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Flashcards in Disease Processes Deck (86):
1

Gestational htn- diagnosed for the first time at ____ , most often after ____ weeks

20, 37

2

Mild htn: ___/___

140-159/90-109

3

Severe htn: ___/___

>160/>110

4

Outcome risks with severe ghtn

Abruption
SGA
preterm delivery

5

Mild ghtn pts need weekly assessments of ___

Proteinuria
Liver enzymes
Platelets
BP (2x/wk, 1 in office)

6

Do you give mild ghtn pts oral hypertensives?

Nope, no salt or activity restrictions either

7

When do you deliver mild ghtn pts ?

EGA 37 or >
spontaneous labor or srom 34 or >

8

What meds are used for severe ghtn?

IV labetolol or IV hydralazine
Oral antihypertensives to maintain BP

9

Preeclampsia definition

Ghtn PLUS proteinuria
OR
without proteinuria but with:
Thrombocytopenia (platelets 1.1 or doubling)
Impaired liver function (2x normal labs)
Pulmonary edema
Cerebral/visual symptoms

10

Proteinuria definition

> or = 300 (24-hr urine)
Protein/creatinine ratio > or = .3
Dipstick 1+

11

Risk factors for preeclampsia

Nulliparity (or new male partner)
Htn
Renal disease
Diabetes
Collagen vascular disease
Thyroid disease
Abnormal placental size or function
40
Hx or family hx of preeclampsia
Inc BMI
Af-American

12

Hypertension definition

Sbp >= 140 OR dbp >= 90
2 measurements, 4 hours apart

13

Signs of worsening preeclampsia

Increase in subjective symptoms
Oliguria
Sudden wt gain or inc facial edema
Hemoconcentration (hgb >12) *fluid leaking
Inc creatinine >.8
Inc uric acid >5

14

Meds for eclampsia

4g mag slow IV push
Do NOT give diazepam

15

What to do during/after eclamptic seizure

Prevent injury
Administer 02
Auscultate lungs
Assess/correct acidemia (blood gasses)
Allow fetus to recover before rushing to delivery

16

What is HELLP syndrome?

Hemolysis
Elevated liver enzymes
Low platelets

17

What is hemolysis (HELLP)

Schistocytes on blood smear
Bilirubin >1.2
LDH >600

18

What are elevated liver enzymes (HELLP)

Inc ALT, AST, LDH

19

What is the cluster of s/s to warrant lab eval for HELLP (htn/proteinuria may be absent)

N/v/d
Malaise
Flank/shoulder pain
Jaundice
Unusual bleeding
Generalized edema

20

What additional management is needed with mild preeclampsia than mild ghtn?

Twice weekly BPP and growth scan
Add umbilical artery Doppler velocimetry if iugr

21

Indications for delivery with mild preeclampsia

Same as mild ghtn
EGA >= 37 wks
Spontaneous labor/srom >=34wks

22

Management for severe preeclampsia or HELLP

4-6g loading dose mag
2-3g/hr maintenance dose mag
Antihypertensives for severe BP

continue intraop mag for c/s
Neuraxial techniques for analgesia/anesthesia

23

Indications for delivery with severe preeclampsia or HELLP

If mom/fetus unstable deliver after stabilization
^even if previable

24

When do you delay delivery 48hrs after steroids with severe preeclampsia /HELLP

PPROM
Spontaneous labor
IUFGR
severe oligo (AFI

25

When do you NOT delay delivery after steroids for

Uncontrollable sever htn
Eclampsia
Pulmonary edema
Abruption
DIC
fetal compromise
IUFD

26

When are mag levels drawn?

Creatinine >1.2 or UOP

27

When do you DC mag for mag toxicity

Absent DTR's
Respirations

28

HTN that presents before the 20th week is considered ___

Chronic htn

29

What meds are used to treat chronic htn?

Labetolol, nifedipine, methyldopa

Low dose ASA in third tri for very high risk

30

What is the goal BP for chronic htn?

120/80-160/105

31

At what gestational age do you deliver chronic htn pts with no other issues?

38 wks

32

What is a side effect of hydralazine to watch out for?

Rebound tachycardia

33

When should you be cautious with labetolol?

When pt is asthmatic and requires rescue inhaler. (Won't work)

34

When should you be cautious with nifedipine use?

