Clin: Medical Conditions in Pregnancy - Wootton Flashcards
when is gestational diabetes screening done?
between weeks 24-28
- 50gm 1 hr oral glucose challenge test (>130-140 = abnormal)
- may perform earlier screen in pt with risk factors
what if a GDM screen is abnormal?
repeat test with 3 hour 100gm oral load glucose test (fail 3 hour with 2 or more abnormal values)
what are the risk factors for development of GDM?
- obesity
- previous hx GDM
- strong family hx of DM
- known glucose intolerance
what are the maternal complications of GDM?
- increased risk of gestational HTN
- increased risk of preeclampsia
- greater risk of cesarean delivery
- increase risk of developing diabetes later in life
what are the fetal complications of GDM?
- macrosomia
- neonatal hypoglycemia
- hyperbilirubinemia
- operative delivery
- shoulder dystocia
- birth trauma
- stillbirth
how often is fetal testing performed?
weekly
- biophysical profiles and non-stress tests
- US for estimated fetal weight (if greater than 4500gm -> recommend cesarean delivery)
can you wait for spontaneous labor or EDD if all testing, growth and glycemic control are ok?
yes!
antepartum - diet controlled GDM
Class A1
- initially frequent monitoring of blood glucose
- typically no treatment required
antepartum - oral or insulin managed GDM
Class A2
- hourly glucose monitoring
- insulin drip
- continuous fetal monitoring in labor
there is a direct link between birth defects and what, in the period of embryogenesis?
increasing glycosylated hemoglobin levels (HgBA1C)
- six-fold increase in risk of congenital anomalies
what are the maternal intrapartum complications of GDM?
worsening nephropathy and retinopathy
- increased risk of developing preeclampsia
- greater risk of diabetic keto acidosis
what are the fetal intrapartum complications of GDM?
increased risk of spontaneous abortion
- anatomic birth defects (sacral agenesis, cardiac)
- fetal growth restriction and prematurity
diabetes onset at age 20 or older, or with duration less than 10 years
Class B
diabetes onset at age 10-19, or duration of 10-19 years
Class C
diabetes onset before age 10, or duration greater than 20 years
Class D
diabetic nephropathy is considered what class in Whites classification?
Class F
proliferative nephropathy is considered what class in Whites classification?
Class R
retinopathy and nephropathy is considered what class in Whites classification?
Class RF
ischemic heart disease is considered what class in Whites classification?
Class H
prior kidney transplant is considered what class in Whites classification?
Class T
what is condiered good glycemic control?
- 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
antepartum maternal evaluation
- renal: 24 hour urine collection every trimester
- cardiac: EKG
- ophthalmic: detailed eye exam
- glycemic control: finger stick blood values
antepartum fetal evaluation
- 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
what do delivery options depend on?
estimated fetal weight and glycemic control
postpartum management
- insulin requirements drop significantly after placenta delivery
- insulin-dependent pt require about 2/3 of pregnancy dose of insulin!
GDM, 2 hour glucose tolerance needs to be tested for how long postpartum?
6-12 weeks, looking for preexisting disease
how do you diagnose maternal hyperthyroidism?
elevated free T4 and suppressed TSH
- monitor TSH levels throughout pregnancy
what is the tx for hyperthyroidism during pregnancy?
- propylthiouracil (PTU) in 1st trimester
- methimazole in 2nd/3rd trimester
what can methimazole cause if given during first trimester?
aplasia cutis (absence of skin, usually on scalp) and choanal atresia (back of nasal passage is blocked by abnormal bone or soft tissue)
what can propylthiouracil cause if given for prolonged periods?
liver toxicity - so only give in first trimester
what is contraindicated in hyperthyroidism?
radioactive iodine
what are the fetal effects of hyperthyroidism?
- medications cross placenta and fetal hypothyroidism/fetal goiter can develop
- increased risk of prematurity, IUGR, preeclampsia and stillbirth
what are the signs and sx of thyroid storm?
- hyperthermia
- tachycardia
- perspiration
- high output cardiac failure
- maternal mortality about 25%
what are the tx of thyroid storm?
- 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
untreated hypothyroidism can lead to what?
- spontaneous abortion
- preeclampsia
- abruption
- low birth weight
- stillbirth
- cretinism (lower intelligence)
what is the tx for hypothyroid in pregnancy?
levothyroxine
- monitor TSH and free T3/T4 monthly
caused by trans-placental transfer of thyroid stimulating antibodies
- transient (2-3 months)
- 16% mortality rate
neonatal thyrotoxicosis
neonatal hypothyroidism can be caused by:
- thyroid dysgenesis
- inborn errors of thyroid function
- drug induced
what is the most common lesion seen in rheumatic heart disease?
mitral stenosis (90%) - high risk of developing heart failure, subacute bacterial endocarditis and thromboembolic disease
why is primary pulmonary hypertension a contraindication to pregnancy?
decompensation during pregnancy and a high mortality rate
- epidural anesthesia is preferred
what is the most common cardiac arrhythmia?
supraventricular tachycardia
- usually benign
atrial fibrillation/flutter is more worrisome for underlying cardiac disease
- 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
postpartum cardiomyopathy
all pregnancy cardiac patients should be co-managed with whom?
a cardiologist
- need EKG and echocardiogam
- avoid excess wt gain and edema
- avoid strenuous activity
- prevent anemia
- avoid infection
how should cardiac patients deliver?
vaginally unless other indications
- pushing may need to be avoided
- strict fluid management
- acute cardiac decomp with CHF is managed as a medical emergency
immunoglobulins attach to maternal platelets
- can be confused with gestational thrombocytopenia
immune idiopathic thrombocytopenia
- tx: prednisone, after platelets drop to 50,000
- IV immunoglobulin if severe
- platelet transfusion
- splenectomy
what can cause neonatal thrombocytopenia?
placental transfer of antiplatelet antibodies
what are the fetal complications of SLE?
