Obstetric Medicine

Question 1

What is the BP cutoff for diagnosis of hypertension during pregnancy?

Answer 1

Office BP SBP >=140 or DBP >=90
Ambulatory BP SBP >=135 or DBP >=85

If SBP >=160 or DBP >=110, SEVERE

Question 2

What is the BP treatment target during pregnancy?

Answer 2

DBP < 85

Question 3

What are BP treatment options during pregnancy? what should you avoid?

Answer 3

Labetalol
Methyldopa
Long acting nifedipine
Metoprolol, propanolol, pinolol, acebutalol (NOT ATENOLOL)
Clonidine
Hydralazine
Thiazide

AVOID ACE/ARB

Question 4

What are criterias to diagnose pre-eclampsia?

Answer 4

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

3. Severe complications.

Question 5

How do you prevent pre-eclampsia?

Answer 5

1. 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)
2. Calcium
3. Placental ultrasound
4. APLA testing

Question 6

How long do you treat acute VTE in pregnancy? What is the drug of choice?

Answer 6

Mininum 3 months including 6 weeks post partum.

LMWF or UFH with weight based dosing

Question 7

Who gets VTE prophylaxis antepartum and postpartum for 6 weeks?

Answer 7

1. Prior VTE - unprovoked, estrogen-related (pregnancy, OCP), associated with low risk thrombophilia.
2. Homozygous Factor V Leiden
3. Combined thrombophilias
4. ATIII deficiency with family history of VTE.
5. APLA or history of pregnancy loss (with low dose ASA).

Question 8

Who gets VTE prophylaxis just postpartum for 6 weeks?

Answer 8

1. Provoked VTE that was not estrogen-related with resolution of risk factors.
2. Protein C or S deficiency with family history of VTE.

Question 9

What should you do with diabetes medications pre-pregnancy?

Answer 9

1. Discontinue ACEi/ARB (if CKD, continue up until pregnancy)
2. Discontinue statin
3. Discontinue non-insulin diabetes meds except for metformin and glyburide
4. Start ASA 162mg daily at 12-16 weeks to decrease risk of pre-eclampsia

Question 10

What are glucose targets during pregnancy?

Answer 10

Fasting <5.3
1h post prandial < 7.8
2h post prandial < 6.7

A1C <6.5 during pregnancy

Intrapartum BG between 4-7

Question 11

When should you screen for gestational diabetes in pregnancy? what counts as positive test?

Answer 11

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

Question 12

How do you manage gestational diabetes post partum? What should you counsel them on?

Answer 12

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

Question 13

What are symptoms of intrahepatic cholestasis of pregnancy? what are treatments?

Answer 13

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

Question 14

What are symptoms of acute fatty liver of pregnancy? what are treatments?

Answer 14

Nausea, vomiting, abdo pain, encephalopathy, jaundice, ascites, polydipsia and polyuria

LFT < 500s
++++ conjugated bili elevation

Treat with delivery or transplant

Question 15

What IBD medications are safe during pregnancy? what should you discontinue?

Answer 15

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

Question 16

What are platelet thresholds for delivery?

Answer 16

> 30 for vaginal
50 for c section
80 for neuroaxial anesthsia

Question 17

What are platelet transfusion thresholds during HELLP or preeclampsia?

Answer 17

< 20 transfuse all
C section < 50 transfuse
> 50 transfuse only if actively hemorrhaging or ongoing coagulopathy

Question 18

What are treatment platelet targets for ITP during pregnancy? What are treatment options?

Answer 18

Treat if plt < 30, clinically bleeding to < 50 near delivery

Give prednisone or IVIG, avoid dex as it crosses the placenta

Question 19

What is the timing of peripartum cardiomyopathy? What should you counsel patients on?

Answer 19

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

Question 20

How do you treat peripartum cardiomyopathy?

Answer 20

Beta blockers (metoprolol, AVOID atenolol), lasix, hydralazine, nitro

AVOID ACE/ARB
AVOID spironolactone
UNCLEAR if early delivery will improve outcome

Question 21

What antiarrhythmics are safe to use during pregnancy? What should you avoid?

Answer 21

Adenosine
CCB (verapamil)
Beta blocker (NOT atenolol)
Digoxin

Avoid amiodarone = fetal hypothyroidism

Question 22

What vaccines are contraindicated in pregnancy? What precautions needs to be taken if received pre-pregnancy?

Answer 22

Live/live attenuated vaccines:

Varicella
MMR
Rabies
Yellow fever
Nasal influenza

If given pre-pregnancy, delay getting pregnant for 4 weeks.

Question 23

When are patients with VWF disease at highest risk of bleeding during pregnancy? When should you repeat testing for diagnosis?

Answer 23

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)

Question 24

What is diabetes associated with in pregnancy?

Answer 24

Fetal still birth, perinatal death, macrosomia/Large for gestational age.

Maternal progression of microvascular disease, pre-eclampsia