pregnancy, labor, and delivery - dr higgins

1 hour = 5 questions

what is gestational age?

280 days

from first day of last menstrual period

what is known as the number of times a woman has been pregnant?

gravidity

what is the number of pregnancies exceeding 20 weeks of gestation?

parity

what is the order in which parity information is presented?

a. term deliveries

b. premature deliveries

c. aborted pregnancies

d. number of living children

practice

a woman has been pregnant 3 times, has had 1 term delivery, 1 premature delivery, one ectopic pregnancy (aborted), and has 2 living children

how would this be represented in terms of gravidity and parity?

G₃P₁₁₁₂

how is absorption different in pregnancy?

______ GI motility

______ gastric acid secretion

altered bioavailability due to ________

______ skin absorption

decreased GI motility

decreased gastric acid secretion

altered bioavailability due to nausea and vomiting

increased skin absorption

what happens to distribution in pregnancy?

blood volume ______ 30-50% during pregnancy

______ TBW

body fat _____ —> ______ Vd of fat-soluble drugs

albumin concentration ______ —> ______ Vd of highly protein bound drugs

severe nausea and vomiting can affect nutrition, _____ protein stores

blood volume increases 30-50% during pregnancy

increased TBW

body fat increases —> increased Vd of fat-soluble drugs

albumin concentration decreases —> increased Vd of highly protein bound drugs

severe nausea and vomiting can affect nutrition, decreasing protein stores

what happens to metabolism in pregnancy?

hepatic perfusion ________

note: CYPs are effected but they can be stimulated or decr…we don’t really know

hepatic perfusion increases

how is elimination effected in pregnancy?

renal blood flow ______ by 25-50%

GFR ______ by 50% at the beginning of the second trimester

renal blood flow increases by 25-50%

GFR increases by 50% at the beginning of the second trimester

note: renal excreted drugs should be adjusted UP to 20-65% to maintain therapeutic concentrations

maternal plasma volume, cardiac output, and glomerular filtration ______ by 30-50%

increase

lowers the concentration of renally cleared drugs

body fat _______ affecting the volume of distribution of fat-soluble drugs

plasma albumin _______

body fat increases affecting the volume of distribution of fat-soluble drugs

plasma albumin decreases

incr. in the Vd of drugs that are highly protein bound

what can affect the absorption of drugs in pregnancy?

• nausea and vomiting (dehydration)

• delayed gastric emptying

• incr. in gastric pH

what drugs have a lower potential to cross the placenta?

high molecular weight

water soluble

shorter half-life

high protein binding

what drugs have a higher potential to cross the placenta?

low molecular weight

lipid soluble

longer half-life

low protein binding

what is a substance that has the potential to produce abnormal development in the fetus?

teratogen

what term means existing at birth?

a. congenital

b. congenital malformation

c. congenital anomaly

a.

what term means structural defect present at birth?

a. congenital

b. congenital malformation

c. congenital anomaly

b.

what term means structural or functional defect at birth?

a. congenital

b. congenital malformation

c. congenital anomaly

c.

what does the “all-or-none” phenomenon mean in the first 4 weeks of gestation?

basically something either has no effect on the fetus or it leads to pregnancy loss

when do structural anomalies develop?

a. first 4 weeks of gestation

b. embryonic period

c. second and third trimester

b.

when can you experience growth restriction, CNS abnormalities, impaired organ function, and fetal demise?

a. first 4 weeks of gestation

b. embryonic period

c. second and third trimester

c.

list meds associated with teratogenic effects during organogenesis

• chemo agents

• sex hormones

• lithium

• retinoids

• thalidomide

• warfarin

• certain antiseizure meds

when are NSAIDs and tetracyclines more likely to exhibit effects? (SATA)

a. first trimester

b. second trimester

c. third trimester

b. c.

idk if we need to know these I’m hoping higgy doesn’t do us like that

meds and their adverse outcomes and management/prevention

meds	adverse outcomes	management/prevention
antiseizure meds	craniofacial, cardiac, limb defects	optimize to lower risk therapy avoid valproic acid use monotherapy start folic acid
retinoids	spontaneous abortion CNS, craniofacial, cardiac defects	d/c at least 1 month before attempting conception
warfarin	fetal warfarin syndrome	switch to LMWH
alcohol use	fetal alcohol syndrome	cease alcohol before conception
tobacco use	preterm birth, low birth weight, spontaneous abortion, orofacial clefts, SIDs	cease tobacco before conception

what is the FDA pregnancy registry?

volunteer to sign up for a pregnancy exposure registry

provide info about their health and their baby’s health

when is gestational diabetes mellitus (GDM) diagnosed?

