EM OB 8: Comorbids in Pregnancy, part 3 (neuro, GI, torsion, HIV) Flashcards
the most common cause for spontaneous intracerebral hemorrhage in pregnancy is
hypertension
if there’s no history of hypertension, then consider other causes
- neoplasm
- hemorrhagic disorder
- vascular malformation
3rd most common cause of nonobstetric maternal death
Subarachnoid hemorrhage
and more than half of cases occur postpartum
majority of strokes occur when
third trimester or pueperium (6 weeks after delivery)
most common cause of pregnancy-related stroke
arterial occlusion
remarks on thrombolysis in stroke in pregnancy
To date, there are no RCTs of thrombolytics for stroke in pregnancy
recombinant tissue plasminogen activator
- risk category C
- does not cross the placental
- and there’s no evidence of teratogenicity in animal studies
- overall maternal mortality and fetal loss are relatively low at 1% and 6% respectively
remarks on central venous thrombosis
usually occurs in the 2nd and 3rd trimesters and may occur up to 4 weeks postpartum
presentation:
- severe headache
- focal neurologic deficit
- vomiting
- seizure
(depending on which veins are occluded)
treatment of central venous thrombosis
mainstain of treatment is anticoagulation (LMWH) for the duration of the pregnancy
remarks on migraine in pregnancy
most patients see an improvement in migraine frequency as the pregnancy progresses
therefore, address red flag symptoms and consider other life-threatening causes of severe headache (central venous thrombosis) especially in the 2nd or 3rd trimester before diagnosing migraine
Metoclopramide is class B
lifestyle modifications in GERD
elevating head of bed
not eating 3 hours before bed
eating small meals
eliminating trigger foods
remarks on cholecystitis in pregnancy
It is preferable to wait until the 2nd trimester if the patient condition allows
first tri: risk of spontaneous miscarriage
3rd tri: technically difficult and can result in preterm labor
most common extrauterine condition requiring abdominal operation in pregnancy
appendicitis
imaging in appendicitis in pregnancy
Recent studies suggest using MRI as the ninitial imaging modality given the high rate of inconclusive US results
Noncontrast MRI is recommended due to recent concerns of fetal effects from gadolinum exposure
CT in pregnancy
in appendicitis, If US or MRI is unavailable, CT should be performed without delay.
an abdomen or pelvis CT confers about 30 milligray (mGy) of radiation, and 50 mGy of radiation is generally accepted to be safe in pregnancy
remarks on ovarian torsion
ovarian torsion is a true gynecologic emergency.
can occur in any trimester, although it is most common in the first trimester
risk factors for ovarian torsion
infertility treatment
corpus luteal cyst and enlarged ovaries stemming from the pregnancy hormones are thought to increase the risk
diagnosis of ovarian torsion
US may show an enlarged or edematous ovary with absent or decreased blood flow.
However, the presence of ovarian blood flow does not exclude the diagnosis of torsion if symptoms are suggestive
Therefore, consult an obstetrician/gynecologist as soon as the diagnosis is clinically suspected
seizure frequency can increase in pregnancy because of:
increased volume of distribution
increased plasma clearance of antiepileptic drugs
poor medication compliance
treatment of seizures in pregnancy
Monotherapy with levetiracetam or lamotrigine should be used whenever possible
Use of benzodiazepines for an acute seizure outweighs any potential risk to the fetus
remarks on HIV in pregnancy
Pregnancy do not appear to alter the natural course of HIV disease, nor do uninfected babies born to HIV-positive women appear to be at increased risk for neonatal complciations.
it is important to initiate antiretroviral therapy ASAP not only for the health of themother but also because appropriate therapy can eliminate mother-to-child transmission
recommended optimal initial regimens for most patients with HIV
2 nucleoside reverse transcriptase inhibitor
plus 1 NNRTI or integrase strand transfer inhibitor
HIV meds with high risk for toxicity in pregnancy
didanosine, stavudine, and treatment-dose ritonavir
efavirenz
- nonnucleoside reverse trancriptase inhibitor
- highly recommended drug as part of the 3-drug regimen
- but is not recommended until after the first 8 weeks of prencny
- HOWEVER, if an HIV-infected woman who is already taking efavirenz becomes pregnant, the regimen may be continued because changing it risks loss of virologic control
pneumocystis jirovecii pneumonia in pregnancy
Although a small increased risk of birth defects may be associated with first-trimester exposure to trimethoprim, women in their first trimester with PCP still should be treated with trimethoprim-sulfamethoxazole because of its considerable benefit
Alternatively, aerosolized pentamidine may be used in the first trimester, as it is minimally systemically absorbed
