Maternal Disease in Pregnancy; Diseases of Pregnancy Flashcards
4 Types of HTN in pregnancy
- chronic HTN
- gestational
- pre-eclampsia
- pre-eclampsia superimposed on chronic HTN
Definition of chronic HTN in pregnancy
- defined as sustained BP >140/90 on 2 occasions btw 6hr and 7d apart
- defined as diagnosis of chronic HTN prior to pregnancy, prior to week 20 of gestation, or persisting beyond day 42 post-partum
Management of chronic HTN in pregnancy
- DO: establish pre-preg baseline data, monitor kidney function and labs (proteinuria, Cre, LFTs, LDH, uric acid), get EKG/Echo, and ophthalmic exam if long-standing HTN; start meds if SBP>150/160 or DBP>100-110; dietary change and quit smoking; serial growth US starting at 32wks, deliver by 39wk if no other complications (otherwise deliver earlier)
- management DON’Ts: don’t give ACEIs or ARBs, best not to give diuretics, don’t encourage weight loss
- *Consider hyperaldosteronism and molar pregnancy if severe range BPs prior to 20wk; work up for SLE/RD if proteinuria is disproportionate to HTN
What are the safe options for anti-HTN medications in pregnancy?
- Methyldopa (central alpha agonist, AEs: hepatitis, hemolytic anemia)
- Labetalol (beta blocker with some anti-alpha activity, AEs: flushing, HA, tremulousness)
- Nifedipine (Ca channel blocker, AEs: HA, tachycardia, ortho-hypo)
- Thiazide diuretics
- Hydralazine
Describe insulin resistance and pregnancy
- pregnancy hormones contribute to insulin resistance
- insulin resistance is highest in the 3rd trimester
- can lead to gestational DM2, which involves significant M&M (SAB, malformations, hyperglycemia, macrosomia, shoulder dystocia, death, neonatal complications, retinopathy, nephropathy, DKA, exacerbation of gastroparesis)
Appropriate pre-conception management for a patient with DM2 includes…
- HgbA1c
Appropriate antepartum management for a pt with DM2 includes…
- baseline evaluation (labs - urine protein, cre, Hgb A1c, TFTs, urinalysis, urine culture; fundoscopic eval, BP and EKG)
- pursue goals of gluc control, Hgb A1c
What is the preferred insulin regimen in pregnancy and delivery?
Antepartum:
- best regimen includes bid injections of NPH and Novolog
- dosing = 2:1 ratio in AM; 1:1 ratio in PM
- will need to increase insulin each trimester
Intrapartum:
- int. acting insulin at bedtime; hold morning dose
- latent labor: give IV saline; monitor BG q2-4hr
- active labor: give 5% dextrose; check BG q1hr and maintain at 100, if above 110 give short acting insulin
Testing for gestational DM
- low-risk: 1hr 50gm GCT btw 24-28wks
- high-risk: 3hr 100gm OGTT at start of prenatal care
- high-risk = women with hx of GDM, macrosomia, stillbirth or congenital anomaly, PCOS, 1˚ relative with DM2, or pre-diabetes
- can avoid screening in women
Antepartum and intrapartum management of Gestational DM
Same as with DM2:
- insulin preferred, Glyburide/Metformin also options; monitor baby more closely as it gets closer to term
- latent and active labor are same recs too
- post-partum: 15-50% will develop DM2 later, up to 1/3 will still have impaired glu metabolism at post-partum screening
Neonate of the diabetic mother
- may have hypoglycemia, correlated with degree of maternal gluc control 6wk prior to delivery
- elevated insulin + chronic pancreatic hypertrophy –> umbilical nutrient disruption –> sig hypoglycemia in the baby
- uncorrected neonatal hypoglycemia can lead to seizures, brain damage, death
- manage with BG checks, early oral feedings, IV gluc if feeding is insufficient
Breastfeeding in Diabetic mother
- concern is that it will make her hypoglycemic, but a small snack just before will reduce that
- will reduce/delay the risk of subsequent DM in the kid
Normal thyroid changes in pregnancy
- normally thyroid gets a little bigger in pregnancy and the mother has inc. TBG, inc. renal excretion of iodide
- 1st trimester: estrogen inc. TBG production and extends half-life, get 2.5-fold inc. in TBG; hCG structural similar to TSH so binds TSHR, stimulates thyroid; net effect is increased pool of TH, unchanged free TH, suppressed TSH
- 2nd trimester: dec. hCG, TSH normalized
- placenta allows pretty much all TH stuff through but not TSH
Thyroid disease in pregnancy
- hyperthyroidism (0.2%) - 95% of cases are Graves; tx with PTU in 1st trim, Methimazole in 2nd/3rd trim, +/- beta-blockers; if untx’d may get IUGR, pre-term birth, preeclampsia
- hypothyroidism (2.5%) - 95% of cases are Hashimoto’s; tx with Levothyroxine, inc. q4wk, mean inc. ~45%; if intx’d may get preeclampsia, anemia, low birth wt (2/2 preterm delivery 2/2 PIH), abruption, fetal death, under-neuro-developed
- screen for thyroid dysfunction if there’s hx of thyroid dz, AI dz, DM1, fam hx, symptomatic, or goiter
- best way to screen is check TSH - if normal, no further work-up; low indicates hyperthyroid, high indicates hypothyroid; routine screening not recommended
Describe some risk factors for premature rupture of membranes (PROM).