24-48 weeks gestation

T/F gestational diabetes mellitus (GDM) causes an increased risk of developing T2DM later in life

TRUE

what are risk factors for GDM?

• history of GDM with previous pregnancy

• overweight (BMI ≥ 25)

• high TGs (> 250)

• indications of insulin resistance

• hx of diabetes in first degree relative

• physical inactivity

• PCOS

• high A1C (> 5.7)

• previous birth of an infant weight ≥ 4 kg

• HTN

• high-density lipoprotein cholesterol < 35

• impaired fasting glucose on previous testing

what are the most common fetal complications with uncontrolled diabetes?

• macrosomia

• neonatal hypoglycemia

• hyperbilirubinemia

• birth trauma

what fetal malformations and long term complications for the child can be seen with uncontrolled diabetes?

• fetal malformations

  • cardiac defects

  • CNS anomalies

  • skeletal malformations

• long term complications for child

  • impaired glucose tolerance

  • T2DM

  • HTN

  • metabolic syndrome and CV disease

what risks does uncontrolled diabetes pose to the pregnant individual?

• cesarean delivery

• HTN and preeclampsia

• metabolic syndrome and CV disease

what is the one step method to screening and diagnosis of GDM?

• 75-gram oral glucose tolerance test (OGTT)

• plasma glucose at fasting, 1 and 2 hours after admin of glucose

  • diagnosis if at least one is met or exceeded

    • fasting: 92

    • 1 hour: 180

    • 2 hour: 153

what is the two step method for diagnosing GDM?

• step 1

  • complete a 50-gram oral glucose loading test in a non-fasting state

  • draw plasma glucose 1 hour after admin of glucose

    • if ≥ 140, move on to step 2

• step 2

  • 100-gram OGTT with fasting, 1-, 2-, and 3-hour levels

  • diagnosis with at least 2 of the following met or exceeded

    • fasting: 95

    • 1 hour: 180

    • 2 hour: 155

    • 3 hour: 140

what is first line tx for GDM?

dietary and exercise changes

blood glucose monitoring 4x daily

most pts can achieve control with this

GDM

when medical nutrition and exercise fail to achieve glucose control within 1-2 weeks, what is first line pharmacotherapy?

barriers to insulin?

• first line

  • basal insulin with bolus if needed

• barriers to insulin

  • metformin or glyburide

when can preeclampsia happen? (SATA)

a. early onset (prior to 34 weeks)

b. late onset

c. present up to 6 weeks postpartum

a. b. c.

how do you diagnose preeclampsia?

• elevated blood pressure with proteinuria

• if no proteinuria:

  • new onset of thrombocytopenia, SCr >1.1, elevated LFTs 2x ULN, PE, or new onset headache nonresponsive to analgesia or with visual symptoms

list high-risk factors for preeclampsia

• preeclampsia in a prior pregnancy

• non-singleton pregnancy

• chronic HTN

• pregestational diabetes

• renal disease

• autoimmune disease

• combo of multiple moderate-risk factors

list moderate-risk factors for preeclampsia

• nulliparity

• prepregnancy BMI > 30

• family history of preeclampsia

• sociodemographic characteristics

• age > 35 yo

• medical history factors

what is eclampsia?

new-onset tonic-clonic, focal or multifocal seizures superimposed on preeclampsia

-proceeded by headache, visual changes, or altered mental status or no warning signs

T/F eclampsia is a medical emergency

TRUE

when can eclampsia occur? (SATA)

a. antepartum

b. intrapartum

c. postpartum

a. b. c.

what are complications of uncontrolled hypertension for the pregnant individual?

• preeclampsia

• eclampsia

• stroke

• labor induction

• placental abruption

what are complications of uncontrolled hypertension in the fetus?

