ANW8022 Module 3 study questions
What percentage of recognized pregnancies result in spontaneous pregnancy loss?
10-20% of clinically recognized pregnancies end in early spontaneous pregnancy loss.
what percentage of pregnant women will experience first trimester bleeding?
15-25% (Jordan, et al, 2019) 20-40% (King et al., 2019)
With iron therapy, when should improvement of the Hgb and Hct be seen in diagnostic labs?
3-4 weeks, if anemia is severe as soon as 14 days
Complete abortion
all products of conception are expelled Sono: uterus is empty
RhoGAM
-anti D immune globulin -an immune serum that prevents a mother's blood from becoming sensitized to foreign antibodies from her fetus -
Identify symptoms of a pulmonary embolism (PE)
-dyspnea, tachypnea, tachycardia, cough, pleuritic chest pain, fever, anxiety, cyanosis, and hemoptysis.
S/S retained products (these warrant further evaluation)
-high fever -heavy bleeding -pelvic pain -feeling ill several days after miscarriage
When is cervical length measurement most reliable?
-After 16 weeks gestation and before 24 weeks gestation. -Prior to 16 weeks, the lower uterine segment is not well developed and measurement is not reliable.
What are the potential maternal consequences of anemia in pregnancy?
●Increased risk for maternal mortality (postpartum hemorrhage) ●Risk for preterm birth ●Increased risk for transfusion ●Increased vulnerability to infection ●Reduction in peripartum blood loss reserves ●Increased cardiovascular burden
Normocytic anemia
●RBC size is considered normal ●MCV 80-100 ●Examples; acute blood loss, sickle cell disease, anemia associated with chronic disease
Iron Binding Capacity __________ during pregnancy.
increases
How soon after a spontaneous miscarriage can a women attempt the next pregnancy?
-1-2 weeks of pelvic rest has been recommended but this is not an EB recommendation -Ovulation may resume as early as day 21 after pregnancy loss and menses typically returns by approximately 6 weeks post-loss -There is no physiological reason to wait, it is common practice to advise most women that it is safe to try for conception when they feel emotionally and physically ready
What is the prevention for Rh isoimmunization?
-Administration of Rh immunoglobulin to prevent maternal sensitization to fetal antigen -Term pregnancy: 300 mcg RhoGAM given @ 28 weeks. 2nd dose given within 72 hr delivery -First trimester abortion or miscarriage: 50mcg
Why use a D&E versus D&C for treatment of Hydatidiform mole pregnancy
-D&E rather than a D&C, because suction lessens the chance of uterine perforation and spread of trophoblastic tissue into the abdominal cavity. -Hysterectomy is also an option. -Medical abortion with methotrexate and misoprostol is not advised.
Where is the most common site for an ectopic pregnancy to occur?
-Fallopian tubes -More rarely it can occur in the ovary, cervical canal, or peritoneum
Gestational thrombocytopenia treatment
-Generally resolves within days to a few months -For women with platelet counts <50,000 and severe bleeding or bleeding that is expected to become severe, platelet transfusion should be given immediately.
Define vonWillebrand's disease
-It is an autosomal recessive condition and the most common inherited bleeding disorder, occurring in approx. 1/4000 pregnant women in the U.S. -type I is mild and is most common -type III is very rare and associated with an increased risk of significant perinatal bleeding
Factor V Leiden
-Most common hypercoagulable state -It is an inherited blood clotting disorder related to a mutation in the blood's factor V protein -contributes to increased risk of thrombosis/VTE
In a normal pregnancy, how much (percentage-wise) does the Beta hCG increase every 48 hours? How does this differ from an ectopic pregnancy?
-Most viable first-trimester IUP have B-hCG levels that increase by 50% every 48hrs. -Women with an ectopic pregnancy can present with increasing or decreasing B-hCG levels, and the rise or decline occurs more slowly than would be expected with an early spontaneous pregnancy loss.
How effective is Misoprostol? How soon after administration does it usually take to evacuate uterine contents?
