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EndoRepro 2 Exam 1 > Clin: Medical Conditions in Pregnancy - Wootton > Flashcards

Clin: Medical Conditions in Pregnancy - Wootton Flashcards

1
Q

when is gestational diabetes screening done?

A

between weeks 24-28

  • 50gm 1 hr oral glucose challenge test (>130-140 = abnormal)
  • may perform earlier screen in pt with risk factors
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2
Q

what if a GDM screen is abnormal?

A

repeat test with 3 hour 100gm oral load glucose test (fail 3 hour with 2 or more abnormal values)

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3
Q

what are the risk factors for development of GDM?

A
  • obesity
  • previous hx GDM
  • strong family hx of DM
  • known glucose intolerance
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4
Q

what are the maternal complications of GDM?

A
  • increased risk of gestational HTN
  • increased risk of preeclampsia
  • greater risk of cesarean delivery
  • increase risk of developing diabetes later in life
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5
Q

what are the fetal complications of GDM?

A
  • macrosomia
  • neonatal hypoglycemia
  • hyperbilirubinemia
  • operative delivery
  • shoulder dystocia
  • birth trauma
  • stillbirth
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6
Q

how often is fetal testing performed?

A

weekly

  • biophysical profiles and non-stress tests
  • US for estimated fetal weight (if greater than 4500gm -> recommend cesarean delivery)
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7
Q

can you wait for spontaneous labor or EDD if all testing, growth and glycemic control are ok?

A

yes!

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8
Q

antepartum - diet controlled GDM

A

Class A1

  • initially frequent monitoring of blood glucose
  • typically no treatment required
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9
Q

antepartum - oral or insulin managed GDM

A

Class A2

  • hourly glucose monitoring
  • insulin drip
  • continuous fetal monitoring in labor
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10
Q

there is a direct link between birth defects and what, in the period of embryogenesis?

A

increasing glycosylated hemoglobin levels (HgBA1C)

- six-fold increase in risk of congenital anomalies

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11
Q

what are the maternal intrapartum complications of GDM?

A

worsening nephropathy and retinopathy

  • increased risk of developing preeclampsia
  • greater risk of diabetic keto acidosis
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12
Q

what are the fetal intrapartum complications of GDM?

A

increased risk of spontaneous abortion

  • anatomic birth defects (sacral agenesis, cardiac)
  • fetal growth restriction and prematurity
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13
Q

diabetes onset at age 20 or older, or with duration less than 10 years

A

Class B

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14
Q

diabetes onset at age 10-19, or duration of 10-19 years

A

Class C

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15
Q

diabetes onset before age 10, or duration greater than 20 years

A

Class D

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16
Q

diabetic nephropathy is considered what class in Whites classification?

A

Class F

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17
Q

proliferative nephropathy is considered what class in Whites classification?

A

Class R

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18
Q

retinopathy and nephropathy is considered what class in Whites classification?

A

Class RF

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19
Q

ischemic heart disease is considered what class in Whites classification?

A

Class H

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20
Q

prior kidney transplant is considered what class in Whites classification?

A

Class T

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21
Q

what is condiered good glycemic control?

A
  • fasting glucose less than 95mg/dL
  • two hour postprandial less than 120mg/dL
  • control with diet, oral hypoglycemic medications (metformin) or insulin (preferred and recommended first line)
  • exercise half an hour after meals
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22
Q

antepartum maternal evaluation

A
  • renal: 24 hour urine collection every trimester
  • cardiac: EKG
  • ophthalmic: detailed eye exam
  • glycemic control: finger stick blood values
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23
Q

antepartum fetal evaluation

A
  • early dating US
  • detailed fetal anatomy US including fetal echocardiogram
  • biocehmical testing for congenital malformations in first trimester (11-13 wks) or quad screen (16-21 wks)
  • fetal growth US every 2-4 wks
  • fetal testing (NST/BPP) every wk starting 32 wks
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24
Q

what do delivery options depend on?

