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
what is adenomyosis?
This is where there’s painful menses rather than amenorrhea and they have some glandular tissue growing in the uterine wall.
tubal sterilization (bilateral tubal ligation) failure rate?
effective form of permanent contraception but failure rates are as much as 36/1000 procedures.
endometrial cancer presentation
abnormal uterine bleeding in premenopausal pts with chronic unopposed estrogen exposure (anovulation, obesity, PCOS)
signs of early pregnancy
fatigue, weight gain, secondary amenorrhea and uterine enlargement.
secondary amenorrhea
prevously had periods and now doesn’t have them
>3 months in previously regular cycles
or >6 months in previous irregular cycles.
Chart with list of normal pregnancy lab values and why this happens
when do maternal physiological changes in pregnancy begin?
4 weeks of gestation
Common changes in lab values due to pregnancy:
Hgb
WBC
ESR/CRP
Alkaline phosphatase
Hgb: becomes anemic due to dilution from expanded plasma volume
WBC: elevated due to increased neutrophil demargination
ESR/CRP: elevated due to stimulation of liver synthetic function by estrogen and progesterone
Alkaline phosphatase: elevated made by placenta often moderately elevated in late pregnancy
What lab values do not change with pregnancy and suggest possible pathology?
AST/ALT do not hcange and so elevations may be signs of hepatobiliary dx
Hormonal changes from pregnancy also decrease gallbladder contractility and increase biliary cholesterol concentration promoting gallstone formation. This can lead to cholelithiasis and biliary cholic.
how to treat pregnant pts who have a bout of biliary cholic (RUQ pain) from symptomatic cholecystitis
if isolated episode of biliary colic can respond to supportive care and pain control and low fat diet.
Clinical features of pre eclampsia
definition of pre eclampsia
new onset HTN SBP>140 and or DBP>90 at 20 weeks gestation + proteinuria and or end organ damage
Name the severe features of pre eclampsia
SBP>160 or DBP>110 (2 x >4 hrs apart)
thrombocytopenia
elevated Cr
elevated transasminases
Pulm edema
visual or cerebral symptoms
Management of Pre eclampsia
Without severe features: delivery at >37 weeks
With severe features delivery at >34 weeks
Magnesium sulfate for seizure prophylaxis
antihypertensives.
when do you start to see preeclampsia start (in pregnancy gestation period)
can start after 20 weeks.
commonly manifests in third trimester
can occur at delivery and up to 6 weeks post partum and most cases can develop 48 hrs of delivery
most common features of preeclampsia during pregnancy:
headache, epigastric or RUQ pain and visual changes.
Most common symptoms post partum of pre eclampsia
pulmonary edema
likely from pre eclampsia induced renal changes (proteinuria and exacerbating physiological post partum fluid shifts.
other causes of post partum changes are capillary leak, left heart failure and iatrogenic volume overload.
for someone who has postpartum pre eclampsia with pulmonary edema what do you do?
blood pressure control, magnesium sulfate for seizure prophylaxis
then fluid restrict and provide oxygen support and diuretics.
amniotic fluid embolism presentation and characteristic clues are:
acute onset of dyspnea, hypotension (cardiogenic shock) and DIC with bleeding and bruising.
peripartum cardiomyopathy presentation
dyspnea, cough, pedal edema, HTN and see this in 3rd trimester and postpartum period
would see JVD
DON’T see proteinuria.
Gestational thrombocytopenia is a
benign self limited condition that happens in 5-7% of pregnancies.
Most cases are late in gestation (usually at delivery) but can arise in 1st trimester. IT is seen incidentally and not associated with any bruising, bleeding or physical exam abnormalities or seen with neonatal thrombocytopenia.
What are the platelet counts seen in gestational thrombocytopenia?
around 100K -150K.
should continue normal prenatal care and delivery management. NO further testing or treatment is needed.
Platelets should normalize within 6 weeks of delivery.
Thrombocytopenia<80K should prompt you to look for alternate diagnosisi
differential diagnosis for gestational thrombocytopenia?
immune mediated thrombocytopenia. ITP is diagnosis of exclusion and distinguish between gestational thrombocytoepnia and mild ITP (plt>100K) in pregnancy
do not use antiplatelet antibody testing for suspected ITP work up because doesn’t beck it very well.
What vaccines are recommended in pregnancy
which ones are contraindicated?
Tdap administration during pregnancy schedule is this:
why is it important to give Tdap every pregnancy
pertussis in US is increased due to waning immunity and infants <3 months can get it and it has high rates or morbidity and mortality.
Thus it’s needed for every pregnancy
who else should get Tdap besides mom in a pregnant pt?
any family member who has not been recently vaccinated and will be in close contact with newborn.
which influenza vaccine is safe for pregnant pts?
