11: Other medical complications

Question 1

hyperemesis gravidarum is common in the setting of ?

Answer 1

molar pregnancies (likely since HCG levels can be very high) and a viable IUP should always be documented in patients with hyperemesis

Question 2

First-line antiemetic therapy for hyperemesis

Answer 2

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

Question 3

if patients will not respond to antiemetics and recurrent rehydration

Answer 3

tx with corticosteroids

Question 4

normal physiologic changes of pregnancy

Answer 4

increased volume of distribution (VD) and increased hepatic metabolism of AEDs–>increased seizure frequency

Question 5

what hormones affect seizures during pregnancy?

Answer 5

estrogen: epilieptogenic, decreasing seizure threshold
progesterone: anti epileptic effect (fewer seizures during luteal phase)

Question 6

AEDs that are notorious for fetal malformations

Answer 6

phenytoin, phenobarbital, primidone, valproate, carbamazepine, and trimethadione

Question 7

congenital abnormalities seen in infants born to epileptic moms on AEDs

Answer 7

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

Question 8

genetic component leading to teratogenesis from AEDs

Answer 8

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

Question 9

how to reduce teratogenesis of AEDs

Answer 9

switch to mono therapy, taper down dose, consider withdrawing if seizure free for 2-5 years

Question 10

new AEDs that may have reduced risk of congenital anomalies

Answer 10

levetiracetam, lamotrigine, felbamate, topiramate, and oxcarbazepine

Question 11

Management of Women with Epilepsy During Pregnancy

Answer 11

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)

Question 12

the drug of choice in patients with a known seizure disorder is usually ? compared to magnesium used in preeclamptic patients

Answer 12

phenytoin

Question 13

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 ?

Answer 13

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

Question 14

CV conditions causing high risk of maternal mortality in pregnancy

Answer 14

primary pulmonary hypertension, Eisenmenger physiology, severe mitral or aortic stenosis, and Marfan syndrome

Question 15

SBE (subacute bacterial endocarditis) prophylaxis may be considered for women with ?

Answer 15

high-risk lesions (mechanical or prosthetic valves, unrepaired cyanotic lesions, etc.) and an infection that could cause bacteremia (chorioamnionitis or pyelonephritis).

Question 16

care of women with congenital heart disease i.e. mitral/aortic stenosis

Answer 16

• 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

Question 17

postpartum period dangerous for woman with congenital heart disease, why?

Answer 17

massive fluid shifts

1. IVC no longer compressed by uterus
2. autotransfusion of blood supply (500cc) redirected from uterus that no longer needs it

Question 18

among the most severe CV conditions in pregnancy:

Answer 18

right-to-left shunts and pulmonary hypertension

i.e. PDA, VSD due to Eisenmenger syndrome

Question 19

peripartum cardiomyopathy (PPCM)
how to manage?

Answer 19

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

Question 20

Chronic kidney disease classification

Answer 20

mild (Cr 2.8)

Question 21

CKD risks in pregnancy

Answer 21

preE, PTD, IUGR

-screen at least once per trimester with a 24-hour urine for creatinine clearance and protein

Question 22

consideration with post renal transplant patients

Answer 22

may be on immunosuppressants that have increased metabolism and Vd during pregnancy
i.e. cyclosporine, tacrolimus, prednisone, and Imuran

Question 23

why is pregnancy a hyper coagulable state

Answer 23

• 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

Question 24

superficial vein thrombosis (SVT) how to treat?

Answer 24

warm compresses and analgesics but watch out for s/s of DVTs and PEs

Question 25

how to dx DVT

treatment?

Answer 25

• 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).

Question 26

teratogenesis of warfarin

Answer 26

When given in the first trimester, it causes warfarin embryopathy, a combination of nasal hypoplasia and skeletal abnormalities.
-CNS abnormalities, including optic atrophy

Question 27

PE Cxray

Answer 27

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

Question 28

PE dx for patients

Answer 28

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

Question 29

PE tx

Answer 29

LMWH (IV heparin or streptokinase in a hypotensive/unstable pt)
enoxaparin
-tx for a minimum of 6 mos

Question 30

Management of thyroid disease changes in pregnancy ?

Answer 30

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.

Question 31

management of TSH in pregnancy to prevent goiters in fetus

Answer 31

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.

Question 32

all women on levothyroxine (Synthroid) supplementation should have their dose changed how?

Answer 32

increased from 25% to 30%.

-increase demand for thyroid hormone including increased VD, increased binding globulin (in particular, SHBG

Question 33

The natural history of SLE in pregnancy follows the one-third rule
med changes ?

Answer 33

1/3 improve, 1/3 worsen, and 1/3 remain unchanged

aspirin and corticosteroids are continued in pregnancy, whereas cyclophosphamide and methotrexate are NOT

Question 34

pathophys of early pregnancy loss in SLE pts

Answer 34

placental thrombosis

-mostly 1st/2nd, can happen in 3rd trimester as well, risk for IUGR, IUFD

Question 35

SLE tx

Answer 35

SQ heparin or Lovenox prophylaxis and low-dose aspirin

Question 36

lupus flare vs preE

why important to ddx?

Answer 36

• 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

Question 37

SLE patients (and more commonly Sjögren syndrome patients) can produce antibodies called anti-Ro (SSA) and anti-La (SSB) that do what?

Answer 37

are tissue-specific to the fetal cardiac conduction system, damage the AV node–>congenital heart block
-tx w. corticosteroids, plasmapheresis, and IVIG

Question 38

for alcohol withdrawal symptoms in pregnancy

Answer 38

use barbiturates not benzos (teratogenic)

Question 39

recommended caffeine intake in pregnancy

Answer 39

less than 150 mg

at risk for spontaneous abortions

Question 40

complications of smoking during pregnancy

Answer 40

spontaneous abortions, preterm births, abruptio placentae, and decreased birth weight, SIDS, respiratory illnesses

Question 41

complications of cocaine during pregnancy

Answer 41

abruptio placentae, IUGR, and an increased risk for preterm labor and delivery,CNS complications, including developmental

Question 42

risks of opioid use in pregnancy

Answer 42

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

Question 43

when babies born to opioid using mothers

Answer 43

Once infants are delivered, they require careful monitoring and slow withdrawal from their narcotic addiction using tincture of opium