Varney's Ch 24: Medical Complications in PREG

Question 1

What is the collective term for Type 1 and Type 2 Diabetes?

Answer 1

PGDM (pregestational diabetes mellitus)

Question 2

Which types (2) of diabetes are forms of insulin resistance?

Answer 2

T2DM and GDM

Question 3

What are the 2 categories of GDM?

Answer 3

A1GDM-diet controlled GDM
A2GDM-medically controlled GDM

Question 4

Does insulin resistance increase or decrease throughout pregnancy?

Answer 4

Increases gradually and peaks in the late second to third trimester.

Question 5

Which hormones produced by the placenta increase cellular resistance to insulin resulting in a higher blood glucose in pregnancy?

Answer 5

hPL (human placental lactogen) and other diabetogenic hormones. Peaks at 26-28 weeks GA.

Question 6

Are both the fetus and placenta stimulated toward hypergrowth in GDM?

Answer 6

Yes

Question 7

T/F. The fetus produces more insulin in response to increased maternal glucose.

Answer 7

True

Question 8

T/F. GDM does not increase the chances for the infant to develop childhood obesity.

Answer 8

False. It increases chances for Type 1, Type 2, and metabolic syndrome.

Question 9

T/F. Gestational diabetes can cause fetal growth restriction.

Answer 9

False. It causes macrosomia.

Question 10

What are the complications related to GDM for the baby?

Answer 10

1. macrosomia=shoulder dystocia
2. neonatal hypoglycemia=NICU
3. neonatal jaundice=NICU
4. congenital heart defects

Question 11

What is the criteria and time frame for diagnosing PGDM (pregestational diabetes mellitus)?

Answer 11

Timing: Diagnosed in the first trimester or early second trimester.
Criteria:
1) HbA1c >6.5%
2) fasting >126, –OR–
3) 2-hour 75-gm >200 mg/dL

Question 12

What are the complications related to GDM for the mother?

Answer 12

1) preeclampsia
2) shoulder dystocia
3) cesarean birth

Question 13

What are the target levels for glucose during pregnancy?
1) Fasting,
2) 1-hr postprandial (after meal)
3) 2-hr postprandial (after meal)
4) HbA1c

Answer 13

1) Fasting <95
2) 1-hr <140
3) 2-hr <120
4) HbA1c <6%

Question 14

How much exercise is recommended for GDM?

Answer 14

30 mins of moderate intensity at least 5 days a week.

Question 15

What is the preferred medication for treatment of A2GDM?

Answer 15

Insulin at 0.7-1.0 unit/kg daily divided into long-acting or intermediate-acting doses with short-acting doses throughout the day.

Question 16

Does insulin cross the placenta?

Answer 16

No

Question 17

Does Metformin cross the placenta

Answer 17

Yes.

Question 18

What is the dosing of Metformin for GDM

Answer 18

1st week - 500 mg nightly
After - increase to 500 mg twice daily

Question 19

At what weeks postpartum will you assess for T2DM for those with GDM?

Answer 19

Week 4-12 PP and Lifelong screening every 3 years.

Question 20

At what weeks gestation would you provide a ultrasounds for GDM patients?

Answer 20

28, 32, and 36 weeks for fetal growth, polyhydramnios, and macrosomia.

Question 21

What screening elements are included in the first trimester for patients with PGDM?

Answer 21

1. HbA1c
2. thyroid function
3. electrocardiogram
4. eye exam - retinopathy
5. 24 hr urine collection

Question 22

What are the recommendations for women with PGDM regarding folic acid and ASA?

Answer 22

1) 400 mcg folic acid to reduce the chances of neural tube defects that are increased with PGDM.
2) Aspirin - 81 mg daily after 12 weeks to reduce preeclampsia risk.

Question 23

A2GDM ultrasounds are recommended how often after 32 weeks?

Answer 23

Twice weekly.

Question 24

For T1DM mothers, are insulin requirements higher or lower in the first trimester?

Answer 24

Lower, creating an increased risk of hypoglycemia.

Question 25

T/F Fetuses of women with diabetes develop respiratory maturity later than those without diabetes?

Answer 25

True, which increases risk of respiratory distress if delivered early.

Question 26

When is induction recommended for a diabetic pregnant mother?

Answer 26

39.0 - 39.6 weeks GA

Question 27

At what week does a qualifying pregnant woman take aspirin for preeclampsia prevention?

Answer 27

12 weeks.

Question 28

Hypertension is the leading cause of postpartum readmission. T or F?

Answer 28

True

Question 29

How is hypertension diagnosed in pregnancy?

Answer 29

1. sitting for at least 10 mins 2. BP >140/90 x 2 (>4 hours apart)

Question 30

What BP is considered a severe-range and is a medical emergency?

Answer 30

BP >160/110 x 2 (>15 mins apart)

Question 31

20%-50% of women with chronic HTN will develop preeclampsia. T or F?

Answer 31

True

Question 32

What is the onset and diagnostic criteria superimposed preeclampsia?

Answer 32

1. prior to pregnancy or <20 weeks 2. BP >140/90 OR 4. Using HTN meds prior to PG AND 3. New finding-proteinuria, elevated liver enzymes, thrombocytopenia, pulmonary edema, vision changes, renal insufficiency.