** intrauterine infection ** Prior hx of PROM or preterm labor Cervical insuff. Polyhydramnios Mult. gest. Trauma Fetal malformations Amniocentesis Low soc. ec. status Smoking STIs
Describe some M&M of premature rupture of membranes (PROM).
Chorioamnionitis Preterm L&D Placental abruption Umb. cord prolapse Seq. of prematurity Pulm. hypoplasia Potters-like sequence Thromboembolic dz due to bedrest (mom)
Do you stick your fingers in a woman that has a suspected mass of fluid waiting to blow out of her cervix if angered?
What else can you do to examine a pt suspected of having preterm membrane rupture?
Nope. Don't do that. Take vitals, incl. temp. Assess for fundal tenderness Sterile speculum exam Ultrasound FHR and contraction monitoring
Describe the management of PROM @ 34 wks or greater and at
> 34 wks: proceed w/ delivery.
Define preterm delivery (PTD).
Contractions that cause cervical change before 37 wks gestation.
Describe the RFs for preterm delivery.
Prior hx of PTD.
Ifxn
Uterine malformations
Uterine distension
Vag. bleeding (2ndary to placenta previa/abruption)
Cervical insuff.
Smoking, cocaine, non-white race, low sec. econ. status…
Describe the short and long-term neonatal consequences of PTD.
Short term: RDS, hypothermia, jaundice, hypoglycemia, intraventricular hemorrhage, necrotizing enterocolitis, bronchopulmonary dysplasia, sepsis, PDA.
Long term: cerebral palsy, mental retardation, retinopathy of prematurity
How do you evaluate for preterm labor?
Thorough hx Examine the pt, inside and out. Fetal fibronectin test* Ultrasound Pertinent labs
*Fetal fibronectin “leaks” into the vagina if a preterm delivery is likely to occur and can be measured in a screening test. When the fFN test is positive, it is an inconclusive result. A positive result can indicate that a woman will go into preterm labor soon, but she may not go into labor for weeks. (wiki)
What is the window (in wks of gestations) for administration of corticosteroids to protect the fetal lungs, GI tract, and CNS?
What GCs do we administer?
24-34 weeks.
Remember, before 24 weeks, the fetus is nonviable regardless of intervention.
Betamethasone, dexamethasone.
What seems to be the only thing that is remotely helpful at preventing preterm labor?
Progesterone analogs
Define the BP measurements and urinary protein loss required to Dx preeclampsia.
1) At least 140/90 on two occasions >6hrs apart but not > 1 wk apart.
2) 300mg proteinuria over 24 hrs and protein:creatinine of at least 0.3
What is the MCC of hypertension in pregnancy?
Gestational hypertension
Define gestational hypertension.
Hypertension of BP after 20 wks in the absence of proteinuria or systemic findings.
What are the RFs of preeclampsia?
Nulliparous, multifetal gestation, obesity, chronic hypertension, SLE, thrombophilia, DM, renal disease, fam. hx of preeclampsia, molar pregnancy.
Describe the findings in severe preeclampsia.
::BP of 160/110 on two occasions as described before.
