Clinical Aspects of Prenancy – Westra/Gilbert – 3.5.10
CLINICAL ASPECTS OF PREGNANCY
Dr. Ruth Westra
March 9, 2010
Objectives
To acquaint you with the medical terminology in pregnancy
To familiarize you with some of the clinical aspects of pregnancy
To prepare you for the OB Clerkships
Topics
Pre-term Labor
Gestational Diabetes
Antepartum Bleeding
Infections
Abnormal Presentations
Fetal Well Being
Depression
Pregnancy Induced Hypertension
Pre-eclampsia/Eclampsia
HELPP Syndrome
Maternal Mortality - #8 in world
Infant Mortality- US is #29
Gestational Diabetes Mellitus
-About 7% of pregnancies are complicated by DM (90% classified
as gestational DM)
-After 12 weeks gestation, maternal glucose crosses the placenta
and fetal beta cells can produce insulin. If maternal glucose level
is elevated after 12 weeks gestation, fetal insulin production
increases. The growth hormone effects of this insulin lead to fetal
macrosomia. (large babies)
-20% of deliveries of women with GDM are macrosomic (4000
grams-8# 13 oz)
Gestational DM Risk
-35 years and older
-BMI greater than 30 kg/m2
-Corticosteroid use
-Personal or family history of DM
-High-risk ethnic group (Hispanic, Asian- American,
Native American, African American)
Gestational DM Screening
-24-28 weeks
-Screening 50-g one-hour glucose challenge >126
mg/dL test is positive
-Diagnostic 100-g three hour oral glucose tolerance test
(Fasting 90, 1 hour 165, 2 hour 145, 3 hour 125)
Gestational Diabetes Treatment (tight G control)
-Diet
-Glyburide (Micronase)
-Intensive Insulin Therapy
-Treatment aims to achieve glucose levels
130 mg per dL one hour postprandially
Case
A healthy 19 year old G I P 0-0-0-0 female presents to the labor
and delivery area at 29 weeks gestation complaining of
intermittent abdominal pain. She denies leakage of fluid or
bleeding per vagina. Her antenatal history has been
unremarkable. She has been eating and drinking normally. On
examination, her BP is 110/70, HR 90 and temp 99 degrees F.
The fetal heart rate tracing reveals a baseline heart rate of 120
and a reactive pattern. Uterine contractions are occurring every
3-5 minutes. On pelvic examination, her cervix is 3 cm dilated,
90% effaced, -1 station cephalic.
-What is the most likely diagnosis? Preterm labor – not norm to
be this dilated, cervix thin, etc.
-What is your next step in management? Stop labor. Baby could
survive. Probs 1-2 pounds.
Preterm labor
-Cervical change associated with uterine contractions
prior to 37 weeks
1
-In nulliparous woman, uterine contractions with 2
cm dilation and 80% or greater effacement
-Incidence in US is 11% of pregnancies
Risk Factors for Preterm Labor
Preterm premature rupture of membranes
- need to watch closely for infection, deliver within 24-48 hrs,
gives time to admin steroids to improve baby lungs.
-Multiple gestation (twins, quads, etc)
-Previous preterm labor or birth
-Hydramnios
-Uterine anomaly
-History of cervical cone biopsy
-Cocaine abuse
-African-American race
-Abdominal trauma
-Pyelonephritis
-Abdominal surgery in pregnancy
Causes of Preterm Labor
-dental hygiene?
-dehydration? Hydration can stop/slow preterm labor
-Urinary Tract Infection
-Cervical Infection
-Bacterial Vaginosis
-Generalized Infection
-Trauma or Abruption
-Hydramnios
-Multiple Gestation
-Idiopathic
Preterm Labor Evaluation
-Speculum exam to R/O PROM, cultures (Grp B Strep,
chlamydia and GC) + FN (fetal fibronectin)
-Ultrasound (Espected date of confinement, Expected
Fetal Weight, presentation, BPP, Cervix length,
biophysical profile)
-Digital Exam – how far dilated
Risk Assessment Markers
-Biophysical Markers-measurement of cervical length
by ultrasound
-Biochemical Markers-Fetal Fibronectin (FN)
-better if neg, if positive not as good of a
predictor
-Prior preterm delivery <35 weeks
Fetal Fibronectin Assay
Large glycoprotein thought to act as adhesive of fetal
membranes to decidua
Better predictive value than cervical dilation or uterine
activity in predicting imminent delivery
High negative predictive value
FN negative 1/125 deliver in 14 days
FN positive 1/6-1/3 deliver in 14 days
Preterm Labor Treatment
-Treatment of possible causes
-Tocolysis (delay labor – Nifetapine, bed rest, etc)
-Reduce prematurity-related morbidity and mortality
-Emergency cervical cerclage
-Psychosocial support
Case
An 18 year old female G I P 0-0-0-0 female has a positive
Chlamydia test at 22 weeks gestation. She denies vaginal
discharge, lower abdominal pain or fever. Heart and Lung
examinations are normal. Her abdomen is non-tender and fundal
height of 22 cm. Fundal Height 140. The GC culture is negative.
