Medical Complications Flashcards
(123 cards)
1
Q
Thrombophilias
A
inherited
3 deficiency-antithrombin 3, protein c or s
2 mutations-FVL or prothrombin hetero or homo, compound hetero
Start anticoagulation as soon as confirmed pregnancy
DVT in pregnancy due therapeutic for 3-6 months and can decrease to intermediate or prophylaxis until 6 wks PP
2
Q
Anti Xa levels
A
Prophylactic 0.2-0.5
Therapeutic 0.6-1.0 (for thrombophilias), 0.7-1.2 (mechanic heart valves)
3
Q
Most common site of DVT
A
Left lower extremity, proximal
Iliac or iliofemoral due to right iliac vein crossing over worsened with compression from gravid uterus
4
Q
Contraindications to valsalva
A
Assisted delivery Pulm HTN Fixed stenotic lesions Ventricular dysfunction (cardiomyopathy) or Single ventricles Moderate degrees of aortic dilation
Need CS-may be others but case specific Eisenmengers Marfan's with dilated aorta (>45) Severe AS CHF
5
Q
Contraindications to epidural
A
Absolute: uncorrected hypovolemia, coagulopathy (clinical), infection at site.
Severe aortic stenosis- cannot tolerate preload reduction
Eisenmengers- cannot tolerate afterload reduction
Relative: spinal cord/LE disease, spinal deformity/instrumentation, back problems, coagulopathy (lab), stenotic cardiac lesions, pulm HTN, bacteremia, potential for hypovolemia (active bleeding)
6
Q
Hypoxemia
diff dx
Workup
A
Asthma-CXR, ABG
Pneumonia-CXR, ABG
Pulmonary edema-CXR, ABG, echo
Pulmonary embolism-CT angio, ABG, ?LE Doppers
7
Q
Hypoxemia treatment
A
Asthma -oxygen, bronchodilator
Pneumonia- oxygen, antibiotics
PE-O2, anticoag
Cardiogenic pulm edema-O2, diuretics, improve cardiac function, reduce afterload
Non cardiogenic pulm edema-O2, diuretic, address cause
8
Q
Aortic aneurysm diff dx
A
Marfan’s
Loeys-Diet
Vascular EDS
Turner’s
9
Q
Physiologic cardiac changes of pregnancy
A
Plasma increase 45-50% RBC volume increase 32% Renal and Na retention cause fluid retention shifted extravascular (P cause increased mineralocorticoid) BP down 10% HR up 20%, SV up 30%, CO up 30-50% PA pressure doesn't change Renal blood flow up 30%
Up:HR SV, CO
Down: SVR, pulm VR, osmotic and oncotic pressure, PCWP
May lose 30% blood volume with minimal PP hct change due to diuresis
10
Q
Cardiac medication classes
A
Inotrope-increase contractility (dig)
Chronotrope-increase HR (beta agonists, atropine)
Neg inotrope/neg chronotrope-beta or CCB
11
Q
Pressors
A
Norepi(levophed)- alpha/beta 1 agonist, strong vasoconstriction, best in septic, cardiogenic or hypovolemic shock
Phenylephrine-alpha-strong vasoconstriction, post anesthesia hypotension or tachyarrhryrymiasa
Epinephrine-alpha 1, beta 1/2, anaphylaxis
Dobutamime-inotrope, beta1/2, good in septic.shock. low dose up CO, down SVR, med dose both up, high dose only SVR up
12
Q
Respiratory changes in pregnancy
A
If PaO2 is normal 60-100 then SaO2 is also normal. Any additional FiO2 increases PaO2 unless lungs abnormal
Down: TLC, functional residual capacity, ERV RV, inspiratory volume
No change: vital capacity, RR
Up: ventilatory drive, minute ventilation, TV, dead space
Minute volume=TVxRR
13
Q
Pregnancy ABG
A
pH 7.4-7.45 (alkalosis) PaO2 101-105 (up) PaCO2 27-34 (down) HCO3 18-21 (down) If mom normal pH or acidotic then baby is always acidotic as.fetus cannot offload CO2 to mom
14
Q
Indications for intubation
A
Unable to protect airway
Unable to ventilate (high CO2, usually asthma)
Unable to oxygenate
Prevent respiratory fatigue
15
Q
Coagulation factor changes
A
Pro-coagulant:
Up: 7,8,10, vWF, fibrinogen, plasminogen activator inhibitor
No change: 2, 5, 9
Anticoagulant:
no change: protein C, AT
Down: protein S
16
Q
Immune changes
A
Shift from cellular (Th1) to humoral (Th2)
17
Q
Asthma
Complications
Meds
A
