Medical Complications in Pregnancy

Question 1

Screening for gestational diabetes is done between 24-28 weeks. How is the diagnosis reached?

Answer 1

50g 1 hr oral glucose challenge test resulting in abnormal result of >130-140 mg/dL

This would be followed by a 3 hr 100g oral glucose tolerance test (failed with 2 or more abnormal values)

Question 2

Maternal complications with gestational diabetes

Answer 2

Increased risk of gestational HTN

Increased risk of preeclampsia

Greater risk of C section delivery [fetal weight >4500g is indication for C section]

Increased risk of developing diabetes later in life

Question 3

Fetal complications of gestational diabetes

Answer 3

Macrosomia
Neonatal hypoglycemia
Hyperbilirubinemia
Operative delivery
Shoulder dystocia
Birth trauma

Question 4

Maternal complications with pregestational diabetes

Answer 4

Worsening nephropathy and retinopathy

Increased risk of preeclampsia

Greater risk of DKA

Question 5

Fetal complications with pregestational diabetes

Answer 5

Direct link between birth defects and increasing HbA1c during embryogenesis, and a six-fold increase risk of congenital anomalies

Increased risk of spontaneous abortion, anatomic birth defects (sacral agenesis and cardiac), fetal growth restriction and prematurity

Question 6

2 classes of gestational diabetes

Answer 6

Class A1 GDM = diet controlled

Class A2 GDM = insulin or oral meds controlled

Question 7

Classification of pregestational diabetes

Answer 7

Class B = onset at age 20+ with duration <10 yrs

Class C = onset at age 10-19 or duration of 10-19 yrs

Class D = onset before age 10 or duration >20yrs

Class F = diabetic nephropathy

Class R = proliferative retinopathy

Class H = ischemic heart disease

Class T = prior kidney transplant

Question 8

When a pregnant mom has preexisting diabetes, her delivery options depend on ______ and _____

Answer 8

Estimated fetal weight; glycemic control

Question 9

Postpartum management of GDM

Answer 9

Insulin requirements drop significantly after delivery of placenta

GDM typically does not require further tx, but should get 2 hour glucose tolerance test 6-12 wks postpartum to look for preexisting disease

Question 10

Fetal effects of maternal hyperthyroidism

Answer 10

Medications cross placenta and fetal hypothyroidism and fetal goiter can develop

Increased risk of prematurity, IUGR, preeclampsia, and stillbirth

Question 11

Untreated hypothyroidism in pregnancy increases risk of what complications?

Answer 11

Spontaneous abortion
Preeclampsia
Abruption
Low birth weight infants
Stillbirth
Lower intelligence levels (cretinism)

Question 12

What is neonatal thyrotoxicosis?

Answer 12

Result of transplacental transfer of thyroid stimulating antibodies

Transient condition usually lasting 2-3 months with a mortality rate of ~16%

Question 13

Effects of neonatal hypothyroidism

Answer 13

Generalized developmental retardation

May be the result of thyroid dysgenesis, inborn errors of thyroid function, or drug induced

Question 14

Most common lesion associated with rheumatic heart disease and potential complications

Answer 14

Mitral stenosis

High risk of developing heart failure, subacute bacterial endocarditis and thromboembolic disease

Question 15

What condition is a contraindication to pregnancy due to decompensation during pregnancy and a high mortality rate?

Answer 15

Primary pulmonary HTN

[if pt does become pregnant, epidural anesthesia is preferred and vaginal delivery may be an option]

Question 16

Cardiac arrhythmias associated with pregnancy

Answer 16

Supraventricular tachycardia

Afib/flutter — worrisome for underlying cardiac dz, increased risk of PE

Question 17

Postpartum cardiomyopathy typically develops within the last weeks of pregnancy or within 6 months postpartum and is not associated with underlying cardiac disease. Women with what conditions are at increased risk of postpartum cardiomyopathy?

Answer 17

Preeclampsia, HTN, poor nutrition

Question 18

Management of antepartum cardiac disease

Answer 18

All pregnant cardiac pts should be co-managed with a cardiologist

Need EKG and echo, avoid excess weight and edema, avoid strenuous activity, prevent anemia, avoid infection, anticoagulation may be necessary, fetus will also need echo at 22-26 wks

Question 19

How should cardiac pts deliver?

Answer 19

Vaginally, although pushing may need to be avoided in second-stage

Other considerations: strict fluid management, antibiotic prophylaxis for endocarditis in high risk pts, monitor for acute cardiac decompensation in CHF pts (medical emergency!)

Question 20

Condition in which immunoglobulins attach to maternal platelets

How does this condition affect the fetus?

