Medical Complications without cardio Flashcards
What are the maternal/fetal risks of pregnancy in patients with asthma?
exacerbation increased risk of hospitalization low birth weight prematurity need for cesarean delivery preeclampsia
How is asthma severity determined?
Symptom frequency
nigttime awakenings
interference with normal activity
FEV1 or Peak flow - % of personal best
What are the different classifications of asthma severity?
Mild intermittent
Mild persistent
Moderate persistent
Severe persistent
What is the stepwise therapy for the different classes of asthma?
mild intermittent: Albuterol PRN
mild persistent: Low dose IC
moderate persistent: Low dose IC AND LABA or Medium dose IC +/- LABA
severe persistent: High dose IC AND LABA +/- oral corticosteroid
What are alternative meds to steroids and beta agonists for asthma?
Cromolyn sodium
LT receptor antagonist
theophylline
What nonpharmacologic approaches should be used for asthma?
Identify and control allergens / irritants (tobacco, mold, dander)
If GERD related -> elevate head of bed, smaller meals
Self monitoring -> Asthma action plan
What percentage of patients will have worsening asthma symptoms during pregnancy?
Approximately 30%
What are the goals of asthma therapy during pregnancy?
Maintain adequate oxygenation of the fetus by preventing hypoxic episodes in the mother.
How do you counsel a patient regarding the use of short acting beta agonists such as albuterol, in pregnancy?
They are the rescue therapy of choice for asthma during pregnancy
Start therapy if feeling symptoms (cough, chest tightness, wheezing, or 20% drop in PEFR)
If symptoms resolve and PEFR reaches 80% of best, continue normal activity, otherwise, seek medical attention.
What is the role of inhaled glucocorticoids in the management of asthma in pregnancy?
They are the first-line controller therapy for persistent asthma
What is the preferred inhaled glucocorticoid in pregnancy?
Budesonide
What is the role of oral glucocorticoids in the management of asthma in pregnancy?
Rescue therapy to treat an asthma exacerbation
OR
long-term control therapy for patients with severe persistent asthma
Describe how you manage a patient with an acute asthma exacerbation?
Asssess airway
O2 Sat / Fetal well being
H&P
FEV1 or PEFR
EFM if viable
Treatment with meds Albuterol -> Ipratropium -> Oral steroids -> IV Magnesium / Subcutaneous terbutaline
Repeat assessments of patient / fetus as treatment continues
What commonly used obstetric medications may exacerbate asthma?
hemabate
beta blocker
indomethacin
methergine
In pregnant patients with an acute asthma exacerbation, what physiologic changes of pregnancy may make interpretation of an ABG challenging?
Drop in normal paco2, so a PaCO2 >35 mmHg represent more severe compromise during pregnancy than in the non-gravid state
How is community acquired pneumonia diagnosed?
How is hospital acquired pneumonia different?
Clinical features (cough, fever, pleuritic chest pain) Lung imaging (infiltrate seen on CXR)
Hospital acquired has similar features but happens 48 hours after admission
What signs and symptoms would make you suspect pneumonia?
Cough Fever Pleuritic chest pain Dypnea Infiltrate on CXR
What is your differential diagnosis of a patient who presents with a cough?
Pneumonia Pneumonitis Bronchitis Upper respiratory infection Lung cancer Bronchiectasis
What is your differential diagnosis of a patient who presents with shortness of breath?
ARDS Pulmonary edema Pneumonia Asthma exacerbation Lung Cancer
What is your first line treatment for community acquired pneumonia?
Hospital acquired pneumonia?
Community: Ceftriaxone and azithromycin
Hospital: Zosyn (adds coverage for pseudomonas) and vancomycin
What organisms are most commonly involved in causing community acquired pneumonia Vs hospital acquired pneumonia?
Community:
Strep pneumonia
H. Influenza
Mycoplasma pneumonia
Hospital:
MRSA, Pseudomonas
Klebsiella, e.coli, enterobacter
What order do you step up respiratory support?
Nasal canula Face mask Nonrebreather High flow O2 CPAP Noninvasive ventillation (Bipap) Mechanical ventillation ECMO
What are the benefits of High flow NC?
Heated/Humidified
FRC increases via delivery of PEEP
What is the difference between CPAP and BiPAP
CPAP: Patient initiates breath, PEEP is constant
BiPAP: Different inspiratory and expiratory pressures
Describe your management of a pregnant patient with community acquired pneumonia?
H&P / Vitals Give O2 to get SaO2 >=95% CBC Lactate CXR Cultures Continuous pulsox EFM/Toco Antibiotics
Indications for admission of a pregnant woman with pneumonia?
Hypotension (<90 SBP /<60 DBP) Increased RR (>30) HR > 125 pH < 7.35 / Elevated lactate Diabetes Altered mental status Multilobar
What are potential maternal complications of pneumonia in pregnancy?
Hospitalization
ICU admission
Need for ventillation
Death
What are potential fetal complications of pneumonia in pregnancy?
Preterm birth
Fetal growth restriction
Perinatal loss
What are indications for delivery in a patient with pneumonia in pregnancy?
Stable and at term
Worsening clinical picture and delivery will improve maternal outcome
Who do you screen for hypothyroidism?
Significant goiter or thyroid nodules
Clinical suspicion of thyroid disease
Personal history of thyroid disease or type 1 DM
Family history of thyroid disease
What are the symptoms of hypothyroidism?
fatigue constipation cold intolerance muscle cramps weight gain edema dry skin hair loss prolonged relaxation phase of deep tendon reflexes
How do you screen for hypothyroidism?
TSH, if abnormal -> Free T4
How do you follow a patient with a diagnosis of hypothyroidism on meds?
Follow TSH levels
titrate T4 replacement to reach goal TSH
What is the most common cause of hypothyroidism in pregnancy?
Hashimoto’s thyroiditis
What are your target TFT for hypothyroid management in pregnancy?
1st tri: 0.1 - 2.5
2nd tri:0.2 - 2.7
3rd tri: 0.3 - 2.9
How are TFTs altered by pregnancy?
TSH decreases in 1st trimester due to effect of hCG and Free T4 increases slightly
Increased total T4 and total T3 due to increased thyroid binding globulin increasing in pregnancy
How do you manage levothyroxine in a pregnant woman?
Can consider increasing dose by 25% when pregnancy confirmed, then follow TSH and titrate to goals
What are the complications of pregnancy in a patient with hypothyroidism?
Spontaneous abortion preeclampsia preterm birth abruptio placentae stillbirth low birth weight impaired fetal neuropsychologic development
How do you treat subclinical hypothyroidism?
You do not
Currently, there is no good evidence that identification and treatment of subclinical hypothyroidism during pregnancy improves adverse perinatal outcomes
What are signs and symptoms of hyperthyroidism?
nervousness tremors tachycardia frequent stools excessive sweating heat intolerance weight loss goiter insomnia palpitations, hypertension ophthalmopathy dermopathy (signs include localized or pretibial myxedema)
How do you diagnose hyperthyroidism?
Decreased TSH, Increased free T4 or Total T4
What is the most common cause of overt hyperthyroidism in pregnancy?
Graves disease
What is Graves’ disease?
Autoimmune disease mediated by autoantibodies that activate the TSH receptor which stimulates the thyroid
How is Graves’ disease diagnosed?
