VUSN Notes Flashcards
Describes a chronic, inflammatory, debilitating, skin follicular disease involving the apocrine gland-bearing areas of the body, most commonly the axillary, inframammary, and anogenital areas. This condition manifests as deep painful cystic nodules, sinuses, and scarring. It is an acute and chronic follicular occlusive process, just like acne vulgaris, and is analogous to acne mechanica.
hidradenitis suppurativa
Most common areas of the body to be affected by hidradenitis suppurativa (3)
- axillary folds
- inframammary folds
- anogenital areas
Gestational diabetes refers to onset of diabetes in pregnancy after ____ weeks EGA
> 20 weeks
GDMA1
controlled with diet and exercise
GDMA2
controlled with medication
Exponential increase in insulin resistance occurs when in pregnancy
2-3rd trimesters
aka, beyond 14 weeks
Screen all folks for GDM at ____ weeks EGA
24-28 weeks
High risk folks who should be screened for DM at the first prenatal visit
overweight + any of the following:
- h/o GDM, macrosomia, stillbirth, or congenital anomalies affecting a prior pregnancy
- A1c >5.7% (prediabetes)
- HLD
- CVD
- PCOS
Positive 1-hr 50g OGTT screening results
> 130-140
if >200, that is diagnostic
Positive 3-hr 100g OGTT diagnostic results
need 2 or more abnormal values
- fasting >95
- 1hr >180
- 2hr >155
- 3hr >140
Are the OGTTs for GDM in pregnancy fasting or non-fasting?
1hr 50-g OGTT for screening is not fasting.
3-hr 100g OGTT is fasting
Definition of macrosomia
> 4000g
Who should be counseled on c-section with GDM and macrosomia
> 4500g
Who should be counseled on c-section with macrosomia but no GDM
> 5000g
Recommended home blood sugars for pregnant person with GDM
fasting <95
1-hr post prandial <140
2-hr post prandial <120
First line medication for GDM
insulin
When to start insulin in someone with GDM
> 25-50% of home blood sugars are elevated
OR
if fasting blood sugars are regularly elevated, as these are unlikely to improve with diet alone
Changes to pregnancy monitoring in GDM
- monitor urine for ketones
- growth US Q3-4 weeks after dx
- weekly NSTs/BPPs after 32 weeks
Delivery timing in GDM
- GDMA1 = await full term
- GDMA2 = deliver in 39th week (before 40 weeks)
- GDM poorly controlled = deliver in 37th or 38th weeks (before 39 weeks)
Changes to postpartum monitoring in GDM
- screen for diabetes or impaired glucose metabolism 4-12 weeks postpartum with a 2-hr 75 OGTT
- A1c DM screening Q1-3 years for the rest of life
- screen early for GDM in all future pregnancies
Results on 75-g 2-hr OGTT post partum that diagnose DM
fasting >125
2-hr >199
% of folks with pre-gestational diabetes (pre-existing) who will have SAB
25%
Changes to pregnancy monitoring if pre-gestational diabetes (pre-existing)
- addtl baseline labs (A1c, TSH, MSAFP, CBC/CMP, 24hr urine PCR, UA with culture)
- ophthalmology referral at first prenatal visit and 3rd trimester
- home blood sugar checks 6-8x daily
- early fetal anatomy US (18-20 weeks)
- fetal echocardiogram (20-22weeks)
- monthly growth US starting at 24 weeks
- twice weekly NST/BPPs starting between 28-32 weeks
Delivery timing in pre-gestational diabetes (pre-existing)
Well-controlled: 39th week (before 40 weeks)
Poorly-controlled: deliver in 36th - 38th weeks (before 39 weeks)
How to diagnose hyperemesis gravidarum
- > 3 episodes vomiting/day
- 5% pre-pregnancy weight loss
- electrolyte imbalance
- ketonuria
prevalence of hyperemesis gravidarum
1% of all pregnancies
anticipatory guidance regarding hyperemesis gravidarum
80% will resolve by 20 weeks
Add’l baseline lab testing to do with hyperemesis gravidarum to assess possible contributory factors
- TSH (thyroid dz)
- h. pylori
Severe HTN
> or = 160 SBP
> or = 110 DBP
Gold standard medication for CHTN in pregnancy
labetalol
alternative options: nifedipine, methyldopa
Changes to pregnancy monitoring & delivery timing in CHTN
- twice weekly NSTs/BPPs after 32 weeks
- deliver in 38th or 39th week (before 40w) if no complications
- if develops superimposed pre-ex, deliver in 34-37th weeks depending on severity
3 methods of defining proteinuria for a pre-eclampsia diagnosis
- 24-hr urine >300mg
- urine protein/creatinine ratio >0.3 mg/dL
- 2+ protein on dipstick
Urine dipstick is the least reliable method for determining proteinuria, compared to a spot urine protein/creatinine ratio. What is the likelihood of false positive on dipstick 2+?
