11: Other medical complications Flashcards
hyperemesis gravidarum is common in the setting of ?
molar pregnancies (likely since HCG levels can be very high) and a viable IUP should always be documented in patients with hyperemesis
First-line antiemetic therapy for hyperemesis
Phenergan, followed by addition of Reglan, Compazine, and Tigan. If these fail, droperidol and Zofran
Persistent N/V during pregnancy can also be treated with vitamin B6 and doxylamine (Unisom). Ginger and supplementation with vitamin B12
if patients will not respond to antiemetics and recurrent rehydration
tx with corticosteroids
normal physiologic changes of pregnancy
increased volume of distribution (VD) and increased hepatic metabolism of AEDs–>increased seizure frequency
what hormones affect seizures during pregnancy?
estrogen: epilieptogenic, decreasing seizure threshold
progesterone: anti epileptic effect (fewer seizures during luteal phase)
AEDs that are notorious for fetal malformations
phenytoin, phenobarbital, primidone, valproate, carbamazepine, and trimethadione
congenital abnormalities seen in infants born to epileptic moms on AEDs
4x increase in cleft lip/palate, 3-4x increase in cardiac anomalies, increase in NTDs (carbamezipine, valproic acid), higher rates of abnormal EEG findings, higher rates of developmentally delayed children, and lower IQ scores
genetic component leading to teratogenesis from AEDs
children whose enzyme activity of epoxide hydrolase is one-third less than normal have an increased rate of fetal hydantoin syndrome
-low epoxide hydrolase activity in children may increase risk of anomalies from carbamazepine
how to reduce teratogenesis of AEDs
switch to mono therapy, taper down dose, consider withdrawing if seizure free for 2-5 years
new AEDs that may have reduced risk of congenital anomalies
levetiracetam, lamotrigine, felbamate, topiramate, and oxcarbazepine
Management of Women with Epilepsy During Pregnancy
Check total and free levels of antiepileptic drugs on a monthly basis
Consider early genetic counseling
Check MSAFP
Level II ultrasound for fetal survey at 19 to 20 wks’ gestation (check face, CNS, and heart)
Consider amniocentesis for α-fetoprotein and acetylcholinesterase
Supplement with oral vitamin K 20 mg QD starting at 37 wks until delivery (optional)
the drug of choice in patients with a known seizure disorder is usually ? compared to magnesium used in preeclamptic patients
phenytoin
increased risk of spontaneous hemorrhage in newborns because of the inhibition of vitamin K–dependent clotting factors (i.e., II, VII, IX, X) secondary to ?
increased vitamin K metabolism and inhibition of placental transport of vitamin K by AEDs
- overcome with aggressive supplementation with vitamin K toward the end of pregnancy (theoretical)
- may need FFP
CV conditions causing high risk of maternal mortality in pregnancy
primary pulmonary hypertension, Eisenmenger physiology, severe mitral or aortic stenosis, and Marfan syndrome
SBE (subacute bacterial endocarditis) prophylaxis may be considered for women with ?
high-risk lesions (mechanical or prosthetic valves, unrepaired cyanotic lesions, etc.) and an infection that could cause bacteremia (chorioamnionitis or pyelonephritis).
care of women with congenital heart disease i.e. mitral/aortic stenosis
- sx repair >1 year before becoming pregnant
- offer termination of pregnancy as first line management
- early epidural analgesia, vacuum/forceps assistance (minimizes cardiac stress)
- monitor fluids carefully
postpartum period dangerous for woman with congenital heart disease, why?
massive fluid shifts
- IVC no longer compressed by uterus
- autotransfusion of blood supply (500cc) redirected from uterus that no longer needs it
among the most severe CV conditions in pregnancy:
right-to-left shunts and pulmonary hypertension
i.e. PDA, VSD due to Eisenmenger syndrome
peripartum cardiomyopathy (PPCM) how to manage?
specifically caused by pregnancy.
classic s/s of heart failure and on echocardiogram have a dilated heart with an ejection fraction far below normal in the 20% to 40% range.
