Pregnancy Complications Flashcards
Who should be screened for GDM at first PNV?
What are risk factors for GDM?
Obese, prior GDM, physical inactivity, 1st degree relative w/ DM, high risk race (AA, asian, pacific islander), prior infant >9lb, HTN, high LPL, cholesterol, PCOS, a1c>5.7, other things associated w/ insulin resistance (BMI>40, acanthosis nigricans), hx cardiovascular disease.
HTN, obesity, prior GDM, fam hx DM, PCOS, hx cardiovascular/renal dz.
Cardiac anomalies seen in fetus if mom has T2DM: cardiac (ASD, VSD), CNS, skeletal, sacral agenesis (caudal regression)
What are values for 1hr and 3hr GTT?
Standard is Coustan (95, 180, 155, 140)
National diabetes group: 105, 190, 165, 145
normal a1c 4 to 5.6%
- a1c of 10% associated w/ anomaly rate of 20%!!!
What is White’s Classification?
Class A: diet alone, any duration or onset age
Class B: onset age 20yr +, duration <10yr
Class C: onset 10-19, duration 10-19 yr
Class D: onset < 10yrs age, duration 20+ yrs, retinopathy or HTN.
Class R: proliferative retinopathy
Class F: nephropathy w/ 500mg/d proteinuria
Class RF: R + F
Class H: arteriosclerotic heart disease
Class T: prior renal transplant
What is the risk of developing diabetes later in life if GDM?
Up to 70% of ppl w/ GDM will develop t2DM. Influenced by race, ethnicity, obesity. Hispanic have highest risk.
How do you counsel GDM pts on diet and exercise?
Carbs 40%, remaining divided between protein (20%) and fat (40%)
3 meals and 2-3 snacks to distribute carb intake and reduce postprandial glucose fluctuations.
Moderate exercise 30min at least 5x week.
What are pharmacologic treatments for GDM?
Who is a candidate for oral meds?
Mechanism of action of metformin?
Why don’t we recommend glyburide anymore?
Insulin recommended if fastings consistently >95, 1hr consistently above 140 adn 2hr >120
.0.7 units/kg in 1st tri, 0.8 in 2nd, 0.9 in 3rd
- 2/3 long-acting and 1/3 short acting. and then 50% AM and 50% PM.
1st line=metformin. If decline insulin, can’t afford, can’t safely administer. Metformin crosses placenta and long-term metabolic effect on offspring is unknown but believed to be OK. absence of long-term neonatal follow up after metformin is why we recommend insulin
biguanide, inhibits hepatic gluconeogenesis and glucose absorption, stimulates glucose uptake in peripheral tissue.
Increases risk of neonatal hypoglycemia. Mechanism of action: sulfonylurea, increases insulin secretion and insulin sensitivity of peripheral tissues. Aovid if sulfa allergy.
What is dosing of metformin
What are side effects?
500mg nightly at initiation, increase to 500mg BID. max dose 300mg/day in 2-3 divided doses
GI (N, diarrhea), minimize by slowly increasing dose.
What is recommend APT for GDM?
What is delivery timing for GDMA1?
What is delivery timing for GDMA2?
When to delivery poorly controlled GDM?
When to deliver women who fail in-hospital admission for glycemic control?
Indicated if poorly controlled or medication requiring GDM at 32w No consensus for APT if GDMA1. j
GDMA1: 39-40w
GDMA2: 39-39w6d
GDM poorly controlled: 37w0d-38w6d
Requiring hospital admission and failed: 34-36w6d.
What is postpartum workup for GDM?
Risk of T2DM 15-70%. Recommend fasting and 2hr GTT.
Fasting >125 or 2hr >200→ definitely DM
Fasting <100 and 2hr < 140, normal. Anything in-between is impaired, refer for management and counseling.
What are glycemic goals for T2DM?
How do you prevent hyperglycemia in AM?
Avoid hypoglycemia <60. A1c <6% is best in 2nd and 3rd trimester.
