Medical - Heme - Onc - Diabetes Flashcards
In a pregnant patient with thrombocytopenia, what is your differential diagnosis?
Gestational thrombocytopenia Pseudothrombocytopenia (Platelet clumping) ITP - antiphospholipid syndrome - lupus TTP / HUS / DIC Preeclampsia / HELLP syndrome HIV / Hep C / CMV Meds: Heparin
In a pregnant patient with thrombocytopenia, what is your workup?
H&P (heavy menses, easy bruising/bleeding, medications, petechiae)
vitals (BP assessment)
CBC
Peripheral smear (pseudothrombocytopenia/clumping)
What is gestational thrombocytopenia? What causes it?
Thrombocytopenia that can occur in pregnancy due to hemodilution and enhanced clearance
How can gestational thrombocytopenia be distinguished from ITP?
ITP:
Also seen out of pregnancy
Can be symptomatic
Associated with neonatal thrombocytopenia
Gestational:
Not outside of pregnancy
Asymptomatic
No neonatal thrombocytopenia
Platelet count usually above 75k and return to normal postpartum
Management of suspected Gestational thrombocytopenia?
CBC follow up
Postnatal CBC to assess resolution
What is ITP?
Immune thrombocytopenic purpura, an autoimmune disorder where antibodies cause destruction of platelets
What causes ITP?
Primary: Autoimmune destruction of platelets
Secondary: HIV, HCV, SLE or Leukemia
Drug induced: Heparin, NSAIDs monoclonal antibodies
How is ITP diagnosed?
Base on history, labs and physical exam findings, mostly a diagnosis of exclusion
What are potential complications associated with ITP in pregnancy?
“Bleeding
Fetal/neonatal thrombocytopenia”
If a patient presented with suspected ITP at 35 weeks with a platelet count of 40,000, How would you counsel her?
Counsel that there is no test to predict course of platelets for her or fetus
Try to minimize bleeding
If she has an indication for a cesarean, we can discuss increasing platelets with steroids
Avoid NSAIDs
If a patient presented with suspected ITP at 35 weeks with a platelet count of 40,000, How would you manage her?
Multidisciplinary approach (Anesthesia, hematology, neonatology)
What are treatment options for ITP in a pregnant patient?
Steroids (Prednisone 0.5mg/kg daily, see response in 2 weeks)
IVIG (see response in 3 days)
Platelet transfusion (3X dose + intravenous high-dose corticosteroids or IVIG)
Splenectomy (avoid in pregnancy)
Rhogam (decreases platelet destruction)
Considerations for labor and delivery and neonatal care in ITP?
“Avoid scalp electrodes / operative vaginal delivery
Neonatal platelet count after delivery and at 2-5d of life
Avoid IM injections / circumcisions till platelet count returns”
When is treatment of ITP warranted?
“Symptomatic bleeding
Platelet count below 30,000
Expected surgery and platelet count <50,000
Neuraxial anesthesia desired and platelet count <70,000”
What are the fetal risks if the mother has ITP?
Fetal thrombocytopenia with hemorrhage (risk is less than 1%).
Below what platelet treshold is neuraxial anesthesia no longer allowed?
What is the goal platelet count before cesarean section?
Neruaxial anesthesia: 70,000
C/s: 50,000
What are the risks of neuraxial anesthesia in a thrombocytopenic patient?
Epidural hematoma
How do you counsel a patient with HELLP syndrome regarding her risks during cesarean section?
Risks of bleeding, DIC, seizures
How do you monitor / counsel about platelets counts after delivery in HELLP syndrome?
“Nadir is about 48 hours postpartum
Most platelet counts are above 100,000/L within a week”
“G1P0101 with a history of a prior 32 week delivery.
She remembers going to hospital with abdominal pain, n/v and confusion.
SHe was told she had mild fever and AST/ALT of 700/800, Bilirubin of 5, WBC 17k, Platelets of 22k and creatinine 2.2.
What is your D/Dx for what prompted this delivery?”
“Acute fatty liver of pregnancy
TTP / HUS
HELLP syndrome
Lupus with flare”
What would help you make a more definitive diagnosis of acute fatty liver of pregnancy?
“Very high LFTs
High Ammonia
Hypoglycemia
Prolonged PT/PTT
Decreased Antithrombin level
Decreased fibrinogen”
Etiology of AFLP?
