EM OB 7: Comorbids in Pregnancy, part 2 (VTE, asthma, UTI) Flashcards
leading cause of maternal morbidity and mortality in industrialized nations as well as developing countries
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
remarks on DVT in pregnant women
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
the only clinical prediction tool available for DVT that’s pregnancy-specific and validated
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
pregnancy and D-dimer
Societies recommend against the use of D-dimer alone to rule out pulmonary embolism in pregnant women
first-lime imaging technique for detecting proximal DVT
Compression duplex US with color flow Doppler
preferred method to evaluate pelvic vein thrombosis
MRI or magnetic resonance venography without contrast
with the addition of contrast only if absolutely necessary
remarks on pulmonary embolism in pregnancy
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
diagnostics in hemodynamically stable patients suspected of pulmonary embolism
in hemodynamically stable patients, consider no further imaging to spare the mother and fetus from additional radiation exposure
diagnostics in hemodynamically unstablestable patients suspected of pulmonary embolism
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
treatment of VTE in pregnancy
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
may be used for prevention and treatment of VTE in heparin-allergic or heparin-intolerant pregnant patients
Fondaparinux
a synthetic, selective anti-factor Xa inhibitor
fetal complications of warfarin
1st tri: embryopathy (chondrodysplasia)
2nd & 3rd tri: CNS and ophthalmologic abnormalities
(3rd tri: also bleeding diatheses)
Warfarin crosses the placenta
massive or high-risk pulmonary embolism is defined as
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
most common medical disease in pregnancy
Asthma
peak expiratory flow rate in pregnancy
PEFR is not altered in pregnancy, with normal rates ranging between 380 and 550 L/min.
Use PEFR as a guide to therapy.
management of asthma in pregnancy
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
steroids in asthma in pregnancy
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
remarks on UTI in pregnancy
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
treatment of asymptomatic bacteriuria and simple cystitis in pregnancy
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
treatment of pyelonephritis in pregnancy
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
the most common reason for treatment failure in pyelonephritis in pregnancy
antibiotic resistance
UTI drugs to avoid in pregnancy
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
