Pathophysiology 3 Flashcards
Preconception Counseling
- name obesity as a health condition (use classification system)
- counsel on risk: high risk conditions associated with obesity
- Encourage lifestyle changes: point the patient to resources, follow up
- Refer to specialist when needed
Identify Obesity
- Screening: ACOG recommends annual weight-BMI calculation
- Definitions: use BMI to identify weight class
Obesity and Conception
- obese women have lower rates of fertility
1. anovulation(PCOS)
2. leptin impairs ovarian functioning
3. low fertilization potential of ova
4. risk of spon abortion
5. success rates of ART impacted negatively
6. infrequent intercourse - reversible if loose weight*
Lifetime/Pregnancy risks of obesity
- diabetes, HTN, cancer (endometrial), arthritis, cholesterol, stroke, heart disease
- gestational HTN, preeclamsia, gestational diabetes, macrosomia, cesarean section, birth defects, still birth
Counsel of Lifestyle Changes
Motivational Interviewing
- feedback-identify behaviors and results
- responsibility-stress who will suffer
- advice-teach, give ideas
- menu-identify difficult situations
- empathy-understand & involved
- self-efficacy-learn from mistakes
Ability for Obesity Counseling
- track calories
- encourage to join support groups (weight watchers)
- exercise (start w/minimal goals, taking stairs)
- track weight loss
Candidates for Bariatric Surgery
- well informed, motivated
- BMI >40
- acceptable surgical risk
- failed nonsurgical management
- BMI >35 with complications of obesity (sleep apnea, diabetes, joint disease)
Pregnancy & Bariatric Surgery
- not during pregnancy but after
1. Restrictive: gastric banding
2. Combination restrictive/malabsorption
Effects of Gastric Bypass of Pregnancy
Lowers risk: -preeclampsia -gestational diabetes -macrosomia -congential anomalies -average weight gain in pregnancy Higher risk: -cesarean section -PPROM
Obesity & Cesarean Section
-higher rates in obesity & bariatric surgery
Obesity & Blood Clots
Give anticoagulation? not if BMI only
- may be necessary if unable to use extremity compression techniques
- compression devices acceptable
- unfractionated/LMWH acceptable (weigh risk of bleeding. dosing)
Obesity Risk during Pregnancy
- Screen for nutritional deficiencies: Fe, B12, Vitamin D, Ca
- (bariatric surgeon, met w/nutritionalist)
- surgical complications: anastomotic leaks, bowel obstruction, hernia, band migration, involve bariatric surgeon
Obesity: Dumping Syndrome
- rapid transit of high glycemic carbohydrates
- do not use glucola
- screen with fasting & postprandial blood sugars for 1 week
- avoid extended release medicine
Pathophys of Thromboembolic Disorders
- physiologic changes of pregnancy contribute to Virchow’s triad
- venous stasis in lower extremities from compression of IVC and pelvic veins by enlarging uterus
- increased hormone-mediated deep vein capacitance secondary to increased circulating levels of estrogen & production locally of prostacyclin & nitric oxide
- Progesterone: inc. decidual & hemostatic systems
- doubling of fibrinogen levels
- increases factors: 7,8,9,10,12 1000%
- vWF inc 400%
- 40% dec in free protein S conc. = resistance to activated protein C
- returns to baseline 6 weeks postpartum
Risk Factors for Thromboembolic Disorders
- age >35
- obseity
- trauma
- immobility
- infection
- smoking
- nephrotic syndrome
- hyperviscosity syndromes
- cancer
- surgery
- history of DVT/PE
Risk Factors for Thromboembolic Disorders
Pregnancy Specific
- increased parity
- postpartum endomyometrisis
- operative delivery
- cesarean delivery (9x increased over vaginal)
Antiphospholipid Antibody Syndrome
-14% of thromboembolic disease in pregnancy
DIAGNOSIS: 1.presence of prior VTE/characteristic obstetric complications 2. anticardiolipid antibodies or lupus
-associated with venous (DVT/PE) and aterial stroke events
Inherited Thrombophilias
- Factor V Leiden homozygous
- Antithrombin III deficency
- Prothrombin Gene G2021A
Diagnosis of Deep Venous Thrombosis
- Venous USG
- D-Dimer
- Contrast Venography (allergy)
- MRI
Diagnosis of Pulmonary Embolism
- EKG Changes
- Chest X-ray
- Spiral CT Scan**gold standard
- Pulmonary arteriography
- VQ scan
- MRA
- D-Dimer Assays
Treatment of Thromboembolic Disorders
- Unfractionated Heparin: reverse with protamine sulfate
- Low Molecular Weight Heparin
- Warfarin/Coumadin: takes 72hrs to start working
- Fondaparinux: doesn’t cross placenta
- IVC filters: doesn’t prevent clot
- Preoperative prevention
Menorrhagia
prolonged (>7days) or excessive (>80mL) uterine bleeding occuring at regular intervals
Metrorrhagia
-uterine bleeding occurring at irregular but frequent intervals
Menometrorrhagia
-prolonged uterine bleeding occurring at irregular intervals