-Pregnancy expulsion with misoprostol occurs in approximately 80-99% of women with incomplete or delayed pregnancy loss in the first trimester. -TAKES 4-16HRS TO EVACUATE UTERINE CONTENTS
Identify risk factors for spontaneous miscarriage.
-Prior hx of early spontaneous pregnancy loss -AMA -Adv. paternal age -Uterine abnormalities Leiomyomas Bicorunate, unicornuate, septate, or didelphic uterus -Medication use in early pregnancy Isotretinoin (Accutane) NSAIDS -Endocrine disorders DM Progesterone deficiency and luteal phase defects -Smoking -Alcohol use -Caffeine intake of 200mg/day or more -Malnutrition -Chronic diseases such as factor V Leiden coagulation defect, kidney or cardiac disease -Autoimmune disorders such as systemic lupus erythematosus (SLE) or antiphospholipid antibody syndrome (APS).
Women who are Rh negative should receive this medication/product after a pregnancy loss? Provide dosage, route, and frequency of dosing.
-Rh(D) Immune globulin should be given within 48-72hrs of onset of bleeding, regardless of whether the pregnancy ends in a loss or continues. -Before 12weeks, the dose is 50ug, though 300ug may be used -After 12weeks, the dose is 300ug
Women with an early pregnancy loss should receive follow-up beta-hCGs until they reach what level?
-The level of B-hCG can be obtained every 2-3 days. -Normally, the values should double approx every 1.5-3 days in the first 5-6 weeks of gestation and every 3-3.5 days before plateauing at approx 8-10 weeks gestation; declines starting at 10-12 weeks gestation. -Once the b-hCG blood level reaches 1500mIU/mL, a gestational sac should be visible during US exam. -Serial serum B-hCG measurements should reach <5 mIU/mL to confirm pregnancy expulsion
When is it recommended that women receive serial cervical length measurements?
-Women with a history of preterm birth -after 24 weeks' gestation as part of evaluation for women who have signs and symptoms of PTL
Identify symptoms of a deep vein thrombosis (DVT)
-pain, tenderness, swelling, palpable cord, changes in color or limb circumference -Calf pain may be present, (Holman's sign no longer used bc it is neither adequately sensitive nor specific). -90% of DVT's that develop in pregnant women occur in the left lower extremity, perhaps d/t compression of left iliac artery by gravid uterus.
When does N/V typically resolve for most women?
-usually abates by 16 to 20 weeks of gestation. -symptoms may continue until the third trimester in 15 to 20 percent of women and until delivery in 5 percent. -Most women experience relief by 12-16 weeks' gestation
Rhogam is given when?
-within 72 hours following birth reduces the risk of alloimmunization significantly in Rh-negative women who had an Rh-positive newborn who is not yet sensitized -It is given to women with Rh neg blood at 28 weeks gestation - after ectopic, or first-trimester miscarriage or abortion -after invasive procedures such as amnio, CVS, or fetal surgery -bleeding during pregnancy, trauma to the abdomen in pregnancy, and external cephalic version
What is the treatment for Hydatidiform mole condition?
D&E -vacuum that stuff out test hCG levels until gone do not get pregnant for 1 year
What is Alloimmunization?
Development of antibodies in response to foreign substances such as antigens, i.e. transfusion reaction.
When a pregnant woman presents to care during the first trimester with vaginal bleeding, the very first diagnosis that must be ruled out is__________ __________ because this is a TRUE obstetrical emergency that can be life threatening!
Ectopic Pregnancy
What lab value is reflective of iron stores?
Ferritin= storage form of iron; serum ferritin level is the most accurate method of assessing iron status
What are common causes of recurrent pregnancy loss?
