11.2c Other Medical Disorders of Pregnancy Flashcards
1
Q
Anemia
A
- Reduced oxygen carrying capacity of blood
- Compensates by increasing cardiac output
- With preeclampsia it can cause CHF (congestive heart failure)
- Majority is caused by iron deficiency
- Loss of blood during birth is not well tolerated making blood transfusion an increased risk
2
Q
Anemia Lab Values
A
Normal Hematocrit - 37-47% (Average is 33.8% during pregnancy)
ANEMIA
- Less than 11 g/dL during 1st and 3rd trimester
- Less than 10.5 g/dL during second
- Less than 6-8 is severe anemia
3
Q
Iron Deficient Anemia
A
- Diagnosed by checking serum ferritin, hemoglobin, hematocrit
- Ferratin measures iron stores (less than 12 mcg/L is anemia)
- Treatable with iron supplements (can cause constipation)
- Increases risk of LBW
4
Q
Folic Acid Anemia
A
- Found in dark leafy vegetables, fruits, eggs, legumes, whole grains
- It is common and can be caused by poor diet, cooking with too much water, and increased alcohol use.
- Need for folate increases during pregnancy due to fetal demand and less absorption through GI tract
Recommended Dosage
- 400 mcg/day before pregnancy
- 600 mcg/day during pregnancy (50% more)
5
Q
Folate Deficiency Risk
A
- Hemoglobinopathies
- Taking anticonvulsants
- Multifetal gestation
- Frequent pregnancies
6
Q
B12 Deficient Anemia
A
- Seen more often due to increasing women becoming pregnant after bariatric surgery
- Crohn’s disease and metformin also increase risk
MEGALOBLASTIC ANEMIA s/s
- Pallor
- Fatigue/Lethargic
- Skin Roughness
- Glossitis (swollen tongue)
7
Q
Sickle Cell Hemoglobinopathy
A
- Presence of abnormal hemoglobin in blood causing RBC sickling (normal lifespan)
- Women with sickle cell hemoglobinopathy usually do well with pregnancy
INCREASED RISK
- Preeclampsia
- Intrauterine Fetal Death
- Preterm Birth
- LBW
- Postpartum endometritis
- UTI
8
Q
Sickle Cell Anemia
A
- Genetic
- Abnormal Hemoglobin (SS or SC)
- RBC only have 5-10 day lifespan (normal 120 days)
- Have recurrent fever/pain most often in abdomen, joints and extremities
- Attacks are caused by vascular occlusion
CRISIS TRIGGERS
- Dehydration
- Hypoxia
- Acidosis
9
Q
Sickle Cell Anemia Risks
A
- Require genetic counseling before pregnancy
- Miscarriage
- Preterm Birth
- IUGR
- Stillbirth
- Preeclampsia
- Infection
- Painful Crises
10
Q
Sickle Cell Anemia Treatment
A
- Folic acid 1mg/day as soon as pregnancy is diagnosed
- Ultrasound fetal examination to monitor growth and NST during 3rd trimester
- Aggressively treat infection with antibiotics
- Crises is treated with analgesia, oxygen and hydration
- Encouraged to have labor in side lying position
- Require Supplemental Oxygen
- Regional Anesthesia recommended for best pain relief
- Vaginal birth is preferred
11
Q
Thalassemia
A
- Insufficient hemoglobin to fill RBC’s
- Abnormal synthesis of B thalassemia
12
Q
B-Thalassemia Minor (heterozygous)
A
- Asymptomatic
- Can cause splenomegaly and significant anemia
- May require blood transfusions during pregnancy
- Treated with folic supplementation
13
Q
B-Thalassemia Major (homozygous)
A
- Cooley Anemia
- Hepatosplenomegaly and bone deformities
- Patients usually die of infection/CVD early in life
- Usually infertile
- Usually experience anemia and CHF if pregnant
14
Q
Pulmonary Disorders
A
- Enlarged uterus can push on thoracic cavity causing respiratory difficulty
15
Q
Asthma
A
- Hypersensitivity of airway responsiveness to stimuli
- Exacerbations caused by allergies, medications, temperature change, emotional tension
RISKS
- Preterm birth
- Preeclampsia
- Small for gestational age
- IUGR
- Increased c-section rate
- Congenital malformations due to asthma exacerbations during 1st trimester
- ULTIMATE GOAL IS TO MAINTAIN ADEQUATE OXYGEN
INTERVENTIONS
- Monitor lung function (peak expiratory flow)
- Avoid triggers (allergies, dust, animal dander, pollen, smoke)
- Educate importance of controlling asthma
16
Q
Asthma Medications
A
- Inhaled corticosteroids
- Albuterol and oxygen for acute exacerbations
- Ultrasound examinations on someone who has poorly controlled asthma to evaluate fetal growth
- IF CORTICOSTEROIDS HAVE BEEN GIVEN DURING PREGNANCY, STRESS DOSES SHOULD BE GIVEN DURING AND AFTER LABOR TO PREVENT ADRENAL CRISES
