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Obstetrical medicine Flashcards

1
Q

Differentiate pre-existing hypertension, gestational hypertension and per-eclampsia/eclampsia

A
  1. Pre-existing hypertension
    1. Prior to 20 weeks gestation
  2. Gestational hypertension
    1. After 20 weeks gestation
  3. Pre-eclampsia/eclampsia
    1. New or worsening HTN with one or more adverse conditions (usually after 20 weeks)
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2
Q

What are the diagnostic criteria for hypertension in pregnancy?

A
  1. Office: SBP ≥ 140, DBP≥90
  2. Ambulatory: SBP≥ 135 DBP ≥85
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3
Q

What are the diagnostic criteria for severe hypertension in pregnancy?

A
  1. SBP ≥ 160 DBP ≥110

*These would be the thresholds for hypertensive “urgency” or “emergency”

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4
Q

What are the diagnostic criteria for resistant hypertension in pregnancy?

A
  1. ≥ 3 antihypertensives
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5
Q

What are the BP targets in pregnancy

A
  1. DBP ≤ 85
  2. SBP 130-140
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6
Q

Give an algorythm for the management of Hypertension in pregnancy

A
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7
Q

What are the first-line antihypertensives in pregnancy

A
  1. Labetalol
  2. Methyldopa
  3. Long acting oral nifedipine
  4. Other beta blockers
    1. NOT atenolol
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8
Q

What medications are second line for HTN in pregnancy

A
  1. Clonidine
  2. Hydralazine
  3. Thiazide diuretics
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9
Q

Which antihypertensives should be avoided in pregnancy?

A
  1. ACEi
  2. ARB
  3. Atenolol
  4. Prazocin and other alpha blockers
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10
Q

Which antihypertensives should be avoided during lactation

A

None, all are safe

*For ACE choose Enalapril, captopril, Quinapril

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11
Q

With what antihypertensives should non-severe hypertension in pregnancy be treated?

A
  1. PO labetalol
  2. PO methyldopa
  3. PO nifedipine XL BID as hyperfiltrated in pregnancy
    1. Longer acting “biigger gun”
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12
Q

How should severe hypertension be treated in pregnancy?

A
  1. IV labetalol
  2. IV hydralazine
  3. IR nifedipine chew
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13
Q

List the risk factors for pre-eclampsia

A
  1. Epidemiologic
    1. First pregnancy
    2. New partner or IVF
    3. Family history
    4. Age <20 or >35
  2. Maternal
    1. Previous pre-eclampsia
    2. Chronic HTN
    3. DM
    4. Renal disease
    5. AI disorders (SLE, APLA)
    6. Obesity
  3. Fetal
    1. Multiple gestation
    2. Hydrops fetalis
    3. Molar pregnancy
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14
Q

What are the diagnostic criteria for pre-eclampsia

A
  1. Hypertension
    1. BP>140/90 x2 or >160/110 x1

Plus one of:

  1. New or worsening proteinuria
    1. ≥2+ dipstick
    2. urine PCR≥30
    3. >300 mg protein on 24hr urine protein
  2. One or more adverse condition
    1. Maternal symptoms
      1. Headache/vision changes
      2. dyspnea/chest pain
      3. RUQ pain
      4. new onset edema/anasarca
      5. Seizures
      6. Hyperreflexia/clonus
    2. Lab abnormalities
      1. Hb
      2. Plt
      3. AST/ALT/ ALP
      4. Cr
      5. Uric acid
      6. LDH
      7. bilirubin
      8. blood film
      9. fibrinogen
      10. PTT/INR
    3. Fetal complications
      1. IUGR
      2. Oligohydramnios
      3. absent/reversed and diastolic flow on placental doppler
    4. One or more severe complications
      1. See table:
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15
Q

How is pre-eclampsia treated in pregnancy

A
  1. Manage the hypertension
    1. Does not prevent progression of pre-eclampsia
  2. Eclampsia prevention
    1. Give MgSO4
  3. Delivery
    1. Decision to be made by OB
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16
Q

What are the indications for MgSO4 in eclampsia prevention?

