Medical Complications of Pregnancy Flashcards
Two most common causes of microcytic anemia in pregnancy?
Two most common causes of macrocytic (megaloblastic) anemia?
Microcytic Anemia
- -iron deficiency; thalassemia
- -1st investigation is therapeutic Fe trial
Macrocytic Anemia
–folate deficiency, B12 deficiency
Thalassemia
- -microcytic anemia
- -Hb electrophoresis helps differentiate
Elevated A2 Hb level?
Elevated HbF level?
Thalassemia
- -microcytic anemia
- -Hb electrophoresis helps differentiate
Beta thalassemia
–Elevated A2 Hb level
Alpha thalassemia
–Elevated HbF level
- -dark colored urine after taking antibiotic for infxn
- -anemia (low Hb)
- -jaundice, fatigue
- -African-American woman
Dx?
G6PD Deficiency
Other hemolytic processes include HELLP Syndrome, malaria, autoimmune hemolytic anemia, sickle cell
Dx?
Maternal fever + 1 of
- -elevated maternal WBC count
- -uterine tenderness
- -maternal/fetal tachycardia
- -purulent/malodorous vaginal discharge
Associated with preterm and prolonged ROM
Tx: 2nd or 3rd generation cephalosporin, or ampicillin + gentamicin + Delivery!
Chorioamnionitis
Maternal fever + 1 of
- -elevated maternal WBC count
- -uterine tenderness
- -maternal/fetal tachycardia
Associated with preterm and prolonged ROM
Tx: 2nd or 3rd generation cephalosporin, or ampicillin + gentamicin + Delivery!
Management of Preterm Labor at less than 34 weeks:
1) Tocolytics to halt contractions
- -name 3 types
2) What drugs to accelerate fetal lung maturity?
3) What drug for neuroprotection?
Management of Preterm Labor at less than 34 weeks:
1) Tocolytics to halt contractions
- -Beta adrenergic agonists; Ca chnl blocker; NSAID
2) Corticosteroids to accelerate fetal lung maturity
- -eg, Betamethasone
3) MgSO4 for neuroprotection
Management of (Pre)eclampsia
- Rx for seizure tx/prophylaxis?
- Rx for HTN? (2)
- Rx for fetal lung maturity if EGA 24-32 weeks
- Vaginal delivery or C-section?
Management of (Pre)eclampsia
- Mg sulfate
- -seizure tx and prophylaxis - Hydralazine or Labetalol
- -blood pressure control
- -only administer if SBP > 160 or DBP > 110 - Betamethasone
- -fetal lung maturity - Vaginal delivery with induction of labor
* except if obstetric indication for C-sec
* except for maternal/fetal instability
**The ultimate tx is DELIVERY!
maternal-fetal transmission of this virus can lead to deafness, cardiac abnormalities (eg, PDA), cataracts, and MR
Rubella (congenital rubella syndrome)
*MMR vaccine is a live virus vaccine. Thus, women should avoid becoming pregnant for one month after receiving MMR vaccine.
- full expulsion of all POC before 20 wks
- partial expulsion of POC before 20 wks
- no expulsion of products; vaginal bleeding, loss of fluid, and cervical dilation
- vaginal bleeding before 20 wks, closed cervix, no expulsion of POC; presence of fetal cardiac activity
- no vaginal bleeding; no fetal cardiac activity; retention of all POC; closed cervix
- complete abortion
- incomplete abortion
- inevitable abortion
- threatened abortion
- missed abortion
Hyperandrogenism in Pregnancy
- ovarian tumor-like solid mass; may be bilateral; may produce androgens resulting in maternal and fetal hirsutism and viralization
- cystic tumors; associated with high FSH and beta-hCG; associated with twins and molar pregnancies
- solid ovarian mass; may be bilateral; mets from GI cancer with associated s/s
Hyperandrogenism in Pregnancy
- Luteoma of Pregnancy
- -ovarian tumor-like mass; may produce androgens resulting in maternal and fetal hirsutism and viralization - Theca Lutein Cyst
- -cystic tumors; associated with high FSH and beta-hCG; associated with twins and molar pregnancies - Krukenburg Tumor
- -solid ovarian mass; may be bilateral; mets from GI cancer; thus display s/s of GI cancer
Acid-base status during pregnancy?
–re PaO2, PaCO2, HCO3
Acid-base status in hyperemesis gravidarum?
