11. Medical Conditions in Pregnancy Flashcards
(75 cards)
1
Q
Anemia:
- Physiologically, anemia is _________.
- Most common reason for anemia?
- Screening
- Treatment
*
A
- ↓ in Hgb/hematocrit during pregnancy (Hct <30% or Hgb concentration is <10g/dL)
- Iron deficiency
- Screening
- At prenatal visit
- 26-28 weeks
- Treatment: IV/oral Iron supplement
2
Q
Gestational DM
- What is it?
- Screening
A
- Glucose intolerance during PG
- Screening
- 24-28 weeks: perform a 1-hour 50g oral glucuse challenge test
- If 130-140 => abnormal
- => 3-hour 100 g oral glucose challenge test.
- If (2+ abnormal values) => FAIL.
3
Q
Risk factors for Gestation DM
A
- Obesity
- Previous hx of GDM
- Strong family hx of DM
- Known glucose intolerance
4
Q
Maternal Complications of Gestational DM
A
↑ risk of:
- Gestational HTN
- Preeclampsia
- C-section delivery
- Developing DM later in life
5
Q
Fetal Complications of Gestational DM
A
- Macrosomia
- Neonatal hypoglycemia
- Hyperbilirubinemia
- Shoulder dystocia
- Operative delivery (bb is extracted from vagina w forceps)
- Birth trauma or stillbirth
6
Q
Antepartum management in Gestation DM
A
- Diabetic teaching
- Monitor blood glucose
- Test fetal health weekly (biophysical profile and/or NST)
- US to determine weight
7
Q
In a patient with gestation DM, when is it recommended to have the bb via c-section?
A
If in US, fetal weight is > 4500 grams.
8
Q
If all testing, growth and glycemic control are good in a person with Gestational DM, the baby can be delivered via _______
A
Spontaneous labor/wait until due date.
9
Q
Intrapartum (DURING childbirth) Managment of Gestation DM
A
- If diet controlled => monitor blood glucose.
- If on meds (oral or insulin) => monitor glucose hourly (80-120 mg/dL) or insulin drip
- Continous fetal monitoring in labor
10
Q
Direct link between birth defects = ____________.
A
↑ HgBA1C during embryogenesis
=> Increase risk of congenital anomalies
11
Q
Maternal Complications Pre-Gestational DM
A
- Worsening nephropathy and retinopathy
- Risk of developing preeclampsia
- Greater risk of DKA
12
Q
Fetal Complications Pre-Gestational DM
A
- ↑ risk of SAB
- Anatomic birth defects (sacral agenesis, and cardiac)
- Fetal growth restriction
- Premature
13
Q
What are the 2 classes of Gestational DB?
A
- Class A1: Gestational DB (diet controlled)
- Class A2: Gestational DB (insulin or oral-meds controlled), exists before PG
14
Q
What is considered good glycemic control during pregnancy when fasting and 2-hours after eating?
A
- Fasting= less than 95 mg/dL
- 2 hour postprandial (2 hours after eating) = less than < 120 mg/dL
15
Q
Management of pre-existing DB right before childbirth (antepartum)
A
- Every trimester: 24 hour urine collection
- 1st trimester: Ophthalamic- eye exam
- EKG
- Check glucose and HgBA1c levels daily using finger stick
16
Q
How do insulin requirements change after delivery of the placenta and onward?
A
- Insulin requirements drop significantly after the placenta = only need 2/3 of dose
17
Q
How soon postpartum should a 2-hour glucose tolerance test be performed in mother who had GDM?
A
6-12 weeks post-partum to look for pre-existing disease
18
Q
Maternal Hyperthyroidism
- Diagnosed
- Treatment (when are they given and AE)
A
- ↑ free T4 and suppressed TSH (dx based on sx is hard bc similar to PG)
- Treatment:
-
PTU (propylthiouracyl) and methimazole
* PTU (1st trimester) only bc ↑ risk of liver toxicity
* Methimazole (2nd/3rd trimester) bc ↑ risk of aplasia cutis and choanal atresia in 1st.
-
PTU (propylthiouracyl) and methimazole
19
Q
Which drug for maternal hyperthryroidism is contraindicated throughout pregnancy?
A
Radioactive iodine
20
Q
Fetal effects due to Maternal Hyperthyroidism
A
- Meds cross placenta => cause fetal hypothyroidism and fetal goiter
- Prematurity, IUGR, preeclampsia, and stillbirth
21
Q
Thyroid storm => life-threatening condition that is associated with untreated or undertreated hyperthyroidism
- Triggers
- Signs and sx
- Maternal mortality = ___%
A
- Triggers: infections, labor/c-section, not taking meds
-
Signs and sx:
- Tachycardia
- Hyperthermia and perspiration
- High-output cardiac failure
- Maternal mortality = 25%
22
Q
Tx of Thyroid Storm during pregnancy?
A
- Dexamethasone (stops conversion of T4 –> T3)
- PTU (stops making thyroid hormone)
- Propranolol
- Sodium iodide (blocks secretion of thyroid hormone)
23
Q
What are the pregnancy outcomes of treated vs untreated hypothyroidism?
