Disease Of Pregnancy

Question 1

Def and Diff for Anemia in Pregnancy

Answer 1

Def = HgB < 10.5

Diff

• Iron Def - (microcytic) do iron trial then recheck in 3 wks - if no improvement then do iron studies and HgB electrophoresis
• Beta thalassemia minor (microcytic) - high A2 HgB; do not give iron
• HELLP - anemia + jaundice + thrombocytopenia; treatment is delivery of baby
• If also low WBCs and low platelets suspect BM problem - acute leukemia or TB of BM - biopsy
• Folate > Vit B12 def (macrocytic)

Question 2

HSV in Pregnancy

Answer 2

• Can cause neonatal encephalitis
• Consider C sect if vesicles on cervix, vagina, uterus OR just if prodromal symptoms (burning, itching, tingling)
• Acyclovir @ 36 wks for any woman who had recurrence or first episode of HSV during pregnancy - dec viral shedding

Question 3

2 Major Causes of Antepartum Bleeding (@ > 20 wks)

Answer 3

1- Placenta Previa

• Painless bleeding (often first time is mild), post-coital spotting
• US first then speculum then digital to avoid bleeding b/f US
• Not associated w/ sig coagulopathy
• C section at 34 wks

2- Placental Abruption

• Painful w/ uterine contractions
• Complications include coagulopathy, fetal to maternal hemorrhage, still birth
• US is not sensitive; blood looks like placenta
• Dx is by clinical picture, serial HgB, fetal erythrocytes in maternal blood, FHR tracings
• Deliver if > 34 wks

Question 4

Risk Factors for Placenta Previa

Answer 4

• grand multiparity
• prior c section
• prior uterine curettage
• prior placenta previa
• mult gestations

Question 5

Risk Factors for Placental Abruption

Answer 5

• cocaine or cig use
• short umbilical cord
• trauma
• uteroplacental insufficiency
• PPROM
• submucosal fibroid
• sudden uterine decompression (hydramnios)

Question 6

Appendicitis in Pregnancy

Answer 6

• nausea, vomiting, anorexia, fever, leuks, superior and lateral to normal McBurney point
• Laproscopic or laparotomy if far along in pregnancy + abx
• Mimics location of pyelonephritis

Question 7

Cholecystitis in Pregnancy

Answer 7

• inc sludge production predisposes to gallstones; if just stones then conservative but if cholecystitis, cholangitis, pancreatitis then surgery
• RUQ pain
• If just biliary colic switch to low fat diet and observe until post-partum

Question 8

Ovarian Torsion in Pregnancy

Answer 8

• Unilateral colicky sudden ab or pelvic pain w/ nausea and vomiting
• Most common around 14 wks and immediately post-partum
• Surgery - untwist to see if blood flow returns; if not then remove ovary
• Can be complication of a benign ovarian cyst

Question 9

Ectopic Pregnancy

Answer 9

• esp in 1st trimester; spotting; unilateral
• Diagnose by transvaginal US and beta hCG
• May have hemoperitoneum

Question 10

Corpus Luteum Cyst Rupture

Answer 10

• Form from normal physiology or excess progesterone
• Rupture because hemorrhage into cyst itself; esp in pregnancy because friable luteum or if bleeding disorder (VWF) or on blood thinner –> hypovolemia and syncope
• If persistent then do lap; stop bleeding and remove cyst
• If b/f 10 wks the corpus luteum makes progesterone for baby so if removed you must replace w/ progesterone

Question 11

Diff for Pruritus in Pregnancy

Answer 11

1- ICP - intrahepatic cholestasis of pregnancy; inc bile acids in blood; itching without rash; esp in third trimester; may cause fetal distress or preterm labor esp if jaundice

• Tx - cornstarch bath, antihistamine, cholestyramine or ursodeoxycholic acid

2- Herpes gestationis - IgG against BM and complement activation; diagnosed by immunofluroesence from biopsy; intense itching w/ erythema and vesicles/bullae on trunks more than abdomen; associated w/ stilbirth and growth restriction

• oral steroids

3- PUPPP - pruritic urticaria w/ papules and plaques of pregnancy (papules w/ pale halo); esp on abdomen and extremities

• Histo - normal epidermis but superficial leuk infiltrate
• No association w/ fetal problem
• Tx - topical antihistamine and topical steroids

Question 12

DVT in Pregnancy (pathophysiology, diagnosis and treatment)

Answer 12

• Pathophysiology - venous stasis from pressure on vena cava and inc estrogen so more clotting factors like fibrinogen
• Diagnosis - CT or MRI angio; no D dimer because naturally elevated in pregnancy (esp if clear CXR)
• Tx - IV heparin for 5 to 7 days then subQ for 3 months (unfractionated or LMWH); no warfarin because teratogenic; cont “full heparinization” thru 6 wks postpartum
  
