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Lecture 53
Obstetrics and Gynecology
Pre-eclampsia 8 12
Stillbirth 5.7 10.4 (4.7)
Neonatal mortality 4.7 12.2 (3.3)
Macrosomia 10 25-42
Shoulder Dystocia 5-7 31
Anomalies 2-3 7-9
Diabetic Embryopathy
Incidence 6-10% (vs 3% in general population)
Related to HbA1c
Major congenital
Initial Maternal
Malformations
HbA1c
(%)
≤ 7.9 3.2
≥ 10 23.5
Screening for Gestational Diabetes
Screening Criteria
1 hour glucose with 50-g load
140 mg/dl: 10-15% need 3 hour, 80% sensitivity
135 mg/dl: 20-25% need 3 hour, 98% sensitivity
A. 10-16 weeks
B. 20-24 weeks
C. 24-28 weeks
D. 33-36 weeks
At what gestational age should laboratory
testing for gestational diabetes (50 Gr glucose
challange test) be performed?
A. 10-16 weeks
B. 20-24 weeks
C. 24-28 weeks
D. 33-36 weeks
A pregnant woman not previously known to be diabetic,
who is at 26 weeks’ gestation, had a routine 50-g (GTT)
with a 1- hour blood glucose value of 144 mg/dL. A
follow-up 100-g, 3-hour oral GTT revealed plasma values
of fasting blood sugar of 102; 1 hour, 180; 2 hours, 162;
and 3 hours, 144.You should do which of the following?
a. drug abuse
b. systemic lupus erythematus
c. preeclampsia or eclampsia
d. sickle-cell disease
e.dehydration
Before we continue….
what is the most common cause of acute
renal failure in pregnancy?
a. drug abuse
b. systemic lupus erythematus
c. preeclampsia or eclampsia
d. sickle-cell disease
e.dehydration
Preeclampsia and Eclampsia
Preeclampsia: New-onset hypertension (SBP ≥
140 mmHg or DBP ≥ 90 mmHg) and proteinuria (>
300 mg of protein in a 24-hour period) occurring at >
20 weeks’ gestation.
Preeclampsia:
If the patient is close to term or preeclampsia worsens, induce
delivery with IV oxytocin, prostaglandin, or amniotomy.
Ectopic Pregnancy
Placenta Previa, Abruptio Placentae
Intrauterine Growth Restriction
Polyhydramnios, Oligohydramnios
Rh Incompatibility
Gestational trophoblastic disease
Ectopic Pregnancy
Any pregnancy that occurs outside of the uterine cavity
Tubal
Ampulla (55%)
Isthmus (25%)
Fimbria (17%) 97%
Cervical
Ovarian
Abdominal 3%
Ectopic Sites
Ectopic Pregnacy
1.9% of reported pregnancies
Abdominal pain
Vaginal bleeding
Approx 7 weeks after amenorrhea
Ectopic Pregnancy
Differential Diagnosis
Acute appendicitis
Miscarriage
Ovarian torsion
Pelvic inflammatory disease
Ruptured corpus luteum cyst or follicle
Tubo-ovarian abcess
Urinary calculi
Ectopic Pregnancy Exam Findings
Vaginal bleeding
Proceed as follows:
First step: + pregnancy test and a
transvaginal ultrasound showing an empty
uterus.
Second step: Confirm with a serial hCG without
appropriate hCG doubling.