Severe or poor control then PTD, CS, PEC, FGR, maternal morbidity and mortality
Controller: inhaled steroids, Cromolyn, long acting beta agonists, theophylline (requires serum monitoring)
First line in pregnancy budesonide low dose then higher and add long acting beta (salmeterol)
Rescue: short acting beta agonists
Beta blocker, methergine and hemabate can cause exacerbation
18
Q
Asthma stepwise
A
Severity. Symptoms. Night. FEV
Intermittent
-well controlled. <2/wk. <2/mon. >80%
Mild persistent
-not well controlled. >2/wk. >2/mo. >80%
13% exacerbation
Mod persistent
-not well controlled. Daily. >1/wk. 60-80%
26% exacerbation
Severe persistent
-very poorly control multiple in day >4/wk. <60%
52% exacerbation
Peak expiratory flow should be >330
19
Q
Asthma exacerbation
A
Treat rescue and continue if FEV >70%
If FEV 50-70% individualize, O2, short acting beta agonists, continuous nebulizer, IV steroids
If FEV <50% admit, need ICU if severe symptoms, drowsy, confusion, PCO2>42
Oral steroids 3-10 days (40-60mg)
Need SDS and third trimester
20
Q
CAP
A
No severe symptoms can treat outpatient
Ceftriaxine or augmentin with azithro
21
Q
Pulm Edema
A
Cardiogenic- volume overload and/or poor heart function
-CHF, MI, cardiomyopathy, PEV, valve problems
Echo shows increase in IVC, low Ears, dilated LV, ?valve abnormalities
non-cardiogenic-imcreased permeability causing fluid leakage, not volume overloaded, normal heart, normal BNP
-sepsis, ARDS, PEC, TRALI
Crackles a late finding
In sepsis neg CXR until lungs 30% full of fluid
Dx: hypoxemia, tachypnea, tachycardia, crackles, chest pain, cough, SOB
TX: O2, diuresis, decrease afterload, may need to intubate, BiPAP or CPAP great for pulm edema
22
Q
ARDS
A
Decrease lung compliance and intrapulmonary shunting (blood leaves lungs without oxygen)
Pregnant causes: pneumonia, sepsis, AFE, PEC, aspiration
Dx: diffuse bilateral infiltrate (pulm Edema) visible after 24 hrs, resp failure not due to cardiogenic factors
PaO2/FiO2 determines severity.
Mild 200-300
Mod 100-200
Sev <100
TX: supportive, correct cause. PEEP, prone and neuromuscular blockade if <150 and maybe need ECMO if <80
Delivery may cause temporary improvement but no change to long term outcomes
23
Q
Influenza
TX
Prophylactic
A
Supportive
Zanamavir or oseltamivir (BID x 5 days)
Tamiflu daily x 10 days
24
Q
Ventilation
Settings and goals
A
SIMV Rate 14-16 TV 6-10 mL/kg PEEP 5 FiO2 100% then wean Must have higher TV than non pregnant to main resp alkalosis
PaO2 > 60 mm
SaO2 >95%
PaCO2 27-34
FiO2 <50%
25
Sepsis
SoFA score >2 with infection , 10%>mortality
Tocolysis in sepsis may cause pulm edema, ARDS, hypotension.
Septic shock 40% mortality
1 hr bundle for sepsis-lactate, blood cultures, antibiotics, fluid resuscitation, correct hypotension
For each hour delay increase mortality 5-7%
Amp/gent/clinda covers 90% sepsis including strep a and aneorobes or vanc/zosyn (1.5mg/kg and 4
T q6)
26
Group a sepsis
20x MC in OB, 85% PP, 7-10% mortality
Risk factors upper resp infection prior to delivery or exp to carrier
MC in 24 hr PP with fever, abdominal pain out of proportion to exam, may have hypothermia from low tissue perfusion
Rapid spread.due to toxins
Typical signs: erythema, increase pain resistant to meds, extreme anxiety
Late sign: purple discoloration of skin.with bullae, edema,.crepitus, black necrotic plaques, muktisystem organ failure
27
Indications for delivery in sepsis
Maternal
Intrauterine infection, DIC, hepatic or renal failure, cardiac arrest, failed response to therapy, severe ARDS. Condition expected to improve with delivery
Fetal
Demise, advanced gestational age with min risk of delivery
If delivering for sepsis always give steroids, no reason to not give.
