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Pregnancy by each term Risks, tests & Complications

Harsimrat Bagga (Nancy) Windsor School of Medicine 1/9/2012

First Trimester

First Month Weeks 1-4


Growth of baby by end of first month = 67mm (1/4 inch) Growth of primitive facial structures, amniotic sac and placenta neural tube formation begins and closure by week 4 Heart begins to beat in week 4 Pronephros- week 4

Tips
Schedule visit to the gynecologist, start prenatal vitamins, folic acids Avoid alcohol and smoking; environmental hazards Get genetic counseling ( optional)

Initial Tests
First visit to doctor: Blood tests- hormones, blood type, Rh (rhesus) factor, hemoglobin, rubella (German measles), hepatitis B, syphilis, and HIV, Tay-Sachs, cystic fibrosis, sickle cell anemia, Urine Tests- Hcg, UTI, kidney infection, blood tests, albumin

Risks or complications
Miscarriages can occur due to low levels of progesterone; chromosomal abnormaties (robertsonian translocation) Bleeding, severe abdominal pain, cramps due to ectopic pregnancy- mimics appendicitis ( causes of ectopic pregnancy- PID, ruptured appendix, past tubal surgery) Placenta previa- painless bleeding in any trimester placenta attached to lower uterine segment; causes- surgeries, C sections, multiple births Severe nausea and fatigue- dehydration, anemia malnourishment increase in birth defects in baby and can induce premature labor Mood swings- depression, anxiety stress- weakened immune system- increase in flu constipation frequent urination, food cravings and aversion weight gain

Any bleeding that occur before the 5th month ( 20 weeks)


First initiate speculum exam in order to exclude vaginal or cervical lesions After this check to see if cervix open or close If cervix is closed: - do Vaginal ultrasound: 1. intrauterine pregnancy- threatened abortion, suggest bed rest 2. snow storm pattern is visible-molar pregnancy (perform D & C) 3. No IUP, No molar, no ectopic pregnancy- order beta HCG quantitative test if beta HCG quantilative < 1500 IU/L- repeat Beta HCG + ultrasound after 2 days If beta HGC quantilative > 1500 IU/L- ectopic pregnancy

Snowstorm Pattern

Molar pregnancy

Ectopic Pregnancy
Unruptured Signs: missed periods, bleeding and unilateral pain, Prescribe methotrexate or perform salpingostomy. Give methothrexate1. beta HCG <6000 mIU, 2. no fetal activity Follow up with serial beta HCG to ensure pregnancy resolution . If Salpingotomy is performedfollow up with serial beta HCG to ensure pregnancy resolution Ruptured Signs- increase HR, decrease in BP, guarding, rigidityTests- do laparotomy: salpingectomy (not salpingostomy)

Missed Abortion If ultrasound revealed non viable pregnancy No vaginal Bleeding but cramping, cervical dilation Perform: D & C; misoprostal or wait for spontaneous abortion

Incomplete Abortion if ultrasound shows cervix is open perform D & C or emergency suction as it is inevitable abortion

Second Month weeks 5-8


Fetus= about 2.54 cm (1 inch) long weight = about 9.45g (1/3 ounce) The neural tube formation is completedimportant to consume folic acid to prevent neural tube defects Upper and lower limbs formation Development of digestive tract and sensory organs begin Heartbeat can be detected on ultrasound increase in weight of mother, however intense morning sickness can lead to loss of weight mild cramps- due to uterine tightening and expanding

Third Month week 9-12


Fetus measures- 4 inches Weighs- 1 ounce improvement in nausea- more energy Weight gain of about 3-5 lbs. Lower chances of miscarriage from now Fully formed fetus

Third month tests


Chorionic villus sampling (CVS) 35 years or older, (10 and 12 weeks) 1% risk of inducing miscarriage; Detect many genetic defects Blood Test + Ultrasound (11 and 14 weeks) Blood test- hCG and/or PAPP-A (pregnancyassociated plasma protein A) Ultrasound- nuchal translucency genetic defects

