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446 Pregnant Flashcards

Chapter 446 Medical Disorders during Pregnancy

1
Q

In pregnancy, cardiac output increases by how much? And the reason for such increased? Does heart rate increase?

A

Cardiac output increases by 40% due to an increase in stroke volume
Heart rate increases by about 10 beats/min during third trimester

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2
Q

Define preeclampsia

A

BP more than 140/90 mmHg
Proteinuria more than 300 mg/24 hours OR
Protein Creatinine ratio more than 0.3
–after 20 weeks of gestation

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3
Q

Renal Histological feature of pre eclampsia

A

Glomerular endotheliosis

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4
Q

Modestly reduces risk of pre-eclampsia at high risk of developing the disease; when it is given

A

Aspirin 81 mg at end of first trimester

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5
Q

Postulated pathophysiology of pre eclampsia

A

Excessive placental production of antagonist VEGF and TGF B which disrupt endothelial and renal glomerular function resulting in edema, hypertension and proteinuria

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6
Q

Most commonly used to acutely managed severe hypertension in pre eclampsia

A

IV labetalol

Hydralazine

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7
Q

Preferred agent for the prevention and treatment of eclamptic seizures

A

Magnesium sulfate

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8
Q

How magnesium sulfate prevent seizure?

A

Magnesium sulfate interacts witb NMDA receptors in the CNS

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9
Q

Most commonly used medication for the treatment of chronic hypertension in pregnancy

A

Labetalol

Nifedipine

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10
Q

Target blood pressure in pregnant patient with chronic hypertension

A

SBP 130-150 mmHg

DBP 80/100 mmHg

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11
Q

Development of elevated blood pressure after 20 weeks of pregnancy or in the first 24 hour post partum in the absence of pre existing chronic hypertension or proteinuria

A

Gestational hypertension

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12
Q

Most common cardiac problem complicated pregnancy

A

Valvular heart disease

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13
Q

Valvular heart disease most likely to cause death during pregnancy

A

Mitral stenosis

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14
Q

Procedure prior to conception for patients with severe mitral stenosis with either symptomatic disease or pulmonary hypertension

A

Valvuloplasty prior to conception preferable percutaneous balloon valvotomy

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15
Q

Pregnancy induced decrease in systemic vascular resistance reduced the risk of cardiac failure in these conditions

A

Mitral regurgitation
Aortic regurgitation
Aortic stenosis

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16
Q

Common cardiac complication of pregnancy

A

Supra ventricular tachycardia

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17
Q

What peak to peak valve gradient in severe aortic stenosis warrants treatment prior to pregnancy?

A

Peak to peak gradient more than 50 mmHg in women with severe aortic stenosis requires treatment prior to pregnancy

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18
Q

What peak to peak gradient in women with aortic stenosis is pregnancy likely to be well tolerated?

A

Peak to peak gradient of less than 25 mmHg

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19
Q

True or false. For women with mitral or aortic regurgitation and LV dysfunction of less than 30% pregnancy should be avoided

A

True

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20
Q

True or false. Adenosine and calcium channels blockers cannot be given to pregnant women with SVT due to it harmful fetal effects

A

False. SVT are treated as if non pregnant. Fetal tolerance to CCB and adenosine are acceptable.

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21
Q

True or false. Electrical caedioversion may be performed to improve cardiac performance and reduce symptoms and is generally tolerated by mother and fetus

A

True

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22
Q

Peripartum cardiomyopathy carry a 10% mutation in this gene

A

Titin sarcomere protein

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23
Q

Autosomal dominant disease associated with increased risk of aortic dissection and rupture in pregnancy

A

Marfan syndrome

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24
Q

In patients with marfan syndrome, aortic root diameter of what is associated with favorable outcome of pregnancy?

A

Aortic root diameter of less than 40 mm

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25
Q

However, patient with marfan syndrome is at increases risk of aortic dissection at what aortic root diameter?

A

Aortic root diameter of more than 40 mm

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26
Q

Associated with premature labor and whic type is linked to increased risk of organ or vascular rupture that may cause death

A

Ehlers- Danlos syndrome, Type IV

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27
Q

True or false. Primary pulmonary hypertension is contraindicated in pregnancy and Termination is advisable to preserve the life of the mother

A

True

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28
Q

Combination of pulmonary hypertension and right to left shunting

A

Eisenmeger syndrome

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29
Q

True or false. In patients with pulmonary hypertension, cesarean delivery is hemodynamically less stressful that vaginal delivery

A

False. Vaginal delivery is less stressful and cesarean delivery reserved for accepted obstetrical indications.

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30
Q

True or false. Pregnancy is associated with venous stasis, endothelial injury and hypercoagulabke state.

A

True.

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31
Q

VTE commonly occurs when? Which is more common in pregnancy: DVT or PE?