Avoid carbs at bedtime, change dose of insulin, switch to different med.
How do you counsel someone w/ T2DM before pregnancy?
What is workup in 1st trimester?
2nd trimester?
3rd trimester?
Pre-conception: counsel on complications (anomalies, PTD, PEC, macrosomia, neonatal complications, worsening disease w/ retinopathy and nephropathy). Eval for HTN, nephropathy, cardiovascular disease, OPHTHO EXAM. Optimize a1c <6.0. Increasing folic acid when getting pregnant bc incr risk neural tube defects/anomalies
1st tri: a1c, TSH, 24hr urine, EKG. Optho, dietician, endo, cardiologist or nephrologist if needed. Ongoing assessment of blood glucose, start LDA at 12w
2nd tri: anatomy US, a1c, fetal echo. Start LDA at 12wks.
3rd tri: a1c, growth US and weekly APT. delivery planning.
When do you deliver T2DM?
39-39w6d if no vascular complications and well controlled. If vascular complications: 36w0d-38w6d.
What are effects of elevated blood sugar on baby?
What are most common congenital defects?
What are neonatal consequences?
Major congenital anomalies
SAB
If a1c 5-6%, associated w/ fetal malformation rate close to normal pregnancies. IF a1c 10%, fetal anomaly rate of 20-25%.
Most common: Cardiac anomalies, CNS (anencephaly, spina bifida), sacral agenesis
NICU admission, hypoglycemia, higher rate RDS, hyperbilirubenamia, electrolyte disturbances, incr risk metabolic syndrome and cardiac disease in adult life.
How do you manage insulin on L&D?
Give usual dose of insulin at bedtime. Hold morning dose depending on timing of admission.
IV NS
In active labor or glucose <70, switch to D5/NS (5% dextrose) and give at 100-150cc/hr to achieve glucose level of 100mg/dL.
Check glucose hourly w/ bedside meter.
Regular insulin via IV if glucose >100. Give at rate of 1.25units/hr.
What are risk factors for DKA?
How do you manage DKA?
New onset DM, Infection, non-compliance with insulin, insulin pump failure, tx w/ beta mimetic tocolytic meds (terbutaline).
Present w/ abdominal pain, N/V, AMS. Lab findings: Low arterial pH<7.3, low bicarb <15, Elevated AG, elevated ketones
IV Hydration w/ NS at 1-2L/hr (total replacement 4-6L in first 12hr)
Potassium: Give K if normal or low (15-20meQ/hr). If potassium elevated, wait until normal.
Insulin: give IV, *loading dose 0.1-0.2u/kg as bolus. Then 0.1units/hr. When glucose reaches 200, reduce dose.
Bicarb: if pH >7, no bicarb. add 1 ampule if pH < 7.1.
Hourly labs in iCU
and IV insulin
Monitor glucose and potassium
What is delivery timing for various complications?
Placenta previa: 36w-37w6d
Vasa Previa: 34 0/7 - 37 0/7
PAS: 34 0 /7 - 35 6/7
Prior classical 36 0/7 - 37 0/7
Prior myomectomy: 37 0/7 - 38 6/7
Prior uterine rupture 36 0/7 - 37 0/7
FGR 3-10%: 38-39 0/7, <3 %: 37w0d
Absent UAD: 33 0/7 - 34 0/7
Reversed UAD: 30 0 /7 - 32 0/7
Di-di twins: 38-38 6/7
Mono-di: 34 0 /7 - 37 6/7
Mono-mono: 32 0 /7 - 34 0/7
Di-di twins w/ FGR: 36 0 /7 - 37 6/7
Mono di with selective FGR: 32 0 /7 - 34 6/7
Alloimmunization: 37 0/7 - 38 6/7
Alloimmunization requiring IUT: individualized.
cHTN no meds: 38 0 /7 - 39 6/7
chTN on meds: 37 0 /9 - 39 6/7
cHTN difficult to control: 36 0 /7 - 37 6/7
T2DM well controlled: 39 0 /7 - 39 6/7
T2DM w/ vascular complications or prior stillbirth: 36 0 /7 - 38 6/7
GDM well controlled: 39 0/7 - 40 6/7
GDM on meds: 39 - 39 6/7
HIV if VL <1000: 38wks
HIV if VL < 1000: 39 weeks
Cholestasis bile acids <100: 36 0 /7 - 39 0/7
Cholestasis bile acids > 100: 36 0 /7 or at diagnosis.