Disorders of Amniotic Fluid


Ultrasound measures the Amniotic Fluid Index (AFI) which detects the amniotic fluid volume Oligohydramnios AFI < 5 cm, too little amniotic fluid (200 ml less than normal) It can lead to fetal distress in the later pregnancy, compression of cord, fetal hypoxia can cause fetal abnormalities- renal agenies; Potter s syndrome; IUGR Diabetes is a factor causing this anomaly treatment- immersion ( acute maternal hydration) Polyhydramnios 2000 ml excess fluid; can lead to preterm labor, cord prolapse, placenta abrutio, postpartum hemorrhage; esophageal and duodenal atresia Causes: maternal diabetes, multiple births, congenital defects- ancephaly treatment- perform amniocentesis to minimize the fluid volume

Second Trimester

Fourth Month Week 13-16


Fetus measures 6 inches Weight- 4 ounces heartbeat audible on fetal doppler sex of the baby can be determined by ultrasound uterus in the expected mother can be felt 3 to 4 inches below navel Fetal movements can be felt- quickening Varicose veins, stretch marks, frequent urination Complications: miscarriages in second trimester occur most commonly due to bicornuate uterus ( incomplete fusion of paramesonephric ducts)

Tests
Week 15-20 - quadruple marker screening test: measures: 1. alpha-fetoprotein (AFP), 2. human chorionic gonadotropin (hCG), 3 . Inhibin A, 4. Estrogen produced by the placenta. Predicts:- Down syndrome more accurately Triple screen testAFP, hCG and unconjugated estriol Mother 35 year and older with suspicious AFP or Quad screen- Amniocentesis Amniocentesis ( 15- 18 weeks) low AFP= Down syndrome High AFP-wrong gestational age, twins, omphalocele, neural tube defect, death of baby

Fifth Month week 17-20


baby measures - 10 inches weight- 1 lb fetal skin is covered in vernix caseosa increase in the bladder infection in mother due to relaxation of urinary tract mucosa Increase in perspiration due to active thyroid gland, backaches, breathing gets deeper

Sixth Month week 21-24


Fetus measures- 12 inches Weights= 2Lbs Heartbeat can be heard by stethoscope Jerky motions due to fetal hiccups mother might experience hemorrhoids Premature babies can survive after 24th week with intensive care

Tests
Glucose sceening test ( 24- 28 weeks) to detect gestational diabetes CBC RPR ( rapid plasma reagin) for syphillis Urine culture

Gestational diabetes
Subtypes: Type A1 abnormal oral glucose tolerance test (OGTT), but normal blood glucose levels during fasting and two hours after meals Treatment: diet modification Type A2: abnormal OGTT plus abnormal glucose levels during fasting and after meals; Treatment- diet modification and medication is required Causes: Previous history, family history, maternal age, ethnicity ( African Americans), obesity, PCOS etc. Symptoms: no visible symptoms or increase in thirst, frequent urination, nausea, vomiting, yeast infections, blurry vision

Non-challenge blood glucose tests If plasma glucose level > 126 mg/dl (7.0 mmol/l) after fasting or >200 mg/dl (11.1 mmol/l) on any random occasion This confirms gestational diabetes ( no further testing is required)

Screening glucose challenge test Performed between 24 28 weeks; simplified version of the oral glucose tolerance test (OGTT) Patient drinks a solution containing 50 grams of glucose, and then blood glucose levels are measured after an hour. Levels > 140 mg/dl (7.8 mmol/l) confirms GD

Oral glucose tolerance test ( OGTT) Performed morning after the all night fast of about 8 -14 hours Patient is asked to drink normally 100 g of glucose solution, blood glucose levels are measured at several times after GD is confirmed if: After Fasting > 95 mg/dl After 1 hour > 180 mg/dl After 2 hour > 155 mg/dl After 3 hour > 140 mg/dl (5.33 mmol/L) (10 mmol/L) (8.6 mmol/L) (7.8 mmol/L)