17% are false positives
Define thrombocytopenia in pre-eclampsia
platelet count <100,000/mL
Define impaired liver function in pre-eclampsia
AST/ALT elevated to 2x normal (>70)
Define renal insufficiency in pre-eclampsia
serum creatinine >1.1mg/dL
or a doubling of the serum creatinine in the absence of other renal disease
What is the pathophysiology behind low platelets in hypertensive disorders of pregnancy?
platelets are used to repair endothelial damage
endothelial damage from hypertension»_space; using up all your platelets
What is the pathophysiology behind elevated liver enzymes in hypertensive disorders of pregnancy?
- liver is working overtime to process all of the platelets
- poor blood flow to the liver from vasoconstriction and vascular damage
What is the pathophysiology behind pulmonary edema in hypertensive disorders of pregnancy?
leaky endothelium s/t endothelial damage from HTN
Complications with which you would lean towards delivery at 34 weeks in someone with pre-eclampsia (4)
- ROM
- IUGR
- oligohydramnios
- non-reactive fetal strip
All folks at high risk for preeclampsia should be starting on aspirin when during pregnancy
after 12 weeks EGA
When should you plan for delivery in someone with pre-eclampsia without severe features or fetal complications
37 weeks
Diagnosis of pre-eclampsia
elevated BP > or = 140 / > or = 90 after 20 weeks
PLUS
proteinuria (>300mg in 24 hrs, >0.3 protein/cre ratio, 2+ on dipstick)
OR
end organ damage
- low platelets (<100,000)
- renal insufficiency (>1.1 creatine, serum)
- elevated liver enzymes (>70)
- new onset headache, unrelieved by OTC measures
- focal neuro symptoms
- pulmonary edema
Mortality rate with eclamptic seizures
15-20%
Only cure for eclampsia
delivery of the placenta
Diagnose gestational HTN
new onset HTN (> or = 140/ > or = 90) after 20 weeks EGA with no proteinuria or severe features
Anticipatory guidance with gestational HTN
BP can be labile, often transient, rarely severe
No medications unless becomes severe
Can usually await full term spontaneous labor if no complications
Pre-eclampsia WITH severe features typically onsets when….
before 34 weeks
Blood type of Rh- or Rh+ is derived from the status of the blood having….
antigens against RhD
When is RhoGAM routinely given
Rh- or unknown status pregnant folks and any of the following:
- 26-28 weeks for all
- 2nd dose is given postpartum if infant is determined to be Rh+
- anytime there is abdominal trauma, bleeding, invasive procedures (e.g., CVS, amnio), or abortion
standard RhoGAM dose
300mcg IM to deltoid muscle
what does the Kleinhauer-Betke test tell you
estimates the volume of RBCs transfused; quantifies the amount of fetal RBCs in maternal circulation
this can be useful for knowing the amount RhoGAM dose needed
Rh negative inheritance is autosomal….
recessive
RhoGAM must be given within ______ of a possible exposure in order to be effective
<72 hours (3 days)
Anticipated fetal outcomes for maternal antibodies to
- Kell antigen
- Lewis antigen
- Duffy antigen
Mnemonic
Kell kills
Lewis lives
Duffy dies
Kell and Duffy = severe hemolytic disease
Presence of Rh antibodies in pregnancy should always warrant this from the WHNP
referral to physician
(3) sequelae for the fetus from maternal isoimmunization in a prior pregnancy
- recurrent early spontaneous miscarriage
- abnormal fetal growth
- fetal immune hydrops
What is fetal hydrops
accumulation of fluid within the fetal body compartments stemming from fetal anemia
typically occurs when fetal RBCs are attacked by maternal antibodies (isoimmunization), causing the fetal RBCs to be lysed, causing massive accumulation of fluid in the fetal tissues.
Hgb definition of anemia, non-pregnant female
<12 g/dL
Hgb definition in pregnancy, by semester
1st = <11 g/dL 2nd = <10.5 g/dL 3rd = <11 g/dL
Hgb >15 or Hct >45% in 2nd trimester of pregnancy
think poor blood volume expansion, as normally hgb/hct would be hemodiluted in 2nd trim
may be associated with HTN, dehydration, smoking, high altitudes
% of anemias in pregnancy that are from iron deficiency
75%
General overview of what is G6PD anemia
a drug-induced hemolytic anemia that results from genetic susceptibility (X-linked) to hemolysis of RBCs
Symptoms r/t to this condition are episodic, as a result to periodic exposures to drugs, surgery, infections
Common drugs to provoke exacerbation:
- sulfonamides
- nitrofurantoins
- antipyretics/analgesics
there is no universal screening for this in pregnancy
Folks with G6PD anemia in pregnancy need this additional screening every trimester
UA with culture and sensitivity, given increased risk for UTI
General overview of what is hereditary spherocytosis
an inherited hemolytic anemia with autosomal dominant inheritance pattern with variable penetrance. Results from a structural defect in the erythrocyte membrane. The RBCs lose their shape and volume, become spherical in appearance, and these morphological changes reduce the oxygen-carrying capacity of the RBC.
