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TN Obstetrics > 9. Medical Complications of Pregnancy (À finir) > Flashcards

9. Medical Complications of Pregnancy (À finir) Flashcards

1
Q

Describe PREVENTION of iron defiency anemia (1)

A

Prevention (non-anemic): 30 mg elemental iron/d (met by most prenatal vitamins)

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2
Q

Describe TREATMENT of iron defiency anemia (3)

A
  • 30-120 mg elemental iron/d
  • 325 mg ferrous fumarate = 106 mg elemental Fe; 325 mg ferrous sulfate = 65 mg elemental Fe; 325 mg ferrous gluconate = 36 mg elemental Fe
  • Polysaccharide-Iron Complex = 150 mg elemental Fe/capsule
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3
Q

Name complications of iron deficiency anemia (8)

A

Maternal:

  • angina
  • congestive heart failure CHF
  • infection
  • slower recuperation
  • preterm labour

Fetal

  • decreased oxygen carrying capacity leading to fetal distress,
  • IUGR
  • low birth weight
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4
Q

Iron requirements increase during pregnancy why? (3)

A
  • due to fetal/placental growth (500 mg)
  • increased maternal RBC mass (500 mg)
  • and losses (200 mg) – more needed for multiple gestations
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5
Q

Describe prevention of folate deficiency anemia (2)

A
  • Prevention: 0.4-1 mg folic acid PO daily for 1-3 mo preconceptually and throughout T1
  • or 5 mg folic acid/d with past history of ONTD, DM, or antiepileptic medication use
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6
Q

Name complications: Folate deficiency anemia (6)

A
  • Maternal:
    • decreased blood volume
    • N/V
    • anorexia
  • Fetal:
    • neural tube defects in T1
    • low birth weight, and
    • prematurity
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7
Q

Folic acid is necessary for what? (1)

A

closure of neural tube during early fetal development (by day 28 of gestation)

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8
Q

Gestational Diabetes Mellitus is testing when? (1)

A

usually tested for around 24-28 wk GA

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9
Q

Describe etiology: GDM (1)

A

anti-insulin factors produced by placenta and high maternal cortisol levels create increased peripheral insulin resistance s leading to GDM and/or exacerbating pre-existing DM

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10
Q

Describe management of type 1 and type 2 DM: PRECONCEPTION (5)

A
  • pre-plan and refer to high-risk clinic
  • commence folic acid 3 mo prior
  • optimize glycemic control (HbA1c <6%)
  • counsel patient on potential risks and complications
  • evaluate for diabetic retinopathy, neuropathy, and CAD
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11
Q

Describe management of type 1 and type 2 DM: PREGNANCY (5)

A
  • for Type 2 DM, if already on oral medication, generally switch to insulin therapy
    • continuing glyburide or metformin controversial
    • teratogenicity unknown for other oral anti-hyperglycemics
  • tight glycemic control
    • insulin dosage may need to be adjusted in T2 due to increased demand and increased insulin resistance
  • monitor as for normal pregnancy, plus initial 24 h urine protein and creatinine clearance, retinal exam, and HbA1c
    • HbA1c: >140% of pre-pregnancy value associated with increased risk of spontaneous abortion and congenital malformations
  • increased fetal surveillance (fetal growth, BPP, NST) starting in the late T2 and T3, consider fetal ECHO in the T2 (if high HbA1c in T1 or just prior to pregnancy) to look for cardiac abnormalities
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12
Q

Describe management of type 1 and type 2 DM: LABOUR (4)

A
  • timing of delivery depends on fetal and maternal health and risk factors (i.e. must consider size of baby, lung maturity, maternal blood glucose)
  • induce by 38-39 wk, depending on glycemic control and presence of end-organ involvementent
  • type of delivery
    • increased risk of cephalopelvic disproportion (CPD) and shoulder dystocia with babies >4000 g (8.8 lbs)
    • consider elective C/S for predicted birthweight >4500 g (9.9 lbs) (controversial)
  • monitoring
    • during labour, monitor blood glucose q1h with patient on insulin and dextrose drip
    • aim for blood glucose between 3.9-7 mmol/L to reduce the risk of neonatal hypoglycemia
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13
Q

Describe management of type 1 and type 2 DM: POSTPARTUM (2)