Hyperthyroidism w/ +TSIs and/or with ophthalmopathy
What is Hashimoto’s thyroiditis?
Chronic lymphocytic throiditis, an autoimmune disease that causes destruction of the thyroid -> hypothyroidism
How is Hashimoto’s diagnosed?
Hypothyroidism w/ antithyroid antibodies (Anti -TPO)
What are the maternal risks of hyperthyroidism in pregnancy?
preeclampsia with severe features
maternal heart failure
thyroid storm
What are the fetal risks of hyperthyroidism in pregnancy?
medically indicated preterm deliveries low birth weight miscarriage stillbirth fetal thyrotoxicosis (due to placental crossing of TSIs)
What is your differential diagnosis of a low TSH in the first trimester of pregnancy?
Normal pregnancy
Subclinical hyperthyroidism
Overt Hyperthyroidism
What workup do you perform when a low TSH is identified in the first trimester of pregnancy?
History
physical exam
free T4
total T3
How do you treat subclinical hyperthyroidism?
You do not
No demonstrated benefit to the mother or fetus
Theoretical risks to fetus from antithyroid medications that cross the placenta
What is the mechanism of action of methimazole?
Inhibitor of thyroid peroxidase
What is the mechanism of action of PTU?
Inhibitor of thyroid peroxidase
AND
Inhibits peripheral conversion of T4 to T3
If the patient requires treatment for hyperthyroidism in pregnancy in the first trimester, which anti thyroid medication will you recommend and why?
PTU,
Avoid methimazole in the first trimester due to risk of esophageal atresia, choanal atresia and aplasia cutis
If the patient requires treatment for hyperthyroidism in pregnancy in the second or third trimester, which anti thyroid medication will you recommend and why?
Methimazole or PTU
But PTU has increased hepatotoxicity risk, so reasonable to switch to methimazole
What are your goals of treatment for hyperthyroidism?
Treatment with the lowest possible thioamide dose to maintain free T4 levels slightly above or in the high-normal range, regardless of TSH levels
Describe your management of antithryoid medications over the course of pregnancy.
Recheck free T4 and total T3 every 2-4 weeks and titrate meds up until in the high normal range.
Once dose stable, can follow less frequently
What are the fetal signs of hyperthyroidism?
fetal hydrops
growth restriction
fetal goiter
persistent fetal tachycardia
Why does a goiter develop in cases of fetal hyperthyroidism?
TSIs cross placenta and can act on fetal thyroid to cause hyperthyroidism and sometimes goiter
What is thyroid storm?
Life threatening exacerbation of thyrotoxicosis.
Thyroid hormone excess -> catecholamine release -> signs/symptoms
How is thyroid storm diagnosed?
Clinically: Fever >103 Tachycardia out of proportion to fever CNS dysfunction: Agitation, Delirium, Coma N/V, Diarrhea -> dehydration Congestive heart failure
What is thyrotoxic heart failure?
Heart failure and Pulmonary HTN caused by cardiomyopathy d/t excess thyroid hormone
How are thyroid storm or thyrotoxic heart failure treated?
Endo consult
Admission to ICU (supportive care: fluids, tylenol, antibiotics, treat CHF)
PTU (PO or by NGTube)
Iodide (inhibits thyroid hormone release)
Dexamethasone (blocks conversion of T4 to T3)
Beta-Blocker (decrease tachycardia)
What is a pituitary microadenoma?
Vs a pituitary macroadenoma?
Micro: Benign slow-growing tumor of the pituitary <10mm.
Macro: Benign slow-growing tumor of the pituitary >10mm.
How do you counsel a patient with a known pituitary adenoma about risks of pregnancy?
Risk of Neurologic symptoms due to tumor growth:
visual disturbances
headaches
diabetes insipidus (rare)
But overall risk is low
What is the likelihood of a pituitary microadenoma or macroadenoma increasing substantially in size during pregnancy?
Very low in microadenoma
Higher risk in macroadenoma
How do you follow pregnant patients with a known pituitary adenoma for evidence of increasing size?
Baseline visual field testing
q3 months evaluation:
Ask about headaches, vision changes
If abnormal -> visual field testing, MRI
If a macroadenoma that extends above the sella, consider routine visual field testing q 3 months
Do you follow PRL levels in women with pituitary adenomas in pregnancy?
No, PRL increases in normal pregnancy, so difficult to distinguish between this and a pathologic rise
If a patient conceives while taking Bromocriptine or Cabergoline for a pituitary microadenoma, how do you counsel her about continuing or discontinuing the medication in pregnancy?
Discontinue meds in early pregnancy because safety has not been established
If adenoma size increases so much as to impair vision can restart dopamine agonists.
What are the fetal risks of bromocriptine and cabergoline exposure?
Not expected to have teratogenic effects
What patients require treatment for a pituitary microadenoma while pregnant?
New onset visual field defects / headaches related to increasing size of the adenoma
What is a postpartum complication of a pituitary adenoma?
What is the presentation?
How do you differentiate from other disorders?
How is it managed?
After postpartum hemorrhage, decreased blood supply to pituitary leads to dysfunction (can happen months later)
Symptoms: absence of lactation, amenorrhea, hot flashes, hypothyroidism, adrenal insufficiency (hypovolemia and tachycardia can mimic shock but hyponatremia and hypoglycemia help differentiate)
Lifelong hormone replacement
What are the maternal symptoms of Crohn’s disease?
Diarrhea Fever Fatigue Abdominal pain Cramping Bloody stool Mouth sores Reduced appetite and weight loss Fistula
What are the features of Crohn’s disease?
It can involve all of the GI tract, In full thickness lesions
Pattern of spread is patchy (skip lesions)
Complications include: granulomas, fistulas, abscesses, bloody diarrhea
Surgery does not cure the disease
What are the features of Ulcerative colitis?
It usually involves the colon, annd the mucosal layer only
Spread is continuous
Complications: bloody diarrhea
Surgery can cure the disease
Which IBD is associated with an increased risk of cancer?
Ulcerative colitis
How is Crohn’s managed during pregnancy?
In consultation with a GI specialist
First line meds: Sulfasalazine or Mesalamine
Anti TNF alpha agents (Inlfiximab or adalimumab)
Avoid NSAIDs
Flagyl
Short doses of steroids for flares
Crohn’s meds to avoid in pregnancy?
MTX
Cyclosporine
Prednisone
How do you counsel a patient regarding maternal risks of Crohn’s disease in pregnancy and ways to decrease them?
Flares can happen, best to try to get pregnant when i remission, as prepregnancy status is best predictor of flares
Stopping smoking can help prevent flares
What are the most common pregnancy complications that occur in a patient with Crohn’s disease?
Miscarriage
PTB
Low birth weight
How do you follow a patient with Crohn’s disease during pregnancy?
Additional growth ultrasounds
How do you counsel a patient regarding the use of sulfasalazine during pregnancy?
Most human reports show no adverse pregnancy outcome.
Take folic acid in 1st trimester
How do you counsel a patient regarding chronic steroid use during pregnancy?
Should be used for short periods to induce remission
Increased risk for maternal DM if used chronically
How do you counsel a patient regarding the use of anti-TNF agents during pregnancy?
Any associated problems?
Category B
Theoretic risk of immune suppression in 3rd trimester which can have implications for vaccine use.
Do you recommend a vaginal birth in patients with Crohn’s disease?
