Class 4 Diabetes and PIH Flashcards
Gestational diabetes is associated with what?
- Advanced maternal age
- Obesity
- Family hx of DM
- Hx of stillbirth, neonatal malformation, or macrosomia
When do Gestational diabetes present? When is it most prevalent? and when does it end?
- When patient cannot mount sufficient insulin response during pregnancy.
- 2nd and 3rd trimesters
- After delivery
Major acute complications with GD
- DKA
- Hyperglycemia (type 2)
- Hypoglycemia
GD is associated with what 3 complications?
- Gestational HTN
- Polyhydramnios
- C-Section
What is the best way to prevent fetal structure abnormalities?
-Early glycemic control
Normal A1C? Risk of vascular disease A1C?
- 4-6%
- 6.5%
What risk factors are associated with stiff joint syndrome?
- Type 1 diabetes
- Short stature
- Joint contractures
- Tight skin
What makes direct laryngoscopy difficult with DM in preggos?
-C-spine rigidity of atlanto-occipital joint
Maternal insulin requirements progressively ______ during the 2nd and 3rd trimester & ______ at the onset of labor and after delivery.
- Increase
- Decrease
Preanesthetic evaluation considerations?
- SQ insulin is unpredictable
- IV insulin more flexible
- Preop blood sugar
- Evaluate for end organ damage
What is the biggest concern for DM end organ damage?
-Diabetic Autonomic Neuropathy
Diabetic autonomic neuropathy can cause what problem for the preggo?
- HTN
- Ortho hypotension
- Painless MI
- Decreased response to meds
- Decreased HR variability
- Resting tachycardia
- Neurogenic bladder
- Gastroperesis
Intraop blood glucose should be in what range?
100-180
2 ways to administer introp insulin?
- Half of daily dose then sliding scale
- Continuous infusion (plasma glucose/desired range = units/hr)
Patients on NPH insulin are at great risk of anaphylaxis from what drug?
-Protamine
What meds take longer to clear in a diabetic preggo?
-Local anesthetics (use less)
How does GD effect the placenta?
Reduces uteroplacental blood flow 35-45%
GD put patients at a great risk for what 3 problems?
- Superimposed preeclampsia
- Diabetic nephropathy
- DKA
How do DKA ketones effect the fetus?
-Decrease fetal O2
Obese women need ______ local anesthetic in the epidural to achieve same block as non obese
-Less
what are the 4 categories of preggo hypertension?
- Chronic HTN
- Pregnancy induced
- Preeclampsia / Eclampsia
- Preeclampsia w/ chronic
name the top 3 causes of maternal mortality in order?
- Thromboembolism
- Non obstetric injuries
- Hypertension
What type of hypertension causes the most morbidity?
-Superimposed preeclampsia
Maternal diastolic BP over 110 is associated with what 2 things?
- Placental abruption
- fetal growth restriction
Pregnancy induced HTN is defined as what? When does it begin? End?
- Sustained SBP>140, DBP>90
- Later in pregnancy
- Resolves 12 weeks postpartum
What is preeclampsia?
- New onset HTN after 20 weeks gestation or early postpartum
- Has Renal or other systemic involvement
Beside HTN what other symptoms can be seen with preeclampsia?
- Proteinuria
- Oliguria
- Headaches
- Visual disturbances
- Increased LFTs
- Thrombocytopenia
- ABD Pain
- Edema
- Rapid weight gain
Maternal risk factors for preeclampsia.
- 1st pregnancy
- younger than 18
- Older than 35
- hx of preeclampsia
- African american
- Twins
- Chronic HTN
- Renal disease
- Diabetes
- Anti-phospholipid
Why might preeclampsia patients be difficult to intubate?
-Upper airway edema
Cardiac problems with preeclampsia
- Increased CO and SVR
- Normal CVP
- Reduced plasma volume
Respiratory problems for preeclampsia
-Pulmonary edema
Renal problems with preeclampsia
- Protienuria
- Decrease GFR and CrCl
- BUN increases w/ severity
- Decreased blood flow
- Acute renal failure
Oliguria and renal failure may occur in the absence of ______. Be careful w/ hydration as to not cause_____.
Hypovolemia
Pulmonary edema
Uterine effects of preclampsia
- Hypersensitivity to oxytocin
- Preterm labor
- Blood flow reduced
- Abruption
- Activity increased
What is the leading cause of maternal death in PIH?
Intercranial hemorrhage
Fetal complications of preclampsia / PIH
- Abruption
- Growth restrictions
- Premature delivery
- Death
What is HELLP syndrome?
- Hemolysis
- Elevated Liver enzymes
- Low platelets
When does HELLP occur and what are the symptoms? And what is the cure?
- Before 36 weeks
- Malaise, epigastric pain, N/V
- Delivery
When is hemostasis a problem?
- < 40,000
- Rate of fall is important
Drug of choice for preeclampsia prevention of seizures? Plasma levels? What is the reversal?
- Mag sulfate
- Keep plasma level between 4-6
- Calcium
What are the goals for PIH and preeclamptic patients
- Control BP
- Prevent seizures
- Delivery
What drugs are used to control BP?
- Hydralizine
- Labetelol
- Nitro
- Nifedipine
- Esmolol
What will you see for mag toxicity?
-5-10 = long PR, wide QRS
-11-14 = Depressed tendon reflexes
-15-24 = SA, AV blocks respiratory paralysis
>25 cardiac arrest
Advantages of epidural?
- Gradual onset of blockade
- Avoids neonatal depression
- Reduce HTN = improve uterine blood flow
Intubation considerations with PIH and preeclampsia?
- Blunted laryngeal response due to pretreatment of BP lowering drugs
- Airway edema
How does Mag effect succs?
-Potentiates its effects
MgSO4 _____response to vasconstrictors and ______ catecholamine release after sympathetic stimulation
- Blunts
- Inhibits
