Complications of Pregnancy Susanna R. Magee MD MPH Brown University Department of Family Medicine...
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Transcript of Complications of Pregnancy Susanna R. Magee MD MPH Brown University Department of Family Medicine...
Complications of Pregnancy
Susanna R. Magee MD MPH
Brown University Department of Family Medicine
October 15, 2008
By Trimester
• 1st trimester– LMP date to 12 weeks
• 2nd Trimester– 12-24 weeks
• 3rd trimester– 24 weeks to term– term is 37-42 weeks
• post dates vs. post term
1st trimester
• Nausea and vomiting• Constipation• Low Back Pain• Bleeding
Nausea and Vomiting
• Very common 1 in 3 pregnancies• Likely secondary to high estrogen and high levels
of Human Chorionic Gonadotropin– made by the placenta– peaks at 10 weeks then levels off
• Occasionally needs intensive therapy– loss of more than 10% of body weight– Dehydration– -ketonuria/serum ketones
Nausea and Vomiting
• Treatment varies– dietary options: carbohydrate vs. protein– IV therapy with normal saline or Lactated Ringers to
reverse ketosis– vitamin B6, Unisom, Reglan, H2 Blocker or PPI,
Ondansetron
• Counseling– huge psychological component– maternal guilt, family misunderstanding
Constipation
• Very common complication of pregnancy as well
• Usually starts in 1st trimester• Dietary options as well
– Increased water!– Fiber– Docusate Sodium– Mineral oil
Low Back Pain
• Usually related to the position of the growing fetus or the stretching uterus
• Pressure on the sciatic nerve
• Stretching of the round ligaments
• PT can be very helpful
• Pregnancy support belt
1st trimester bleeding
• Threatened Abortion– bleeding is bright red– usually associated with pain/like menstrual cramping
• Placental formation/implantation– bleeding is usually brownish or pinkish– usually not painful– occurs at 9-10 weeks– subchorionic hemmorhage
2nd trimester
• Round Ligament Pain
• Pre-term Labor
• Abnormal genetic screening tests
Round Ligament Pain
• Usually in nullips
• Related to the round ligaments of the uterus that attach to the abdominal wall stretching with fetal growth
• Can be exquisitely uncomfortable– in differential: appendicitis, colitis, abruption, severe
constipation, UTI, etc.– Treat with Pregnancy Support Belt
• formal and informal types
Preterm labor
• 2 categories– History of preterm labor– Having preterm labor now
History of Preterm Labor
Pre-term Labor Now
• Causes– cervicitis, trauma, urinary infection, abruption, drug
use, polyhydramnios, multiple gestation
• Diagnosis– Fetal fibronectin swab– Cerivcal length ultrasound– check for cervicitis, rupture of membranes– check for dilitation– consider urine toxicology screen
Pre-term Labor
• Treatment oral NIFEDIPINE
• Previously:– Indomethacin (complications)– Bedrest (not effective)– Terbutaline (not effective)
• IM or PO (not a lot of data for the po-hardly used now)• heart rate increases
– Magnesium (not effective)• IV
• flushing, nausea, hyporeflexia, need to watch levels
AFP testing is now COMPLICATED
Genetic Screening
• Integrated screen– NT ultrasound– PAPP- A serum– Correlate with AFP Quad later
• Less false positives• More sensitive
• AFP Quad– Blood test with 4 parts
• Higher false positive• Less sensitive
Abnormal NT/PAPP-A
• Referral to MFM– Amniocentesis– Level 2 ultrasound
– Decisions on pregnancy outcome before 20 weeks in Rhode Island
Abnormal Results AFP Quad
• Test of maternal serum at 15-22 6/7 weeks
• optimal at 16-18 weeks
• screening test--high false positive rate– 4-10%
• 4 hormone levels tested– msAFP, inhibin A, HCG, estradiol
• If abnormal requires further testing with level 2 u/s or amniocentesis
Abnormal AFP
• Interpretation depends on mothers weight and age
• Low levels AFP <0.25 MOM: Down’s syndrome– Trisomy 21
• High Levels AFP >2.5 MOM: Neural tube defects– spina bifida and anencephaly
Abnormal AFP
• Even with normal screen, baby usually normal– 9 times out of 10, the amnio and or level 2 will
be normal
Abnormal AFP
• Other issues that it can predict– Abnormal inhibin A
• IUGR
– Abnormal HCG• risk IUFD--usually followed with weekly testing
3rd trimester
• Placenta Previa
• Gestational Diabetes
• Pre-eclampsia– (think about all these in second trimester, but
usually manifest in third)
Placenta Previa
• Implantation over the cervix– painless vaginal bleeding– vaginal delivery contraindicated
– marginal previa• next to but not quite covering surface• may see a marginal previa on early u/s such as fetal survey
at 18-20 weeks• needs follow up--as uterus grows, placenta often is
dragged up out of the way as muscle stretches
Gestational Diabetes
• All women screened at 26-28 weeks
• Earlier if risk factors
• 50 g glucose load
• Positive: > 130– non-fasting
• If positive, 3 hour OGTT– special diet three days before
– fasting morning of test
– 100 g glucose load
Gestational Diabetes
• Once diagnosis confirmed:– FG = 95, 1 hour > 180, 2 hour > 155, 3 hour > 140
• Treatment:– glucometer, test strips and lancets
• pt checks FG and 2 hours postprandial every day
– VNA to teach patient diet/exercise– call in sugars after 4 days– needs glyburide or insulin when
• FG > 95, PP > 120 (20% values abnormal)
Gestational Diabetes
• If insulin is required, usually use one long acting type and one short acting type.
• NST/AFI weekly• Rule of 1/3• At least one injection/day, may be as many as 4• Signs Symptoms hypoglycemia
– shaky, sweaty, confused, dizziness, passing out– rare in pregnancy
Gestational Diabetes
• Delivery recommended by 40 weeks
• May require induction, especially if uncontrolled sugars
• Risk macrosomia and neonatal hypoglycemia
Preeclampsia
• Triad– edema, proteinuria, hypertension
• Not before 20 weeks
• ? Related to abnormal placental implantation
• Symptoms:– Headache, blurred vision, edema, decreased
urine output, nausea and vomiting
Pre-eclampsia
• Exam:– swelling hands face
• “lion faces”
– hyper-reflexia
– oliguria
Preeclampsia
• Progression slow or speedy• Mild (> 300 mg/24 hour urine) or severe (> 5
grams); no in-between• lab tests can be helpful
– CBC – Bun/Cr– Uric acid– AST/ALT– UA/24 hour urine for protein
Pre-eclampsia
• Treated when severe with Magnesium sulfate infusion to prevent eclampsia
• Only cure is delivery– a patient may have to be induced preterm, or
undergo a c/s depending on severity– Growth restriction is common
Thank You
Good Luck Brown MOMS