Medical Complications of Pregnancy

Question 1

Two most common causes of microcytic anemia in pregnancy?

Two most common causes of macrocytic (megaloblastic) anemia?

Answer 1

Microcytic Anemia

• -iron deficiency; thalassemia
• -1st investigation is therapeutic Fe trial

Macrocytic Anemia
–folate deficiency, B12 deficiency

Question 2

Thalassemia

• -microcytic anemia
• -Hb electrophoresis helps differentiate

Elevated A2 Hb level?
Elevated HbF level?

Answer 2

Thalassemia

• -microcytic anemia
• -Hb electrophoresis helps differentiate

Beta thalassemia
–Elevated A2 Hb level

Alpha thalassemia
–Elevated HbF level

Question 3

• -dark colored urine after taking antibiotic for infxn
• -anemia (low Hb)
• -jaundice, fatigue
• -African-American woman

Dx?

Answer 3

G6PD Deficiency

Other hemolytic processes include HELLP Syndrome, malaria, autoimmune hemolytic anemia, sickle cell

Question 4

Dx?

Maternal fever + 1 of

• -elevated maternal WBC count
• -uterine tenderness
• -maternal/fetal tachycardia
• -purulent/malodorous vaginal discharge

Associated with preterm and prolonged ROM

Tx: 2nd or 3rd generation cephalosporin, or ampicillin + gentamicin + Delivery!

Answer 4

Chorioamnionitis

Maternal fever + 1 of

• -elevated maternal WBC count
• -uterine tenderness
• -maternal/fetal tachycardia

Associated with preterm and prolonged ROM

Tx: 2nd or 3rd generation cephalosporin, or ampicillin + gentamicin + Delivery!

Question 5

Management of Preterm Labor at less than 34 weeks:

1) Tocolytics to halt contractions
- -name 3 types

2) What drugs to accelerate fetal lung maturity?
3) What drug for neuroprotection?

Answer 5

Management of Preterm Labor at less than 34 weeks:

1) Tocolytics to halt contractions
- -Beta adrenergic agonists; Ca chnl blocker; NSAID

2) Corticosteroids to accelerate fetal lung maturity
- -eg, Betamethasone

3) MgSO4 for neuroprotection

Question 6

Management of (Pre)eclampsia

1. Rx for seizure tx/prophylaxis?
2. Rx for HTN? (2)
3. Rx for fetal lung maturity if EGA 24-32 weeks
4. Vaginal delivery or C-section?

Answer 6

Management of (Pre)eclampsia

1. Mg sulfate
   - -seizure tx and prophylaxis
2. Hydralazine or Labetalol
   - -blood pressure control
   - -only administer if SBP > 160 or DBP > 110
3. Betamethasone
   - -fetal lung maturity
4. Vaginal delivery with induction of labor
   * except if obstetric indication for C-sec
   * except for maternal/fetal instability

**The ultimate tx is DELIVERY!

Question 7

maternal-fetal transmission of this virus can lead to deafness, cardiac abnormalities (eg, PDA), cataracts, and MR

Answer 7

Rubella (congenital rubella syndrome)

*MMR vaccine is a live virus vaccine. Thus, women should avoid becoming pregnant for one month after receiving MMR vaccine.

Question 8

1. full expulsion of all POC before 20 wks
2. partial expulsion of POC before 20 wks
3. no expulsion of products; vaginal bleeding, loss of fluid, and cervical dilation
4. vaginal bleeding before 20 wks, closed cervix, no expulsion of POC; presence of fetal cardiac activity
5. no vaginal bleeding; no fetal cardiac activity; retention of all POC; closed cervix

Answer 8

1. complete abortion
2. incomplete abortion
3. inevitable abortion
4. threatened abortion
5. missed abortion

Question 9

Hyperandrogenism in Pregnancy

1. ovarian tumor-like solid mass; may be bilateral; may produce androgens resulting in maternal and fetal hirsutism and viralization
2. cystic tumors; associated with high FSH and beta-hCG; associated with twins and molar pregnancies
3. solid ovarian mass; may be bilateral; mets from GI cancer with associated s/s

Answer 9

Hyperandrogenism in Pregnancy

1. Luteoma of Pregnancy
   - -ovarian tumor-like mass; may produce androgens resulting in maternal and fetal hirsutism and viralization
2. Theca Lutein Cyst
   - -cystic tumors; associated with high FSH and beta-hCG; associated with twins and molar pregnancies
3. Krukenburg Tumor
   - -solid ovarian mass; may be bilateral; mets from GI cancer; thus display s/s of GI cancer

Question 10

Acid-base status during pregnancy?
–re PaO2, PaCO2, HCO3

Acid-base status in hyperemesis gravidarum?

