Medical Cx of Pregancy Flashcards
(124 cards)
1
Q
Adverse consequences of hypoxic heart disease include
A
miscarriage, fetal death, preterm
delivery, and increased perinatal morbidity and mortality
2
Q
The most common acquired lesion in pregnancy is
A
rheumatic heart disease
3
Q
The most common rheumatic heart disease is _____
A
mitral stenosis
4
Q
The most common congenital lesions are
A
atrial (ASDs) and ventricular septal defects (VSDs).
5
Q
The most common cyanotic congenital heart disease
in pregnancy is ________
A
tetralogy of Fallot.
6
Q
Diseases with high Maternal MR
A
High maternal mortality (25–50% risk of death): pulmonary hypertension,
Eisenmenger’s syndrome, Marfan syndrome with aortic root >40 mm diameter, and
peripartum cardiomyopathy
7
Q
What condition
This condition is characterized by pulmonary hypertension and a bidirectional intra-cardiac shunt.
The normal decrease in systemic vascular resistance (SVR) in pregnancy places the patient at risk for having the pulmonary vascular resistance (PVR) exceed the SVR
A
Eisenmenger syndrome
8
Q
What condition
This is an autosomal dominant connective tissue disorder. In pregnancy, if the aortic root diameter is >40 mm, the risk of aortic dissection is high, placing the patient at a 50% mortality
risk.
A
Marfans
9
Q
In this condition, the patient has no underlying heart disease, but develops idiopathic biventricular
cardiac decompensation between the last few weeks of pregnancy and the first few months postpartum
A
Peripartum cardiomyopathy
10
Q
New York Heart Association (NYHA) functional classifications of heart disease in pregnancy
A
- Class I—no signs or symptoms of cardiac decompensation with physical activity
- Class II—no symptoms at rest, but minor limitations with activity
- Class III—no symptoms at rest, but marked limitations with activity
- Class IV—symptoms present at rest, increasing with any physical activity
11
Q
General Principles in Pregnancy Management of Rheumatic Mitral Heart Disease
A
- Minimize tachycardia.
* Minimize excessive intravascular volume.
12
Q
Intrapartal Mx of RHD
A
Aim for vaginal delivery, left lateral rest, monitor intravascular volume, administer oxygen, reassurance, sedation, SBE prophylaxis, epidural, no pushing, elective
forceps to shorten the second stage of labor, possible arterial line and pulmonary artery catheter (if Class III or IV status).
13
Q
Postpartum Mx of RHD
A
Watch closely for postpartum intravascular overload caused by sudden emptying of uterine venous sinuses after placental delivery
14
Q
Increased thyroid blood flow leads to ______
Increased glomerular filtration rate (GFR) in pregnancy enhances ________
A
thyromegaly.
iodine excretion, lowering plasma iodine concentrations.
15
Q
_____ causes an increase in liver-produced thyroid binding globulin (TBG), thus increasing total T3 and T4.However, free T3 and T4 remain unchanged
A
Estrogen
16
Q
Fetal thyroid function begins as early as _____
A
12 weeks with minimal transfer of T3 or T4 across the placenta.
17
Q
Cx of uncontrolled hyperthyroidism
A
it is associated with increased spontaneous abortions, prematurity, intrauterine growth retardation (IUGR), and perinatal morbidity and mortality.
18
Q
_______ is a life-threatening hypermetabolic state presenting with pyrexia, tachycardia, and severe dehydration
A
Thyroid storm
19
Q
This is the most common kind of hyperthyroidism in pregnancy.
A
Graves disease
20
Q
It is mediated by autoimmune production of ________ that drives thyroid hormone production independent of thyrotropin (TSH).
A
thyrotropin-receptor antibodies
TSHR-Ab
21
Q
TSHRAb can cross the placenta, potentially causing ________
A
fetal hyperthyroidism.
22
Q
Dx of Graves
A
The diagnosis is confirmed by elevated free T4 and TSHR-Ab, as well as low TSH
in the presence of clinical features described above.
23
Q
Graves
____is an FDA pregnancy category D so
should not be used in the first trimester, though it is acceptable in the second and third.
A
Methimazole
24
Q
Graves
_______ has a risk of liver failure (rare) so it should be used only in the first trimester.
A
PTU
25
Graves
_______ is primarily indicated when antithyroid medical therapy fails and is ideally performed in the second trimester.
Subtotal thyroidectomy
26
Graves in Pregnancy
______ is contraindicated because it can cross the placenta, destroying the fetal thyroid.
Thyroid ablation with radioactive iodine (I131)
27
This condition is most commonly a primary thyroid defect and often results in anovulation
and infertility
Hypothyroidism
28
Management of Hypothy.
