Upload
matilda-scott
View
215
Download
0
Tags:
Embed Size (px)
Citation preview
Breeding TroubleBreeding TroubleEarly Complications & Diabetes Early Complications & Diabetes
Jennifer K. McDonald
Spontaneous AbortionSpontaneous Abortion
Delivery before the 20th completed week of gestation
Implies fetus less than 500 grams
IncidenceIncidence
15% clinically evident pregnancies 60% chemically evident pregnancies
80% occur prior to 12 weeks gestation
Genetic AbnormalitiesGenetic Abnormalities
Aneuploidy = abnormal number of chromosomes
Autosomal trimsomies 50% losses Trisomy 16 most common autosomal
trisomy Monosomy X (Turners) = most common
aneuploidy (20%) Polyploidy found in 20% miscarriages
Typically results in blighted ovum
TerminologyTerminology
Complete abortion Incomplete abortion Inevitable abortion
Missed abortion Septic abortion
Threatened vs InevitableThreatened vs Inevitable
Threatened Abortion20% pregnancies experience 1st trimester bleeding
Cervix remains closed
Inevitable AbortionAbdominal or back pain and bleeding with an open cervix.Abortion is inevitable when cervical dilation, effacement,
and/or rupture of membranes is present
Complete vs IncompleteComplete vs Incomplete
Complete AbortionPassage of the entire conceptus. Bleeding continues
for short time and pain usually ceases.
Incomplete AbortionProducts of conception have partially passed from theuterine cavity. Cramping usually present. Bleeding
can be severe.
Missed AbortionPregnancy has been retained after the death
of the fetus.
Blighted ovumBlighted ovum
Anembryonic pregnancy Fertilization without subsequent development of embryonic tissue
Maternal FactorsMaternal Factors
Maternal infection Congenital uterine defects (25-50% risk)
Acquired uterine defects (fibroids) Immunologic disorders
Severe malnutrition Toxic factors (radiation, alcohol,
antineoplastic drugs) Trauma
DiagnosisDiagnosis
Vaginal bleeding Abdominal pain
Need to rule out ectopic pregnancy Decreased symptoms of pregnancy
Abnormally rising hCG Abnormal ultrasound findings
TreatmentTreatment
Expectant management D&C
Important to know blood type & Rh Rhogam for Rh - blood types
Recurrent AbortionRecurrent Abortion
3 or more consecutive losses before 20 weeks gestation
Incidence 0.4-1%
Recurrence risk higher if the embryo has a normal karyotype
Ectopic PregnancyEctopic Pregnancy
Leading cause of pregnancy related death in the 1st trimester
9% of all pregnancy related deaths 1% of pregnancies
Increasing over past 10 years
AmpullaryAmpullary
• 80-90% of ectopics
• Tubal damage minimal since
usually growing outside lumen
• Can open tube to remove contents (linear salpingostomy)
IsthmicIsthmic
• 5-15% of ectopics
• Grow within tubal lumen
• Usually tube needs to be
resected (salpingectomy)
Cornual/InterstitialCornual/Interstitial
• 1-2% of ectopics
• Growing within muscular wall of
uterus
• Removal very difficult
AbdominalAbdominal
• Ectopic that has been extruded from tube and implants in the
abdomen
• 20x higher maternal mortality
• Often placental tissue left in situ
CervicalCervical
• <1% of ectopics
• Abundant blood supply (uterine
vessels)
• Non-surgical methods employed
Heterotopic PregnancyHeterotopic Pregnancy
An ectopic in combination with an intrauterine pregnancy 1 in 15,000-40,000
1% of patients undergoing IVF
Risk FactorsRisk Factors
History of sexually transmitted diseases or PID Prior ectopic pregnancy Previous tubal surgery
Prior pelvic or abdominal surgery resulting in adhesions
Endometriosis In vitro fertilization or other ART
Congenital abnormalities of the fallopian tubes Use of an IUD
DiagnosisDiagnosis
Abdominal pain (90-100%) Vaginal bleeding (75%)
No evidence of intra-uterine pregnancy on ultrasound (hCG 1500-2000
mIU/mL) Abnormally rising hCG Abnormal hematocrit
Timing of RuptureTiming of Rupture
Isthmic pregnancies rupture earliest 6-8 weeks
