complications2-Table 1 Flashcards
What is the effect of asthma on pregnancy?
Rule of thirds
How is asthma managed in pregnancy?
maintain adequate oxygenation, use of inhaled B-agonists (albuterol), steroids &/or nebulizers PRN - depending on severity
What do influenza A/B increase the risk of in preggos?
Susceptibility to pneumonia
Can pregnant women get the flu vaccine?
Yes at any time
If you suspect your pt has been exposed to influenza, what can you do?
Chemoprophylaxis
tamiflu
What heat disease is common in pregnancy?
Rheumatic heart dz
What can rheumatic heart dz cause?
subacute bacterial endocarditis, HF, pulmonary edema, mitral valve stenosis
Why does mitral valve stenosis worsen with pregnancy?
increased cardiac output needs d/t pregnancy
What is the most common arrhythmia in pregnancy?
paroxysmal atrial tachycardia (PAT)
When might peripartum cardiomyopathy present?
Last month of pregnancy through the first 6 mo PP
What are the 5 proposed mechanisms for HTN dz of pregnancy?
- Vascular changes
- Hemostatic changes
- Changes in prostanoids
- Changes in endothelium-derived factors
- Lipid peroxide, free radical, antioxidant release
What is the predominant change in preeclampsia and GHTN?
Maternal vasospasm
What are the hematological effects of HTN dz of preggo?
Plasma volume contraction ↑Hct = risk of hypovolemic shock in event of hemorrhage
Risk of DIC, liver involvement, third spacing of fluid (↑BP / ↓plasma oncotic pressure
What are the renal effects of HTN dz of preggo?
decreased GFR & proteinuria d/t atherosclerotic-like changes in renal vessels
↓uric acid filtration leading to ↑maternal serum levels
oliguria
What are the neuro effects of HTN dz of preggo?
hyperreflexia w/possible progression to grand mal (eclamptic) seizures
What are the pulmonary effects of HTN dz of preggo?
Edema, left heart failure, fluid overload
What are the fetal effects of HTN dz of preggo?
Decreased placental perfusion 2˚ to vasospasm leads to IUGR, oligohydramnios, placental abruption, increased incidence of perinatal mortality
Placental size & function are decreased -> progressive fetal hypoxia & malnutrition
What are risk factors for preeclampsia?
—Primiparity —Prior hx w/IUP —Chronic HTN, chronic renal dz or both —Hx thrombophilia —Multi-fetal gestation or in vitro fertilization —FHx —DM type 1 or 2; obesity —SLE --- > 40 y/o
What are the classifications of HTN dz of preggo?
Chronic HTN
Gestational HTN
Chronic HTN with superimposed preeclampsia
Preeclampsia- eclampsia syndrome
What constitutes chronic HTN?
Elevated BP that predates conception or before 20 weeks EGA
What constitutes gestational HTN?
New onset BP elevation > 20 weeks EGA/near term in absence of associated proteinuria
This can progress to preeclampsia 1-3 weeks after diagnosis
What is preeclampsia?
New onset HTN, new onset proteinuria > 20 weeks EGA
Alternate symptomatology w/ new onset HTN
Preeclampsia w/out severe symptoms progress to severe w/in days
What is eclampsia?
Additional presence of seizures in patient w/pre-eclampsia & w/out hx of neurologic disease
What is a complication of Preeclampsia- eclampsia syndrome?
HELLP syndrome
What is HELLP syndrome?
Hemolysis, Elevated Liver enzymes, Low Platelet count
How is HELLP managed?
-Requires cardiovascular stabilization, correction of coag abnormalities (platelet transfusion) & delivery
—Stat delivery:
What is preeclampsia without severe features?
—HTN w/proteinuria & edema > 20th week of pregnancy
—New onset HTN & TCP ( 20 weeks EGA
—New onset HTN & elevated LFTs (transaminases 2x normal) > 20 weeks EGA
—New onset HTN & serum creatinine > 1.1 mg/dL or doubling serum creatinine in absence of other renal dz > 20 weeks EGA
—New onset HTN & pulmonary edema or cerebral-visual disturbances > 20 weeks EGA
How is it diagnosed?
HTN: Persistent SBP >140-160 mm Hg or DBP > 90-110 mm Hg on 2 occasions 4 hours apart in pt w/previously normal BP
Proteinuria: 1+/dipstick or > 300 mg per 24 hr urine or protein/creatinine ratio > 0.3 mg/dL
Is proteinuria necessary for diagnosing preeclampsia?
NO
What is preeclampsis with severe features?
—HTN w/proteinuria & edema > 20th week of pregnancy??? WHY IS THIS THE SAME
- Persistent SBP >160 mm Hg or DBP > 110 mm Hg on 2 occasions 4 hours apart in pt on bed rest
- TCP 1.1 mg/dL or doubling serum creatinine in absence of other renal dz
- Pulmonary edema or new onset cerebral-visual symptoms
What are the biomarkers for preeclampsia?
