Pregnancy and Chronic Conditions

Question 1

Risks of pregnancy with diabetes

Answer 1

Fetal growth restriction
Spontaneous abortion
Major congenital malformations (congenital heart, neural tube, limb) - related to metabolic control in 1st trimester

Question 2

Complications of ACEi use during pregnancy

Answer 2

2nd trimester: impaired fetal renal function
Oligohydramnios
Fetal growth restriction
Anuria
Renal failure
Hypotension
Pulmonary hypoplasia
Joint contractures
Death

Question 3

When should zidovidine be administered for pregnant HIV patient?

Answer 3

IV in labor and for neonate

Question 4

When is cesarian indicated for HIV patient?

Answer 4

Viral loads >1,000 copies/mL and prior to labor

Less benefit after onset of labor or ruptured membranes

Question 5

Acute treatment of thyroid storm in pregnancy

Answer 5

Propylthiouracil (decreases thyroid hormone synthesis)
Propranolol
Sodium iodide
IV fluid replacement
Dexamethasone

DO NOT give radioactive iodine

Note: propylthiouracil also given for Graves disease management during pregnancy

Question 6

Homeless women are at highest risk for what pregnancy complication?

Answer 6

Preterm birth (even after controlling for smoking)
Low birth weight

Question 7

When should patients be screened for gestational diabetes, and how?

Answer 7

24-28 weeks for those without risk factors
First visit for those who do

1-hr 50-g oral glucose challenge test, followed by diagnostic 3-hr 100-g oral glucose tolerance test if initial results exceed

2-hr 75-g OGTT omits screening test

If early test normal, repeat between 24-28 weeks

Question 8

Treatment for bacterial vaginosis

Answer 8

Metronidazole or clindamycin

Question 9

What maternal heart diseases can be acquired during pregnancy?

Answer 9

Heart failure, arrhythmia, MI, aortic dissection

Question 10

What to do for symptomatic mitral valve prolapse?

Answer 10

Beta-blocker

Symptoms include anxiety, chest pain, palpitations, syncope

Question 11

Which thalassemias are most severe?

Answer 11

Beta thalassemia
HbH disease (Alpha thalassemia with 3 nonfunctioning genes)

Question 12

Obesity increases risk of…?

Answer 12

cHTN, GDM, preeclampsia, fetal macrosomia, C-section, postpartum complications

NOT preterm labor, post-term pregnancy, small for gestational age, or malpresentation

Question 13

When should anticoagulation be given if history of VTE?

Answer 13

When pregnancy is diagnosed and inclusive of postpartum period; risk is highest in 3rd trimester and then even higher postpartum

Unfractionated heparin and LMWH

VTE more likely to occur with C-section compared to vaginal

Question 14

Pruritis during pregnancy

Answer 14

Intrahepatic cholestasis of pregnancy –> bile salt retention –> pruritis

Treat with ursodeoxycholic acid if resistant to antihistamines, topical steroids, topical emollients, or opioid antagonist naltrexone

Question 15

Challenge of appendicitis during pregnancy

Answer 15

Uterus may shift appendix up and out toward the flank
Symptoms similar to normal pregnancy symptoms

Question 16

Patients with gastric bypass are at risk for…?

Answer 16

Iron deficiency, especially pregnant patients

Question 17

What are the signs of Mg toxicity, and what should you do

Answer 17

Muscle weakness; loss of reflexes; nausea; respiratory depression; cardiac arrest at very high doses

Discontinue and give calcium gluconate

Question 18

What is 2nd-line for eclampsia if Mg is contraindicated?

Answer 18

Valium; barbiturates

Question 19

At what levels does Mg cause which side effects?

Answer 19

Therapeutic: 4-7 mEq/L
Loss of reflexes: 7-10
Respiratory depression: 11
Cardiac arrest: 15

Question 20

When should baby aspirin be given for patient with hx of preeclampsia in previous pregnancy?

Answer 20

Before 16 wga and until term (also decreases risk of fetal growth restriction)

Question 21

How would lupus affect fetus?

Answer 21

Bradycardia due to AV block, caused by transfer of maternal anti-SSA (Ro) and anti-SSB (La) Ab

Question 22

What is treatment for sickle cell pain in pregnancy?

Answer 22

Fluid resuscitation and opioid pain control

Question 23

Sickle cell in pregnancy predisposes to what major condition?

Answer 23

Preeclampsia and its sequelae, requiring more frequent prenatal visits, baseline protein testing, and low-dose aspirin

Question 24

How does pregnancy unmask undiagnosed diabetes insipidus?

Answer 24

Placenta produces vasopressinase, which further breaks down vasopressin (ADH) and exacerbates

Normal sodium

Question 25

When should thyroidectomy be performed during pregnancy if absolutely necessary?

Answer 25

2nd trimester

Question 26

Gestational diabetes - postpartum management

Answer 26

Fasting glucose at 24-72 hr
2-hr 75-g GTT at 6- to 12-week visit (compare to 1-hr 50-g GCT or 3-hr 100-g GTT screening in 2nd trimester)

If negative, continue to screen every 3 years

Question 27

Gestational diabetes - 2nd-line management after diet

Answer 27

Insulin, glyburide (sulfonylurea, causes pancreas to produce insulin), metformin

Question 28

Fetus with spina bifida should be delivered how and why?

Answer 28

Cesarean delivery, even if repaired in utero (due to risk of uterine rupture with labor)

If not repaired in utero, cesarean is required because:
-Limited fetal mobility due to neural tube defect (NTD) space occupation
-Hydrocephalus from increased ventricular size with NTD

Also see:
-Polyhydramnios (due to impaired fetal swallowing, particularly with higher-level NTD such as anencephaly)
-Fetal growth restriction

Question 29

Indications for cell-free fetal DNA testing

Answer 29

Maternal age >=35
Abnormal maternal serum screening test (e.g. quadruple screen)
Abnormal ultrasound consistent with fetal aneuploidy
Prior pregnancy with fetal aneuploidy
Parental-balanced Robertsonian translocation

Can be performed at >=10 weeks gestation

Abnormal results confirmed by fetal karyotyping via 1st-trimester CVS or 2nd-trimester amniocentesis

Question 30

What is required for diagnosis of antiphospholipid antibody syndrome during pregnancy?

Answer 30

One of the following clinical + one lab showing positive Ab:
>=3 consecutive, unexplained fetal losses before 10th week
>=1 unexplained fetal loss after 10th week
>=1 premature birth of normal neonates before 34th week due to preeclampsia, eclampsia, or placental insufficiency
or hx of vascular thrombosis (arterial or venous, regardless of pregnancy)

APAS Ab can cause false positive VDRL or artificially prolonged aPTT

They disrupt function of platelets and vascular endothelial cells to create hypercoagulable state