Chapter 11 Other Medical Complications of Pregnancy Flashcards
diagnosis of hyperemesis gravidarum
- persistent vomiting,
- weight loss of greater than 5% of prepregnancy body weight,
- ketonuria
first line antiemetic therapy
phenergan. followed by Reglan, Compazine, and Tigan RCT.
___ may also contribute to the sumptom of nausea, frequent small meals can help maintain more stable blood glucose and decrease nausea
hypoglycemia
increased levels of estrogen and progesterone may have direct effects on seizure activity during pregnancy. Estrogen has been shown to be epileptogenic, __ seizure threshold.
decreasing.
rising estrogen levels in pregnancy that peak in 3rd trimester may have some impact on the observed increase in seizure frequency
true
___ has antiepileptic effect
progesterone
infants born to epileptic mothers have a __ increase in cleft lip and palate and a __ increase in cardiac anomalies
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.
patients who have been seizure free for 2-5 years may wish to attempt complete withdrawal from AEDs prior to conception.
true
pregnancy is considered a __ state
hypercoagulable.
virchow’s triad:
increased coagulation factors, endothelial damage, venous stasis.
venous stasis 2 main principal causes:
- decreased venous tone during pregnancy related to smooth muscle relaxant properties of high progesterone state.
- uterus, as it enlarges, compresses the inferior vena cava, iliac, and pelvic veins. this compression likely contributes to increase in pelvic vein thrombosis.
diagnosis of deep vein thrombosis:
confirmation by doppler studies or venography.
typical pt with DVT presents with….
unilateral lower extremity pain and swelling.
on examination, pts will have edema, local erythema, tenderness, venous distension, and palpable cord
when clinical suspicion is high, pt is sent for noninvasive lower extremity studies with doopler ultrasound for confirmation of a venous obstruction.
true
treatment of DVT during pregnancy
low dose molecular weight heparin or unfractionated heparin.
is warfarin ok to give during pregnancy?
no warfarin is contraindicated in pregnancy because it is teratogenic.
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.
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.
diagnosis of PE depends on the clinical picture correlated with a variety of diagnostic tests.
- 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.
- ECG may also be entirely normal or simply show sinus tachycardia.
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.
true
- increased circulating thyroid binding globulin and
- sex hormone binding globulin (SHBG)
binds to
thyroid hormone, which decreases the availability of thyroid hormone.
metabolic demands increase in pregnancy TSH and FT4 levels are commonly followed every 6-8 weeks.
true.
most common cause of hyperthyroidism
Graves disease.
patients with medically managed Graves disease can continue their propylthiouracil (PTU) or
methimazone
antenatal testing with serial NST recommended given the risk of
fetal hyperthyroidism, which can be diagnosed with fetal tachycardia.
PTU and methimazole can/cannot cross placenta?
CAN, leading to fetal goiter as well. thus, during pregnancy, it is best to use the minimum dosage possible.
general populationTSH should be kept between 0.5 and 2.5 in pregnancy, it should be kept closer to
closer to 0.5 than 2.5 (lower) TSH for hyperthyroidism if possible.
HYPOTHYROIDISM - most common etiology is hashimoto thyroiditis, second is ablation / removal of thyroid after Graves disease / cancer.
true
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
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.
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.
true
sle and other collagen vascular disorders such as sjogren syndrome, antiphospholipid antibody syndrome increases risk for
- preeclampsia
- iugr
- preterm deliveries.
SLE in pregnancy: 1/3 improve, 1/3 stay the same, 1/3 worsen.
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?
placental thrombosis.
hallmark of sle, antiphospholipids, sjogren’s is
iugr by 18-20 weeks gestation.
treatment and prophylaxis with
low-dose aspirin, heparin, and corticosteroids have been tried with some improvement in prognosis.
Later pregnancy complications: 3rd trimester
placenta can be thrombosed leading to IUGR and Intrauterine fetal demise. frequent antenatal testing is performed starting at week 32.
patients are at increased risk of developing
preeclampsia.
LUPUS FLARES vs PREECLAMPSIA.how to differentiate
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.
SLE patients and Sjogren syndrome patients can produce antibodies called
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.
test to confirm diagnosis of DVT deep vein thrombosis
extremity venous doppler ultrasound
best initial treatment for deep vein thrombosis
subcutaneous low-molecular weight heparin
which test to diagnose PE (pulmonary embolism)
spiral chest X-Ray
what are risk factors for venous thromboembolism during pregnancy?
- increased serum clotting factors.
- uterine compression of inferior vena cava (IVC)
- progesterone-induced decreased venous tone.
Lupus prenatal labs
- ob panel
- complete metabolic panel,
- baseline preeclampsia labs
- complement levels
- antidouble stranded dna antibodies.
- anti-Ro (SSA) and anti-La (SSB)
maternal complications with lupus
- recurrent miscarriage
- intrauterine growth restriction (IUGR)
- preeclampsia
- stillbirth
SLE patients and more commonly Sjogren syndrome can produce antibodies called
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.
how to diagnose her with preeclampsia and not a lupus flare?
normal c3 and c4 values. .
how is lupus flare managed?
high dose corticosteroids and, if unresponsive, cyclophosphamide.
elevated uric acid, hypertension, thrombocytopenia, and increasing urine protein can be present in both
preeclampsia and lupus.
most significant neonatal complication of maternal lupus?
neonatal heart block.
patient with a history of thyroid cancer and had a total thyroidectomy. how would you manage her dose of synthroid at this initial visit?
increase synthroid dose by 25-30%.
after increasing synthroid, what is the goal TSH for hx of thyroid cancer?
tsh levels should be kept low (0.5-2.5) by increasing levothyroxine supplementation throughout pregnancy and following TSH level each trimester.
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?
US, weekly NST to monitor for fetal tachycardia, which could be evidence of placental transfer of TSI to fetal circulation.