  • Goal aPTT = 1.5 to 2.5
  • Same for DVT
  • Main side effect is osteoporosis

Question 13

Blood Gas in Pregnancy

Answer 13

• Inc tidal volume and minute ventilation - so respiratory alkalosis; higher O2 and lower CO2 in arteries
• Higher pH (7.45)
• Lower bicarbonate because try to partially compensate for respiratory alkalosis thru inc bicarbonate excretion; this makes pregnant women more prone to metabolic acidosis (less buffer)
• Give oxygen if PaO2 < 80 in pregnant women

Question 14

Chlamydia

Answer 14

• No inc risks of preterm birth
• Chlamydia eye infection and pneumonia in neonate; not protected by erythromycin eye ointment; give baby 14 days oral erythromycin if conjunctivitis
• Also late postpartum endometritis in mom
• Tx for mom - erythromycin or amox for 7 days, azithromycin 1X (no doxy because yellow fetal teeth)

Question 15

Gonorrhea

Answer 15

• Can cause preterm birth, stillbirth, PPROM, chorioamnionitis, postpartum infection, neonatal sepsis
• Erythromycin eye cream protects baby
• More likely to become disseminated in pregnant women
• Tx for mom - IM ceftriaxone w/ treatment of Chlamydia too

Question 16

HIV

Answer 16

• Transplacental or vertical transmission during delivery; risk transmission related to viral load
  
  • Goal = < 1000 RNA copies per millimeter
• Polytherapy during pregancy; monitor LFTs and CBC for toxicity
• Consider C section; if vaginal delivery give mom IV ZDV at time of delivery
  
  • If already ROM or in labor then C section is pointless; at that point give IV ZDV and minimize trauma (scalp electrode, IUPC, forceps, etc)
• ZDV oral syrup for baby and avoid breastfeeding

Question 17

Parvovirus in Fetus

Answer 17

• suppression of bone marrow erythrocytes production –> anemia (mild or severe) –> hydrops fetalis (excess fluid in 2+ body cavities)
  • Hydramnios (uterus size> gestational age; hard to palpate fetal parts)
  • Skin edema
  • Ascites
  • Pericardial effusion
  • Pleural effusion

Question 18

Parvovirus Serology

Answer 18

• serology (IgM and IgG)
• If pos IgM and neg IgG then acute infection
• If neg IgM and pos IgG then prior infection so now immune (may be false negative so repeat in 1-2 wks)
• If both neg … think about incubation period; if < 20 wks since exposure then can still be infected so repeat test in 1-2 wks; if > 20 days sine exposure then not infected

Question 19

Mgt of Mom w/ Parvovirus Exposure

Answer 19

• • f/u for 10 wks w/ weekly US; refer to MFM if signs; observation if mild and transfusion if severe
• Can also use MCA Doppler; inc velocity suggests compensatory mechanism from anemia to maintain brain flow

Question 20

Eclampsia Terms

Answer 20

• Chronic HTN - >140/90 before pregnant or before 20 wks
• Superimposed pre-eclampsia - pre-eclampsia in setting of chronic HTN; diagnosed by sudden inc BP or proteinuria
• Gestation HTN - >140/90 after 20 wks w/o proteinuria
• Pre-eclampsia - BP >140/90 after 20 wks + proteinuria > 300 mg in 24 hrs
• Eclampsia - w/ seizure
• Severe Pre-eclampsia - w/ end organ damage OR 160/110; requires immediate delivery

Question 21

Risk Factors for Pre-eclampsia

Answer 21

Nulliparous, black, extremes of age, personal or family history, chronic HTN, renal disease, antiphospholipid, multifetal gestation, obesity, DM

Question 22

H&P for Pre-eclampsia

Answer 22

LOOK FOR SIGNS OF END ORGAN DAMAGE

• Non-dependent edema
• Headache, vision changes, seizure, blindness, hyper-reflexes
• Oligouria, proteinuria, dec GFR
• Pulmonary edema
• Thrombocytopenia, microangiopathic anemia, coagulopathy
• Fetal - IUGR, oligohydramnios, late decelerations
• Inc liver enzymes, subcapsular hematoma, hepatic rupture; RUQ pain from liver ischemia

Question 23

Pathophysiology and Main Cause of Death in Pre-eclampsia

Answer 23

• Pathophysiology - vasospasm and leaky vessels

* Seizure –> death due to intracerebral hemorrhage

Question 24

Pre-Eclampsia Mgt

Answer 24

• If severe or > 37 wks then deliver; give magnesium at time of delivery and 24 hrs after (greatest risk seizure)
• If not severe and < 37 wks close monitoring then deliver once at term
• Look for signs of Mg toxicity - urine output, dyspnea/ resp depression, dec in deep tendon reflexes is first sign
• F/u in 1-2 wks to recheck BP and urine protein
• Must also treat BP itself - labetolol or hydralazine

Question 25

Thyroid Changes in Pregnancy

Answer 25

* High estrogen --> inc thyroid binding globulin (so takes more levothyroxine therpy to saturate globulin and get same free/active T4) * Inc levothyroxine dose once know pt is pregnant * Inc in total T4 but unbound/active T4 and TSH stay unchanged