28
Always abnormal in pregnancy
```
Severe dyspnea
Exertional syncope and chest pain
Paroxysmal nocturnal dyspnea
S4 gallop ( blood hitting stiff ventricles in diastole)
Cyanosis
Clubbing
Diastolic murmur
Sustained arrhythmias
Loud, harsh systolic murmur
```
29
Conditions that need repaired prior to pregnancy
```
ASD or VSD with shunting and any pulm HTN
PDS with an pulm HTN
severe AS or MS or mitral regurg
Severe coarc
TOF
```
Highest risk conditions: anything with Pulm HTN, Eisenmengers, Marfan's, dilated CM EF <40%
30
Maternal mortality rates by cardiac disease
```
AS 10-20%
Coarc 5%
Marfan's (aorta >40) 10-20%
Peripartum CM 15-60%
Severe pulm.HTN 50%
TOF 10%
```
31
Maternal ASD
Often undetected before pregnancy
If no pulm HTN preg likely uncomplicated
May cause systolic ejection murmur, RBBB, enlarged RA
Contraindications to pregnancy: large ASD, chronic a-fib, RV dysfunction, pulm HTN
IE prophylaxis not indicated
32
Maternal VSD
If no pulm HTN well tolerates
Pan systolic murmur
Contraindications to pregnancy if SVR =PVR
IE prophylaxis only needed if recent repair
33
Maternal PDA
Continuous machinery murmur
Should be repaired pre-pregnancy
IE prophylaxis is unrepaired
If no pulm HTN then tolerated
34
Eisenmengers
RV heave
Palpable Pulm valve closure
Can have bidirectional shunting depending on hemodynamic status
MCC large VSD then PDA
Pulm HTN irreversible so surgical repair of defect worsens condition unless concomitant lung transplant
35
Pulmonary hypertension
Need right heart Cath if peak tricuspid regurg velocity >2.9 with signs of pHTN or >3.4
Tx with IV vasodilators, inhaled NO, diuretics, dig, anticoag
If responds to IV prostacyclins (epoprostenol, sildenafil) than good prognostic factor, may respond to oral nifed.
Main treatment to correct cause then symptoms
36
Mitral stenosis
Diastolic murmur
Usually rheumatic fever (multiple valves, 10-20 yrs) rarely congenital
Pulm congestion/edema, atrial arrhythmias, 25% CHF
Symptoms present if valve <2 cm2, critical 1.5. worsen with tachycardia
If AFib need anti-coag
Gentle Regional anesthesia without bolus to minimize tachycardia with assisted second stage (IV esmolol gtt if needed).
Gentle diuresis PP as proud dependent. Need euvolemia.
Pulm Edema occurs with tocolysis, PEC, or fluid overload
Percutaneous balloon valvuloplasty can be done in pregnancy under echo
Phenylephrine pressor of choice as no tachycardia
37
Aortic stenosis
Systolic ejection murmur. Symptoms do not always correlate with severity.
Congenital, bicuspid or rheumatic fever
Medical management is class 1 or 2, surgery with balloon valvuloplasty of replacement if needed. 20% fetal loss with bypass needed for replacement.
May cause post valve aorta dialtion, if >45mm recommend cesarean.
If severe (area <1 or gradient >40) replace prior to pregnancy, highest risk CHF mean at 27 wks. Must be wet.
moderate (area 1-1.5 or gradient 24-40) should complete child bearing then repair.
Critical area <0.5 or gradient >100
If LV failure sure dig and diuresis
Bicuspid associated with coarc.
Assisted second stage with local or regional combined, want to avoid preload reduction.
IE prophylaxis only if history of IE
38
AS labor management
Avoid aortocaval compression
Avoid bradycardia
Avoid SVR
Maintain venous return and LV filling
Single shot spinal absolute contaidincation due to fixed cardiac output and inability to compensate for decrease in afterload
Caution with oxytocin as could cause hypotension
39
Pulmonary stenosis
Preload dependent
Usually repaired in childhood
Generally well tolerated
20% offspring with CHD and 50% are PS
40
Maternal TOF
MC cyanotic heart disease in pregnancy
2-13% recurrence in offspring
RV and LV pressure equal but normal PA pressure
If complete repair well tolerated
If.residual PS at risk for regurg and RV failure
Uncorrected requires IE prophylaxis and 4-15% maternal mortality and 30% fetal mortality
Risk factors for death
-SaO2 <85%, RV pressure >120, h/o syncope+CHF or cardiomegaly, Hg>20
Anesthesia
Avoid drop SVR, ensure venous return, phenylephrine to maintain SVR if needed, echo to monitor volume status. CSE best choice
41
Preload dependent lesions
Left sided obstructions-AS, MS, coarc
Lesions that require afterload reduction
Regurg tx with hydralazine and diuretics
Must maintain euvolemia to avoid pulm edema