Acid-base status in diarrhea?
Pregnancy Acid Base
- -respiratory alkalosis with compensation
- -increased PaO2, decreased PaCO2 and HCO3
Hyperemesis Gravidarum
–hypochloremic metabolic alkalosis
(*loss of gastric acid –> alkalosis)
Diarrhea
–metabolic acidosis
(*loss of HCO3, anions)
Post-partum woman with hx of vaginal bleeding during delivery that required blood transfusion. S/s of
1) hypopituitarism: eg, lactation failure
2) hypogonadism: eg, decreased pubic hair
3) hypothyroidism: eg, lethargy, weight gain, fatigue, dry skin, hyporeflexia
Dx?
Mechanism?
Sheehan’s Syndrome
–ischemic necrosis of anterior pituitary secondary to maternal hemorrhage during delivery
Features:
hypopituitarism: eg, lactation failure
hypogonadism: eg, decreased pubic hair
hypothyroidism: eg, lethargy, fatigue, dry skin, hyporeflexia
Pathogenesis of Rh Alloimmunization:
Rh(-) mother is immunized by Rh(+) fetal RBCs in first pregnancy. Mother develops anti-Rh(D) ABs (IgG). These ABs cross placenta to damage Rh(+) fetus in subsequent pregnancies.
To prevent maternal alloimmunization, administer RhoGAM at how many weeks gestation, and when post-partum?
Test for presence of maternal anti-D ABs in subsequent pregnancies.
Name of disease that results in the fetus?
To prevent alloimmunization:
–RhoGAM at 28 weeks gestation, and within 72 hours post-partum
(*RhoGAM is anti-D immune globulin; prevents development for anti-D ABs)
Erythroblastosis Fetalis
- -hydrops fetalis: severe edema due to CHF caused by hemolytic anemia
- -hepatosplenomegaly
- -extramedullary hematopoiesis in liver, spleen, LN
- -kernicterus (bilirubin encephalopathy)
Hyperemesis Gravidarum
(+) pregnancy; severe, persistent n/v; often dehydration and electrolyte abnormalities
Often associated with increased placental mass
–Name 2 conditions.
Tx:
- -rehydration
- -antiemetics: Compazine, Phenergan, Tigan, Reglan
- -other: ginger; B12
Hyperemesis Gravidarum
(+) pregnancy; severe, persistent n/v; often dehydration and electrolyte abnormalities
Often associated with increased placental mass
–multifetal gestation, molar pregnancy
Tx:
- -rehydration
- -antiemetics: Compazine, Phenergan, Tigan, Reglan
- -other: ginger, B12
Complete Molar Pregnancy
- -s/s include vaginal bleeding in early pregnancy, passage of molar vesicles, hyperthyroidism, hyperemesis gravidarum, preeclampsia
- -trophoblastic proliferation with diffuse swelling of chorionic villi
- -Labs: extremely high B-hCG ( > 100,000)
- -Imaging: “snowstorm pattern” on pelvic ultrasound; bilateral multilocular ovarian cysts (theca lutein); absent fetus
Pathogenesis? re: fertilization
Uterine size compared to EGA?
Weeks to normalization of B-hCG?
Complete Molar Pregnancy
- -fertilization of empty ovum by 1 sperm, which replicates itself (all chromosomes are paternal)
- -uterine size greater than EGA
- -avg time to normalization: 16 weeks
Partial Molar Pregnancy
- -s/s include vaginal bleeding from miscarriage or incomplete abortion
- -Labs: normal or slightly elevated B-hCG
- -Imaging: fetal tissue present; fetal anomalies; IUGR; “swiss-cheese” appearance of anechoic spaces against chorionic villi
Pathogenesis? re: fertilization
Weeks to normalization of B-hCG?
Partial Molar Pregnancy
- -normal ovum fertilizaed by 2 sperm; triploid
- -avg time to normalization: 8 weeks
Two signs of magnesium toxicity?
Tx?
Magnesium Toxicity
- loss of DTRs
- respiratory depression
Tx: calcium gluconate (and stop Mg)
Sheehan’s Syndrome
–ischemic necrosis of anterior pituitary secondary to maternal hemorrhage during delivery
S/S include lactation failure, sexual hair loss, hypotension, anorexia, amenorrhea, hyponatremia
Name 6 hormones produced by the AP.
