Obstetric Medicine Flashcards
What is the BP cutoff for diagnosis of hypertension during pregnancy?
Office BP SBP >=140 or DBP >=90
Ambulatory BP SBP >=135 or DBP >=85
If SBP >=160 or DBP >=110, SEVERE
What is the BP treatment target during pregnancy?
DBP < 85
What are BP treatment options during pregnancy? what should you avoid?
Labetalol Methyldopa Long acting nifedipine Metoprolol, propanolol, pinolol, acebutalol (NOT ATENOLOL) Clonidine Hydralazine Thiazide
AVOID ACE/ARB
What are criterias to diagnose pre-eclampsia?
BP > 140/90 x 2 or 160/110 x 1
PLUS one of:
1) New or worsening proteinuria >=2+ on dipstick, PCR > 30, or >300mg of protein 24hr
2) One of: headache/vision changes, dyspnea/chestpain, RUQ pain, new edema/anarsarca, seizures, hyperreflexia/clonus
OR
Lab abnormalities: Hb, PLT, LFT, Cr, Uric acid, LDH, bili, bloodfilm, INR/PTT, fibrinog
OR
Fetal complications: IUGR, oligohydramnios
- Severe complications.
How do you prevent pre-eclampsia?
- ASA 81-162mg daily (start before 16 weeks, continue until 36 weeks). Indications:
- Previous pre-eclampsia
- chronic HTN
- Type 1 or 2 DM
- CKD
- SLE
- APLA
- Multiple gestation
- 2 of (nulliparous, age > 40, BMI > 30, IVF) - Calcium
- Placental ultrasound
- APLA testing
How long do you treat acute VTE in pregnancy? What is the drug of choice?
Mininum 3 months including 6 weeks post partum.
LMWF or UFH with weight based dosing
Who gets VTE prophylaxis antepartum and postpartum for 6 weeks?
- Prior VTE - unprovoked, estrogen-related (pregnancy, OCP), associated with low risk thrombophilia.
- Homozygous Factor V Leiden
- Combined thrombophilias
- ATIII deficiency with family history of VTE.
- APLA or history of pregnancy loss (with low dose ASA).
Who gets VTE prophylaxis just postpartum for 6 weeks?
- Provoked VTE that was not estrogen-related with resolution of risk factors.
- Protein C or S deficiency with family history of VTE.
What should you do with diabetes medications pre-pregnancy?
- Discontinue ACEi/ARB (if CKD, continue up until pregnancy)
- Discontinue statin
- Discontinue non-insulin diabetes meds except for metformin and glyburide
- Start ASA 162mg daily at 12-16 weeks to decrease risk of pre-eclampsia
What are glucose targets during pregnancy?
Fasting <5.3
1h post prandial < 7.8
2h post prandial < 6.7
A1C <6.5 during pregnancy
Intrapartum BG between 4-7
When should you screen for gestational diabetes in pregnancy? what counts as positive test?
Screen at 24-28 weeks
50g 1 hr OGCT: >=11.1 GDM diagnosed; 7.8-11.1 move to OGTT; <= 7.8 normal
75g 2hr OGTT: FPG >=5.3, 1hr >=10.6, 2hr >=9
How do you manage gestational diabetes post partum? What should you counsel them on?
STOP insulin/metformin/glyburide postpart.
75 OGTT in 6 weeks - 6 months to rule out T2DM
Encourage breastfeeding immediately to avoid neonatal hypo.
50% will have GDM in subsequent pregnancy. 20% will develop T2DM in 10 years
What are symptoms of intrahepatic cholestasis of pregnancy? what are treatments?
Pruritis WITHOUT rash of palms and soles, worse at night.
LFT tends to be <1000s, mild elevation in bili
Treat with ursodiol, hydroxyzine or rifampin
What are symptoms of acute fatty liver of pregnancy? what are treatments?
Nausea, vomiting, abdo pain, encephalopathy, jaundice, ascites, polydipsia and polyuria
LFT < 500s
++++ conjugated bili elevation
Treat with delivery or transplant
What IBD medications are safe during pregnancy? what should you discontinue?
Discontinue MTX at least 3 months preconception
5-ASA, Azathioprine, anti-TNF, prednisone considered safe.
If using anti-TNF, avoid live vaccines in baby until > 6 months of age
What are platelet thresholds for delivery?
> 30 for vaginal
50 for c section
80 for neuroaxial anesthsia
What are platelet transfusion thresholds during HELLP or preeclampsia?
< 20 transfuse all
C section < 50 transfuse
> 50 transfuse only if actively hemorrhaging or ongoing coagulopathy
What are treatment platelet targets for ITP during pregnancy? What are treatment options?
Treat if plt < 30, clinically bleeding to < 50 near delivery
Give prednisone or IVIG, avoid dex as it crosses the placenta
What is the timing of peripartum cardiomyopathy? What should you counsel patients on?
Last month of pregnancy until 5 months post partum in absence of alternative etiology
If EF recovers >40% = 20% recurrence
If EF remains < 40% = 50% recurrence with 20% mortality
How do you treat peripartum cardiomyopathy?
Beta blockers (metoprolol, AVOID atenolol), lasix, hydralazine, nitro
AVOID ACE/ARB
AVOID spironolactone
UNCLEAR if early delivery will improve outcome
What antiarrhythmics are safe to use during pregnancy? What should you avoid?
Adenosine
CCB (verapamil)
Beta blocker (NOT atenolol)
Digoxin
Avoid amiodarone = fetal hypothyroidism
What vaccines are contraindicated in pregnancy? What precautions needs to be taken if received pre-pregnancy?
Live/live attenuated vaccines:
Varicella MMR Rabies Yellow fever Nasal influenza
If given pre-pregnancy, delay getting pregnant for 4 weeks.
When are patients with VWF disease at highest risk of bleeding during pregnancy? When should you repeat testing for diagnosis?
Highest risk bleed postpartum 7-14 days
Repeat testing 6 weeks post partum for diagnosis (VWF level go up in 3rd trimester for all women)
What is diabetes associated with in pregnancy?
Fetal still birth, perinatal death, macrosomia/Large for gestational age.
Maternal progression of microvascular disease, pre-eclampsia