“It can be due to Long Chain 3hydroxyacyl CoA Dehydrogenase (LCHAD) deficiency
But other enzyme deficiencies have also been demonstrated (more rare)”
If the diagnosis was Acute fatty liver of pregnancy, how do you counsel her regarding a future pregnancy?
Higher risk of recurrence in another pregnancy, but unclear how high
~25%
Follow up in future pregnancies when AFLP occurred prior?
Baseline labs, and increased monitoring of labs starting 1 month prior to gestational age of prior diagnosis.
“Pregnant patient in the ICU with a platelet count of 5, high fever and was not arousable.
What is your differential diagnosis?”
“Thrombotic thrombocytopenic purpura
HUS
DIC
HELLP
AFLP”
What findings should make you suspect TTP?
“Microangiopathic hemolytic anemia (MAHA)
Thrombocytopenia
Fever
Acute Kidney Injury
Severe neurologic findings”
What lab test is a hallmark of TTP?
Reduced ADAMTS13 activity (<10%)
What is the treatment for TTP?
“Plasmapheresis in consultation with Hematology / Critical care
Steroids
Avoid platelet transfusion as can precipitate disease”
If you suspect a hemophilia, what tests would you send?
Factor 8
Factor 9
VWF antigen
ristocetin cofactor activity level
What are the risks of VWD in pregnancy?
Increased risk of bleeding
Risk of fetus having VWD
How do you follow patients with VWD in pregnancy?
Meds to avoid?
Labs?
Hematology for comanagement
Genetic counsultation
Anesthesia consult
Avoid antiplatelet drugs and IM injections
Labs q trimester:
-Factor 8
-Ristocetin cofactor activity
-VWF antigen
Goal VWF ristocetin cofactor activity level?
“50% for vaginal
100% for c/s”
How do you treat VWF in case of emergency or preoperativelly?
DDAVP intranasally or IV (elicits release of VWF from endothelial cells)
VWF precautions during labor and for newborn?
“No scalp electrodes
Avoid episiotomy
Avoid circumcision until VWD ruled out”
How is VWD inherited?
Autosomal Dominant
How are hemophilias inherited?
X linked recessive
Which patients should be screened for thrombophilia in pregnancy?
“Personal history of VTE (w/ or w/out risk factor and no prior testing)
1st degree relative with high risk thrombophilia”
When screening for thrombophilia what tests do you send?
“Prothrombin gene mutation - DNA analysis
Antithrombin 3 deficiency - Antithrombin activity
Protein S deficiency - Protein S Functional assay
Protein C deficiency - Protein C activity
Factor V Leiden - Activated protein C resistance -> DNA analysis”
What thrombophilia test results are not impacted by pregnancy?
All of the main ones are not impacted, only Protein S is
What are the most common thrombophilias?
1 Factor V leiden heterozygote (1-15%)
#2 Prothrombin gene mutation (2-5%)
What are the low risk thrombophilias?
“FVL heterozygote
PT gene mutation heterozygote
Protein C deficiency
Protein S deficiency”
What management do you offer for low risk thrombophilias without a prior VTE?
Antepartum vs. postpartum?
“Antepartum:
Surveillance without anticoagulation
Postpartum:
Surveillance or prophylactic anticoagulation (if additional risk factors such as obesity, c/s, or prolonged immobility)”
“What management do you offer for low risk thrombophilias with a family history (1st degree relative) of VTE?
Antepartum vs. postpartum?”
“Antepartum:
Surveillance without anticoagulation OR
Prophylactic dose anticoagulation
Postpartum:
Prophylactic dose anticoagulation OR
Intermediate dose anticoagulation”
“What management do you offer for low risk thrombophilias with a single episode of VTE - not receiving long term anticoagulation?
Antepartum vs. postpartum?”
“Antepartum and postpartum:
Prophylactic dose anticoagulation OR
Intermediate dose anticoagulation “
What are the high risk thrombophilias?
“FVL homozygote
PT gene mutation homozygote
FVL and PT combined heterozygote
Antithrombin 3 deficiency”
“What management do you offer for high risk thrombophilias without a prior VTE?
Antepartum vs. postpartum?”
“Antepartum and postpartum:
Prophylactic dose anticoagulation OR
Intermediate dose anticoagulation “
“What management do you offer for high risk thrombophilias with a personal history of a previous single VTE or a family history (1st degree relative) of VTE?