Answer 20

Immune idiopathic thrombocytopenia

Neonatal thrombocytopenia can occur d/t placental transfer of antiplatelet antibodies

Question 21

Maternal effects of SLE during pregnancy

Answer 21

Symptoms may improve, worsen, or stay the same

Question 22

Fetal complications of SLE in pregnancy

Answer 22

Preterm delivery
Fetal growth restriction
Stillbirth
Miscarriage

10% risk for neonatal lupus-passive transfer of antibodies

Question 23

Pregnancy complications with antiphospholipid syndrome

Answer 23

Increased risk of miscarriage

Risk for developing preeclampsia

Fetal growth restriction

Question 24

Tx for renal disorders in pregnancy

Answer 24

Pre-renal: restore volume, monitor electrolytes

Renal: diuretic therapy, fluid restriction, hemodialysis

Postrenal: remove obstruction, left lateral position, urethral catheter, possible surgical intervention

Question 25

Pregnancy after a renal transplant is not recommended due to risk of losing graft function or experiencing rejection. If mom does get pregnant, what are some fetal complications?

Answer 25

Steroid induced adrenal and hepatic insufficiency

Prematurity

Intrauterine growth restriction

Question 26

Asymptomatic bacteriuria complications in pregnancy

Answer 26

More likely to lead to cystitis and pyelonephritis in pregnant women

Question 27

Pyelonephritis complications in pregnancy

Answer 27

20% will have increased uterine activity and preterm labor

Can result in adult respiratory distress syndrome

Question 28

Signs/symptoms of hyperemesis gravidarum

Answer 28

Persistent nausea and vomiting associated with >5% loss of pre-pregnancy weight, ketonuria, and dehydration

Question 29

Risk factors for hyperemesis gravidarum

Answer 29

First pregnancy, multiple pregnancies, and trophoblastic disease

Question 30

What effect does pregnancy tend to have on peptic ulcer disease?

Answer 30

Pregnancy may improve PUD

Question 31

What is Mendelson’s syndrome?

Answer 31

Acid-aspiration syndrome [pregnant women at greater risk d/t delayed gastric emptying and increased intraabdominal pressure]

Can result in adult respiratory syndrome

Question 32

How does IBD (Crohn’s and UC) change during pregnancy

Answer 32

Pts usually do well during pregnancy, although UC may be a little more active

Can increase miscarriage risk if bowel disease is active at the time of conception

Question 33

Intrahepatic cholestasis of pregnancy (ICP) is characterized by cholestasis and pruritis in the second half of pregnancy; risk factors include oral contraceptives and multiple gestations. What are maternal and fetal risks associated with ICP?

Answer 33

Benign course for maternal consequences

Increased risk of meconium stained amniotic fluid and fetal demise; fetal surveillance is important, and early term delivery may occur

Question 34

Acute fatty liver of pregnancy is characterized by diffuse fatty infiltration of the liver resulting in hepatic failure. What are some associated symptoms and lab findings?

Answer 34

Sxs: abd pain, N/V, jaundice, irritability, polydipsia/pseudodiabetes insipidus, HTN/proteinuria

Labs: increase PT and PTT, elevated bilirubin, ammonia, and uric acid, and elevation of liver transaminases

Question 35

Tx for acute fatty liver of pregnancy

Answer 35

Termination of pregnancy and supportive care with IV fluids, glucose, FFP, and cryoprecipitate

Question 36

What causes anemia in pregnancy?

Answer 36

Physiologic decrease in HgB/hematocrit during pregnancy (dilutional anemia); also iron-deficiency

Screening occurs at 26-28 weeks and iron supplementation may be initiated

Question 37

Pregnancy is a hypercoagulable state with up to 5x risk of venous thrombosis. When is the risk the highest? what conditions is mom at increased risk for?

Answer 37

First 5 weeks postpartum

Increased risk for superficial vein thrombosis, deep vein thrombosis, and PE

Question 38

Pts with a DVT or PE require a ______ workup

Answer 38

Thrombophilia (includes lupus anticoagulant, anticardiolipin Ab, factor V leiden, Protein C and S, antithrombin III, and prothrombin G20210A)

Question 39

Most common pulmonary disease in pregnancy and its maternal/fetal effects

Answer 39

Asthma

When severe, associated with miscarriage, preeclampsia, intrauterine fetal demise, intrauterine fetal growth restriction, and preterm delivery

Question 40

How does multiple sclerosis change during pregnancy

What are fetal risks?

Answer 40

Usually experience fewer and less severe episodes during pregnancy, but may exacerbate postpartum

Increased risk of lower birth weight infants

Increased risk of cesarean delivery

Question 41

T/F: typically, seizure frequency increases during pregnancy

Answer 41

False — seizure frequency does not typically change in pregnancy

Question 42

Complications of seizures during pregnancy

Answer 42

Preeclampsia
Placental abruption
Hyperemesis
Premature labor
Intrauterine fetal demise

Increased risk of congenital malformations — cleft lip, cleft palate, and cardiac anomalies

Question 43

70-80% of women experience the “baby blues” post partum, usually due to hormonal fluctuations. If this persists after ______ postpartum, then there is concern for postpartum depression

Answer 43

2 wks