7/4/2014 11:06:00 AM

Pregnancy:
1
st
trimester= 1-12 weeks
2
nd
trimester= 13-28 weeks
3
rd
trimester= 29-40 weeks

Case 10: Placenta Previa
Placenta Previa: placenta overlying the internal cervical os.
(presents as painless antepartum bleeding) may present with
spotting after intercourse
Dx with ultrasound
Antepartum vaginal bleeding: occurs after 20 weeks gestation. Most
common causes are placenta previa and placental abruption
Risk factors for Placenta Previa:
o Multiparity
o Prior c section, uterine curettage
o Multiple gestation

Case 11: Placental Abruption
Presents: painful antepartum bleeding
o Couvelaire uterus: bleeding into the myometrium of uterus
causing discolored uterine surface
o Fetal to maternal hemorrhage
Risk factors: HTN, cocaine abuse, trauma, smoking, Uteroplacental
insufficiency, leiomyomata
Treatment: for >34 weeks, delivery. Ultrasound does not work well
in abruption
Complications: Coagulopathy in 1/3 of cases secondary to
hypofibrinogenemia
Dx: difficult
o Painful bleeding, preterm labor, stillbirth, FHR abnormalities
o Ultrasound not sensitive
o Serial hemoglobin levels with fundal height and FHR
assessment is helpful

Case 12: Placenta accreta
= adherence of placenta to uterine wall due to abnormal decidua
basalis layer. Placental villi attached to myometrium
Placenta Increta: penetrates myometrium
Placenta Percreta: penetrates entirely through myometrium, can
invade bladder
Treatment: hysterectomy
Risk factors: placenta previa, prior c section, curettage, fetal down
syndrome, age >35, especially if multiple cesareans with placental
previa/partial previa

Case 13: Ovarian Torsion
Presentation: acute onset colicky lower abdominal pain, N/V. Most
commonly occurs at 14 weeks gestation when uterus rises above
pelvic brim. Or immediately post partum
Risk: complication of benign ovarian cyst
Treat: surgery, sometimes untwisting can lead to reperfusion and
saving of the ovary
DDX
Acute Appendicitis: N/V, fever. Pain superior and lateral to McBurney point in
pregnant women due to enlarged uterus pushing on appendix moving it
upwards and outwards

Acute Cholecystitis: RUQ pain following a meal.

Ectopic Pregnancy: sharp pain with N/V, amenorrhea, vaginal spotting. Dx
with Transvaginal sonograph and hCG levels.

Ruptured Corpus Luteum: corpus Luteum secretes progesterone to maintain
pregnancy up to about 10 weeks gestation. If corpus Luteum must be
removed before 10-12 weeks, patient will require supplemental
progesterone to sustain pregnancy.

Case 14: Cholestasis in Pregnancy
Presentation: pruritus without rashes. Usually in 3
rd
trimester
Hormone related pathogenesis
Some a/with ATP binding cassette gene
Increased circulating bile acids can lead to adverse fetal effects like
prematurity, fetal distress, fetal loss
Treatment: antihistamines, cornstarch bath, cholestyramine,
ursodeoxycholic acid, weekly fetal testing and delivery at 37 weeks.
Ddx:
Pruritic urticarial papules and plaques of pregnancy: hives
beginning in abdominal area and spreading to buttocks. IF
negative. Edema of papillary dermis. Treat with antihistamines and
topical steroids. NOT associated with adverse pregnancy outcomes
Herpes Gestationis: itching vesicles on abdomen and extremities
only seen in pregnancy. Autoimmune against basement membranes
activate classic complement pathway. Dx with IF staining. Treat
with corticosteroids
Acute Fatty Liver of Pregnancy: mitochondrial dysfunction, often
heterozygous for long chain 3-hydroxyacyl-coenzyme A
dehydrogenase deficiency. Presents with RUQ pain, N/V, acute renal
failure, hypoglycemia (due to compromised glycogen storage),
coagulopathy

Case 15: Pulmonary Embolus
Pregnant women are predisposed to DVT due to venous obstruction
and hypercoagulable state. Estrogen increases fibrinogen, uterus
compresses vena cava
Dx with spiral CT or MR angiography. Dont use V/Q scans because
of higher radiation to fetus. D-Dimer is normally elevated in
pregnant women, so not as helpful.
Presentation: pleuritic chest pain, severe dyspnea
Treatment: IV anticoagulation with heparin or LMWH. O2 therapy
should be started if pulse oximetry <90% (O2 tension <60mmHg)
DVT:
Dx with Doppler ultrasound
Treat: anticoagulation with heparin, bed rest, extremity elevation
Pregnancy induces respiratory alkalosis with partial metabolic compensation
(lower bicarb level than non-pregnant person)
- Long term heparin use leads to osteoporosis, thrombocytopenia

