Disease Processes Flashcards
Gestational htn- diagnosed for the first time at ____ , most often after ____ weeks
20, 37
Mild htn: ___/___
140-159/90-109
Severe htn: ___/___
> 160/>110
Outcome risks with severe ghtn
Abruption
SGA
preterm delivery
Mild ghtn pts need weekly assessments of ___
Proteinuria
Liver enzymes
Platelets
BP (2x/wk, 1 in office)
Do you give mild ghtn pts oral hypertensives?
Nope, no salt or activity restrictions either
When do you deliver mild ghtn pts ?
EGA 37 or >
spontaneous labor or srom 34 or >
What meds are used for severe ghtn?
IV labetolol or IV hydralazine
Oral antihypertensives to maintain BP
Preeclampsia definition
Ghtn PLUS proteinuria OR without proteinuria but with: Thrombocytopenia (platelets 1.1 or doubling) Impaired liver function (2x normal labs) Pulmonary edema Cerebral/visual symptoms
Proteinuria definition
> or = 300 (24-hr urine)
Protein/creatinine ratio > or = .3
Dipstick 1+
Risk factors for preeclampsia
Nulliparity (or new male partner) Htn Renal disease Diabetes Collagen vascular disease Thyroid disease Abnormal placental size or function 40 Hx or family hx of preeclampsia Inc BMI Af-American
Hypertension definition
Sbp >= 140 OR dbp >= 90
2 measurements, 4 hours apart
Signs of worsening preeclampsia
Increase in subjective symptoms Oliguria Sudden wt gain or inc facial edema Hemoconcentration (hgb >12) *fluid leaking Inc creatinine >.8 Inc uric acid >5
Meds for eclampsia
4g mag slow IV push
Do NOT give diazepam
What to do during/after eclamptic seizure
Prevent injury Administer 02 Auscultate lungs Assess/correct acidemia (blood gasses) Allow fetus to recover before rushing to delivery
What is HELLP syndrome?
Hemolysis
Elevated liver enzymes
Low platelets
What is hemolysis (HELLP)
Schistocytes on blood smear
Bilirubin >1.2
LDH >600
What are elevated liver enzymes (HELLP)
Inc ALT, AST, LDH
What is the cluster of s/s to warrant lab eval for HELLP (htn/proteinuria may be absent)
N/v/d Malaise Flank/shoulder pain Jaundice Unusual bleeding Generalized edema
What additional management is needed with mild preeclampsia than mild ghtn?
Twice weekly BPP and growth scan
Add umbilical artery Doppler velocimetry if iugr
Indications for delivery with mild preeclampsia
Same as mild ghtn
EGA >= 37 wks
Spontaneous labor/srom >=34wks
Management for severe preeclampsia or HELLP
4-6g loading dose mag
2-3g/hr maintenance dose mag
Antihypertensives for severe BP
continue intraop mag for c/s
Neuraxial techniques for analgesia/anesthesia
Indications for delivery with severe preeclampsia or HELLP
If mom/fetus unstable deliver after stabilization
^even if previable
When do you delay delivery 48hrs after steroids with severe preeclampsia /HELLP
PPROM
Spontaneous labor
IUFGR
severe oligo (AFI
When do you NOT delay delivery after steroids for
Uncontrollable sever htn Eclampsia Pulmonary edema Abruption DIC fetal compromise IUFD
When are mag levels drawn?
Creatinine >1.2 or UOP
When do you DC mag for mag toxicity
Absent DTR’s
Respirations
HTN that presents before the 20th week is considered ___
Chronic htn
What meds are used to treat chronic htn?
Labetolol, nifedipine, methyldopa
Low dose ASA in third tri for very high risk
What is the goal BP for chronic htn?
120/80-160/105
At what gestational age do you deliver chronic htn pts with no other issues?
38 wks
What is a side effect of hydralazine to watch out for?
Rebound tachycardia
When should you be cautious with labetolol?
When pt is asthmatic and requires rescue inhaler. (Won’t work)
When should you be cautious with nifedipine use?
When used together with mag sulfate
In postpartum period when would you treat a BP with antihypertensives ? What BP ?