I evaluate for active flare or lesion (abscess / fistula), if found I’d recommend cesarean section
What are symptoms of a Crohn’s disease flare in pregnancy?
Diarrhea, abdominal pain, fevers, mouth sores
Postpartum considerations for Crohn’s disease?
Thromboprophylaxis, especially if s/p c/section
What are maternal symptoms of ulcerative colitis?
Bloody diarrhea, cramping, inability to defecate
How do you counsel a patient regarding risks (obstetric and maternal) of ulcerative colitis in pregnancy?
Preterm birth
Low birth weight
Risk of flare
Increased risk of C/s
How do you follow a patient with ulcerative colitis during pregnancy?
Additional growth ultrasounds
Do you recommend a vaginal birth in patients with ulcerative colitis?
Yes, reserve cesarean for usual obstetric indications
Differential diagnosis for a patient with IBD and symptomatic colitis?
C diff Infectious colitis Diverticulitis Ischemic colitis NSAID related colitis
In a patient with crohns with prolonged second stage of labor, are there any differences in management compared to patients without crohns?
Think carefully before performing episiotomy
Evaluate for signs of abscesses
What is the difference between malabsorptive and restrictive types of bariatric surgery?
Restrictive: reduces the size of the stomach to limit the amount of food that can be consumed increasing the feeling of fullness
Malabsorptive: limits nutrient absorption by bypassing parts of bowel
How long after bariatric surgery should a patient wait to get pregnant?
12-24 months
What are potential pregnancy complications in a patient with a history of a bariatric surgery?
Vitamin deficiencies
Surgical complications
Maternal intestinal obstruction
Which types of bariatric surgeries are considered malabsorptive?
Roux en Y
Which types of bariatric surgeries are considered restrictive?
Gastric band, sleeve gastrectomy
Can a patient with a prior history of malbasorptive bariatric surgery undergo GDM screen with a glucose load?
Can result in dumping syndrome so not ideal
What is the dumping syndrome?
Ingestion of sugars -> stomach rapidly empties into the small intestine.
Fluid shifts from intravascular to the bowel (small-bowel distention) Hyperinsulinemia and hypoglycemia
Resulting in tachycardia, palpitations, anxiety, and diaphoresis
Can patients with a history of a restricive bariatric surgery undergo GDM screen with a glucose load?
Can result in dumping syndrome, but less frequently than Malabsorptive surgeries
How does bariatric surgery impact pregnancy outcomes?
Decreased risk of: LGA GDM C/s Preeclampsia
Describe your baseline lab evaluation of a patient with a history of malabsorptive bariatric surgery?
protein iron B12 folate vitamin D calcium CBC
What are your options for correcting iron deficiency anemia in a patient with a history of bariatric surgery?
Oral vs. Iron
Why is oral iron absorption impacted by bariatric surgery?
Iron absorbed in duodenum which is bypassed in malabsorptive procedures
How do you follow a patient in pregnancy with a history of bariatric surgery?
Fetal growth
Monitor B12, Folate, Ferritin, Calcium, Vitamin D q trimester
Continue follow up for surgical complications
What are the classes of obesity
Class 1: 30-34.9 BMI
Class 2: 35-39.9 BMI
Class 3: 40+ BMI
What is your differential diagnosis for RUQ pain?
Cholelithiasis Cholecystitis Cholangitis Gall stone pancreatitis Appendicitis Acute fatty live Kidney (Nephrolithiasis, pyelonephritis) OB (uterine rupture, preterm babor, intraamniotic infection)
What is your workup for RUQ pain?
Detailed H&P Vitals Labs: CBC, CMP, amylase, lipase, urinalysis RUQ U/s Pain management Fetal assessment
Treatment for acute cholecystitis?
NPO
Pain meds / IV fluids
Antibiotics (zosyn, or ceftriaxone+flagyl)
If gall stone pancreatitis is suspected, how do you proceed?
NPO Pain meds / IV fluids RUQ imaging MRCP if RUQ imaging not helpful Antibiotics (zosyn or ceftri + flagyl) Consult GI and surgery
How do you treat gall stone pancreatitis?
Supportive care (NPO, IV fluid, pain medication)
MRCP
GI and surgery consult
Definitive treatment (Biliary stent, cholecystectomy, ERCP/sphincterotomy)
When would you consider an ERCP?
Severely ill and ERCP may be therapeutic
What CT findings are suspicious for appendicitis?
Periappendiceal fat stranding
Enlarged non-filling tubular structure in RLQ
Appendiceal wall thickening
Considerations for laproscopic surgery?
Ideally not in 3rd trimester
Risk of abruption
Risk of injury with port placement
Is General anesthesia teratogenic?
No teratogenic effects from anesthesia
No effects on brain development
How is lupus diagnosed?
No accepted diagnostic criteria Used to be 4 of 11 Serositis Oral ulcers Arthritis Photosensitivity Blood disorders (anemia, leukopenia, thrombocytopenia) Renal involvement Antinuclear antibodies Immunologic phenomena (dsdna in 80-90% of patients) Neurologic disorder (psych, seiures) Malar rash Discoid rash
How do you counsel patients regarding maternal risks risks of lupus in pregnancy?
Increased risk of SLE Flares (especially if she had a flare in 6 months prior to conceiving)
Lupus nephritis
Preeclampsia
Increased mortality
How do you counsel patients regarding fetal risks risks of lupus in pregnancy?
Spontaneous abortion Fetal demise Fetal growth restriction PTB (indicated) Neonatal lupus Congenital heart block
What focused H&P questions should you ask patients with lupus?
symptoms flares teratogenic meds up to date on vaccines prior pregnancy complications other comorbidities
What baseline evaluation do you perform on a patient with lupus during pregnancy?
SSA and SSB Antiphospholipid antibodies CBC CMP DsDNA Antibodies Complement levels (CH50, or C3/C4) Urine P/C ratio Urinalysis with urine sediment
What effect does the control of her condition have on the outcome of pregnancy?
More likely to have adverse outcomes if lupus has been not well controlled in the 6 months periconception
How do you follow a patient during pregnancy with lupus?
Multidisciplinary approach with Rheumatology, Nephrology and other specialists depending on comorbidities
Aspirin 81mg
Serial growth ultrasounds
If SSA / SSB positive (PR intervals (16-26 weekly, 26-34 q 2 weeks)
Weekly antenatal testing starting at 32 weeks
When do you recommend delivery of a patient with lupus?
Delivery at 39weeks
How do you consel a patient regarding the use of hydroxychloroquine during pregnancy?
Continue during pregnancy to minimize the risk of flares
No evidence of advere fetal or neonatal effects
Compatible with breasfeeding
Benefits of hydroxychloroquine in pregnancy?
Reduces risk of congenital heart block and neonatal lupus rash
Controls disease activity
Which lupus meds are considered safe in pregnancy?
Prednisone
Hydroxychloroquine
Azathioprine
Tacrolimus
Which lupus meds are contraindicated in pregnancy?
Methotrexate
Mycophenolate mofetil
Cyclophosphamide
Leflunomide
How do you counsel a patient regarding the use of chronic glucocorticoids during pregnancy?
Not ideal to be on chronic steroids as it is associated with increased risk of permanent later organ damage
Short burst treatment with a week of methylprednisolone can be used to treat some flares
How do you counsel a patient regarding the use of azathioprine during pregnancy?