Case 16: Preeclampsia and hepatic rupture
Gestational HTN: >140/90mmHg at greater than 20 weeks
gestation
Preeclampsia: HTN plus proteinuria (>300mg/24 hrs)
Eclampsia: preeclampsia+ seizures. Severe eclampsia has end
organ damage due to vasospasm
Risk factors for preeclampsia: nulliparity, extremes of age, African
Americans, + family hx, HTN, chronic renal disease, obesity,
antiphospholipid syndrome, diabetes, multiple gestation
Complications of preeclampsia: placental abruption, eclampsia,
intracerebral hemorrhage, coagulopathy, renal failure, hepatic
subscapular hematoma, hepatic rupture, Uteroplacental
insufficiency
Treatment: magnesium sulfate during labor (Side effect of Mg is
pulmonary edema, toxicity causes loss of deep tendon reflexes).
Treat severe HTN with hydralazine or labetalol

Case 17: Preterm Labor
Dx: 2cm dilation, 80% effacement, contractions at 20-37 weeks
Treat: Tocolytic (indomethacin, nifedipine, terbutaline=B2 agonist,
ritodrine)
Nifedipine side effects: pulmonary edema, respiratory depression,
neonatal depression, osteoporosis. Do not give with MgSO4,
because both act on calcium channels
Beta agonist side effect: pulmonary edema
Indomethacin side effect: closes PDA pulmonary HTN,
oligohydramnios
Give betamethasone or dexamethasone IM to pregnant women if
<34 weeks
Fetal Fibronectin assay: detected by vaginal swab. binds placental
membrane to decidua or uterus. Negative result is predictive of not
delivering within the week
Shortened cervix indicates risk of premature birth
Start Mg if <31 6/7 weeks to reduce risk of cerebral palsy
Weekly injection of 17 alpha-hydroxyprogesterone can prevent
preterm labor in high risk women
Gonococcal cervicitis is linked with preterm labor (but no
chlamydia)

Case 21: Thyroid storm in pregnancy:
Treatment: 3 Ps Propranolol (beta blocker), PTU, Prednisolone
(corticosteroid)
Saturated solution of potassium iodide can also be used in extreme
cases
Side effect of PTU: agranulocytosis (leukopenia)
Methimizole is associated with aplasia cutis (skin and scalp defects)
Both PTU and methimazole can cross placenta and cause transient
neonatal hypothyroidism
High estrogen level during pregnancy lead to increased TBG and
total T4. Free T4 stays the same

Case 22: IUGR (birth weight <10
th
percentile for gestational age)
Risk factors: HTN, renal disease, cardiac, respiratory disease,
underweight, anemia, cocaine, tobacco, placenta issues, multiple
gestation
Symmetric(all body parts are small)- TORCH infections,
chromosomal abnormalities. Most common cause is constitutionally
small baby w/ no adverse problems. A/w earlier insults
Asymmetric (head spared)- hypoxia, decreased nutrients, HTN,
smoking, drug use. a/w later insults
Dx: repeat ultrasound in 3 weeks to evaluate severity of IUGR. If
interval growth is ok, its probably a dating error
CMV is associated with early onset (<20wks) IUGR
Decreased AFI (amniotic fluid index) is associated w/ IUGR
Doppler studies: absent or reverse of end diastolic flow in umbilical
arteries is suggestive of poor fetal condition.

Case 29: Health maintenance age >66
Calculate BMI,
stool occult blood test, colonoscopy
pneumococcal vaccine, influenza vaccine, herpes zoster vaccine
tdp vaccine every 10 yrs
lipid profile, TFT every 5 year
fasting glucose every 3 years
bone density if >65 years old
urinalysis, annual mammography
most common cause of death in <29yo women is car accident
most common cause of death in >39yo women is CVD
no need for pap smears in >65 yo if patient has hx of normal pap

Case 30: Perimenopause
Test: FSH, LH, TSH levels
Symptoms:
Hot flash: due to hypoestrogen, vasomotor reaction
o Treat: clonidine, SSRI, estrogen+progestin replacement
therapy. Or estrogen alone in women without a uterus
o Raloxifene (SERM): only prevents bone loss, does not treat
hot flashes
Decreased vaginal epithelium thickness due to low estrogen
Elevated FSH, LH
Long term treatment with estrogen-progestin has small increase
risk of breast cancer, heart disease, PE, stroke
Hormone replacement therapy reduce fracture risk and incidence of
colon cancer
Detecting Menopause:
Anti-mullerian hormone decrease is the first to indicate decreased
ovarian reserve
Inhibin B falls next, then estradiol