Disease states in pregancy and Lactation

Question 1

How is diabetes diagnosed in pregnant women, what are reasons the test would be given earlier

Answer 1

Oral Glucose Tolerance Test (OGTT) between 24-28 weeks gestation/

pregnant patient is overweight or obese and also

• physically inactive
• History or familial history of diabetes
• High risk race
• Previously gave birth to infant over 9 pounds
• Hypertension
• Polycystic overian syndrome
• Hisotry of cardiovascular disease
• A1c greater than or equal to 5.7%

Question 2

How is the OGTT done, when is gestational diabetes diagnosed

Answer 2

Patient is given 50 grams of glucose, after one hour if blood sugar is greater than 140 mg/dl then a 3 hour 100 gram OGTT is done on a different day

• If the one hour glucose test is done and the blood sugar is greater than 200 they are automatically diagnosed as having GD
• If after the three hour glucose test is done and the patient has blood sugar greater than 140 mg/dl again the patient is diagnosed as having GD
• If the patient has an 8 hour fast that is greater than 95 mg/dl

Question 3

How is GDM controlled

Answer 3

Weight management, dietary modifications, light or moderate exercise as tolerated

Question 4

What is the pharmacological options for GDM

Answer 4

Insulin (doesn’t cross the placenta), Metformin

Question 5

T/F: If a patient was already taking insulin before pregnancy they will not be switched off

Answer 5

True

Question 6

What are the goals for GDM

Answer 6

Fasting 65-95 mg/dl

2 hour post-prandial: Less than 120

Question 7

What is the most common complication in pregancy due to Hypertension

Answer 7

Pre-eclampsia

Question 8

What is chronic hypertension, gestational hypertension

Answer 8

HTN diagnosis prior to pregnancy OR blood pressure greater than 140/90 mmHg on two seperate readings before 20 weeks of gestation

Blood pressure greater than 140/90 mmHg on two seperate readings after20 weeks of gestation

Question 9

What are the pre-eclampsia risk factors

Answer 9

History of pre-eclampsia in previous pregnancies, family history, first pregnancy/twins ortriplets, age greater than 35, comorbidities including

• Diabetes
• Hypertension
• CKD
• Obesity

Question 10

How is pre-eclampsia diagnosed

Answer 10

blood pressure greater than 140/90 on two different readings at least 20 mins apart PLUS

• Proteinuria
• Thrombocytopenia: less than 100,000
• SCr greater than 1.1 or doubling from baseline
• AST/ALT two times greater than ULN
• Pulmonary edmea
• Cerebral/Visual symptoms

OR

Blood pressure greater than 160/110 mmHg on two seperate readings at least 1-2 minutes apart

Question 11

What are the non-pharmacological options for hypertension

Answer 11

Reduce stress, avoid smoking and alcohol

Question 12

When and how is HTN handled in pregnant patients while using pharmacotherapy

Answer 12

Controlled hypertension: if medication controlled prior to pregnancy either continue medication or change to preferred agent

Gestational hypertension: Initiate therapy when blood pressure is over 150/100 OR when blood pressure is over 140/90 PLUS one other comorbid condition

Question 13

What 1st line drugs are used to treat HTN in pregnant patients, 2nd line, avoid

Answer 13

• Labetalol, Nifedipine, Methyldopa (not as effective)
• Thiazide diuretics, Non-DHP CCBs
• Avoid: ACEs and ARBS, Atenolol

Question 14

How is pre-eclampsia/eclampsia cured, other options

Answer 14

Delivery, betamethasone, labetalol or hydralazine for acute HTN, magnesium to prevent seizures

Question 15

How is aspirin used in pre-eclampsia

Question 16

T/F: Treating women with asthma is not worth the risk that is accompanied

Answer 16

False: It is safer for pregnant women with asthma to be treated with asthma medications than it is for them to have asthma symptoms and exacerbations

Question 17

What medications would be used for rescue and other ashtma treatments

Answer 17

Resuce: Albuterol, budesonide, montelukast

Question 18

What should be used for VTE in pregnant patients

Answer 18

LMWH (enoxaparin: 40 mg sc once daily or BID), heparin

Question 19

When is warfarin ok to use in pregnant patients

Answer 19

2nd/3rd trimester for mechanical valves

Question 20

What physiological changes effect the thyroid

Answer 20

Increased thyroid binding globulin (TBG), low iodide levels

Question 21

What medications are used to hyperthyroidism, hypothyroidism

Answer 21

Propylthiouracil (1st trimester) and methimazole(2nd/3rd trimester)

Levothyroxine: 30% higher dose possbily requiring titration throughout pregnancy

Question 22

What labs can be used for thyroid monitoring per trimester

Answer 22

TSH: First trimester- 0.1-2.5, 2nd/3rd trimester- 0.2/0.3-3.0

Free T4: First trimester- 0.8-1.2, 2nd/3rd trimester- 0.6-1 and 0.5-0.8

Question 23

T/F: If someone has a moderate or high risk of pre-eclampsia they should be given aspirin started between 12-28 weeks, ideally prior to 16 weeks

Answer 23

True

Question 24

What should be given for epilpsy management in pregnant patients

Answer 24

Folic acid, Vitamin K, ONE AED (except valproic acid)

Question 25

T/F: A patient is on an AED before pregnancy they would stay on it throughout the pregnancy

Answer 25

True

Question 26

What hormone controls lactation

Answer 26

Prolactin

Question 27

T/F: If a drug is place in L5 it is the safest while L1 is dangerous

Answer 27

False: L1 is most safe while L5 is most dangerous

Question 28

How much maternal dose goes to a baby while breast feeding

Answer 28

Less than one percent

Question 29

When should a pregnant patient get Tdap shot

Answer 29

Between 27 and 36 weeks of gestation

Question 30

Why should patients avoid estrogen while pregnant, how long till they can revieve it

Answer 30

VTE risk, 6 weeks after giving birth

Question 31

If a patient is taking a nicotine lozenge while breastfeeding what should be done

Answer 31

Take a lozenge right before scheduled feedings