Genetic chromosomal abnormalities. Uterine structural abnormalities (e.g bicornuate uterus). Immunological factors such as antiphospholipid antibody syndrome. Endocrine abnormalities such as Hypothyroidism, PCOS, DM. infectious causes. Luteal phase defect; loss of progesterone to keep the pregnancy. Environmental such as excessive alcohol intake or caffeine.
vonWillebrand's disease risk factors in pregnancy
Greatest risk for bleeding is during the first trimester and immediately after birth
Moderate Risk factors for ectopic pregnancy
Infertility Assisted reproductive technology Prior hx of genital tract infection including PID Smoking- risk is dose dependent
What is Thalassemia?
Inherited defect in the ability to produce hemoglobin, usually seen in persons of Mediterranean background. Thalassemia occurs most frequently among people of Italian, Greek, African, Southern Asian, and Middle Eastern descent
What is the drug of choice for anticoagulation therapy in pregnancy?
Low-molecular weight heparin
What medication, including dosage, is used to manage an incomplete or delayed pregnancy loss?
Misoprostol (prostaglandin analogue) -initial dose 800ug intravaginally repeating the dose between 3hrs and 7days after administration -If heavy bleeding- can also be given in doses of 600ug PO or 400ug Sublingually, can be repeated twice with 3hr interval.
missed abortion
Nonviable products of conception are retained with or without vaginal bleeding. Sono: -irregular shaped/collapsing gestational sac; no embryo, mean sac diameter of >/= 25mm -CR length >/= 7mm and lack cardiac motion -Absence of embryo with heart beat >/= 2wks after US showed gestational sac without yolk sac or >/= 11days after US showed gestational sac with a yolk sac.
Idiopathic thrombocytopenia treatment
Prednisone Intravenous gamma globulin (IVIg)
Low risk factors for ectopic pregnancy
Prior C-section Douching
Define hyperemesis gravidarum
Refractory vomiting leading to weight loss, dehydration, ketosis from starvation, and metabolic alkalosis that typically persists beyond 14-16 weeks gestation
Septic abortion
Serious maternal infection that occurs after an abortion SONO: may or may not show retained products of conception on the sonogram
Recurrent pregnancy loss
Spontaneous abortion that has terminated the course of ≥3 consecutive pregnancies SONO: no diagnostic US findings
Kleihauer-Betke test
Test that detects the presence and amount of fetal blood in the maternal circulation when there's a r/o Rh isoimmunization -leads to the appropriate dose of RhIg to administer
Subchorionic hemorrhage (subchorionic hematoma)
This is defined as bleeding due to separation of the chorion from the uterine lining. Results in collection of blood between the uterine wall and the chorionic membrane (retroplacental clot).
High risk factors for ectopic pregnancy
Tubal ligation Tubal pathology/surgery Prior ectopic pregnancy IUD-especially Mirena
What is Hydatidiform mole?
a condition of varying degrees of abnormal trophoblastic proliferation of tissue with an absent embryo (complete mole) or some fetal or embryonic tissue (partial mole)
The peak timing of pregnancy loss
between 5 and 8 weeks gestation with 80% occurring within the first trimester
What is the etiology of most first trimester losses?
chromosomal abnormalities
Gestational trophoblastic disease
conditions that develop from placental (trophoblastic) tissue that develop into tumors ranging from benign to malignant the most common → hydatidiform mole
incomplete abortion
incomplete expulsion of the products of conception Sono: tissue visible in the uterus w/o evidence of viable gestation
Diagnostic criteria for a shortened cervical length is ________________after 16 weeks and before 24 weeks gestation
less than 20-30 mm
Secondary recurrent pregnancy loss
occurs in a woman who has had a previous live birth
Primary recurrent pregnancy loss
recurrent losses in a woman who has never experienced a live birth
Factor V Leiden risks associated with this condition include:
spontaneous abortion, fetal loss, and stillbirth fetal growth restriction preeclampsia abruption fetal inherited thrombophilia
What infection is pregnant women with sickle cell trait at increased risk for?
urinary tract infections
What are some Examples of food sources that are high in heme iron?