Used in lupus nephritis.
Considered safe in pregnancy because the fetus lacks the enzyme to activate it
How do you counsel a patient regarding the use of tacrolimus during pregnancy?
Used in severe lupus nephritis.
Does have adverse effects (hair growth, tremot, DM, gout and can cause renal insufficiency)
What is the likelihood of a lupus flare occuring during pregnancy?
25-60%
Patient with Lupus presents at 25 weeks with:
BP 155/96
P/C ratio 2.1
Asymptomatic w/ good fetal movement
What is your differential diagnosis and how would you initially manage this patient?
Lupus flare vs Preeclampsia vs. CHTN Admit to hospital Steroids for fetal lung maturity Fetal monitoring Growth U/s Monitor vitals CBC / CMP Complement levels Anti ds DNA 24 hour urine total protein / creatinine clearance
Patient with Lupus presents at 25 weeks with:
BP 155/96 , P/C ratio 2.1, Asymptomatic w/ good fetal movement
Hb 12.4, Plt 86k, 24 hour urine 3600mg, Cr: 1.7
AST/ALT: normal, UA: negative, no casts
Complement levels: normal, Anti ds DNA negative
BP now 162/106 and she has a HA.
What is your diagnosis? How can you distinguish between lupus flare and preeclampsia?
Preecalmpsia with severe features
Worsening proteinuria with no urine sediment
Normal complement and anti ds DNA levels
Look at the clinical picture, sometimes difficult to distinguish between the two, ds DNA and complement being normal as well as no urine sediment are more suggestive of preeclampsia than lupus.
How is lupus nephritis diagnosed?
Urine p/c ratio > 0.5, confirmed by kidney biopsy (can be done in 1st and early 2nd trimester)
How does a history of lupus nephritis impact pregnancy risk?
Patients with lupus nephritis have a good prognosis if in remission up to 6 months prior to pregnancy.
Pregnancy increases the chance for a lupus nephritis flare
Lupus nephritis increases the risk for premature birth and maternal hypertension.
How do you counsel a patient with multiple sclerosis about the maternal risks of pregnancy?
Pregnancy usually dicreases disease activity, but it increases 3-6 months postpartum
What obstetric complications are increased in patients with multiple sclerosis?
None
What are common symptoms of a multiple sclerosis exacerbations?
Optic neuritis
Numbness
Weakness
Ataxia
How does pregnancy affect the risk of multiple sclerosis exacerbations?
Pregnancy usually dicreases disease activity, but it increases 3-6 months postpartum
Do you continue MS meds during pregnancy?
How do you treat flares?
Suggest d/c meds (interferons) when trying to get pregnant
Steroids for acute events
Symptoms of pseudotumor cerebri in pregnancy?
Headache, vision changes / papilledema
Treatment of Pseudotumor cerebri in pregnancy?
Steroids
Diamox (carbonix anhydrase inhibitor)
Repeat LPs
Symptoms of myasthenia gravid?
Fatigable weakness after repetitive muscle use
What is the pathology in myasthenia gravid?
Antibodies against ACh receptor on NMJ
Medication that is contraindicated in myasthenia gravis?
Magnesium sulfate, use Keppra instead (levetiracetam)
What is autonomic dysreflexia?
Can be a life threatening complication of patients with spinal cord injuries
Massive, unbalanced reflex sympathetic discharge that occurs in patients with SCIs above T6
What are the symptoms of autonomic dysreflexia?
sudden elevation in blood pressure severe vasoconstriction below the neurologic level arrhythmias piloerection skin pallor
Triggers for autonomic dysreflexia?
Distended bladder / bowel / uterus
Pain in genital region (labor)
How frequent is autonomic dysreflexia seen?
85% of patients with injury above T6
Treatment for autonomic dysreflexia?
Preventative: prevent bladder distention (foley)
Limit cervical exams and fundal massage
Neuraxial anesthesia
Treat Hypertension with nifedipine / labetalol
Mode of delivery in autonomic dysreflexia?
Assisted / Operative vaginal delivery can be attempted, but C/s may be warranted if cannot control symptoms (70% c/s rate)
Are there spinal cord injuries that make it so patients cannot appreciate labor pain? How do you manage them?
Above T10
Start SVEs at 26 weeks and consider in house at 32 weeks
How do you counsel a patient with rheumatoid arthritis about the maternal risks of pregnancy?
Should plan pregnancy when under good control on meds
Test for Anti SSA/SSB (screen for neonatal lupus & heart block risk)
If spine involvement, will need consultation with anesthesia
What obstetric complciations are increased in rheumatoid arthritis patients?
Unclear
Maybe an increase in SGA and PTD, but could be related to medication use
What are common symptoms of a rheumatoid arthritis exacerbation?
Increased stiffness in joints
Whole body pain
Intense fatigue
Flu like symptoms
How does pregnancy affect the clinical course of rheumatoid arthritis?
RA usually has improvement during pregnancy
How does breastfeeding affect the risk of rheumatoid arthritis exacerbations?
Does not affect disease course
What are common treatment approaches for pregnant women with rheumatoid arthritis?
Avoid NSAIDS after 20 weeks
Can consider continuing hydroxychloroquine
TNF alpha inhibitors can be used in 1st 2 trimesters
No methotrexate
How do these treatments for RA impact the fetus?
NSAIDs can have oligohydramnios or narrowing of ductus arteriosus if used later in pregnancy
Hydroxychloroquine - not associated with adverse outcomes, especially if not at very high doses
TNF alpha inhibitors - theoretic risks of immune suppression in infant, so discontinue in 3rd trimester
If a patient has a 4th generation screening test positive for HIV what additional evaluation do you perform?
Step 2: HIV-1 / HIV-2 Antibody differentiation immunoassay
Step 3: HIV-1 RNA assay
If HIV-1/HIV-2 antibody differentiation immunoassay is positive what is your next step in the evaluation of the patient?
HIV Viral load
If a patient is confirmed to be HIV-positive, what baseline labs do you perform?
Viral load CD4 count CBC CMP Hepatitis A,B,C, G/C, Syphilis TB HIV viral resistance genotyping Toxoplasmosis immunity
What immunizations are recommended for an HIV positive pregnant woman?
pneumococcal flu hepatitis A hepatitis B HPV MMR (live, not in pregnancy) varicella (live, not in pregnancy) tDAP
How do you counsel women on HIV ART about teratogenicity?
Many studies showed no difference in birth defect rates for 1st trimester exposure vs later ARV esposures, so ARV during pregnancy does not increase the risk of birth defects.
Which ARVs should ideally not be used in pregnancy, why?
Efavirenz: NTD risk, but safety data is better now
Drug interactions with ARV meds?
Which ob related drug should not be used?
Protease inhibitors can inhibit P450 and result in increased levels/activity of Methergine
Methergine should not be used unless last resort in patients on PIs
What are the two primary goals of antiretroviral therapy during pregnancy?
(1) Prevent vertical transmission reducing maternal viral load to <1000 copies/mL
(2) Treat maternal HIV disease
What are the ways that maternal ART protect the fetus?
(1) Reduce maternal plasma viral load -> reduced in utero exposure
(2) Reduce genital viral load -> reduce infant exposure in birth canal
(3) Placentally crossing drugs provide PrEP and PEP to infant
How do you counsel patients regarding HIV viral loads and vertical transmission rates?