Oligo: 36 0/7-37 6/7
Poly: consider 37wks for severe (AFI>35)
What is amniotic fluid embolism?
rare cause maternal cardiac arrest
- mortality 20% to 60%
- Diagnostic triad: Sudden hypoxia | Hypotension | Coagulopathy
- Treatment: CPR, TTE once stabilized to diagnosed R heart strain. Meds for RHF. Manage DIC, may need MTP.
Who is LDA recommended for?
High risk PEC w/ 1+ following RF: hx PEC, multiple gestation, HTN, pregestational DM, kidney disease, autoimmune (SLE, APLS)
1 or more RF: Nullips, obesity, fam hx, black race, low income, age 35+, IVF
What are effects of obesity on fetus development?
Effects of obesity on pregnancy?
Intrapartum effects of obesity?
What is antepartum care for obese patient?
SAB, Fetal anomalies (NTD, hydrocephaly, cardiovascular, orofacial, limbs)
cardiac dysfunction, OSA, NAFLD, GDM, PEC, stillbirth. In postpartum: postpartum weight retention, metabolic dysfunction, early termination of breastfeeding, depression
PTB, CS, failed TOL, endometritis, wound issues, venous thrombosis.
Genetic screening, early US, anatomy US. detection of incr NF, echogenic bowel and EIF NOT altered by BMI.
LDA, nutrition, a1c, baseline PEC labs, early GCT. serial growth scans
What are causes of FGR?
MATERNAL:
- cHTN or HPD
- T2DM
- renal dz
- autoimmune dz (SLE, APLS)
- heart disease
- substance use
- teratogens (valproic acid)
FETAL:
-multiple gestation
- anomalies
- infections (Toxo, rubella, CMV, syphilis, malaria)
PLACENTAL
- umbilical cord (velamentous)
- chorioangioma
- TTTS
- GA/fundal height discrepancy >3 at 23wks is concern for FGR.
- S/D ratio is ratio of peak systolic/diastolic flow velocity.
What are recommendations for epilepsy in pregnancy?
What are risks?
- continue AED
- Keppra (Levetiracetam) and Lamotrigine are best
- need normal amount folic acid 0.4mg/day
- single agent is best, monitor drug levels and adjust pro, assess for nTD, confirm fetal growth
- 1MG FOLIC ACID PRE-CONCEPTION.
Inc risks:
- FGR
- IUFD
- PEC
- congenital anomalies
- pTD
- maternal mortality
Who needs early GCT?
BMI >40
1st degree relative w/ DM
prior macrosomia/SD/stillbirth
prior GDM
PCOS
physical inactivity
–postpartum: 75 gm GTT, screen ALL at 6-12weeks.
What is White classification?
a1 - GDM diet controlled
a2 - GDM requiring meds
B: onset age >20, duration <10
C: onset age 10-20, duration 10-20
D: onset < 10, duration >20
F: ne-F-phropathy
H - HEART involvement (CAD)
R - Retinopathy
What are recs for cardiovascular disease in pregnancy?
What is NYHA classification?
RF: risk of heart attack: Race, obesity, HTN, age
- most common: HF, MI, arrhythmia, aortic dissection.
Do: fetal echo
NYHA classification
- Class 1: asymptomatic
Class 2: mild fatigue w/ ordinary activity
Class 3: marked fatigue w/ less than ordinary activity
Class 4: fatigue at rest.