When used together with mag sulfate

35

In postpartum period when would you treat a BP with antihypertensives ? What BP ?

SBP >150 or DBP>100

*2 readings, 4 hrs apart

>160/110 treat as hypertensive emergency

36

If somebody has any htn disorder how long should BP be monitored after delivery?

For 72 hrs after delivery, and at office at 7-10 days

37

First half of pregnancy is ___ , while second half is ___

Anabolic- fat storage
Catabolic- fat breakdown

Anabolic
Catabolic

38

Insulin infusion is started for type 1 diabetics if blood glucose is higher than ___

120

39

Cardiac output in pregnancy rises to ___% of normal by ___wks

150, 24-28

40

What are the three periods of high risk for cardiac decompensation?

When fluid volume peaks at end of 2nd tri
During work of labor
With fluid shifts that occur postpartum

41

What are the NYHA functional classes?

1- asymptomatic
2- symptoms with normal activity
3- symptoms with less than normal activity
4- symptoms at rest

42

What should you know about coarctation of aorta?

Aorta narrows
Associated with intracranial aneurysms
Epidural ideal, shorten second stage

43

What should you know about rheumatic heart disease?

Eradicate pathogen, reduce inflammation
Long acting pnc, NSAIDs or corticosteroids

44

What types of valvular defects are there?

Stenosis and regurgitation

45

Which type of valvular defect tends to be worse in pregnancy?

Stenotic- >60% have worsening NYHA class

Can also have CHF, PTL, IUFGR, stillbirth

46

What are complications of mitral stenosis?

Pulmonary edema, RV failure, arrhythmias, PE

47

How do you treat mitral stenosis?

Preventing/controlling tachycardia is ESSENTIAL

Pain management, beta blockers

48

What happens in aortic stenosis?

Stenosis between LV and aorta (to circulation)
Created fixed stroke volume, dec CO, hypotensive tachycardia

49

How do you manage aortic stenosis?

Prevent hypotension and tachycardia!

Generous hydration, cautious epidural use
Shorten second stage
Active management of PPH

50

What do you need to know about mitral valve prolapse?

Most common
Mostly asymptomatic
Some experience chest pain, dyspnea, weakness, palpitations
Low risk during pregnancy

51

What do you need to know about mechanical heart valves?

Anticoagulation very difficult (no warfarin)
Advised to have valve repair/replacement

52

What do you need to know about dysthymias and treatment?

SVT common
Treatment unaltered by pregnancy
Vagal maneuvers
IV adenosine (causes fetal bradycardia)
Frequent episodes- beta blockers, calcium channel blockers, digoxin

53

What do you need to know about marfans syndrome?

Aortic root diameter critical
Surgical replacement if root diameter >5.5cm
High risk if root diameter >4.5cm- csection
Treat htn aggressively- beta blockers

54

What do left-to-right shunts cause? (Seen with ASD, VSD, PDA)

Pulmonary htn

55

What do you need to know about pulmonary htn?

Causes right sided heart failure, ⬇️ 02 to body
Tx with vasodilators- prostacyclin infusion
Avoid hypotension

56

What do you need to know about eisenmengers syndrome?

L-->R shunt, pulm htn, R-->L shunt, deoxygenated blood to circulation
Maternal mortality mostly postpartum
Repair of breech before pulm htn
After pulm htn only tx heart lung transplant
Maintain preload!

57

What do you need to know about peripartum cardiomyopathy?

Pulm edema and CHF
usually in 3rd tri or postpartum

Tx with Anticoagulation for high risk of thromboembolism
Reduce preload (Na/fluid reduction, diuretics, nitrates)
Afterload reduction (hydralazine, ACE inhibitors PP)
Digoxin

58

What do you need to know about endocarditis?

Routine antibiotic prophylaxis not recommended


Cyanotic congenital heart defects considered high risk and should receive prophylaxis for vaginal delivery

59

What do you need to know about ischemic heart disease?

Mostly seen in pregnancy in women who have had type 1 diabetes for over 10 years

Delay delivery for 2 weeks after MI

vaginal delivery preferred

60

When do you test for GBS and how?

35-37 weeks with vaginal-rectal culture

61

What antibiotics are used for GBS?