RNA level at 3rd trimester is strong predictor
What is the vertical transmission rate for patient with: undetectable viral load? 1000 copies? 10,000 copies? 100,000 copies?
0.1-0.3%
2%
11%
40%
When should antiretroviral therapy be started in the patient with a new diagnosis of HIV infection in pregnancy?
Immediately, transmission risk is lowest the earlier ART is started
If a patient is already established on an antiretroviral regimen and presents with a new diagnosis of pregnancy, how will you manage her medications?
Choose anti-retrovirals that are safe in pregnancy
NRTI (Emtricitabine/Lamivudine/Tenofovir)
Integrase Inhibitor (Raltegravir, Dolutegravir)
Protease Inhibitor
How do you counsel an HIV-infected pregnant patient regarding recommended route of delivery?
If viral load is suppressed (<1000), vaginal delivery (no benefit of elective c/s for maternal to child transmission if <1000)
If viral load > 1000, c/s to decrease risk of transmission
How do you counsel an HIV infected pregnant woman with a high viral load regarding the benefits of cesarean delivery?
It decreases her risk of vertical transmission, compared to a vaginal delivery
In an HIV infected pregnant woman with a high viral load, at what gestational age do you plan her delivery?
38 weeks by c/s
How do you manage a patient with preterm premature rupture of membranes who is HIV positive?
Shared decision making
Unlikely to benefit from a cesarean section so would not perform
How do you manange an HIV-positive patient scheduled for cesarean delivery at 38 weeks gestation who presents in labor at 37 weeks?
Delivery by vaginal can be considered, as no longer a benefit of a c/s once labor has started
How do you manage an HIV-positive patient schedule for cesarean delivery at 38 weeks gestation who presents with ruptured membranes at 37 weeks?
Delivery by vaginal can be considered, as no longer a benefit of a c/s once ruptured membranes has occurred
Describe your management of a patient with unknown HIV status who presents in labor at term?
Rapid HIV test if positive -> zidovudine
Which patients do you consider to be candidates for a rapid HIV test?
Not tested earlier in pregnancy
HIV status is otherwise unknown
How do you manage a pregnant woman in labor at term with a positive rapid HIV test?
Immediately administer antiretroviral prophylaxis for mother and neonate
Which HIV infected pregnant patients should receive zidovudine intrapartum?
VL >1000
or unknown
(Can be considered in viral load of 50-999)
Which neonates born to HIV-infected pregnant patients should be given zidovudine in the neonatal period
All who were exposed prenatally should receive ARV to reduce the risk of perinatal transmission
What do you prophylax for in HIV with:
CD4 <200?
CD4<100?
CD4<50?
CD4 <200: Pneumocystis - Bactrim
CD4<100: Toxoplasmosis - Bactrim
CD4<50: Mycobacterium avium complex (MAC) - azithromycin
Is breast feeding recommended in HIV+ patients?
Recommended against breastfeeding in moms positive for HIV
Things to avoid in labor of a patient with HIV?
AROM
Fetal scalp electrode
Operative delivery
How do you counsel patients regarding covid vaccine?
Vaccines are effective at preventing covid19 diseae, especially severe illness and death
Vaccination may help transfer protective antibodies to your baby through the placenta and breast milk.
Pregnant patients with COVID are more likely to be very sick compared to nonpregnant
No increased risk of pregnancy loss, growth problems or birth defects in vaccinated patients compared to non vaccinated.
Booster shots are recommended in pregnancy
How do you treat Covid patients with mild disease?
Monoclonal antibodies within 10 days of symptom onset
Paxlovid (protease inhibitors, nirmatrelvir w/ ritonavir) within 5 days of symptom onset
When do you treat Covid in pregnancy as an inpatient?
When the patient meets criteria for severe infection
What criteria sets Covid as severe?
SaO2 <94%, RR >30, or PF<300 or greater than 50% lung involvement on imaging
Hospitalize and treat
What are the pregnancy risks of patients with Covid?
Increased risk of preeclampsia and preterm delivery in patients with severe covid.
Possible increased risk in FGR, and fetal demise
When positive for Covid and severe/hospitalized, how do you treat?
Dexamethasone and Remdesivir, consider anticoagulation
What amount of radiation exposure okay in pregnancy?
0-2 weeks: 50-100mGy
2-8 weeks: 200mGy
8-15 weeks: 60-310mGy
16-25 weeks: 250-280mGy
What are the risks of radiation depending on GA at exposure?
0-2 weeks: all or none (death)
2-8 weeks: Growth restriction, anomalies (skeletal,eyes,genitals)
8-15 weeks: Severe Intellectual disability (high risk), Microcephaly
16-25 weeks: Severe intellectual disability (low risk)
How much radiation is in? CXR? Abdominal CT? Pelvic CT? CT angio?
CXR: 0.0005-0.01
Abdominal CT: 1.3-35
Pelvic CT: 10-50
CT Angio: 0.01-0.66
IS MRI with Gadolinium ok with breastfeeding?
Yes
IS MRI with Gadolinium ok with pregnancy?
Ideally not, unless there is a clear benefit that changes management
Is oral contrast in pregnancy okay?
Not absorbed by patient and dont cause real or theoretical harm
Is IV contrast okay in pregnancy?
Can cross placenta, and there is a lack of known harm, but recommended only to be used if absolutely required to obtain additional diagnostic information that will affect care.
Can you breastfeed after IV iodinated contrast?
Yes
Differential diagnosis for flank pain?
Pyelonephritis
Nephrolithiasis
Renal abscess
Pneumonia
What signs and symptoms would lead you to suspect nephrolithiasis?
Flank pain
Hematuria
In a pregnant patient with suspected nephrolithiasis, what is your initial workup?
Urinalysis
Renal ultrasound
CBC
What is the accuracy of renal and pelvic ultrasound in identifying a renal calculus in a pregnant woman?
60%
If renal and pelvic US does not identify a calculus, what is your next step in management?
Consider MR urography, CT as last resort if inconclusive
How do you manage a pregnant woman with nephrolithiasis?
Hydration Lying on the non-affected side Pain management Strain urine Flomax (Tamsulosin, alpha 1 blocker that relaxes bladder neck) Category B, can help pass stone, but 80% will pass on their own
What patietns are candidates for more aggressive interventions such as nephrostomy tube to address nephrolithiasis?
When sepsis
Severe refractory pain
Obstruction in a single functioning kidney
What are potential complications of nephrolithiasis in pregnancy?
Pyelonephritis
Acute kidney injury
G1 at 33w2d presents w/ T:102.1, uterine contractions, chills, & back pain.
What is your differential diagnosis?
Pyelonephritis Nephrolithiasis Chorioamnionitis Influenza Covid
G1 at 33w2d presents w/ T:102.1, uterine contractions, chills, & back pain.
What is your inital workup?
H&P CBC CMP Urinalysis Urine culture Covid / Flu swabs Fetal monitoring \+/- Renal ultrasound
G1 at 33w2d presents w/ T:102.1, uterine contractions, chills, & back pain.
WBC of 18.2 with 10 bands, Urinalysis shows moderate ketones 3+ bacteria, LE and Nitrite positive
She has right sided CVA tenderness, and has regular contractions on toco.
What is your next step in management?
