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hyperemesis gravidarum is common in the setting of ?

molar pregnancies (likely since HCG levels can be very high) and a viable IUP should always be documented in patients with hyperemesis


First-line antiemetic therapy for hyperemesis

Phenergan, followed by addition of Reglan, Compazine, and Tigan. If these fail, droperidol and Zofran
Persistent N/V during pregnancy can also be treated with vitamin B6 and doxylamine (Unisom). Ginger and supplementation with vitamin B12


if patients will not respond to antiemetics and recurrent rehydration

tx with corticosteroids


normal physiologic changes of pregnancy

increased volume of distribution (VD) and increased hepatic metabolism of AEDs-->increased seizure frequency


what hormones affect seizures during pregnancy?

estrogen: epilieptogenic, decreasing seizure threshold
progesterone: anti epileptic effect (fewer seizures during luteal phase)


AEDs that are notorious for fetal malformations

phenytoin, phenobarbital, primidone, valproate, carbamazepine, and trimethadione


congenital abnormalities seen in infants born to epileptic moms on AEDs

4x increase in cleft lip/palate, 3-4x increase in cardiac anomalies, increase in NTDs (carbamezipine, valproic acid), higher rates of abnormal EEG findings, higher rates of developmentally delayed children, and lower IQ scores


genetic component leading to teratogenesis from AEDs

children whose enzyme activity of epoxide hydrolase is one-third less than normal have an increased rate of fetal hydantoin syndrome
-low epoxide hydrolase activity in children may increase risk of anomalies from carbamazepine


how to reduce teratogenesis of AEDs

switch to mono therapy, taper down dose, consider withdrawing if seizure free for 2-5 years


new AEDs that may have reduced risk of congenital anomalies

levetiracetam, lamotrigine, felbamate, topiramate, and oxcarbazepine


Management of Women with Epilepsy During Pregnancy

Check total and free levels of antiepileptic drugs on a monthly basis
Consider early genetic counseling
Level II ultrasound for fetal survey at 19 to 20 wks’ gestation (check face, CNS, and heart)
Consider amniocentesis for α-fetoprotein and acetylcholinesterase
Supplement with oral vitamin K 20 mg QD starting at 37 wks until delivery (optional)


the drug of choice in patients with a known seizure disorder is usually ? compared to magnesium used in preeclamptic patients



increased risk of spontaneous hemorrhage in newborns because of the inhibition of vitamin K–dependent clotting factors (i.e., II, VII, IX, X) secondary to ?

increased vitamin K metabolism and inhibition of placental transport of vitamin K by AEDs
-overcome with aggressive supplementation with vitamin K toward the end of pregnancy (theoretical)
-may need FFP


CV conditions causing high risk of maternal mortality in pregnancy

primary pulmonary hypertension, Eisenmenger physiology, severe mitral or aortic stenosis, and Marfan syndrome


SBE (subacute bacterial endocarditis) prophylaxis may be considered for women with ?

high-risk lesions (mechanical or prosthetic valves, unrepaired cyanotic lesions, etc.) and an infection that could cause bacteremia (chorioamnionitis or pyelonephritis).


care of women with congenital heart disease i.e. mitral/aortic stenosis

-sx repair >1 year before becoming pregnant
-offer termination of pregnancy as first line management
-early epidural analgesia, vacuum/forceps assistance (minimizes cardiac stress)
-monitor fluids carefully


postpartum period dangerous for woman with congenital heart disease, why?

massive fluid shifts
1. IVC no longer compressed by uterus
2. autotransfusion of blood supply (500cc) redirected from uterus that no longer needs it


among the most severe CV conditions in pregnancy:

right-to-left shunts and pulmonary hypertension
i.e. PDA, VSD due to Eisenmenger syndrome


peripartum cardiomyopathy (PPCM)
how to manage?

specifically caused by pregnancy.
classic s/s of heart failure and on echocardiogram have a dilated heart with an ejection fraction far below normal in the 20% to 40% range.
-deliver if >34 wga
-manage with diuretics, digoxin, and vasodilators


Chronic kidney disease classification

mild (Cr 2.8)