L&D:
- avoid fluid overload, get epidural, vaginal delivery preferred (Avoid valsalva, shorten 2nd stage w/ operative delivery)
- supplemental o2
- PP is highest risk: inc.
Highest risk (pregnancy contra-indicated):
- pulm HTN, severe cardiomyopathy, severe AS, Marfan w/ dilated aortic root, class 4 disease.
– corrected valvular disease is lower risk!
What is management of sickle cell disease in pregnancy?
autosomal recessive disorders involving abnormal hemoglobin (hemoglobin S)
- Asymptomatic individuals with heterozygous Hb S genotypes (carriers) are said to have sickle cell trait
- hgb status of partner -> genetic counseling, diagnostic testing
- Maternal complications: PEC, sickle cell crisis, VTE
- Fetal complications: FGR, PTD
- Risk-reducing: folic acid 4mg qd and LDA
- Labs: PEC labs to assess renal function, CBC
TTE if symptoms
What is APLS?
1 clinical + 1 lab criteria
CLINICAL:
- vascular thrombosis
- fetal death > 10 wks w/ structurally normal fetus
- severe PEC before 34wks
- 3+ SAB < 10 wks
LAB (2 occasions 12wks apart)
- LAC (predicts poor pregnancy outcome)
- B2 glycoprotein
- anti-cardiolipin
Risks:
- thrombosis, fetal loss, PEC, PTL FGR
Tx:
- prophylactic anticoagulation + LDA
- avoid estrogen COC postpartum.
What are causes of symmetric vs asymmetric FGR?
Symmetric: early, 2/2 genetic causes, symmetrically small
- TORCH, syphilis, genetics, congenital anomalies, malaria
Asymmetric: occurs later in pregnancy. head and organ sparing
- 2/2 placental insufficiency.
What are risk factors for IUFD?
What is evaluation?
- black race
- obesity
- smoking
- T2DM
- HTN
- AMA
- nulips
- IVF
- alcohol use
- male fetal sex
- late/post term pregnancy
- maternal history/exam
- placental exam
- fetal autopsy
- fetal karyotype/microarray
- test for KB
- test for syphilis
- test for APLS
– can delivery at 39w
What is oligo?
Causes?
Delivery timing?
DVP <2cm
Causes:
- Maternal: smoking, PEC, idiopathic
- Fetal: FGR, PPROM, fetal anomaly (kidney/bladder), abruption, idiopathic
When do you deliver? 36-37w6d
What is poly?
Causes?
Delivery timing?
AFI >25cm. causes=T2DM, GDM, idiopathic, hydrops, infections, multiple gestation, fetal TEF or duodenal atresia
- not before 39wks
What is nausea/vomiting in pregnancy?
What is regimen?
What is differential?
- small frequent meals
- Non-pharmacologic: convert PNV to those with folic acid, ginger capsules
- Pharmacologic: B6 10-25mg, Diclegis (B6 + doxylamine 10mg of both, can increase dose) QID, Reglan, Phenergan, Zofran. Read practice bulletin. Avoid zofran in organogenesis period 2/2 small risk birth defects.
- steroids if persistent
DD n/V:
- hyperemesis (>5% body weight loss, inability to tolerate oral intake), molar pregnancy, twin gestation. GI (PUD, gastroparesus), GU (pyelo, kidney stones, torsion), metabolic (DKA), neurologic (migraines, CNS tumors), pregnancy (PEC, AFLP), miscellaneous (drug toxicity)
-torsion, degenerating fibroid, hyperthyroid
What is the NPV of reactive NST? BPP?
PPV of NST?
What affect BPP parameters adversely?
NPV is The likelihood that a person who has a negative test result indeed does not have the disease
NST is 99.8% and 99.9% for BPP
PPV is 10%
Fetal sleep status, maternal meds/intoxication, maternal smoking, fetal CNS abnormalities.
What is incidence of twins, triplets, quads?
1:250
1:10K
1:700K
What is effect of timing on amnionicity and chorionicity?
