Pregnancy related issues Flashcards
chronic hypertension in pregnancy
systolic pressure >140 and diastolic pressure >90 prior to conception or 20 weeks gestation
gestational hypertension
new onset elevated BP AFTER 20 weeks gestation no proteinuria or end organ damage
preeclampsia
new onset elevated blood pressure at >20 weeks gestation AND proteinuria OR signs of end organ damage
eclampsia
pre-eclampsia AND new onset grand mal seizures
chronic HTN with superimposed pre-eclampsia
chronic HTN and 1 of the following:
new onset proteinuria
worsening of existing proteinuria at >20 weeks gestation.
Sudden worsening of HTN signs of end organ damage
when to start blood pressure medications for hypertension in pregnancy?
severe HTN (>160/110) and evidence of end organ damage. Treatment of BP <160/110 does not improve fetal or maternal outcomes.
what are pregnancy safe HTN medications:
labetalol,
methyldopa,
nifedipine
hydralazine.
treatment of UTI in pregnancy asymptomatic bacteruria and cystitis
amoxicillin clavulanate
fosfomycin
cephalosporin (cefpodoxime, cephalexin)
nitrofurantoin (avoid in first trimester)
TMP-SMX - avoid in 1st trimester and at term
treatment in pregnancy - mild to moderate pyelonephritis
3rd generation cephalosporin (ceftriaxone and cefepime) aztreonam ampicillin and gentamicin
treatment in pregnancy with severe pyelonephritis (immunocompromised or urinary retention)
zosyn carbapenems
if patient is pregnant and has mitral stenosis with afib (from rheumatic heart disease) and was on warfarin, what do you do with her anticoagulation now that she’s pregnant?
keep anticoagulation because mitral stenosis and afib is high risk for thrombosis.
AC of choice: low molecular weight heparin until final few weeks of pregnancy and then can be transitioned to unfractionated heparin (for easier reversibility)
why do we prefer low molecular weight heparin instead of unfractionated heparin in pregnancy?
both can be used but we reserve subcutaneous unfractionated heparin q12h for anticoagulation with severe renal insufficiency (CrCl <30)
try to use LMW heparin due to lower risk of HIT.
When does this intrahepatic cholestasis of pregnancy (ICP) occur in gestation?
pregnancy complication that happens in 2nd or 3rd trimester
condition improves spontaneously wihtin 48 hrs of delivery
2nd or 3rd trimester pregnant woman presents with generalized intolerable pruritis that is most intense in palms and soles and at night. See Jaundice in
intrahepatic cholestasis of pregnancy
cardinal feature of intrahepatic cholestasis of pregnancy
intolerable itching esp on palms and soles of feet.
laboratory studies of intrahepatic cholestasis of pregnancy
elevated total bili acid, see elevated bilirubin, alkaline phosphatase, AST and ALT levels.
INR/PT are normal. GGT is normal or mildly elevated.
U/S RUQ is normal.
IF AST/ALT >1000 need to check viral hepatitis.
is intrahepatic cholestasis of pregnancy a major issue?
It can increase fetal prematurity and fetal demise and neonatal respiratory distress syndrome.
it doesn’t cause significant maternal complications or postpartum hepatic dx.
Guidelines for delivery with women who have intrahepatic cholestasis of pregnancy
delivery at 37 weeks gestation to prevent fetal complications delivery prior to 36 weeks gestation is suggested only in cases to prevent fetal complications - only meant for unremitting pruritis (not relieved by pharmacotherapy) or previous fetal demise from ICP
how to treat intrahepatic cholestasis of pregnancy
1st line treatment is ursodeoxycholic acid to improve bile flow, reduce pruritis, and improve liver function tests. It does not lower risk to baby for fetal demise or premature delivery
second line therapy for intrahepatic cholestasis of pregnancy
cholestyramine - not as effective. also causes steatorrhea and vitamin K deficiency so this limits its usefulness.
does prednisolone help with intrahepatic cholestasis of pregnancy tx?
no. it doesn’t improve pruritis or decrease serum bile acid levels or decrease risk to fetus.
management of acute fatty liver of pregnacy
prompt delivery, life threatening condition
presentation of acute fatty liver of pregnancy:
nausea, vomiting, RUQ pain and anorexia and jaundice and hypertension with proteinuria. No itching.
There’s elevated AST/ALT, bilirubin, PT/INR low platelets and low glucose.
Think acute liver failure because of pregnancy
when do you start to see HELLP syndrome?
in 2nd trimester to post partum
nausea, vomiting, epigastric/RUQ pain with hypertension and proteinuria
HELLP
management of HELLP
prompt delivery management with magnesium sulfate seizure prophylaxis and HTN control
Hemolysis, Elevated Liver Enzymes and Low Platelets - HELLP - is an advanced complication of preeclampsia.
See abdominal pain, new onset N/V, pruritis, and jaundice. Will see schistocytes.
lab findings of HELLP?
elevated AST/ALT, LDH>600 and platelets<100K and see schistocytes on smear
intrahepatic cholestasis of pregnancy labs
elevated AST/ALT and increased bile acids and normal INR.
labs of acute fatty liver of pregnancy
elevated AST/ALT, bilirubin, PT/INR
low platelets and low glucose.
think liver failure
dangerous liver conditions in pregnant women chart