A
  • insulin requirements dramatically drop with expulsion of placenta (source of insulin antagonists)
  • monitor glucose q6h, restart insulin at two-thirds of pre-pregnancy dosage when glucose >8 mmol/L
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14
Q

Name: Risk Factors for GDM (9)

A
  • Age >25 yr
  • Obesity
  • Ethnicity (Aboriginal, Hispanic, Asian, and African)
  • FHx of DM
  • Previous history of GDM
  • Previous child with birthweight >4.0 kg
  • Polycystic ovarian syndrome
  • Current use of glucocorticoids
  • Essential HTN or pregnancy-related HTN
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15
Q

Screen for GDM for who? (1)

A
  • all pregnant women between 24-28 wk GA (or at any stage if high risk)
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16
Q

Describe screening options of GDM (2)

A
  • 2-step screening
    • Step 1: perform a random non-fasting 50 g oral glucose challenge test (OGCT)
      • 1 h PG <7.8 mmol/L is normal
      • 1 h PG ≥11.1 mmol/L is GDM
      • if 1 h PG 7.8-11.0 mmol/L, proceed to Step 2
    • Step 2: perform a fasting 75 g oral glucose tolerance test (OGTT), GDM if ≥1 of:
      • fasting plasma glucose FPG ≥5.3 mmol/L
      • 1 h PG ≥10.6 mmol/L
      • 2 h PG ≥9.0 mmol/L
  • Alternative 1-step screening with fasting 75 g OGTT; GDM if ≥1 of:
    • FPG ≥5.1 mmol/L
    • 1 h PG ≥10.0 mmol/L
    • 2 h PG ≥8.5 mmol/L
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17
Q

Describe management of GDM (6)

A
  • first line: diet modification and increased physical activity
  • initiate insulin therapy if glycemic targets not achieved within 2 wk of lifestyle modification alone
  • glycemic targets:
    • FPG <5.3 mmol/L
    • 1 h PG <7.8 mmol/L
    • 2 h PG <6.7 mmol/L
  • oral agents can be used in pregnancy but is off-label and should be discussed with patient
  • stop insulin and diabetic diet postpartum
  • follow-up with 75 g OGTT between 6 wk-6 mo postpartum, counsel about lifestyle modifications
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18
Q

Describe prognosis: GDM (1)

A

most maternal and fetal complications are related to hyperglycemia and its effects

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19
Q

Name MATERNAL complications of DM: Obstetric (2)

A
  • HTN/preeclampsia (especially if pre-existing nephropathy/ proteinuria): insulin resistance is implicated in etiology of HTN
  • Polyhydramnios: maternal hyperglycemia leads to fetal hyperglycemia, which leads to fetal polyuria (a major source of amniotic fluid)
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20
Q

Name MATERNAL complications of DM: Diabetic Emergencies (3)

A
  • Hypoglycemia
  • Ketoacidosis
  • Diabetic coma
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21
Q

Name MATERNAL complications of DM: End-Organ Involvement or Deterioration (occur in type 1 DM and type 2 DM, not in GDM)

(2)

A
  • Retinopathy
  • Nephropathy
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22
Q

Name MATERNAL complications of DM: OTHER (2)

A
  • Pyelonephritis/UTI: glucosuria provides a culture medium for E. coli and other bacteria
  • Increased incidence of spontaneous abortion (in type 1 DM and type 2 DM, not in GDM): related to pre-conception glycemic control
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23
Q

Name FETAL complications of DM: Growth abnormalities (2)

A
  • Macrosomia: maternal hyperglycemia leads to fetal hyperinsulinism resulting in accelerated anabolism
  • IUGR: due to placental vascular insufficiency
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24
Q

Name FETAL complications of DM: Delayed Organ Maturity (1)

A

Fetal lung immaturity: hyperglycemia interferes with surfactant synthesis (respiratory distress syndrome)

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25
Q

Name FETAL complications of DM: Congenital Anomalies (occur in type 1 DM and type 2 DM, not in GDM) (5)

A
  • 2-7x increased risk of
    • cardiac (ventricular septal defect)
    • neural tube defects NTD
    • GU (cystic kidneys)
    • GI (anal atresia)
    • MSK (sacral agenesis) anomalies due to hyperglycemia
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26
Q

Pregnancies complicated by GDM do not manifest an increased risk of congenital anomalies why?