Ampullary 8-12 weeks Interstitial pregnancies 12-16
weeks
TreatmentTreatment
Unstable
Stabilize with IV fluids, blood
products Immediate
laparotomy
Stable
Laparoscopyor
Methotrexate injection
MethotrexateMethotrexate
Folate antagonist Destroys proliferating trophoblastic
tissue May be useful in small unruptured
ectopics Relative contraindications
Adnexal mass > 3.5 cm Fetus with cardiac activity
TeratogenesisTeratogenesis
Effect of a teratogen is dependent on when the drug is given during the
pregnancy Incidence of major structural anomalies
~6%
Pre-implantation = conception to week 20
Embryogenic period = week 3 to week 8
Fetal period = week 21 to term
Pregnancy CategoriesPregnancy CategoriesA Controlled studies fail to demonstrate risk
B Animal reproductive studies failed to identify a risk but there are no controlled studies in pregnant women or animal studies showed an effect that was not confirmed in human studies
C Studies in animals showed an adverse effect or no controlled studies available in women. Use when benefit justifies potential risk to the fetus
D Positive evidence of human fetal risk. May be acceptable in a life threatening situation if
better options not available
X Studies have confirmed fetal abnormalities. Risk always outweighs benefit
StatisticsStatistics
Pre-gestational diabetes 1-3/1000 births
Gestational diabetes = any degree of glucose intolerance with first recognition
during pregnancy Complicates 4% of pregnancies
Diabetic women 4x more likely to develop pre-eclampsia
Twice as likely to have an SAB
MetabolismMetabolism
HPL and cortisol normally lower glucose levels, promote fat deposition and
stimulate appetite Rising estrogen & progesterone increase
insulin production and tissue sensitivity Overall result is lowered glucose levels
70-80 mg/dL by 10th week Also decrease in postprandial glucose
levels
22ndnd Trimester Trimester
Fasting and post-prandial levels rise Facilitates transfer of glucose across the
placenta (facilitated diffusion) Fetal levels 80% of maternal levels HPL rises steadily through 2nd & 3rd
trimesters Cortisol levels rise stimulating endogenous glucose production &
glycogen storage
Type 1 DiabetesType 1 Diabetes
Cellular mediated autoimmune destruction of the cells of the pancreas
Incidence 0.1-0.4% One of most common maternal disorders
resulting in anomalous offspring 6-10% (2-3x general population)
Incidence of malformations directly related to level of glucose over embryonic period
Common AnomaliesCommon Anomalies
Caudal regression Neural tube defects
Transposition of the great vessels Ventricular septal defects
Renal agenesis Duodenal atresia
Approach to Prenatal CareApproach to Prenatal Care
Ideally pre-conceptual care Normalization of blood sugars
Initiation of prenatal vitamins with 400 g folic acid
Dilated eye exam Baseline labs: HbA1C, thyroid studies,
24 hour urine
Glucose GoalsGlucose Goals
Fasting glucose 80-95 mg/dL One hour post-prandial < 130
mg/dL Two hour post-prandial < 120
mg/dL
RetinopathyRetinopathy
Diabetic retinopathy leading cause of blindness between ages 24-64
Some form in 100% of patients with Type 1 DM for 25 years or more
5% of patients with background retinopathy experienced worsening
during pregnancy with improvements following delivery
NephropathyNephropathy Peak incidence of nephropathy
after 16 years of DM Renal blood flow and GFR increase
30-50% 3rd trimester mean arterial
pressure and PVR increase Women with microvascular disease
experience worsening renal function
Gestational DiabetesGestational Diabetes
Screening
~28 weeks 50 gram glucose load followed by
1 hour glucose measurement > 130 requires diagnostic test
Diagnosis GDMDiagnosis GDM
8 hour overnight fast100 gram glucose load
O’Sullivan Carpenter
Fasting 90 95
1 hour 165 180
2 hour 145 155
3 hour 125 140
Need 2 or more
abnormal values