Increase supplemental thyroid hormone by 30% in pregnancy
29
MCC of Hypothy
Hashimoto’s thyroiditis
30
Cx of Hypothy
Anovulation, spontaneous
| abortion
31
Sz rates during pregnancy
Up to 25% of these women will experience deterioration of seizure control during pregnancy, with 75% seeing no change.
32
T or F,
The more severe the disorder, the more likely it will worsen
T
33
Seizure medication clearance may be
| _________
enhanced by higher hepatic microsomal activity, resulting in lower blood levels.
34
Effect of anticonvulsants on fetus and infant
Congenital malformation rate is increased from 3% to >10%.
35
Maternal phenytoin use is associated with neonatal deficiency of ________
vitamin K-dependent clotting factors: II, VII, IX, and X.
36
Sz DO in pregnancy
Ensure ________before conception and during embryogenesis to minimize neural tube defects.
extra folic acid supplementation
37
What screening to do during pregnancy
Anomaly screening. Offer triple-marker screen and second trimester sonography to
identify neural tube defects (NTDs) or other anomalies
38
Dx
A pregnant woman is unable to maintain fasting (FBS) or postchallenge glucose
values in the normal pregnant range before or after a standard 100-g glucose challenge.
DM
39
Prevalence of glucose intolerance in pregnancy is_______
2–3%.
40
Pathophysio of DM in pregnancy
Pathophysiology involves the diabetogenic
| effect of human placental lactogen (hPL), placental insulinase, cortisol, and progesterone.
41
______ is juvenile onset, ketosis prone, insulin-dependent diabetes caused by pancreatic islet cell deficiency
Type 1 DM
42
______is adult onset, ketosis resistant, non–insulin-dependent diabetes caused by
insulin resistance
Type 2 DM
43
DM
Screening is performed on all pregnant women 24–28 weeks’ gestation when the
_______
anti-insulin effect of hPL is maximal
44
DM screening in pts with high risk
On patients with risk factors it is performed on the _______
first prenatal visit then repeated at 24–28 weeks if initially negative.
45
_______ of
| patients with GDM can maintain glucose control with diet therapy
Eighty percent
46
DM
Home blood glucose monitoring. Patient checks her own blood glucose values at least
four times a day with target values of FBS _____ and 1 h after meal of ______
<90 mg/dL
<140 mg/dL
47
Total insulin units in pregnancy
actual body weight in kilograms × 0.8 (first trimester), 1.0 (second trimester), or 1.2 (third trimester)
48
How Insulin is given during pregnancy?
Insulin is divided with two thirds of total daily dose in morning (split into 2/3 NPH and
1/3 regular) and one third of total daily dose in evening (split into 1/2 NPH and 1/2 regular
49
T or F
Insulin is a large molecule and does not cross the placenta
t
50
_______ appears to cross the placenta minimally, if at all, and is being used for
patients with GDM who cannot be controlled by diet alone.
Glyburide
51
Oral hypoglycemic agents. These were contraindicated in the past because of concern that
they would cross the placenta and cause fetal or neonatal hypoglycemia
52
What to monitor in anterpartum for DM
Hemoglobin A1C
Renal status
Retinal status.
Home blood glucose monitoring
53
Preconception Anomaly Prevention
1. Anomaly risk. This risk can be minimized by ______
2. Folate supplementation._______a day, should be started 3 months prior to
conception
3. Euglycemia for 3 mos
lifestyle modification
Folic acid, 4 mg
54
Anomalies are mediated through hyperglycemia and are highest with poor glycemic control during______
embryogenesis
55
Most common fetal anomalies with overt DM are ___________
NTD and congenital heart disease.
56
An uncommon anomaly, but one highly specific for overt DM, is________
caudal regression syndrome.
57
DM Dx
Obtain a ________ at 16–18 weeks to assess for NTD as well as a______ at 18–20 weeks to look for structural anomalies
quadruple-marker screen
targeted ultrasound
58
If the glycosylated hemoglobin is elevated, order a ________ at 22–24 weeks to assess for congenital heart disease.
fetal echocardiogram
59
Monthly sonograms will assess fetal _________ (most commonly
| seen) or _____(seen with longstanding DM and vascular disease).
macrosomia
IUGR
60
DM
Fetal surveillance. Start weekly _______ and ________ at 32 weeks if
taking insulin, macrosomia, previous stillbirth, or hypertension.
NSTs and amniotic fluid index (AFIs)
61
Start NSTs and AFIs at
| _________ if small vessel disease is present or there is poor glycemic control
26 weeks
62
_______ is often delayed in fetuses of diabetic mothers, yet
| prolonging the pregnancy may increase the risk of stillbirth
Fetal maturity
63
The target delivery gestational age is ______ but may be necessary earlier in the presence of fetal jeopardy and poor maternal glycemic
contro
40 weeks,
64
```
The cesarean section rate in diabetic pregnancies approaches 50%
because of
1
2
3
```
fetal macrosomia, arrest of labor, and concern regarding shoulder dystocia.