- Angiogenesis proteins
- PAPP-A
- Placental protein 13
- Uric acid
How is preeclampsia managed if no severe features or only gestational HTN?
Monitor
—Another maternal BP w/NST visit
—Urine protein w/each visit – gestational HTN pt
—Abnormal FH:
How is preeclampsia managed if severe gestational HTN or severe preeclampsia features are present?
Magnesium sulfate - prevent seizures
Antihypertensive meds
When should baby be delivered with preeclampsia?
> 37.0 weeks EGA or suspect abruption
> 34.0 wks EGA plus progressive labor &/or ROM, of US fetal wt
How long should you monitor PP to make sure symptoms resolve?
Monitor closely 24- 48 hrs PP
How can you screen for opioid addiction?
CRAFT: Car, Relax, Alone, Forget, Family/Friends, Trouble
What might be some signs that your preggo mom has an opioid addiction?
—Seek PN late in pregnancy —High non-compliance w/appointments —Poor wt gain —Seem intoxicated or sedated --- Track marks, skin abscesses
What do you need to watch for with withdrawal syndrome?
Fetus @ risk: IUGR, preterm labor, placental abruption, death
What labs do you want to run if suspect opioid addiction?
basic panel (CBC, STD/HIV include Hep C w/Hep B w/ IVDU or high risk exposure, urine drug screen
When is detox recommend?
during 2nd trimester to avoid risk miscarriage or after 32 weeks EGA to limit preterm labor risk
How can withdrawal be managed?
Methadone/ buprenorphine…. This will not just be you, lots of people will be involved in care
When should you monitor fetus when giving methadone? Why?
NSTs or BPPs: 4-6 hours s/p methadone dose
Methadone decreases baseline FHR, variability, breathing movements & tone
What is NAS?
neonatal abstinence syndrome
What are s/s of NAS?
CNS/ANS hyperactivity, poor feeding/uncoordinated sucking reflex, irritability, high pitch cry
When do symptoms of NAS become apparent?
w/in 72 hrs after delivery & last days to weeks
Whats with methadone and bup in breast milk?
Methadone minimally excreted in breast milk
Buprenorphine maintenance may be safe but research literature is too sparse
What is the most common cause of jaundice in pregnancy?
Acute viral hepatitis
Which antibodies cross the placenta? What does this mean?
anti-HAV IgG antibodies
risk for vertical or puerperium transmission
Where might a preggo woman pick up hep A?
Travel
What will be their diagnostic lab finding for acute hep A?
anti-HAV IgM positive (serum or feces)
How is hep A tx in preggos?
supportive & outpatient ……
inpatient only if: severe dz w/coagulopathy, encephalopathy, extreme malaise or hepatic necrosis
What would indicate hepatic necrosis?
high fever, acute abd’l pain, vomiting, altered MS
Can you immunize against hep A while pregnant?
Inactivated form is ok
Does hep A affect ability to breast feed?
No, it is not contraindicated for breastfeeding
What is the most common form of chronic hep?
B
Does hep B cross the placenta?
No
What does hep B put your pt at risk for?
chronic hepatic insufficiency or hepatocellular CA
How is it transferred to baby?
Perinatal infection – mom to baby during delivery
What lab values indicate what type of infection?
—anti-HBc antibodies – acute infection
—HBsAg, HBeAg &/or HBV DNA positive = infection
How is hep B managed?
Neonate: IZ, HBIG postexposure prophylaxis
Can you immunize against hep B while preggo or breast feeding?
Yes
What are risk factors for hep c?
alcoholism, IVDU, HIV
What is hep C a major cause of?
chronic hepatitis, cirrhosis & HCC
How is hep c transmitted to baby?
—Vertical or perinatal: viral load & HIV status dependent
Is c section recommended for hep c positive moms?
Not unless HIV co-infected
Can you tx hep c while pregnant?
Interferon CI and ribavirin category X
Is there prophylaxis for hep C?
No pre/post exposure prophylaxis yet
What does hep D use for transmission?
Uses HBsAg for transmission
Co-infection or super-infection w/chronic HBV
What lab findings will there be with hep D positive?
anti-HDAg positive, HDV DNA
How do you tx hep D?
No effective meds, immunize against hep B
What happens with hep E infection in preggo?
severe w/fulminant hepatitis
20% mortality w/acute infection 3rd trimester
What will the lab findings be with hep E?
IgM antibodies Hep E (anti-HEV antibodies)
Is there any tx for hep E?
No immunoglobulin available… monitor for renal failure, fulminant hep, premature labor and delivery and eclampsia
Is hep E contraindicated in breastfeeding?
No
What other infections does hep G commonly happen with?
Hep C and HIV
What will be lab findings in hep G?
RNA-PCR amplification; anti-HGVE2 antibodies
Should all pregnant women be screened for hep G?
Not recommended
