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Breeding Trouble Early Complications & Diabetes . Jennifer K. McDonald. Spontaneous Abortion. Delivery before the 20 th completed week of gestation Implies fetus less than 500 grams. Incidence. 15% clinically evident pregnancies 60% chemically evident pregnancies
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Breeding TroubleEarly Complications & Diabetes Jennifer K. McDonald
Spontaneous Abortion • Delivery before the 20th completed week of gestation • Implies fetus less than 500 grams
Incidence • 15% clinically evident pregnancies • 60% chemically evident pregnancies • 80% occur prior to 12 weeks gestation
Genetic 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
Terminology • Complete abortion • Incomplete abortion • Inevitable abortion • Missed abortion • Septic abortion
Threatened vs Inevitable Threatened Abortion 20% pregnancies experience 1st trimester bleeding Cervix remains closed Inevitable Abortion Abdominal 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 Incomplete Complete Abortion Passage of the entire conceptus. Bleeding continues for short time and pain usually ceases. Incomplete Abortion Products of conception have partially passed from the uterine cavity. Cramping usually present. Bleeding can be severe. Missed Abortion Pregnancy has been retained after the death of the fetus.
Blighted ovum • Anembryonic pregnancy • Fertilization without subsequent development of embryonic tissue
Maternal Factors • Maternal infection • Congenital uterine defects (25-50% risk) • Acquired uterine defects (fibroids) • Immunologic disorders • Severe malnutrition • Toxic factors (radiation, alcohol, antineoplastic drugs) • Trauma
Diagnosis • Vaginal bleeding • Abdominal pain • Need to rule out ectopic pregnancy • Decreased symptoms of pregnancy • Abnormally rising hCG • Abnormal ultrasound findings
Treatment • Expectant management • D&C • Important to know blood type & Rh • Rhogam for Rh - blood types
Recurrent 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 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
Sites of Ectopic Pregnancy 95% occur in the fallopian tube
Ampullary • 80-90% of ectopics • Tubal damage minimal since • usually growing outside lumen • Can open tube to remove contents (linear salpingostomy)
Isthmic • 5-15% of ectopics • Grow within tubal lumen • Usually tube needs to be resected (salpingectomy)
Fimbrial • 5% of ectopics • Partially extruded ectopic that stays at the end of the tube
Cornual/Interstitial • 1-2% of ectopics • Growing within muscular wall of uterus • Removal very difficult
Ovarian • <1% of ectopics • Abundant blood supply • Difficult to save the ovary
Abdominal • Ectopic that has been extruded from tube and implants in the abdomen • 20x higher maternal mortality • Often placental tissue left in situ
Cervical • <1% of ectopics • Abundant blood supply (uterine vessels) • Non-surgical methods employed
Heterotopic Pregnancy • An ectopic in combination with an intrauterine pregnancy • 1 in 15,000-40,000 • 1% of patients undergoing IVF
Risk 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
Diagnosis • 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 Rupture • Isthmic pregnancies rupture earliest 6-8 weeks • Ampullary 8-12 weeks • Interstitial pregnancies 12-16 weeks
Unstable Stabilize with IV fluids, blood products Immediate laparotomy Stable Laparoscopy or Methotrexate injection Treatment
Methotrexate • Folate antagonist • Destroys proliferating trophoblastic tissue • May be useful in small unruptured ectopics • Relative contraindications • Adnexal mass > 3.5 cm • Fetus with cardiac activity
Teratogenesis • 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 Categories A 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
Diabetes in Pregnancy Chapter 18
Statistics • 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
Metabolism • 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
2nd 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 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 Anomalies • Caudal regression • Neural tube defects • Transposition of the great vessels • Ventricular septal defects • Renal agenesis • Duodenal atresia
Approach 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 Goals • Fasting glucose 80-95 mg/dL • One hour post-prandial < 130 mg/dL • Two hour post-prandial < 120 mg/dL
Retinopathy • 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
Nephropathy • 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 Diabetes Screening • ~28 weeks • 50 gram glucose load followed by 1 hour glucose measurement • > 130 requires diagnostic test
8 hour overnight fast 100 gram glucose load Diagnosis GDM Need 2 or more abnormal values
Risk Factors GDM • > 25 years of age • Obesity • Family history • Previous infant > 4000 grams • Previous stillborn • Previous polyhydramnios • History of recurrent SABs