Acid-base status in diarrhea?

Answer 10

Pregnancy Acid Base

• -respiratory alkalosis with compensation
• -increased PaO2, decreased PaCO2 and HCO3

Hyperemesis Gravidarum
–hypochloremic metabolic alkalosis
(*loss of gastric acid –> alkalosis)

Diarrhea
–metabolic acidosis
(*loss of HCO3, anions)

Question 11

Post-partum woman with hx of vaginal bleeding during delivery that required blood transfusion. S/s of

1) hypopituitarism: eg, lactation failure
2) hypogonadism: eg, decreased pubic hair
3) hypothyroidism: eg, lethargy, weight gain, fatigue, dry skin, hyporeflexia

Dx?
Mechanism?

Answer 11

Sheehan’s Syndrome
–ischemic necrosis of anterior pituitary secondary to maternal hemorrhage during delivery

Features:

hypopituitarism: eg, lactation failure
hypogonadism: eg, decreased pubic hair
hypothyroidism: eg, lethargy, fatigue, dry skin, hyporeflexia

Question 12

Pathogenesis of Rh Alloimmunization:
Rh(-) mother is immunized by Rh(+) fetal RBCs in first pregnancy. Mother develops anti-Rh(D) ABs (IgG). These ABs cross placenta to damage Rh(+) fetus in subsequent pregnancies.

To prevent maternal alloimmunization, administer RhoGAM at how many weeks gestation, and when post-partum?

Test for presence of maternal anti-D ABs in subsequent pregnancies.

Name of disease that results in the fetus?

Answer 12

To prevent alloimmunization:
–RhoGAM at 28 weeks gestation, and within 72 hours post-partum
(*RhoGAM is anti-D immune globulin; prevents development for anti-D ABs)

Erythroblastosis Fetalis

• -hydrops fetalis: severe edema due to CHF caused by hemolytic anemia
• -hepatosplenomegaly
• -extramedullary hematopoiesis in liver, spleen, LN
• -kernicterus (bilirubin encephalopathy)

Question 13

Hyperemesis Gravidarum
(+) pregnancy; severe, persistent n/v; often dehydration and electrolyte abnormalities

Often associated with increased placental mass
–Name 2 conditions.

Tx:

• -rehydration
• -antiemetics: Compazine, Phenergan, Tigan, Reglan
• -other: ginger; B12

Answer 13

Hyperemesis Gravidarum
(+) pregnancy; severe, persistent n/v; often dehydration and electrolyte abnormalities

Often associated with increased placental mass
–multifetal gestation, molar pregnancy

Tx:

• -rehydration
• -antiemetics: Compazine, Phenergan, Tigan, Reglan
• -other: ginger, B12

Question 14

Complete Molar Pregnancy

• -s/s include vaginal bleeding in early pregnancy, passage of molar vesicles, hyperthyroidism, hyperemesis gravidarum, preeclampsia
• -trophoblastic proliferation with diffuse swelling of chorionic villi
• -Labs: extremely high B-hCG ( > 100,000)
• -Imaging: “snowstorm pattern” on pelvic ultrasound; bilateral multilocular ovarian cysts (theca lutein); absent fetus

Pathogenesis? re: fertilization
Uterine size compared to EGA?
Weeks to normalization of B-hCG?

Answer 14

Complete Molar Pregnancy

• -fertilization of empty ovum by 1 sperm, which replicates itself (all chromosomes are paternal)
• -uterine size greater than EGA
• -avg time to normalization: 16 weeks

Question 15

Partial Molar Pregnancy

• -s/s include vaginal bleeding from miscarriage or incomplete abortion
• -Labs: normal or slightly elevated B-hCG
• -Imaging: fetal tissue present; fetal anomalies; IUGR; “swiss-cheese” appearance of anechoic spaces against chorionic villi

Pathogenesis? re: fertilization
Weeks to normalization of B-hCG?

Answer 15

Partial Molar Pregnancy

• -normal ovum fertilizaed by 2 sperm; triploid
• -avg time to normalization: 8 weeks

Question 16

Two signs of magnesium toxicity?

Tx?

Answer 16

Magnesium Toxicity

1. loss of DTRs
2. respiratory depression

Tx: calcium gluconate (and stop Mg)

Question 17

Sheehan’s Syndrome
–ischemic necrosis of anterior pituitary secondary to maternal hemorrhage during delivery

S/S include lactation failure, sexual hair loss, hypotension, anorexia, amenorrhea, hyponatremia

Name 6 hormones produced by the AP.