Her human immunodeficiency virus (HIV) test by Elisa is
positive.
What is your next step in therapy for Chlamydia? If not tx can
cause preterm labor – so Tx
Clinical Aspects of Prenancy – Westra/Gilbert – 3.5.10
What is the optimal treatment for a pregnant woman who has an
HIV infection? Confirm it with Western Plot. Tx so no
transmission to infant. Tx infant when delivered. Can be
transmitted by breast feeding. Do a C- Section to dec risk of
transmission
Infections During Pregnancy
-UTI – common cuz of pressure, more frequent
urnination
-Bacterial vaginosis
-Group B Strep
-Chorioamnionitis_ premature rupture of membranes
 infection
Infections Affecting the Fetus
Herpes Simplex Virus (HSV)
-Neisseria gonorrhea
-Varicella Zoster Virus (VZV)
-Chlamydia trachomatis
-Parvovirus B19 (Fifth
-Hepatitis B
Disease)
-Syphilis
-Cytomegalovirus (CMV)
-Toxoplasmosis: cat litter,
-Rubella Virus
intracranial abnormalities are
-HIV
complication of Toxo.
Case
A 30 year old G V P 4-0-0-4 woman complains of significant
bright-red vaginal bleeding at 32 weeks gestation. She denies
uterine contractions, leakage of fluid, or trauma. The patient
states that 4 weeks earlier she had some vaginal spotting after
intercourse. Her BP is 110/60, HR 80 and temp 99 F. Heart and
lung exam normal. Fundal height 32 cm. No uterine contractions
are noted. FHT 128.
What is your next step? Put on fetal monitor,
What is the most likely diagnosis? placental previa, placenta
abruption
Antepartum Bleeding
Placenta Previa (painless bleeding)
Placenta Abruption (painful contractions)
Antepartum Bleeding
-Evaluation FIRST by Ultrasound or speculum exam –
DON’T do a bimanual exam! Could make it worse
Antepartum Vaginal Bleeding
-Complete placenta previa: placenta completely covers
the internal cervical os
-Partial placenta previa: placenta partially covers the
internal cervical os
-Marginal placenta previa: placenta abuts against the
internal cervical os
-Low lying placenta: edge of placenta is within 2-3 cm of
the internal cervical os
-Placental abuption: Premature separation of a
normally implanted placenta
-Vasa previa: Umbilical cord vessels that insert in the
membranes with the vessels overlying the internal
cervical os, vulnerable to fetal exsanguination upon
rupture of the membranes
Placenta Previa
low lying placenta, baby can be delivered vaginally.
Partial Placenta Previa
2
Vasa previa – The presentation of the umbilical blood
vessels in advance of the fetal head during labor
Placenta Previa
-Placenta overlying the internal os of the cervix
-Painless bleeding
-History of postcoital spotting earlier during the
pregnancy
Risk Factors for Placenta Previa
-Grand multiparity
-Prior cesarean delivery
-Prior uterine curettage
-Previous placenta previa
-Multiple gestation
Treatment
Delivery by C-section
Placenta accreta: invasion of the placenta into the
uterus – more common with placenta previa
Predisposing/Precipitation Factors for Placental Abruption
-Hypertension
-Advanced maternal age
-Multiparity
-Multiple pregnancy
-Diabetes Mellitus
-Trauma
-External/internal version
-Delivery of first twin
-Rupture of membranes with polyhydramnios
Abruptio Placenta: Occurs in 0.5-1.5% of pregnancies and 30% of
cases of third-trimester bleeding with 15% mortality of
both mom and baby
Treatment
-Stabilize the patient
-Prepare for the possibility of future hemorrhage
-Prepare for preterm delivery
-Deliver if bleeding is life threatening or fetal testing is
non-reassuring
Clinical Aspects of Prenancy – Westra/Gilbert – 3.5.10
Cephalic Presentations
External Podalic Version – do this under US, know where the
placenta is. Not comfortable! This is for someone who REALLY
doesn’t want a C-Section
-palpate suture line. Do everything by occiput – feel “V” of suture
line. LOA is the most common presentation. Can be transverse
too.
Prolapsed Umblical Cord – OB emergency! Usually with breech
presentation.
Fetal Presentations
Breech Presentations
FETAL WELL-BEING
-Non-stress testing
-Oxytocin stress testing
-Ultrasound
-Biophysical Profile
-Amniocentesis
Biophysical Profile
-Five categories with score 0-2 for each
-Amniotic Fluid Volume
-Fetal Tone
-Fetal Activity
-Fetal Breathing Movements
-Fetal Heart Rate Reactivity (Nonstress test)
-Score of 8-10 normal
Bishop’s Score for Induction – use to tell if the induction will be
successful.