Management fast-acting insulin before the meal, oral hypoglycemics- glyburide, Metformin Complications Macrosomia in fetus- difficult delivery, hypoglycemia in neonatals, respiratory distress syndrome ( impaired surfactant secretion), pre-eclampsia, congential deformities

Third Trimester

Seventh Month weeks 26-30


Baby measures 14 inches weighs- 2 to 4 Lbs fully developed hearing and responses to stimuli- sound, pain, light mother gaining a 1 LB/ week mild increase in blood pressure In Rh negative mothers, with fetal incompatibility, receives injection at 28 weeks to refrain from developing antibodies if missed leads to erythroblastosis: Anemia, jaundice, severe neonatal edema etc.

Risks and complications


Placenta previa painless bleeding that stops spontaneously with or without uterine contractions Causes- multiparity, previous C section, advanced maternal age, prior placenta previa Pelvic exam is contraindicated in this case. Do ultrasound if fetal is in danger or mother is not stable- do emergency C-section if lower placental edge is more than 2 cm from cervical internal os- do vaginal delivery Mother and fetus is stable ( fetal lung is matured after 36 weeks)- do scheduled C- section Vasa Previa Painless bleeding, ruptured membranes and fetal is in distress- tachycardia or bradycardia etc. Life threatening for fetus- perform emergency C section

Placenta abruptio
Sudden onset of dark red painful bleeding in 3rd trimester (around 30 weeks) associated with uterine contractions; severe constant pain normally occur during hypertension, trauma, or due to cocaine, smoking etc. Placenta gets detached from the implantation site premature; can lead to DIC Treatment: insert bore IV and foley cathether initial step in all cases If patient is stable- tocolysis with magnesium sulfate If patients is at 36 weeks or after with controlled bleeding- vaginal delivery If patient is unstable- emergency C- section

Uterine Rupture
Sudden onset of abdominal pain and vaginal bleeding; loss of fetal heart rate; uterine contractions; recession of fetal head History of uterine scar/incisions or aggressive oxytocin supplementation; preivous myometromy

Treatment If patient is stable- uterine repair surgery If patient is unstable hysterectomy (also if patient desires no more pregnancy in future)

Pre-Eclampsia
Mostly occur at 32 weeks but can develop at 20 weeks as well Triad: proteinuria, hypertension and edema headaches, blurry vision, pain, intense edema of face and legs, hemolysis, increase liver function tests, low platelets Death can occur due to acute respiratory distress syndrome or cerebral hemorrhage Causes: ongoing conditions like hypertension, diabetes, renal diseases, autoimmune disorders; Placenta ischemia Treatment: Delivery of fetus, bed rest, treat hypertension, diet modification

Eclampsia
Pre-eclampsia + seizures Treatment- IV magnesium sulfate and diazepam

Risks and complications


Premature labor- anytime before 37 weeks Signs: 1. Cramps and contractions every ten minutes or more 2. Vaginal discharge, leaking of fluid 3. Vaginal bleeding 4. Increase pressure in the pelvic area 5. Dull pain in your back doesn t relieved by changing positions 6. nausea, vomiting, or diarrhea. 7. Decreased fetal movements Complications: Respiratory Distress Syndrome (RDS) due to immature lungs Transient tachypnea ( shallow breathing) Bronchopulmonary Dysplasia (BPD) Pneumonia; infections PDA Jaundice; Anemia Retinopathy Necrotizing Enterocolitis

Eighth Month Weeks 31-34


Baby measures=19.4 inches Weight = 5 Lbs increase in baby kicks Increase in fat reserves in baby lungs might not be fully developed Braxton-hick contractions might be initiated Mother gained 22-28 lbs

Ninth Month weeks- 35-40


Baby measures= 18-20 inches Weight= 7 lbs baby s lungs fully developed, Coordinated reflexes baby s position changes in preparation of delivery