IV fluids Start antibiotics Send urine culture Evaluate cervix (+/- steroids) Consider renal u/s to rule out abscess
G1 at 33w2d presents w/ T:102.1, uterine contractions, chills, & back pain.
WBC of 18.2 with 10 bands, Urinalysis shows moderate ketones 3+ bacteria, LE and Nitrite positive
She has right sided CVA tenderness, and has regular contractions on toco.
She gets her IV fluids and IV antibiotics, received 2L of IV fluid and then 3L more in the 12 hours on the antepartum floor.
The next day she is complaining of shortnesss of breath.
Physical exam shows decreased lung sounds at bilateral bases.
What is your next step in management for her?
Lasix
Urine output
Less aggressive hydration
Continuous O2 sat
What are the symptoms of pyelonephritis?
Flank pain
Fever
N/v
CVA tenderness
What evaluation do you perform on a pregnant patient suspected of having pyelonephritis?
Urinalysis Urine culture CBC CMP \+/- Renal U/s
What are the most common bacteria that cause pyelonephritis?
E.coli, Klebsiella, enterobacter, proteus
What is your first-line antibiotic choice in treatment of pyelonephritis?
Ceftriaxone
What is your choice of antibiotic in a pregnant woman with pyelonephritis and a high risk penicillin allergy?
Aztreonam
What is your choice of antibiotic in a pregnant woman with pyelonephritis and a low risk penicillin allergy?
Ceftriaxone
Do you admit pregnant women to the hospital when diagnosed with pyelonephritis?
Yes
How long should the patient remain in the hospital?
Till afebrile 24-48 hours
What are the fetal risks due to pyelonephritis?
Preterm delivery
If the patient is admitted with pyelonephritis and develops contractions at 28 weeks gestation, do you recommend tocolysis? If so, what is your first line tocolytic?
I wouldnt unless her cervix was dilated and I was giving it for the purpose of getting steroids on board.
Are steroids for fetal benefit appropriate in a patient with pyelonephritis?
Only if I think there is an imminent risk of delivery
What are the maternal risks of pyelonephritis in pregnancy?
Sepsis
ARDS
Pulmonary edema
Renal dysfunction
How do you evaluate the patient who does not respond promptly to IV antibiotic therapy?
Renal ultrasound looking for abscess
Evaluate for alternative source if picture is unclear
Is hepatitis B vaccine okay in pregnancy?
Yes
What % of patients who get infected with HBV will have chronic infection?
10-15%
How do you counsel a pregnant patient with a positive HBsAg?
It usually suggests an acute or chronic infection and that further testing is necessary to assess risk to her and the fetus
What is the initial workup for a patient with a positive HBsAg?
Suspect some sort of active infection (acute or chronic)
History / Physical exam
Test for: HBeAg, HBeAb, HBcAb (IgM) and AST/ALT
Test quantitative HBV-DNA level in early third trimester.
Test HIV
Summary of counseling about HBV in pregnancy and postpartum?
Increased risk of perinatal transmission
Test viral load in 3rd rimester with plan to treat with tenofovir if elevated
Breastfeeding is okay unless nipples cracked/bleeding
Cesarean is not required
Counsel re: safe sex practices and partner testing
How do you interpret these results?
HBsAb(+), HBsAg (-)
Immunized against Hepatitis B
How do you interpret these results?
HBsAg(+), HBsAb (-), HBcAb (+)
Chronic hepatitis B
How is hepatitis B transmitted?
Blood and sex
Who is a candidate for hepatitis B vaccine?
High risk of exposure (healthcare workers, IV drug users, household contacts)
High risk of complications if they got sick (Diabetes, Liver disorders, HIV)
Travel to area where it is more common
What is the likelihood of vertical transmission in a patient with acute hepatitis B infection?
What if HBeAg positive?
20-30% with no intervention (closer to 90% if HBeAg positive)
What is the role of hepatitis B viral load and risk of vertical transmission?
High viral loads = increased intrauterine transmission risk
Can a patient with hepatitis B infection breast-feed?
Yes, not contraindicated
But abstain if bleeding or cracked
How should a neonate born to a hepatitis B infected mother be managed?
HBIG
Hep B vaccine
*Decreases intrapartum transmission by 85-95%
**But doesnt affect rate of transmission prior to labor and delivery
Is cesarean delivery recommended for increased hepatitis B viral load?
No
Who is a candidate for antiretroviral therapy for hepatitis B infection in pregnancy? What drug?
Viral load >6-8 log 10 copies/mL, Tenofovir
What are the options for invasive testing in HBV patients?
CVS or amniocentesis can be offered but should counsel that risk for transmission increases with a HBV viral load > 7 log 10 IU/mL
What are the risks and benefits of tenofovir use in pregnancy?
Decrease risk of viral transmission
No resistance to medication
No increased risk of toxicity or adverse outcomes from medication
What are maternal risks of chronic hepatitis B infection?
Hepatitis -> death (<1%)
Cirrhosis
Liver cancer
Who should be screened for Hepatitis C in pregnancy?
All pregnant patients in each pregnancy
What is your initiatl workup for a patient with a positive Hepatitis C antibody?
History and physical exam
Send HCV RNA
If positive - can Baseline labs (Bilirubin, AST/ALT, ALbumin, PLT, PT)
Test for other STIs (HIV, syphilis, g/c,HBV)
Treatment for HCV patients?
No, but can immuniza Hep A / Hep B, or treat STI’s if positive
How is Hepatitis C transmitted?
Blood mostly (less sexually transmitted the HBV)
What is the likelihood of vertical transmission in a patient with hepatitis C infection when viremia is detected?
4-7% if viremia is detectable
What is the role of Hepatitis C viral load and risk of vertical transmission?
Unclear, conflicting reports
Can a patient with Hepatitis C infection breast feed?
Yes, not contraindicated
But abstain if bleeding or cracked
How should a neonate born to a hepatitis C infected mother be managed?
antiHCV antibodies >18 months of age
OR
HCV RNA on 2 occasions in infants >1 month of age.
Is cesarean delivery recommended for patients with high hepatitis C viral load?
No
What are maternal risks of chronic hepatitis C infection?
Cholestasis of pregnancy SGA /LBW NICU admission PTB Hepatocellular damage / liver fibrosis
How is maternal infection with varicella diagnosed?
Clinically
Can be confirmed with Serology for IgM or polymerase chain reaction (PCR) for VZV
How is varicella infection transmitted?
Respiratory droplets and vesicle contact
Do you recommend screening for varicella immunity routinely in pregnancy? Why or why not?
Yes, screen via documenting previous infection or varicella vaccination
Can pregnant women recieve varicella vaccination? why or why not?
No it is a live vaccine & ideally should delay conception by 3 months
How do you counsel a patient with a positive varicella IgM and negative IgG result?
Acute/recent infection or false positive
When are patients with varicella infectious?
From 48 hours before rash
until all lesions are crusted over
If the patient is exposed to varicella and found to be nonimmune, what is the next step in your management?
VZIG
Ultrasound 5 weeks after rash appears
How long after exposure must VZIG be given
within 96 hours
How is acute varicella in pregnancy treated?
Acyclovir / Valacyclovir
Does treatment with acyclovir for acute varicella in pregnancy reduce fetal risks?
No
What are maternal risks of varicella infection?
bacterial superinfection of skin lesions
varicella pneumonia (increases risk of maternal mortality)
post-infectious acute cerebellar ataxia encephalitis
thrombocytopenia
What are maternal symptoms of varicella infection?
