Maternal Disease in Pregnancy; Diseases of Pregnancy Flashcards

1
Q

4 Types of HTN in pregnancy

A
  1. chronic HTN
  2. gestational
  3. pre-eclampsia
  4. pre-eclampsia superimposed on chronic HTN
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Definition of chronic HTN in pregnancy

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Management of chronic HTN in pregnancy

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are the safe options for anti-HTN medications in pregnancy?

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Describe insulin resistance and pregnancy

A
  • 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)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Appropriate pre-conception management for a patient with DM2 includes…

A
  • HgbA1c
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Appropriate antepartum management for a pt with DM2 includes…

A
  • baseline evaluation (labs - urine protein, cre, Hgb A1c, TFTs, urinalysis, urine culture; fundoscopic eval, BP and EKG)
  • pursue goals of gluc control, Hgb A1c
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is the preferred insulin regimen in pregnancy and delivery?

A

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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Testing for gestational DM

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Antepartum and intrapartum management of Gestational DM

A

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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Neonate of the diabetic mother

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Breastfeeding in Diabetic mother

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Normal thyroid changes in pregnancy

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Thyroid disease in pregnancy

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Describe some risk factors for premature rupture of membranes (PROM).

A
** intrauterine infection **
Prior hx of PROM or preterm labor
Cervical insuff.
Polyhydramnios
Mult. gest. 
Trauma
Fetal malformations
Amniocentesis
Low soc. ec. status
Smoking
STIs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Describe some M&M of premature rupture of membranes (PROM).

A
Chorioamnionitis
Preterm L&D
Placental abruption
Umb. cord prolapse
Seq. of prematurity
Pulm. hypoplasia
Potters-like sequence
Thromboembolic dz due to bedrest (mom)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

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?

A
Nope. Don't do that. 
Take vitals, incl. temp.
Assess for fundal tenderness
Sterile speculum exam
Ultrasound
FHR and contraction monitoring
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Describe the management of PROM @ 34 wks or greater and at

A

> 34 wks: proceed w/ delivery.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Define preterm delivery (PTD).

A

Contractions that cause cervical change before 37 wks gestation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Describe the RFs for preterm delivery.

A

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…

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Describe the short and long-term neonatal consequences of PTD.

A

Short term: RDS, hypothermia, jaundice, hypoglycemia, intraventricular hemorrhage, necrotizing enterocolitis, bronchopulmonary dysplasia, sepsis, PDA.

Long term: cerebral palsy, mental retardation, retinopathy of prematurity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

How do you evaluate for preterm labor?

A
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)

23
Q

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?

A

24-34 weeks.
Remember, before 24 weeks, the fetus is nonviable regardless of intervention.
Betamethasone, dexamethasone.

24
Q

What seems to be the only thing that is remotely helpful at preventing preterm labor?

A

Progesterone analogs

25
Q

Define the BP measurements and urinary protein loss required to Dx preeclampsia.

A

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

26
Q

What is the MCC of hypertension in pregnancy?

A

Gestational hypertension

27
Q

Define gestational hypertension.

A

Hypertension of BP after 20 wks in the absence of proteinuria or systemic findings.

28
Q

What are the RFs of preeclampsia?

A

Nulliparous, multifetal gestation, obesity, chronic hypertension, SLE, thrombophilia, DM, renal disease, fam. hx of preeclampsia, molar pregnancy.

29
Q

Describe the findings in severe preeclampsia.

A

::BP of 160/110 on two occasions as described before.
::Thrombocytopenia ( 1.1mg/dL)
::Pulm. edema
::new-onset of visual or cerebral disturbances.

30
Q

At/after what gestational week do we just deliver if mom’s/fetus’s health is threatened?

A

37 weeks

31
Q

How do we tx seizures of eclampsia?

A

Mg sulfate

32
Q

What do we do if mom is having severe preeclampsia before 23 weeks?

A

Terminate the pregnancy

33
Q

What do we administer to control BP in a severely preeclamptic mom?

A

Labetolol, hydralazine

NOT ACE-Is or ARBs!

34
Q

What is HELLP syndrome?

Describe the common symptoms.

A

Hemolysis
Elevated Liver enzymes
Low Platelets

Symptoms:
RUQ/epigastric pain (90%)
n/v (50%)
Viral syndrome-like sx
Jaundice, hematuria, bleeding
35
Q

What are the two greatest risks (by probabilty) of HELLP syndrome?

A

Perinatal death

DIC in mom

36
Q

How do we manage HELLP syndrome before 24 weeks, between 24-34 weeks, after 34 wks?

A

34 wks: delivery

37
Q

How do you know you have crossed over from preeclampsia to full blown eclampsia?
What are the common symptoms?

A

Seizures or coma or both in a pt with preeclampsia.
Headache (75%)
Visual changes
RUQ/epigastric pain

38
Q

What is proven to reduce recurrence of eclampsia when started at the first trimester?

A

Daily low-dose aspirin

39
Q

Describe some complications of acute fatty liver of pregnancy (AFLP).

A
Acute renal failure**
pulmonary edema
met. acidosis
pancreatitis
sepsis
urinary tract infection
resistant DIC**
encephalopathy
death of fetus/mom
hypoglycemia in mom**
40
Q

Describe presenting symptoms of AFLP.

A
n/v
RUQ/epigastric pain
Jaundice
Diarrhea
Malaise
Low grade fever
Anorexia
Vaginal/GI bleeding
Altered mental status
41
Q

Describe evaluation of AFLP.

A
Labs: Elevated LFTs
Leukocytosis w/ left shift (bands)
Coagulopathy
Elevated uric acid
Hypoglycemia*
Increased lactate
Elevated Cr
Reduced albumin
Incr. direct bilirubin
Incr. LDH
42
Q

Describe the tx of AFLP.

A

Stabilize maternal conditions
Immediate fetal monitoring
Prompt delivery
Supportive care

43
Q

Describe the role of amniotic fluid.

A
Protects the fetus from mechanical trauma
Bacteriostatic
Development of lungs and limbs
Necessary for fetal growth/development
Sampling for karyotyping/genetic tests
44
Q

Where does amniotic fluid come from during the 1st trimester?

A

We dunno, lolz.

45
Q

Where does amniotic fluid come from in the 2nd trimester?

A

Fetal urine and lung secretions

46
Q

Describe the causes of oligohydramnios (not enough amniotic fluid).

A

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

47
Q

How does oligohydramnios present?

A

Small fetus for gestational age
Potter’s sequence
Clubbed feet, bell shaped chest, and contractures
Pulmonary hypoplasia

48
Q

How do you Dx oligohydramnios?

A

Maximum verticle pocket, (MVP) (deepest verticle fluid pocket in uterus)

49
Q

How do you tx oligohydramnios?

A

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

50
Q

Define polyhydramnios in a quantitative way.

A

Amniotic fluid >1500-2000 cm3
AFI > 25cm
MVP > 8cm

51
Q

Describe the etiologies of polyhydramnios.

A
\::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
52
Q

Describe the complications of polyhydramnios.

A
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)
53
Q

How do we tx polyhydramnios?

A

Treat underlying path (DM)
Drain amniotic fluid (amniocentesis)
Indomethacin (remember, this is a RF for oligohydr, so this makes sense)