42
Maternal coarc
Uncorrected 3% mortality
Balloon dilation in pregnancy
10% aortic root aneurysm may rupture in labor, risk death 15%. Offer termination. All patients need MRA thoracic aorta and head and neck vessels at least once in lifetime to assess risk of aneurysm
May need multiple.repairs through out life
May cause distal hypotension and uteroplacental insifficiency
Increased risk PEC with worse morbidity and mortality
43
MV regurg not prolapse
Young women-comgential or rheumatic
Older women-HTN, ischemia, idiopathic, myocardial disease, IE
If greatly enlarged and hypokinetic ventricle than pregnancy contraindicated. 50% risk FGR, IUFD, fetal hypoxia
If mild to mod pregnancy safely managed with decreased activity, salt restriction, low dose diuretic, if a fib then low dose dig
44
Aortic regurgitation
MCC rheumatic then bicuspid, Marfan's, IE, SLE
Causes volume not pressure overload
Usually well tolerated in pregnancy
Blowing diastolic murmur
Stable for long time. Once progresses to HF then rapid decompensation
45
Peripartum cardiomyopathy
1 mo pre-delivery to 5 mo PP
EF<45%
No other identifiable causes
Echo:
EF<45%
Decreased shortening fraction <30%
LV end diastolic volume >2.5
High BNP
46
Peripartum cardiomyopathy
Risk factors
Prognosis
Recurrence
Treatment
Increased age, HTN, AA multiples
20% progressive decline, need transplant
30-50% partial recovery
30-50% near complete recovery
No further recovery after 2-3 months
If normal EF, 20% recurrence, low mortality
If abnormal EF, 40% recur, 20% mortality
Vasodilation to decrease afterload-hydral then Amlodipine then nitro
Beta blocker to decrease O2 consumption
Dig for increased contractility
47
Marfan's
AD, high penetrance, variable expressivity
Decreased fibrillin leading to aortic dissection, deficiency of elastic tissue causes myxomatous breakdown of aortic and mitral valves. Cystic medial necrosis of aorta
90% MVP, 60% aortic root dilation
Risk dissection 1% if <40mm and 10% >40mm and recommend CS
If >50mm recommend repair prior to pregnancy. 50% will need repeat repair.
TX: limit.physical activity, avoid HTN, beta blocker.to keep <130/70
Labor concern due to rupture avoid volume overload, HTN, tachycardia
48
Artificial valves
Risk clotting increased 2x with lovenox compared to warfarin, 12-24%
Warfarin to heparin not before 6 wks, if 5mg or less no transition
4-10% risk embryopathy with warfarin >5mg, 2-3% lower dose. INR
Lovenox 4hr postdose.anti Xa 0.7-1.2, check weekly
IE prophylaxis if dental but not uncomplicated VD
40% if valve infected
IV heparin 36 hrs pre delivery and 4-6 hrs PP
```
Highest risk thrombosis
MV esp if older type valve
AFib
H/o embolic event
EF<30%
Multiple valves
```
49
SBE prophylaxis
Prosthetic valve or other prosthetic repair
H/o IE
Unrepaired cyanotic CHD (shunts or conduits)
CHD repaired less than 6 months
Repaired CHD with residual defect (high flow impairs endotheliatization
50
Acute MI or acute coronary syndrome
Coronary artery dissection MCC
Early.PP highest risk time
5-10% mortality
Dx: ischemic symptoms, new q waves or ST changes,.new LBBB, elevated troponins
TX: decrease cardiac work.
Epidural, left lateral, treat HTN or tachycardia
O2, nitrates, ASA, IV UFH, beta blockers
Persistent symptoms than move to angiogram
Goal to delay delivery 2-3 weeks if able
51
Risk factors for cardiovascular related maternal mortality
Race/ethnicity- non Hispanic black 3.4x higher death
Age- >40 increase 30x
HTN- 10% all pregnancies
Obesity(esp OSA) 60% all maternal mortalities overweight
52
Preconception counseling maternal CHD
1. Risk permanent progression of heart disease
2. Risk morbidity and mortality
3. Risk fetal CHD, FGR, PTD, IUFD, perinatal mortality
53
Maternal MI diff
H and T (hypovolemia, hypoxemia, hypokalemia, H+, hypothermia, tension pneumothorax, tamponade, toxin, thrombosis)
```
Anesthetic
Bleeding (MCC 38%)
Cardiovascular disease
Drugs (mag sulfate)
Embolisms (VTE or AFE which is second MCC 13%)
Fever (sepsis)
General (metabolic, electrolyte)
Hypertension
```
54
Management maternal MI
CAB not ABC
1. early intubation due to high O2 needs
2. Uterine displacement
3. Concurrent interventions
4. Deliver by 5 mins (unwitnessed by 1 min)
5. CPR 100-120 using same landmarks
6. 30:2 bag.mask 100%
Steroids shortly after MI may.cause ventricle rupture