Itchy rash
Blisters
Fever
What ultrasound findings are consistent with in utero varicella infection?
FGR Microcephaly Echogenic foci in liver/bowel Limb deformitis (due to scarring of extremities) Ventriculomegaly Hydrops
How is in utero varicella infection confirmed?
Amniotic fluid PCR
When is the risk of getting congenital varicalla greatest?
<20 weeks
In which trimester of pregnancy is the greatest risk of fetal infection with varicella?
3rd trimester, specifically in the 5 days prior to delivery and 2 days after
How do you counsel a patient regarding fetal and neonatal outcomes following in utero varicella infection
Prior to 20 weeks?
Late in 3rd trimester?
Prior to 20 weeks: 0.5-2% varicella embryopathy
1-4 weeks before delivery: clincial varicella
Severe chicken pox in the infant can occur if mom was infective from 5 days before birth to 2 days after
If a pregnant patient is diagnosed with acute varicella and delivers, when is the greatest risk period for neonatal transmission?
5 days before and up to 2 days after delivery (7 day window)
Not enough time to allow protective antibodies to cross placenta
What is the treatment for HSV in pregnancy?
Acyclovir for 7-10days if primary
or 5d if recurrence
Suppression starting at 36 weeks
When is cesarean indicated in HSV?
Active genital lesions
Prodromal genital symptoms
Can offer if first known outbreak was in the 3rd trimester OR recurrent outbreaks in the 3rd trimester
How is HSV with PPROM managed?
No consensus, give antiviral therapy if expectantly managing
Is amniocentesis or CVS okay with HSV?
Yes
What are the symptoms of TB?
Cough, Fever, Sweating, Hemoptysis, Weight loss
How do you test for TB?
Sputum culture
Treatment for TB?
RIPE (Rifampin, isoniazid, pyrazinamide, ethambutol)
But no Pyrazinamide in pregnancy
How is latent TB diagnosed and treated?
Positive TB test without symptoms and with a negative CXR
Treat with Isoniazid, can be delayed for 2-3 months postpartum unless high risk (recent contact with someone infectious)
Can you breast feed with active/untreated TB?
No, start 2 weeks post therapy
What is the risk of vertical infection in primary first genital infection, nonprimary first genital infection and recurrence?
Primary genital infection: 40%
nonprimary, 1st genital infection: 30%
recurrence:1-3%
Who and how do you screen for depression?
I recommend screening of all patients for depression in the perinatal and postnatal periods.
I choose to use the edinburgh postnatal depression scale (<13 is a positive screen) as it takes less than 5 mins to administer, is available in spanish and had high sensitivity and specificity
How do you counsel patients about the risks of depression in pregnancy?
Increased risk for:
miscarriage
low birth weight
preterm delivery
How do you counsel patients about the risks of benzodiazepines for anti-anxiety in pregnancy?
Risk of neonatal abstinence syndrome
Best to limit its use, use the lowest dose to control symptoms
BZD Less likely to accumulate in fetus: lorazepam or clonazepam
What are the potential neonatal risks of SSRI use in pregnancy?
Low birth weight
Neonatal abstinence syndrome
Persistent pulmonary hypertension
As a general rule, do you recommend patients continue their antidepressants during pregnancy?
In general yes,
If not treated there is a risk of postpartum depression, bonding with neonate/infant.
And anxiety that is not under control has been associated with preterm labor, preterm birth and miscarriage.
Id also recommend she see a mental health provider regularly
How do you counsel patients with a history of depression about the risk of postpartum depression?
There is an increased risk of postpartum depression
If a patient presented to your office with suicidal thoughts, describie how you would address that situation?
I would sit with them ask about whether they have a plan
Call an ambulance and send them to hospital
Get in touch with emergency psychiatric services
Management steps for first appointment with substance use disorder?
SBIRT
Screening
Brief intervention
Referral to treatment
In your practice, do you screen all pregnant women for substance abuse?
Yes, early universal screening
How do you screen pregnant women for substance abuse in your practice?
I ask the 4 P’s
Did/do your Parents have a problem with drugs or alcohol
Does your partner have a problem with drugs or alcohol
Have you had difficulties in the past because of alcohol or drugs
In the past month (present) have you drunk any alcohol or used other drugs?
If a patient screens positive for history of substance abuse, what are your next steps?
Assess desire for cessation
Route to program that can help with cessation
Social work or nurse navigator involvement
What would you discuss in a “Brief Intervention” with the patient?
Engage the patient in a short conversation
providing feedback and advice
assess for withdrawal symptoms
assess desire to quit
assess social situation
discuss recommendation / resources to help
If a patient is found to have opioid use disorder how would you recommend managing the pregnancy?
Refer patient to addiction services to initiate medication assistance with buprenorphine or methadone
Refer for social services
Assess for signs of withdrawal
Fetal Growth due to risk of IUGR
Test for STI’s HIV, Hep Panel, RPR, G/C, TB
Consider echo if IV drug use suspected
What are signs/symptoms of withdrawal?
Elevated pulse Restlessness Yawning Tremor lacrimation/rhinorrhea nausea/vomiting/diarrhea diaphoresis Piloerection Joint/muscle ache
Do you recommend opioid agonist pharmacotherapy or medical withdrawal of opioids in your patients with opioid use disorder?
I recommend opioid agonist therapy (MAT- medication assisted treatment) over medical withdrawal due to high relapse rate.
What is neonatal abstinence syndrome?
What are some signs/symptoms?
Neonatal withdrawal from medications mother was on
Agitation, irritability, insomnia, poor feeding, shivering, seizures
What are the pros/cons of buprenorphine over methadone in pregnancy for patients with opioid use disorder?
Pros: Outpatient without daily visits, low risk of overdose, less dose adjustments needed and less risk of neonatal abstinence
Risk: Increased risk of selling meds
What are the maternal and fetal risks of opioid / use abuse in pregnancy
Preterm birth
IUGR
fetal death
What are maternal risks of opioid withdrawal in pregnancy?
Increased risk of relapse
Unclear effect on Fetal stress and fetal death (once associated but now that is unclear)
What are the fetal risks of opioid withdrawal?
SAB
What are the maternal and fetal risks of amphetamine use and abuse in pregnancy?
hypertension stroke MI abruption IUGR IUFD
A patient with a known seizure disorder presents at 24 weeks due to new onset seizure, she has been on Keppra in the past which has not worked and is currently on Lamotrigine. She was found to have a grand mal seizure last week.
How would you approach this patient?
Neurology referral
Check her dose of lamictal and discuss increasing with her neurologist
Assess lamictal levels
Counsel re: adequate hydration / sleep
Counsel re: avoiding high risk activities (driving, ironing, etc…)
Detailed anatomy
Fetal echocardiogram
How do you approach a patient with Opioid use disorder in labor?
Epidural / spinal Avoid narcotic agonist-antagonist meds Continue methadone / buprenorphine (possibly with split doses) Injectable Tylenol or Toradol postpartum Neonatalogy consult
Can you breast feed with opioid use disorder?
Yes (results in less NAS)
But avoid if on tramadol or codeine
What is your plan of management for a 33 weeker with chronic back pain?
