Women's Health L24: Surgical and Medical Complications of Pregnancy

what is gestational diabetes mellutis?

1. a diagnosis of diabetes at 24-28 weeks of gestation

2. can resolve postpartum but carries an increased risk of developing type 2 diabetes

what is the pathophysiology of gestational diabetes?

the growing placenta synthesizes human placental lactogen (hPL) which leads to insulin resistance

what is a diagnosis of diabetes earlier in pregnancy most consistent with?

previously undiagnosed type 2 diabetes

what are the risk factors of gestational diabetes?

1. gestational diabetes or macrosomia in a previous pregnancy

2. family history of diabetes

3. pre-pregnancy BMI ≥ 30

4. PCOS

5. advanced maternal age

6. Hispanic American/Native American/Pacific Islander

how do you screen for gestational diabetes in early pregnancy?

1. no standard testing

2. check an A1C in those with risk factors for undiagnosed type 2 diabetes

how do you screen for gestational diabetes between 24-28 weeks of gestation?

1. two-step approach

2. 1st -- screen ALL patients

3. 2nd -- diagnose gestational diabetes

how is step one in screening for gestational diabetes completed?

1. 1-hour glucose tolerance test (GTT) -- need not be fasting

2. measure serum glucose at 1 hour after administration

3. glucose ≥ 135 mg/dL is a positive finding and requires the patient to complete the second step

how is step two in screening for gestational diabetes completed?

1. measure a fasting serum glucose level at 1, 2, and 3 hours after administration

2. a diagnosis of gestational diabetes is made if 2+ glucose levels are above the threshold

what are the maternal complications of gestational diabetes?

1. preeclampsia

2. gestational hypertension

3. postpartum -- type 2 diabetes, metabolic syndrome, or cardiovascular disease

what are the fetal complications of gestational diabetes?

1. macrosomia and LGA

2. polyhydramnnios

3. stillbirth

4. childhood obesity

how is gestational diabetes managed?

1. glucose monitoring

2. medical nutritional therapy

3. pharmacotherapy

4. US

how often should a patient with gestational diabetes monitor their glucose?

1. several times throughout the day

2. fasting AM and 1-2 hours postprandial

what is the initial treatment for gestational diabetes?

medical nutritional therapy

3 multiple choice options

most patients with gestational diabetes can achieve target glucose levels with lifestyle modifications alone

true

1 multiple choice option

what are the components of medical nutritional therapy for management of gestational diabetes?

1. follow with a registered dietician

2. 2 small/moderate meals and 2-4 snacks daily with a specific calorie/carb/protein/fat requirements

3. 30-60 minutes of moderate aerobic activity

4. monitor weight

in which patients with gestational diabetes is pharmacotherapy indicated?

1. those who do not achieve glucose targets with nutritional therapy and exercise

2. those with fetal hyperinsulinemia

what is the first line pharmacotherapy for gestational diabetes?

insulin

3 multiple choice options

what is an adverse reaction of insulin?

hypoglycemia

in which patients with gestational diabetes is oral antihyperglycemics indicated?

1. second line

2. those who decline to take or are unable to to comply with insulin therapy

which are the only non-insulin antihyperglycemics used in pregnancy?

1. metformin

2. glyburide

which oral antihyperglycemic used in pregnancy has an adverse reaction of hypoglycemia?

glyburide

1 multiple choice option

what are the classifications of gestational diabetes?

1. A1

2. A2

what is gestational diabetes A1?

glycemic control achieved without medication

1 multiple choice option

what is gestational diabetes A2?

glycemic control achieved with medication

what is an US between 36-39 weeks gestation used to assess for in patients with gestational diabetes?

macrosomia

3 multiple choice options

when is a C-section at 39 weeks offered in a patient with gestational diabetes?

if the EFW ≥ 4500 g

when can you offer an induction in a patient with gestational diabetes A1?

39 weeks

3 multiple choice options

what specific management is involved in a patient with gestational diabetes A2?

NST and amniotic fluid check twice a week, starting at 32 weeks gestation

when can you induce a patient with gestational diabetes A2?

1. 39 weeks

2. between 37 and 38+6 weeks if glycemic control is suboptimal

when and why do most patients return to pre-pregnancy glycemic status?

1. within a week

2. the effects of hPL stop quickly after birth

all patients should have a 2-hour GTT between 4-12 weeks postpartum

true

2 multiple choice options

what is an abnormal 2-hour GTT that indicates prediabetes postpartum?

140-199 mg/dL

what is an abnormal 2-hour GTT that indicates diabetes postpartum?

≥ 200 mg/dL

what is the treatment for pre-gestational diabetes?

1. medical nutritional therapy for all

2. insulin if needed -- switch to insulin if previously on an oral antihyperglycemic

3. measure A1C each trimester

what other ways can pre-gestational diabetes be managed?

1. folic acid

2. aspirin 81 mg at 12 weeks

3. manage BP -- goal is < 140/90

4. ophthalmic exam

5. US at 28 weeks and repeat every 4 weeks

6. NST/BPP twice a week at 32 weeks

what are the hypertensive disorders in pregnancy?

