How to Deal with Pregnancy Complications for the Physician Assistant Exam
All is well when the pregnancy proceeds normally without any complications. As the Physician Assistant Exam will cover, unfortunately, complications can and do happen in pregnancy. You should be familiar with some of these conditions, from uncontrolled hypertension to emergent bleeding disorders.
Ectopic pregnancy is a pregnancy outside of the uterus. The most common place for an ectopic pregnancy to occur in the ampullary portion of the Fallopian tube, with the abdominal area being next in line. Ectopic pregnancy is a potentially life-threatening situation for the mother if left untreated. The embryo will not survive. Risk factors include tobacco use, advancing maternal age, and a history of pelvic inflammatory disease.
Common presenting symptoms include acute onset lower-quadrant abdominal pain with elevated β-hCG. Other signs can include bleeding, especially vaginal bleeding. The diagnosis is confirmed by an ultrasound.
Treatment of an ectopic pregnancy can be either medical or surgical. Methotrexate has been used in the treatment of an ectopic pregnancy, because it can end the pregnancy. If medical treatment isn’t warranted, then she needs emergent surgical intervention.
Gestational trophoblastic disease
Sometimes the fetus winds up sharing the uterus with unexpected tumors. Gestational trophoblastic disease refers to abnormal cells growing in the uterus that form a mass. They form grapelike clusters and can form a hydatidiform mole, which is not malignant. The usual presentation is vaginal bleeding late in the second trimester.
On examination, the fundal height of the uterus is a lot higher than you’d expect for gestational age. In addition, the β-hCG level is super high. The mother can also present with symptoms reminiscent of hyperthyroidism. You can see “grape-like clusters” on the ultrasound; however, tissue is required to make a diagnosis.
Treatment, which is always necessary, is evacuation of the pregnancy. Suction curettage is the preferred method.
A choriocarcinoma is a form of GTD that is a rapid-growing, intrauterine malignancy. Presenting symptoms can include uterine swelling, vaginal bleeding, and abdominal pain. Physical examination can reveal uneven swelling of the uterus. Like a hydatidiform mole, the serum β-hCG is super high. The mainstay of treatment is usually chemotherapy.
Blood pressure problems in pregnancy
Hypertension frequently occurs during pregnancy. You need to be able to diagnose and tell the difference between pre-eclampsia and gestational hypertension:
Pre-eclampsia: In pre-eclampsia, hypertension arises and you see significant proteinuria on or after the 20th week of gestation. The blood pressure is usually greater than 140/90 mmHg and as high as 160/110 mmHg. The proteinuria needs to be in excess of 300 mg/dL in a 24-hour period for pre-eclampsia to be diagnosed. There can also be increased serum uric acid and lactate dehydrogenase levels.
Gestational hypertension: Gestational hypertension, or pregnancy-induced hypertension, is high blood pressure that occurs after the 20th week of pregnancy without proteinuria being present.
The gold standard of treatment for pre-eclampsia is delivery of the fetus via C-section. If this can’t be done, the patient needs to be closely monitored, sometimes in the hospital. Medications that can help control blood pressure during pregnancy for both pre-eclampsia and gestational hypertension — that is, meds that aren’t toxic to the fetus — include methyldopa (Aldomet), labetalol (Normodyne), hydralazine (Apresoline), and amlodipine (Norvasc).
Potential complications of pre-eclampsia include the following:
Eclampsia: Eclampsia is a bad, bad complication characterized by seizures. Patients with pre-eclampsia are given magnesium sulfate for eclampsia prophylaxis. The treatment of choice is delivery of the baby via an emergent C-section.
HELLP syndrome: HELLP syndrome is characterized by hemolysis, elevated liver enzymes, and low platelets. It can also be associated with disseminated intravascular coagulation (DIC) and acute kidney injury (AKI). The treatment is delivery of the baby.
Gestational diabetes is elevated blood glucose levels that occur during pregnancy, usually diagnosed by a positive oral glucose tolerance test. This screening occurs between the 24th and 28th weeks of pregnancy. In addition to the results of the oral glucose tolerance test, pay attention to the blood glucose levels before and after meals. If they’re elevated, the mother may need insulin therapy.
If gestational diabetes is left untreated, a potential complication is fetal macrosomia. This means that the baby is large and is at risk for complications such as shoulder dystocia.
In this situation, the baby’s head is deliverable but the shoulder is unable to move below the mother’s pubic bone. Shoulder dystocia can be fatal because the umbilical cord can get squeezed in the process. Often a C-section is necessary.
When a baby has Rh-positive blood and the pregnant mom has Rh-negative blood, the mother’s body can make antibodies to the Rh-positive blood, leading to Rh incompatiblity. A hemolytic anemia can develop. At its worst, Rh incompatibility can result in fetal death due to the buildup of bilirubin. An Rh immune globulin shot is given to Mom at the 24- to 28-week mark to prevent Rh incompatibility.
In the movies, you’ve seen where the mother’s water breaks. Premature rupture of membranes occurs before 37 weeks gestation. The treatment is the use of antibiotics to avoid infection. Infection can be a trigger for delivery, and the goal of antibiotic treatment is to forestall delivery. Depending on the estimated gestational age, the fetus may not be viable for extrauterine life, with the lungs being the last to mature.