obs med total Flashcards
define htn in pregnancy
> 140/90 ( office)
135/85 (ambulatory)
severe htn and consequence
> 160/110
- stroke, placental abruption, ischemia
BP target in pregnancy per SGOC 2022
<85 mm hg ( diastolic)
SBP target in practice
130-140
CHIPS NEJM 2015 vs htn ( tight vs less tight)
those with less tight and would reach ad 160/110 had labs more in keeping with HELP
2nd line meds in BP in pregnancy
- hydralazine
- clonidine
- thiazide
lactation safe ACEI
- captopril
- enalapril
- quinapril
example of meds to avoid in pregnancy
- atenolol
- acei
- prazosin
what type of issue acei in pregancy can cause
- fetal renal agenesis
-oligohydramnios - pulmo aplasia
Treatment non severe HTN
- labetalol 100mg TID ( max 1200 mg DIE)
- methyldopa 250 mg TID : max 750 TID
- nifedipine XL 30 mg DIE ( max 120 mg IDE)
severe hypertension tx
- nifedipine IR : 5-10
- labetalol 10-20 push
- hydralazine 5-10 mg IV q30min
name 7 high risk factors for preeclampsia
- chronic htn
- db
- obesity
- autoimmune conditons ( SLE/APA)
- renal issue
- IVF
- hx of preeclampsia
name moderate RF ( 3)
- age >40
- nullipartity /multiple gestation
- abruption, still birth, fetal growth restriction
preeclampsia dx
- htn
and one of the following - proteinuria ( 2+ dipstick, urine pcr >30, acr >8, >300 24H)
+/-
- mat sx : headache, cp, ruq pain, vision change, edema, anasarca, seizures, clonus
- lab abn : hb, plt, lft, ldh, bili, fibrinogen, coag , blood film
- fetal : iugr, oligohydramnios, abnormla doppler in placental ( reversed endd or absent in diastolic phase)
Does BP treatment prevent progression of preeclampsia ? yes no ?
what dodes it prevent the progression of
- no
- progression of severe htn and reduction in stroke risk
what does the MAGPIE TRIAL
- in woman with preeclampsia : magnesium decrease elampsia risk and decreases maternal mortality ( trended towards)
magnesium toxicity risk
- decrease bp, hr, gcs, urine output, reflex
magnesium tox antidote
- calcium gluconate
what do you monitor for mg toxicity - 2
- uo
- reflex
plt level which epidural is safe ?
75
antenatal corticosteroid as of what week
<35 weeks
all women with hypertensive disorders of preg should have what measured in PP ?
lipids !
in htn prego, who should you consider vte ppx?
– C-section
- preeclampsia with IUGR
- postpartum hemorrhage >1L
- bedrest >7days antepartum
- assistant reproductive technology
- pre- pregnancy BMI >30
- age>35
- smoking
- placenta previa
- IUGR… and more
Two or more risks = suggest thromboprophylaxis
diagnostic OBS APS criteria
1) ≥ 3 consecutive unexplained prefetal deaths <10 weeks and/or early fetal deaths > 10 weeks - 16 weeks, or
2) Fetal death 16 weeks - 34 weeks, or
3) Pre-eclampsia with severe features and/or
placental insufficiency* with severe features (<34 weeks) with or without fetal death
+
Lupus anticoagulant, anti-cardiolipin, or beta-2- glycoprotein, if positive repeat in 12 weeks
3 crtieria of YEARS algorithm for PE . what else do you add to this ? this is based on which study ?
Assess for 3 criteria of YEARS algorithm + D- Dimer.
1. S&S dvt
2. hemoptysis
3. PE felt like most likely diagnosis
d dimmer
artemis study ( NEJM 2019 )
- 3 negative clinical criteria + d-dimer <1000 ng/mL: PE ruled out
- 1 or more clinical criteria + d-dimer <500 ng/mL: PE ruled out
can d dimer rule out vte safely in those with low/intermediate or unlikely pretest probability ?
yes
does tpa cross placenta
no
Noacs in pregnancy? bf ?
no and no
in what cases do you give VTE with at3 deficiency ( antepartum & PP)
in the case of + family history
do you give vte ppx in contex tpof protein c or S deficiency
usually no, but could consider in PP if + fam hx
heterozygous VFL, do you given vte ppx ?
no
APLA , do you give vte ppx
yes
- antepartum with ASA
- PP continued
if on therapeutic anticoagulation, how long before epidural do you hold LMWH and UFH
- 24h pre
- 6h pre
how long after delivery do you resume anticoagulation
- ppx 4hrs post neuraxial anesthesia removal
- 4-6h post vag delivery
- 6-8h post c section
antiocagulation not safe in breastfeading ?