A

because GDM develops after the critical period of organogenesis (in T1)

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27
Q

Name FETAL complications of DM: Labour and Delivery (4)

A
  • Preterm labour/prematurity: most commonly in patients with HTN/preeclampsia
  • Preterm labour is associated with poor glycemic control but the exact mechanism is unknown
  • Increased incidence of stillbirth
  • Birth trauma: due to macrosomia, can lead to difficult vaginal delivery and shoulder dystocia
28
Q

Name FETAL complications of DM: Neonatal (4)

A
  • Hypoglycemia: due to pancreatic hyperplasia and excess insulin secretion in the neonate
  • Hyperbilirubinemia and jaundice: due to prematurity and polycythemia
  • Hypocalcemia: exact pathophysiology not understood, may be related to functional hypoparathyroidism
  • Polycythemia: hyperglycemia stimulates fetal erythropoietin production
29
Q

Name Long-Term Maternal Complications of diabetes (2)

A
  • type 1 and type 2 DM: risk of progressive retinopathy and nephropathy
  • GDM: 50% risk of developing type 2 DM in next 20 yr
30
Q

Describe epidemiology: Early-Onset Group B Streptococcus (1)

A
  • 15-40% recto-vaginal carrier rate
31
Q

Name risk factors: Early-Onset Group B Streptococcus (5)

A
  • maternal intrapartum GBS colonization during current pregnancy
  • GBS bacteria at any time during the current pregnancy
  • previous infant with invasive GBS disease
  • prolonged rupture of membranes ≥18 h
  • maternal fever (temperature ≥38°C)
32
Q

Name clinical features: Early-Onset Group B Streptococcus (2)

A
  • not harmful to mother
  • risk of vertical transmission (neonatal sepsis, meningitis or pneumonia, and death)
33
Q

Describe investigations: Early-Onset Group B Streptococcus (2)

A
  • offer screening to all women at 35-37 wk with vaginal and anorectal swabs for GBS culture
34
Q

Describe tx: Early-Onset Group B Streptococcus (3)

A
  • prophylactic treatment of maternal GBS at delivery decreases neonatal morbidity and mortality
  • antibiotics for GBS prophylaxis (should be given 4 h prior to delivery to be considered adequate)
  • if maternal fever, broad spectrum antibiotic coverage is advised
35
Q

Name indications for antibiotic prophylaxis of GBS (4)

A
  • : positive GBS screen
  • GBS in urine
  • previous infant with GBS disease
  • or GBS status unknown + one of the other risk factors
36
Q

Name antibiotics for GBS prophylaxis (3)

A
  • penicillin G, 5 million IU IV, then 2.5 million IU IV q4h until delivery
  • penicillin allergic but not at risk for anaphylaxis: cefazolin 2 g IV then 1 g q8h
  • penicillin allergic and at risk of anaphylaxis: vancomycin 1 g IV q12h until delivery (vancomycin and clindamycin levels in amniotic fluid do not reach therapeutic levels, all babies should be screened for GBS despite treatment)
37
Q

Name: Indications for Intrapartum Antibiotic GBS Prophylaxis (4)

A

Centres for Disease Control and Prevention. Prevention of Perinatal Group B Streptococcal Disease. MMWR 2010;59(RR-10):14

  • 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 labour (culture not done, incomplete, or results unknown) and any of the following:
    • Delivery at <37 wk gestation
    • Amniotic membrane rupture ≥18 h
    • Intrapartum temperature ≥38.0 °C ( ≥100.4 °F)
    • Intrapartum nucleic-acid amplification test positive for GBS
38
Q

Describe epidemiology: Urinary Tract Infection (3)

A
  • most common medical complication of pregnancy
  • asymptomatic bacteriuria in 2-7% of pregnant women, more frequently in multiparous women
  • note: asymptomatic bacteriuria should be treated in pregnancy due to increased risk of pyelonephritis and preterm labour
39
Q

Describe etiology: Urinary Tract Infection (2)

A
  • increased urinary stasis from mechanical and hormonal (progesterone) factors
  • organisms include GBS as well as those that occur in non-pregnant women
40
Q