Sheehan’s Syndrome
–ischemic necrosis of anterior pituitary secondary to maternal hemorrhage during delivery
–S/S include lactation failure, sexual hair loss, hypotension, anorexia, amenorrhea, hyponatremia
Hormones produced by AP: Prolactin FSH, LH TSH Growth Hormone ACTH
Preeclampsia
- BP cutoffs?
- -SBP, DBP, at what EGA? - urine protein/creatinine ratio?
Tx?
- -seizure prophylaxis?
- -anti-HTN? (IV-2; oral-1)
Preeclamspia
- SBP > 140 or DBP > 90 at EGA > 20wks
- protein/creatinine ratio > 0.3
Tx:
- -seizure prophylaxis: MgSO4
- -antiHTN: labetolol, hydralazine (IV); nifedipine (oral)
Preeclampsia with severe features
- BP cutoffs?
- serum creatinine?
- thrombocytopenia?
- elevated transaminases
- pulmonary edema
- new onset visual or cerebral symptoms
Preeclampsia with severe features
- SBP > 160 or DBP > 110 at EGA > 20wks
- serum creatinine > 1.1
- thombocytopenia
- elevated transaminases
- pulmonary edema
- new onset visual or cerebral symptoms
Distinguishing Lupus vs Preeclampsia
Common Features: HTN, proteinuria, edema
Lupus
- -ANA ab’s; low C3 and C4
- -urine RBC casts
- -malar rash
Tx for lupus in pregnancy?
Lupus carries higher risk of pregnancy loss. What is the pathogenesis? Tx?
Lupus in Pregnancy
- -tx: high dose corticosteroids
- -pathogenesis of pregnancy loss: placental thrombosis
- -prophylax with subQ heparin, low dose aspirin
Abx in Pregnancy
Recommended abx (3)
- Penicillin?
- Cephalosporin?
- Other?
Contraindicated:
- class associated with bone deformities, arthropathies
- interfere with bone and tooth development; causes grey tooth discoloration
- interferes with folic acid metabolism (1st trimester); increase risk of kernicterus (3rd trimester)
Abx in Pregnancy
Recommended:
- Amoxicillin
- Cephalexin
- Nitrofurantoin
Contraindicated:
- fluoroquinolones
- -bone deformities, arthropathies - tetracyclines
- -bone and tooth development; grey teeth discoloration - trimethoprim-sulfamethoxazole
- -interfere with folic acid metabolism (1st trimester)
- -may increase risk of kernicterus (3rd trimester)
How often does b-hCG double in normal pregnancy?
At what b-hCG levels can transvaginal US detect viable intrauterine pregnancy?
Normal pregnancy: b-hCG doubles every 48 hrs
1500-2000
Amniotic Fluid Index
- Oligohydramnios?
- Polyhydramnios?
AFI
Oligohydramnios
- -AFI less than 5
- -associated with congenital anomalies (especially genitourinary) and growth restriction
Polyhydramnios
- -AFI greater than 20 or 25
- -associated with diabetes, hydrops, multiple gestation, GI tract obstruction
HEELP Syndrome
Acute Fatty Liver of Pregnancy
- two unique lab values in AFLP?
- AFLP is caused by disordered metabolism of fatty acids by fetal mitochondria due to deficiency of what enzyme?
- Management of both conditions?
- AFLP
- -hypoglycemia
- -increased serum ammonia - AFLP
- -deficiency in LCHAD enzyme - HEELP / AFLP
- -prompt delivery is indicated
Explain how fetal hyperinsulinemia can result in polycythemia in a neonate born to a mother with GDM?
fetal hyperinsulinemia –> increased metabolic demand –> fetal hypoxia –> fetal erythropoiesis –> polycythemia
- HSV
- -What type of delivery if lesions are present?
- -Which is more dangerous during pregnancy - primary infection or recurrent infection? - What virus attacks fetal RBCs, leading to hemolytic anemia, hydrops, and death?
- What viral infection is usually asymptomatic in the mother, and in the fetus is manifested by hepatosplenomegaly, thrombocytopenia, jaundice, cerebral calcifications, chorioretinitis, and interstitial pneumonitis?