Answer 17

Sheehan’s Syndrome
–ischemic necrosis of anterior pituitary secondary to maternal hemorrhage during delivery

–S/S include lactation failure, sexual hair loss, hypotension, anorexia, amenorrhea, hyponatremia

Hormones produced by AP:
Prolactin
FSH, LH
TSH
Growth Hormone
ACTH

Question 18

Preeclampsia

1. BP cutoffs?
   - -SBP, DBP, at what EGA?
2. urine protein/creatinine ratio?

Tx?

• -seizure prophylaxis?
• -anti-HTN? (IV-2; oral-1)

Answer 18

Preeclamspia

1. SBP > 140 or DBP > 90 at EGA > 20wks
2. protein/creatinine ratio > 0.3

Tx:

• -seizure prophylaxis: MgSO4
• -antiHTN: labetolol, hydralazine (IV); nifedipine (oral)

Question 19

Preeclampsia with severe features

1. BP cutoffs?
2. serum creatinine?
3. thrombocytopenia?
4. elevated transaminases
5. pulmonary edema
6. new onset visual or cerebral symptoms

Answer 19

Preeclampsia with severe features

1. SBP > 160 or DBP > 110 at EGA > 20wks
2. serum creatinine > 1.1
3. thombocytopenia
4. elevated transaminases
5. pulmonary edema
6. new onset visual or cerebral symptoms

Question 20

Distinguishing Lupus vs Preeclampsia
Common Features: HTN, proteinuria, edema

Lupus

• -ANA ab’s; low C3 and C4
• -urine RBC casts
• -malar rash

Tx for lupus in pregnancy?

Lupus carries higher risk of pregnancy loss. What is the pathogenesis? Tx?

Answer 20

Lupus in Pregnancy

• -tx: high dose corticosteroids
• -pathogenesis of pregnancy loss: placental thrombosis
• -prophylax with subQ heparin, low dose aspirin

Question 21

Abx in Pregnancy

Recommended abx (3)

1. Penicillin?
2. Cephalosporin?
3. Other?

Contraindicated:

1. class associated with bone deformities, arthropathies
2. interfere with bone and tooth development; causes grey tooth discoloration
3. interferes with folic acid metabolism (1st trimester); increase risk of kernicterus (3rd trimester)

Answer 21

Abx in Pregnancy

Recommended:

1. Amoxicillin
2. Cephalexin
3. Nitrofurantoin

Contraindicated:

1. fluoroquinolones
   - -bone deformities, arthropathies
2. tetracyclines
   - -bone and tooth development; grey teeth discoloration
3. trimethoprim-sulfamethoxazole
   - -interfere with folic acid metabolism (1st trimester)
   - -may increase risk of kernicterus (3rd trimester)

Question 22

How often does b-hCG double in normal pregnancy?

At what b-hCG levels can transvaginal US detect viable intrauterine pregnancy?

Answer 22

Normal pregnancy: b-hCG doubles every 48 hrs

1500-2000

Question 23

Amniotic Fluid Index

1. Oligohydramnios?
2. Polyhydramnios?

Answer 23

AFI

Oligohydramnios

• -AFI less than 5
• -associated with congenital anomalies (especially genitourinary) and growth restriction

Polyhydramnios

• -AFI greater than 20 or 25
• -associated with diabetes, hydrops, multiple gestation, GI tract obstruction

Question 24

HEELP Syndrome
Acute Fatty Liver of Pregnancy

1. two unique lab values in AFLP?
2. AFLP is caused by disordered metabolism of fatty acids by fetal mitochondria due to deficiency of what enzyme?
3. Management of both conditions?

Answer 24

1. AFLP
   - -hypoglycemia
   - -increased serum ammonia
2. AFLP
   - -deficiency in LCHAD enzyme
3. HEELP / AFLP
   - -prompt delivery is indicated

Question 25

Explain how fetal hyperinsulinemia can result in polycythemia in a neonate born to a mother with GDM?

Answer 25

fetal hyperinsulinemia --> increased metabolic demand --> fetal hypoxia --> fetal erythropoiesis --> polycythemia

Question 26

1. HSV - -What type of delivery if lesions are present? - -Which is more dangerous during pregnancy - primary infection or recurrent infection? 2. What virus attacks fetal RBCs, leading to hemolytic anemia, hydrops, and death? 3. What viral infection is usually asymptomatic in the mother, and in the fetus is manifested by hepatosplenomegaly, thrombocytopenia, jaundice, cerebral calcifications, chorioretinitis, and interstitial pneumonitis?

