Late Pregnancy

HELLP Syndrome

1. Hemolysis
2. Elevated Liver enzymes
3. Low Platelets

• Variant of severe preeclampsia, about 10% of pre-eclampsia pts develop HELLP.
• BP often normal
• Epigastric pain (Beware of heartburn)
• Blood Smear: low platelets, fragments (Schistocytes)
• Mechanism:
  • Endothelial activation
  • Fibrin deposition causing piano-wire type strands cause RBCs to fragment and get broken apart.
• Tx:
  • Typically once get HELLP, try to do emergent delivery.
  •  If symptoms persist after delivery, can think about plasma exchange. 

• OB Emergency
• Pregnant Mother w/ seisure is Elcampsia until proven otherwise

1. ABC
2. Control seizure MgSO4, valium (protect airway)
3. Stabilize and deliver

• Physiologic changes of pregnancy apparent 24-29 wks
• Screen at 27-29 wks
• Anti-insulin factors produced by placenta + high serum cortisol = insulin resistance
  
• Glucose challenge test
  • 50g oral glucose, check serum in 1hr
    • if <7.8 = normal
    • if 7.8-10.3 = do glucose tolerance (GTT)
  • • if >10.3 = Gest. diabetes mellitus (GDM) present
• Glucose tolerance test (GTT) - if GCT 7.8-10.3
  • fasting blood sugar + 75g oral, check serum glucose (details later)

• ka Rhogam, RHig
• Indicated if mother is Rh- and no Rh antibodies
• Prevents mounting immune reaction against fetal Rh+ red cells
• Give 300ug IM at 28wks (protects against 25mL of fetal blood)
• Protection lasts 12 weeks
• If >25mL of fetal blood in maternal circulation do Betke-Kleihauer test to see how much Rhogam to give (300ug/25mL of fetal blood)
• Rh Antibody testing at 20 and 26-28 weeks
• Given at 28 weeks or if possibility of feto-maternal hemorrhage:
  • Spontaneous abortion
  • Termination
  • Ectopic
  • CVS/amniocentesis
  • Antepartum Hemorrhage
  • Post-partum
• Protection lasts 12 weeks (antibody screen will be positive)
• Test father (if Rh-, then baby is Rh- too, Ab not required- make certain of parternity)

Other Serum antibodies can be identivied with group&screen, refer to high-risk clinic if +'ve
.

-  Consider Hb and MCV (iron def, B12, folate)
-  Repeat 28-30 weeks and 36wks

-  Done at 36wks

-  GBS - Strep. agalactiae
-  Repeat 28-30 weeks and 36wks
-  Many women carriers, status can change (10-30%)
-  If negative within 5 weeks of delivery, no antibiotics
-  Give antibiotics (Ancef) to prevent neonatal GBS infection
 

• Neonatal GBS infection:
  • Strep. agalactiae - normally in gut flora, only infects immunocompromised people, can give mastitis in cows causing no milk (hence called "agalactiae" meaning "no milk").
  • Early septicimia: 0-7days: often accompanied by pneumonia (if aspirated during birth)
  • Late septicimia: 7-90 days: often accompanied by meningitis
• GBS Prophylaxis criteria: (2010 CDC guidelines - US)
  •  gestation of <37 weeks
  •  the membranes have been ruptured 18 hours or longer, or
  •  a temperature of 38°C (100.4°F) or greater.
  • intrapartum nucleic acid amplification test (NAAT) is positive for GBS
  • Previous infant with invasive GBS disease
  • GBS bacteriuria during any trimester of the current pregnancy
  • Positive GBS vaginal-rectal screening culture in late gestation during current pregnancy
  • Unknown GBS status at the onset of labor (culture not done, incomplete, or results unknown) and any of the following:
    • Delivery at <37 weeks’ gestation
    • Amniotic membrane rupture ≥ 18 hours

    • Intrapartum temperature ≥ 100.4°F (≥ 38.0°C)
    • Intrapartum NAAT positive for GBS

 

Antepartum Hemorrhage

Vasa Previa

DIC

aka miscarriage (use "miscarriage" when patients are around)

• Tell patients:
  • "There is nothing you have done to prevent it"
  • "There is nothing you could have done to cause it"
  • "Nature's way"