17-OHP caution I'm heart dysfunction
55
Resuscitative CS
Local
1% plain- 4mg/kg, total 300 mg (30mL)
1% with epi- 7mg/kg, total 500 mg (50mL)
56
WHO 1
No increase mortality
No or mild increased morbidity
2-5% cardiac event
Mild/small, uncomplicated PS, PDA, MVP
Repaired ASD/VSD/PDA, TAPVR
isolated ectopic beats
Cards 1-2x/pregnancy
Local delivery
57
WHO 2
Small Inc mortality
Mod Inc morbidity
6-10% risk event
Unrepaired ASD/VSD
Repaired TOF
Most arrhythmias
Cards q trimester
Consult MFM
Local delivery
58
WHO 2/3
11-19% risk event
```
Mild LV impairment
HCM
Native valve disease not in WHO 1 or 4
Marfan's without dilation
Aorta <45mm
Repaired coarc
```
Cards q trimester
Consult MFM
Care/delivery at appropriate level
59
WHO 3
20-27% event
```
Mechanical valve
Systemic RV
Fontans
Unrepaired cyanotic HD
Complex CHD
Marfan's 40-45 mm
Aorta 45-50mm
```
Cards q 1-2 months
Consult MFM
Local delivery
60
WHO 4
Pregnancy contraindicated
>27% risk event
```
Pulm HTN
LVEF <30%
PPCM with residual LV dysfunction
Severe MS or AS
Marfan aorta >45
Aorta >50mm
Native severe coarc
```
61
Increased risk of DKA pregnancy
Increased insulin resistance
Accelerated starvation
Decreased buffering due to resp alkalosis
Increased production of insulin antagonists (glucagon, prolactin, cortisol, catecholamines)
62
Ketones
Acetone
Beta hydroxy butyrate
Anion gap >12, BE
63
DKA physiology
Insulin resistance or absence cause high tissue glucose inability to use glucose
Glucose causes.osmotic diuresis-low.Na, K, PO4
Diuresis causes high osmolarity and increase intravascular fluid
Inability to use glucose causes gluconeogenesis, which cause imcrase free fatty acids
These oxidized to ketones
Ketones imcrase acid
Acid buffered by HCO3
HCO3 depletion causes further acidosis and shifting/depleting of K
Tocolysis stimulates gluconeogenesis and glycogenolysis and shifts K into cells
64
DKA treatment
Replace fluids-start NS, 1-2L I'm first hour. Change to D5 1/2NS when glucose <200
Insulin 0.1unit/kg/hr, reduce glucose slowly to minimize risk of cerebral edema
Glucose-check Q1 hr and replace when <200
K-will drop when start insulin so if <3.3 replace prior to starting insulin
65
Aortopathy Syndromes
Marfans Loey Dietz vEDS Turners
AD AD AD 45XO
CV dilated aortic root and dissection aortic dissection A diss
mortality 6-50%
OB PTD, PPROM, FGR PTD, PPROM HTN
PPH, VTE, spont uterine rupture Ut rupture PEC
pneumothorax FGR
Tx beta blockers, echo q trimester echo q trim echo qT
anesthesia consult CS anes
66
Maternal myotonic dystrophy
PPH
Prolonged second stage and operative delivery
Annual EKG
Anesthesia consult- sensitivity to opiates and anesthetics
Inc risk PP pneumonia
30% worse symptoms in pregnancy that resolve PP
67
Hereditary hemorrhagic telangiectasias
AD
Epistaxis, mucocutaneous telangiectasias (Petechiae)
AV malformations-brain, lung, GI
In pregnancy- Brain MRI, chest CT, RUQ US
Avoid prolonged valsalva in vag delivery
Avoid NSAIDs and ASA
68
Klippel -trenaunay syndrome
Sporadic, unknown genes
Clusters in families
Capillary and venous malformations
Varicosities
Hypertrophy soft tissue and bone, usually one lower extremity
VTE
In pregnancy assess vascular status, esp abnormal pelvic vasculature
MRI
If large vulva/vagina varicosities consider CS
69
PKU
AR
Phenylalanine hydroxylase deficiency, unable to make tyrosine from phenylalanine
Check maternal phenylalanine levels, goals 2-6 mg/dl, high levels damage CNS
Need supplemental tyrosine
Untreated: impaired brain development, microcephaly, behavior problems, musty body odor, eczema, light hair and skin (low pigmentation b/c tyrosine needed for melonin production), hyperreflexia, tremors, hemiplegia
Supplement with synthetic protein
If baby has then no breastfeeding
70
Thyroid Disease
```
fetal thyroid functions at 12 weeks
20% lower TSH
inc thyroid binding globulin (from estrogen) leads to lower free thyroid levels (free better to check in pregnancy)
T3/T4 crosses placenta
TSH by trimester 2.0, 3, 3
```
71
Hyperthyroidism
Diff Dx
Symptom
Cause
hyperemesis, trophoblastic disease
heat intolerance, diaphoresis, tachycardia, fatigue, wide pulse pressure, anxiety, emotional liability
Graves, toxic adenoma, toxic goiter, TSH producing tumor, thyroiditis, struma ovarii
72
PTU
prevents peripheral conversion T4->T3.
