Module 7: Primary Care Adaptations In Pregnancy - Chronic Conditions Flashcards
1
Q
Common Chronic Conditions in Pregnancy
A
- Asthma
- HTN
- DM
- Thyroid Disease
- Anxiety
- Substance Abuse
2
Q
Managing Asthma in Pregnancy
A
- Stepwise therapy is recommended
- Uncontrolled asthma may adversly affect both maternal quality of life nad perinatal outcomes
- Pregnancy may be complicated by new onset or pre-existing asthma
3
Q
Asthma Step-Wise Therapy in Pregnancy
A
- Mild intermittent — SABA PRN
- Mild Persistent — Low Dose ICS OR cromolyn, leukotriene, Theophylline
- Moderate Persistent — Low dose ICS + Salmeterol
- Medium dose ICS
- Medium dose ICS and Salmeterol
- Low or medium corticosteroid, LRA, and Theophylline - Severe Persistent
- High dose ICS and Salmeterol and oral steroid (if needed)
- Alt high dose ICS and theophylinne and oral steroid (if needed)
4
Q
HTN in Pregnancy
A
- Common medical condition in pregnancy
- Managed in consultation w/ Women’s health provider
- Occur in 5-10% of pregnancies
- 5 types
- Chronic HTN
- Gestational HTN
- Pre-eclampsia
- Superimposed Pre-eclampsia on chronic HTN
- Eclampsia
5
Q
Diagnostic Criteria in HTN
A
- Chronic - Asymptomatic BP > 140/90 <20 wks w/ no proteinuria
- Gestational - Asymptomative BP > 140/90 >20 wks w/ no proteinuria
- Pre-eclampsia
- Mild - BP >/= 140/90 w/ urin protein > 2g/24 hrs
- Severe >/= 160/110 w/ urine protein > 5g/24 hrs, Platelets <100,000, elevated AST, ALT, LDH, and serum creatinine > 1.2mg/dl
- Sx’s include: Headache, Altered mental status, visual changes - Superimposed Pre-eclampsia
- Sudden increase in BP >/= 140/90, proteinuria, and low platlets <20 wks - Eclampsia - Seizures
6
Q
Baseline HTN testing in Pregnancy
A
- Urine Dip for protein
- Hct, Hgb
- Plt count
- Serum Creatinine
- Electrolytes
- LFTs
7
Q
HTN Medications Safe in Pregnancy
A
- Nifedipine
- Labetalol
- Methyldopa
- AVOID ACE and ARBs **
8
Q
Diabetes in Pregnancy
A
- Approximately 6-9 % of pregnancies are complicated by DM - 90% by destational DM
- Fetal risk is dependent on how well BS is controlled in 1st trimester — PRE-CONCEPTION COUNCELING IS CRUCIAL**
- EVEN MILD LEVELS of hyperglycemia can cause anencephaly, microcephaly, and congenital heart disease
- Work with Womens health provider and endocrinology if necessary
9
Q
Gestational Diabetes Diagnosis Criteria
A
- Typically diagnosed at 24-28 weeks gestation
- Women at HIGH RISK screened sooner
- Previous GD
- Previous large for gestational age delivery
- Family Hx
10
Q
Diabetes Treatment in Pregnancy
A
- Encourage TIGHT glycemic control
- Refer for a nutritional consult
- Managed w/ insulin if diet along is not helpful
- Test for DM post-delivery, every 1-3 yrs after diagnosis of GD
11
Q
Maternal Thyroid Changes
A
- Maternal Thyroid changes are SUBSTANTIAL
- Structure — Mild increase in size
- Function — Changes in thyroiglobulin concentrations and a diluted blood volume lead to TSH/T4 level alterations
12
Q
Thyroid Lab Values
A
- TSH is the most reliable indicator of hypo and hyperthyroid
- Most labs do NOT provide trimester specific reference ranges for pregnancy
- Reference ranges are generally lower during pregnancy
13
Q
Hypothyroidism in Pregnancy
A
- There is an increased need for T4 as early as 4-6 weeks
- Most common cause is Hashimoto’s thyroiditis
- 5-8% increased incidence w/ Type 1 diabetes
Other causes:
- Thyroidectomy
- Ablative radioactive therapy
- Iodine deficiency
- Subacute thyroiditis
14
Q
Hypothyroidism Maternal/Fetal Risks
A
- Stillbirth
- Spontaneous abortion
- Pre-eclampsia
- Gestational HTN
- Placental abruption
- Low birthweight
- Preterm labor
- With iodine deficiency, there can be congenital cretinism and mental defects
15
Q
Hyperthyroidism in Pregnancy
A
- Prevalence is 0.05 - 0.02%
- Graves disease is the most common cause (up to 95%)
Other causes include:
- Toxic multinodular goiter
- Pituitary Tumor
- Metastatic Disease
- Exogenous T4 and T3
16
Q
Hyperthyroid Maternal/Fetal Risks
A
- Spontaneous AB
- Premature birth
- Low-birth weight
- Stillbirth
- Preeclampsia
- High output heart failure
- Thyroid storm
17
Q
Hyperthyroidism Treatment in Pregnancy
A
- Anti-Thyroid medications cause congenital abnormalities and neonatal hypothyroidism
- Radio-Active ablation can cause
- Neonatal Goiter or hyperthyroidism - Thyroidectomy*
18
Q
Anxiety in Pregnancy
A
- Non-pharmacological treatemtns such as cognitive behavioral therapy should be employed whenever possible for tx of anxiety disorders during pregnancy
19
Q
Anxiety Medications in Pregnancy
A
- Based on severity, two classes of drugs are prescribed
- SSRIs — Fuoxetine, sertraline, citalopram
- Severe cases - Benzodiazapines (Let psych or womans health prescribe this)*** Don’t give from FNP standpoint
20
Q
Substance Abuse in Pregnancy
A
- The 5 P’s is an effective tool of engagement for use with pregnant women who may use alcoholr or drugs
- Poses questions r/t substance use by womens Parents, Peers, Partner, during past Pregnancy and in her Past - Alcohol and cigarettes are most used substances in pregnancy
- Screen ALL pregnant women for substance use w/ validated screening tool
21
Q
Tobacco and pregnancy
A
- Risk is dose dependent and can cause
- Pre-term birth
- Placental abruption
- Low birth weight - Treatment
- Nicotine patch +/- gum or lezenge
- Offer tools/therapy
22
Q
Alcohol and Pregnancy
A
- There is NO safe amount of alcohol
- Risk for Fetal Alcohol Syndrome is Dose dependent
- Can lead to physical, behavioral, and learning disabilities - Risk for withdrawal syndrome — refer for counseling and treatment ASAP
23
Q
Illicit Drugs in Pregnancy
A
- Refer for specialized care
2. Mothers are at risk for avoiding prenatal care, overdose and death
24
Q
Points to Remember
A
- Primary Care Clinicians MUST focus on chronic disease management in the PRE-CONCEPTION period
- Primary Care clinicians MUST work with women’s health providers and specialists in concert to prevent chronic illnesses that occur before during and after delivery
