Other medical complications of pregnancy Flashcards
Hyperemesis gravidarum:
Persisting past wk 16
Very common in setting of molar pregnancy (document IUP!)
Management of Hyperemesis gravidarum:
Maintain FEN/GI status! Can get hypoCl, hypoK, met acidosis Use NS + D5W Can use antiemetics safely Also B12 supplementation Small frequent meals
Seizure disorders:
Increase in pregnancy
Watch doses (increased GFR → faster clearance)
Phenobarb / primidone / phenytoin = folate antagonists → NTD risk
Valproic acid → NTDs too
Management of seizure disorders
Take lots of folate prior to pregnancy, follow AFP, may or may not decide to switch (to single AED, lowest possible dose) - but seizures are bad for baby too
Maternal cardiac disease:
Remember 50% CO increase.
Highest risk with primary pulmonary HTN, Eisenmenger physiology, severe MS / AS, or Marfan
Remember big fluid shifts PP (autotransfusion) → big demand on heart
Management of maternal cardiac dx
ACEi, coumadin contraindicated in pregnancy, diuretics risky too.
May do assisted vaginal delivery to avoid valsalva - better than C/S results.
Hx MI: get baseline ECG
Eisenmenger syndrome / pulmHTN
Really bad, up to 50% mortality, especially postpartum 2-4 wks (follow closely!
Eisenmenger: from R → L shunts (PDA, VSD).
Valvular disease management:
SBE (subacute bacterial endocarditis) ppx during labor if valuvular disorder
Consider fixing MS/AS 1 yr prior to pregnancy. If really bad, may even do it while pregnant!
Valvular disease
AS sx may get better early in pregnancy (as SVR decreases, less afterload)
MS pts may not be able to meet increased CO → CHF sx!
Mitral valve prolapse: small % of women with sx (anxiety, palpitations, atypical chest pain, and syncope).
Management of Mitral valve prolapse
If pt has sx, beta-blockers are given to decrease sympathetic tone, relieve chest pain and palpitations, and reduce the risk of life-threatening arrhythmias.
Marfan syndrome risk
Watch out for aortic dissection / rupture
Marfan syndrome management
Should be on beta blockers & not exert self during pregnancy
Peripartum cardiomyopathy:
Dilated cardiomyopathy before / during / after delivery
EF drops to 20-40%
Management of peripartum cardiomyopathy
Manage with diuretics, digoxin, vasodilators like HF pt.
If > 34wks, deliver
If earlier, BMZ → check lung maturity
Maternal renal disease:
Pregnancy can make it worse
Higher risk PEC.
Screen qtrimester with 24h urine for Cr/prot Antenatal testing from 32-34 wks onward
If s/p transplant, may need to increase meds to avoid rejection (higher Vd- volume of distribution)
Maternal coagulopathies
Pregnancy → extra coagulable. mechanism not precisely known.
Higher risk pelvic vain thrombus 2/2 IVC compression).
Superficial vein thrombosis presentation:
Painful, visible venous cord.
Superficial vein thrombosis Rx:
Warm compress / analgesic (won’t cause PE) and watch for si / sx of DVT/PE
DVT management
Treat with IV heparin → subQ heparin for rest of pregnancy.
No coumadin → nasal hypoplasia, skeletal problems
PE management
Get EKG, spiral CT
Rx IV heparin → subQ heparin / LMW heparin
Will switch to unfractionated heparin @ 36 wks - shorter half life, so can d/c if presents to L&D
Can switch to Coumadin x 6mo postpartum
If unstable / massive, consider tPA / thrombectomy
Maternal thyroid disease: Grave’s disease Rx
Methimazole (MMI) and propylthiouracil (PTU) Depends on practitioner, PTU is classic but more using MMI now
Maternal thyroid disease: Hashimoto’s Rx
Levothyroxine
SLE:
Early pregnancy: high risk loss in 1st/2nd trimester 2/2 placental thrombosis, esp if antiphospholipid Ab
Later pregnancy: also can lose 2/2 thrombosis. Antenatal testing @ 32wks onwards. Higher risk PEC
Lupus flares
Can look like PEC, but have low complement.
Treatment of lupus flares
If flaring, try high dose steroids → cyclophosphamide if that doesn’t work
If PEC, deliver.
Neonatal problems in SLE
Can get irreversible congenital heart block 2/2 anti-Ro (and anti-La, but more Ro)
antibodies which cross-react with fetal cardiac conduction system.
Screen for anti-Ro at first visit; interventions vary.
Substance abuse:
Alcohol Caffeine Cigarettes Cocaine Opiates
Fetal alcohol syndrome, # of drinks to put at risk
FAS possible with > 2-5 drinks / day
Sequelae of fetal alcohol syndrome
Growth retardation, CNS effects, abnormal facies, cardiac defects, etc.
Treatment of alcohol withdrawal in pregnancy
Try barbituates instead of benzos (less teratogenic)
Caffeine
> 1 cup coffee (150 mg) may increase miscarriages
Cigarettes
a/w SAB, preterm birth, placental abruption, LBW risk, also higher risk SIDS. Stop!
Cocaine
a/w placental abruption, IUGR, preterm birth.
Opiates:
Heroin, methadone most common.
No teratogenicity.
Risk is with withdrawal → put on NAS (neonatal abstinence syndrome) protocol with tincture of opium, etc for baby.
Asthma in pregnancy chronic Rx
Short-acting beta agonists, then inhaled corticosteroids or cromolyn, then theophylline.
Asthma in pregnancy acute Rx
Subq terbutaline, systemic corticosteroids.
Pruritis gravidarum:
Mild variant of intrahepatic cholestasis of pregnancy; retain bile salt → dermis deposits → pruritis
Use antihistamines / topical emollients initially, then can try cholestyramine →
ursodeoxycholic acid if really bad.
If appendicitis suspected
Get a graded compression ultrasound (best for eval - CT has lots of radiation)
Depression
Paxil (Paroxetine) is class D Increased risk fetal cardiac malformations & persistent pulmonary HTN