■ oysters, canned ■ beef ■ turkey ■ light tuna canned in water ■ chicken ■ crab (cooked0 ■ pork ■ shrimp (cooked) ■ halibut (cooked)
Hyperemesis gravidarum DX criteria
■Diagnostic criteria- persistent vomiting before 9 weeks gestation ■Dehydration and/or ketonuria ■Weight loss > 5% of initial body weight ■Electrolyte imbalance
Gestational thrombocytopenia
■Typically develops in the second trimester ■platelet count is barely less than 70 cells/mL ■not associated with fetal thrombocytopenia ■generally resolves within days to a few months
What is Alpha Thalassemia?
■a condition in which the body does not produce enough alpha globin (a component of hemoglobin). ■Microcytic anemia and normal hemoglobin electrophoresis
What is Beta Thalassemia?
■a condition in which the body does not produce enough beta globin (another component of hemoglobin). ■Microcytic hypochromic anemia.
Examples of food sources of nonheme iron
■iron-fortified cereal ■fortified oatmeal ■soybeans ■lentils ■beans (kidney, lima, navy, black, pinto, etc) ■black-eyed-peas ■tofu ■spinach ■raisins ■grits ■molasses ■bread
idiopathic thrombocytopenia
■self-originating disease with a deficiency or decrease in the ■number of cells causing clot formation platelet count <100,000/microL ■Can occur at any time during pregnancy ■platelet counts can be quite low
Why should sulfa derivative medications or nitrofurantoin never be prescribed for women with glucose-6-phosphate dehydrogenase deficiency (G6PD)?
○G6PD deficiency is an inherited defect in a red blood cell enzyme that protects the RBC from oxidative injury ○The primary maternal risk associated with G6PD deficiency is severe hemolysis as a result of use of medications such as nitrofurantoin and sulfa derivatives, infection or surgery, and ingestion of certain foods such as fava beans
What are the characteristics of a folic acid deficiency?
○Hyperpigmentation of the digits and mucous membrane ○Numbness and tingling in lower extremities ○Decreased mental alertness ○Memory problems
How is iron deficiency anemia treated in pregnancy?
○Iron replacement and dietary changes ○Iron supplement of 60-120mg daily ○Iron supplements ■Ferrous gluconate 300mg tablet ■Ferrous sulfate 325mg ■Ferrous fumarate 325mg
What is the most common anemia during pregnancy?
○Iron-Deficiency Anemia (IDA) is the most common. ○Accounts for 75-90% of anemias. ○In the United States, an estimated 18% of all pregnant women have IDA. Globally, 41.8 %.
What is the inheritance pattern for a couple who both have sickle cell trait (SCT)?
○It's an autosomal recessive disorder ○If both parents have SCT there is a 50% chance that the will have SCT and a 25% chance of Sickle Cell Disease (SCD). ○If only one parent has SCT, there is a 25% chance of the fetus having SCT but a 0% chance of SCD.
What are the risk factors for iron deficiency anemia?
○Multifetal gestation ○Multiparity ○Short interval between pregnancies ○anemia prior to pregnancies ○poor nutrition ○poor socioeconomic status
Identify factors that contribute to more severe nausea and vomiting in pregnancy.
○Multiple pregnancy ○Past pregnancy with nausea and vomiting (either mild or severe) ○Hydatidiform molar pregnancy ○Nonuse of multivitamins before six weeks of gestation or during the periconceptional period ○Acid reflux or other gastrointestinal disorders ○History of motion sickness or migraines ○Being pregnant with a female fetus
Identify common side effects of iron therapy.
○Nausea ○Vomiting ○Abdominal pain ○Diarrhea ○Black stool
what would you expect on a lab report of a pregnant woman who has a normocytic anemia?
○Normocytic anemia is diagnosed when the hgb and hct are low, but the mcv is normal 80-100 fL
What test is commonly used to screen for sickle cell disease?
○Pregnant women with SCT should receive genetic counseling regarding their infant's risk of SCD (this requires testing of the fetus's biological father) ■SCD is an autosomal recessive disorder
Are pregnant women at increased risk for venous thrombolic events?