A

estimated fetal weight and glycemic control

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25
Q

postpartum management

A
  • insulin requirements drop significantly after placenta delivery
  • insulin-dependent pt require about 2/3 of pregnancy dose of insulin!
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26
Q

GDM, 2 hour glucose tolerance needs to be tested for how long postpartum?

A

6-12 weeks, looking for preexisting disease

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27
Q

how do you diagnose maternal hyperthyroidism?

A

elevated free T4 and suppressed TSH

- monitor TSH levels throughout pregnancy

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28
Q

what is the tx for hyperthyroidism during pregnancy?

A
  • propylthiouracil (PTU) in 1st trimester

- methimazole in 2nd/3rd trimester

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29
Q

what can methimazole cause if given during first trimester?

A

aplasia cutis (absence of skin, usually on scalp) and choanal atresia (back of nasal passage is blocked by abnormal bone or soft tissue)

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30
Q

what can propylthiouracil cause if given for prolonged periods?

A

liver toxicity - so only give in first trimester

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31
Q

what is contraindicated in hyperthyroidism?

A

radioactive iodine

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32
Q

what are the fetal effects of hyperthyroidism?

A
  • medications cross placenta and fetal hypothyroidism/fetal goiter can develop
  • increased risk of prematurity, IUGR, preeclampsia and stillbirth
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33
Q

what are the signs and sx of thyroid storm?

A
  • hyperthermia
  • tachycardia
  • perspiration
  • high output cardiac failure
  • maternal mortality about 25%
34
Q

what are the tx of thyroid storm?

A
  • beta blockers: propranolol
  • blocking secretion of thyroid hormone-sodium iodide
  • PTU stops synthesis of thyroid hormone
  • dexamethosone halts peripheral conversion of T4->T3
  • replacing fluid loss
  • reduce temp
35
Q

untreated hypothyroidism can lead to what?

A
  • spontaneous abortion
  • preeclampsia
  • abruption
  • low birth weight
  • stillbirth
  • cretinism (lower intelligence)
36
Q

what is the tx for hypothyroid in pregnancy?

A

levothyroxine

- monitor TSH and free T3/T4 monthly

37
Q

caused by trans-placental transfer of thyroid stimulating antibodies

  • transient (2-3 months)
  • 16% mortality rate
A

neonatal thyrotoxicosis

38
Q

neonatal hypothyroidism can be caused by:

A
  • thyroid dysgenesis
  • inborn errors of thyroid function
  • drug induced
39
Q

what is the most common lesion seen in rheumatic heart disease?

A 
mitral stenosis (90%)
- high risk of developing heart failure, subacute bacterial endocarditis and thromboembolic disease
40
Q

why is primary pulmonary hypertension a contraindication to pregnancy?

A

decompensation during pregnancy and a high mortality rate

- epidural anesthesia is preferred

41
Q

what is the most common cardiac arrhythmia?

A

supraventricular tachycardia
- usually benign

atrial fibrillation/flutter is more worrisome for underlying cardiac disease

42
Q
  • no underlying cardiac disease
  • develops within last weeks of pregnancy or within 6 months postpartum
  • women with preeclampsia, HTN and poor nutrition are at risk
  • 10% mortality rate
A

postpartum cardiomyopathy

43
Q

all pregnancy cardiac patients should be co-managed with whom?

A

a cardiologist

  • need EKG and echocardiogam
  • avoid excess wt gain and edema
  • avoid strenuous activity
  • prevent anemia
  • avoid infection
44
Q

how should cardiac patients deliver?

A

vaginally unless other indications

  • pushing may need to be avoided
  • strict fluid management
  • acute cardiac decomp with CHF is managed as a medical emergency
45
Q

immunoglobulins attach to maternal platelets

- can be confused with gestational thrombocytopenia

A

immune idiopathic thrombocytopenia

  • tx: prednisone, after platelets drop to 50,000
  • IV immunoglobulin if severe
  • platelet transfusion
  • splenectomy
46
Q

what can cause neonatal thrombocytopenia?