- HSV
- -if lesions present –> C-section
- -primary infection has higher risk of fetal transmission
* recurrent infxn displays IgG - Parvovirus B19
- -fetal anemia
- -midtrimester and later infections associated with hydrops - Cytomegalovirus
- -asymptomatic in mother
- -hepatosplenomegaly, thrombocytopenia, jaundice, cerebral calcifications, chorioretinitis, interstitial pneumonitis
- -late complications include MR, sensorineural hearing loss, neuromuscular disorders
- viral infection in fetus; in infant, syndrome includes deafness, cardiac abnormalities, cataracts, MR
- Neonatal infection with chlamydia; s/s include conjunctivitis and chlamydial pneumonia
- -Tx of chlamydia during pregnancy? (3 options) - Toxoplasma tx
- -in mother?
- -in fetus? (2)
- Rubella
- -Congential Rubella Syndrome: deafness, cardiac abnormalities (eg, PDA), cataracts, MR - Chlamydia
- -pregnancy tx: amoxicillin, azithromycin, erythromycin - Toxoplasma tx
- -mother: spiramycin
- -fetus: pyrimethamine, sulfadiazine
* administer with folic acid due to bone marrow suppression
HTN in Pregnancy
- BP greater than 140/90 prior to conception or EGA 20 wks; no end organ damage or proteinuria
- BP greater than 140/90 after EGA 20 wks; no end organ damage or proteinuria
- BP greater than 140/90 after EGA 20 wks; (+) end organ damage or proteinuria
- BP greater than 140/90 after EGA 20 wks; (+) end organ damage or proteinuria; seizures
- BP greater than 140/90 prior to conception or EGA 20 wks; (+) end organ damage or proteinuria
HTN in Pregnancy
- Chronic hypertension
- Gestational HTN
- Preeclampsia
- Eclampsia
- Chronic HTN with superimposed preeclampsia
Gestational Diabetes
Pathophysiology is related to metabolism of large carbohydrate boluses; not baseline carbohydrate intolerance
Which hormone is responsible for insulin resistance?
Fasting levels should always be less than?
Screening test: 50g glucose load
–1h: 140 or less
Confirmatory test: 100g, 3hr GTT
- -fasting: 95 or less
- -1h: 180 or less
- -2h: 155 or less
- -3h: 140 or less
Gestational Diabetes
- -hPL –> insulin resistance
- -manifests in 2nd/3rd trimesters
RFs: increased maternal age, obesity, diabetes family hx, previous infant weighing more than 4000g, previous stillborn
Screening test: 50g glucose load
–1h: 140 or less
Confirmatory test: 100g, 3hr GTT
- -fasting: 95 or less
- -1h: 180 or less
- -2h: 155 or less
- -3h: 140 or less
Maintenance of blood sugar target values:
- -fasting less than 90
- -1 hr PP less than 140
- -2 hr PP less than 120
For an average woman, what is the expected amount of weight gain during pregnancy?
Normal woman: 20-30 pounds
- Overweight woman: 15-25 pounds
- Underweight woman: 28-40 pounds
In a newborn/infant…
- chorioretinitis, hydrocephalus, intracranial calcifications
- intermittent fever, osteitis or osteochondritis, mucocutaneous lesions, lymphadenopathy, hepatomegaly, persistent rhinitis
- deafness, cataracts, cardiac defects
Congenital Infections
- Toxoplasmosis
- -chorioretinitis, hydrocephalus, intracranial calcifications
- -look for hx of maternal exposure to cat feces, infected meat, unpasteurized goat’s milk - Syphilis
- -intermittent fever, osteitis or osteochondritis, mucocutaneous lesions, lymphadenopathy, hepatomegaly, persistent rhinitis - Rubella
- -deafness, cataracts, cardiac defects (eg, PDA)
What cardiac defect classically becomes symptomatic during pregnancy?
Mitral stenosis
*mitral stenosis –> L atrial overload –> A-Fib, pulmonary edema
Hepatitis C and Pregnancy
- Factors that increase risk of vertical transmission include high viral load and what other disease?
- Vaccinations? (2)
- Complications: GDM, cholestasis of pregnancy, preterm delivery
- Breastfeeding?
Hepatitis C and Pregnancy
- RFs for vertical transmission: high viral load;
* C-section not protective; do not use scalp electrodes - Vaccinate mother against HAV, HBV (inactivated, killed vaccines)
- Complications: GDM, cholestasis of pregnancy, preterm delivery
- Breastfeeding OK
Management of Spontaneous Abortion
- Threatened AB
- -expectant mgmt - Inevitable, Incomplete, or Missed AB
- -hemodynamically stable?