SBP >150 or DBP>100
*2 readings, 4 hrs apart
> 160/110 treat as hypertensive emergency
If somebody has any htn disorder how long should BP be monitored after delivery?
For 72 hrs after delivery, and at office at 7-10 days
First half of pregnancy is ___ , while second half is ___
Anabolic- fat storage
Catabolic- fat breakdown
Anabolic
Catabolic
Insulin infusion is started for type 1 diabetics if blood glucose is higher than ___
120
Cardiac output in pregnancy rises to ___% of normal by ___wks
150, 24-28
What are the three periods of high risk for cardiac decompensation?
When fluid volume peaks at end of 2nd tri
During work of labor
With fluid shifts that occur postpartum
What are the NYHA functional classes?
1- asymptomatic
2- symptoms with normal activity
3- symptoms with less than normal activity
4- symptoms at rest
What should you know about coarctation of aorta?
Aorta narrows
Associated with intracranial aneurysms
Epidural ideal, shorten second stage
What should you know about rheumatic heart disease?
Eradicate pathogen, reduce inflammation
Long acting pnc, NSAIDs or corticosteroids
What types of valvular defects are there?
Stenosis and regurgitation
Which type of valvular defect tends to be worse in pregnancy?
Stenotic- >60% have worsening NYHA class
Can also have CHF, PTL, IUFGR, stillbirth
What are complications of mitral stenosis?
Pulmonary edema, RV failure, arrhythmias, PE
How do you treat mitral stenosis?
Preventing/controlling tachycardia is ESSENTIAL
Pain management, beta blockers
What happens in aortic stenosis?
Stenosis between LV and aorta (to circulation)
Created fixed stroke volume, dec CO, hypotensive tachycardia
How do you manage aortic stenosis?
Prevent hypotension and tachycardia!
Generous hydration, cautious epidural use
Shorten second stage
Active management of PPH
What do you need to know about mitral valve prolapse?
Most common
Mostly asymptomatic
Some experience chest pain, dyspnea, weakness, palpitations
Low risk during pregnancy
What do you need to know about mechanical heart valves?
Anticoagulation very difficult (no warfarin)
Advised to have valve repair/replacement
What do you need to know about dysthymias and treatment?
SVT common Treatment unaltered by pregnancy Vagal maneuvers IV adenosine (causes fetal bradycardia) Frequent episodes- beta blockers, calcium channel blockers, digoxin
What do you need to know about marfans syndrome?
Aortic root diameter critical
Surgical replacement if root diameter >5.5cm
High risk if root diameter >4.5cm- csection
Treat htn aggressively- beta blockers
What do left-to-right shunts cause? (Seen with ASD, VSD, PDA)
Pulmonary htn
What do you need to know about pulmonary htn?
Causes right sided heart failure, ⬇️ 02 to body
Tx with vasodilators- prostacyclin infusion
Avoid hypotension
What do you need to know about eisenmengers syndrome?
L–>R shunt, pulm htn, R–>L shunt, deoxygenated blood to circulation
Maternal mortality mostly postpartum
Repair of breech before pulm htn
After pulm htn only tx heart lung transplant
Maintain preload!
What do you need to know about peripartum cardiomyopathy?
Pulm edema and CHF
usually in 3rd tri or postpartum
Tx with Anticoagulation for high risk of thromboembolism
Reduce preload (Na/fluid reduction, diuretics, nitrates)
Afterload reduction (hydralazine, ACE inhibitors PP)
Digoxin
What do you need to know about endocarditis?
Routine antibiotic prophylaxis not recommended
Cyanotic congenital heart defects considered high risk and should receive prophylaxis for vaginal delivery
What do you need to know about ischemic heart disease?
Mostly seen in pregnancy in women who have had type 1 diabetes for over 10 years
Delay delivery for 2 weeks after MI
vaginal delivery preferred
When do you test for GBS and how?
35-37 weeks with vaginal-rectal culture
What antibiotics are used for GBS?
PNC or ampicillin preferred
Cefazolin if allergy and low risk anaphylaxis
Clinda/vanco if allergy and high risk
What hgb levels diagnose anemia in pregnancy?