Question 26

Most Common Cause Post-Partum Hyperthyroidism

Answer 26

lymphocytic thyroiditis (autoimmune flare when cortisol suddenly dec after labor); detect antimicrosomal and antiperoxidase antibodies NOT graves like normal population

Question 27

IUGR (definition, assessment, mgt)

Answer 27

IUGR (< 10th percentile) * Symmateric (early) - chromosome abnormality or early TORCH infection * Assymetric (head circumference spared compared to body to maintain brain flow - late) - maternal HTN, smoking, cocaine, low BMI and low wt gain by mom * Assessment * If just measured fundal ht then do actual US wt meas * Biophysical profile - 10 pt score based on 30 min US (tone, breathing, movements, amniotic fluid) * Amniotic fluid index - IUGR associated w/ low index (oligohydramnios) * Umbilical artery Doppler - look for inc resistance seen as inc flow index OR absence/reversal of diastolic flow * Mgt * Repeat measurement in 2-4 wks; if no change then confirms IUGR * Deliver if > 37 wks because risk of prematurity less than risk of IUGR

Question 28

Pyelonephritis (mgt and complications)

Answer 28

Mgt - *Hospitalize to give IV abx (ceftriaxone or gentamicin/amp) * Repeat cx to confirm eradications and use suppressive therapy rest of pregnancy * Suppressive therapy rest of pregnancy to prevent recurrence (nitro w/ monthly urine cx) * If no improvement in 48-72 hrs then suspect urinary obstruction or abscess (CT or US) Complications - *Endotoxins from gram neg bacteria --> ARDS (dyspnea, patchy infiltrate on CXR) --> give O2 * #1 cause sepsis in pregnancy Prevention - urine cx at first prenatal visit; only time you treat asymptomatic bacturia

Question 29

Criteria and Tx for DKA in Pregnancy

Answer 29

CRITERIA * PH < 7.35 * Serum Ketones > 5 * Serum glucose > 200 * Serum bicarb < 18 or ketonuria * Tx - same as non-preg; IV normal saline + insulin + correct electrolyte abnormalities (mainly K+) and treat underlying cause * DO NOT DO C SECT DUE TO FETAL LATE DECEK; wait until mom is stable and see if they correct on own

Question 30

Gestational DM Testing

Answer 30

* Routine screen at 26-28 wks * First ... 50 g 1 hr test ... pos if > 130- to 140 * Second (confirm) ... 100 g 3 hr test (need 2/4 abnormal) * fasting - 95 to 105 * 1 hr - 180 to 190 * 2 hr - 155 to 165 * 3 hr - 140 to 145 * Check 6 wks postpartum w/ 75 g test (pos if >126 fasting or >200 at 2 hr)

Question 31

Which Rh antibodies are dangerous to fetus?

Answer 31

Kell & Duffy NOT Lewis

Question 32

Mgt of Abnormal Pap in Pregnancy

Answer 32

HSIL / LSIL - do colposcopy If ASC-US - just re pap postpartum (will not change mgt)

Question 33

At what values do you expect to see an IUP?

Answer 33

Expect intrauterine pregnancy at beta of 1500-2000 and progesterone >25

Question 34

Work Up for Spotting in Pregnancy

Answer 34

* Are they symptomatic (aka hypovolemia and pelvic pain?) * Yes - laproscopy * No - get hCG level * Beta hCG > 1500 - 2000 so do US, if IUP then just observe and if no IUP do laproscopy because ectopic very likely * Beta -hCG < 1500- 2000 then its okay if no IUP on USm recheck beta in 48 hrs * Should inc by 66% ib 48 hrs - normal; redo US once at 1500 * If not inc that much then non-viable but do not know location; do curettage to see if villi * Villi = miscarriage * No Villi = ectopic

Question 35

Ectopic Triad

Answer 35

1- ab pain 2- vag spotting 3- amenorrhea

Question 36

Medical and Surgical Tx of Ectopic

Answer 36

* Medical - methotrexate * Surgical * Salpingectomy - if rupture, large or do not care about fertility * Conservative - salpingostomy (cut, remove tissue and let incision open to avoid strictures); only if no rupture and want fertility

Question 37

Molar Pregnancy

Answer 37

* Trophoblastic tissue without fetus * Presentation - spotting, no heart tones, size > dates, elevated hCG, snowstorm on US * Tx - D&C then track beta-hCG; if persists then CHEMO

Question 38

Septic Abortion (presentation, labs, tx)

Answer 38

* Retained products after D&C may act as nidus of infection /(esp ascending from vagina) * Labs - CBC, electrolytes, UA + swab for gram stain from cervical d/c * May also get blood cx, chest X-ray and coagulation labs if hypotensive * Tx * Stabilize; IV fluids * Monitor BP, urine output and oxygenation * Give broad antibiotics (including anaerobes); allow 4 hrs antibiotics before surgery; often gentamicin + clindamycin * Redo curettage * If see air bubbles / gas pockets may be necrotizing metrisis - need urgent hysterectomy (Clostridial species)