Answer 26

1. HSV - -if lesions present --> C-section - -primary infection has higher risk of fetal transmission * recurrent infxn displays IgG 2. Parvovirus B19 - -fetal anemia - -midtrimester and later infections associated with hydrops 3. Cytomegalovirus - -asymptomatic in mother - -hepatosplenomegaly, thrombocytopenia, jaundice, cerebral calcifications, chorioretinitis, interstitial pneumonitis - -late complications include MR, sensorineural hearing loss, neuromuscular disorders

Question 27

1. viral infection in fetus; in infant, syndrome includes deafness, cardiac abnormalities, cataracts, MR 2. Neonatal infection with chlamydia; s/s include conjunctivitis and chlamydial pneumonia - -Tx of chlamydia during pregnancy? (3 options) 3. Toxoplasma tx - -in mother? - -in fetus? (2)

Answer 27

1. Rubella - -Congential Rubella Syndrome: deafness, cardiac abnormalities (eg, PDA), cataracts, MR 2. Chlamydia - -pregnancy tx: amoxicillin, azithromycin, erythromycin 3. Toxoplasma tx - -mother: spiramycin - -fetus: pyrimethamine, sulfadiazine * administer with folic acid due to bone marrow suppression

Question 28

HTN in Pregnancy 1. BP greater than 140/90 prior to conception or EGA 20 wks; no end organ damage or proteinuria 2. BP greater than 140/90 after EGA 20 wks; no end organ damage or proteinuria 3. BP greater than 140/90 after EGA 20 wks; (+) end organ damage or proteinuria 4. BP greater than 140/90 after EGA 20 wks; (+) end organ damage or proteinuria; seizures 5. BP greater than 140/90 prior to conception or EGA 20 wks; (+) end organ damage or proteinuria

Answer 28

HTN in Pregnancy 1. Chronic hypertension 2. Gestational HTN 3. Preeclampsia 4. Eclampsia 5. Chronic HTN with superimposed preeclampsia

Question 29

Gestational Diabetes Pathophysiology is related to metabolism of large carbohydrate boluses; not baseline carbohydrate intolerance Which hormone is responsible for insulin resistance? Fasting levels should always be less than? Screening test: 50g glucose load --1h: 140 or less Confirmatory test: 100g, 3hr GTT - -fasting: 95 or less - -1h: 180 or less - -2h: 155 or less - -3h: 140 or less

Answer 29

Gestational Diabetes - -hPL --> insulin resistance - -manifests in 2nd/3rd trimesters RFs: increased maternal age, obesity, diabetes family hx, previous infant weighing more than 4000g, previous stillborn Screening test: 50g glucose load --1h: 140 or less Confirmatory test: 100g, 3hr GTT - -fasting: 95 or less - -1h: 180 or less - -2h: 155 or less - -3h: 140 or less Maintenance of blood sugar target values: - -fasting less than 90 - -1 hr PP less than 140 - -2 hr PP less than 120

Question 30

For an average woman, what is the expected amount of weight gain during pregnancy?

Answer 30

Normal woman: 20-30 pounds * Overweight woman: 15-25 pounds * Underweight woman: 28-40 pounds

Question 31

In a newborn/infant... 1. chorioretinitis, hydrocephalus, intracranial calcifications 2. intermittent fever, osteitis or osteochondritis, mucocutaneous lesions, lymphadenopathy, hepatomegaly, persistent rhinitis 3. deafness, cataracts, cardiac defects

Answer 31

Congenital Infections 1. Toxoplasmosis - -chorioretinitis, hydrocephalus, intracranial calcifications - -look for hx of maternal exposure to cat feces, infected meat, unpasteurized goat's milk 2. Syphilis - -intermittent fever, osteitis or osteochondritis, mucocutaneous lesions, lymphadenopathy, hepatomegaly, persistent rhinitis 3. Rubella - -deafness, cataracts, cardiac defects (eg, PDA)

Question 32

What cardiac defect classically becomes symptomatic during pregnancy?

Answer 32

Mitral stenosis *mitral stenosis --> L atrial overload --> A-Fib, pulmonary edema

Question 33

Hepatitis C and Pregnancy 1. Factors that increase risk of vertical transmission include high viral load and what other disease? 2. Vaccinations? (2) 3. Complications: GDM, cholestasis of pregnancy, preterm delivery 4. Breastfeeding?