IM influenzae as this is the inactivated influenza. The intranasal influenza is a live attenuated vaccine and that is contraindicated in pregnancy
is the pneumoccocal vaccine safe to give to pregnant pts?
it’s safe but only recommended for pts who have risk factors for invasive pnuemonia infection (chronic lung dx, immune deficiency)
Why is the varicella zoster vaccine contraindicated in pregnant women?
it can cause maternal issues (pneumonia and encephalitis) and congenital defects like cataracts, chorioretinitis) complciations and non immune pregnant pts should betreated with prophylactic varicella zoster immunoglobulin.
Incomplete abortion is a
partially dispelled remains of fetus
presents with heavy vaginal bleeding and resutling in hemodynamic instability and can have DIC.
Will see a dilated cervix with partial expulsion of the pregnancy
management of ectopic pregnancy
first trimester vaginal bleeding,
lower abdominal pain
complex adnexal mass on transvaginal ultrasound
can have hemodynamic instability
ectopic pregnancy
risk factors for ectopic pregnancy are:
prior pelvic surgery, pelvic inflammatory dx, infertility and tobacco use
Locations for ectopic pregnancy
fallopian tubes, ovaries, and cornua of uterus
anemia, free fluid in posterior cul-de-sac, and hemodynamic instability in a young female
ruptured ectopic pregnancy life threatening emergency due to intraabdominal bleeding
see anemia
how to manage someone with ectopic pregnancy?
expectantly or medically managed with methotrexate
expectant management is for women who have no adnexal mass on U/s and beta Hcg<200. Methotrexate can be used with no medical contraindications to therapy (immunodeficiency, renal failure, active pulm TB) and beta hcg<5000.
If someone is hemodynamically unstable, then pt needs surgical management (laparoscopy)
vaginal bleeding and lower abdominal pain in third trimester and can have some uterine tenderness
abruptio placentae
hydratiform mole is
first trimester vaginal bleeding with enlarged uterus and marked elevated beta hCG (>100K) and intrauterine heterogenous mass with cystic areas (snow storm appearance on ultrasound)
anticoagulation during pregnancy
anticoagulation prior to delivery of baby with VTE
hold anticoagulation with low molecular weight heparin for 24 hrs prior to delivery. During the 24 hrs, high risk for recurrenct (acute PE, proximal dvt within the last month), and so switch to unfractionated heparin (IV heparin) and then discontinued 4-6 hrs prior to surgery or delivery
Then anticoagulation is started 6 to 12 hrs after delivery and continued for >6 weeks post partum.
Anemias of pregnancy
expected physiological levels of Hgb during pregnancy:
>11 g/dl in 1st trimester
>10.5 g/dl in 2nd trimester
>11 g/dl in 3rd trimester
baseline Hgb returns to normal after 6-8 weeks post partum. See increased fluid with pregnancy.
Pruritic urticarial papules and plaques of pregnancy (PUPPP) is a
common specific dermatosis of pregnancy - seen by appearance of late third trimester erythematous itchy plaques in the distribution of striae.
Plaques are pruritic and hallmark of condition. NO jaundice or elevated LFTs and this is why this is not intrahepatic cholestasis of pregnancy.
condition resolves after delivery and 1st line tx is topical steroids of low to mid potency.
topical steroids do not relieve intrahepatic cholestasis of pregnancy
management of breast pain (mastalgia)
breast pain is c_ommon and benign symptom_ in most women due to estrogen and progesterone changes in menstrual cycle.
pain is cyclical and beginning before menses and subsiding before onset of menses
pain is described as heavy, dull, diffuse and bilateral
Generalized swelling and mildly tender nodularity may be present but no discrete masses or nipple discharge should be there.
how to treat bilateral cyclical mastalgia?
needs to treat pain with wearing a properly fitted braw with good breast support that miminizes breast movement.
can give tylenol for pain relief
danazol can be given for mastalgia but can cause permanent androgenic side effects (hirsutism) and increases risk for VTE
only get U/S or imaging of breast if there’s unilateral, non cyclical, or focal breast pain.
what medications to stop prior to getting pregnant?
lisinopril
methotrexate- stop 3 months prior
leflunomide - extremely tetraogenic - need cholestyramine to remove drug from body and needs to be followed with drug level
mycophenolate mofetil stop 3 months prior
no NSAIDs. ACEi ARBs, phenytoin or valproic acid
ribavirin - for RSV treatment in immunocompromised pts . need to stop it 6 months prior to pregnancy
sirolimus and everolimus - stop 3-6 months prior to pregnancy
needs to get folate supplement.
Are SSRI’s ok to take in pregnancy?
SSRI’s like citalopram, fluvoxamine, sertraline, are pregnancy category C agents that can be continued with pregnancy.
diabetic goal A1c goal for pregnancy
which medication is ok to use while pregnant?
A1c<6.5
metformin is ok to take.