CKD risks in pregnancy

-screen at least once per trimester with a 24-hour urine for creatinine clearance and protein


consideration with post renal transplant patients

may be on immunosuppressants that have increased metabolism and Vd during pregnancy
i.e. cyclosporine, tacrolimus, prednisone, and Imuran


why is pregnancy a hyper coagulable state

-production of all clotting factors is increased except for II, V and IX
-Turnover time for fibrinogen is also decreased during pregnancy and there are increased levels of fibrinopeptide A, which is cleaved from fibrinogen to make fibrin


superficial vein thrombosis (SVT) how to treat?

warm compresses and analgesics but watch out for s/s of DVTs and PEs


how to dx DVT

-often made clinically with confirmation by Doppler studies or venography (rarely used)
-adjusted dose LMWH(enoxaparin 1 mg/kg BID) or unfractionated heparin (goal aPTT of 1.5 to 2.5 times normal).


teratogenesis of warfarin

When given in the first trimester, it causes warfarin embryopathy, a combination of nasal hypoplasia and skeletal abnormalities.
-CNS abnormalities, including optic atrophy


PE Cxray

chest X-ray may be entirely normal. However, when abnormal, two common signs on chest X-ray are the abrupt termination of a vessel as it is traced distally and an area of radiolucency in the region of lung beyond the PE


PE dx for patients

most common: Spiral CT scan
Pulmonary angiography is the gold standard for diagnosis of PE: intraluminal filling defects or if sharp vessel cutoffs are seen


PE tx

LMWH (IV heparin or streptokinase in a hypotensive/unstable pt)
-tx for a minimum of 6 mos


Management of thyroid disease changes in pregnancy ?

the Vd increases circulating thyroid binding globulin, and sex hormone binding globulin (SHBG), which also binds thyroid hormone.
-leads to decreased availability of thyroid hormone.


management of TSH in pregnancy to prevent goiters in fetus

TSH should be kept between 0.5 and 2.5 in general population
in pregnancy, it should be kept closer to 0.5 than 2.5 if possible.


all women on levothyroxine (Synthroid) supplementation should have their dose changed how?

increased from 25% to 30%.
-increase demand for thyroid hormone including increased VD, increased binding globulin (in particular, SHBG


The natural history of SLE in pregnancy follows the one-third rule
med changes ?

1/3 improve, 1/3 worsen, and 1/3 remain unchanged

aspirin and corticosteroids are continued in pregnancy, whereas cyclophosphamide and methotrexate are NOT


pathophys of early pregnancy loss in SLE pts

placental thrombosis
-mostly 1st/2nd, can happen in 3rd trimester as well, risk for IUGR, IUFD


SLE tx

SQ heparin or Lovenox prophylaxis and low-dose aspirin


lupus flare vs preE

why important to ddx?

-lupus flare will have reduced C3 and C4 and are accompanied by active urine sediment
-lupus tx with steroids/cyclophosphamide while preE is tx with delivery


SLE patients (and more commonly Sjögren syndrome patients) can produce antibodies called anti-Ro (SSA) and anti-La (SSB) that do what?

are tissue-specific to the fetal cardiac conduction system, damage the AV node-->congenital heart block
-tx w. corticosteroids, plasmapheresis, and IVIG


for alcohol withdrawal symptoms in pregnancy

use barbiturates not benzos (teratogenic)


recommended caffeine intake in pregnancy

less than 150 mg

at risk for spontaneous abortions


complications of smoking during pregnancy

spontaneous abortions, preterm births, abruptio placentae, and decreased birth weight, SIDS, respiratory illnesses


complications of cocaine during pregnancy

abruptio placentae, IUGR, and an increased risk for preterm labor and delivery,CNS complications, including developmental


risks of opioid use in pregnancy

opioid withdrawal may pose a greater risk to the fetus than chronic narcotic use. Risks of opiod withdrawal include miscarriage, preterm delivery, and fetal death.
-tx with Suboxone (buprenorphine) > methadone > quitting outright


when babies born to opioid using mothers

Once infants are delivered, they require careful monitoring and slow withdrawal from their narcotic addiction using tincture of opium