Assess for organic cause Discuss exercise, physical therapy, stretches Tylenol (no more than 3500mg in 24 hours) Belly band Cool/warm compress Behavior changes Follow up to reassess Avoid narcotics use
How do you counsel a patient with a seizure disorder about the maternal risks of pregnnacy?
Epilepsy can be variable during pregnancy
Seizure risk is highest in the 1st trimester
Usually reverts to the pregestational pattern postpartum
What is the best predictor of seizure activity during pregnancy?
Being seizure free in the year prior to pregnancy
How do you counsel a patient with a seizure disorder about the obstetric risks of pregnnacy if she is having breakthrough seizures?
If having breakthrough seizures, increased risk of:
preterm delivery
reduced birth weight
hemorrhage
What is the likelihood of worsening seizures during pregnancy?
Depends on prepregnancy seizure control
Which antiepileptic drugs should be avoided in pregnancy if possible?
Phenytoin
Valproic acid
Which antiepileptic drugs carry the highest risk of fetal malformations?
Valproic acid,topamax
What are the risks of valproate in pregnancy?
Neural tube defects
hypospadias
orofacial clefts
Lower IQ
What are the risks of phenytoin in pregnancy?
Fetal hydantoin syndrome (but usually have some features not all) FGR Microcephaly Cardiac defects Finger / Nail defects Craniofacial abnoralities
How do you follow a patient who was taking valproic acid throughout first trimester?
Early anatomy (NTD, hypospadias, clefts)
MSAFP
Detailed anatomy
Fetal echocardiogram
Which patients are candidates for high dose folic acid supplementation?
History of NTD in previous child
Using antiepileptic medication like valproic acid
MTHFR deficiency??
What are maternal / fetal risks of seizures in pregnancy?
fetal hypoxia acidosis decreased placental blood flow deceleration in fetal heart rate maternal trauma from a convulsion and maternal sudden unexpected death in epilepsy
How should anti-seizure medication levels be followed in pregnancy and postpartum?
q monthly to maintain therapeutic level
Once postpartum, more often, because can return to prepregnancy values quick
Considerations for breastfeeding in women with epilepsy?
Breastfeeding is beneficial
Some drugs can pass into breast milk and cause sedation
How is nephrotic syndrome diagnosed?
Proteinuria >3.5g daily
Hypoalbuminemia <3g/dL
Peripheral edema
What is your differential diagnosis for a patient with proteinuria in pregnancy?
Preeclampsia
Nephrotic syndrome
Nephritis
Diabetic nephropathy
How do you assess proteinuria in pregnancy?
24 hour urine protein and creatinine clearance
spot p/c ratio
What are possible etiologies for nephrotic syndrome?
Primary: Minimal change disease, Focal segmental glomerulosclerosis, Membranous nephropathy
Secondary: Diabetes, Lupus
Can you have a renal biopsy in pregnancy?
If proteinuria cause is unclear from H&P it can be done in 1st and early 2nd trimester, though it is rarely necessary in pregnancy
(reserve for when diagnosis cannot be established without biopsy and establishing the diagnosis is necessary before initiating therapy)
Major risk in pregnancy is bleeding
What complications may occur during pregnancy in a patient with nephrotic syndrome?
Superimposed preeclampsia Acute kidney injury Worsening edema Venous thromboembolism Preterm birth
How is edema managed in patients with nephrotic syndrome in pregnancy?
Salt restriction, reserve diuretics for intractable cases of edema
What baseline evaluation do you recommend in a pregnant patient with chronic kidney disease?
H&P (symptoms, review meds any that need renal dosing)
HbA1c, early GCT
24 hour urine protein/creatinine collection
CBC, CMP
Nephrology consultation
GFR
What factors will increase the risk of adverse pregnancy outcomes in the setting of chronic kidney disease?
Women with stages 1 and 2 CKD, in general, have successful pregnancies and do not have a worsened renal prognosis.
Stages 3 and above have a increased risk of renal failure within a year of delivery
What are the most common pregnancy complications in the setting of chronic kidney disease?
Hypertension / Preeclampsia Preterm Labor Fetal growth restriction Proteinuria Worsening renal failure Anemia
How do you counsel a patient on the use of ACE-I and ARBs in pregnancy?
They are teratogenic and should not be used during pregnancy
How do you counsel a patient on the use of diuretics in pregnancy?
Can be used if volume-mediated hypertension / volume overload
Monitor for electrolyte disturbances
How do you follow a patient with chronic kidney disease in pregnancy?
Close follow up q 2-4 weeks until 32 weeks, then weekly
BP monitoring and evaluation for proteinuria
Aggressive treatment of BP (Goal DBP <90)
Frequent urine culture
Serial growth ultrasounds
Weekly antenatal testing starting at 32 weeks
What are indications for dialysis?
Decision must be individualized and in consultation with nephrology
Estimated GFR (eGFR) <20 mL/min/1.73 m2
Blood urea nitrogen (BUN) increases >50 to 60 mg/dL (18 to 21 mmol/L)
What are maternal/fetal risks for a pregnant woman undergoing dialysis?
Stillbirth / neonatal death (as high as 30%) PTD and associated morbidity PEC w/ SF HTN Anemia Maternal death
How do you counsel a woman getting dialysis who wants to get pregnant?
She should receive a renal transplant and wait for 1-2y before attempting pregnancy
How do you counsel a patient with a renal transplant regarding risks in pregnancy?
Increased risk of HTN
FGR
PEC
PTD
Following a renal transplant, what factors predict higher likelhood of poor pregnancy outcome?
Cr<1.5 at conception low risk of irreversible loss of graft function
Cr>1.5 at conception higher risk of irreversible loss of graft function
How does pregnancy impact renal function in the transplanted organ?
Kidney allograft outcomes in pregnant transplant recipients with a well-functioning allograft appear to be comparable with that of nonpregnant transplant recipients
What baseline evaluation should be performed in a pregnant patient with a renal transplant?
H&P (what medications they are on, where is kidney located, when was surgery)
Monthly: CBC, CMP (BUN Cr, electrolytes), Uric acid, 24 hour creatinine clearance and protein levels.
CMV, Toxoplasmosis, HSV serology
Immunosuppressant levels
How do you monitor a patient with a renal transplant who is currently pregnant?
Close follow up q 2-4 weeks until 32 weeks, then weekly
BP monitoring and evaluation for proteinuria
Monthly: CBC, CMP (BUN Cr, electrolytes), Uric acid, 24 hour creatinine clearance and protein levels.
CMV, Toxoplasmosis, HSV serology
Immunosuppressant levels
Frequent urine culture
Serial growth ultrasounds
Weekly antenatal testing starting at 32 weeks
How do you counsel a transplant recipient considering pregnancy regarding immunosuppressants?
Teratogenic meds (Mycophenolate mofetil, sirolimus, everolimus) Meds that increase / decrease levels of immunosuppressants
Which immunosuppressants are recommended during pregnancy?
prednisone (low dose)
cyclosporine
azathioprine
tacrolimus
Is mode of delivery altered for pregnant transplant recipients?
Cesarean should be reserved for the usual obstetric indications
Does pregnancy increase the likelhood of renal allograft graft rejection?
Pregnancy within the first 6 to 12 months after transplantation is not recommended due to high risk for acute allograft rejection
How does acute renal allograft rejection present?
Fever
Oliguria
Deteriorating renal function
Renal enlargement / tenderness