0-3 d
4-8
9-12
>13
0-3: di-di (delivery 38-39w)
4-8: mono/di (delivery 34-38w)
9-12: mono/mono (delivery 32-24w by CD)
>13 conjoined
- need additional 300kcal/day
What are maternal, obstetrical, and fetal complications of multiple gestation?
MATERNAL:
- hypermesis
- IDA
- DVT/PE
- CD
- pulmonary edema
OB:
- PTL
-PPROM
- HDP
- GDM
- abruption
- PPH
FETAL:
- FGR
- discordant growth
- congenital anomalies
- cerebral palsy
- cord accident in mono/mono
what is fetal weight at 20, 30 and 40 weeks?
What is neonatal survival at 24wks and 28 wks?
20=400g
30=1200g (400x3)
40=3600g (1200x3)
24wks: 30-50% survival
28wks: 90% survival
What are neonatal complications of PTL?
rest in peace neonates
RDS
IVH
PDA
NEC
Sepsis
BMZ reduces RDS, NEC, IVH.
What are contraindications to tocolysis?
IUFD
Chorio
PPROM
Maternal bleeding w/ instability
lethal fetal anomaly
non-reassuring fetal status
maternal contra-indications to tocolysis
- Procardia (CCB): dizziness, flushing hypotension. avoid if pre-load dependent cardiac condition.
- Indocin (NSAID): N/V, platelet dysfunction, gastritis. avoid if bleeding disorder.
- Beta agonist (Terbutaline: tachycardia
-Mag sulfate
What is US accuracy at various gestational ages?
< 9 weeks
9-14 wks
14-16
16-22
22-28
28+
< 9: CRL, +/- 5d
9-14: CRL, +/- 7d
14-16: biometry, +/- 7d
16-22: +/-10d
22-28: +/- 14d
28+: +- 21d
What is a normal pH for umbilical cord gas?
Normal base excess?
pH 7.3
A more significant base deficit signifies a metabolic acidosis – i.e., the process causing insult has been longstanding, and there has been time to utilize bicarbonate to buffer the acid.
A lower base deficit signifies a respiratory acidosis – i.e., the process has been acute, so there has been no buffering of the hydrogen ions.
A base deficit of 12 mmol/L has been suggested as severe, and more suggestive of metabolic acidosis.
What are risk factors for PPROM?
low maternal BMI
low SES
smoking and illicit drug use
2nd/3rd trimester bleeding
OB:
- short cervix
hx PPROM
- IAI
What are risk factors for abruption?
risk factors for previa? accreta?
DD placentomegaly?
prior abruption, HTN, cocaine, smoking, abdominal trauma, PPROM
PREVIA: prior previa, AMA, IVF pregnancy, prior CS, prior uterine surgery. CS at 37w.
ACCRETA: AMA, placenta previa, prior uterine surgery or CS, prior accreta.
Syphilis, T21, DM, hydrops
What are risk factors for stillbirth?
What is workup
What is management of subsequent pregnancy?
MATERNAL: prior stillbirth, AMA, nullips, black race, smoking, T2DM, abruption, HTN, APLS, SLE
FETAL: fetal anomalies, infections. Placental: previa, cord accident, vasa previa.
Labs to order: If personal/fam hx thrombosis, factor V, prothrombin G, antithrombin 3. CBC, KB, TSH, syphilis, parvo
growths at 28wks and kick counts at 28wks. APT at 32wks
What are categories for when to begin antenatal testing?
Category 1: at or by 32wks
- uncomplicated monochorionic twins
- cHTN
- gDM or T2DM
- SLE
- APLS
- sickle cell
Category 2: at or by 36wks
- uncomplicated dichorionic twins
- IVF
- alcohol use
Category 3: start at 39wks
- late term (>41 wks)
What is the differential diagnosis of fetal hydrops?