Describe clinical features: Urinary Tract Infection (3)

A
  • may be asymptomatic
  • dysuria, urgency, and frequency in cystitis
  • fever, flank pain, and costovertebral angle tenderness in pyelonephritis
41
Q

Describe investigations: Urinary Tract Infection (2)

A
  • urinalysis, urine C&S
  • cystoscopy and renal function tests in recurrent infections
42
Q
A
43
Q

Describe management: uncomplicated UTI (3)

A
  • first line: amoxicillin (250-500 mg PO q8h x 7 d)
  • alternatives: nitrofurantoin (100 mg PO bid x 7 d) or cephalosporins
  • follow with monthly urine cultures
44
Q

Describe management: pyelonephritis (1)

A
  • hospitalization and IV antibiotics
45
Q

Describe prognosis: UTI (2)

A
  • complications if untreated: acute cystitis, pyelonephritis, and possible preterm labour
  • recurrence is common
46
Q

Describe: Chicken Pox

  • Agent
  • Source of Transmission
  • Greatest Transmission Risk to Fetus
  • Effects on Fetus
  • Effects on Mother
  • Diagnosis
  • Management
A
  • Agent: Varicella zoster virus (herpes family)
  • Source of Transmission:
    • To mother: direct, respiratory
    • To baby: transplacental
  • Greatest Transmission Risk to Fetus: 13-30 wk GA, and 5 d pre- to 2 d post-delivery
  • Effects on Fetus: Congenital varicella syndrome (limb aplasia, chorioretinitis, cataracts, cutaneous scars, cortical atrophy, IUGR, hydrops), preterm labour
  • Effects on Mother: Fever, malaise, vesicular pruritic lesions
  • Diagnosis: Clinical, ± vesicle fluid culture, ± serology
  • Management:
    • Varicella-zoster immune globulin for mother if exposed, decreases congenital varicella syndrome
    • Note: do not administer vaccine during pregnancy (live attenuated vaccine)
47
Q

Describe: Cytomegalovirus

  • Agent
  • Source of Transmission
  • Greatest Transmission Risk to Fetus
  • Effects on Fetus
  • Effects on Mother
  • Diagnosis
  • Management
A
  • Agent: DNA virus (herpes family)
  • Source of Transmission:
    • To mother: blood/ organ transfusion, sexual contact
    • To baby: transplacental, during delivery, breast milk
  • Greatest Transmission Risk to Fetus: T1-T3
  • Effects on Fetus: 5-10% develop CNS involvement (mental retardation, cerebral calcification, hydrocephalus, microcephaly, deafness, chorioretinitis)
  • Effects on Mother: Asymptomatic or flu-like
  • Diagnosis: Serologic screen; isolate virus from urine or secretion culture
  • Management: No specific treatment; maintain good hygiene
    and avoid high risk situations
48
Q

Describe: Erythema Infectiosum (Fifth Disease)

  • Agent
  • Source of Transmission
  • Greatest Transmission Risk to Fetus
  • Effects on Fetus
  • Effects on Mother
  • Diagnosis
  • Management
A
  • Agent: Parvovirus B19
  • Source of Transmission:
    • To mother: respiratory, infected blood products
    • To baby: transplacental
  • Greatest Transmission Risk to Fetus: 10-20 wk GA
  • Effects on Fetus: Spontaneous abortion (SA), stillbirth, hydrops in utero
  • Effects on Mother: Flu-like, rash, arthritis; often asymptomatic
  • Diagnosis: Serology, viral PCR, maternal AFP; if IgM
    present, follow fetus with U/S for hydrops
  • Management: If hydrops occurs, consider fetal transfusion
49
Q

Describe: Hepatitis B

  • Agent
  • Source of Transmission
  • Greatest Transmission Risk to Fetus
  • Effects on Fetus
  • Effects on Mother
  • Diagnosis
  • Management
A
  • Agent: DNA virus
  • Source of Transmission:
    • To mother: blood, saliva, semen, vaginal secretions
    • To baby: transplacental, breast milk
  • Greatest Transmission Risk to Fetus:
    • T3
    • 10% vertical transmission
    • if asymptomatic and HBsAg +ve; 85-90% if HBsAg and HBeAg +ve
  • Effects on Fetus:
    • Prematurity, low birth weight, neonatal death
  • Effects on Mother:
    • Fever, N/V, fatigue, jaundice, elevated liver enzymes
  • Diagnosis: Serologic screening for all pregnancies
  • Management: Rx neonate with HBIG and vaccine (at birth, 1, 6 mo); 90% effective
50
Q