○Pregnant women's risk is four-fold higher during pregnancy than when she is not pregnant. ○Pregnancy, as a hypercoagulable state, is a significant risk factor for VTE.
What is the most sensitive measure for iron deficiency?
○Serum ferritin levels ■Ferritin is the storage form of iron ■H/H Levels do not begin to decrease until stored iron is depleted, so a pregnant woman may have normal H/H values yet also be Iron depleted. ■ serum iron levels and total iron binding capacity can also be obtained but both have variations with higher concentrations noted later in the day.
What are potential perinatal outcomes for women with thalassemia?
○Thalassemia minor does not usually affect pregnancy beyond a diagnosis of anemia. ○Thalassemia major or intermedia can put women at risk for cardiac failure, alloimmunization, viral infections, thrombosis, endocrine, and bone disorders. ○If both parents are confirmed carriers of the same thalassemia genetic mutation (alpha or beta), the possibility of the fetus having thalassemia major is one in four. Fetal diagnostic testing can be performed using CVS or amniocentesis.
What are some Dietary sources that are high in iron?
○dietary iron comes in two forms (heme and nonheme) ○heme iron is found in animal products such as meat, poultry, and fish ○nonheme iron is found in grains, cereal, eggs, vegetables, fruits, and dairy products
What are the classical signs and symptoms of deep vein thrombosis?
○pain ○tenderness ○swelling ○palpable cord ○changes in color or limb circumference ○Calf pain may be present
Why is nausea and vomiting in pregnancy more prevalent in the first trimester?
○serum concentrations of human chorionic gonadotropin (hCG) peak during the first trimester ○The mean onset of symptoms occurs at five to six weeks of gestation, peaks at approximately nine weeks
Women with sickle cell disease are at increased risk for what perinatal outcomes?
○symptoms of SCD may increase during pregnancy, and is associated with serious pregnancy complications such as: infection, pulmonary complications, HTN, preeclampsia, fetal growth restriction, spontaneous abortion, fetal demise and PTB. ○Women with SCD are also at a much higher risk of thromboembolic events, and will require anticoagulation under certain circumstances.
What are the potential complications from hyperemesis gravidarum (HG)?
○vomiting induced esophageal rupture can result in GI bleeding ○hyponatremia ○fetal complications ○Wernicke's encephalopathy
What are the potential Fetal consequences of anemia in pregnancy?
●Delayed cognitive development ●Delayed psycho motor development ●fetal/infant infection ●Infant mortality ●Compromised fetal iron stores ●Fetal growth restriction ●Low birth weight and prematurity
What is the criteria for macrocytic anemia?
●RBC size is larger than normal ●MCV greater than 100. ●Not common among pregnant women ●Examples: Secondary to G6PD - Glucose -6 phosphate dehydrogenase, Vitamin B12 and folate deficiency, alcoholism, and medicines used in treatment for HIV.
What is the criteria for Microcytic anemia? And give some examples
●Smaller than normal RBC size ●MCV less than 80 or normal ●MCH less than 27 or normal ●Ferritin less than 12 * most specific and gold standard for dx of iron deficiency anemia* ●Examples; Iron- deficiency anemia (IDA) , Thalassemias, hemoglobin E disorders (HbE), sideroblastic anemia, lead toxicity.
What are the Two types of alpha thalassemia?
●The more severe type is known as hemoglobin Bart hydrops fetalis syndrome, which is also called Hb Bart syndrome or alpha thalassemia major. ●The milder form is called HbH disease. HbH disease causes mild to moderate anemia
What is a normal platelet count range?
●normal is 150,000-400,000 ●thrombocytopenia= platelet count <150,000 ●platelet count declines as pregnancy progresses but remains in normal nonpregnant range
What are the Two types of Beta thalassemia?
●thalassemia major (aka Cooley's anemia) ●thalassemia intermedia ●Of the two types, thalassemia major is more severe