rare complication agranulocytosis
Recommended until 16 weeks then switch to methimazole
check lab q2 wk when starting med
73
Methimazole
prevents thyroglobulin iodination and synthesis
| May cause cutis aplasia
74
hyperthyroidism treatment
PTU until 16 weeks then methimazole
check labs q2 weeks
in later pregnancy switches to inhibiting antibodies so may not need medication after 32-34 weeks
storm/throtoxic heart failure
1. PTU prevents further release TH and conversion
2. iodine 1-2 hrs later, decrease circulation of thyroid hormones. Given after PTU so not used as substrate for more TH
3. beta blocker if tachycardia to control symptoms. If concerned for HF get echo first
4. Dexamethasone blocks peripheral conversion of needed
Surgery can also be if needed
75
Fetal/neonatal hyperthyroidism
Fetal hypothyroidism from treatment with bradycardia, FGR, goiter
transplacental passage of TSIs, most common in Graves but also with Hashimotos
antibodies >300% highest risk, check at 20 weeks
fetal thyrotoxicosis-FHR>160, FGR, advanced bone age, craniosynostosis
76
Hypothyroidism
MCC MR worldwide
complications: SAB, PEC, abruption, SGA, PTD, IUFD, GHTN
Hashimoto: MCC, hypothyroid +antibodies (TPO MC)
Do not use desiccated thyroid to treat hypothyroidism
start 1-2microgram/kg/d. Increase meds needed up to 20 weeks, occasional in third trimester. Decrease dose immediately PP
Subclinical hypothyroidism causes same complications if TSH >10
10% PP moms develop autoimmune thyroiditis
77
Pituitary Tumors
GH-acromegaly
ACTH-Cushings
Prolactin-MC
non hormone producing often large at diagnosis, may grow in pregnancy causing visual field defects. Treat with bromocriptine and resect PP
78
Prolactinoma
bromocriptine or cabergoline to become pregnant and stop treatment when pregnant
micro<10, macro>10 (consider formal visual field testing qtrimester)
screen for headache and visual changes each visit. can treat in pregnancy, if no response than transsphenoid surgery
79
acromegaly
60% from macroadenoma
dx wtih GTT with no suppression of GH
50% glucose intolerance and 20% diabetes
Levodopa causes decrease GH levels (not in pregnancy)
same treatment as prolactinoma
80
Cushing Syndrome
```
SAB, FGR, PEC, DM, CHF, Psych issues, death
high ACTH (pituitary or ectopic) causing excess cortisol
```
Dx with cortisol suppression following dexamethasone, difficult in pregnancy due to urinary cortisol secretion. May need high dose dexa and adrenal imaging.
81
Ornithine transcarbamylase deficiency
X linked. Males severely affected, females only symptomatic during increased stress (labor)
With x inactivation mom can be symptomatic carrier
Dx: Low citrulline and high orotic acid (urea cycle)
Males: Normal at birth, after begin eating, develop hyperammonemia, n/v, coma, death
Crisis: 10% dextrose at high rate, iV ammonul-sodium benzoate and phenylacetate to increase excretion, IV arginine, if refractory then dialysis
Chronic tx: diet to prevent catabolism, oral phenylbutyrate
Labor: 10% dextrose high rate, watch for hyperammonia
82
NF
Type 1: AD, cafe au lait spots >6, axillary freckling, cutaneous neurofibroma, lisch nodules, optic gliomas
Type 2: AD, vestibular schwanoma, glioma, cataracts, meningiomas
50% tumors grow in pregnancy, cHTN/PEC, CS if large pelvic neurofibroma
83
How to minimize risk of aspiration in surgery
Pre-oxygenate
Give antacids
Prefer rapid sequence intubation
SaO2 drops faster in pregnancy (10% in 3vs9 mins)
84
Non-OB surgery considerations
```
FiO2 >50%
End tidal CO2 32-34 mm
VTE prophylaxis
Inhaled agents can decrease uterine tone
General anesthesia causes vasodilation possible decreased placental blood flow
Avoid excess uterine manipulation
Consider cEFM
BMZ
Monitor for PTL
```
Highest risk PTD following appendectomy
85
Risks of general anesthesia
SAB, hemorrhage, need for transfusion, infection, aspiration, failed intubation due to airway edema, stroke, anesthesia reactions, PTL,
Prefer elective cases in second trimester due to possible higher SAB in 1st trim
86
Non-OB antibiotics prophylaxis
Cephalosporin, PCN, erythromycin, azithromycin, Clindamycin, aminoglycosides
Do not give: doxycycline, trimethoprin or macrobid in first trimester, fluoroquinolines
87
Oophorectomy prior 10 wks
Supplement progesterone IM until 10 weeks
88
Post op pain control non OB surgery
Tylenol
NSAIDs prior to 32 wks limited to 48 hours, can check maternal Cr prior
Epidural
Narcotics
89
Adnexal mass differential
Mature teratoma
Para-ovarian cyst, corpus luteum
Hydrosalpinx
Malignancy-3-6% all masses, germ cell, stromal, epithelial
Consider removal if rapidly growing or >8cm
50-70% resolve in pregnancy
90
Thyroid storm
```
Tachycardia
Dysrhythmia
CNS dysfunction
Fever
Labs showing hyperthyroidis
```
Labs: TSH, free and total T3/T4
TRAb, CBC, CMP, urinalysis
Fetal US
Admit to ICU and repeat labs frequently
91
Thyrotoxic heart failure
CM and pHTN more common then storm with high T4
Consider echo
92
Hypoparathyroidism
Low calcium and low PTH
Tetany, parathesia, stridor, cramps, mental changes
Diff: vit D deficiency (high PTH), excess chelation, pancreatitis, sepsis
TX: calcium (goal 8-9) vit D. Often need double dose in pregnancy.