Describe: Herpes Simplex Virus

  • Agent
  • Source of Transmission
  • Greatest Transmission Risk to Fetus
  • Effects on Fetus
  • Effects on Mother
  • Diagnosis
  • Management
A
  • Agent: DNA virus
  • Source of Transmission:
    • To mother: intimate mucocutaneous contact
    • To baby: transplacental, during delivery
  • Greatest Transmission Risk to Fetus: Delivery (if genital lesions present); less commonly in utero
  • Effects on Fetus: Disseminated herpes (20%); CNS sequelae (35%); self-limited infection
  • Effects on Mother: Painful vesicular lesions
  • Diagnosis: Clinical diagnosis
  • Management: Acyclovir for symptomatic women, suppressive therapy at 36 wk controversial Suggested C/S if active genital lesions, even if remote from vulva
51
Q

Describe: HIV

  • Agent
  • Source of Transmission
  • Greatest Transmission Risk to Fetus
  • Effects on Fetus
  • Effects on Mother
  • Diagnosis
  • Management
A
  • Agent: RNA retrovirus
  • Source of Transmission:
    • To mother: blood, semen, vaginal secretions
    • To baby: in utero, during delivery, breast milk
  • Greatest Transmission Risk to Fetus:
    • 1/3 in utero, 1/3 at delivery, 1/3 breastfeeding
  • Effects on Fetus: IUGR, preterm labour, PROM
  • Effects on Mother: See Infectious Diseases, ID25
  • Diagnosis: Serology, viral PCR All pregnant women are offered screening
  • Management:
    • Triple anti-retroviral therapy decreases transmission
      to <1%
    • Elective C/S: no previous antiviral
    • Rx or monotherapy only, viral load unknown or >500 RNA copies/mL, unknown prenatal care, patient request
52
Q

Describe: Rubella

  • Agent
  • Source of Transmission
  • Greatest Transmission Risk to Fetus
  • Effects on Fetus
  • Effects on Mother
  • Diagnosis
  • Management
A
  • Agent: ssRNA togavirus
  • Source of Transmission:
    • To mother: respiratory droplets (highly contagious)
    • To baby: transplacental
  • Greatest Transmission Risk to Fetus: T1
  • Effects on Fetus: SA or congenital rubella syndrome (hearing loss, cataracts, CV lesions, mitral regurgitation, IUGR, hepatitis, CNS defects, osseous changes)
  • Effects on Mother: Rash (50%), fever, posterior auricular or occipital lymphadenopathy, arthralgia
  • Diagnosis: Serologic testing; all pregnant women screened (immune if titre >1:16); infection if IgM present or >4x increase in IgG
  • Management: No specific treatment; offer vaccine following pregnancy Do not administer during pregnancy (live attenuated)
53
Q

Describe: Syphilis

  • Agent
  • Source of Transmission
  • Greatest Transmission Risk to Fetus
  • Effects on Fetus
  • Effects on Mother
  • Diagnosis
  • Management
A
  • Agent: Spirochete (Treponema pallidum)
  • Source of Transmission:
    • To mother: sexual contact
    • To baby: transplacental
  • Greatest Transmission Risk to Fetus: T1-T3
  • Effects on Fetus: Risk of preterm labour, multisystem involvement, fetal death
  • Effects on Mother: See Infectious Diseases, ID23
  • Diagnosis: VDRL screening for all pregnancies; if positive, requires confirmatory testing
  • Management:
    • Penicillin G 2.4 million IU IM x 1 dose if early syphilis, 3 doses if late syphilis, monitor VDRL monthly
    • If penicillin G allergic: clindamycin 900 mg IV q8h
54
Q

