Pregnancy Complications

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Pregnancy Complications

• Anna Mae Smith, MPAS, PA-C
• Lock Haven University of PA
• Physician Assistant Program

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FIRST TRIMESTER

• Characterisitcs
• Abdominal Pain
• Vaginal Bleeding
• Uterus smaller than expected
• Uterus larger than expected
• Fetal heartbeat not audible with hand held
  doppler after 10-12 weeks

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Differential Diagnosis Of 1st Trimester Pain or
Bleeding

• Pregnancy related
• NORMAL IUP
• Threatened miscarriage (abortion)
• Complete abortion
• Incomplete abortion with retained products
• Subchorionic hemorrhage
• Missed Ab, embryonic demise, embryonic absorption
• Blighted ovum
• Hydatiform mole
• Ectopic pregnancy

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Non-Pregnancy Related

• Appendicitis
• Adnexal torsion
• Tubo-ovarian abscess/infection
• Ureteral stone with colic
• Cystitis or pyelonephritis
• Ruptured ovarian cyst
• Corpus luteum cyst

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History

• LMP PMP
• Previous preg. History
• OCP use
• Meds
• Febrile illness
• Abortion attempts
• Hx of tubal surgery, PID, IUD

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History

• Onset, severity, duration of pain
  bleedinggeneralized pain or pain referred to the
  shoulder may signal a ruptured pregnancy with
  hemoperitoneum
• Any tissue passed
• Rubella titer?
• Blood type Rh
• General health

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Physical Exam

• Vitals, tilt test
• HLA
• Pelvic with rectal!!
• Note amount of blood
• Cervical OS
• Posterior fornix bulging
• Cervical cultures GC chlamydia
• Vag/perineal culture for Gp. B strep.

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Testing

• Ultrasound - Cardiac activity by 6 weeks with
  the crown rump length 5-8mmdefinitely seen by
  crown-rump length of 14mm
• Heart rate at first is 100b/mindemise likely!!

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hCG human chorionic gonadotropin

• Quantitative level of 1800-2000 mIU/mL should see
  an embryonic sac!
• Quant levels of 5000 should reveal a yolk sac

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Complications After the First Trimester

• GDM
• HTN
• Multiple Gestation
• Bleeding
• IUGR
• Small Large for dates
• Oligohydramnios
• Polyhydramnios

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Vaginal Bleeding

• Second trimester miscarriage
• Cervical/vaginal causes
• Cervicitis/vaginitis
• Cervical polyp
• Cervical or vaginal laceration
• Cervical carcinoma
• Coagulopathy either pre-existing or pregnancy
  related

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Vaginal Bleeding

• Intrauterine causes
• Molar pregnancy
• Placenta previa
• Abruptio placentae
• Marginal sinus rupture
• Uterine leiomyomata

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Diagnostic Approach

• Minimal Bleeding
• May occur after intercourse
• May need U/S
• Can remain outpatient if no other risks involved!
• No intercourse
• RTO ASAP for increased bleeding, pain, decreased
  fetal movement or labor symptoms!

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Heavy BleedingOB emergency!! Find that Placenta!!

• Placenta Previa occurs when the placenta
  partially or completely covers the cervical
  opening
• 1/20 common on early U/S
• 1/10 patients cont with previa after 30 wks of
  pregnancyplacental migration
• Common between 27-32 weeks

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Risk Factors of Placenta Previa

• Previous uterine surgery/scar
• Multiple gestation
• Previously abnormal placental implantation
• Advanced maternal age
• Increasing parity

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Complications of Placenta Previa

• IUGR
• Velamentous cord insertion
• Postpartum hemorrhage
• Placenta Accreta

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Abruptio Placenta

• Premature separation (partial or complete) of the
  placenta from the uterine wall
• 2 of pregnancies with 0.2 resulting in fetal
  demise
• Usually present with pain!
• May hide the bleeding!

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Risk Factors for abruption

• HTN disorders
• Substance abuse
• Sudden decompression of uterine cavity
• Trauma

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Small-for-Dates

• Prior to 20 weeks may be hard to gage! By 20
  weeks should measure to the umbilicus!
• 20-32 weeks measurements should correlate well
  with gestational age!

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Why?

• Wrong dates??LMP
• Improper measurement
• Transverse lie
• IUGR, oligohydramnios, or both
• Small baby!

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IUGR

• 5 in general population but higher rates in at
  risk populations
• AIUGR Assymetric head bones grow at a
  normal rate but the viscera abdomen do not
• Associated with long-term problemslearning
  disablities, ADD

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SIUGR (symmetrical)

• Refection of early insult to fetus ie infection
  or chromosomal abnormality
• May want amnio, TORCH titers
• Both SIUGR AIUGR are associated with all
  pregnancy complications!

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Large-For-Dates

• Obesity
• Very short patient
• Uterine enlargement
• Wrong dates
• Polyhydramnios
• Fetal macrosomia
• Multiple gestation
• Structural abnormalities of the uterus
• Molar pregnancy

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OLIGOHYDRAMNIOS

• Placental insufficiency or abnormalities
• Preeclampsia
• Twin-to-twin transfusion
• IUGR
• Postdates pregnancy
• Renal agenesis
• Pulmonary hypoplasia
• Implies a deteriorating pregnancy status!!

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POLYHYDRAMNIOS

• DM
• Fetal macrosomia without maternal DM
• Rh other isoimmunization
• GI anomalies usually upper that prevent
  swallowing
• Esoph/duoden/intestinal atresia
• Diaphragmatic hernia
• Omphalocele
• Gastroschisis

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POLYHYDRAMNIOS

• IDIOPATHIC
• CNS
• Neural tube defects
• Hydrocephalus
• Intrauterine infections
• CMV
• Varicella
• Parvovirus