::Thrombocytopenia ( 1.1mg/dL)
::Pulm. edema
::new-onset of visual or cerebral disturbances.
At/after what gestational week do we just deliver if mom’s/fetus’s health is threatened?
37 weeks
How do we tx seizures of eclampsia?
Mg sulfate
What do we do if mom is having severe preeclampsia before 23 weeks?
Terminate the pregnancy
What do we administer to control BP in a severely preeclamptic mom?
Labetolol, hydralazine
NOT ACE-Is or ARBs!
What is HELLP syndrome?
Describe the common symptoms.
Hemolysis
Elevated Liver enzymes
Low Platelets
Symptoms: RUQ/epigastric pain (90%) n/v (50%) Viral syndrome-like sx Jaundice, hematuria, bleeding
What are the two greatest risks (by probabilty) of HELLP syndrome?
Perinatal death
DIC in mom
How do we manage HELLP syndrome before 24 weeks, between 24-34 weeks, after 34 wks?
34 wks: delivery
How do you know you have crossed over from preeclampsia to full blown eclampsia?
What are the common symptoms?
Seizures or coma or both in a pt with preeclampsia.
Headache (75%)
Visual changes
RUQ/epigastric pain
What is proven to reduce recurrence of eclampsia when started at the first trimester?
Daily low-dose aspirin
Describe some complications of acute fatty liver of pregnancy (AFLP).
Acute renal failure** pulmonary edema met. acidosis pancreatitis sepsis urinary tract infection resistant DIC** encephalopathy death of fetus/mom hypoglycemia in mom**
Describe presenting symptoms of AFLP.
n/v RUQ/epigastric pain Jaundice Diarrhea Malaise Low grade fever Anorexia Vaginal/GI bleeding Altered mental status
Describe evaluation of AFLP.
Labs: Elevated LFTs Leukocytosis w/ left shift (bands) Coagulopathy Elevated uric acid Hypoglycemia* Increased lactate Elevated Cr Reduced albumin Incr. direct bilirubin Incr. LDH
Describe the tx of AFLP.
Stabilize maternal conditions
Immediate fetal monitoring
Prompt delivery
Supportive care
Describe the role of amniotic fluid.
Protects the fetus from mechanical trauma Bacteriostatic Development of lungs and limbs Necessary for fetal growth/development Sampling for karyotyping/genetic tests
Where does amniotic fluid come from during the 1st trimester?
We dunno, lolz.
Where does amniotic fluid come from in the 2nd trimester?
Fetal urine and lung secretions
Describe the causes of oligohydramnios (not enough amniotic fluid).
Fetal causes: account for 20% of cases
GU tract nomalies
Fetal chest anomalies
Aneuploidy (trisomy 18, 13, triploidy)
Intrauterine growth restriction 30-40% of cases
- est. fetal weight is
How does oligohydramnios present?
Small fetus for gestational age
Potter’s sequence
Clubbed feet, bell shaped chest, and contractures
Pulmonary hypoplasia
How do you Dx oligohydramnios?
Maximum verticle pocket, (MVP) (deepest verticle fluid pocket in uterus)
How do you tx oligohydramnios?
Bladder-amnion shunt placement to allow for urine flow from fetus.
Consider early delivery for IUGR
Induce labor if post-term
Amnioinfusion during active labor to reduce risk of cord compression
Define polyhydramnios in a quantitative way.
Amniotic fluid >1500-2000 cm3
AFI > 25cm
MVP > 8cm
Describe the etiologies of polyhydramnios.
\::Idiopathic 50-60% \::DM 30%** \::Fetal anomalies -GI (won't swallow amnion) -CNS (won't swallow) -Hydrops -Musculoskeletal anomaly \::IUGR- trisomy 18 MCC \::Twin-twin transfusion
Describe the complications of polyhydramnios.
Idiopathic has an excellent prognosis Preterm L&D Malpresentation x4 CSection rate x6 postpartum hemorrhage rate Placental abruption (rapid uterine decompression) ^ risk of cord prolapse Amniotic fluid embolism (RARE)
How do we tx polyhydramnios?
Treat underlying path (DM)
Drain amniotic fluid (amniocentesis)
Indomethacin (remember, this is a RF for oligohydr, so this makes sense)