Describe: Toxoplasmosis

  • Agent
  • Source of Transmission
  • Greatest Transmission Risk to Fetus
  • Effects on Fetus
  • Effects on Mother
  • Diagnosis
  • Management
A
  • Agent: Protozoa (Toxoplasma gondii)
  • Source of Transmission: To mother: raw meat, unpasteurized goat’s milk, cat feces/urine To baby: transplacental
  • Greatest Transmission Risk to Fetus: T3 (but most severe if infected in T1); only concern if primary infection during pregnancy
  • Effects on Fetus: Congenital toxoplasmosis (chorioretinitis, hydrocephaly, intracranial calcification, mitral regurgitation, microcephaly) NB: 75% initially asymptomatic at birth
  • Effects on Mother: Majority subclinical; may have flu-like symptoms
  • Diagnosis: IgM and IgG serology; PCR of amniotic fluid
  • Management: Self-limiting in mother; spiramycin decreases fetal morbidity but not rate of transmission
55
Q

Describe: Venous Thromboembolism (2)

A
  • incidence of 12.1/10,000 (DVT), and 5.4/10,000 (PE)
  • increased risk of VTE throughout pregnancy with highest risk of DVT in T3 and post-partum period; highest risk of PE post-partum (first 6 wk)
56
Q

Describe: Venous Thromboembolism (2)

A
57
Q

Name risk factors: Venous Thromboembolism (7)

A
  • previous VTE
  • age >35
  • obesity
  • infection
  • bedrest/immobility
  • shock/dehydration
  • thrombophilias
58
Q

Describe: Risk Factors for VTE Specific to Pregnancy (3)

A
  • Hypercoagulability
  • Stasis
  • Endothelial
59
Q

Describe this specific to pregnancy risk factor for VTE: Hypercoagulability (5)

A
  • Increased Factors:
  • II, V, VII, VIII, IX, X, XII, fibrinogen
  • Increased platelet aggregation
  • Decreased protein S, tPA, factors XI, XIII
  • Increased resistance to activated protein C Antithrombin can be normal or reduced
60
Q

Describe this specific to pregnancy risk factor for VTE: Statis (4)

A
  • Increased venous distensibility
  • Decreased venous tone
  • 50% decrease in venous flow in lower extremity by T3
  • Uterus is mechanical impediment to venous return
61
Q

Describe this specific to pregnancy risk factor for VTE: Endothelial (3)

A
  • Vascular damage at delivery (C/S or SVD)
  • Uterine instrumentation
  • Peripartum pelvic surgery
62
Q

Describe: Virchow’s Triad for VTE

A
  • Hypercoagulable state
  • Stasis
  • Endothelial damage
63
Q

Name clinical features: Venous Thromboembolism (2)

A
  • most DVTs occur in the iliofemoral or calf veins with a predilection for the left leg
  • signs of a pulmonary embolism are non-specific
64
Q

Describe investigations: Venous Thromboembolism (2)

A
  • duplex venous Doppler sonography for DVT
  • CXR and V/Q scan or spiral CT for PE
65
Q

Describe management: Venous Thromboembolism (7)

A
  • before initiating treatment, obtain a baseline CBC including platelets and aPTT
  • treatment with Low-molecular-weight heparin (LMWH) preferred
    • dosing varies depending on specific LMWH used
    • should be discontinued at least 24 h prior to delivery
  • unfractionated heparin
  • warfarin is contraindicated during pregnancy due to its potential teratogenic effects
  • compression stockings
  • poor evidence to support a recommendation for or against avoidance of prolonged sitting
  • VTE prophylaxis
66
Q

Describe use of unfractionated heparin in VTE in pregnant women (5)

A
  • bolus of 5000 IU followed by an infusion of ~30,000 IU/24h
  • measure aPTT 6 h after the bolus
  • maintain aPTT at a therapeutic level (1.5-2x normal)
  • repeat q24h once therapeutic
  • heparin-induced thrombocytopenia (HIT) uncommon (3%), but serious complication
67
Q

Describe VTE prophylaxis in pregnant women (4)

A
  • women on long-term anticoagulation: full therapeutic anticoagulation throughout pregnancy and for 6-12 wk postpartum
  • women with a non-active PMHx of VTE: unfractionated heparin regimens suggested
  • insufficient evidence in pregnancy to recommend routine use of LMWH for all patients
  • current prophylaxis regimens for acquired thrombophilias (e.g. APS) include low dose ASA in conjunction with prophylactic heparin

TN Obstetrics (16 decks)

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