Module 7: (b) Primary Care Adaptations In Pregnancy - Acute

Question 1

Respiratory Conditions in Pregnancy Background

Answer 1

1. Mucosa of Nasopharynx becomes edematous
2. Hypersecretion of mucus occurs secondary to an increase in estrogen
3. Nasal congestion secondary to hyperemia
4. Dyspnea is common 60-70%
5. Throughout Pregnancy, a woman, breaths in MORE AIR with each breath

Question 2

Examples of Respiratory Conditions in Pregnancy

Answer 2

1. Upper Respiratory tract
   - Allergic Rhinitis — URI
2. Lower Respiratory Tract
   - Bronchitis, PNA, Asthma
3. Systemic Conditions
   - Influenza, COVID

Question 3

Clinical Management of Respiatory Conditions

-Approved Medications

Answer 3

1. Treat w/ approved OTC Medications
   - Sudafed
   - Allegra
   - Claritin, Claritin D
   - CHlor-Trimeton D/Chlor-Trimeton DM
2. Approved Antibiotics
   - Amoxicilin, first-generation Cephalosporins,
   - Azythromycin

Question 4

GERD

Answer 4

1. Occurs in 30-50% of pregnancies
2. Sx’s
   - Dysphagia & Reflux
3. Prevention
   - Avoid food triggers, excessive weight gain, increase water consumption between meals
   - Smoking cessation
   - Elevate HOB during sleep

Question 5

Treatment of GERD

Answer 5

1. Calcium Carbonate - MAX 1000 mg/day
2. Famotidine (Pepcic) — 20-40 mg BID
3. Lansoprazole (Prevacid) 15 mg daily

Question 6

Constipation

Answer 6

1. Extremely common in pregnancy
2. S/Sx’s
   - <3 stools per week
   - Hard stools w/ straining
   - Incomplete evacuation
   - Rare SBO (more common w/ bowel or gastric bypass Sx

Question 7

Constipation Treatment

Answer 7

1. Prevention
   - Fiber, fluids, physical activity, and probiotics
2. Treatment
   - Milk of magnesia
   - Senokot
   - Biscadoyl
   - Colace

Question 8

Hemorrhoids

Answer 8

1. Caused by increase blood flow to the pelvic region and straining secondary to constipation
2. Sx’s typically most painful 1-2 days post-partum

Question 9

Hemorrhoid Treatment

Answer 9

1. Fiber, fluids, activity
2. Stool softeners (Colace) - Prevent straining during stools

Treatments

• Warm soaks
• Witch hazel pads
• Hydrocortisone-pramoxine cream of suppository BID —NO MORE THAN 7 days

Question 10

Nausea and Vomiting

Answer 10

1. Caused by delayed gastric emptying and relaxed gastroesophageal sphincter
2. Most prevelant in 1st trimester but may persist into 3rd trimester
3. Treatment
   - Maintain adequate hydration and nutrition
   - Doxylamine (Unisom) and Vitamin B6
   - Emetrol

• Antiemetics — Promethazine (Caution d/t neonatal resp depression) , metoclopramide (reglan)
• Rehydrate and correct electrolyte imbalances (IV may be needed)

Question 11

Food Cravings

Answer 11

1. COMMON in pregnancy
2. Some have PICA
   - Dirt, Ice, laundry or corn starch, coffee grounds, paint chips, rocks

Question 12

UTI’s

Answer 12

1. Occur in up to 20% of pregnancies
2. 10 % of antepartum hospital admissions
3. Increased incidence of Pyelonephritis (20-30 fold)
4. Risk for Pre-term labor
5. Caused by
   - Reduced bladder tone
   - Ureteral and renal pelvis dilation
   - Decreased ureteral peristalsis and incomplete bladder emptying
   - OBstruction of ureters d/t mecahnical compression

FOLLOW UP CULTURE to make sure infection is resolved

Question 13

Dermatologic Complaints Treatments

Answer 13

1. Antihistamines
2. Topical steroids
3. Oral steroid tapers for severe cases

REFER to dermatology

Question 14

MATERNAL MORTALITY AND PREGNANCY COMPLICATIONS

Answer 14

MATERNAL MORTALITY AND PREGNANCY COMPLICATIONS

Question 15

Maternal Mortality Definitions

Answer 15

1. Pregnancy associated death — Death of a person occuring while pregnancy or w/in 1 yr of pregnancy regardless of cause
2. Pregnancy associate but not related death —Ex: pregnannt person dies in an earthquake
3. Pregnancy Related death TEST
   - Person who dies from preganncy complication, chain of events initiated by pregnancy, or aggravation of an unrelated condition by physiology effect of prenangy - Eclampsia

Question 16

Pregnancy Complications

-Chronic HTN

Answer 16

1. HTN presenting <20 weeks gestation or persisting for more than 6 wks postpartum
2. 1/3 of women w/ chronic HTN will develop superimposed pre-eclampsia
3. Fetal risk are secondary to poor vascular development
   - Growth restriction, placental abruption, premature delivery
4. Management
   - Baseline labs at 1st prenatal visit — CMP, CBC, baseline 24 hr urine protein, creat, ECG
   - Treat BP >160/105 — Labetalol and nifedipine** preferred
   - AVOID ACE/ARBs
   - Low dose ASA after 12 wks to prevent pre-eclampsia

Question 17

Pregnancy Complications

-Pre-eclampsia

Answer 17

1. Involves maternal and fetal factors resulting abnormal devleopment of placental vasculature and maternal systemic endothelial dysfunction
2. Fetal hypoxia, growth restriction, stillbirth placental abruption, preterm labor
   - Maternal HTN, prteinuria, organ damage
   - Increase risk of CV disease in the future
3. Risk Factors — Hx of pre-eclampsia, chronic HTN, pre gestational DM, Renal disease, autoimmune dz. (Ie lupus)

Question 18

Pre-Eclamspia Diagnostic Criteria

Answer 18

1. Blood pressure
   - BP >140/90 on more than 2 occasions at least 4 hrs apart after 20 wks
   - BP> 160/110

AND

2. Proteinuria
   - 300mg or more per 24 hr urine collection
   - Protein/creatinine dipstick ration of 0.3mg/dL or more
   - Dipstick reading of 2+ (only if other methods not available)

OR

• Thrombocytopenia (PLT <100k)
• Renal insufficiency (Creatinine >1.2mg/dL)
• Impaired liver function (LFT 2x higher than normal)
• Pulmonary edema
• New HA unresponsive to meds OR visual sx’s

Question 19

Eclampsia

Answer 19

1. New onset of tonic-clonic, focal, or multifocal seizures in the absence of epilepsy, cerebral arterial ischemia, drug use, intracranial hemorrhage
2. Significant cause of maternal death
3. Treatment
   - Seizure mgmt
   - Magnesium sulfate for prophylaxis
   - manage HTN
   - Delivery once stabalized

Question 20

Placenta Previa

Answer 20

1. Painless bright red vaginal bleeding**TEST
2. Abnormal implantation of placenta over the internal cervical os
3. Diagnosed with Transvaginal US
4. AVOID vaginal exam
5. REFER

Question 21

Placental Abruption

Answer 21

1. Premature seperation of the normally implanted placenta from the uterine wall
   - 50% occur prior to labor
   - High fetal/neonatal mortality rate
2. Risk factors
   - HTN, Cocaine, prior abruption, tobacco, abdominal trauma
3. Sx’s
   - Sudden onset of DARK red vaginal bleeding with PAIN
4. Tx - stabalize, fetal monitoring, prepare for hemorrhage, delivery