Antepartum vs. postpartum?”
“Antepartum and postpartum:
Prophylactic dose anticoagulation OR
Intermediate dose anticoagulation OR
Adjusted dose anticoagulation”
Which thrombophilias are candidates for adjusted dose (therapeutic dose) anticoagulation?
High risk with personal history
High risk with 1st degreefamily history
Any thrombophilia with 2 or more epsiodes of VTE
What are the risks and benefits of UFH use in pregnancy?
“Risks: unpredictable pharmacodynamics (dose-response), severe bleeding complications, and the risk of HIT
Benefits: prevention of VTE, short halflife / easy reversibility”
What are the risks and benefits of LMWH in pregnancy?
“Risks: severe bleeding complications
Benefits: once daily dosing prophylactically, lower risk of HIT”
Describe how you manage anticoagulation near-term in a patient on LMWH?
Switch from LMWH to UFH due to the easier reversibility / short halflife of UFH.
How long do you hold LMWH prior to IOL or C/S?
Prophylactic: 12 hours before IOL or C/S
Adjusted dose: 24 hours before IOL or C/S
How is FVL inherited?
Autosomal dominant
Is FVL a low-risk or high risk thrombophilila?
“Low risk if heterozygote
High risk if homozygote”
What is the risk of VTE in a patient with a low risk thrombophilia?
0.5-3%
As high as 6% in protein s deficiency
How is prothrombin gene mutation inherited?
Autosomal dominant
Is prothrombin gene mutation a low or high risk thrombophilia?
“Low risk if heterozygote
High risk if homozygote”
Anticoagulation offered ante and pp? LR No hx: LR fam hx: LR Pers hx: HR no hx: HR fam or pers hx: 2+ clots not on lt coag: 2+ clots on lt coag:
LR No hx: S SP
LR fam hx: SP PI
LR Pers hx: PI PI
HR no hx: PI PI
HR fam or pers hx: PIA PIA
2+ clots not on lt coag: IA IA
2+ clots on lt coag: A Lt coag
What is antiphospholipid antibody syndrome?
Autoimmune disorder defined by presence of clinical features and circulating antiphospholipid antibodies
How is antiphospholipid antibody syndrome diagnosed?
1 positive clinical criteria and 1+ positive lab criteria on 2 occasions 12 weeks apart.
What are the clinical criteria for the diagnosis of antiphospholipid antibody syndrome?
“1: Vascular thrombosis
2: Pregnancy morbidity:
(a) 1+ SAB after 10 weeks (unexplained, morphologically normal)
(b) 3+ SAB before 10 weeks (consecutive, unexplained, maternal hormonal/anatomic and parental chromosomal abnormalities ruled out)
(c) Pregnancy complicated with placental insufficiency, eclampsia/severe preeclampsia before 34 weeks”
What are the laboratory criteria for the diagnosis of antiphospholipid antibody syndrome?
(1) Lupus anticoagulant +
(2) Beta 2 glycoprotein IgM, IgG (titer greater than 99th percentile)
(3) Anticardiolipin antibody IgM, IgG (greater than 40 GPL or MPL, or greater than the 99th percentile)
How do you counsel a patient about the risks of antiphospholipid antibody syndrome?
thrombosis
preeclampsia
fetal growth restriction
fetal loss
autoimmune thrombocytopenia autoimmune hemolytic anemia
What are the rare complications of APS?
livedo reticular is cutaneous ulcers chorea gravidarum multiinfarct dementia transverse myelitis
How do you manage pregnancy in a patient with antiphospholipid antibody syndrome?
Hx of stillbirth, RPL: heparin and aspirin
Prior thrombotic event: heparin
No prior thrombotic event: surveillance or heparin
How do you manage anticoagulation postpartum for patients with antiphospholipid antibody syndrome?
“If no history of thrombosis: Postpartum heparin/aspirin x 6 weeks
If there is a history of thrombosis: Warfarin (lifelong)”
Long term risks of antiphospholipid syndrome?
Thrombosis, SLE
“42 yo G6P3023 at 11 weeks with history of stroke 2 years ago.
Meds: plavix, aspirin 81mg, Atorvastatin.
MTHFR homozygote
3 prior uncomplicated vaginal deliveries >10 years ago
What is your initial workup for this patient?”
