controlled studies fail to demonstrate riskB 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

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 availableX Studies have confirmed fetal abnormalities. Risk

always outweighs benefit

Diabetes in PregnancyDiabetes in Pregnancy

Chapter 18

StatisticsStatistics

Pre-gestational diabetes 1-3/1000 births

Gestational 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

MetabolismMetabolism

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

22ndnd Trimester 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 DiabetesType 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

AnomaliesAnomalies

I nitial HbA1C % Major Anomalies

< 7.9 3.2%

8.9-9.9 8.1%

> 10 23.5%

Common AnomaliesCommon Anomalies

Caudal regression Neural tube defects

Transposition of the great vessels Ventricular septal defects

Renal agenesis Duodenal atresia

Approach to Prenatal CareApproach 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 GoalsGlucose Goals

Fasting glucose 80-95 mg/dL One hour post-prandial < 130

mg/dL Two hour post-prandial < 120

mg/dL

RetinopathyRetinopathy

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

NephropathyNephropathy 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 DiabetesGestational Diabetes

Screening

~28 weeks 50 gram glucose load followed by

1 hour glucose measurement > 130 requires diagnostic test

Diagnosis GDMDiagnosis GDM8 hour overnight fast

100 gram glucose loadO’Sullivan Carpenter

Fasting 90 95

1 hour 165 180

2 hour 145 155

3 hour 125 140

Need 2 or moreabnormal values

Risk Factors GDMRisk Factors GDM

> 25 years of age Obesity

Family history Previous infant > 4000 grams

Previous stillborn Previous polyhydramnios History of recurrent SABs