93
Osteoporosis
In pregnancy due to low estrogen, high glucocorticoids
Common before 28 wks and first 6 mo breastfeeding
Partial recovery PP
TX: PP bisphosphonates
Pregy-vit d and calcium
94
Breast lump with nipple drainage
```
80% benign
Lactating adenoma
Fibroadenoma
ductal epitheliul/lobar hyperplasia
Galactocele
Cystic disease
Infiltrating ductal carcinoma (MC malignancy)
Ductal or lobar carcinoma
```
95
Breast cancer
Stage for stage same prognosis as not pregnant
Chemo: cyclophosphamide, doxorubicin, 5FU
Fetal risk chemo: SAB, heme suppression, FGR, oligo, PTD, anomalies
Radiation risks: SAB, anomalies(eye, skeletal, genitalia) cognitive delay, microcephaly
Always send placenta for path
96
Coag changes pregnancy
Pro-coagulant:
Up-fibrinogen, factors 7, 8, 10, vWF, plasminogen activator inhibitor 1&2
No change-factora 2, 5, 9
Anticoagulant
No change-protein C, antithrombin
Down-free protein S
97
VTE risk factor pregnancy
1. History VTE
2. Thrombophilias
3. Physiologic change in pregnancy, delivery/CS, medical complications
VTE 2-4 wks prior to delivery consider IVC filter
98
Anticoagulation misc
Allergy to heparin or HITT use fondaparinox
Overlap heparin and warfarin PP 5 days to avoid paradoxical thrombosis due to anti protein c effect
Mechanical valve warfarin INR 3
Heparin/lovenox cause osteoporosis so give but d and calcium
Restart PP 6 hr VD and 12 hr CS
99
Thrombophilias in pregnancy treatment
Low risk without VTR-surveillance
Low risk with family history VTE- surveillance vs prophylaxis
Low risk with VTR-prophylaxis or intermediate
High risk without VTE- prophylaxis or intermediate
High risk with VTR-prophylaxis to therapeutic
Thrombophilias with more than 2 VTE- intermediate or therapeutic
Pp should be equal or greater
100
Thrombocytopenia
Diff
Evaluation
Gestational, ITP, PEC, HELLP, pseudo ITP (clumping), infection, lupus, APLS, medications
Rarely: TTP, HUS, DIC, bleeding disorders (vWD)
H&P, med review (heparin, lasix, NSAIDS, PCN), BP, splenomegaly, CBC with peripheral smear, CMP
101
ITP
CBC q trimester at least
If prior splenectomy needs vaccine for pneumococcus, H. Flu, meningococcus
Infant needs Platelet count before IM shots or circumcision
TX: steroids (responds 4-14 days), IVIG (responds 1-3), immunosuppressant (azathioprine, rhogam), splenectomy
Transfuse VD<10K CS<50K
102
Von willebrands
Dx
Tx
Can present as thrombocytopenia
Check factors 8,vWF antigen and ristocitin cofactor activity and repeat each trimester
Treat with DDAVP goal vWF>50iu/dl
DDAVP causes release vWF from endothelium )not in type 3)
Avoid episiotomy, deep injections, anti-platelet drugs, FSR, circumcision
103
Side effects DDAVP
Anti-diuretic (low k), tachyphylaxis, flushing, headache (vasodilation)
104
vWB type 1
1. MC, AD, low quantity vWF, mild to mod bleeding risk, inc risk PPH, no inc mortality in pregnancy
Due to physiologic inc vWF in pregnancy may normalize, risk PP
105
Crohn's disease
```
Transmural granulomatous inflammation
Colon with skip lesions
50% have rectal disease
Causes abscesses, fistulas and structures
2-5% recurrence in offspring
```
```
Complications: SAB, FGR, PTD/PPROM
All meds safe except MTX and thalidomide. Mesalamine and sulfadalazine first line
Surgery not currative
No smoking!