A
  1. Severe pre-eclampsia
  2. severe hypertension
  3. headaches/vision changes/RUQ pain
  4. platelets <100
  5. elevated liver enzymes
  6. renal insufficiency

*also first line treatment of seizures in pregnancy

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17
Q

What are the symptoms of MgSO4 toxicity

A
  1. Respiratory suppression
  2. Bradycardia
  3. hypotension
  4. reduced GCS
  5. Decreased reflexes
  6. Decreased urine output
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18
Q

How do you monitor patients on a MgSO4 infusion for toxicity

A
  1. DONT NO LEVELS
  2. Monitor clinically
    1. Reflexes
    2. Urine output
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19
Q

How is magnesium toxicity treated

A
  1. Stop Mg
  2. Calcium gluconate
  3. HD
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20
Q

What are the indications for delivery in pre-eclampsia

A
  1. severe pre-eclampsia
  2. Refractory maternal symptoms
    1. Resistant HTN
    2. end organ damage
    3. persistant Sx
  3. Fetal complications
    1. IUGR
    2. doppler abnormalities
    3. fetal distress
  4. Wome at term: >37 weeks

*decision to be made by OB

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21
Q

When should antenatal corticosteroids be given

A

Fetus born <35 weeks

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22
Q

How should women be councilled in the post-partum period following pre-eclampsia, what are they at higher risk for?

A
  1. Council regarding futur pregnancy risk, CVD risk,
  2. Quit smoking, lose weight, support breastfeeding
  3. They are at higher risk for
    1. Chronic HTN (4x)
    2. Heart disease (2x)
    3. Stroke
    4. VTE
    5. DM
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23
Q

When should you calculate a women’s CVD risk after an episode of pre-eclamsia

A

Immediately (Don’t wait till age 40)

