Week 11: High Risk Pregnancy Part 2

Advanced Maternal Age

35+ at time of delivery

Multiple pregnancies more common

Other increased risks

Pregestational DM

Type 1 or 2 DM prior to conception

4 cardinal s/s of DM

Polydipsia

Polyuria

Polyphagia

Weight loss

Gestational DM

Glucose intolerance with onset during pregnancy (usually around 24th weeks)

Not caused by lack of insulin -- pregnancy hormonal shifts can lead to insulin resistance

Risks of hyperglycemia in pregnancy

CV, renal, neurodevelopmental defects

Fetal death

Very important to stabilize blood levels BEFORE pregnancy

Macrosomia & newborn hypoglycemia

DM managment in pregnancy

EYE EXAM d/t incr damage potential

Dx if necessary

Lab tests

Carb counting & balanced diet

Artificial sweeteners is safe but should be limited

Insulin

Goal: fasting glucose

GDM screening

1 hour glucose challenge test - wants to be between 130-140

If abnormal, 3 hour glucose tolerance test -- 95, 180, 155, 140

Hyperthyroidism in pregnancy

95% time is Graves Disease

Risks: Preterm delivery, low birth weight, fetal demise

Hypothyroidism in pregnancy

More common than hyperthyroidism

Risks: infertility, miscarriage, preeclampsia, preterm delivery, fetal demise

Treated with Synthroid

Asthma in pregnancy

Most common chronic dx in pregnancy

Uncontrolled --> HTN, premature delivery

Can improve in pregnancy

Inhaled meds are generally preferred

Cholestasis

VERY SERIOUS CONCERN

Slowing of bile d/t hormonal effects on biliary system --> liver inflammation

Increase fetal demise as much as 10x d/t buildup of bile

ITCHING - WORSE AT NIGHT

Late stage: jaundice & dark-colored urine

Dx: Liver Function tests (LFT) and Serum Bile Acid

Delivery: recommended 36-37 weeks

Epilepsy in pregnancy

Many meds unsafe

Needs to see neurologist to determine meds

Seizure threshold can change

MS in pregnancy

Many meds unsafe

PT can be helpful

Bell's Palsy

Facial parlysis caused by inflammation of the facial nerves

Most common during 3rd trimester

Can be a warning of impending HTN

Lupus in pregnancy

Systemic Inflammation

Increases risk of HTN

Hydroxychloroquine -- most common med -- safe in pregnancy!

Hyperemesis Gravidarum

Extreme, persistent nausea

Dx: weight loss of >5% pre-pregnancy weight

Malnutrition & dehydration

Women with motion sickness or migraines are at increased risk

S/s typically improve between 15-20 weeks

Partner support!

Pyelonephritis in pregnancy

Kidney infection

Often requires hospitalization for IV antibiotics

S/s: fever, burning with urination, general malaise, flank pain

HIV in pregnancy

Rate of vertical transmission now is 1%

Antiretroviral meds are safe in pregnancy

Breastfeeding NOT recommended, though risk is low

Hydatidiform Mole (Molar Pregnancy)

Gestational Trophoblastic Disease

Tumor formed in placenta

Sperm fertilizes egg -- maternal chromosomes missing & paternal chromosomes duplicate

Risk for cancer & metastasis

Dx: U/S

Requires surgical removal

S/S: dark brown bleeding, severe n/v, uterine size larger than date, higher hCG than expected

Category A Drugs in Pregnancy

no risk

Category D drugs in pregnancy

evidence of risk

Category X drug in pregnancy

contraindicated

Oral retinoids

Accutane, Clavaris

Category X drug

Can cause severe damage to developing fetus

Meds not safe in pregnancy

Many BP meds

Statin drugs

NSAIDs

Oral retinoids

Anti-seizure drugs

Benzos

Med safe for HAs, body aches, pain in pregnancy

Acetaminophen

Implantation

Occurs at time of implantation

Experienced by 1 in 4 women

Usually pink or brown blood

Spontaneous abortion (Miscarriage)

Usually in 1st trimester d/t chromosomal abnormalities, teratogenic drugs, etc.

Late miscarriages are usually d/t a maternal factor

Before week 20 or less than 500 grams

Preterm delivery

spontaneous abortion after 20 weeks

Threatened spontaneous abortion

unexplained bleeding, closed cervix

fetus may die or issue may resolve

Imminent abortion

Increase bleeding & cramping

Cervical dilation, ROM

Habitual abortion

spontaneous abortion occurs in 3+ consecutive abortion

Incomplete abortion

Part of products retained, cervical dilation

Complete abortion

All products expelled

Missed abortion

Fetus dies in utero, but not expelled

Clinical therapy for spontaneous abortions

Pelvic rest

Medication & surgical management - Mifepristone & Misoprostol

Rh immune globulin within 72 hrs (if Rh Neg)

Possible blood transfusion

Cervical Insufficiency

Painless cervical dilation with s/s of preterm labor

Risks: prior preterm labor, cervical procedures/lacerations, abnormalities

Treatment: Cerclage

Cerclage

Stitch placed around the cervix to prevent cervical dilation in cervical insufficiency

Placenta Previa

Placenta completely or partially covers the opening (internal os) of the cervix

S/s: bright red, painless vaginal bleeding after 20 weeks gestation

C-section needed at birth

Risks: Many prior pregnancies

Partial placenta previa

Total placenta previa

Placenta abruption

Premature separation of the placenta

Grades: 1 (mild), 2 (moderate), 3 (severe)

Dx by U/S

Most common cause is maternal HTN

Usually during 3rd trimester

S/s: Painful, 'board-like' abdomen, bleeding

Ectopic Pregnancy

Implantation of fertilized ovum in a site other than the endometrium

6% of all maternal deaths in the US

S/s: dull lower quadrant pain on one side, colicky referred shoulder pain

Risks: Chlamydia, pelvic inflammatory disease, endometriosis, prior hx of ectopic pregnancy

NEVER VIABLE

Treatment: Methotrexate, NEVER PUSH ON ABDOMEN UNTIL ECTOPIC PREGNANCY IS RULED OUT, preserve tube or remove tube