17
Q
Asthma Considerations
A
- Pulse Ox
- Epidural anesthesia can reduce oxygen consumption (recommended for pain relief)
- Fentanyl is safer than morphine (due to histamine release)
- Indomethacin (tocolytic) should be avoided due to bronchospasm risk in aspirin sensitive women
- Asthma patients have increase risk of hemorrhage. PG (Prostaglandins) can be given but respiratory status should be monitored
- AVOID carboprost, ergonovine, methylergonovine as they can cause bronchospasm
- WOMEN RETURN TO PREPREGNANT ASTHMA STATUS 3 MONTHS AFTER BIRTH
18
Q
Cystic Fibrosis
A
- Genetic disorder where exocrine glands produce excessive viscous secretions
- Causes respiratory and digestive issues
EXAMPLES
- COPD
- Pancreatic Exocrine Insufficiency
- Elevated Sweat Electrolytes (chloride)
19
Q
Cystic Fibrosis Risks
A
- Severe disease can cause chronic hypoxemia and pulmonary infections which can be harmful for baby
RISK FACTORS THAT DETERMINE POOR PREGNANCY
- Poor pre-pregnancy nutrition
- Significant hypoxemia
- Pulmonary hypertension
- Liver Disease
- Diabetes
- INCREASES RISK OF IUGR AND UTEROPLACENTAL INSUFFICIENCY
20
Q
Cystic Fibrosis Care
A
- Proper weight should be handled before pregnancy
- Pancreatic insufficiency causes risk of malnutrition. May require TPN
- Monitor weight, glucose, hemoglobin, total protein, albumin, PTT, pancreatic enzymes
- MONITOR PULMONARY FUNCTION TESTS
- Inhaled 7% saline can have benefits
- EARLY DETECTION OF INFECTION IS VERY IMPORTANT
21
Q
Cystic Fibrosis Fetal Care
A
- RISK IS HIGHER FOR UTEROPLACENTAL INSUFFICIENCY AND IUGR
- Assess fundal height routinely
- Ultrasound to measure fetal growth and amniotic fluid volume
- Start counting fetal movements at 28 weeks
- NST at 32 weeks
- Labor causes increased CO which can lead to cardiopulmonary failure or cor pulmonale. More susceptible to right sided heart failure
- Vaginal birth with epidural/local is preferred
- If c-section is needed or general anesthesia, DO NOT GIVE ANTICHOLINERGICS before as they may dry airways
22
Q
Pruritis
A
- Pruritis Gravidarum (generalized itching without a rash. Limited to abdomen, caused by skin distension and stretch marks - striae)
- Does not cause poor perinatal outcomes
ASSOCIATED WITH
- Twin gestation
- Fertility treatment
- Diabetes
- Nulliparity
TREATMENT
- Skin lubrication, topical ointments, oral antihistamines, UV light, limited sunlight exposure
- Disappears after birth
23
Q
Pruritic Urticarial Papules and Plaques of Pregnancy
A
- Rash during pregnancy (polymorphic eruption)
- Occurs in first time pregnancies in late 3rd trimester
- Occurs more often when carrying male babies
- Rash starts at abdomen and moves to arms, thighs, back, butt
ASSOCIATED WITH
- Increased weight gain
- Multiple gestations
- Hypertension
- Induction of Labor
- DOES NOT CAUSE POOR PREGNANCY OUTCOMES
INTERVENTIONS
- Relieve discomfort with topical ointments, topical steroids, oral antihistamines
- Severe symptoms may need oral prednisone
- Resolves before birth or after birth
24
Q
Intrahepatic Cholestasis of Pregnancy
A
- Most common liver disease of pregnancy
- Causes general itchiness early in the 3rd trimester
- Itchiness in palms and soles and are worse at night. No skin lesions
S/S
- Elevated serum bile acids and liver function tests
- Jaundice
- Dark urine, Light colored stools
RISKS
- Family history
- Winter time
- Multiple gestations
- 35+ y/o
TREATMENT
- ursodeoxycholic acid
- Monitor liver function tests
- Antihistamines
- Cool bath or oatmeal baths
- Oatmeal cream or lotion
- Baking soda bath
25
ICP Risks
- Meconium staining
- Asphyxia events
- Still birth or preterm birth
26
ICP Care
- NST twice a week
- Birth at 37 weeks should be considered
- Symptoms disappear after birth
27
Neurologic Disorders
- Woman may have to deal with teratogenic effects of prescribed medications
- Mobility ability may change
- Impaired ability to care for the baby
28
Epilepsy
- Recurrent seizures
- Mortality rate is high during perinatal period (counseling must be done ASAP)
- Achieving effective seizure control before contraception is important, medications should be obtained on seizure medications.