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24
Q

What are the indications for ASA in pre-eclampsia prevention

A
  1. Previous pre-eclampsia
  2. chronic HTN
  3. DMT1 or DMT2
  4. CKD
  5. SLE
  6. APLA
  7. multiple gestations
  8. ≥2 minor RF
    1. nulliparous or new partner
    2. IVF
    3. age>35
    4. BMI >30
    5. 1st degree family Hx of pre-eclamsia
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25
When should calcium be supplemented in pregnancy?
1. if intake \<600mg in diet give 1000mg daily
26
How should women with obstetrical APS be managed through pregnancy?
ASA + LMWH through pregnancy
27
What amount of exercise may reduce the risk of hypertensive disorders of pregnancy including pre-eclamsia
150 min/week moderate intensity
28
What councilling should be offered to hypertensive women of childbearing age
1. Pregnancy test before initiating health and behavior changes 2. Plan pregnancy (adequate contraception otherwise) 3. Individualize antihypertensive management during pregnancy 4. Pre-eclampsia prevention (ASA, exercise) 5. In patients planning pregnancy, D/C ACEi ARB if appropriate
29
When is the VTE risk highest in pregnancy
3rd trimester and 1st 6 weeks post-partum
30
Where do DVTs typically occur in pregnancy
1. 80% in left leg 2. 60% iliofemoral vein (rather than popliteal)
31
What are the symptoms of DVT in pregnant women
Back/buttock/thigh pain rather than calf pain
32
What is the workup for suspected DVT in pregnancy?
33
What is the workup of suspected PE in pregnancy
ARTEMIS study
34
What are the imaging options, if imaging is indicated, to diagnose PE in pregnancy. Why do some physicians prefer one to the other
CTPE or V/Q scan V/Q has less chest radiation to the mother, reduced risk of breast CA
35
For how long should women be anticoagulated following a PE in pregnancy
Minimum 3 months including 6 weeks post-partum
36
What anticoagulant should be used in pregnancy
LMWH or UFH
37
What is the anticoagulant of choice in pregnant patients with HIT
Danaparoid first line Fondaparinux second line Consult hematology
38
What should be done in the case of hemodynamic instability for PE in pregnancy or limb-threatening DVT
give tPA
39
What are the indications for an IVC filter in pregnancy
1. Same indications as outside of pregnancy 2. Consider if new VTE diagnosed close to delivery with prompt removal post-partum 1. Heme consultation
40
How should therapeutic anticoagulation be managed around delivery
1. Arrange for planned delivery 2. Withhold LMWH for 24 hours pre-neuraxial anesthesia 3. IF VTE diagnosed \<4 weeks from delivery, admit for UFH and hold 6 hours pre neuraxial anesthesia 4. If patient is in spontaneous labor, withhold ACO 5. Restart anticoagulation 4-6 hours post-vaginal delivery or 6-8 hours post C-section, if hemostasis is achieved
41
How should prophylactic anticoagulation be managed surrounding delivery
1. Planned OR spontaneous labor 2. Withhold LMWH 12 hours pre-neuraxial anesthesia 3. Restart 4 hours post-removal of neuraxial anesthesia
42
Which anticoagulants are safe in breastfeeding
1. LMWH 2. UFH 3. Danaparoid 4. Warfarin
43
When should VTE prophylaxis be considered in pregnancy if a patient has a history of a previous VTE
44
When should VTE prophylaxis be considered in patients with _no prior history of VTE_?
45
What other factors should be weighed in when deciding on prophylactic anticoagulation in the context of pregnancy
1. Pre-pregnancy BMI\>30 2. Pre-eclampsia 3. C-Section 4. Age \>35 5. Smoking 6. Post-partum hemorrhage 7. Placenta previa 8. IUGR 9. Bed rest\>7 days antepartum 10. ... and more! As per SOGC, consider port-partum VTE prophylaxis if \> 2 major RF above
46
What are the top 3 elements in your DDx of thrombocytopenia in pregnancy
1. Gestational thrombocytopenia 2. ITP 3. Pre-eclampsia with HELLP
47
What are the platelet targets for vaginal delivery, C-Section and neuraxial anesthesia in ITP?
1. Vaginal delivery \>30 2. C-Section \>50 3. Neuraxial anesthesia \>80
48
When should patients be transfused in HELLP?
1. \<20 transfuse all 2. C-Section, transfuse \<50 3. Active hemorrhage, rapidly falling counts, other coagulopathy, thransfuse even if PLT \>50
49
What investigations should be done in thrombocytopenic pregnant patients
1. CBC, retic 2. Blood smear 3. LFT 4. HIV, HBV, HCV 5. UA, urine ACR 6. COnsider 1. TSH 2. ANA 3. APLA testing 4. H. Pilori 5. INR/PTT 6. DAT
50
Compare and contrast gestational thrombocytopenia and ITP in pregnancy
