Exam 4 Flashcards
physiologic anemia
increase in plasma volume in contrast to the red cell mass results in decreased hemoglobin, hematocrit, and red cell counts during pregnancy.
diagnosis of anemia in pregnancy
first - less than 11
second less than 10.5
third- less than 11
causes of anemia
iron deficiency is the most common
MCV less than 80 is indicative of microcytic
MCV more than 100 is indicative of macrocytic anemia
MCH normal is 27-32
hypochromic is less than 27
serum ferritin to assess iron stores
iron supplementation
30-60mg in all pregnant women
in IDA, an extra 60-120 is recommended
iron deficiency numbers
MCV less than 80, but may be normal
MCH less than 27, but may be normal
Ferritin less than 12!!! (the only one with this)
thalassemia numbers
MCV less than 80
MCH less than 25-27
ferritin NORMAL
thallasemia major has increased production of RBCs (only one)
Hemoglobin S
sickle cell trait!!
one hemoglobin is A, one is S (AS)
maybe no symptoms.. maybe an increased risk for preclam, LBW, and PP endometritis, also more UTIs
SCD: hydrate, avoid cold, decrease stress, SCD needs 5mg folic acid
Thalassemia
differential diagnosis in people with hypochromic, microcytic anemia. MCH under 25 could be intermedia or major
5mg folic acid daily
Folate deficiency
folate deficiency associated with anemia, placental abruption, pregnancy loss, and neural tube defects.
look at vitamin B 12 too- similar symptoms
vitamin B12 deficiency
levels decrease steadily throughout pregnancy
increased risk of birth defects such as neural tube
symptoms are a change in bowel habits, diarrhea, constipation, fatigue, SOB, and loss of appetite. red tounge or bleeding gums could also happen
MACROCYTIC anemia
meds that cause thrombocytopenia
ASA, acetaminophen, indomethacin
antibiotics: ampicillin, PCN, bactrim
gestational thrombocytopenia
mid second to third trimester
CBC and smear
<100 probably ITP, less than 50, definitely
if sudden in third trimester.. think PEC stuff
risk of bleeding minimal
check weekly platelets as early as 34 weeks
pp- check platelets at 1-3 months
DVT
d dimer not helpful
calf swelling, pain
warfarin crosses placenta
PEP/PUPS
polymorphic eruption of pregnancy
pruritic urticarial papule and plaques of pregnancy
rash along the ABDOMINAL STRIAE
HALO around the umbilicus
no specific test, clinical findings
will want to rule out PG by doing immunopathologic testing
rule out intrahepatic cholestasis by doing bile acids
no RISKS
PP
eczema of pregnancy may be underlying, may be cholestasis extensor surfaces of arms, leg, abdomen. topical corticosteroid NO risk
PF
very rare rule of PG andn PEP papules, pustules around hair follicles, starts on trunks and extends to extremities if no itching, no need to treat NO risk
PG (HG)
NOT herpes
severe itching, papules in periumbilical region, extremeties
usually not on face, palms, soles, MM
have tense blisters
patho: autoimmune, IgG attacks a hemidismosome transmembrane protein
BIOPSY
pre-blistering stage do steriods
prednisone
oral contraceptives can cause flare
RISK: increased risk of SGA, some newborns may have lesions
MFM collab
ICP
intrahepatic cholestatis of pregnancy
bile acids build up in skin
risk: twin pregnancies, history of ICP
lots of itching, worse at night
higher bile acids
ursodeoxycholic acid not FDA approved, but use
complications: none with mom, premature birth, fetal discress, IUFD,
MFM collab
treatments for common derm things
acne: topical antibiotics, peroxide, laser therapy, maybe salicylic acid
fungal: topical imidazole, not oral azole meds (associated with miscarriage)
early pregnancy loss
80% in first trimester
considered less than 20 weeks or when fetus is less than 500g
Rhogam 48-72 hours after onset of bleeding whether pregnancy continues or not
less than 12 weeks, give 50. more than that give 300
late pregnancy loss
greater than 20 weeks, less than 400g
birth defects, placental problems, growth restriction, infection
misoprostol before 28 weeks, pit after
evaluation: autopsy, placental pathology, fetal karyotype, KB test on mother, coombs test,
perinatal death- early, late, or neonatal death
Recurrent pregnancy loss
greater than 3 losses before 20 weeks
hypothalmic- pituitary- thyroid network
negative feedback
hypothalamus responds to circulating levels of t3 and t4
if levels are rising, it signals to decrease TSH
if t3 and t4 are decreasing, it will make TRH, which will increase amount of TSH
TSH values
first 0.1-2.5
second 0.3-3.0
third- 0.3-3.0
hypothyroidism symptoms
weight gain cold intolerance fatigue depression constipation dry skin, thin hair \+++ when well-managed, maternal and neonatal outcomes are the same was without thyroid disease
hypothyroid labs
TSH will be elevated (between 2.5 and 10) and t4 will be decreased
antithyroid antibodies
hypothyroid surveillance
no need for antenatal surveillance when hypothyroidism is being treated and is well-controlled
TSH rechecked every 4-6 weeks during the first 20 weeks of gestation, again between 26 and 32 weeks
return to pre-pregnancy dose of levo post-partum and have level rechecked at 6 weeks
treatment
treated when between 2.5-10
levothyroxine started at 25-50
might need higher doses in pregnancy because of increased metabolic demand
subclinical hypothyroidism
elevated TSH without elevated t4… make sure it does not progres to overt, draw labs..
Screen if..
history of thyroid dysfunciton older than 30 morbidly obese miscarriage or preterm birth diabetes 1 or autoimmune disorder head or neck radiation family history infertility area without iodine
hyperthyroid in pregnancy
suppression of TSH, elevation of T4
(conception is very hard!)
higher rate of SAB, LBW, stillbirth, neonatal mortality
enlarged thyroid is almost always present
hyperthyroid labs
TSH very low (maybe undetectable), T4 is very elevated
Hyperthyroid treatment
propylthiouracil and methimazole, PTU in first trimester (bad effect on liver) and MMI in second trimester
hyperthyroid surveillance
fetus should be monitored for thyroid dysfunction by periodic US to determine if there is evidence of thyroid enlargement, growth restriction, hydrops, tachycardia, or heart failure
postpartum thyroididitis
no signs or symptoms prior to pregnancy
hyperthyroid, then hypo
anemia again..
Microcytic: Iron deficiency, thalassemias
Macrocytic: folate and B12
MCH isues: thallesemias
ferritin: only iron deficiency is an issue.. will be less than 12!!!
thalassemia major is the only one with increased production of RBCs
antibiotics not for pregnancy
no fluroquinolones no doxycycline
respiratory changes in pregnancy
increased gas exchange
respiratory rate remains the same
increase in tidal volume and resting minute ventilation
decreased functional residual capacity
progesterone stimulates respiratory drive
compensated respiratory alkalosis
meds causing asthma exacerbation
aspirin, NSAIDS, beta blockers
meds not safe in pregnancy
motrin ACE/ARB Benzos miso carbamazepine, phenytoin, dilantin, valproic acid, lithium retinoids tetracyclines (doxy) thalimdomide coumadin folic acid agonist: aminopterin/methotrexate aminogylcocides (gent) amnidarone anticonvulsants dilantin tamoxifen vit a lithium, lindane methylprednisone diazepam
big issues with early loss
thrombophilias
immune endocrine
