EM OB 8: Comorbids in Pregnancy, part 3 (neuro, GI, torsion, HIV)

Question 1

the most common cause for spontaneous intracerebral hemorrhage in pregnancy is

Answer 1

hypertension

if there’s no history of hypertension, then consider other causes
- neoplasm
- hemorrhagic disorder
- vascular malformation

Question 2

3rd most common cause of nonobstetric maternal death

Answer 2

Subarachnoid hemorrhage
and more than half of cases occur postpartum

Question 3

majority of strokes occur when

Answer 3

third trimester or pueperium (6 weeks after delivery)

Question 4

most common cause of pregnancy-related stroke

Answer 4

arterial occlusion

Question 5

remarks on thrombolysis in stroke in pregnancy

Answer 5

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

Question 6

remarks on central venous thrombosis

Answer 6

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)

Question 7

treatment of central venous thrombosis

Answer 7

mainstain of treatment is anticoagulation (LMWH) for the duration of the pregnancy

Question 8

remarks on migraine in pregnancy

Answer 8

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

Question 9

lifestyle modifications in GERD

Answer 9

elevating head of bed
not eating 3 hours before bed
eating small meals
eliminating trigger foods

Question 10

remarks on cholecystitis in pregnancy

Answer 10

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

Question 11

most common extrauterine condition requiring abdominal operation in pregnancy

Answer 11

appendicitis

Question 12

imaging in appendicitis in pregnancy

Answer 12

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

Question 13

CT in pregnancy

Answer 13

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

Question 14

remarks on ovarian torsion

Answer 14

ovarian torsion is a true gynecologic emergency.
can occur in any trimester, although it is most common in the first trimester

Question 15

risk factors for ovarian torsion

Answer 15

infertility treatment
corpus luteal cyst and enlarged ovaries stemming from the pregnancy hormones are thought to increase the risk

Question 16

diagnosis of ovarian torsion

Answer 16

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

Question 17

seizure frequency can increase in pregnancy because of:

Answer 17

increased volume of distribution
increased plasma clearance of antiepileptic drugs
poor medication compliance

Question 18

treatment of seizures in pregnancy

Answer 18

Monotherapy with levetiracetam or lamotrigine should be used whenever possible

Use of benzodiazepines for an acute seizure outweighs any potential risk to the fetus

Question 19

remarks on HIV in pregnancy

Answer 19

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

Question 20

recommended optimal initial regimens for most patients with HIV

Answer 20

2 nucleoside reverse transcriptase inhibitor
plus 1 NNRTI or integrase strand transfer inhibitor

Question 21

HIV meds with high risk for toxicity in pregnancy

Answer 21

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

Question 22

pneumocystis jirovecii pneumonia in pregnancy

Answer 22

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