Tests
GBS screening Group B Streptococcus is a part of normal flora of genital tract in 20 40% women but can results in neonatal infection and death Vaginal and rectal cultures are obtained in 35- 36 weeks In GBS positive women- treatment with antibiotics If there is a premature labor- treatment with IV penicillin or ampicillin is required regardless of the cultures or prior lab tests Other tests taken during 35- 36 weeks Chlamydia, Gonorrhea, HIV etc. NST non stress test- monitor uterine contractions; fetal heart rate

Baby s gluteus is facing the direction of birth canal; Flexion of hips, extension of knees, Increase chances of looping umbilical cord

Frank breech

Both knee and hips are flexed

Complete Breech

Ideal for labor; baby s head is positioned downward it faces the back of the mother

Most preferred position

Baby is facing the mother s abdomen painful and prolonged labor

Occiput or Cephalic Posterior

Baby is positioned crosswise; shoulder will enter the pelvis Requires cesarean section

Transverse lie

Baby s booth feet are leading to the birth canal, umbilical cord cab wrap around the womb, cutting the blood supply

Footling breech

Complications
Placenta accreta- heavy bleeding after the delivery malformed decidual layer of the uterus causes the placenta to attach to the myometrium Causes- placenta previa, C section etc Retained placental tissue leads to postpartum hemorrhage C section Infections, blood loss, injury to fetus, anesthesia complications, nausea, constipation, maternal death, immature fetal lungs, incision scars, placenta previa, placenta accreta

Drugs to avoid during pregnancy


ace inhibitors- renal damage Alcohol- FAS, mental retardation Cocaine- placenta abruptio DES (diesthystilbestrol)- vaginal clear cell adrenocarcinoma Folate anatagonists- neural tube defects Lithium- Ebstein s anomaly Maternal diabetes- caudal regression syndrome Smoking- preterm labor. IUGR, ADHD Tetracycline- discolored and malformed teeth Thalidomide Limb anomalies Warfarin- abortion, fetal hemorrhage Excess Vitamin A- abortion, cleft palate, cardiac anomalies

Fetal abnomalities
Esophageal Atresia chocking spells at birth in order to diagnose it, the NG tube is inserted in the mouth, if it is coiled up in the upper chest and this will confirm the diagnosis Imperforate Anus absence of normal anal opening, absence of flatulence or stool at birth Congenital Diaphragmatic Hernia Dyspnea at birth; X-ray will reveal- loops of bowel in left chest Omphalocelle the sac which is formed from an outpouching of the peritoneum, protrudes in the midline through the umbilicus Gastroschisisthe intestines protrude outside the fetal abdomen with no protective membrane Exstrophy of Urinary Bladder Failure of the abdominal wall to close during the fetal development and results in the protrusion of the posterior bladder wall through the lower abdominal wall.

Still in a sac

Gastroschisis

Exstrophy of Urinary Bladder

Thank You!

References
Wikipedia (2012) Gestational Diabetes; Retrieved from: http://en.wikipedia.org/wiki/Gestational_diabetes Wikipedia (2012) Group B Streptococcus; Retrieved from: http://en.wikipedia.org/wiki/Group_B_streptococcal_infection American Pregnancy Association (2012) Premature Birth Complications; Retrieved from: http://www.americanpregnancy.org/labornbirth/complicationspremature.htm Webmd (2010) Cesarean section Risks and Complications; Retrieved from: http://www.webmd.com/baby/tc/cesarean-section-risks-and-complications josephmedman (2011)USMLE Alogarithms; Retrieved from: http://www.youtube.com/user/josephmedman/featured

Hoffman M (2008) Health and Pregnancy, retrieved from: http://www.webmd.com/baby/healthtool-fetal-positions-slideshow Nihira M (2009) Health and Pregnancy; Retrieved from: http://www.webmd.com/baby/1to3-months Le T, Bhushan V, Vasan N (2010) First aid for the USMLE step 1; 20th Edition; Mc Graw Hill productions

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