Pregnancy Disorders PDF

Maternal-Fetal Disorders Jason Ryan, MD, MPH Ectopic Pregnancy Pregnancy outside the uterus 98% occur in fallopian tube Most commonly ampulla (mid portion) Wikipedia/Public Domain Ectopic Pregnancy Symptoms in 1st trimester Vaginal bleeding Abdominal pain (may...

Maternal-Fetal Disorders Jason Ryan, MD, MPH Ectopic Pregnancy Pregnancy outside the uterus 98% occur in fallopian tube Most commonly ampulla (mid portion) Wikipedia/Public Domain Ectopic Pregnancy Symptoms in 1st trimester Vaginal bleeding Abdominal pain (may mimic appendicitis) Abnormal ↑hCG based on dates Wikipedia/Public Domain Ectopic Pregnancy Diagnosis: ultrasound Treatment: Methotrexate Surgery James Heilman, MD/Wikipedia Ectopic Pregnancy Risk Factors Damage to fallopian tube Prior ectopic pregnancy Tubal disorders Tubal ligation (rarely pregnancy occurs) Tubal surgery (tumor) Pelvic inflammatory disease (Chlamydia, Neisseria) Ectopic Pregnancy Risk Factors Infertile women: higher incidence Kartagener syndrome (1° ciliary dyskinesia) Fallopian tubes: ciliated epithelium Spontaneous Abortion Miscarriage Pregnancy loss before 20 weeks After 20 weeks: stillbirth or fetal demise Presents as vaginal bleeding Often requires D&C to remove all tissue 50% cases due to fetal chromosomal abnormalities Spontaneous Abortion Risk Factors Maternal smoking, alcohol, cocaine Maternal infection (TORCH) Hypercoagulable states Lupus/antiphospholipid syndrome Amniotic Fluid Primary sources: fetal urine and lung secretions Major source for removal: fetal swallowing Oligohydramnios Decreased amniotic fluid Often a fetal kidney problem Polyhydramnios Excessive amniotic fluid Often a swallowing/GI problem Oligohydramnios Fetal renal abnormalities Bilateral renal agenesis Posterior urethral valves (males) Placental insufficiency Preeclampsia Maternal vascular diseases Premature rupture of membranes Image courtesy of Piotr Michał Jaworski Oligohydramnios Can lead to Potter’s sequence Loss of fetal cushioning to external forces Compression of the fetus Limb deformities Flat face Pulmonary hypoplasia Polyhydramnios Fetal swallowing malformations Esophageal/duodenal atresia Anencephaly Maternal diabetes Fetal hyperglycemia  polyuria Fetal anemia Leads to high fetal cardiac output Increased urine production Can occur in parvovirus infection Multiple gestations More fetal urine Low Birth Weight Less than 2500 grams (5.5lbs) Caused by: Premature delivery Intrauterine growth restriction (IUGR) Increased risk of: Pixabay/Public Domain Neonatal mortality Newborn complications Lower birth weight  greater risk complications Low Birth Weight Selected Risk Factors/Causes Congenital abnormalities of fetus Multiple gestation Maternal conditions Preeclampsia Abruptio placenta Alcohol Smoking Cocaine use Øyvind Holmstad/Wikipedia Low Birth Weight Newborn Problems Hypothermia Less white adipose tissue (insulation) Less brown adipose tissue (heat generation) Large ratio surface area to weight (lose heat easily) Hypoglycemia Loss of maternal glucose Insufficient fetal generation of glucose Hyperbilirubinemia ↑ unconjugated bilirubin May lead to newborn jaundice Nevit Dilmen/Wikipedia Low Birth Weight Newborn Problems Respiratory distress Neonatal RDS Deficiency of surfactant Transient tachypnea of the newborn Inadequate lung fluid clearance Pneumonia Respiratory failure Need for ventilator support Patrick J. Lynch Persistent Fetal Circulation In utero: high PVR Blood shunted right  left Via foramen ovale and ductus arteriosus At birth  oxygen to lungs  PVR falls Persistent high PVR  shunting  hypoxemia Abnormal development of pulmonary vasculature Small vessels Thickened walls Excessive vasoconstriction Immune Function Cellular immunity impaired ↓ T-cells and B-cells at birth Some babies have neutropenia Mgiganteus/Wikipedia Low Birth Weight Newborn Problems Databese Center for Life Science Polycythemia of the newborn Excessively elevated hematocrit at birth (>65) Newborns normally have increased red cell mass Fetus in a relatively hypoxic environment in utero Increased hemoglobin production Placental blood may transfer to baby at birth Usually asymptomatic Rarely may cause symptoms Hypoglycemia (excessive RBC glucose utilization) Hyperbilirubinemia Low Birth Weight Newborn Problems Necrotizing Enterocolitis Intestinal necrosis and obstruction Usually terminal ileum or colon Can lead to perforation Mikael Häggström/Public Domain Major risk factor is prematurity, low birth weight Low Birth Weight Newborn Problems Intraventricular Hemorrhage Hemorrhage into lateral ventricle Hypotonia Pixabay/Public Domain Loss of spontaneous movements Seizures, coma Germinal matrix problem Highly vascular area near ventricles Premature infants: poor autoregulation of blood flow here In full term infants, this area has decreased vascularity Low Birth Weight Long Term Outcomes SIDS Sudden infant death syndrome Leading cause infant mortality 1 month to 1 year in US Increased risk with preterm birth or low birth weight Increased risk of neurocognitive problems Cognition Social skills Behavioral and emotional skills SIDS Sudden Infant Death Syndrome Sudden death of infant < 1 year of age Unexplained by other causes Risk factors Stomach sleeping Maternal smoking during pregnancy Very young maternal age (100,000 ) early in pregnancy Ovarian theca lutein cysts Ovarian stimulation by hCG Often bilateral Complete Molar Pregnancy Clinical Features Hyperthyroidism Requires very high hCG hCG stimulation of TSH receptor Low TSH High T3/T4 Preeclampsia Partial Molar Pregnancy Clinical Features Uterine size May be normal (some villi drainage to fetus) May be small for gestational age (slow growth of fetus) Marked ↑hCG less common Molar Pregnancy Treatment Uterine suction curettage Rarely hysterectomy Chemotherapy: Methotrexate or Actinomycin D For high risk patients only Features suggesting high likelihood of choriocarcinoma Choriocarcinoma Rare malignant gestational neoplasm Can follow a normal pregnancy Complete molar pregnancy 15% develop locally invasive disease 5% develop metastatic disease Partial mole