65
IN GDM
Maintain maternal blood glucose levels between 80 and 100 mg/dL
using _______
5% dextrose in water and an insulin drip.
66
Neonatal Cx of GDM
• ____ caused by persistent hyperinsulinemia from excessive prenatal transplacental
glucose.
* _____ caused by failure to increase parathyroid hormone synthesis after birth.
* _____ caused by elevated erythropoietin from relative intrauterine hypoxia.
• ______ caused by liver immaturity and breakdown of excessive neonatal
red blood cells (RBCs).
• ___ caused by delayed pulmonary surfactant production
Hypoglycemia
Hypocalcemia
Polycythemia
Hyperbilirubinemia
Respiratory distress syndrome
67
Definition of anemia during pregnancy
A hemoglobin concentration of <10 g/dL during pregnancy or the puerperium
68
Dx of IDA
RBCs are microcytic and hypochromic. Hemoglobin <10 g/dL, MCV <80, RDW
>15
69
A pregnant woman needs 800 mg of elemental iron, of which 500
mg goes to ______ and 300 mg goes to the ________
expand the RBC mass
fetal-placental unit
70
RF for IDA
Chronic bleeding, poor nutrition, and frequent pregnancies.
71
Fetal effects of IDA
Increased IUGR and Preterm birth.
72
Tx of IDA
Treatment._______
Prevention. _______
FeSO4 325 mg po tid.
Elemental iron 30 mg per day.
73
This is a nutritional anemia resulting in decreased hemoglobin production.
Folate Deficiency Anemia
74
This is a nutritional anemia resulting in decreased hemoglobin production.
Folate Deficiency Anemia (FDA)
75
Folate stores in the body are usually enough for _____. Falling hemoglobin
values do not occur until complete depletion of folate stores.
90 days
76
RF for FDA
Chronic hemolytic anemias (e.g., sickle cell disease), anticonvulsant use (phenytoin,
phenobarbital), and frequent pregnancies
77
SSx of FDA
Findings may vary from none to general malaise, palpitations, and ankle edema.
78
Fetal Cx of FDA
Increased IUGR ,Preterm birth and NTD.
79
This is an inherited autosomal recessive disease resulting in normal production of abnormal globin chains
Sickle cell anemia
80
Sickle cell anemia
These are peripheral blood tests used to detect the presence or absence of
______ They do not differentiate between disease and trait
hemoglobin S.
81
A_______ will differentiate between SA trait (<40% hemoglobin S) or SS disease (>40% hemoglobin S).
hemoglobin electrophoresis
82
____ and _____ descent is the only significant risk factor for sickle
cell anemi
African and Mediterranean
83
With Sickle cell trait , the patient may have increased _______
urinary tract infections (UTIs) but pregnancy
| outcome is not changed.
84
With sickle cell disease the pregnancy may be complicated by increased
spontaneous abortions, IUGR, fetal deaths, and preterm delivery.
85
_______ is stimulated by estrogen in genetically predisposed women in the second half of pregnancy. Risk is increased with twins
Intrahepatic cholestasis
86
Intrahepatic Cholestasis of Pregnancy
The most significant symptom is ____
intractable pruritus on the palms and soles of the feet, worse at night, without specific skin findings.
87
Intrahepatic Cholestasis of Pregnancy
Laboratory tests show a mild elevation of bilirubin but diagnostic findings are _____
serum bile acids increased 10- to 100-fold.
88
Intrahepatic Cholestasis of Pregnancy
* _____ can be helpful in mild cases.
* _____has been used to decrease enterohepatic circulation.
Oral antihistamines
Cholestyramine
89
Intrahepatic Cholestasis of Pregnancy
* _____ can be helpful in mild cases.
* _____has been used to decrease enterohepatic circulation.
Oral antihistamines
Cholestyramine
90
Intrahepatic Cholestasis of Pregnancy
____ is the treatment of choice. Antenatal fetal testing should be initiated
at 34 weeks. Symptoms disappear after delivery.
Ursodeoxycholic acid
91
Maternal mortality rate is 20%. It is thought to
be caused by a disordered metabolism of fatty acids by mitochondria in the fetus, caused by deficiency in the long-chain 3-hydroxyacyl-coenzyme A dehydrogenase (LCHAD) enzyme.
Acute Fatty Liver
92
Acute Fatty Liver SSx
• Symptom onset is gradual, with nonspecific flulike symptoms including nausea,
vomiting, anorexia, and epigastric pain.
• Jaundice and fever may occur in as many as 70% of patients.
93
What are the unique Sx of Acute Fatty Liver
Hypoglycemia and increased serum ammonia are unique laboratory abnormalities.
94
UTI
The most common organisms are
gram-negative enteric bacteria with Escherichia coli the most frequent.