Immune - Rh disease
Non-immune:
- Infectious: parvo, CMV
- Congenital: heart defects, SVT
- Placental: AV malformation (chorioangioma), TTTS
- Aneuploidy (Turner’s, T13, T18)
- Structural: CPAM
Random
- fetal blood volume =80 mg/kg.
- corpus luteum/placental shift takes place at 70d - if you need to give progesterone support if you lose corpus luteum
- NTD prophylaxis: if routine, 0.4mg 1 mo before contraception. If hx nTD or on anti-epileptic, 4mg and start it 3 mo prior to conception.
What drugs are contraindicated in pregnancy?
Tetracyclines - dental discoloration
Quinolones - affects cartilage
- Erythromycin - maternal hepatic toxicity
- Retinoic acid - CNS, craniofacial
- ACEi: heart defects, oliguria/renal failure
- MTX: multiple anomalies, IUFD
- Coumadin: anomalies, IUFD
- Valproate: NTD
- Macrobid in 3rd tri: neonatal hemolytic anemia
- Fluconazole: 1st tri, increased miscarriage.
What are contra-indications for breastfeeding?
substance abuse
HIV pos
- active hSV lesion (stop until lesion resolved)
untreated TB or varicella
What are recs for pre-conception counseling?
- counseling on general heatlth/wellness. optimize medical conditions
- healthy diet and folate supplementation at least 1 mo prior to conception
- Vaccinations: Tdap, MMR, varicella, hep B, Covid, flu
- address travel/Zika
- Hep C screen
- carrier screening: CF, SMA, hemoglobinopathies, fragile X
— if European jewish: Tay-Sachs, CF, Canaan, familial dysautonomia.
What are recommendations for tobacco/nicotine cessation during pregnancy?
What are risks of smoking during pregnancy?
What are neonatal risks?
smoking associated w/ oralfacial anomalies
- FGR
- previa
- abruption
- PPROM
- mortality
- neonatal: risk respiratory infections, asthma, childhood obesity
- 5As, offer bupropion. no data on varenicline w/ lactation.
How do thyroid hormones change in pregnancy?
TSH decr in 1st trimester 2/2 HCG but otherwise unchanged
- total T4 and t3 increase 2/2 increase in estrogen binding globulins but no change in free T4
What is hyperemesis?
- recurrent severe emesis
- weight loss 5% or more of pre-pregnancy weight
- recurrent dehydration
- abnormal liver function tests
- N/V in 2nd trimester r/o GERD, PUD, chronic gastritis.
What is differential diagnosis for a rash in pregnancy?
- contact dermattis
- PEP: polymorphic eruption of pregnancy
–tx=topical steroids (clobetasol 0.025%), oatmeal bath. if severe, PO steroids taper x1wk - parvo (more papular)
- Varicella, rubella
- ICP (pruritic but ABSENT rash)
What is counseling for seizures in pregnancy?
- incr risk seizures 30-50%
- fetal risks: FGR, stillbirth, PEC
- single agent anti-seizure: lamotrigine or levetiracetam.
- folate supplementation 4mg daily starting 3 months prior to conception
- fetal effects of anticonvulsants: NTD (valproate and carbamazepine), cardia defects (ASD, VSD), clefting.
What is management of early and delayed breakdown of 4th degree repair?
When to consider CD for next pregnancy?
EARLY
- debride necrotic tissue. obtain cultures
- observe until granulation tissue present and no exudae
- IV abx If cellulitis
- enema and NPO day prior to repair.
- debride, 4-layer repair
LATE:
- remove all remaining suture material
- inspect for necrotizing fasciitis (deeper tissue inflammation)
risk recurrent OASIS in subsequent pregnancy is 3%
- consider CD for next preg if anal incontience present, wound infection occurred post-laceration, psychological trauma 2/2 OASIS.
What is management of mastitis?
penicillin or cephalosporin
- dicloxacillin 500mg QID or keflex 500mg QID for 10-14d
If no resolution in 48-72hr, consider beta-lactam resistance and give Augmentin AND consider abscess/MRSA - need vans.