“Targeted H&P specifically asking about residual symptoms, if the patient has ever been told to be on lifelong anticoagulation, is she followed by a neurologist fam hx of VTE
Inherited thormbophilias and APLS workup
Consider basic coags / cbc
+/-Imaging of the brain
Request old records”
“42 yo G6P3023 at 11 weeks with history of stroke 2 years ago.
Meds: plavix, aspirin 81mg, Atorvastatin.
MTHFR homozygote
3 prior uncomplicated vaginal deliveries >10 years ago
Labs: low protein C and S prior to pregnancy and not on anticoagulation
Negative for APLS
Records show 50% stenosis of internal carotid artery.
What is your plan of management for this patient in the antepartum period?”
“Neurology consultation (follow up for carotid scan)
Discontinue statins
Discontinue plavix
Start LMWH (talk to neuro about prophylactic vs. intermediate)
Continue ASA, add 1mg folic acid
Maternal Echo (PFO)
Counsel on low saturated fat diet
Growth / Antenatal testing “
What is alpha thalassemia?
Disorder of decreased alpha globin gene production due to gene microdeletions.
What does it mean to be a silent carrier for alpha thalassemia?
Microdeletion of 1 of 4 alpha globin genes
What is alpha thalassemia minor?
“Microdeletion of 2 of 4 alpha globin genes
Mild microcytic anemia”
What are the two forms of alpha thalassemia minor?
cis (both deletions on the same side), trans (both deletions on opposite sides)
What is Hemoglobin H disease?
“Microdeletion of 3 of 4 alpha globin genes.
HbH forms which is a β tetramer (4 x β chains)
Moderate microcytic anemia”
What is Hemoglobin Barts disease?
“Alpha thalassemia major
Microdeletion of all 4 alpha globin genes,
Severe microcytic anemia, hydrops fetalis”
How is Alpha thalassemia inherited?
Autosomal recessive
How do you diagnose microcytic anemia?
“Hb <11.0 (10.5 in 2nd trimester)
MCV < 80”
What is your differential diagnosis for microcytic anemia?
“Iron deficiency anemia
Thalassemias
Anemia of chronic disease
Lead/copper poisoning”
What are the fetal risks with Alpha thalassemia?
If the fetus has 4 microdeletions (Hb Barts), hemolytic disease -> hydrops
Why does hydrops develop in fetuses with hemoglobin Barts?
“The fetus is unable to synthesize normal Hb as alpha globin is needed for all of them.
This deficiency results in high-output cardiac failure, hydrops fetalis, and stillbirth.”
Why is hemoglobin Barts more likely to develop in fetuses of Asian ancestry?
They are more likely to have cis configuration of 2 microdeletions which are needed in both parents to have a fetus with Hb Barts.
How do you screen for Alpha thalassemia?
CBC, if anemic and not iron deficiency -> Hb electrophoresis, if normal –> alpha globin gene testing
What would you expect to see on a hemoglobin electrophoresis for a patient with Alpha thalassemia?
Normal Hb electrophoresis
What are pregnancy risk for patients with Alpha thalassemia?
“α-thalassemia trait: no significant different from normal.
Hb H disease: mild to moderate chronic anemia, with overall favorable outcomes”
If you identify pregnant woman with a microcytic anemia, what are the next steps in your evaluation?
H&P (fam hx, lead exposure) , Ferritin, Hb electrophoresis
What is beta-thalassemia?
Disorder of decreased beta globin gene production due to gene mutations
What is the difference between beta+ vs beta0?
“Beta+: decreased globin production
Beta0: absent globin production”
How is beta thalassemia inherited?
autosomal recessive
What does a Hb electrophoresis of a patient with beta thalassemia look like?
Increased HbA2 (>3.5)
Which beta thalassemia is transfusion dependent vs. non transfusion dependent?
“Transfusion dependent: Beta thal major (beta0:beta0 or beta0:beta+)
Not transfusion dependent: Beta thal intermedia (beta+:beta+)”
How is sickle cell disease inherited?
autosomal recessive
What is the difference between sickle cell disease and sickle cell trait?
“SCD: has mutations in both chromosomes and results in an affected state
SCT: has mutations in only one chromosome and result is a carrier state”
Who should be screened for sickle cell disease carrier status?
African american, Mediterranean, Latin american
How do you screen for sickle cell disease carrier status?