1. Gestational thrombocytopenia 1. Decreasing plt count in pregnancy worst in T3 or newly discovered thrombocytopenia 2. Typically plt\>70, generally \>100 3. Diagnosis of exclusion 4. No treatment required resolves \<6 weeks PP 2. ITP 1. Pre-existing thrombocytopenia 2. More profound generally
51
How is ITP in pregnancy treated?
1. Treat if PLT \<30, or \<50 if nearing delivery 2. Use prednisone or IVIG (Dex crosses placenta) 3. Consult pediatrics to rule out neonatal thrombocytopenia (10%) 1. OB should avoid instrumentation like vacuum extraction
52
What effects does maternal DM have on the fetus?
1. Teratogen 1. Congenital cardiac malformation 2. spinal cord defect 3. cleft lip/palate 2. Miscarriage 3. Macrosomia 4. Shoulder dystocia 5. pre-term labor 6. stillbirth 7. Neonatal 1. Hypoglycemia 2. Hypocalcemia 3. hyperbilirubinemia
53
What effect does DM have on the pregnant mother?
1. Exacerbation of microvascular complications 2. DKA 3. Bladder infections 4. operative delivery 5. Pelvic injury during vaginal delivery 6. Pre-eclampsia
54
How should Diabetic patients be optimized for pregnancy?
1. Planned pregnancy 2. HbA1C \<7, ideally \<6.5 3. Folate 1mg daily for 3 months pre- and 12 months post-conception 4. Screen for retinopathy, nephropathy, BP, A1C +/- ECG and ECHO 5. Discontinue contraindicated meds 1. ACEi/ARB (continue until pregnancy if DM nephropathy) 2. Statin 3. Non-insulin oral hypoglycemic agents except metformin and glyburide 6. Start ASA 162mg daily at 12-16 weeks until 36 weeks for pre-eclampisa prevention
55
How should T1DM be managed through pregnancy
1. MDI or insulin pump 1. Continuous glucose monitoring seems to be better
56
How should T2DM be managed through pregnancy
1. Continue metformin and glyburide 2. If on any other antihyperglycemic agent switch to insulin prior to conception
57
What are the BG targets in pregnancy
1. Fasting \<5.3 2. 1hr post prandial \<7.8 3. 2hr post prandial \<6.7 4. HbA1C \<6.5% 5. Intrapartum: 4-7
58
How often should BG be monitored in pregnancy
1. QID. Fasting and 1 or 2 hrs after meals
59
When should pregnant women be screened for Gestational DM
at 24-28 weeks
60
How do you screen for gestational DM
1. 50g 1hr OGTT: 1. ≥11.1 GDM diagnosed 2. 7.8-11.1 Borderline-- Do 2hrs 75g OGTT 3. Less than 7.8 normal 2. 75g 2hrs OGTT 1. if used as second step: 1. fasting ≥ 5.3 2. 1hr≥10.6 3. 2hr≥9 2. if used as first step (not recommended) 1. fasting ≥5.1 2. 1hr ≥10 3. 2hrs≥8.5
61
In patients at high risk for gestational DM, how should screening be modified
Screen earlier with HbA1C or FBG If negative proceed with OGTT at 24-28 weeks
62
How is gestational diabetes treated?
1. lifestyle: diet and exercise 2. First line: 1. NPH +/- rapid insulin 3. Metformin may be used as an alternative 1. 40% still require insulin 4. Glyburide reasonable
63
How should pregnant patients with pre-existing DM be managed in the post-partum period
1. Decrease insulin to below pre-pregnancy dose 2. OK to use metformin and glyburide when breastfeeding 3. Resume ACE for DM nephropathy (enalapril during breastfeeding) 4. In T1DM, screen for autoimmune thyroiditis
64
How should pregnant patients with gestational DM be managed in the post-partum period
1. Stop insulin, Glyburide, metformin 2. 75g OGTT @ 6 weeks-6 months PP, R/O T2DM 3. Encourage breastfeeding immediately -- prevent neonatal hypoglycemia \*50% will have GDM at next pregnancy \*20% will have T2DM in 10 years
65
What pregnancy risks are associated with maternal obesity?
1. Increased pregnancy loss 1. Stillbirth 2. miscarriage 2. Increased odds of operative delivery 3. Maternal risks 1. GDM 2. HTN 3. Preeclampsia 4. VTE 5. UTI 4. Fetal/neonatal risks 1. Shoulder dystocia 2. Macrosomia 3. fetal malformations (open neural tube defects, carrdiiac, spinal bifida) 4. hypoglycemia 5. NICU admission 6. preterm birth 7. meconium aspiration
66
What are the recommendations to manage obesity in the intrapartum period
1. Maternal weight gain targets: 5-10 kg 2. \>150 min moderate intensity exercise per week 3. ASA to prevent pre-eclampsia if other maternal risks 4. Folic acid, Vitamin D 5. Closer surveillance
67
What are the recommendations to manage obesity in the POST partum period
1. Higher risk of PP depression, anxiety, recommend to screen for same 2. Higher rates of breastfeeding discontinuation-- recommend lactation support 3. Thrromboprophylaxis if C-Section
68
How should COVID 19 be treated in pregnancy
1. Give methylpred, pred orr hydrocort instead of dex (dex crosses placenta) 1. 22-34 weeks Dex x2 days then methylpred x 8 days 2. \<22 weeks or \>34 weeks pregnant methylpred x 10 days 3. Post-partum just give dex 2. Remdesevir and tocilizumab as otherwise indicated