-Station – 0 at pubis, higher
-Dilation
-Effacement
-Position
-Consistency
Parameter\Score
0
1
2
3
Position
Posterior
Intermediate
Anterior
-
Consistency
Firm
Intermediate
Soft
-
Effacement
0-30%
40-50%
60-70%
80%
3
Clinical Aspects of Prenancy – Westra/Gilbert – 3.5.10
Dilation
0 cm
1-2 cm
3-4 cm
>5 cm
Fetal station
-3
-2
-1, 0
+1, +2
Cervical ripening
-Mechanical ripening: balloon catheter
-Oxytocin
-Prostaglandins
Dinoprostone (Cervidil) intravaginal inserts
Misoprostol (Cytotec) 25 mcg vag tablet
Postpartum Depresssion
“Major depressive episodes with post-partum onset-diagnoses
within 4 weeks after childbirth” DSM-IV
1.“Maternity blues”
2.Fatigue from newborn
3.Post-partum depression
Criteria for Major Depressive Episode
-Mood
-Interests
-Eating and weight
-Sleep
-Observable psychomotor activity
-Fatigue
-Self-worth
-Concentration
-Thoughts of death or suicide
Treatment
-SSRI (also may be used during pregnancy and with
breast feeding)
-Counseling
-Family support
Clinical Aspects of Pregnancy II
Objective:
-To advance your knowledge of hypertension in
pregnancy
-To describe the new advances in pre-eclampsia
research
-Case
A 19 year old G I P 0-0-0-0- has severe preeclampsia with several
blood pressures of 160/110 and 4+ proteinuria at 34 weeks
gestation. She denies headaches or visual abnormalities. She has
a 2 day history of severe unremitting epigastric tenderness. Her
platelet count was 130,000/mm3, Hgb 13 mg/dL, SGOT 2100
mIU/mL (normal <35). Shortly after admission, she received IV
Magnesium sulfate and was induced with oxytocin. She delivered
vaginally. Two hours after delivery, the patient complains of
sudden onset of severe abdominal pain had has a syncopal
episode. The patient is found to have a BP is 80/60, a distended
abdomen and HR 140 with thready pulse.
-What is the most likely diagnosis?
-What is your next step?
Hypertension
-Chronic Hypertension
-Pregnancy Induced Hypertension
-Pre-eclampsia
-Eclampsia
-HELLP
Chronic Hypertension
-BP 140/90 mm HG before pregnancy or at less than 20
week’s gestation
-Treatment controversial – may continue prior meds
(Beta-blocker, calcium channel blocker, methyldopa,
diuretic)
4
-DO NOT USE ACE-inhibitors -- associated with
oligohydramnios and neonatal renal failure
-Pregnancy Induced Hypertension
-Hypertension without proteinuria at greater than 20
week’s gestation
Pre-eclampsia
-Systolic BP >140/90 mm Hg occurring after 20 weeks
of gestation in a woman whose BP has previously been
normal
-Proteinuria, with excretion of 300 mg or more of
protein in a 24-hour urine specimen
-Non-dependent edema is usually present but not a
criterion (global swelling, hands and legs, hard to
differentiate from normal swelling).
-Underlying pathology ?vasospasm?
-5-8% of pregnancies
Severe Pre-eclampsia
-Systolic BP >160 mm Hg/Diastolic BP >110 mm Hg
-Proteinuria: >5 g in 24 hours
-Oliguria
-Pulmonary edema or cyanosis
-Impairment of liver function
-Visual or cerebral disturbances
-Pain in the epigastric area or right upper quadrant
-Decreased platelet count
-Intrauterine growth restriction
Complications of Pre-eclampsia
-Eclampsia
-Placenta abruption
-Coagulopahties
-Renal Faulire
-Hepatic Subcapsular Hematoma
-Hepatic Rupture
-Uteroplacental insufficiency – bld to infant is
compromised
Treatment
-Delivery is the definitive treatment dependent on the
gestational age
-BP: Hydralazine or Labetolol
-Magnesium sulfate to prevent seizures
Eclampsia
-Preeclampsia with new-onset grand mal seizures
-Magnesium sulfate: anticonvulsant Rx excreted by the
kidneys so monitor for urine output, respiratory
depression, dyspnea (side effect of MgSO4 pulmonary
edema) and hyporeflexia (loss of deep tendon reflexes)
HELLP Syndrome –related to preecampsia
-Hemolysis
-Elevated Liver Enzymes
-Low Platelet Count
Practice Questions:
1. What is a complication of gestational diabetes?
2. What does a negative FN mean?
3. Describe the difference in presentation of placental previa and
placental abruption?
4. Should you do a bimanual exam on a pregnant patient with
vaginal bleeding?
5. what is the primary Tx of pre-ecamplsia?
6. Define HELLP Syndrome
Answers:
1. Macrosomia
2. FN negative 1/125 deliver in 14 days;
3. Placenta Previa (painless bleeding); Placenta Abruption
(painful contractions)
4. No!
5. Delivery
6. –Hemolysis Elevated Liver Enzymes Low Platelet Count