Hb electrophoresis
What would you expect to see on a Hb electrophoresis for a patient with sickle cell trait?
An HbS peak and a similar decrease in HbA
What would you expect to see on a Hb electrophoresis for a patient with sickle cell disease?
An HbS peak and no HbA (though may look closer to SCT if got a transfusion)
What are the maternal risks to pregnancy for a patient with sickle cell disease?
Hypertensive disorders of pregnancy Abruption Preterm labor Fetal growth restriction Hospitalization VTE Infections (UTI/pyelo, Pneumonia, Sepsis) Sickle crises Need for transfusion Pulmonary HTN Acute Chest Syndrome Death
What are the maternal risks to pregnancy for a patient with sickle cell trait?
UTI
If your patient is a sickle cell disease carrier, what are the next steps in your evaluation?
“Hb electrophoresis of FOB
Genetic counseling
Urine culture q trimester”
What is the likelihood of a sickle pain crisis occuring in pregnancy?
20-50% (berghella book)
What can precipitate a sickle pain crisis?
“Infection
Dehydration
Pain
Cold
Hypoxia (high altitudes)”
What are the typical signs and symptoms of a sickle pain crisis?
Pain in
chest
Abdomen
Joints
How do you manage a pregnant patient with a sickle pain crisis?
“Mostly symptomatic;
treat pain with opioids,
hydration,
antibiotics if infection suspected,
hematology consultation
fetal monitoring and consider steroids if viable”
How is acute chest syndrome defined?
New radiodensity on CXR accompanied by respiratory symptoms
The leading cause of death in sickle cell
Signs/symptoms of acute chest syndrome?
Temp > 38.5
Hypoxia
Tachypnea
Chest pain
Cough / wheezing / rales
How is acute chest syndrome managed?
“Pain control
Hydration
Oxygen/incentive spirometry
Blood transfusion
Antibiotics”
What are the potential complications of acute chest syndrome?
Pulmonary hypertension,
restrictive lung disease,
death
Prenatal care management in SCD?
“Genetic counseling / paternal testing
Aspirin for preeclampsia prevention??
Vaccinations
Folate
Baseline assessment for end organ damage
Iron only if ferritin low
Pain control
Avoid triggers
More frequent visits
Growth scans
Antenatal surveillance
C-section for usual obstetric indication”
What are risk factors for VTE?
“Cesarean delivery
obesity
hypertension
autoimmune disease
heart disease
sickle cell disease
multiple gestation
preeclampsia”
What are signs and symptoms of lower extremity VTE?
“unilateral extremity edema
erythema
warmth
pain and tenderness”
How do you evaluate a patient with a suspected lower extremity VTE?
Compression ultrasound of proximal veins
How do you manage a pregnant patient with an acute VTE?
“Adjusted dose anticoagulation for 3-6 months
Followed by intermediate or prophylactic dose for remainder of pregnancy and 6 weeks postpartum”
Do you perform a thrombophila evaluation on pregnant patients with an acute VTE or PE?
“Yes
But testing for protein c, protein s and antithrombin 3 def are not reliable during acute thrombosis
and FVL active protein c resistance testing is not reliable with anticoagulation
So I prefer to test postpartum, at least 6 weeks post thrombosis and while not on anticoagulation”
If you perform thrombophilia evaluation on a pregnant patient, what do you test for?
If not currently on anticoagulation or with acute thrombosis, I send all but protein S.
How do you follow anti-coagulation in a pregnant patient with an acute VTE?
“In LMWH: consider factor Xa levels (goal 0.6-1.0 units/mL) occasionally 4-6 hours post injection
In UFH: aPTT, goal of 1.5-2.5 x control, 6 hours after injection”
If a patient is on LMWH or UFH what are some risks?
“Bleeding
HIT (check platelet count at start and 7-14 days after initiation)
Osteopenia (recommend daily calcium and vit D supplementation)”
How long do you continue anticoagulation after diagnosis of acute VTE?
3-6 months adjusted dose, followed by intermediate or prophylactic dose for the remainder of pregnancy and 6 weeks postpartum.
How do you counsel a patient about recurrence risks of VTE?
3-4x risk of recurrence or higher depending on if thrombophilias are found
What signs and symptoms suggest possible pulmonary embolism(PE)?