95
If not treated, 30% of cases will develop acute pyelonephritis
Asymptomatic Bacteriuria
96
Dx of Asymptomatic Bacteriuria
Made with a positive urine culture showing >100K colony-forming units (CFU) of
a single organism
97
Urgency, frequency, and burning are common.
If not treated, 30% of cases will develop acute pyelonephritis.
Acute Cystitis
98
Dx of Acute Cystitis
Made with a positive urine culture showing >100 K CFU of a single organism.
99
This is a UTI involving the upper urinary tract with systemic findings. This is one of the most common serious medical complications of pregnancy.
Acute Pyelonephritis
100
Acute Pyelonephritis Cx
Confirmed with a positive urine culture showing >100 K CFU of a single organism
101
The thrombophilias are a group of disorders that promote blood clotting,
because of either ______ or ______
an excess of clotting factors or a deficiency of anticlotting proteins that
limit clot formation
102
More than half of pregnant women who develop a pulmonary embolus or other VTE
have an underlying_______
thrombophilia
103
Inherited thrombophilias to test for:
```
Factor V Leiden (FVL) mutation, prothrombin
gene mutation (PGM) G2021 OA, protein C deficiency (PCD), protein S deficiency
(PSD), antithrombin deficiency (ATD)
```
104
One or more of the following 3 antiphospholipid antibodies must be positive on ≥2 occasions at least 12 weeks apart.
1
2
3
– Lupus anticoagulant
– Anticardiolipin antibody (lgG & IgM)
– Anti-b2-glycoprotein 1 (lgG & IgM)
105
VTE
Disadvantage of Unfractionated heparin (
cannot use orally, short half-life, needs monitoring with aPTT levels, heparin-induced osteopenia, heparin-induced thrombocytopenia (HIT)
106
VTE
• Low molecular weight heparin (LMWH) can be used antepartum & postpartum
– Advantages: _________
longer half-life, less need for monitoring with antifactor Xa levels
107
Advantages and disadv of Warfarin
– Advantages: oral administration, long half-life, inexpensive, OK for breast feeding
– Disadvantages: crosses placenta, needs monitoring with INR
108
Mx of VTE
Use_______ from first trimester to 36 weeks; then at 36 weeks transition to
______ until delivery
LMWH
UFH
109
Whom to give Prophylactic or intermediate-dose for VTE
* Low-risk thrombophilia with single VTE episode
| * High-risk thrombophilia without VTE episode
110
Whom to give Therapeutic dose for VTE
* High-risk thrombophilia with single VTE episode
| * Any thrombophilia with VTE in current pregnancy
111
MX of VTE Intrapartum
• Discontinue UFH during immediate peripartum interval to decrease risk of hemorrhage
and permit regional anesthesia
• Protamine sulfate can be used to reverse UFH effect
112
VTE risk increased _______in the first week postpartum
20-fold
113
VTE Tx
Resume anticoagulation______ after vaginal delivery and ____ after cesarean section
6 hours
12 hours
114
Clinical Criteria for Diagnosis / Indications for Laboratory testing for APAS
• Vascular thrombosis: 1 or more clinical thrombotic episodes (arterial, venous, or
small vessel)
• Pregnancy morbidity (unexplained): fetal demise: 1 or more at ≥10 weeks; consecutive
miscarriages: 3 or more at <10 weeks
115
Laboratory criteria: 1 or more of the following 3 anti-phospholipid antibodies must be positive on ≥2 occasions at least 12 weeks apart.
* Lupus anticoagulant
* Anticardiolipin antibody (lgG & IgM)
* Anti-132-glycoprotein I (lgG & IgM)
116
Antepartum anticoagulation in APAS
* APS without a thrombotic event: no heparin or only prophylactic heparin
* APS with a thrombotic event: prophylactic heparin
117
The mediating factor is frequently endothelial injury from traumatic delivery or cesarean
section.
THROMBOEMBOLISM
118
THROMBOEMBOLISM
Enhanced blood coagulability in pregnancy is due to increased factors________
II, VII, VIII, IX, and X.
119
Symptoms include localized pain and sensitivity. Signs include erythema,
tenderness, and swelling. Diagnosis is one of exclusion after ruling out DVT
Superficial Thrombophlebitis
120
T or F
Superficial thrombophlebitis does not predispose to thromboembolism but may mimic moresevere disease
T
121
DVT Tx
Treatment is full anticoagulation with IV heparin to increase PTT by 1.5 to 2.5 times the control value
122
DVT
No ______ is used antepartum because of teratogenicity concerns with the fetus. Thrombophilia workup should be performed.
warfarin
123
____ is a potentially fatal result of DVT in which emboli travel through the venous system to
the lungs
PE
124
_______ is the
| most definitive diagnostic method for DVT
Pulmonary angiography