-deliver if >34 wga
-manage with diuretics, digoxin, and vasodilators
Chronic kidney disease classification
mild (Cr 2.8)
CKD risks in pregnancy
preE, PTD, IUGR
-screen at least once per trimester with a 24-hour urine for creatinine clearance and protein
consideration with post renal transplant patients
may be on immunosuppressants that have increased metabolism and Vd during pregnancy
i.e. cyclosporine, tacrolimus, prednisone, and Imuran
why is pregnancy a hyper coagulable state
- production of all clotting factors is increased except for II, V and IX
- Turnover time for fibrinogen is also decreased during pregnancy and there are increased levels of fibrinopeptide A, which is cleaved from fibrinogen to make fibrin
superficial vein thrombosis (SVT) how to treat?
warm compresses and analgesics but watch out for s/s of DVTs and PEs
how to dx DVT
treatment?
- often made clinically with confirmation by Doppler studies or venography (rarely used)
- adjusted dose LMWH(enoxaparin 1 mg/kg BID) or unfractionated heparin (goal aPTT of 1.5 to 2.5 times normal).
teratogenesis of warfarin
When given in the first trimester, it causes warfarin embryopathy, a combination of nasal hypoplasia and skeletal abnormalities.
-CNS abnormalities, including optic atrophy
PE Cxray
chest X-ray may be entirely normal. However, when abnormal, two common signs on chest X-ray are the abrupt termination of a vessel as it is traced distally and an area of radiolucency in the region of lung beyond the PE
PE dx for patients
most common: Spiral CT scan
Pulmonary angiography is the gold standard for diagnosis of PE: intraluminal filling defects or if sharp vessel cutoffs are seen
PE tx
LMWH (IV heparin or streptokinase in a hypotensive/unstable pt)
enoxaparin
-tx for a minimum of 6 mos
Management of thyroid disease changes in pregnancy ?
the Vd increases circulating thyroid binding globulin, and sex hormone binding globulin (SHBG), which also binds thyroid hormone.
-leads to decreased availability of thyroid hormone.
management of TSH in pregnancy to prevent goiters in fetus
TSH should be kept between 0.5 and 2.5 in general population
in pregnancy, it should be kept closer to 0.5 than 2.5 if possible.
all women on levothyroxine (Synthroid) supplementation should have their dose changed how?
increased from 25% to 30%.
-increase demand for thyroid hormone including increased VD, increased binding globulin (in particular, SHBG
The natural history of SLE in pregnancy follows the one-third rule
med changes ?
1/3 improve, 1/3 worsen, and 1/3 remain unchanged
aspirin and corticosteroids are continued in pregnancy, whereas cyclophosphamide and methotrexate are NOT
pathophys of early pregnancy loss in SLE pts
placental thrombosis
-mostly 1st/2nd, can happen in 3rd trimester as well, risk for IUGR, IUFD
SLE tx
SQ heparin or Lovenox prophylaxis and low-dose aspirin
lupus flare vs preE
why important to ddx?
- lupus flare will have reduced C3 and C4 and are accompanied by active urine sediment
- lupus tx with steroids/cyclophosphamide while preE is tx with delivery
SLE patients (and more commonly Sjögren syndrome patients) can produce antibodies called anti-Ro (SSA) and anti-La (SSB) that do what?
are tissue-specific to the fetal cardiac conduction system, damage the AV node–>congenital heart block
-tx w. corticosteroids, plasmapheresis, and IVIG
for alcohol withdrawal symptoms in pregnancy
use barbiturates not benzos (teratogenic)
recommended caffeine intake in pregnancy
less than 150 mg
at risk for spontaneous abortions
complications of smoking during pregnancy
spontaneous abortions, preterm births, abruptio placentae, and decreased birth weight, SIDS, respiratory illnesses
complications of cocaine during pregnancy
abruptio placentae, IUGR, and an increased risk for preterm labor and delivery,CNS complications, including developmental
risks of opioid use in pregnancy
opioid withdrawal may pose a greater risk to the fetus than chronic narcotic use. Risks of opiod withdrawal include miscarriage, preterm delivery, and fetal death.
-tx with Suboxone (buprenorphine) > methadone > quitting outright
when babies born to opioid using mothers
Once infants are delivered, they require careful monitoring and slow withdrawal from their narcotic addiction using tincture of opium
