Pregnancy Complications Flashcards
Pregestational HIV Infection
- 90% of pediatric HIV infection d/t vertical transmission
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Treatment in pregnancy
- Treat prenatally, in labor, newborn
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HAART (Highly active antiretroviral therapy)
- Goal HIV viral load < 1,000
- Attempt vaginal delivery if < 1,000
- Elective C-section of > 1,000
- Goal HIV viral load < 1,000
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HAART (Highly active antiretroviral therapy)
- If no prenatal care prior to onset of labor ⇒ ✓ rapid HIV test
- Treat prenatally, in labor, newborn
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Minimize invasive procedures
- Artificial rupture of membranes
- Operative vaginal delivery
- Fetal scalp electrodes
- Postpartum – No breastfeeding
Pregestational Asthma
Characteristics
- One of the most common medical conditions in pregnancy
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Management complicated by:
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Effect of pregnancy on asthma is variable
- Elevation of diaphragm by gravid uterus ⇒ ↓ FRC but ↔︎ peak expiratory flow rate and FEV1
- Potential effect of meds used to tx
- Adverse effects of asthma on fetus and pregnancy progression
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Effect of pregnancy on asthma is variable
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Important to monitor severity of disease:
- Maternal sx: wheezing, SOB
- Track FEV1 (nl 380-550 L/min in pregnancy)
Pregestational Asthma
Management
Goal to prevent acute exacerbations and optimize pulmonary function.
Treatment is the same as w/o pregnancy except avoid systemic steroids.
Pregestational Thyroid Disease
Overview
- 2nd most common endocrine disease in pregnancy
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Thyroid function changes in pregnancy:
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↑ Thyroxine binding globulin d/t estrogen
- ↑ total T3 and T4 but not free hormone levels
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hCG ⇒ ⊕ TSH receptor
- ↑ free T3/T4 & ↓ TSH
- Effect is transient during peak hCG levels (10-12 wks)
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↑ Thyroxine binding globulin d/t estrogen
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T4 important in fetal brain development until 18-20 wks (then fetal thyroid takes over)
- Must dx and tx hypothyroidism in early pregnancy
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Thyroid function testing: use TSH and free T4 levels
- Hx of thyroid disease
- Sx of hypo/hyperthyroidism
Pregestational Hypothyroid
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Most common etiologies:
- Hashimoto’s thyroiditis
- Post-ablative therapy
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Diagnosis:
- Overt: ↑ TSH and ↓ free T4
- Subclinical: ↑ TSH and nl free T4
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Treatment:
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Levothyroxine
- Pregnancy ↑ dose requirements
- Check TFTs every 4 wks while adjusting
- Check every trimester when stable
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Levothyroxine
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Complications:
- Neuropsychological impairment of fetus
- Preeclampsia
- Placental abruption
- Preterm delivery
- Postpartum hemorrhage
Pregestational Hyperthyroid
- Occurs in 0.2% of pregnancies
- Grave’s disease in 90% of cases
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Diagnosis:
- ↓ TSH and ↑ free T4
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Treatment:
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Primarily medical: PTU and Methimazole
- Both cross placenta and can cause fetal hypothyroidism
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1st trimester: PTU
- Risk of maternal liver toxicity w/ PTU
- Safer for baby
- Methimazole is a teratogen
- 2nd / 3rd trimester: Methimazole
- Safer for mom
- Lowest dose to maintain free T4 in high nl range
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Thyroidectomy in refractory cases
- Ablation contraindicated in pregnancy
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Primarily medical: PTU and Methimazole
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Complications:
- Miscarriage
- Preterm labor
- Low birth weight
- IUFD
- Preeclampsia
- Heart failure
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Thyroid Storm
- Life threatening
- N/V, fever, tachycardia, delirium
- Treat in ICU, high dose PTU, steroids, propranolol
Venous Thromboembolism
Overview
- DVT and PE
- Rate 4-50x higher in pregnant vs non-pregnant women
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Higher incidence:
- Postpartum
- Cesarean section
- Pregnancy promotes all the components of Virchow’s Triad
- Inherited thrombophilia ⇒ significantly ↑ risk VTE
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Diagnosis:
- Difficult as signs/sx mimic nl pregnancy
- Low extremity swelling
- Dyspnea
- Labs:
- ABG: low sensitivity and specificity
- D-dimer: high sensitivity but low specificity
- Imaging:
- Lower extremity Doppler U/S (DVT)
- MRI (DVT)
- V/Q scan (PE)
- CT angio (PE)
- Difficult as signs/sx mimic nl pregnancy
Venous Thromboembolism
Treatment & Prophylaxis
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Treatment:
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Anticoagulation
- Unfractionated heparin
- LMW heparin (Lovenox)
- Coumadin post-partum only
- Teratogenic
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Duration of therapy
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At least 6 months after dx and 6 wks postpartum
- Can be transitioned to Coumadin postpartum
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At least 6 months after dx and 6 wks postpartum
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Anticoagulation
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Prophylaxis:
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Women at high risk
- Hx of VTE
- Cardiac valves
- Thrombophilia
- Morbid obesity
- Prolonged immobility
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Therapy
- Depending on indication: duration of pregnancy and postpartum
- Heparin or LMW Heparin, prophylactic doses
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Women at high risk
Pregestational Seizure Disorder
Overview
- Most frequent neurologic complication of pregnancy
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Pregnancy may ↑ seizure frequency
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↓ Levels of antiepileptic drugs (AEDs)
- ∆ Clearance, protein binding, volume of distribution
- ↓ Compliance
- Sleep deprivation
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↓ Levels of antiepileptic drugs (AEDs)
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Concerns:
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↑ Risk of malformations w/ all AEDs
- Depakene (valproic acid) ⇒ neural tube defects
- Dilantin (phenytoin) ⇒ hydantoin syndrome
- ? ↑ Rate of fetal growth restriction and stillbirth
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↑ Risk of malformations w/ all AEDs
Pregestational Seizure Disorder
Management
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Consultation w/ neurologist
- Are meds needed?