- preterm delivery
- fetal growth restrictions
- stillbirth
- miscarriage
- 10% risk for neonatal lupus-passive transfer of anti-Ro/SSA or anti-La/SSB
what is associated with arterial or venous thrombosis, and may coexist with SLE?
antiphospholipid syndrome
- increased risk of miscarriage
- risk for developing preeclampsia
- fetal growth restriction
how is antiphospholipid syndrome treated during pregnancy?
heparin/low molecular weight heparin and low-dose aspirin
- if hx of thrombosis: full anticoagulation
what type of acute renal failure does lupus nephritis cause?
renal
NOTE: urologic obstructive lesions (kidney stones) cause post-renal ARF
what labs need to be done with ARF during pregnancy?
- urine output
- BUN:creat
- fractional excretion of sodium
- urine osmolality
what might need to be done in labor for an ARF patient?
swan ganz catheter (pulmonary artery catheter)
what is the tx of pre-renal ARF?
restore volume
- pay attn to electrolytes
what is the tx of renal ARF?
goal is to prevent further damage
- diuretic
- fluid restriction
- hemodialysis
what is the tx of post-renal ARF?
goal is to remove the obstruction
- left lateral position
- urethral catheter
- possibly surgical intervention
serum creatinine greater than what, worsens prognosis in chronic renal failure?
- 5 - 2
- monitor renal function
- manage HTN
- fetal surveillance
why is post-renal transplant not recommended during pregnancy?
may lose graft function or experience rejection
what are the fetal complications of post-renal transplant?
steroid induced adrenal and hepatic insufficiency
- prematurity
- intrauterine growth restriction
more likely to lead to cystitis and pyelonephritis in pregnant women
- d/t urinary stasis and glucosuria
- E.coli most common agent
asymptomatic bacteriuria (UTI) - may need suppressive abx with recurrent infections (3+)
fever, costovertebral tenderness, malaise
- elevated WBC, abnormal UA
- can result in adult respiratory distress syndrome
pyelonephritis
- tx: IV hydration, abx, antipyretics, tocolytics if needed
what is the tx for morning sickness?
vit b6, doxylamine, promethazine
persistent nausea and vomiting associated with >5% loss of pre-pregnancy weight, ketonuria, dehydration
hyperemesis gravidarium (1-2% incidence)
- occurs more frequently in first pregnancy
- if severe, may need hospitalization, NG tube feeding or parental nutrition
occurs in 70% of pregnant women
- tx: small meals, avoid laying down after meals, elevate head when sleeping, antacids, H2 blockers/proton pump inhibitors
GERD
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
peptic ulcer
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
Mendelson’s syndrome
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
intrahepatic cholestasis of pregnancy (ICP)
- tx: local treatment- cold baths, bicarbonate washes
- ursodeoxycholic acid
- fetal surveillance and early delivery (36-37 weeks)
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
acute fatty liver of pregnancy
- tx: termination of pregnancy
- supportive care
- maternal mortality 7-18%
- fetal mortality 9-23%
- full recovery if they survive
- decrease in HgB (less than 10g/dL)
- hematocrit (less than 30%)
- iron deficiency most common reason
anemia
- screened at initial visit and again 26-28 weeks
- tx: oral or IV iron-supp
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
superficial thrombophlebitis
- tx: bed rest, pain meds, local heat, compression socks, NO need for anticoagulants
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
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
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
PE
- dx: EKG, CXR, arterial blood gas, VQ, helical computed tomography
- tx: anticoagulation
patients with DVT or PE require what?
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
what is the most common pulmonary disease is pregnancy?
asthma - severe cases associated with increased:
- miscarriage
- preeclampsia
- intrauterine fetal demise
- intrauterine fetal growth restriction
- preterm delivery
what is the tx for asthma during pregnancy?
same as non-pregnancy pt
- mild short-acting inhaled beta agonist
- mild persistent low-dose inhaled corticosteroid
- severe persistent: add systemic corticosteroid
what can be given during labor and delivery to mom with asthma?
stress dose of IV steroids if using daily inhaled or high potency oral for more than 3 weeks
what is the most common type of headache during pregnancy?
tension HA
- tx: acetaminophen
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
multiple sclerosis
what seizure medication should NOT be used during pregnancy, as it is more teratogenic than other anti-epileptics?
valporate
- use dilantin and phenobarbital instead
- monitor serum levels to achieve therapeutic dosing
women on anti-epileptics should also be on what?
folic acid
antidepressants taken in the third trimester cause increased risk of what?
neonatal withdrawal
sadness that lasts more than 2 weeks postpartum is considered what?
postpartum depression
- 70-80% of women experience “baby blues” usually due to hormonal fluctuations