A

VTE commonly occurs 6 weeks post partum

DVT is more common than PE in pregnancy

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32
Q

Leg most commonly involved in DVT in pregnancy and why?

A

Left leg DVT is more common because the left iliac vein is compressed by right iliac artery and the uterus compressed the Inferior vena cava

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33
Q

True or false. D Dimer can be used to test for VTE in pregnant women.

A

False. D Dimer values are elevated in normal pregnancy.

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34
Q

Indicated for women with DVT

A

LMWH or UFH

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35
Q

LMWH is associated with what and should be discontinued when?

A

LMWH is associated with epidural hematoma in women receiving epidural anesthesia and should be discontinued 24 hrs before placement of an epidural catheter

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36
Q

Why is warfarin contraindicated in the first trimester?

A

Warfarin is associated with fetal chondrodysplasia punctata during the first trimester

37
Q

Why is warfarin contraindicated in 2nd and 3rd trimester of pregnancy?

A

Fetal optic atrophy and mental retardation

38
Q

Use of warfarin in pregnancy is restricted to what?

A

Warfarin use in pregnancy is restricted to women with mechanical heart valves

39
Q

True or false. In pregnancy, glucose and amino acids are shunted to the fetus while the mother uses Ketones and Triglycerides for fuel for metabolic needs

A

True

40
Q

True or false: pregnancy is associated with accelerated ketosis, plasma hydoxybutyrate and acetoacetate rise to 2x-4x normal after a fast

A

True

41
Q

True or false. Folate supplementation is diabetic pregnant women is need to reduce fetal neural tube defects which occur with greater frequency in diabetic mothers

A

True

42
Q

True or false. Glucose control in pregnant women is same as in non pregnant state

A

False. Glucose control should be managed more aggressively in pregnant women

43
Q

Target fasting blood sugar in diabetic pregnant women

A

FBS less than 105 mg/dl or less than 5.8 mmol/L

44
Q

Why is there minimal value of HbA1c monitoring in pregnancy?

A

HbA1c is used minimally because there is a higher rate of RBC turnover during pregnancy

45
Q

Why is blood sugar difficult to control as pregnancy progresses?

A

As pregnancy progresses, there is also increase in insulin resistance

46
Q

True or false. All pregnant women should be screened for GDM

A

True

47
Q

Typical 2 step strategy in diagnosis of GDM is performed at what weeks of gestation?

A

Establishing the diagnosis of GDM is performed at 24-28 weeks gestation

48
Q

What is step one in the process of diagnosing GDM? What is the cut off value? When is step two done?

A

50 gram oral glucose challenge and single measurement of sugar at 60 min
Result of plasma glucose less than 7.8 mmol/L or less than 130 mg/dl is considered normal
Plasma glucose result more than 7.8 or 130 mg/dl warrants step two

49
Q

What is step two in diagnosing GDM? What are the normal values and what constitute a positive test?

A

Step two is administration of 100 grams Oral glucose challenge with plasma glucose taken at fasting, 1, 2, and 3 hours post prandial
Fasting: less than 5.3 or 95
1 hr: less than 10 or 180
2 hr: less than 8.6 or 155
3 hr: less than 7.8 or 140
Two elevated values indicated positive test

50
Q

Two step strategy in GDM

A

Dietary intervention

Insulin injections

51
Q

Target glucose levels in GDM

A

FBS less than 5.6 or 100

2 hr: less than 7.0 or 126

52
Q

Oral hypoglycemic agents that can be used in GDM

A

Glyburide

Metformin

53
Q

Women with GDM develop to DM type 2 in 10 yrs after index pregnancy by how many percent?

A

40% of patients with GDM will develop into DM type 2 in 10 years

54
Q

GDM patients should be screen for DM type 2 at how many weeks?

A

All women with GDM should have formal glucose tolerance test to screen for T2DM at 6 weeks post partum

55
Q

What is the target weight gain based on BMI accoridng to the National Academy of Medicine

A

BMI less than 18.5- 24.9 - -12.5 - 18 kg
BMI 25-29.9 - - 11.5-16 kg
BMI more than 30- - 5-9 kg

56
Q

True or false. Estrogen induced increase in TBG increases circulating TT3 and TT4, placental hCG directly stimulating the thyroid to increase FT3 and FT4

A

True

57
Q

Why is methimazole not given on the first trimester?

A

Methimazole crosses the placenta and is associated with fetal aplasia cutis.

58
Q

Why is PTU not given on the 2nd or 3rd trimester of pregnancy?

A

PTU is associated with liver failure

59
Q

What is the goal of therapy for hypothyroidism in pregnancy?

A

Maintain the TSH in the normal range

60
Q

What is the drug of choice for hypothyroidism in pregnancy?

A

Thyroxine

61
Q

What is the dose of thyroxine?

