Other medical complications of pregnancy

Question 1

Hyperemesis gravidarum:

Answer 1

Persisting past wk 16

Very common in setting of molar pregnancy (document IUP!)

Question 2

Management of Hyperemesis gravidarum:

Answer 2

Maintain FEN/GI status! 
Can get hypoCl, hypoK, met acidosis 
Use NS + D5W
Can use antiemetics safely
Also B12 supplementation
Small frequent meals

Question 3

Seizure disorders:

Answer 3

Increase in pregnancy
Watch doses (increased GFR → faster clearance)
Phenobarb / primidone / phenytoin = folate antagonists → NTD risk
Valproic acid → NTDs too

Question 4

Management of seizure disorders

Answer 4

Take lots of folate prior to pregnancy, follow AFP, may or may not decide to switch (to single AED, lowest possible dose) - but seizures are bad for baby too

Question 5

Maternal cardiac disease:

Answer 5

Remember 50% CO increase.

Highest risk with primary pulmonary HTN, Eisenmenger physiology, severe MS / AS, or Marfan

Remember big fluid shifts PP (autotransfusion) → big demand on heart

Question 6

Management of maternal cardiac dx

Answer 6

ACEi, coumadin contraindicated in pregnancy, diuretics risky too.

May do assisted vaginal delivery to avoid valsalva - better than C/S results.

Hx MI: get baseline ECG

Question 7

Eisenmenger syndrome / pulmHTN

Answer 7

Really bad, up to 50% mortality, especially postpartum 2-4 wks (follow closely!

Eisenmenger: from R → L shunts (PDA, VSD).

Question 8

Valvular disease management:

Answer 8

SBE (subacute bacterial endocarditis) ppx during labor if valuvular disorder

Consider fixing MS/AS 1 yr prior to pregnancy. If really bad, may even do it while pregnant!

Question 9

Valvular disease

Answer 9

AS sx may get better early in pregnancy (as SVR decreases, less afterload)

MS pts may not be able to meet increased CO → CHF sx!

Mitral valve prolapse: small % of women with sx (anxiety, palpitations, atypical chest pain, and syncope).

Question 10

Management of Mitral valve prolapse

Answer 10

If pt has sx, beta-blockers are given to decrease sympathetic tone, relieve chest pain and palpitations, and reduce the risk of life-threatening arrhythmias.

Question 11

Marfan syndrome risk

Answer 11

Watch out for aortic dissection / rupture

Question 12

Marfan syndrome management

Answer 12

Should be on beta blockers & not exert self during pregnancy

Question 13

Peripartum cardiomyopathy:

Answer 13

Dilated cardiomyopathy before / during / after delivery

EF drops to 20-40%

Question 14

Management of peripartum cardiomyopathy

Answer 14

Manage with diuretics, digoxin, vasodilators like HF pt.
If > 34wks, deliver
If earlier, BMZ → check lung maturity

Question 15

Maternal renal disease:

Answer 15

Pregnancy can make it worse
Higher risk PEC.
Screen qtrimester with 24h urine for Cr/prot Antenatal testing from 32-34 wks onward
If s/p transplant, may need to increase meds to avoid rejection (higher Vd- volume of distribution)

Question 16

Maternal coagulopathies

Answer 16

Pregnancy → extra coagulable. mechanism not precisely known.

Higher risk pelvic vain thrombus 2/2 IVC compression).

Question 17

Superficial vein thrombosis presentation:

Answer 17

Painful, visible venous cord.

Question 18

Superficial vein thrombosis Rx:

Answer 18

Warm compress / analgesic (won’t cause PE) and watch for si / sx of DVT/PE

Question 19

DVT management

Answer 19

Treat with IV heparin → subQ heparin for rest of pregnancy.

No coumadin → nasal hypoplasia, skeletal problems

Question 20

PE management

Answer 20

Get EKG, spiral CT
Rx IV heparin → subQ heparin / LMW heparin
Will switch to unfractionated heparin @ 36 wks - shorter half life, so can d/c if presents to L&D

Can switch to Coumadin x 6mo postpartum

If unstable / massive, consider tPA / thrombectomy

Question 21

Maternal thyroid disease: Grave’s disease Rx

Answer 21

Methimazole (MMI) and propylthiouracil (PTU) Depends on practitioner, PTU is classic but more using MMI now

Question 22

Maternal thyroid disease: Hashimoto’s Rx

Answer 22

Levothyroxine

Question 23

SLE:

Answer 23

Early pregnancy: high risk loss in 1st/2nd trimester 2/2 placental thrombosis, esp if antiphospholipid Ab

Later pregnancy: also can lose 2/2 thrombosis. Antenatal testing @ 32wks onwards. Higher risk PEC

Question 24

Lupus flares

Answer 24

Can look like PEC, but have low complement.

Question 25

Treatment of lupus flares

Answer 25

If flaring, try high dose steroids → cyclophosphamide if that doesn’t work If PEC, deliver.

Question 26

Neonatal problems in SLE

Answer 26

Can get irreversible congenital heart block 2/2 anti-Ro (and anti-La, but more Ro) antibodies which cross-react with fetal cardiac conduction system. Screen for anti-Ro at first visit; interventions vary.

Question 27

Substance abuse:

Answer 27

``` Alcohol Caffeine Cigarettes Cocaine Opiates ```

Question 28

Fetal alcohol syndrome, # of drinks to put at risk

Answer 28

FAS possible with > 2-5 drinks / day

Question 29

Sequelae of fetal alcohol syndrome

Answer 29

Growth retardation, CNS effects, abnormal facies, cardiac defects, etc.

Question 30

Treatment of alcohol withdrawal in pregnancy

Answer 30

Try barbituates instead of benzos (less teratogenic)

Question 31

Caffeine

Answer 31

> 1 cup coffee (150 mg) may increase miscarriages

Question 32

Cigarettes

Answer 32

a/w SAB, preterm birth, placental abruption, LBW risk, also higher risk SIDS. Stop!

Question 33

Cocaine

Answer 33

a/w placental abruption, IUGR, preterm birth.

Question 34

Opiates:

Answer 34

Heroin, methadone most common. No teratogenicity. Risk is with withdrawal → put on NAS (neonatal abstinence syndrome) protocol with tincture of opium, etc for baby.

Question 35

Asthma in pregnancy chronic Rx

Answer 35

Short-acting beta agonists, then inhaled corticosteroids or cromolyn, then theophylline.

Question 36

Asthma in pregnancy acute Rx

Answer 36

Subq terbutaline, systemic corticosteroids.

Question 37

Pruritis gravidarum:

Answer 37

Mild variant of intrahepatic cholestasis of pregnancy; retain bile salt → dermis deposits → pruritis Use antihistamines / topical emollients initially, then can try cholestyramine → ursodeoxycholic acid if really bad.

Question 38

If appendicitis suspected

Answer 38

Get a graded compression ultrasound (best for eval - CT has lots of radiation)

Question 39

Depression

Answer 39

``` Paxil (Paroxetine) is class D Increased risk fetal cardiac malformations & persistent pulmonary HTN ```