CS if perianal disease
```
106
Ulcerative colitis
```
Mucosa inflammation
Only in colon and 100% rectum
Continuous GI spread
MC symptoms bloody diarrhea
Cured with surgery
Inc risk colon cancer
```
107
Regional Anesthesia complications
```
Post dural headache
High spinal
Aspiration
Hypotension
Inability to ventilate/intubate
Fetal bradycardia
Local anesthesia toxicity-metallic taste, bradycardia, decr cardiac contractility. Tx with lipid emulsion (TPN)
```
108
Bariatric surgery
Labs: protein, B12, folate, vit.D, calcium, iron, ferritin, CBC
Lower risk:HTN, GDM, PEC
higher risk: GI obstruction or hemorrhage, CS
Wait 12-24 mo to conceive
Avoid extended release meds and NSAIDS
109
Acute fatty liver
Usually 3rd trimester
N/v, epigastric pain, anorexia, jaundice
50% have PEC
Labs may show DIC, high ammonia, acute renal failure
20% recurrence
110
Idiopathic intracranial hypertension
TX steroids, acetazolamide, diuresis, LP or shunt
111
Spinal cord injury
Baseline PFTs
Risk for anemia, recurrent UTIs, decub ulcers, impaired thermoregulation
Above T10 cannot feel labor, consider early admission to monitor for labor, use non-absorbable sutures for vaginal repair
Above T5/6 high risk for PTL, 85% autonomic dysreflexia
112
Autonomic dysreflexia
Caused by bladder/bowel/vagina/cervix distention
Malignant HTN, bradycardia, nasal congestion, facial flushing
Tx: reserpine, atropine, clonidin
Prevent with epidural and Foley
113
Rash and pruritis diff dx
```
Cholestasis
PUPPS
impetigo
Herpetic lesions
Varicella
Pemphigoid gestationalis
Atopic eruption
Pustular psoriasis
Scabies
Folliculitis
Drug rxn
```
114
Pustular psoriasis
Erythematous plaques with rings of pustules
Nails and between fingers affects, spared hands, feet, face
Not pruritic
Low calcium and +WBC and RBC in urine
Causes placental insufficiency, SAB, FGR, IUFD
Serial US and NST
TX: IV steroids, correct calcium, antibiotics if secondary infection
115
PUPPS
MC skin disease in pregnancy
MC in nulliparous and multiples
Periumbilical sparing
Erythematous pappules in striae
Develops.late 3rd trimester, rare recurrence, may worsen PP
No significant morbidity
TX topical steroids, oral antihistamine
116
Pemphigoid gestationalis
```
Herpetiform vesicles
Autoimmune pruritis
2/3 trimester or PP
Starts at umbilicus and spreads out
On palms and soles
Can flare PP and recur on OCP
Dx skin biopsy with eosinophils and +X3
```
Tx: topical steroids and oral antihistamine (topical antihistamine may cause allergic rxn)
May cause placental insufficiency
Link with graves antibodies
117
Sequential organ failure assessment (SOFA)
| Score
```
PaO2/FiO2
Platelets
Bilirubin
Hypotension
Glasgow coma scale
Cr
Urine output
```
The worse each variable the higher the score. More than 2 points is sepsis with 10% mortality rate.
Septic.shock 40% mortality
118
How to assess volume status
VS- narrow pulse pressure with low systolic
Capillary refill, skin turgor, skin warm/cold, clammy/dry
Central line and measure CVP and SvO2 (high venous O2 means blood bypassing lots of.tissues and O2 not being extracted)
Beside ultrasound-EF and size of chambers and IVC
119
Septic shock
Sepsis (lactate >2) with hypotension requiring pressure to maintain MAP >65 (MAP doesn't change in pregnancy)
Must volume replete before starting pressors or will cause vasoconstriction and worsening end organ damage.
Pressor of choice for septic shock norepi and must have arterial line.
120
Goals of sepsis.treatmemt
```
CVP 8-12
MAP >65
SvO2 >70%
Normal lactate level
Urine output>0.5ML/KG/HR
```
121
Maternal long QT
>480
Meds contraindicated: azithromycin/erythromycin, celexa, Cipro, flecanaide, haldol, methadone, zofran, propofol
Relative: buprenorphine, ephedrine, fluoxetine, furosemide, hydroxy chloroquine, Imodium, levaquin, reglan, bactrim, oxytocin
122
Renal transplant
6% rejection I'm pregnancy, same as non pregnant
Acute rejection-pain, fever, worsening labs
Overall no impact from pregnancy if no HTN and Cr<1.5
Test CMV/toco q trimester
No IUD due to immunosuppressant meds
123
Hep c
Indication for screen:
IV drug use, unprofessional tattoo, jail, dialysis, other STI, persistent high ALT
5% risk vertical transmission, if HIV+ then 44% risk
Need to check genotype
50-89% chronic infection
Chronic infection risks B cell lymphoma, cryoglobulinemia, HCC or cirrhosis MCC liver transplant
Treatment not in pregnancy causes multiple anomalies, wait 6 months before getting pregnant