- -hemodynamically unstable: DandC - Septic AB
- -cultures
- -broad spectrum abx
- -surgical evacuation
Management of Spontaneous Abortion
- Threatened AB
- -expectant mgmt - Inevitable, Incomplete, or Missed AB
- -hemodynamically stable: expectant, prostaglandins, or surgical (pt preference)
- -hemodynamically unstable: DandC - Septic AB
- -cultures
- -broad spectrum abx
- -surgical evacuation
Which ABs does each blood type possess?
- A
- B
- AB
- O
- A – ab’s against B
- B – ab’s against A
- AB – no ab’s
- O – ab’s against A and B
*HDN can be seen in type O mother who has type A or type B baby. This form of HDN is mild; neonatal jaundice treated with phototherapy.
Diabetes Screening in Pregnancy
- -done at 24-28 weeks for average risk
- -done ASAP if high risk
Screening test: 1 hr, 50g oral glucose load
–What is the cutoff for normal value?
Diagnostic test: 3hr, 100g oral glucose load
- -Normal fasting level?
- -Normal 1 hr level?
- -Normal 2 hr level?
- -Normal 3 hr level?
Diabetes Screening in Pregnancy
- -done at 24-28 weeks for average risk
- -done ASAP if high risk
Screening test: 1 hr, 50g oral glucose load
–less than 140
Diagnostic test: 3hr, 100g oral glucose load
- -fasting less than 95
- -1 hr less than 180
- -2 hr less than 155
- -3 hr less than 140
GDM - 2 or more abnormal values
Thyroid Physiology in Pregnancy
Normal thyroid function in pregnancy
- What hormone causes increased total T3-T4?
- TSH levels?
- What hormone causes increased TBG?
- free T3-T4 levels?
Hypothyroidism in Pregnancy
- -requires higher dose of supplemental TH
- -pregnancy is hyper-metabolic state; hypothyroid can’t keep up
Thyroid Physiology in Pregnancy
Normal thyroid function in pregnancy
- increased total T3-T4 due to increased b-hCG
- Slightly decreased TSH due to high total T3-T4
- increased TBG due to increased estrogen
- high-normal free T3-T4 due to binding by TBG
DDx: Liver Disorders in Pregnancy
- intense pruritus; elevated bile acids, bilirubin, AST/ALT
- HTN, proteinuria, RUQ pain, elevated LDH, elevated LFTs, thrombocytopenia
- malaise, n/v, RUQ pain, jaundice, encephalopathy, hypoglycemia, hyperammonemia
- red papules within striae
DDx: Liver Disorders in Pregnancy
- Intrahepatic Cholestasis of Pregnancy
- -intense pruritus, esp at palms, soles; worse at night
- -elevated bile acids, bilirubin, AST/ALT
- -2nd or 3rd trimester
- -tx: ursodeoxycholic acid - HELLP Syndrome
- -preeclampsia, n/v, RUQ pain
- -hemolysis, elevated LFTs, thrombocytopenia - AFLP
- -malaise, n/v, RUQ pain, ascites, jaundice, encepahlopathy, coagulopathy, AKI
- -hypoglycemia, hyperammonemia - Pruritic urticarial papules and plaques of pregnancy (PUPP)
- -red papules and plaques within striae; sparing around umbilicus; may extend into extremities, but rarely involves palms, soles, or face
UTI in Pregnancy
Screening in what trimester?
Management
- -medication for 5-7 days?
- -med for 3-7 days?
- -single dose med?
UTI in Pregnancy
–1st trimester screening (12-16 weeks)
Management
- -Nitrofurantoin for 5-7 days
- -Amoxicillin or Amoxicillin-Clavulanate for 3-7 days
- -Fosfomycin single dose
- hospitalization and IV abx for acute pyelonephritis
- -meropenem, beta-lactams
Tiers of asthma tx in pregnancy
- Beta agonist?
- Inhaled corticosteroids; cromolyn sodium
- Theophylline
Acute asthma:
- -subQ ?
- -systemic corticosteroids
Tiers of asthma tx in pregnancy
- Albuterol - beta agonist
- Inhaled corticosteroids; cromolyn sodium
- Theophylline
Acute asthma:
- -subQ terbutaline
- -systemic corticosteroids
