Medical and Surgical Complications of Pregnancy III -Castro

Question 1

What is hyperemesis gravidarum? What increases the incidence of this?

Answer 1

• Severe nausea and vomiting that persists into the third trimester or causes dehydration, ketosis and electrolyte imbalance
• increased incidence if multiple gestation, molar pregnancy, past history of hyperemesis or eating disorder

Question 2

How should hyperemesis gravidarum be managed?

Answer 2

• assess level of dehydration/electrolyte imbalance
• IV hydration
• anti-emetics (consider B-6)
• small frequent meals
• may need parenteral nutrition or the feeding
• normally good pregnancy outcome

Question 3

Why do we screen for bacteriuria in the first pregnancy check up?

Answer 3

4-8% pregnant women have asymptomatic bacteriuria: may lead to cystitis, pyelonephritis and preterm labor/delivery

–> treat with antibiotic for 3-7 days (nitrofurantoin or cephalexin)

Question 4

What are the signs and symptoms of pyelonephritis? What are these pregnant women at risk for? How should this be treated?

Answer 4

• fever, chills, flank pain, CVA tenderness
• At risk for bacteremia, septic shock, pulmonary edema, ARDS, preterm labor (serious)
• Tx: hospitalization IV antibiotics, hydration

Question 5

What can hydronephrosis in a pregnant woman indicate?

Answer 5

mild-moderate (and greater on right) can be a NORMAL finding due to the effect of progesterone

Question 6

Are murmurs a normal finding in pregnancy?

Answer 6

Systolic murmurs are normal

Diastolic murmurs=ABNORMAL

Question 7

How can cardiac disease be affected by pregnancy?

Answer 7

-CO and intravascular volume increase by 50% in pregnancy (peak in 3rd tri)
-inc more in labor
-inc more with delivery of the placenta (“auto transfusion” and no more vena cava compression –> inc BP)
-

Question 8

What classifications of heart disease are at a higher risk for morbidity and mortality in pregnancy?

Answer 8

class III (no symptoms at rest but major limitations in activity)

class IV (symptoms at rest)

Question 9

What is the highest cardiac mortality risk in pregnancy?

Answer 9

Eisenmengers syndrome (50% mortality risk)

Question 10

If a pregnant woman undergoes sudden heart failure at the end of delivery or early post partum, what should be considered?

Answer 10

cardiomyopathy of pregnancy (heart chambers dilate and left ventricle is hypo kinetic)

diagnosis of exclusion

Question 11

How are thyroid hormone levels affected by pregnancy?

Answer 11

• Increase total T3 and T4 (because of increase in TBG)

- Free T3 and T4 remain unchanged

Question 12

What are some signs and symptoms of hyperthyroidism in pregnancy? What can this lead to?

Answer 12

• Graves disease is the most common
• Signs and Symptoms: weight loss, tachycardia, increased pulse pressure with systolic hypertension, proptosis, heat intolerance, tremor (high output state)
• Can lead to preterm delivery, preeclampsia, intrauterine growth restriction (IUGR) and IUFD
• thyroid storm can be triggered by delivery, c-section or infection and can lead to severe maternal morbidity and death when undiagnosed (tachy and super elevated BP)

Question 13

What is the first line treatment for hyperthyroidism? How should this be monitored?

Answer 13

Medical therapy (Propylthiouracil, PTU or methimazole)

Surgery only if medication fails

monitor with serial free T4 –> stop medication therapy once goal free T4 (upper limit of normal) is reached

Question 14

What treatment should NEVER be considered for hyperthyroidism in pregnancy?

Answer 14

Radioactive iodine therapy –> can destroy the fetal thyroid

Question 15

What is the most common cause of hypothyroidism in pregnancy? What is this associated with? What should be used to monitor it?

Answer 15

• Hashimoto’s thyroiditis
• Common-associated with miscarriage, preeclampsia, IUFD and lower IQ in offspring
• monitor with free T4 and TSH levels

Question 16

What are anti-SSA and anti-SSB associated with? What can cause this?

Answer 16

congenital fetal/neonatal heart block

Mom had SLE

Question 17

What are women with SLE at risk for in pregnancy? What increases the chance of a poor pregnancy outcome?

Answer 17

• fetal loss (miscarriage or IUFD), IUGR, preterm birth
• severe preeclampsia
• lupus flare leading to acute organ system dysfunction

-anti-phospholipid syndrome increases chance of poor pregnancy outcome

Question 18

What is the diagnostic criteria for Antiphospholipid Syndrome? What is the treatment?

Answer 18

-Presence of antiphospholipid antibodies (anti- cardiolipin and/or lupus anticoagulant)
AND
-Clinical event such as thrombosis, or pregnancy complication (IUFD, multiple SAB’s or severe preterm preeclampsia)

Tx:

• heparin or lovenox and low dose aspirin
• frequent fetal assessment –> high risk of fetal loss

Question 19

What test should be ordered to confirm a suspected DVT in a preggo? What is the treatment? What treatment should be avoided?

Answer 19

• lower extremity US with doppler flow studies
• tx: anti coagulate with regular heparin or low molecular weight heparin for 3-6 months, until 6 weeks postpartum
• avoid warfarin–> teratogenic*

Question 20

If a woman has a history of PE or DVT in a previous pregnancy, what should be given?

Answer 20

prophylactic heparin

Question 21

What are the signs and symptoms of a PE in a pregnant woman? What is the treatment?

Answer 21

Signs and symptoms may be subtle OR Chest pain, SOB, cough, hemoptysis

anti coagulate with heparin or LMW Heparin x 6 months

if untreated–> 80% mortality*

Question 22

*What are the symptoms of Intrahepatic Cholestasis of Pregnancy? What lab will be elevated? What should be used to treat it?

Answer 22

• diffuse itching +/- jaundice. No rash, no pain or tenderness. May see scratch marks.
• elevated Bile acids
• Tx: ursodeoxycholic acid (ursodiol), Antihistamines, soothing lotions, Antepartum fetal testing, Delivery at 37 weeks gestation (NOT benign for the fetus)

Question 23

How is Acute Fatty Liver of Pregnancy diagnosed? What are the signs?

Answer 23

• dx of exclusion:r/o other causes of hepatitis/liver failure (especially preeclampsia
• Jaundice, nausea, vomiting, abdominal pain, loss of appetite, hypotension
• Abnormal liver function, hypoglycemia, coaguloathy, proteinuria

HIGH mortality if develop hepatic coma and renal failure

Question 24

How can aspiration pneumonia be prevented?

Answer 24

do not ear 8-12 hours before surgery

use antacids before surgery

Question 25

If a pregnant woman needs surgery, when is the best time to operate?

Answer 25

2nd trimester is the safest time to operate but if there is an emergent surgical condition, do NOT wait!

Question 26

Why is acute appendicitis hard to diagnose in pregnancy?

Answer 26

• symptoms may seem milder

- appendix is displaced upward and laterally so exam can be confusing

Question 27

What thyroid hormones can cross the placenta? What problems can these lead to in the fetus?

Answer 27

Thyroid stimulating immunoglobins can cross the placenta and stimulate fetal thyroid ==> neonatal thyrotoxicosis

Anti-thyroid medication can cross the placenta too and depress the fetal thyroid–> cause goiter

Placenta secretes thyrotropin like hormone (TRH) that can cross the placenta

Iodine freely crosses