there is no universal screening for this in pregnancy
General overview of what is hereditary elliptocytosis
An inherited hemolytic anemia with autosomal dominant inheritance pattern and usually mild disease. Results from a defect in the polarization of hemoglobin molecules, causing the RBC to contract along its long-axis becoming rod-shaped, elongated. These morphological changes reduce the hemoglobin-binding affinity of the RBC
Thalassemias refer to ______ changes in Hgb production
quantitative
Normal hemoglobin is being synthesized at an abnormally slow rate, in contrast to structural hemoglobinopathies which are being produced at a normal rate but the Hgb is not normal in structure
Hemoglobin is made up of ____ subchains.
4 subchains, 2 alpha and 2 beta
[alpha vs. beta] subchains produce most of the adult hemoglobin
alpha
Racial/ethnic groups with highest proportion of hemoglobinopathies
- mediterranean
- african
- middle eastern
- south east asian
most abundant form of fetal hemoglobin
hemoglobin F, which has a higher affinity for oxygen than adult hemoglobin
Inheritance pattern of the thalassemias
autosomal recessive
General overview of alpha thalassemia
a diagnosis of exclusion, based on the exclusion of iron-deficiency anemia and beta thalassemia
1 alpha chain affected = silent carrier, asymptomatic
2 alpha chains affected = alpha thalassemia minor, mild hypochromic microcytic anemia that is difficult to tell from IDA
3 alpha chains affected = severe
4 alpha chains affected = incompatible with life, stillbirth
there is no universal screening in prenatal care
Most common thalassemia encountered in WHNP practice
beta thalassemia minor (heterozygous)
General overview of beta thalassemia
A diagnosis of exclusion, based on the exclusion of IDA (not responding to iron supplementation), low MCV (<80) is the key feature, diagnosed on hemoglobin electropheresis.
Beta thalassemia minor (heterozygous) tends to be minor
Beta thalassemia major (homozygous) typically dies in the first few decades of life, severe disease
there is no universal screening in prenatal care
Key feature of thalassemias = MCV that is….
low (<80)
Normal results on hemoglobin electrophoresis
HgbA1 = 95-98% HgbA2 = 2-3% HgbF = 0.8-2% HgbS = 0% HgbC = 0%
elevated HgbA2 (>3.5%) on hemoglobin electrophoresis, think…..
beta thalassemia
Prevalence of sickle cell TRAIT (Ss) in African Americans
1 in 12
Sickle cell disease is autosomal….
recessive
% of pregnancies ending in miscarriage, stillbirth, or neonatal death if mother has sickle cell disease SS genotype (homozygous)
33%
Pregnant folks with sickle cell TRAIT require this additional screening every trimester
UA with culture (higher risk of asymptomatic bacteruria and UTI)
Risks of sickle cell TRAIT for pregnancy
- increased risk of UTI
- increased risk of asymptomatic bacteruria
- increased risk of pre-eclampsia suggested in some studies
- NO increase in risk of miscarriage, perinatal mortality, low birth weight, or GHTN has been found
Symptoms in sickle cell DISEASE are related to (3)
- hemolysis
- vasooclusive disease
- increased risk for infection
WHNP management of pregnant patient presenting in sickle cell crisis
hospitalization
General overview of hemoglobinopathies C and E in pregnancy
Heterozygous for these (trait) is usually asymptomatic and no pregnancy consequences
Homozygous for these (disease) is usually only mild and stable
Abnormal antibody production in Antiphospholipid Antibody Syndrome (APLS) leads to increased risk for….
blood clots
Clinical presentations suggestive of antiphospholipid antibody syndrome (APLS) (4)
- recurrent pregnancy loss
- severe early-onset pre-Ex
- abnormal fetal growth
- unexplained blood clots
There is no routine anticoagulation recommended for inherited thrombophilias except in cases of….. (3)
- compound heterozygotes
- family history of a VTE
- personal history of a VTE
Common types of inherited thrombophilias
- Factor V Leiden (heterozygous, homozygous)
- Protein C deficiency
- Protein S deficiency
- Prothrombin mutation
- Antithrombin deficiency
- Homocystein mutation (MTHFR)
Who requires endocarditis prophylaxis before birth or any medical procedures (e.g., dental procedure)
- prosthetic (mechanical) heart valve
- prosthetic (mechanical) material used for a valve repair
- h/o infective endocarditis
Do you require endocarditis prophylaxis in patient with mitral valve prolapse?
NO! not anymore
Do you require endocarditis prophylaxis in patient with prosthetic heart valve?
yes
Endocarditis prophylaxis is done with a single dose of ______ 30 min before procedure
penicillin