A
- Treated => NL outcomes
-
Untreated => ↑ risk of
- SAB or stillbirth
- LBW bb
- Preeclampsia
- Abruption
- Lower IQ—cretinism
24
Q
Maternal Hypothyroidism
- Treat
- Monitor
A
- Treat: levothyroxine (thyroid replacement)
- Monitor: check free T3/4 and TSH monthly
25
**_Neonatal thyrotoxicosis_**
* How does it develop
* How long does it last
* Mortality rate
* **Thyroid stimulaing Abs** are transferred to baby via the placenta.
* Effects:
* **Lasts 2-3 months** (transient)
* **Mortality rate of 16%.**
26
**Neonatal hypothryoidism**
* Causes:
* Effects:
* Thyroid dysgenesis, inborn errors of thyroid function, drugs
* Generalized *_developmental retardation_*
27
Which pulmonary condition is a **contraindication** to pregnancy due to _decompensation_ during pregnancy and a _high mortality rate?_
**Primary pulmonary HTN**
28
\_\_\_\_\_\_\_\_\_ = preferred **anesthesia** in patient with **primary pulmonary HTN.**
**Epidural,** allowing vaginal delivery to be an option.
29
What is the most common lesion caused by **rhematic heart disease?**
**Mitral stenosis**
30
What are the **most common cardiac arrhythmias** in pregnancy; which are most worrisome?
1. **SVT** = most common and usually benign
2. **A. fib/flutter** = more worrisome for underlying cardiac disease
31
Who is at greatest risk of developing **postpartum cardiomyopathy**?
Women with
1. Preeclampsia
2. HTN
3. Poor nutrition
32
**_Postpartum cardiomyopathy_**
* When does it develop?
* Mortality rate?
1. Last weeks of pregnancy or 6 months postpartum
2. 10%
33
What is important to note about **ALL PREGNANT CARDIAC PATIENTS**?
**Co-managed with a cardiologist.**
34
How should **cardiac patients** be delivered?
**Vaginally,** unless obstetric indications: DON'T push in 2nd stage of delivery.
35
What type of cardiac condition is a **medical emergency?**
**Acute cardiac decompensation w/ CHF**
36
**_Immune Idiopathic Thrombocytopenia_**
* What is it?
* How does **neonatal thrombocytopenia** develop?
* Ig attach to moms platlets
* Neonatal thrombocytopenia develops when anti-platelet AB go to bb via placenta.
37
What is treatment for **immune idiopathic thrombocytopenia** during pregnancy?
1. **- Begin after platelets \<50,000** ---\> give prednisone
1. - If severe, =\> IV immunoglobulin
2. - Platelet transfusion
3. - Splenectomy
38
**_Antiphospholipid syndrome_**
* What is present?
* Can coexist with \_\_\_\_\_.
* Associated with: \_\_\_\_\_\_\_\_\_\_
* Treatment during pregnancy
* **Lipid anticoagulants** and **anticardiolipin AB**
* **SLE**
* **Arterial/venous thrombrosis**
* Treatment:
1. Heparin/LMW heparin/ low-dose ASA
2. If history of thrombosis =\> full anti-coagulant
39
What are the 3 types of **Acute Renal Failure** seen in pregnant patients?
Treatment goals of each?
1. **Pre-renal:** causes acute blood/fluid loss
1. Restore volume (electrolytes!!!)
2. **Renal**: d/t prexisting disease (lupus nephritis) or a hypercoagulable state)
1. Prevent more damage (diuretics, fluid restriction)
3. **Post-renal**: rare; kidney stones
1. Remove obstruction (lay left lateral position)
40
Which _serum Cr_ level **worsens** the prognosis of _chronic kidney failure_ during pregnancy?
Serum Cr. **\> 1.5 - 2**
41
What is **asymptomatic bacteriuria** more likely to cause in pregnancy?
**Cystitis** and **pyelonephritis** ---\> due to _urinary stasis_ and _glucosuria_
42
**Culprit** for causing Asymptomatic Bacteruria
**E.coli**
43
**Increased** risk for what complications if pregnant woman has _pyelonephritis_?
1. **↑ uterine contractions** and **preterm labor**
2. Can result in **adult respiratory distress syndrome**
44
**Treatment of N/V in pregnancy,** which is most common in 8-12 weeks.
1. **Vit B6**
2. **Doxylamine**
3. **Promethazine**
45
What is **hyperemesis gravidarum?**
**Persistent N/V** assoc. with **\>5% loss of pre-pregnancy weight + ketonuria + dehydration**
46
What is treatment for hyperemesis gravidarum if **severe** (fails all conservative measures)?
May need **nasogastric feeding** or **parenteral nutrition**
47
What is **Mendelson's Syndrome** and what complications can it cause?
1. - **Acid aspiration syndrome** that is more common in pregnant people because they have _delayed gastric emptying_ and _↑ intra-abdominal pressure/intra-gastric pressure_
2. **Complications**: _adult respiratory distress syndrome (ARDS)_
48
**Treatment** for Mendelsons Syndrome (acid aspiration)
1. **Supp O2**
2. **Maintain airway**
3. Tx for **acute respiratory failure**
49
**_Intrahepatic cholestasis of pregnancy_**
* What is it?