“Tachycardia
Tachypnea
Hypoxia
Bloody sputum”
If a pregnant patient is suspected of having a PE, what workup do you perform?
“CXR -> V/Q scan if normal
CXR -> CTPA if abnormal”
How do you manage a pregnant patient with a PE?
3-6 months adjusted dose, followed by intermediate or prophylactic dose for the remainder of pregnancy and 6 weeks postpartum.
How do you monitor anti coagulation in a patient with a PE?
“In LMWH: consider factor xa levels occasionally 4-6 hours post injection
In UFH: aPTT, goal of 1.5-2.5 x control, 6 hours after injection”
How do you counsel a patient about recurrence risks of PE?
3-4x risk of recurrence or higher depending on if thrombophilias are found
What is a saddle embolism?
thromboembolus at the bifurcation of the pulmonary artery
What patients are considered candidates for thrombolysis?
Pulmonary embolism and hemodynamic instability due to increased risk of mortality (50% verses 2% in uncomplicated PE)
What are the risks of using thrombolytic agents such as TPA in a pregnant patient?
“Hemorrhage
Placental abruption”
When do you recommend delivery in a patient with VTE or PE?
39 weeks
How do you manage adjusted dose anticoagulation pre, during and post delivery?
“Discontinue heparin or Lovenox 24 hours prior to scheduled delivery with neuraxial blockade
Consider waiting at least 24 hours after neuraxial blockade and at least 4 hours after catheter removal to restart LMWH.
Sequential compression devices placed preoperatively, intraoperatively and for 12 to 24 hours postoperatively “
What % of breast masses in pregnancy are benign?
80%
What are the physiologic changes in the breast during pregnancy?
“Hypertrophy of ductal - alveolar system -> more dense and lobular
Makes diagnosis in pregnancy more challenging”
“37 year old G1 at 12 weeks presents with a painless lump in her left breast and some intermittent nipple discharge.
What is your initial workup?”
“Physical exam
Mammography / ultrasound
Possible MRI of the breast
DO NOT DELAY DIAGNOSIS”
“37 year old G1 at 12 weeks presents with a painless lump in her left breast and some intermittent nipple discharge.
What is your d/dx?”
“Benign: Lactating adenoma, fibroadenoma, ductal or lobular hyperplasia, galactocele
Malignant: Most common is infiltrating ductal adenocardioma, ductal carcinoma, lobular carcinoma”
If breast cancer diagnosis is made, <37 weeks what do you do?
“Staging: US liver, CXR, MRI bone
Intervention: Surgery, sentinel procedure
Chemo if >14 weeks
Radiation if <3rd trimester”
If breast cancer diagnosis is made in pregnancy, how do you counsel her regarding treatment options?
“1st tri: surgery, radiation
2nd tri: surgery, radiation, chemo
3rd tri: surgery chemo
Multidisciplinary approach to bring the least fetal harm and best maternal care”
If the initial diagnosis was made at 38 weeks gestation, would this change your management options for this patient?
Would delay treatment till after delivery (2-3 weeks postpartum)
Is mammography safe in pregnancy?
Minimal radiation (<0.01Gy) with abdominal shielding
Is breast surgery safe in pregnancy?
Minimal risk to fetus in all trimesters
In a patient s/p breast cancer 2 months ago in treatment with chemoa after bilateral mastectomy. What are her options regarding becoming pregnant in the future?
“Ideally wait 6 months post chemo, to allow oocytes time to mature
There is a risk of relapse,so consider waiting more than 2 years after diagnosis
I would personalize the discussion for each patient, particularly discussing the risk of relapse, future fertility options, age for starting a family and type of adjuvant tx and how long these various treatments would last.”
Breast cancer in pregnancy, symptoms and initial eval?
“Palpable painless mass, bloody nipple discharge, skin changes
US, Core needle biopsy”
Cervical cancer in pregnancy, symptoms and initial eval?
“Abnormal pap, friable exophytic mass
Colposcopy / biopsy”
Melanoma in pregnancy, symptoms and initial eval?
“New / growing pigmented lesion
Tumor excision / biopsy”
Ovarian cancer in pregnancy, symptoms and initial eval?
“Incidental ovarian mass / abdominal pain / bloating
US, surgery”
Lymphoma in pregnancy, symptoms and initial eval?
“Painless lymphadenopathy, systemic symptoms
CXR, biopsy, Bone marrow biopsy, Abdominal ultrasound”
Thryoid cancer in pregnancy, symptoms and initial eval?