Focal Epilepsy - Most common type with unknown cause
29
Anticonvulsant Medication Fetal Risks
- Cleft lip and palate
- Congenital heart disease
- NTD (Neural Tube Defects)
- Hypospadias (effect boys where opening of urethra is not located on the tip of penis)
30
Medications for Epilepsy
- Lamotrigine
- Levetiracetam
- Carbamazepine is used as well but declining in usage
31
Considerations of Epilepsy
- Folic acid should be taken if anticonvulsants are being used
- They should take supplemental vitamin D in addition to prenatal vitamin
- Anticonvulsant medication should be limited to only 1 and the lowest effective dose
- Drug dosages may need to be altered due to increased plasma volume
- RISK OF IUGR AND CONGENITAL ANOMALIES ARE HIGHER IN EPILEPTIC PATIENTS
- Assess a-fetoprotein at 16 weeks for NTD
- Ultrasound at 18-22 weeks for NTD
- NST not necessarily unless women has seizures during 3rd trimester
- Risk of seizure during labor is small
- Monitor anticonvulsant medication after birth first few weeks
32
Multiple Sclerosis
- Demyelination of spinal cord and CNS (Viral)
- Effects women more than men
SYMPTOMS
- Paresthesia (numbness in lower extremities)
- Weakness
- Visual impairment
- Loss of coordination
- Usually remission occurs during pregnancy and exacerbations may return during postpartum
33
MS Considerations
- Treatment of acute relapse is corticosteroids or IV immunoglobins
- Same routine care
- Daily prenatal vitamins with supplemental vitamin D
- May be at higher risk for UTI if there is disturbance in bladder function
- Epidural can be used
- C-sections are not usually indicated (only severe or active distress prevent safe labor)
34
Bell Palsy
- Idiopathic facial paralysis (maybe related to herpes)
- Increased risk of gestational hypertension and preeclampsia
MANIFESTATIONS
- Unilateral facial weakness
- Pain surrounding ear
- Difficulty closing eye on affected side
- Hyperacusis (abnormal acuteness of hearing)
- Loss of taste
- Outcomes of pregnancy are usually good unless there is a complete nerve block.
- Steroids is the only treatment
CARE
- Prevention of injury (cornea is constantly exposed due to not being able to close eyes)
- Facial massage
- Careful chewing
- Manual removal of food from affected cheek
- Reassurance
35
Autoimmune Disorders
- Collagen Vascular Diseases
| - Body attacks itself
36
Systemic Lupus Erythematosus
- Multisystem inflammatory disease effecting skin, joints, kidneys, lungs, nervous system, liver
SYMPTOMS
- Myalgias (muscle pain)
- Fatigue
- Weight change
- Fever
- DIAGNOSED WITH LAB TESTING ON AUTOANTIBODIES
- Disease activity at beginning of pregnancy is best predictor of exacerbations during pregnancy. Pregnancy itself does not increase likelihood of exacerbations.
