Chronic condition in pregnancy

What is the most common cause of pregnancy-related deaths

Cardiovascular conditions

The maternal mortality rate in what state is more than twice the national rate

GA

What race/ethnicity group experiences the most pregnancy-related mortality rates?

non-Hispanic black

Define pregestational diabetes

diabetes diagnosed prior to pregnancy or during 1st trimester

Define GDM

carbohydrate intolerance first detected during pregnancy

GDM affects what percentage of births/year

5-10%

GDM accounts for ____% of diabetes cases during pregnancy

90%

>___% of women with GDM will develop T2D later in life

50%

Treatment options of diabetes in pregnancy (diet)

• medical nutrition therapy (MNT)

True or false: MNT may be adequate alone for some women with GDM

true

What is recommended daily from 12 wga until delivery to reduce preeclampsia risk?

ASA 81mg

What is the preferred therapy in treatment of diabetes?

Insulin therapy

Preferred basal insulins

NPH, detemir, glargine

Preferred bolus insulins

regular, aspart, lispro

What oral agents are considered if women decline/cant use insulin?

• metformin

• glyburide

True or false: metformin crosses placenta but not glyburide

false; they both do

What are the ACOG classifications of HTN disorders

• gestational

• chronic

• chronic with superimposed preeclampsia

• preeclampsia-eclampsia

Chronic HTN is diagnosed before ____ wga

20

What is preeclampsia?

• progressive in nature

• elevated BP along with

  • proteinuria

  • increased SCr

  • thrombocytopenia

  • elevated AST/ALT

  • headache

  • blurred vision

  • epigastric pain

What is eclampsia?

seizures in a woman with preeclampsia

Goal with chronic HTN in pregnancy

minimize risk to the mother without compromising placental perfusion

When do you initiate pharmacotherapy with chronic HTN?

140/90

What are 1st line agents in chronic HTN?

• Labetalol 100mg PO BID; up to 2400mg/day

• Nifedipine XL 30mg PO daily; up to 120mg/day

Management of preeclampsia/eclampsia without severe features

expectant management until delivery at 37+0 wga

Management of preeclampsia/eclampsia with severe features

consider expectant management until delivery at 34+0 wga

Anti-HTN agents used for expectant management

• Labetalol

• Hydralazine

• Nifedipine IR

There is an increased risk of _____ in pregnancy

VTE

Why is there an increased risk of thrombosis in pregnancy?

• increased clotting factors

• activation of platelets and venous stasis

• decreased protein S, antithrombin, fibrinolytic activity

• resistance to activated protein C

What are anticoagulation medications used in pregnancy?

• LMWH

• Unfractionated heparin

• direct thrombin inhibitors

• warfarin

• factor Xa

What anticoagulant is preferred in outpatient setting?

LMWH

Prophylaxis dosing of enoxaparin

40mg SQ daily

Treatment dosing of enoxaparin

1mg/kg SC BID

Prophylaxis dosing with dalteparin

5000 units SC daily

Treatment dosing with dalteparin

100 units/kg SC BID

Monitoring parameters for anticoag therapy

anti-factor Xa levels

When do you draw peak of antifactor Xa

4-6 hour after last dose

For prophylaxis, may check every 1-3 months

Treatment- check monthly; may consider weight-based dose adjustments

What levels for prophylaxis in antifactor Xa monitoring

0.1-0.6 IU/ml

Levels for treatment with antifactor Xa monitoring

0.6-1.0 IU/ml

True or false: if patient is stable on current ICS, you can leave them on it

true

What type of therapy prevents preterm birth

tocolytic

Tocolytic therapy may be used in what range of wga?

24-34 weeks

When would you consider tocolytic therapy?

• to administer antenatal corticosteroids

• transport mother

• prolong pregnancy if there is underlying condition

Purpose of betamethasone

reduce risk of neonatal death, respiratory distress, intraventricular hemorrhage

Purpose of administering magnesium

reduce risk of infant cerebral palsy

What are some tocolytic agents

• Nifedipine

• Indomethacin

• Terbutaline

What are the two phases of labor?

1. onset of labor to complete cervical dilation

2. time between complete cervical dilation and delivery

What type of pain happens in 1st phase of labor?

visceral pain caused by uterine contractions

What type of pain occurs during 2nd phase of labor?

somatic pain

What are the 2 common pharmacologic approaches for labor

1. parenteral opioids

2. epidural analgesia

Puncturing of the subarachnoid space can cause what?

severe headache

What is the most common cause of PPH?

uterine atony

Treatment options for PPH

uterotonic agents

What are the uterotonic agents?

• oxytocin administered before placental delivery

• methylergonovine, carboprost, misoprostol, tranexamic acid

• uterine artery embolization

• intrauterine balloon catheters

• surgery

Dosing of oxytocin after placenta delivery

5-10 units IV given initially and may be followed by infusion of 10 units/hour, (max 40 units)

What type of dosing is recommended due to kinetics changes in pregnancy? (anti-coag)

BID

Recommendation for someone high risk for preeclampsia?

Low dose ASA (81-160mg) at >12 weeks if the patient has 1+ of high risk factors

High risk factors for preeclampsia

• T2D

• Multifetal gestation

• chronic HTN

• kidney disease

• autoimmune disease

Moderate risk factors for preeclampsia

• nullparity

• obesity (BMI>30)

• family hx

• black persons

• low income

• >35yo

• in vitro contraception

When can neuraxial anesthesia be considered during spontaneous delivery?

LMWH: at least 12 hours from the last prophylactic dose and 24 hours from the last treatment dose

UFH: at least 4 hours from last prophylactic

When should you plan a C-section or induction with transition off LWMH

24-36 hours in advance

Change anticoag therapy to SC _____ TID for spontaneous delivery

UFH