• intrauterine growth restriction

• preterm delivery

• low birth weight

• still birth

list complications of chronic hypertension in pregnancy

• death

• pulmonary edema

• renal insufficiency and failure

• MI

• cesarean delivery

• postpartum hemorrhage

• GDM and congenital anomalies

what meds are recommended for treating preeclampsia?

i guess we’re talking about oral or like take home dosing for this one

labetalol and nifedipine

ER BID

what meds are recommended to to treat preeclampsia if it is an URGENT need?

IV labetalol

IV or IM hydralazine

IR nifedipine

T/F magnesium is recommended with severe HTN with preeclampsia to prevent progression to eclampsia and treat eclamptic seizures

TRUE - use throughout labor and 12-24 hours

what is HELLP syndrome?

H: hemolysis

EL: elevated liver enzymes

LP: low platelet count

different from preeclampsia as pts may not have HTN or proteinuria

list sx of HELLP syndrome and tx

• sx

  • right upper quadrant abdominal pain

  • blurred vision

  • malaise or fatigue

  • edema and quick weight gain

  • n/v

  • blurred vision or headache (less common)

• tx

  • delivery and management of sx

postaprtum hemorrhage is blood loss ______ or blood loss with s/sx of _______ within 24 hours after delivery

blood loss > 1000 mL

or s/sx of hypovolemia

________ should be administered before placental delivery to reduce blood loss

oxytocin

__________ has been shown to reduce deaths from obstetric hemorrhage if given within 3 hours of delivery

tranexamic acid

what are the “baby blues”?

do we treat it?

sx: anxiety, anger, fatigue, insomnia, tearfulness, sadness

-within the first 10 days of delivery

no tx

describe depression in and after pregnancy

may develop during pregnancy or up to 6 months after delivery

risks: poor parental health, decr. QOL, risky behavior, relationship difficulties with caring for infant

tx: psychotherapy, CBT, group/family therapy

if we have a pt with postpartum depression, what medications are options?

• low transfer to breast milk

  • sertraline, paroxetine, fluoxetine, nortriptyline

• brexanolone: FDA approved for tx of postpartum depression

  • REMS program

  • boxed warning: excessive sedation and sudden loss of consciousness

  • IV med

what is the leading cause of infant mortality and hospitalizations?

preterm labor

how is preterm labor diagnosed?

uterine contractions begin before 37 weeks gestation with changes in cervical dilation and/or effacement

regular contractions and cervical dilation of ≥ 2 cm

list risk factors for preterm labor

• previous preterm delivery

• hx of cervical surgery

• short cervical length

• infections

• vaginal bleeding

• UTIs

• periodontal disease

• low pregnancy weight

• smoking

• substance use disorders

• shorten interval between pregnancies

what are nonpharm options to prevent preterm labor?

• bed rest

• refrain from sexual intercourse and orgasm

• hydration

note: not proven to decr. risk

______ postpones delivery long enough to allow for maximal effect of antenatal corticosteroid and magnesium administration

tocolytic therapy

list classes of tocolytic therapy

• beta adrenergic receptor agonist

  • terbutaline

• magnesium (not used alone)

• CCBs

• NSAIDs

how long does tocolytic therapy prolong pregnancy?

48 hours - 1 week

10-30% of pregnant individuals are colonized with ______

Group B Strep (GBS)

when does a pregnant individual get screened for GBS?

36-38 weeks gestation

GBS

when do we give intrapartum antibiotics?

• GBS colonization

• previous birth to infant with invasive GBS disease

• GBS bacteriuria during pregnancy

IV ampicillin Q4H until delivery

what do we do if someone has PROM before 34 weeks?

• prophylactic antibiotics

  • 7 day course

  • broad-spectrum

  • common regimen: IV ampicillin and erythromycin for 2 days, oral amoxicillin and erythromycin for 5 days

who is recommended to receive antenatal corticosteroids?

24-34 weeks gestation who are at risk for preterm delivery in next 7 days, including those with ruptured membranes

what are the most common regimens for antenatal corticosteroids?

• betamethasome IM

  • 2 doses 24 hours apart

• dexamethasone

  • 4 doses 12 hours apart

when do we administer a rescue course of corticosteroids?

more than 14 days after previous course

at risk for delivering before 34 weeks gestation