H
What causes gestational thrombocytopenia and what platelet count is considered mild to moderate?
Dilution and inc platelet destruction
Mild to moderate 50-149k
*spontaneously resolves after delivery
What is immune thrombocytopenic purpura? (ITP) and what is the treatment
Antiplatelet antibodies (autoimmune) Tx with steroids
What is thrombocytopenic purpura (TTP) and what is the treatment?
Extensive microscopic clots form- 90% mortality untreated
Tx with plasma exchange
What are risks of sickle cell?
Preterm delivery
Preeclampsia
What are risks of thalassemia?
Hydrops fetalis
IUFGR
When are Rh-D negative mothers given rhogam?
28 wks, after delivery, and other situations where fetal-maternal hemorrhage can occur
What are thrombophilias (lead to increased thrombosis)?
Factor V Leiden Protein c deficiency Protein s deficiency Prothrombin g20210a mutation Antithrombin III deficiency
What drug is used as anticoagulant for VTE prophylaxis in pregnancy?
Heparin- unfractionated (UH), or LMWH
doesn’t cross placenta
Switch from LMWH to UH in last mo of pregnancy
Stopped when pt goes into labor
What is DIC
Dysregulated coagulation cascade that results in uncontrollable bleeding
What are common causes of DIC?
Abruption
Preeclampsia
Sepsis
Anaphylactoid syndrome
What diagnoses DIC?
Abnormal bleeding Prolonged PT/aPTT Thrombocytopenia Fibrinogen reduced High levels of fibrin split products (d-dimer) Shistocytes on blood smear
What is the treatment for DIC?
Identify/reverse cause
Platelets/FFP can be given to prevent death but can worsen process
What do you need to know about renal function in pregnancy ?
Renal volume inc 30%
Renal blood flow inc 60-80% in first tri
Dec to 50% inc at term
GFR inc 40-50%
Serum creatinine decreases
Angiotensinogen, angiotensin II, renin, and aldosterone all elevated
Mild proteinuria
What do you need to remember about pyelonephritis and PTL?
Use great caution with tocolytics and steroids in acute phase
Withholding is appropriate in pts with respiratory or hemodynamic instability
What happens to thyroid hormones in pregnancy?
Demand for thyroid hormones inc in pregnancy
Fetal CNS development depends on good T4
Fetus cannot produce T4 until 18wks
T4 converts to T3 (more metabolically active)
What do low/high levels of TSH mean?
Low levels - hyperthyroidism
High levels - hypothyroidism
What is treatment for hypothyroidism in pregnancy?
Synthroid (levothyroxine) synthetic T4
Dosage inc in pregnancy
What do you need to know about hyperthyroidism in pregnancy?
Rare- most caused by Graves’ disease
Often masked due to normal inc in thyroid function
Associated with PTL, IUFGR, low birth weight, neonatal thyroid dysfunction
What do you need to know about Graves’ disease?
Autoimmune disorder
Fetal hyper turns into neonatal hypo
Tx with propylthiouracil or methimazole
^1st tri ^2nd tri
Goal is T4 upper limits/slightly over normal
What are signs/symptoms of a thyroid crisis?
Altered mental status, temp >41c, htn, diarrhea
ICU admit, aggressive tx
What do you need to know about postpartum thyroiditis?
Transient thyroid dysfunction in 1st year PP
symptoms mimic pp depression
If over one year consider chronic
What do you need to know about systemic lupus erythematosus?
Autoantibodies cause inflammation/tissue damage
High risk for preeclampsia
Avoid NSAIDs
Associated with SAB, IUFD, IUFGR, PTL
Complete heart block most common neonatal cardiac complication
What do you need to know about antiphospholipid syndrome?
Autoantibodies
Promotes thrombosis/clot formation
High occurrence of fetal death, preeclampsia, IUFGR
tx with heparin, low dose ASA
What do you need to know about appendicitis?
Most common non ob surgical emergency
Ultrasound 1st, if inconclusive then MRI
surgery required
Maternal/fetal mortality inc in cases of perforation