* Effects on mom and fetus?
* Cholestasis and pruritis that occurs in 2nd half of pregnancy
* _Mom_ (benign); _fetus_ (meconium stained amnoitic fluid and fetal demise)
50
Intrahepatic cholestasis of pregnancy (ICP)
* Sx
* Tx
* Sx: **itching** without abdominal pain or rash
* Tx:
* Cold baths/ bicarb washes
* Ursodeocycholic acid
* Watch fetus and deliver early (36-37 weeks)
51
What liver disease is REALLY SCARY?
**Acute fatty liver of pregancy** =\> can cause liver failure
52
What is treatment for **acute fatty liver of pregnancy?**
1. **Termination of pregnancy** --\> need to tx the Mom
2. **Supportive care** ---\> IV fluids w/ 10% glucose; replace blood products (FFP and cryoprecipitate)
53
What is the maternal and fetal mortality with Acute Fatty Liver of Pregnancy?
* Maternal = 7-18%
* Fetal= 9-23%
54
What is the **most common type of HA** in pregnancy?
How is it **treated**?
**Tension HA**
**Acetaminophen**
55
Due to pregnancy being a **hypercoagulable** **state** there is a _5-fold increase_ in **venous thrombosis** and the greatest risk is when?
* **First 5 weeks postpartum**
56
**Superficial thrombophlebitis** is most common in pregnant pt's with what characteristics;
* MC in the \_\_\_\_\_, which ______ risk of PE
- Most common in those w/ **varicose veins,** **obesity** and **little physical activity**
- Most common in **calf** =\> NO inc risk of PE
57
**Superficial Thrombophlebitis**
* Sx
* Treatment
* **Sx:** swelling and tender
* **Treat**:
* bed rest, pain meds, local heat, NO anticoag, support hose
58
**DVT's** during pregnancy most commonly occur in which leg and what are the signs/sx's?
- More common in **LEFT** leg
- Pain in the **calf** w/ **dorsiflexion** (Homans sign)
- May also have **dull ache, tingling, or pain w/ walking**
59
If patient has **DVT,** what values should you follow if you give **LMW lovenox vs. unfractionated heparin** to assure therapeutic levels?
- **aPTT** values =\> _heparin_
- **Factor Xa** values =\> _lovenox_
60
When should **coumadin** be used during pregnancy for **DVT's**?
**6 weeks postpartum** but NOT during pregnancy due to risk of _fetal hemorrhage_ or _teratogenesis_
61
**Diagnosis** of DVT in pregnant patient
* Difficult to dx because 50% are asx
* 1. **Compression US + doppler**
* 2. If suspect pelvic thrombosis =\> **MRI**
62
Why is treatment of a PE supppper important?
* Treat early = 1% of dying
* Untx = 80% of dying
63
**PE** is most often due to \_\_\_\_\_
**DVT**
64
What are **sx's of PE** during pregnancy?
1. Pleuritic chest pain
2. Shortness of air/ air hunger
3. Palpitations
4. Hemoptosis
65
What 5 things used for diagnosis/evaluation of **suspected PE?**
1. EKG
2. CXR
3. ABG's
4. VQ scan
5. HELICAL CT
66
ALLLLLL pregnant pt's with **DVT** or **PE** require what?
**Thrombophilia work-up,** which includes
1. Lupus anticoagulant
2. Anticardiolipin antibody
3. Factor V leiden
4. Protein C /S
5. Antithrombin III
6. Prothrombin G20210A
67
Pregnant person presents with a **history of thromboembolism,** what do we do?
Give them a **prophylactic anticoagulant**
68
What is the most common pulmonary disease in pregnancy?
Asthma
69
If pregnant patient w/ asthma has been **using daily inhaled steroids** or **high potency oral** for _more than 3 weeks_ what is done during labor and delivery?
**Stress dose** of **IV steroids** to prevent **adrenal crisis**
70
**All anti-epileptics have teratogen risk,** but what 2 are most commonly used during if pregnancy if needed?
Avoid what\>
1. **Dilantin**
2. **phenobarbital**
## Footnote
**Avoid: _Valproate_**
71
What is the course of **asthma** during prengnacy?
**Variable**: 1/3 improve; 1/3 worsen; 1/3 stay the same
72
Severe asthma is associated with what complications? (5)
1. **Miscarriage**
2. **Preclampsia**
3. **Intrauterine fetal demis**
4. **Intrauterine fetal growth restriction**
5. **Preterm delivery**
73
Treatment of asthma in PG vs nonpregnant pt
same
74
**SEIZURES**
* How does the frequency change when PG?
* If on anti-epileptic, should also be on \_\_\_\_\_\_
* How does labor and delivery change?
* does not
* folic acid (1-4 mg)
* does not ; dec anti-epleptic dose after surgery
*
75
* Avoid taking antidepressants in ____ trimester.
* If used in ___ trimester =\> greater risk of neonatal withdrawal
* Post-partum depression is a concern if baby blues persists for ____ after birth
* 1st
* 3rd
* 2 weeks
