EM OB 7: Comorbids in Pregnancy, part 2 (VTE, asthma, UTI)

Question 1

leading cause of maternal morbidity and mortality in industrialized nations as well as developing countries

Answer 1

venous thromboembolism (DVT and PE)
The risk of VTE increases 5x during pregnancy and is increased by even more in the first 3 months after delivery

Question 2

remarks on DVT in pregnant women

Answer 2

DVT in pregnant women is more often left-sided and is more commonly found in proximal iliofemoral veins

It is recommended to treat any DVT found in pregnancy

Question 3

the only clinical prediction tool available for DVT that’s pregnancy-specific and validated

Answer 3

Chan’s LEFt
Left leg symptoms
Edema (calf circumference difference >2 cm)
First trimester presentation
3 variable are predictive of positive imaging for DVT in pregnant women.

However, the LEFt rule does not help after the first trimester and has not yet been applied prospectively in clinical trial.
Therefore, it should not be used in isolation to rule out DVT

Question 4

pregnancy and D-dimer

Answer 4

Societies recommend against the use of D-dimer alone to rule out pulmonary embolism in pregnant women

Question 5

first-lime imaging technique for detecting proximal DVT

Answer 5

Compression duplex US with color flow Doppler

Question 6

preferred method to evaluate pelvic vein thrombosis

Answer 6

MRI or magnetic resonance venography without contrast
with the addition of contrast only if absolutely necessary

Question 7

remarks on pulmonary embolism in pregnancy

Answer 7

Pregnant women with symptoms suggestive of pulmonary embolism who are positive for DVT by compression US should receive anticoagulation without waiting for further confirmatory diagnostic studies

Question 8

diagnostics in hemodynamically stable patients suspected of pulmonary embolism

Answer 8

in hemodynamically stable patients, consider no further imaging to spare the mother and fetus from additional radiation exposure

Question 9

diagnostics in hemodynamically unstablestable patients suspected of pulmonary embolism

Answer 9

In unstable patients, further imaging may be required to eliminate other causes of hypotension and evaluate the need for aggressive treatment

Bedside or formal echocardiography can detect acute right ventricular dysfunction, which suggests a large clot burden that may benefit from more aggressive therapy than standard anticoagulation alone

Question 10

treatment of VTE in pregnancy

Answer 10

currently includes unfractionated heparin or LMWH because neither crosses the placenal barrier

most guidelines recommended LMWH as first line
- highly efficacious
- low risk of bleeding complications
- negligible risk of HIT
- do not need daily drug activity monitoring

protamine sulfate may be used safely in pregnancy for patients who require rapid reversal of heparin anticoagulation

Question 11

may be used for prevention and treatment of VTE in heparin-allergic or heparin-intolerant pregnant patients

Answer 11

Fondaparinux
a synthetic, selective anti-factor Xa inhibitor

Question 12

fetal complications of warfarin

Answer 12

1st tri: embryopathy (chondrodysplasia)
2nd & 3rd tri: CNS and ophthalmologic abnormalities
(3rd tri: also bleeding diatheses)

Warfarin crosses the placenta

Question 13

massive or high-risk pulmonary embolism is defined as

Answer 13

sustained hypotension (SBP <90 mm Hg for more than 15 minutes) with the patient showing symptoms of shock

as of this writing, there is no formal consensus on whether systemic versus catheter-guided trettment is preferred

Question 14

most common medical disease in pregnancy

Answer 14

Asthma

Question 15

peak expiratory flow rate in pregnancy

Answer 15

PEFR is not altered in pregnancy, with normal rates ranging between 380 and 550 L/min.
Use PEFR as a guide to therapy.

Question 16

management of asthma in pregnancy

Answer 16

Treat rapidly and aggressively to reduce readmission rates and improve fetal outcomes.
The principles of management are the same as in non-pregnant patients
Avoid epinephrine because concerns exist about epinephrine vasoconstriction of the uteroplacental circulation

Question 17

steroids in asthma in pregnancy

Answer 17

For discharged women, prescribe oral prednisone, 40-60 mg/day (or equivalent), for 5-10 days, and a short acting rescue beta-agonist.

Inhaled corticosteroids reduce recurrence during pregnancy and decrease readmission rates following a hospitalization for asthma
Budesonide has been safely used in pregnancy

Question 18

remarks on UTI in pregnancy

Answer 18

treatment reduced the incidence of pyelonephritis and low birth weight

UTI need prompt treatment because acute pyelonephritis can precipitate preterm labor, bacteremia, or septic shock

Question 19

treatment of asymptomatic bacteriuria and simple cystitis in pregnancy

Answer 19

firstline for asymptomatic bacteriuria and simple cystitis:
amoxicillin 500 mg PO 2-3x daily for 3-7 days
cephalexin 500 mg PO 2-4x daily for 3-7 days

Question 20

treatment of pyelonephritis in pregnancy

Answer 20

2nd- or 3rd-gen cephalosporin
Continue IV antibiotics until the patient is afebrile for at least 48 hours and costovertebral angle tenderness has resolved.
Patients discharged after hospitalization need to complete a 10-day course of therapy

Question 21

the most common reason for treatment failure in pyelonephritis in pregnancy

Answer 21

antibiotic resistance

Question 22

UTI drugs to avoid in pregnancy

Answer 22

avoid nitrofurantoin in the first rimester unless there are no other options available

trimetoprim, a folate antagonist, can’t be used during the first trimester

sulfonamides can be taken during the first and second trimesters *but not during the third trimester because sulfonatmides can cause kernicterus in the infant

Do not use fluoroquinolones and tetracyclines during pregnancy
fluoroquinolones: observed fetal malformations in animal studies
tetracyclines: impair bone and tooth calcification