PNC or ampicillin preferred
Cefazolin if allergy and low risk anaphylaxis
Clinda/vanco if allergy and high risk

62

What hgb levels diagnose anemia in pregnancy?

H

63

What causes gestational thrombocytopenia and what platelet count is considered mild to moderate?

Dilution and inc platelet destruction
Mild to moderate 50-149k

*spontaneously resolves after delivery

64

What is immune thrombocytopenic purpura? (ITP) and what is the treatment

Antiplatelet antibodies (autoimmune)
Tx with steroids

65

What is thrombocytopenic purpura (TTP) and what is the treatment?

Extensive microscopic clots form- 90% mortality untreated

Tx with plasma exchange

66

What are risks of sickle cell?

Preterm delivery
Preeclampsia

67

What are risks of thalassemia?

Hydrops fetalis
IUFGR

68

When are Rh-D negative mothers given rhogam?

28 wks, after delivery, and other situations where fetal-maternal hemorrhage can occur

69

What are thrombophilias (lead to increased thrombosis)?

Factor V Leiden
Protein c deficiency
Protein s deficiency
Prothrombin g20210a mutation
Antithrombin III deficiency

70

What drug is used as anticoagulant for VTE prophylaxis in pregnancy?

Heparin- unfractionated (UH), or LMWH
doesn't cross placenta
Switch from LMWH to UH in last mo of pregnancy
Stopped when pt goes into labor

71

What is DIC

Dysregulated coagulation cascade that results in uncontrollable bleeding

72

What are common causes of DIC?

Abruption
Preeclampsia
Sepsis
Anaphylactoid syndrome

73

What diagnoses DIC?

Abnormal bleeding
Prolonged PT/aPTT
Thrombocytopenia
Fibrinogen reduced
High levels of fibrin split products (d-dimer)
Shistocytes on blood smear

74

What is the treatment for DIC?

Identify/reverse cause
Platelets/FFP can be given to prevent death but can worsen process

75

What do you need to know about renal function in pregnancy ?

Renal volume inc 30%
Renal blood flow inc 60-80% in first tri
Dec to 50% inc at term
GFR inc 40-50%
Serum creatinine decreases
Angiotensinogen, angiotensin II, renin, and aldosterone all elevated
Mild proteinuria

76

What do you need to remember about pyelonephritis and PTL?

Use great caution with tocolytics and steroids in acute phase

Withholding is appropriate in pts with respiratory or hemodynamic instability

77

What happens to thyroid hormones in pregnancy?

Demand for thyroid hormones inc in pregnancy
Fetal CNS development depends on good T4
Fetus cannot produce T4 until 18wks
T4 converts to T3 (more metabolically active)

78

What do low/high levels of TSH mean?

Low levels - hyperthyroidism
High levels - hypothyroidism

79

What is treatment for hypothyroidism in pregnancy?

Synthroid (levothyroxine) synthetic T4
Dosage inc in pregnancy

80

What do you need to know about hyperthyroidism in pregnancy?

Rare- most caused by Graves' disease
Often masked due to normal inc in thyroid function
Associated with PTL, IUFGR, low birth weight, neonatal thyroid dysfunction

81

What do you need to know about Graves' disease?

Autoimmune disorder
Fetal hyper turns into neonatal hypo
Tx with propylthiouracil or methimazole
^1st tri ^2nd tri
Goal is T4 upper limits/slightly over normal

82

What are signs/symptoms of a thyroid crisis?

Altered mental status, temp >41c, htn, diarrhea


ICU admit, aggressive tx

83

What do you need to know about postpartum thyroiditis?

Transient thyroid dysfunction in 1st year PP
symptoms mimic pp depression
If over one year consider chronic

84

What do you need to know about systemic lupus erythematosus?

Autoantibodies cause inflammation/tissue damage

High risk for preeclampsia
Avoid NSAIDs
Associated with SAB, IUFD, IUFGR, PTL
Complete heart block most common neonatal cardiac complication

85

What do you need to know about antiphospholipid syndrome?

Autoantibodies
Promotes thrombosis/clot formation
High occurrence of fetal death, preeclampsia, IUFGR
tx with heparin, low dose ASA

86

What do you need to know about appendicitis?

Most common non ob surgical emergency
Ultrasound 1st, if inconclusive then MRI
surgery required
Maternal/fetal mortality inc in cases of perforation