Answer 33

Hepatitis C and Pregnancy 1. RFs for vertical transmission: high viral load; * C-section not protective; do not use scalp electrodes 2. Vaccinate mother against HAV, HBV (inactivated, killed vaccines) 3. Complications: GDM, cholestasis of pregnancy, preterm delivery 4. Breastfeeding OK

Question 34

Management of Spontaneous Abortion 1. Threatened AB - -expectant mgmt 2. Inevitable, Incomplete, or Missed AB - -hemodynamically stable? - -hemodynamically unstable: DandC 3. Septic AB - -cultures - -broad spectrum abx - -surgical evacuation

Answer 34

Management of Spontaneous Abortion 1. Threatened AB - -expectant mgmt 2. Inevitable, Incomplete, or Missed AB - -hemodynamically stable: expectant, prostaglandins, or surgical (pt preference) - -hemodynamically unstable: DandC 3. Septic AB - -cultures - -broad spectrum abx - -surgical evacuation

Question 35

Which ABs does each blood type possess? 1. A 2. B 3. AB 4. O

Answer 35

1. A -- ab's against B 2. B -- ab's against A 3. AB -- no ab's 4. O -- ab's against A and B *HDN can be seen in type O mother who has type A or type B baby. This form of HDN is mild; neonatal jaundice treated with phototherapy.

Question 36

Diabetes Screening in Pregnancy - -done at 24-28 weeks for average risk - -done ASAP if high risk Screening test: 1 hr, 50g oral glucose load --What is the cutoff for normal value? Diagnostic test: 3hr, 100g oral glucose load - -Normal fasting level? - -Normal 1 hr level? - -Normal 2 hr level? - -Normal 3 hr level?

Answer 36

Diabetes Screening in Pregnancy - -done at 24-28 weeks for average risk - -done ASAP if high risk Screening test: 1 hr, 50g oral glucose load --less than 140 Diagnostic test: 3hr, 100g oral glucose load - -fasting less than 95 - -1 hr less than 180 - -2 hr less than 155 - -3 hr less than 140 GDM - 2 or more abnormal values

Question 37

Thyroid Physiology in Pregnancy Normal thyroid function in pregnancy 1. What hormone causes increased total T3-T4? 2. TSH levels? 3. What hormone causes increased TBG? 4. free T3-T4 levels? Hypothyroidism in Pregnancy - -requires higher dose of supplemental TH - -pregnancy is hyper-metabolic state; hypothyroid can't keep up

Answer 37

Thyroid Physiology in Pregnancy Normal thyroid function in pregnancy 1. increased total T3-T4 due to increased b-hCG 2. Slightly decreased TSH due to high total T3-T4 3. increased TBG due to increased estrogen 4. high-normal free T3-T4 due to binding by TBG

Question 38

DDx: Liver Disorders in Pregnancy 1. intense pruritus; elevated bile acids, bilirubin, AST/ALT 2. HTN, proteinuria, RUQ pain, elevated LDH, elevated LFTs, thrombocytopenia 3. malaise, n/v, RUQ pain, jaundice, encephalopathy, hypoglycemia, hyperammonemia 4. red papules within striae

Answer 38

DDx: Liver Disorders in Pregnancy 1. Intrahepatic Cholestasis of Pregnancy - -intense pruritus, esp at palms, soles; worse at night - -elevated bile acids, bilirubin, AST/ALT - -2nd or 3rd trimester - -tx: ursodeoxycholic acid 2. HELLP Syndrome - -preeclampsia, n/v, RUQ pain - -hemolysis, elevated LFTs, thrombocytopenia 3. AFLP - -malaise, n/v, RUQ pain, ascites, jaundice, encepahlopathy, coagulopathy, AKI - -hypoglycemia, hyperammonemia 4. Pruritic urticarial papules and plaques of pregnancy (PUPP) - -red papules and plaques within striae; sparing around umbilicus; may extend into extremities, but rarely involves palms, soles, or face

Question 39

UTI in Pregnancy Screening in what trimester? Management - -medication for 5-7 days? - -med for 3-7 days? - -single dose med?

Answer 39

UTI in Pregnancy --1st trimester screening (12-16 weeks) Management - -Nitrofurantoin for 5-7 days - -Amoxicillin or Amoxicillin-Clavulanate for 3-7 days - -Fosfomycin single dose * hospitalization and IV abx for acute pyelonephritis - -meropenem, beta-lactams

Question 40

Tiers of asthma tx in pregnancy 1. Beta agonist? 2. Inhaled corticosteroids; cromolyn sodium 3. Theophylline Acute asthma: - -subQ ? - -systemic corticosteroids

Answer 40

Tiers of asthma tx in pregnancy 1. Albuterol - beta agonist 2. Inhaled corticosteroids; cromolyn sodium 3. Theophylline Acute asthma: - -subQ terbutaline - -systemic corticosteroids