A

placental transfer of antiplatelet antibodies

47
Q

what are the fetal complications of SLE?

A
  • preterm delivery
  • fetal growth restrictions
  • stillbirth
  • miscarriage
  • 10% risk for neonatal lupus-passive transfer of anti-Ro/SSA or anti-La/SSB
48
Q

what is associated with arterial or venous thrombosis, and may coexist with SLE?

A

antiphospholipid syndrome

  • increased risk of miscarriage
  • risk for developing preeclampsia
  • fetal growth restriction
49
Q

how is antiphospholipid syndrome treated during pregnancy?

A

heparin/low molecular weight heparin and low-dose aspirin

- if hx of thrombosis: full anticoagulation

50
Q

what type of acute renal failure does lupus nephritis cause?

A

renal

NOTE: urologic obstructive lesions (kidney stones) cause post-renal ARF

51
Q

what labs need to be done with ARF during pregnancy?

A
  • urine output
  • BUN:creat
  • fractional excretion of sodium
  • urine osmolality
52
Q

what might need to be done in labor for an ARF patient?

A

swan ganz catheter (pulmonary artery catheter)

53
Q

what is the tx of pre-renal ARF?

A

restore volume

- pay attn to electrolytes

54
Q

what is the tx of renal ARF?

A

goal is to prevent further damage

  • diuretic
  • fluid restriction
  • hemodialysis
55
Q

what is the tx of post-renal ARF?

A

goal is to remove the obstruction

  • left lateral position
  • urethral catheter
  • possibly surgical intervention
56
Q

serum creatinine greater than what, worsens prognosis in chronic renal failure?

A
  1. 5 - 2
    - monitor renal function
    - manage HTN
    - fetal surveillance
57
Q

why is post-renal transplant not recommended during pregnancy?

A

may lose graft function or experience rejection

58
Q

what are the fetal complications of post-renal transplant?

A

steroid induced adrenal and hepatic insufficiency

  • prematurity
  • intrauterine growth restriction
59
Q

more likely to lead to cystitis and pyelonephritis in pregnant women

  • d/t urinary stasis and glucosuria
  • E.coli most common agent
A 
asymptomatic bacteriuria (UTI)
- may need suppressive abx with recurrent infections (3+)
60
Q

fever, costovertebral tenderness, malaise

  • elevated WBC, abnormal UA
  • can result in adult respiratory distress syndrome
A

pyelonephritis

- tx: IV hydration, abx, antipyretics, tocolytics if needed

61
Q

what is the tx for morning sickness?

A

vit b6, doxylamine, promethazine

62
Q

persistent nausea and vomiting associated with >5% loss of pre-pregnancy weight, ketonuria, dehydration

A

hyperemesis gravidarium (1-2% incidence)

  • occurs more frequently in first pregnancy
  • if severe, may need hospitalization, NG tube feeding or parental nutrition
63
Q

occurs in 70% of pregnant women
- tx: small meals, avoid laying down after meals, elevate head when sleeping, antacids, H2 blockers/proton pump inhibitors

A

GERD

64
Q

pregnancy may improve condition

  • endoscopy reserved for severe cases or signs of GI bleeding
  • avoid caffeine, alcohol, tobacco, spicy foods
  • tx: antacids, H2 blockers/PPI
  • abx for H. pylori
A

peptic ulcer

65
Q

aka acid aspiration syndrome

  • pregnant women at greater risk due to delayed gastric emptying and increased intra-abdominal/intra-gastric pressure
  • can result in adult respiratory syndrome
  • tx: supplemental O2
  • maintain airway
  • decrease acid in stomach
  • do not feed in labor
A

Mendelson’s syndrome

66
Q

cholestasis and pruritis in second half of pregnancy

  • can recur with each pregnancy
  • association with oral contraceptives and multiple gestations
  • benign course for maternal consequences
  • inrease risk of meconium stained amniotic fluid and fetal demise
  • sx: itching without abdominal pain or rash
  • elevated serum bile acids and occasionally elevted liver enzymes
A

intrahepatic cholestasis of pregnancy (ICP)