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AED: lowest dose, newer meds, monotherapy
- Avoid valproate if possible
- Monitor drug levels
- Folic acid supplementation 4 mg/day
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Malformation screening
- Ultrasound
- Maternal serum AFP
Trauma During Pregnancy
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Penetrating trauma
- More likely to injure fetus than maternal abd structures
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Blunt trauma
- Non-viable fetus (< 24 wks)
- Assess maternal blood type and administer Rhogam
- Viable fetus (> 24 wks)
- Monitor for evidence of abruption
- Non-viable fetus (< 24 wks)
Appendicitis During Pregnancy
- Most common surgical condition in pregnancy
- Location of the appendix can be altered in pregnancy
- Imaging: attempt US first, but CT scan as needed
- Outcomes worse if perforation occurs
- Surgical approach depends on gestation (laparoscopy vs. open)
Hyperemesis Gravidarum
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Severe nausea and vomiting of pregnancy with:
- Electrolyte abnormalities (hypokalemia)
- Starvation ketosis
- Weight loss from pre-pregnancy (> 5%)
- Mostly during 1st trimester
- Affects 2% of pregnancies
- Unclear etiology (possible related to elevated hCG levels)
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Differential Dx: anything that causes N/V
- Pancreatitis, appendicitis, DM, migraines, drug intoxication
- Rarely results in severe adverse maternal or fetal effects
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Management:
- Hospitalization
- Antiemetics, vitamin B6
- IVF until able to tolerate meals
- If persistent weight loss ⇒ PICC line and TPN
Intrahepatic Cholestasis of Pregnancy
- Elevated serum bile acid concentration and severe itching (palms and soles)
- 2nd and 3rd trimester
- Variable incidence (1-15%)
- Higher in Latin ethnic groups
- Genetic link, but thought to be related to estrogen effect on bile acids
- Differential Dx: other liver or biliary diseases
- No adverse maternal effects
- ↑ risk of fetal death and respiratory distress syndrome
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Management:
- Actigall (ursodiol): improves bile flow
- Benadryl for pruritus
- Fetal testing w/ delivery between 36-38 wks
Gestational Thrombocytopenia
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Low platelet count during pregnancy
- Mild > 70k, most are >120k
- Women are asymptomatic
- No hx of platelet abnormality predating pregnancy
- Returns to nl postpartum
- Occurs in 3rd trimester
- Roughly 5% of pregnancies
- Unclear etiology
- Anti-platelet antibodies present similar to ITP
- Accelerated platelet consumption
- DDx: ITP, TTP, Preeclampsia/HELLP syndrome
- No significant fetal or maternal effects
- Some anesthesiologists will not place epidural w/ low platelets
- No specific management
Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPs)
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Erythematous and itchy papules and plaques that develop striated areas
- Mostly on abd, less on thighs
- Not on palms and soles ⇒ diff. from IHCP
- 3rd trimester and postpartum
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Etiology:
- Stretching of skin causes inflammatory response
- Fetal DNA found in some lesions
- DDx: bed bugs bites, IHCP, Eczema
- Rash and itching can be uncomfortable but no severe fetal or maternal effects
- Management: symptomatic treatment
- Topical corticosteroids
- Oral antihistamines
- Systemic steroids if severe
Hypertension in Pregnancy
- Chronic HTN
- Gestational HTN
- PreEclampsia and Eclampsia
- Chronic HTN w/ superimposed PreEclampsia
Chronic Hypertension (CHTN)
Characteristics
↑ Risk of fetal death, growth restriction, placental abruption, and developing a hypertensive disorder of pregnancy
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Diagnosis
- BP > 130/80, prior to 20th week of pregnancy, 2 separate occasions
- Known dx of chronic HTN prior to pregnancy
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Initial Evaluation
- Hx of age of onset, duration, and severity of disease
- May need more extensive work up depending on above
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Labs/Studies
- EKG, echocardiogram, ophthalmologic exam
- BMP: electrolytes, particularly kidney function
- 24-hour urine collection (protein)
- CBC, LFTs, ± Uric acid
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Antenatal Testing
- Baseline US at 18-20 wks (anatomy)
- Repeat US every 4 wks starting at 28 wks (growth)
- Non-stress test and/or Biophysical Profile weekly starting at 32 wks
Chronic Hypertension (CHTN)
Management
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Mild to moderate HTN (140-159/90-109)
- No proven benefit to prevent progression to preeclampsia, growth restriction, neonatal death, or preterm birth
- Therapy instituted for BP > 150/90
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Severe HTN (> 160/110)
- Prevention of ICH, hypertensive encephalopathy, and ↓ risk of maternal death
Gestational Hypertension
- Systolic BP > 140 or Diastolic BP > 90 on 2 occasions 6 hours apart
