EM OB 6: Comorbids in Pregnancy, part 1 (endo, cardio)

Question 1

goals for maintaining euglycemia in pregnant diabetic pateints

Answer 1

FBG ≤95 mg/dL
2-HPPG ≤120 mg/dL

Question 2

when pharmacologic treatment is indicated, what’s the preferred treatment for diabetes in pregnancy?

Answer 2

insulin

Question 3

insulin requirement in pregnancy

Answer 3

first trimester: initial insulin requirement is 0.7 units/kg/day
by late pregnancy, patients generally require 1 unit/kg/day

Question 4

DKA most commonly affects women in the ________ trimester

Answer 4

2nd or 3rd

Question 5

a pregnant diabetic who is ill appearing, has persistent nausea and vomiting, and/or has a blood glucose ___________ should be screened for DKA

Answer 5

≥180 mg/dL

Question 6

diabetic pregnant women who are more prone to develop more severe DKA

Answer 6

diabetic pregnant women >20 weeks of gestation
- develop more severe and rapidly progressive episodes of DKA (usually over hours)
- and at lower glycemic levels (<300 mg/dL*)

Question 7

DKA and delivery

Answer 7

DKA is NOT an indication for delivery.
Although fetal heart rate monitoring in maternal DKA may initially demonstrate a nonreassuring pattern, patterns usually improve as maternal ketoacidosis is corrected, and mother will tolerate delivery or cesarean section better once acidosis resolves

Question 8

remarks on transient hyperthyroidism of hyperemesis gravidarum (THHG)

Answer 8

with THHG, TSH may be suppressed and free thyroxine elevated, but triiodothyronine is lower than in true hyperthyroidism

Question 9

congenital abnormalities of methimazole

Answer 9

esophageal and choanal atresia
aplasia cutis

Question 10

rare but serious complications of antithyroid tdrugs

Answer 10

agranulocytosis
liver failue
aplastic anemia

Question 11

recommended regimen of antithyroid meds in pregnancy

Answer 11

PTU through 16 weeks of pregnancy, followed by transitioning to methimazole for the 2nd and 3rd trimesters

Question 12

pregnancy and cardioversion

Answer 12

just as in a nonpregnant patient, treat any hemodynamically unstable arrhythmia in pregnancy with direct-current cardioversion (50-200 J)

Question 13

only beta-blocker singled out as being a US FDA class D drug for influencing fetal and newborn size

Answer 13

atenolol

Question 14

cardiac drugs that have their usual efficacy without adverse fetal effects

Answer 14

Verapamil
Diltiazem
Adenosine
Digoxin

Question 15

Drug Category A

Answer 15

Controlled studies show no fetal risk in any trimester, and so the possibility of fetal harm is remote

Question 16

Drug Category B

Answer 16

Animal studies show no fetal risk, but there are no controlled human studies
or
Animal studies have shown an adverse effect that was not confirmed in controlled human studies in women in the first trimester (and there’s no evidence of risk in later trimesters)

Question 17

Drug Category C

Answer 17

Animal studies have shown adverse fetal effects (teratogenic or embryocidal), and there are no controlled studies in humans.
or
No human or animal studies are available.
Drugs should be used only if the potential benefit justifies the potential fetal risk

Question 18

Drug Category D

Answer 18

Evidence of human fetal risk exists, but the benefits of use in pregnant woman may be acceptable despite the risk.

Question 19

Drug Category X

Answer 19

Studies in animals or humans have shown fetal risk, or there’s evidence of fetal risk based on human experience.
The risk of use in pregnancy CLEARLY OUTWEIGHS any possbible benefit
Drugs are CONTRAINDICATED for use in women who are or may become pregnant

Question 20

most common non-sinus tachycardia in women of childbearing age

Answer 20

paroxysmal SVT

Question 21

Pregnancy and anticoagulation

Answer 21

Anticoagulation with unfractionated or low-molecular-weight heparin is safe in pregnancy and should be used if the patient meets criteria for antioagulation described for nonpregnant patients

Question 22

Amiodarone and pregnancy

Answer 22

1. Amiodarone is categorized as class D
   because its main metabolite (desethylamiodarone) and iodine cross the placenta
2. Chronic fetal exposure to amiodarone and its subsequent iodine overload is associated with neurotoxicity, fetal/neonatal hypothyroidism, and less commonly, goiter
3. therefore, use of amiodarone in pregnancy is limited to maternal/fetal tachyarrhtymias that are resistant to other drugs or are life-threatening because short-term use has not been linked to any harmful effects

Question 23

pregnancy and pacemakers

Answer 23

The presence of an artificial pacemaker or implantable cardiac defibrillator does not affect the course of pregnancy

Question 24

remarks on chest pain differential in pregnancy

Answer 24

Aortic dissection and cardiomyopathy are actually more common in pregnancy

Question 25

remarks on ACS in younger pregnant patietns

Answer 25

ACS in younger pregnant women is more likely caused by spontaneous coronary artery dissection, coronary vasospasm, or coronary embolus, which are all extreemely rare in the younger, nonpregnant patient

Question 26

most common cause of pregnancy-related AMI

Answer 26

spontaneous coronary artery dissection
- thought to be due to progesterone and other hormone-related vessel wall change
- and shear forces secondary to increased blood volume

Question 27

thrombolytics in pregnancy

Answer 27

use of thrombolytics during pregnancy can cause maternal hemorrhage, placental abruption, uterine bleeding, and PPH

thrombolytic therapy is not recommended [in chest pain pregnant patients] due to lack of reversibility and the risk of worsening a possible coronary dissection

Question 28

remarks on peripartum cardiomyopathy

Answer 28

a dilated cardiomyopathy that can occur at any stage of gestation, but is classically defined as occurring in the last month of gestation (third timester) or within the first 5 months after delivery, without an apparent cause or preexisting history of cardiac disease

Question 29

treatment of sympathetic crashing acute pulmonary edema in pregnancy

Answer 29

initial treatment is the same for the nonpregnant patient:
high-dose IV nitroglycerine (500 to 1000 mcg) until stabilization and ventilatory support with BPAP, HFNC, or intubation, as needed