Ectopic Pregnancy Diagnositc Tests
Ultrasound (test of choice)
No intrauterine gestational sac
bHCG
Do not increase appropriately
Urine pregnancy test
Pregnant / not pregnant
Progesterone level (less reliable)
Ectopic Pregnancy Treatment
5/1,000 deliveries
Maternal mortality rate of 0.03%
Placenta Previa
Total placenta previa
internal os is completely covered by the placenta
Partial placenta previa
internal os is partially covered by the placenta
uterus enlarges, placental site moves cephalad
Marginal placenta previa
placenta is at the margin of the internal os
Low-lying placenta previa
placenta is implanted in the lower uterine segment
edge of the placenta is near the internal os but does not reach it
Placenta Previa Risk Factors
Prior previa
Multiparity
Multiple gestations
Advanced maternal age
Previous cesarean delivery
Prior induced abortion
Smoking
Placenta Previa Presentation
History Exam Findings
Vaginal bleeding Profuse hemorrhage
Bright red and painless Hypotension
(recurrent) Tachycardia
Occurs on average at 27-
Soft and nontender uterus
32 weeks' gestation
Normal fetal heart tones
Contractions may or may
not occur simultaneously (usually)
with the bleeding
Placenta Previa Differential
Abruptio Placenta
Disseminated Intravascular Coagulation
Pregnancy, Delivery
Vasa previa
Infection
Vaginal bleeding
Lower genital tract lesions
Bloody show
Placenta Previa Diagnosis
Ultrasound
Management
<37 weeks without hemorrhage
expectant management
Hemorrhage or >37 weeks and in labor
delivery
C-section
trial of labor may be considered for anterior
marginal previa
Abruptio Placentae
Separation of the normally located placenta
after the 20th week of gestation (prior to birth)
1% of all pregnancies
Class 0
Asymptomatic
Diagnosis is made retrospectively
organized blood clot or a depressed area
on a delivered placenta
Abruptio Placentae (Class 0-3)
Class 1
Mild
~48% of all cases
Characteristics :
No vaginal bleeding to mild vaginal bleeding
Slightly tender uterus
Normal maternal BP and heart rate
No coagulopathy
No fetal distress
Abruptio Placentae (Class 0-3)
Class 2
Moderate
~27% of all cases
Characteristics:
Vaginal bleeding: none to moderate
Moderate-to-severe uterine tenderness with
possible tetanic contractions
Maternal tachycardia with orthostatic changes in BP
and heart rate
Fetal distress
Hypofibrinogenemia (ie, 50-250 mg/dL)
Abruptio Placentae (Class 0-3)
Class 3
Severe
~24% of all cases
Characteristics:
vaginal bleeding: none to heavy
Very painful tetanic uterus
Maternal shock
Hypofibrinogenemia (ie, <150
mg/dL)
Coagulopathy
Fetal death
Abruptio Placentae Causes
Sudden decompression of
Maternal hypertension
(44%) the uterus
Maternal trauma (1.5- premature rupture of
9.4%) membranes, delivery of first
MVA, assaults, falls twin
Cigarette smoking Retroplacental bleeding
Alcohol consumption from needle puncture
Cocaine use postamniocentesis
Short umbilical cord Idiopathic
Advanced maternal age probable abnormalities of
Retroplacental uterine blood vessels and
fibromyoma decidua
Abruptio Placentae Complications
Maternal Fetal complications
complications Hypoxia
Hemorrhagic shock Anemia
Coagulopathy/DIC
Growth retardation
Uterine rupture
CNS anomalies
Renal failure
Fetal death
Ischemic necrosis of
distal organs (eg, hepatic,
adrenal, pituitary)
Intrauterine Growth Restriction (IUGR)
Defined as an EFW less than the 10th percentile
for GA.
Steroid therapy
enhance fetal lung maturity if preterm labor is
expected
Genetic counseling
if congenital anomaly is present
Oligohydramnios
Inadequate levels of amniotic fluid
results in poor development of the lung
tissue and can lead to fetal death
Increased risk of
Pulmonary hypoplasia
Meconium staining of the amniotic fluid
Fetal heart conduction abnormalities
Poor tolerance of labor
Lower Apgar scores
Fetal acidosis
Intrauterine growth restriction (IUGR)
Oligohydramnios Complications
Fetal distress before or during labor
Meconium
potential for aspiration
Fetal infection
(prolonged rupture of the membranes)
Oligohydramnios Management
Rule out inaccurate gestational dates.