69
In COVID patients who gave birth, should skin to skin contact be encouraged?
1. yes
70
List liver diseases in pregnancy by trimester of onset
71
What symptoms are associated with hyperemesis gravidarum
1. persistant vomiting 2. 5% weigh loss 3. dehydration
72
What symptoms are associated with IHCP
1. pruritus _without rash_ 1. _​_Sarts in palms and soles 2. Worst at night
73
What symptoms are associated with HELLP
1. RUQ pain 2. N/V 3. Sx of pre-eclampsia 4. **15% presents normotensive**
74
What symptoms are associated with AFLP?
1. Vomiting 2. Abdo pain 3. encephalopathy 4. jaundice 5. ascites 6. _polydypsia and polyuria_ No fatty liver on U/S
75
Compare the ALT/AST levels in HG, IICP, HELLP and AFLP
1. HG 1. 100s 2. IICP 1. \<1000 3. HELLP 1. 1000s 4. AFLP 1. \<500
76
Compare the bilirubin levels in HG, IHCP, HELLP and AFLP
1. HG 1. Normal 2. IHCP 1. Normal or mild elevaton 3. HELLP 1. Increased unconjugated form hemolysis 4. AFLP 1. Very elevated conjugated
77
What diagnsotic tests should be sent to confirm IHCP
1. Bile acid level 1. \>10 diagnostic 2. \>40 increased risk of meconial aspiration and preterm birth 3. \>100 increased risk of stillbirth
78
What lab findings are associated with HELLP?
1. Plt\<100 (early finding) 2. MAHA (late finding)
79
What diagnosstic test should be done when suspecting HELLP
Abdo U/S: R/O hepatic hemorrhage, infarct and rupture
80
What are laboratory findings in AFLP
1. Leukocytosis 2. Hypoglycemia 3. elevated amonia 4. Renal failure 5. Ascites 6. Liver BX: microvessicular steatosis
81
How is HG treated?
1. Anti-emetics 2. fluids 3. electrolyte replacement
82
How is IHCP treated?
1. URSO 2. Hydroxyzine 3. Rifampin
83
How is HELLP treated?
1. Delivery 2. BP 3. Eclampsia prevention
84
How is AFLP treated?
1. Delivery 2. Liver transplant if hepatic failure 3. Screen newborns for LCHAD
85
What antinauseants can be given in HG
Metoclopramide Gravol PPI
86
How can morning sickness be managed during pregnancy
1. Non-pharmacological 1. Stop iron containing prenatals, use folic acid only 2. Small frequent meals, fluids 'cold, clear, carbonated' 3. Ginger, acupressure, mindfulness retraining 2. Pharmacological 1. 1st line: pyridoxine(vit B6) or pyridoxine-doxylamine (Diclectin) 2. 2nd line: H1 blockers (Gravol) 3. Then: chlorpromazine, Metoclopramide, then ondansetron 3. IV hydration and multivitamins
87
How is GERD treated in pregnancy?
1. Calcium carbonate 2. H2 blocker 3. PPI
88
What is the biggest predictor of IBD flares in pregnancy?
1. Pre-pregnancy disease control 1. Consensus: Steroids free remission x 3 months before remission
89
How should women with IBD be optimized for pregnancy?
1. Folate 2. Stop smoking 3. update vaccines 4. optimize comorbidities 5. Evaluate disease control 6. **Discontinue MTx (3 months before conception)** 7. 5-ASA -- Continue 8. Continue azathioprine, anti-TNF
90
How should an IBD flare be treated in pregnancy?
1. Consult GI and high risk OB 2. Can give prednisone, 5-ASA, anti-TNF 3. Screen early and frequently for DM 4. Consider stress dose at delivery
91
What special precautions should be undertaken for babies exposed to anti-TNFs in utero
no live vaccines until \>6mo of age
92
Describe the normal physiological changes to the cardiovascular system in pregnancy
1. Increase in cardiac output and plasma volume by 50% peak at T2 1. Decline 2 weeks PP but can take 6 months to get back to normal
93
List the cardiovascular symptoms that are normal in pregnancy
1. Dizzieness 2. palpitations 3. dyspnea 1. 2/2 progesterone 2. Mild and not progressive 4. orthopnea 5. peripheral edema 6. Sinus tachycardia 7. Prominent or mildly elevated JVP 8. Displaced apex 9. S3 commonly, occasional S4 10. soft systolic flow murmur 11. varicose veins 12. peripheral edema
94
How is peripartum cardiomyopathy
1. EF\<45% 2. Last month of pregnancy until 5 months post-partum 3. No alternative etiology
95
List a DDx of pulmonary edema in pregnancy
1. peripartum cardiomyopathy 2. per-eclampsia 3. ischemic CMP 4. arrythmia 5. amnionic fluid embolism 6. sepsis
96
How is peripartum cardiomyopathy treated?
1. Diuretics 2. Beta blockers: Metoprolol\>labetalol as cardioselective. Avoid atenolol 3. Other agents: 1. Nitrates 2. Hydralazine 3. Digoxin
97
List the cardiac drugs that are safe in pregnancy
98
List drugs with limited/conflicting data that should be used with caution in pregnancy
99
List cardiac drugs that are contraindicated in pregnancy