ADVICE
- Wait until they have been in remission for 6 months before getting pregnant
37
Maternal Risks of Lupus
- Increased rate of miscarriage
- Preterm birth
- Preeclampsia
- Stillbirth
- IUGR
- Preterm birth
38
Lupus Medications
- Medical therapy is minimal for those in remission or mild form
- NSAIDS can treat arthralgia (joint stiffness). Do not give these medications chronically due to risk of oligohydramnios and ductus arteriosus closure
- Low dose aspirin throughout therapy
- Prednisone to treat flares or maintenance during pregnancy. (Risk of cleft lip and palate if used during 1st trimester. Can also cause maternal bone loss, gestational diabetes, hypertension, preeclampsia, and adrenal suppression)
- Antimalarial drug BEST MEDICATION FOR MAINTENANCE OF SLE (no adverse effects on fetus)
39
CARE FOR SLE
- Ultrasound weekly after 24-28 weeks
- NST twice a week with amniotic fluid assessments, BPP at 32 weeks
- Birth should be given at 39 weeks
- Earlier birth if there is IUGR, preeclampsia, worsening renal functions
- Chronic glucocorticoid therapy (need to be weened off)
- Vaginal birth is preferred but c-sections are common
40
Myasthenia Gravis
- Autoimmune disease of muscle that involves acetylcholine
SYMPTOMS
- Muscle weakness of eyes, face, tongue, neck, limbs, respiratory muscles
- Diplopia (double vision), ptosis (drooping eyelids), dysphagia (trouble swallowing)
- Pregnancy does not affect MG but respirations can be compromised due to uterus enlargement
TREATMENT
- Same as normal pregnancy
- Medications include glucocorticoids and acetylcholinesterase inhibitors.
41
MG Considerations
- IV-Immunoglobins for severe weakness
- Labor is well tolerated
- Vaginal birth is recommended but vacuum and forceps may be used due to muscle weakness
- Do not give muscle relaxants during labor
- Avoid opioids due to respiratory depression (MG already at risk for respiratory muscle weakness)
- Regional anesthesia preferred
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BABY MAY HAVE NEONATAL MYASTHENIA (due to antibody against acetylcholine transferring through placenta)
SYMPTOMS
- Weak Cry
- Respiratory Difficulty
- Weakness in Sucking
- Feeble limb movements (after 72 hours)
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42
Cholelithiases
- Gallstones
- Increased incidence during pregnancy due to increase hormone levels and enlarged uterus which interferes with gallbladder drainage
- Usually asymptomatic but can cause RUQ/Epigastric pain that radiates to shoulder
- Pain usually occurs after eating high fat meal
43
Cholecytitis
- Inflammation of gallbladder
- Caused when gallstone obstructs cystic ducts
Symptoms
- RUQ/Epigastric pain
- N/V and fever
- Surgery is usually delayed until postpartum
- Recurrent stones require immediate surgery
44
IBD
- Ulcerative Colitis and Crohn's Disease
- Pregnancy usually does not affect these diseases
RISKS
- Preterm Birth
- LBW
- Small for Gestational Age
TREATMENT
- Daily folic acid
- Calcium Supplements (osteoporosis is a significant complication for IBD)
- Prolonged flares may require TPN
45
UTI
- Cystitis and Pyelonephritis
- Most commonly caused by E-Coli
Nitrofurantoin - Suppresses bacteria
46
Cystitis
- Bladder Infection
S/S
- Dysuria, Urgency, Frequency, Lower ABD Pain
- WBC found in urine
TREATMENT
- Antibiotics and Analgesics for pain
47
Pyelonephritis
- Renal Infection
COMPLICATIONS
- SEPTIC SHOCK
- Acute Respiratory Distress Syndrome (ARDS)
- Preterm Labor
S/S
- Fever, Chills, Flank Pain
- Dysuria, Urgency, Frequency
- N/V
- Tender costovertebral angles
48
Pyelonephritis Treatment
- IV antibiotics and cultures
- Prophylactic antibiotic (nitrofurantoin) for remainder of pregnancy or cultures for the rest of pregnancy
- Monitor for sepsis, ARDS, preterm labor
- IV fluids to maintain adequate urinary output (50 mL an hour) EXTREMELY IMPORTANT
- Ultrasound for obstruction if no improvement within 48-72 hours