  • tx: local treatment- cold baths, bicarbonate washes
  • ursodeoxycholic acid
  • fetal surveillance and early delivery (36-37 weeks)
67
Q

diffuse fatty infiltration of liver resulting in hepatic failure = BAD

  • incidence is 1 per 14,000 pregnancies
  • unknown cause
  • sx: abd pain, NV, jaundice, irritability, polydypsia, HTN, proteinuria
  • increase PT and PTT, elevated bilirubin, ammonia and uric acid, elevation of ALT/AST
A

acute fatty liver of pregnancy

  • tx: termination of pregnancy
  • supportive care
  • maternal mortality 7-18%
  • fetal mortality 9-23%
  • full recovery if they survive
68
Q
  • decrease in HgB (less than 10g/dL)
  • hematocrit (less than 30%)
  • iron deficiency most common reason
A

anemia

  • screened at initial visit and again 26-28 weeks
  • tx: oral or IV iron-supp
69
Q

most common in patients with varicose veins, obesity and little physical activity

  • most common in calf, will not result in pulmonary emboli
  • sx: swelling/tenderness
A

superficial thrombophlebitis

- tx: bed rest, pain meds, local heat, compression socks, NO need for anticoagulants

70
Q

more common in left leg than right

  • positive Homans sign (pain in calf with dorsiflexion)
  • dull ache, tingling or pain with walking
  • dx: compression US with doppler flow
A

DVT

  • tx: anticoagulant, low-molecular wt (lovenox) or unfractionated heparin
  • coumadin used for 6 weeks postpartum, but NOT during pregnancy d/t risk of fetal hemorrhage or teratogenesis
71
Q

pleuritic chest pain

  • SOA, air hunger
  • palpitations
  • hemoptosis
  • tachypnea/tachycardia
  • low grade fever
  • pleural friction rub
  • chest splinting
  • pulmonary rales
  • accentuated pulmonic valve second heart sound
A

PE

  • dx: EKG, CXR, arterial blood gas, VQ, helical computed tomography
  • tx: anticoagulation
72
Q

patients with DVT or PE require what?

A

thrombophilia workup

  • lupus anticoagulant
  • anticardiolipid antibody
  • factor V leiden
  • protein C and S
  • antithrombin III
  • all patients with hx of thromboembolism need prophylactic anticoagulant therapy
73
Q

what is the most common pulmonary disease is pregnancy?

A

asthma - severe cases associated with increased:

  • miscarriage
  • preeclampsia
  • intrauterine fetal demise
  • intrauterine fetal growth restriction
  • preterm delivery
74
Q

what is the tx for asthma during pregnancy?

A

same as non-pregnancy pt

  • mild short-acting inhaled beta agonist
  • mild persistent low-dose inhaled corticosteroid
  • severe persistent: add systemic corticosteroid
75
Q

what can be given during labor and delivery to mom with asthma?

A

stress dose of IV steroids if using daily inhaled or high potency oral for more than 3 weeks

76
Q

what is the most common type of headache during pregnancy?

A

tension HA

- tx: acetaminophen

77
Q

diagnosis most common around age 30

  • usually experience fewer and less severe episodes in pregnancy
  • may exacerbate postpartum
  • increased risk of lower birth rate infants
  • increased risk of cesarean
A

multiple sclerosis

78
Q

what seizure medication should NOT be used during pregnancy, as it is more teratogenic than other anti-epileptics?

A

valporate

  • use dilantin and phenobarbital instead
  • monitor serum levels to achieve therapeutic dosing
79
Q

women on anti-epileptics should also be on what?

A

folic acid

80
Q

antidepressants taken in the third trimester cause increased risk of what?

A

neonatal withdrawal

81
Q

sadness that lasts more than 2 weeks postpartum is considered what?

A

postpartum depression

- 70-80% of women experience “baby blues” usually due to hormonal fluctuations

EndoRepro 2 Exam 1 (25 decks)

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