Question 33

What is the onset and diagnostic criteria of gHTN ?

Answer 33

1. >20 weeks 2. BP >140/90 x 2 (>4 hrs apart) 3. withOUT proteinuria or features

Question 34

What is the onset and diagnostic criteria of preeclampsia?

Answer 34

# <100,000 platelets 1. NEW ONSET HTN >140/90 x2 (>4hrs) 2. proteinuria >300 mg/24 hrs OR 2+ dipstick OR >0.3 mg/dL protein/creatinine ratio 3. If no proteinuria, can include: - twice elevated liver enzymes - <100,000 platelets - >1.1 serum creatinine or doubling - pulmonary edema - vision changes

Question 35

What is the onset and diagnostic criteria of preeclampsia with SEVERE FEATURES?

Answer 35

# BP >160/110 Same criteria for preeclampsia with one of the following: - BP >160/110 x 2 (>15 mins) - <100,000 platelets - >1.1 serum creatinine or doubling - severe RUQ pain - pulmonary edema - NEW ONSET cerebral or vision changes

Question 36

What labs are used to evaluate chronic hypertension?

Answer 36

- serum creatinine - electrolytes - uric acid - liver enzymes - platelet - urine protein

Question 37

What symptom is the difference between preeclampsia and eclampsia?

Answer 37

Seizures

Question 38

What is the diagnostic criteria for postpartum HTN?

Answer 38

- up to 12 weeks PP - BP >140/90

Question 39

Do antihypertensive medications cross the placenta?

Answer 39

YES

Question 40

Which antihypertensive medications can cause fetal malformations if taken during pregnancy?

Answer 40

- ACEs - ARBs - spironolactone - direct renin inhibitors

Question 41

Can statins in pregnancy cause fetal harm?

Answer 41

Yes, they are teratogenic

Question 42

Are salt-restricted diets and weight loss recommended for chronic HTN during pregnancy?

Answer 42

No

Question 43

What medications are used to treat hypertension in a pregnant woman?

Answer 43

- nifedipine - labetalol - methyldopa - amlodipine

Question 44

When should serial fetal growth ultrasounds begin in a woman with chronic HTN that is controlled with medication?

Answer 44

32 weeks, weekly or bi-weekly depending on severity.

Question 45

What are preeclampsia warning signs?

Answer 45

- persistent or severe headach - visual disturbances - new onset swelling of face or sudden weight gain - new N/V in second half of PG - RUQ or epigastric pain - new onset dyspnea, orthopnea

Question 46

What is the cause of hemoconcentration in preeclampsia?

Answer 46

fluid shifts from intravascular to extracellular spaces, reducing plasma volume that abnormally concentrates the Hgb and Hct.

Question 47

Does creatinine clearance go up or down in preeclampsia?

Answer 47

It goes down.

Question 48

What causes thrombocytopenia in preeclampsia?

Answer 48

Inappropriate activation of leukocytes, complement, and clotting factors depletes platelets, increases clotting time, and leads to hemolysis.

Question 49

What causes FGR (fetal growth restriction) in preeclampsia?

Answer 49

Inadequate remodeling of spiral arteries leading to vasoconstriction and reduced placental perfusion.

Question 50

How many risk factors for preeclampsia are found in this case scenario? A 36 yo G1P0 with in vitro conception with twins. Family hx of her sister having preeclampsia. Med Hx of BMI 40, Type 2 DM, and chronic HTN.

Answer 50

EIGHT risk factors: 1. >35 years 2. nulliparity 3. In vitro conception 4. multifetal gestation 5. family hx of preeclampsia 6. >30 BMI 7. T2DM 8. chronic HTN

Question 51

How many minutes should treatment be given after finding severe-range hypertension?

Answer 51

30 mins

Question 52

How soon do you need to reevaluate BP postpartum for a woman who had severe hypertension?

Answer 52

within 72 hours after birth and again by day 7-10.

Question 53

What does HELLP stand for?

Answer 53

H-hemolysis EL-elevated liver enzymes LP-low platelet count

Question 54

What are the symptoms of HELLP syndrome?

Answer 54

- elevated BP - RUQ or epigastric pain - persistent HA - visual changes - significant weight gain - malaise - dyspnea - N/V

Question 55

What is the symptom associated with hepatic rupture?

Answer 55

Severe pain in the RUQ.

Question 56

What are the classes of HELLP syndrome?

Answer 56

Class 1 (severe) = platelets <50 K Class 2 (moderate) = platelets 50-100 K Class 3 (mild) = platelets 100-150

Question 57

When is birth recommended in cases of preeclampsia?

Answer 57

37 weeks

Question 58

When is birth recommended in cases of severe hypertension or HELLP?

Answer 58

34 weeks

Question 59

When can antihypertensive medications be discontinued postpartum?

Answer 59

Once BPs remain controlled for at least 48 hours.

Question 60

What does the acronym TORCH stand for?

Answer 60

T-toxoplasmosis O-syphilis R-rubella C-cytomegalovirus H-herpes