“Palpable thyroid nodule
Fine needle aspiration”
Colorectal cancer in pregnancy, symptoms and initial eval?
“Bloody stool, abdominal pain diarrhea
Colonoscopy”
What are the maternal risks of pregnancy in patients with preexisting type 2 DM?
“Hyperglycemia
Preeclampsia / Gestational hypertension
Cesarean section
Perineal trauma
Postpartum hemorrhage”
What are the fetal risks of pregnancy in patients with preexisting type 2 DM?
“spontaneous abortion
fetal malformation
fetal macrosomia
shoulder dystocia
preterm delivery
fetal death
neonatal morbidity”
What are the maternal risks of pregnancy in patients with preexisting type 1 DM?
“Hyperglycemia
Preeclampsia / Gestational hypertension
Cesarean section
Perineal trauma
Postpartum hemorrhage
DKA
Renal disease
Retinopathy
Cardiac disease
Hypothyroidism”
What are the fetal risks of pregnancy in patients with preexisting type 1 DM?
“spontaneous abortion
fetal malformations
fetal macrosomia / fetal growth restriction
shoulder dystocia
preterm delivery
fetal death
neonatal morbidity”
How is HbA1C associated with fetal anomalies?
HbA1c 10% assosicated with a fetal anomaly rate of 20-25%
What are the most common fetal anomaly in patients with pre-existing diabetes?
“Complex cardiac defects
Anencephaly
Spina bifida
Skeletal malformations (sacral agenesis)”
What is a normal HbA1c level?
HbA1c<5.7%
What baseline laboratory evaluation do you perfrom in pregnant patients with preexisting diabetes?
“HbA1c
24 hour urine protein
CBC
CMP
TSH”
What other work up besides labs do you perform in pregnant women with preexisting diabetes?
“Ophthalmologist evaluation
EKG +/- Echo”
Outline your antepartum management of the pregnant woman with preexisting type 1 and 2 DM?
“Baseline labs
Establish dating
Referral to ophthalmologist
Referral to dietitian
Aspirin 81mg
NT scan
Detailed anatomic survey at 18-20 weeks
Fetal echocardiogram at 20-22 weeks
Fetal growth monthly
Twice weekly antenatal testing at 32 weeks
Delivery between 39 weeks and 39 weeks and 6 days
In women with vascular complications or poorly controlled blood glucose, consider delivery at 36 0/7 weeks to 38 6/7 weeks of gestation, and in rare cases, even earlier”
How do you counsel patients on continuing metformin in pregnancy?
“Gold standard/first line is insulin because it doesn’t cross placenta
Limited long-term safety information on metformin”
How do you counsel patients on nutritional requirements during pregnancy?
“Carb counting:
breakfast: 30-45g
lunch: 45-60g
dinner: 45-60g
15g snacks (2-3 hours post meals)”
When do you recommend patients with preexisting type 2 DM check their glucose while pregnant?
Fasting and 2 hours postprandial
What are your target glucose values in pregnancy?
“Fasting<95mg/dL
2 hours postprandial <120mg/dL “
How do you screen for diabetic retinopathy?
“Screening by ophthalmologist before pregnancy and 1st trimester
Plan for laser photocoagulation therapy to arrest progression”
How does pregnancy impact diabetic retinopathy progression?
It tends to progress 1/3 of the time
How do you assess for preexisting diabetic nephropathy?
“24 hour urine protein and creatinine clearance
24 hour urine protein should be <300mg
Creatinine clearance should be >87-107 mL/min (increased GFR)”
How do you counsel a patient regarding pregnancy risks if she has diabetic nephropathy?
“Increased hypertensive disorders
Increased uteroplacental insufficiency
Increased iatrogenic preterm birth d/t worsening renal function”
Describe how you will calculate the starting dose of insulin for a pregnant patient with diabetes?
“1st trimester: 0.7U/kg/day
2nd trimester: 0.8U/kg/day
3rd trimester: 0.9U/kg/day”
How do you calculate divided daily dose of insulin?
"50% glargine qhs 50% rapid acting divided by 3 with meals" Or 2/3 am 1/3 pm Am: 1/3 rapid , 2/3 nph Pm: 1/2 rapid, 1/2 nph
How do you counsel a patient regarding the risks and benefits of insulin vs oral hypoglycemic agents in pregnancy?