DOAC
when is gestational thrombocytopenia the worst ?
t3
gest thromobcytopenia, how low dod you usually go and do you need to tx?
- around 70-100
- no tx , resolves 6 weeks PP
when do you transfuse in itp
- plt <30
- bleeding
- for delivery <50 near delivery
itp tx in pregnancy
prednisone
IVIG
IDA associated w/ ?
- PPH
- Depression/anxiety
- fatigue/SOB
what can you do to reduce PPH` ?
- iron tranfusion
- transexamic acid
“SEUIL” to dx anemia in pregnancy ?
<110
only AHA to use in pregnancy ?
mtf, glyburide
what did the conceptt trial in type 1 db pregnant woman say ?
cgm kept hba1c in target, less LGA, fetal hypoglycemia andd NICU admission
mity trial stated what about t2d
type 2
diabetes of Metformin vs placebo:
- No difference in composite neonatal morbidity and mortality
- Mothers had better glycemic control, less weight gain, and less requirement for insulin.
- Lower infant weight noted in secondary outcome.
- Long term effects on infants/children weren’t studied, paucity of data in literature.
2nd step 75g OGTT test values
5.3, 10.6, 9
1st step if 75g OGTT
5.1, 10, 8.5
BG targets in pregnancy
- fasting
-1h post
- 2h post
- hba1c
-intrapartum BG
- 5.3
- 7.8
- 6.7
-6.5% - 4-7
who do you screen for PP thyroiditis? and how long after ?
- those with t1dm
-3M post
do you repeat 75G ogtt postpartum ? when ?
yes
- 6w - 6M
morning sickness or hyperemesis gravidarium is associated with transaminitis?
HG
what are you first line treatment for HG ?
metoclopramide + gravol + ppi + e+ replacement
1st line gerd tx in prego, followed with what ?
calcium carbo –> h2i –>ppi
HG is highest at what time during pregnancy
t1
budchiari when in pregnancy ?
pp
ALFP when in pregnancy
end t3, PP
IH cholestasis when in pregnancy
t2-t3
help/preeclampsia when ?
t2-pp
bile acid level assocaited with still birth
100
tenofovir started when in mothers
28-32
do you treat hep c during pregnancy ?
no
hypoxia vs dyspnea, which is abN in pregnancy
hypoxia
prominent/mildly elev ated jvp normal in pregnancy ?
yes
definition of peripartum cardiomyopathy and timing ?
systolic with EF <45% . timing is last month of pregnancy ad 5M PP
treatment of peripartum cardiomyopathy
- lasix
- mtp
- nitro vs hydralazine vs digoxin ( if refractory)
number one unstable syncopal reason in pregnacy ?
embolism ( PE/amniotic fluid)
VT/VF in pregnancy
- meds to give
- meds to avoid + why
- bb
- amiodarone – fetal hypot4
dose of warfarin considered safe in pregnant woman if really have no choice ? sinon..
5 mg
sinon - switch to lmwh
which valve lesions better tolerated in pregnancy ?
regurgitant
antibio CAP pregnancy
macolide and beta lactam
CAP risk in pregnancy
preeclampsia, preterm bb, low birth weight
risk if give fq in cap prego
cartilage prob
risk if give tetracycline in prego
- teeth staining and bone growth suppression
risk if give sulfa in pregnancy
having kernicterus
IBD - when to stop mtx ?
3 months pre conception
what meds can continue during pregnacy with IBD
- aza
- anti tnf
- 5 ASA ( ensure phthalate free)
if bb exposed to tnf, what’s precaution to take
don’t give them live vaccine x >6 months ( i.e. rotavirus)
