Lecture 14: Medical Conditions in Pregnancy

Question 1

If the one hour 50 g oral glucose tolerance test (OGTT) is abnormal when testing for gestational diabetes what is done and what is abnormal?

Answer 1

Follow w/ 3-hour 100 g OGTT (fail 3 hour w/ 2+ abnormal values)

Question 2

What are 6 fetal complications assoc. w/ gestational diabetes?

Answer 2

• Macrosomia
• Neonatal hypoglycemia
• Hyperbilirubinemia
• Operative delivery
• Shoulder dystocia
• Birth trauma

Question 3

In mother with GDM, which fetal weight warrants C-section delivery?

Answer 3

>4500 gm

Question 4

What is the effect of ↑ HbA1C in the period of embryogenesis?

Answer 4

Direct link between birth defects and ↑ HbA1C = 6-fold ↑ congenital anomalies

Question 5

What are the 2 classes of gestational diabetes?

Answer 5

• Class A₁ = gestational DM; diet controlled
• Class A₂ = gestational DM; insulin or oral meds controlled

Question 6

Which value of fasting glucose and 2-hour postprandial is considered good glycemic control during pregnancy?

Answer 6

• Fasting <95 mg/dL
• 2-hour postprandial <120 mg/dL

Question 7

When should renal function and opthalmic function be assessed in pregnant pt with preexisting diabetes?

Answer 7

• Renal = 24-hour urine collection every trimester
• Opthalmic = detailed eye exam in first trimester

Question 8

How soon postpartum should a 2-hour OGTT be performed in mother who had GDM?

Answer 8

6-12 weeks post-partum to look for pre-existing disease

Question 9

Which drug for hyperthryroidism is contraindicated throughout pregnancy?

Answer 9

Radioactive iodine

Question 10

Triggers of thryoid storm in pregnancy can be infection, labor, C-section, and non-compliance to meds; what are signs/sx’s?

Answer 10

• Hyperthermia
• Tachycardia
• Perspiration
• High output cardiac failure

Question 11

What drugs used in tx of thyroid storm during pregnancy?

Answer 11

• Propranolol
• Sodium iodide (blocks secretion of thyroid hormone)
• PTU
• Dexamethasone (halts peripheral conversion of T4 –> T3)

Question 12

What is the cause of neonatal thyrotoxicosis; lasts how long?

Answer 12

• Placental transfer of thyroid stimulating antibodies
• Transient (lasting 2-3 months)

Question 13

Which pulmonary condition is a contraindication to pregnancy due to decompensation during pregnancy and a high mortality rate?

Answer 13

Primary pulmonary HTN

Question 14

What type of anesthesia is preferred in patient with primary pulmonary HTN?

Answer 14

Epidural anesthesia and vaginal delivery MAY be an option

Question 15

What are the most common cardiac arrhythmias in pregnancy; which are most worrisome?

Answer 15

• SVT is most frequent and usually benign
• A. fib/flutter is more worrisome for underlying cardiac disease

Question 16

Who is at greatest risk of developing postpartum cardiomyopathy?

Answer 16

Women w/ preeclampsia, HTN and poor nutrition

Question 17

How should cardiac patients be delivered?

Answer 17

Vaginally unless contradiction present

Question 18

What is treatment for immune idiopathic thrombocytopenia during pregnancy?

Answer 18

• Begin after platelets <50,000 —> give prednisone
• IV immunoglobulin if severe
• Platelet transfusion
• Splenectomy

Question 19

Which serum creatinine level worsens the prognosis of chronic kidney failure during pregnancy?

Answer 19

Serum Cr. >1.5-2

Question 20

What is asymptomatic bacteriuria more likely to cause in pregnancy?

Answer 20

Cystitis and pyelonephritis —> due to urinary stasis and glucosuria

Question 21

There is an increased risk for what complications if pregnant woman has pyelonephritis?

Answer 21

• ↑ uterine contractions and preterm labor
• Can result in adult respiratory distress syndrome

Question 22

What is hyperemesis gravidarum?

Answer 22

Persistent N/V assoc. with >5% loss of pre-pregnancy weight + ketonuria + dehydration

Question 23

What is treatment for hyperemesis gravidarum if severe (fails all conservative measures)?

Answer 23

May need nasogastric feeding or parenteral nutrition

Question 24

What is Mendelson’s Syndrome and what complications can it cause?

Answer 24

• AKA acid aspiration syndrome
• Pregnant women at > risk due to delayed gastric emptying and ↑ intra-abdominal pressure/intra-gastric pressure
• Can result in adult respiratory distress syndrome

Question 25

Intrahepatic cholestasis of pregnancy increase the risk of what complications?

Answer 25

**Meconium stained amniotic fluid** and **fetal demise**

Question 26

What is treatment for acute fatty liver of pregnancy?

Answer 26

- **Termination** of **pregnancy** --\> need to tx the Mom - **Supportive care** ---\> IV fluids w/ **10% glucose**; blood product replacement FFP and cryoprecipitate

Question 27

What is the most common cause of anemia during pregnancy and when do you screen these pt's?

Answer 27

- **Iron deficiency** - Screened at **initial prenatal visit** and again at **26-28 weeks**

Question 28

Due to pregnancy being a hypercoagulable state there is a 5-fold increase in venous thrombosis and the greatest risk is when?

Answer 28

**First 5 weeks postpartum**

Question 29

Superficial thrombophlebitis is most common in pregnant pt's with what characteristics; risk of PE?

Answer 29

- Most common in those w/ **varicose veins**, **obesity** and little **physical activity** - Most common in **calf**, will **NOT** result in **PE**

Question 30

DVT's during pregnancy most commonly occur in which leg and what are the signs/sx's?

Answer 30

- **More** **common** in **LEFT leg** - **Pain** in the **calf** w/ **dorsiflexion (Homans sign)** - May also have **dull ache, tingling,** or **pain** w/ **walking**

Question 31

If patient has DVT what values should you follow if you give LMW lovenox vs. unfractionated heparin to assure therapeutic levels?

Answer 31

- Follow **aPTT** values with **heparin** - **Factor Xa** values with **lovenox**

Question 32

When should coumadin be used during pregnancy for DVT's?

Answer 32

Used for **6 weeks POST-partum**, but **NOT** during pregnancy

Question 33

What are sx's of PE during pregnancy?

Answer 33

- Pleuritic chest pain - Shortness of air - Air hunger - Palpitations - Hemoptosis

Question 34

What 5 things used for diagnosis/evaluation of suspected PE?

Answer 34

- **EKG** - **CXR** - **ABG's** - **VQ scan** - **HELICAL CT**

Question 35

All pregnant pt's with DVT or PE require a thrombophilia work-up which includes what markers?

Answer 35

- **Lupus anticoagulant** - **Anticardiolipin antibody** - **Factor V leiden** - **Protein C** and **Protein S** - **Antithrombin III** - **Prothrombin G20210A**

Question 36

All pregnant patients with hx of thrombombolism will need prophylactic?

Answer 36

Anti-**coagulant** therapy

Question 37

What is the most common pulmonary disease in pregnancy?

Answer 37

**Asthma**

Question 38

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?

Answer 38

**Stress** dose of **IV** steroids to **prevent** adrenal crisis

Question 39

What is the most common HA during pregnancy; treated how?

Answer 39

**Tension**; tx w/ **acetaminophen**

Question 40

All anti-epileptics have teratogen risk, but what 2 are most commonly used during if pregnancy if needed?

Answer 40

**Dilantin** and **phenobarbital**