“Gold standard/first line is insulin because it doesn’t cross placenta
Limited long-term safety information on metformin”
How you will manage insulin in labor in pregestational DM patient?
“Take bedtime dose of insulin, Check glucose every 1 hour starting in morning along with the following:
<90: D5 1/2 NS, No Insulin
91-120 : D5 1/2 NS 0, Insulin 0.5 units / hr
121-140: D5 1/2 NS, Insulin 1 units / hr
141-160: 1/2 NS, Insulin 2 units / hr
161-180: 1/2 NS, Insulin 3 units / hr
181-200: 1/2 NS, Insulin 4 units / hr
>200: 1/2 NS, Insulin 4 units / hr + IV push 2U”
How will you manage insulin in pregestational DM patient prior to scheduled c/s?
“Consider taking only half her dose of long acting the night before
Hold AM doses of insulin
Use NS for anesthesia dose (not D5 to avoid hyperglycemia)”
Describe how you will manage glucose control in the immediate postpartum period for a type 1 DM patient?
“Reduced insulin requirements in first 24-48 hours.
Postop: D5 1/2 NS with 1/2 of there basal insulin until eating
Check glucose q 4-6 hours and treat with sliding scale
If low give juice or increase D5 or give a 100mL bolus of D10”
Describe how you will manage glucose control in the immediate postpartum period for a type 2 DM patient?
“Glucose levels tend to be normal or slightly elevated
Fasting, pre and postprandial glucose levels should be measured. Treat hyperglycemia with Insulin sliding scale.
After 24-48 hours should be back to close to pre-pregnancy levels.”
Describe how you will manage glucose control in the immediate postpartum period for a GDM patient?
“Stop diabetic medications after delivery
Can do sliding scale, or just check fasting glucose levels to assess for overt diabetes
If negative follow up 4-12 weeks postpartum with 2 hour OGTT”
A type 1 DM in on an insulin pump, describe how you will manage her pump at the time of induction of labor?
“Decreasing the basal rate by 50 percent
Administering bolus insulin doses as needed to correct hyperglycemia
During active labor, as insulin requirements rapidly drop, if the pump catheter becomes difficult to maintain, insulin administration, if needed, should be changed to continuous intravenous infusion “
A type 1 DM in on an insulin pump, describe how you will manage her pump at the time of scheduled cesarean delivery?
??? continuous insulin infusion until arrival to hospital for c/s
When do you recommend delivery in patients with pre-existing type 2 DM that is well controlled with insulin?
39w0d-39w6d
When do you recommend delivery in patients with well controlled GDM?
“39w0d-39w6d if on medications
39w0d-40w6d if diet controlled”
When do you recommend delivery in patients with pre-existing type 1 DM that is well controlled with insulin?
39w0d-39w6d
When do you start antepartum testing in patients with type 1 dm?
32 weeks
When do you start antepartum testing in patients with type 2 dm?
32 weeks
When do you start antepartum testing in patients with GDM?
32 weeks if on medication, none if on diet control
In patients with diabetes, at what estimated fetal weight do you recommend c/s?
At 4500g I say that you can consider c/s to prevent traumatic birth injury to the fetus
Who do you screen early for GDM?
“Obesity
Family history
Previous fetus >4kg
Previous GDM
HTN
PCOS
African american / Latino / Native american / Asian / Pacific islander”
How do you screen for GDM?
50g glucose challenge test
What are the diagnostic criteria for GDM?
“50g GCT >200
100g GTT with 2+ abnormal values
Carpenter/Coustan Cutoffs: 95, 180, 155, 140”
Once GDM is diagnosed, how do you counsel the patient about this diagnosis?
Can increase morbidity if uncontrolled.
hypertensive disorders
cesarean section
fetal macrosomia
fetal hyperbilirubinemia,
hypocalcemia,
hypoglycemia.
Increase risk of operative delivery, shoulder dystocia,
birth trauma.
What are your goals of therapy for gestational diabetes?
Fasting < 95, 2 hours postprandial <120
What is your first line medication for management of GDM? Why?
Insulin because it is effective and doesnt cross the placenta
When and how do you screen for diabetes postpartum for a patient with GDM?
a 75-g, 2-hour OGTT in the postpartum period (4-12 weeks postpartum)