- After 20 wks of gestation
- No other signs or sx
- Deliver for OB indications only
Antihypertensives in Pregnancy
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Acute management
- Recommended for any BP > 170/100
- Labetalol 20-40mg IV q10min
- Hydralizine 5-10mg IV q20min
- Procardia 10-20 mg IV q20-30min
- Sodium Nitroprusside
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Tritate BPs to no lower than 140/90
- Sign. ↓ BP to “normal” ⇒ ↓ fetal blood flow & uteroplacental insufficiency
- Applies to chronic HTN and HTN disorders of pregnancy
- Recommended for any BP > 170/100
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Chronic management
- Nifedipine
- Labetalol
- Methyldopa
Diabetes and Pregnancy
- Pregestational vs gestational
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Hormones of pregnancy ⇒ ↑ insulin resistance as pregnancy progresses
- Progesterone, HPL, Prolactin
- 40% ↑ prevalence of Type II DM
- 90% of diabetes in pregnancy is gestational
Pregestational Diabetes
- Evaluate for hx of DM or undiagnosed pre-existing DM
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If hx of pre-existing, assess for end-organ damage @ initial prenatal visit
- Retinopathy: ophthalmologic exam
- Cardiovascular: EKG ± ECHO
- Renal: creatinine and 24 hr urine collection to assess proteinuria
- ✓ HgbA1c
- If no hx of DM, screen for gestational or consider testing for type II
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Important to classify type of DM
- Further along continuum ⇒ ↑ risk of maternal and fetal complications
Gestational Diabetes
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Risk factors:
- Age (older)
- Race (AA, Latina, Asian)
- Obesity (BMI > 25)
- Family hx (1st deg relative w/ DM)
- Prior GDM or prior adverse OB outcomes suggestive of prior GDM
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Diagnosis
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Screening: 1 hr glucose challenge test
- 50-gram glucose load, check BS at one hour
- > 135 considered elevated and need further testing
- Performed b/t 24-38 wks gestational age
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Diagnostic: 3 hr glucose tolerance test
- 100-gram glucose load, check FBS, one hour, two hr, and three hr BS
- Abnl values are greater than: 90/180/155/140
- At least two abnl values qualifies for diagnosis of GDM
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Screening: 1 hr glucose challenge test
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Classifications of DM
- A1/A2: gestational
- B/C/D/F/R/H: pregestational
Diabetes
Pregnancy Complications
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Maternal
- Diabetic complications may worsen:
- Retinopathy
- Renal, cardiac disease
- ↑ Incidence of DKA
- Spontaneous abortion
- Preeclampsia
- Diabetic complications may worsen:
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Fetal
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Congenital anomalies
- Cardiac, CNS
- IUFD (stillbirth)
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Macrosomia and birth injury
- Big babies indicative of GDM
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Growth restriction
- Small babies indicative of pre-gestational DM
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Neonatal cardiomyopathy
- Mostly hypertropic
- Respiratory distress syndrome
- Neonatal hypoglycemia
- ↑ Risk of childhood obesity
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Congenital anomalies
Classifications of Diabetes in Pregnancy
Diabetes in Pregnancy
Management
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DM treatment
Achieving glycemic control is the most important factor-
Diet and exercise (A1)
- BS goal: fasting < 95, 2 hrs PP < 120
- Measure BS 4 times daily
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If BGL remains elevated ⇒ initiate medication therapy
- Glyburide or metformin (PO)
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Insulin (IV)
- Many regimens available
- Insulin requirements ↑ through pregnancy
- ⅔ and ⅓ rule: ⅔ in the AM, ⅓ in the PM
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Diet and exercise (A1)
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Imaging: many ultrasounds
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1st trimester
- Early to date and assess viability (high miscarriage rate)
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2nd trimester
- Level II US to assess for fetal anomalies @ 18-20 wks
- Fetal ECHO @ 22 wks
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3rd trimester
- Growth scans every 4 wks until delivery
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1st trimester
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Antenatal testing
- NST/AFI or BPP twice weekly
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Timing and mode of delivery
- Glycemic control
- Fetal size
- Amniocentesis
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Postpartum testing
- Screen at 6 wks to assess for non-gestational DM
- ↑ Maternal risk of developing DM later in life