100
List cardiac meds contraindicated in _breastfeeding_
101
How should warfarin be managed in pregnancy in patients with mechanical heart valves?
1. Continue warfarin in preconception phase 2. See cardiologist for counseling pre-pregnancy 3. If requiring Warfarin \<5mg daily 1. Continue through all 3 trimesters OR 2. dose-adjusted LMWH in 1st trimester then warfarin trimester 2-3 4. If requiring warfarin \> 5mg 1. Dose adjusted LMWH 1st trimester then warfarin trimester 2-3 2. Dose adjusted LMWH all 3 trimesters 5. For LMWH, adjust based on anti-Xa levels 0.8-1.2 6. At delivery 1. Planned delivery 2. Switch ACO to dose adjusted LMWH or IV UFH at least 1 week prior to delivery 3. If on LMWH, switch to UFH 36hrs pre delivery 4. Stop UFH 6hrs pre delivery 5. Bridge back to warfarin post-partum 6. \* if labor begins on VKA reverse ACO and do C/S
102
How should patients with severe stenotic valve lesions be managed pre-pregnancy
1. Repair severe symptomatic stenotic lesions before surgery 2. Consider repairing severe asymptomatic stenotic valve lesions and MR pre-pregnancy 3. Regurgitant lesions usually better tolerated in pregnancy
103
How should known SVT be managed in pregnancy?
1. SVT usually gets worst in pregnancy 1. May require daily supressive meds 2. Adenosine, non DHP-CCB, BB safe 3. Cardiovert if needed
104
How should atrial fibrillation/atrial flutter be managed in pregnancy
1. Avoid warfarin in tri 1 1. Discuss risks and benefits of anticoagulation 2. Dig, BB safe 3. If unstable, D/C cardioversion 1. With fetal heart monitoring 4. Consider maternal echo, R/O structural heart disease , TSH, OSA screening
105
How should VT/VF be managed in pregnancy
1. Betablock agressively 2. Can use amio, but concerns for fetal hypoT4 3. Echo, R/O congenital heart disease
106
How should patients with AV block be managed through labor
1. Continuous cardiac monitoring 2. Watch fluids in delivery 3. Risk of worsening block given increased vagal tone in delivery
107
Give a DDx for syncope in pregnancy
1. Orthostatic/vasovagal 2. PE 3. Arrythmia 4. Hemorrhage/anemia 1. Think abruption 5. Exacerbation of congenital heart problem
108
What antibiotics are safe for the treatment of CAP in pregnancy
1. Macrolide or betalactam
109
Can oseltamivir be used in pregnancy?
1. yes
110
Is the flu vaccine safe in pregnancy?
yes
111
Are FQs safe in pregnancy
1. Associated with cartilage problems in animal models 2. Can use them where appropriate but council first
112
Are tetracyclines safe in pregnancy
NO, they cause fetal teeth staining and bone growth supression
113
Is sulfa safe in pregnancy?
No, causes kernicterus
114
List the safe and unsafe antibiotics in pregnancy
1. Safe 1. Macrolides 2. Penicillins/beta lactams 3. Carbapenems 4. INH (with B6) 5. Nitrofurantoin (avoid after week 36) 2. Avoid 1. Fluoroquinolones (relative) 2. Tetracyclines 3. Septra (avoid but not contraindicated)
115
List the safe and unsafe anticoagulants/antiplatelets in pregnancy
1. Safe 1. LMWH/UFH 2. ASA 2. Avoid 1. Warfarin in tri 1 2. DOACS
116
List the safe and unsafe endocrine meds in pregnancy
1. Safe 1. Thyroxine 2. Metformin 3. Insulin 4. antithyroid drugs (no MMI in t1) 2. Avoid 1. Sulfonylureas 2. TZD 3. DPP-4 (probably OK but not recommended)
117
List the safe and unsafe GI meds in pregnancy
1. Safe 1. H2 blockers 2. PPI 3. Maxeran 4. Gravol 5. Ondansetron 2. Avoid 1. Excessive QT prolongation
118
List the safe and unsafe neuro meds in pregnancy
1. Safe 1. MgSO4 2. Pyridostigmine 3. Most antidepressants 2. Avoid 1. Most antiepileptics (esp carbamazepine, valproate, phenytoin) 2. Benzos
119
List the safe and unsafe ani-inflammatory meds in pregnancy
1. Safe 1. Prednisone 2. Plaquenil 3. 5-ASA 2. Avoid 1. MTx 2. Azathioprine (council) 3. Biologics (council)
120
List the safe and unsafe analgesics in pregnancy
1. Safe 1. acetaminophen 2. NSAIDS 1. Stop 32 weeks: PDA issues, oligohydramnios 2. Avoid 1. COdeine if breasfeeding 2. chronic narcotics
121
List the safe and unsafe vaccines in pregnancy
1. Unsafe 1. Live/live attenuated 1. Varicella 2. MMR 3. Rabies 4. yellow fever 5. nasal influenza 2. Can give pre-pregnancy, council to avoid pregnancy for 4 weeks 2. Safe 1. COVID MRNA vaccines 2. Inactivated influenza 3. Tdap every pregnancy 21-32 weeks 4. Inactivated vaccines safe \* all vaccines safe if breastfeeding
122
How is HIV treated in pregnancy
1. Start ART 2. PJP can be treated with septra 3. ensure high dose folate 4. C-Section delivery unless VL \<1000
123

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