Chapter 11 Other Medical Complications of Pregnancy

Question 1

diagnosis of hyperemesis gravidarum

Answer 1

1. persistent vomiting,
2. weight loss of greater than 5% of prepregnancy body weight,
3. ketonuria

Question 2

first line antiemetic therapy

Answer 2

phenergan. followed by Reglan, Compazine, and Tigan RCT.

Question 3

___ may also contribute to the sumptom of nausea, frequent small meals can help maintain more stable blood glucose and decrease nausea

Answer 3

hypoglycemia

Question 4

increased levels of estrogen and progesterone may have direct effects on seizure activity during pregnancy. Estrogen has been shown to be epileptogenic, __ seizure threshold.

Answer 4

decreasing.

Question 5

rising estrogen levels in pregnancy that peak in 3rd trimester may have some impact on the observed increase in seizure frequency

Answer 5

true

Question 6

___ has antiepileptic effect

Answer 6

progesterone

Question 7

infants born to epileptic mothers have a __ increase in cleft lip and palate and a __ increase in cardiac anomalies

Answer 7

four fold increase,
3-4 fold increase.
there si also an increase in rate of neural tube defects in offspring of epileptic patients who are using carbamazepine or valproic acid.

Question 8

patients who have been seizure free for 2-5 years may wish to attempt complete withdrawal from AEDs prior to conception.

Answer 8

true

Question 9

pregnancy is considered a __ state

Answer 9

hypercoagulable.

Question 10

virchow’s triad:

Answer 10

increased coagulation factors, endothelial damage, venous stasis.

Question 11

venous stasis 2 main principal causes:

Answer 11

1. decreased venous tone during pregnancy related to smooth muscle relaxant properties of high progesterone state.
2. uterus, as it enlarges, compresses the inferior vena cava, iliac, and pelvic veins. this compression likely contributes to increase in pelvic vein thrombosis.

Question 12

diagnosis of deep vein thrombosis:

Answer 12

confirmation by doppler studies or venography.

Question 13

typical pt with DVT presents with….

Answer 13

unilateral lower extremity pain and swelling.

on examination, pts will have edema, local erythema, tenderness, venous distension, and palpable cord

Question 14

when clinical suspicion is high, pt is sent for noninvasive lower extremity studies with doopler ultrasound for confirmation of a venous obstruction.

Answer 14

true

Question 15

treatment of DVT during pregnancy

Answer 15

low dose molecular weight heparin or unfractionated heparin.

Question 16

is warfarin ok to give during pregnancy?

Answer 16

no warfarin is contraindicated in pregnancy because it is teratogenic.

Question 17

Pulmonary embolus (PE) results when embli from DVTs travel to the right side of the heart and then lodge in the pulmonary arterial system, leading to pulmonary hypertension, hypoxia, and depending on extent of the emboli right sided heart failure and death.

Answer 17

clinical suspicion of PE is high whenever a patient presents with acute onset of SOB, simultaneous onset of pleuritic chest pain, hemoptysis, or tachycardia, and/or concomitant signs of DVT.

Question 18

diagnosis of PE depends on the clinical picture correlated with a variety of diagnostic tests.

Answer 18

1. Chest x-ray (may be entirely normal. however, when abnormal, 2 common signs on cxr are abrupt termination of a vessel as it is traced distally and an area of radiolucency in region of lung beyond the PE.
2. ECG may also be entirely normal or simply show sinus tachycardia.

Question 19

Maternal thyroid disease in pregnancy changes because of the increased circulating thyroid binding globulin and sex hormone binding globulin (SHBG) which also binds thyroid hormone.

Answer 19

true

Question 20

1. increased circulating thyroid binding globulin and
2. sex hormone binding globulin (SHBG)
   binds to

Answer 20

thyroid hormone, which decreases the availability of thyroid hormone.

Question 21

metabolic demands increase in pregnancy TSH and FT4 levels are commonly followed every 6-8 weeks.

Answer 21

true.

Question 22

most common cause of hyperthyroidism

Answer 22

Graves disease.

Question 23

patients with medically managed Graves disease can continue their propylthiouracil (PTU) or

Answer 23

methimazone

Question 24

antenatal testing with serial NST recommended given the risk of

Answer 24

fetal hyperthyroidism, which can be diagnosed with fetal tachycardia.

Question 25

PTU and methimazole can/cannot cross placenta?

Answer 25

CAN, leading to fetal goiter as well. thus, during pregnancy, it is best to use the minimum dosage possible.

Question 26

general populationTSH should be kept between 0.5 and 2.5 in pregnancy, it should be kept closer to

Answer 26

closer to 0.5 than 2.5 (lower) TSH for hyperthyroidism if possible.

Question 27

HYPOTHYROIDISM - most common etiology is hashimoto thyroiditis, second is ablation / removal of thyroid after Graves disease / cancer.

