EM OB 6: Comorbids in Pregnancy, part 1 (endo, cardio) Flashcards
goals for maintaining euglycemia in pregnant diabetic pateints
FBG ≤95 mg/dL
2-HPPG ≤120 mg/dL
when pharmacologic treatment is indicated, what’s the preferred treatment for diabetes in pregnancy?
insulin
insulin requirement in pregnancy
first trimester: initial insulin requirement is 0.7 units/kg/day
by late pregnancy, patients generally require 1 unit/kg/day
DKA most commonly affects women in the ________ trimester
2nd or 3rd
a pregnant diabetic who is ill appearing, has persistent nausea and vomiting, and/or has a blood glucose ___________ should be screened for DKA
≥180 mg/dL
diabetic pregnant women who are more prone to develop more severe DKA
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*)
DKA and delivery
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
remarks on transient hyperthyroidism of hyperemesis gravidarum (THHG)
with THHG, TSH may be suppressed and free thyroxine elevated, but triiodothyronine is lower than in true hyperthyroidism
congenital abnormalities of methimazole
esophageal and choanal atresia
aplasia cutis
rare but serious complications of antithyroid tdrugs
agranulocytosis
liver failue
aplastic anemia
recommended regimen of antithyroid meds in pregnancy
PTU through 16 weeks of pregnancy, followed by transitioning to methimazole for the 2nd and 3rd trimesters
pregnancy and cardioversion
just as in a nonpregnant patient, treat any hemodynamically unstable arrhythmia in pregnancy with direct-current cardioversion (50-200 J)
only beta-blocker singled out as being a US FDA class D drug for influencing fetal and newborn size
atenolol
cardiac drugs that have their usual efficacy without adverse fetal effects
Verapamil
Diltiazem
Adenosine
Digoxin
Drug Category A
Controlled studies show no fetal risk in any trimester, and so the possibility of fetal harm is remote
Drug Category B
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)
Drug Category C
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
Drug Category D
Evidence of human fetal risk exists, but the benefits of use in pregnant woman may be acceptable despite the risk.
Drug Category X
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
most common non-sinus tachycardia in women of childbearing age
paroxysmal SVT
Pregnancy and anticoagulation
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
Amiodarone and pregnancy
- Amiodarone is categorized as class D
because its main metabolite (desethylamiodarone) and iodine cross the placenta - Chronic fetal exposure to amiodarone and its subsequent iodine overload is associated with neurotoxicity, fetal/neonatal hypothyroidism, and less commonly, goiter
- 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
pregnancy and pacemakers
The presence of an artificial pacemaker or implantable cardiac defibrillator does not affect the course of pregnancy
remarks on chest pain differential in pregnancy
Aortic dissection and cardiomyopathy are actually more common in pregnancy
remarks on ACS in younger pregnant patietns
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
most common cause of pregnancy-related AMI
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
thrombolytics in pregnancy
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
remarks on peripartum cardiomyopathy
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
treatment of sympathetic crashing acute pulmonary edema in pregnancy
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