A

Pre pregnancy: 0.1 mg/kg/day

Pregnancy: 0.15 mg/kg/day

62
Q

When does thyroxine requirement increase in pregnancy? And what is one approach to deal with this increase in requirement?

A

Increase in thyroxine requirement occurs on the 5th week of pregnancy and one approach is to increase thyroxine dose by 30%

63
Q

True or false. Pregnancy is a described as a state of physiologic dilutional anemia

A

True

64
Q

Four cancers that occur most commonly in pregnancy

A

Cervical cancer
Breast cancer
Melanoma
Lymphomas

65
Q

At what weeks of gestation can definitive treatment be done in urgent cases of cancer in pregnancy?

A

Beyond 24 weeks of gestation

66
Q

True or false. Spread of cancer from mother to fetus occur frequently.

A

False. Spread from mother to fetus is exceedingly rare

67
Q

What to do if pregnant women has seizure and is maintained on valproate? Any supplements needed?

A

Valproate/valproic acid has to be stopped and switched to another anti epileptic drug as it is teratogenic
Folic supplementation in these patients is increased to 4 mg/day

68
Q

What peripheral nerve disorder is more likely to occur 3x the general population? And when does it often occur

A

Bells Palsy. Likely to occurs during the 3rd trimester and immediate post partum

69
Q

Most common peripheral nerve and movment disorder in pregnancy and what is its suspected etiology

A

Restless leg syndrome; disordered iron metabolism is its suspected etiology

70
Q

Severe form of nausea and vomiting in pregnant women and when does it commonly occur?

A

Hyperemesis gravidarum is severe form of nausea and vomiting among pregnant women in the first trimester

71
Q

True or false. Exacerbation of gallbladder disease is common during pregnancy and that intra hepatic cholestasis occurs in the 3rd trimester

A

True

72
Q

Characterized by increased levels of bilirubin, ammonia, hypoglycemia in pregnancy

A

Acute fatty liver of pregnancy

73
Q

Most common bacterial infection during pregnancy involving the urinary tract

A

Bacterial vaginosis

74
Q

Cause of asymptomatic bacteruria in pregnancy?

A

Stasis is cased by progestational effect on ureteral and bladder smooth muscle
Later in pregnancy, compression of the uterus on the bladder

75
Q

True or false. Pregnant woman with recurrent UTI or one episode of Pyelonephritis should consider for daily antibiotic suppressive treatment throughout remainder of pregnancy

A

True

76
Q

What should be done to pregnant women with exposure to zika virus within 2 weeks of symptom onset?

A

Serum and urine tested for ZV RNA by real time RT- PCR

77
Q

If with zika virus exposure, testing 2 to 12 weeks after symptom onset utilizes what serum measurement?

A

Zika and Dengue virus IgM

78
Q

Most common cuss eif congenital viral infection in the US? Women with this infection should delay conception for how long?

A

CMV; women with primary CMV infection should delay conception for 6 months as there is currently no accepted treatment for CMV during pregnancy

79
Q

True or false. Rubella carries a high risk of fetal anomalies on all trimester.

A

False. High risk of fetal anomalies occurs in rubella infection in the first trimester and risk decreases significantly in later trimesters

80
Q

All women who might become pregnant and who are not immune to rubella should be vaccinated at least before conception?

A

Vaccinated at least 3 months before conception

81
Q

What can reduce the risk of active genital herpes at term?

A

Acyclovir for the last 4 weeks of pregnancy in all women who had an episode of genital herpes during the pregnancy

82
Q

What is recommended for pregnant women with active genital herpes at the time time of presentation in labor?

A

Delivery by ceasarean section

83
Q

Most predominant cause of HIV infection in children?

A

Transmission of the virus from the mother to newborn during the perinatal period

84
Q

True or false. Women with less than 1000 copies of plasma HIV RNA and receiving antireteoviral therapy, risk for newborn transmission is approx 1%

A

True

85
Q

What is recommended for women with viral load of more than 1000 copies prior to 38 weeks gestation to reduce the risk of HIV transmission to newborn?

A

Scheduled for prelabor Cesarean delivery at 38 weeks

86
Q

What vaccination can be given to pregnant women?

A

Influenza
Tetanus, Diphtheria and pertusis (Tdap)

TIPID

87
Q

Define maternal death

A

Death occurring during pregnancy or 42 days of completion of pregnancy

88
Q

Most common causes of maternal death in the US

A 
Pulmonary embolism
Obstetric hemorrhage
Hypertension
Sepsus
CV events including peripartum cardiomyopathy and stroke
Ectopic pregnancy
89
Q

Most common cause of maternal death in sub Sahara and southern Asia?

A 
Maternal hemorrhage
Hypertensive disorder
Infection
Obstructed labor
Complications from unsafe pregnancy termination

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