Answer 27

true

Question 28

pregnancy increases demand for thyroid hormone. Increased binding globulin (in particular SHBG), increased clearance, and increased basal metabolic rate. as a result, all women on synthroid should have their dose

Answer 28

increased 25-30%. TsH should e kept low normal by increasing levothyroxine supplementation throughout pregnancy and following the TSH level. in women with hx of thyroid cancer, TsH should be kept BELOW the reference range of TSH to prevent recurrence of disease.

Question 29

Systemic lupus erythematosus and other associated collagen vascular disorders (CVD) such as Sjogren syndrome, scleroderma, and antiphospholipid antibody syndrome can be particularly worrisome in pregnancy.

Answer 29

true

Question 30

sle and other collagen vascular disorders such as sjogren syndrome, antiphospholipid antibody syndrome increases risk for

Answer 30

1. preeclampsia
2. iugr
3. preterm deliveries.
   SLE in pregnancy: 1/3 improve, 1/3 stay the same, 1/3 worsen.

Question 31

patients with SLE and in particular antiphospholipid antibody syndrome have a high risk of early pregnancy loss in both first and second trimesters. what is pathophysiology of these losses?

Answer 31

placental thrombosis.

Question 32

hallmark of sle, antiphospholipids, sjogren’s is

Answer 32

iugr by 18-20 weeks gestation.

Question 33

treatment and prophylaxis with

Answer 33

low-dose aspirin, heparin, and corticosteroids have been tried with some improvement in prognosis.

Question 34

Later pregnancy complications: 3rd trimester

Answer 34

placenta can be thrombosed leading to IUGR and Intrauterine fetal demise. frequent antenatal testing is performed starting at week 32.

Question 35

patients are at increased risk of developing

Answer 35

preeclampsia.

Question 36

LUPUS FLARES vs PREECLAMPSIA.how to differentiate

Answer 36

checking complement levels. patients having a lupus flare will have reduced C3 and C4 whereas patients with preeclampsia should have normal levels. In addition, lupus flares are often accompanied by active urine sediment, whereas preeclampsia is not.

management of lupus flare = high dose corticoteroids and if unresponsive, cyclophosphamide. Worsening preeclampsia in contrast is managed by delivery.

Question 37

SLE patients and Sjogren syndrome patients can produce antibodies called

Answer 37

anti-Ro and anti-La that are tissue specific to fetal cardiac conductive system, because these antibodies damage AV node in particular , congenital heart block seen in 5% of pts.

Question 38

test to confirm diagnosis of DVT deep vein thrombosis

Answer 38

extremity venous doppler ultrasound

Question 39

best initial treatment for deep vein thrombosis

Answer 39

subcutaneous low-molecular weight heparin

Question 40

which test to diagnose PE (pulmonary embolism)

Answer 40

spiral chest X-Ray

Question 41

what are risk factors for venous thromboembolism during pregnancy?

Answer 41

1. increased serum clotting factors.
2. uterine compression of inferior vena cava (IVC)
3. progesterone-induced decreased venous tone.

Question 42

Lupus prenatal labs

Answer 42

1. ob panel
2. complete metabolic panel,
3. baseline preeclampsia labs
4. complement levels
5. antidouble stranded dna antibodies.
6. anti-Ro (SSA) and anti-La (SSB)

Question 43

maternal complications with lupus

Answer 43

1. recurrent miscarriage
2. intrauterine growth restriction (IUGR)
3. preeclampsia
4. stillbirth

Question 44

SLE patients and more commonly Sjogren syndrome can produce antibodies called

Answer 44

anti Ro (SSA) and anti-la (SSB) that are tissue specific to the fetal cardiac conduction system which damage the AV node in particular. congenital heart block is seen in 5% of these patients.

Question 45

how to diagnose her with preeclampsia and not a lupus flare?

Answer 45

normal c3 and c4 values. .

Question 46

how is lupus flare managed?

Answer 46

high dose corticosteroids and, if unresponsive, cyclophosphamide.

Question 47

elevated uric acid, hypertension, thrombocytopenia, and increasing urine protein can be present in both

Answer 47

preeclampsia and lupus.

Question 48

most significant neonatal complication of maternal lupus?

Answer 48

neonatal heart block.

Question 49

patient with a history of thyroid cancer and had a total thyroidectomy. how would you manage her dose of synthroid at this initial visit?

Answer 49

increase synthroid dose by 25-30%.

Question 50

after increasing synthroid, what is the goal TSH for hx of thyroid cancer?

Answer 50

tsh levels should be kept low (0.5-2.5) by increasing levothyroxine supplementation throughout pregnancy and following TSH level each trimester.

Question 51

pt with thyroidectomy now hypothyroid and on synthroid replacement. in addition to monitoring her TSH, what other additional testing should you perform during her pregnancy?

Answer 51

US, weekly NST to monitor for fetal tachycardia, which could be evidence of placental transfer of TSI to fetal circulation.