1. preeclampsia

2. eclampsia

3. HELLP syndrome

4. gestational hypertension

5. chronic hypertension

6. preeclampsia superimposed on chronic hypertension

what are the maternal cardiovascular effects of hypertension?

1. stroke

2. MI

3. heart failure

what are the maternal renal effects of hypertension?

1. proteinuria

2. reduced GFR

3. reduced uric acid filtration

4. risk of AKI

what are the maternal neurologic effects of hypertension?

1. headaches

2. blurred vision

3. seizures

what are the maternal pulmonary effects of hypertension?

1. capillary leak

2. pulmonary edema

3. fluid overload

what are the fetal effects of hypertension?

1. preterm birth

2. low birth weight

3. reduced placental perfusion

4. oligohydramnios

5. placental abruption

what is preeclampsia?

1. new onset hypertension with proteinuria > 20 weeks

2. signs/symptoms of end-organ dysfunction

what is the typical presentation of preeclampsia?

1. new onset hypertension

2. proteinuria

what is the severe presentation of preeclampsia?

1. new onset hypertension ≥ 160/110 mm Hg

2. headache

3. blurred vision

4. abdominal pain

5. altered mental status

6. dyspnea

what are the UA findings in a patient with preeclampsia?

1. protein/Cr ratio is ≥ 0.3

2. 2+ proteins on dipstick

how is preeclampsia managed?

1. antihypertensive for severe hypertension -- labetalol, hydralazine, or nifedipine

2. intrapartum magnesium sulfate for seizure prophylaxis

3. delivery

4. expectant management

what is the definitive treatment for preeclampsia?

delivery

3 multiple choice options

how will you manage a patient with severe preeclampsia who is > 37 weeks gestation?

delivery

3 multiple choice options

how will you manage a patient with typical preeclampsia who is < 37 weeks gestation?

1. expectant

2. deliver at 37 weeks

how will you manage a patient with severe preeclampsia who is < 37 weeks gestation?

delivery regardless of gestational age

what is involved in expectant management of preeclampsia?

1. CBC and CMP at least twice a week

2. monitor BP at least twice a day

3. daily kick counts

4. NST/BPP twice a week

5. corticosteroids if < 34 weeks gestation

what is eclampsia?

onset of seizures or coma in a patient with preeclampsia

what are the prodromal symptoms of eclampsia?

1. hypertension

2. headache

3. visual disturbances

4. RUQ/epigastric pain

what are the physical exam findings of eclampsia?

1. brisk DTRs

2. vision deficits

3. altered mental status

4. cranial nerve deficitse

what are the characteristics of seizures in eclampsia?

1. clonic-tonic

2. resolves within a few minutes

eclampsia is a clinical diagnosis, based on new onset seizures and in the absence of other causative conditions

true

1 multiple choice option

how is eclampsia managed?

1. maternal ABCs

2. IV lorazepam or midazolam

3. treat severe hypertension

4. initiate magnesium sulfate

5. evaluate for delivery

what is HELLP syndrome?

1. hemolysis

2. elevated liver enzymes

3. low platelets

4. a severe form of preeclampsia, but does not always involve hypertension or proteinuria

what is the presentation of HELLP syndrome?

1. RUQ/epigastric pain

2. proteinuria

3. malaise

4. hypertension

5. nausea/vomiting

6. headache

7. vision changes

8. jaundice

how is a diagnosis of HELLP syndrome made?

1. hemolysis -- schistocytes/burr cells, bilirubin ≥ 1.2 mg/dL, and Hgb < 8 g/dL

2. liver enzymes -- AST or ALT ≥ 2x ULN

3. low platelets -- < 100K

how is HELLP syndrome managed?

1. treat severe hypertension

2. hepatic imaging to evaluate for bleeding

3. volume replacement and blood transfusion as needed

4. IV magnesium sulfate

5. prompt delivery for severe presentations or is > 34 weeks gestation

what can you administer if a patient with HELLP syndrome is < 34 weeks gestation and without serious complications?

corticosteroids

what is gestational hypertension?

1. new onset BP ≥ 140/90 mm Hg on at least 2 occasions 4 hours apart after 20 weeks gestation

2. should resolve within 12 weeks postpartum

3. no proteinuria or signs/symptoms of end-organ dysfunction

what lab finding will not be present on a UA?

proteinuria

1 multiple choice option

how is severe gestational hypertension managed?

managed the same as severe preeclampsia

how is gestational hypertension < 160/110 mm Hg managed?

1. monitor BP twice a week

2. UA/CBC/LFTs once a week

3. NST/BPP twice a week

4. delivery between 37-39 weeks

what is chronic hypertension in pregnancy?

1. hypertension present before conception

2. first recognized prior to 20 weeks gestation

how is chronic hypertension managed in early pregnancy?

1. baseline CBC, CMP, UA, and EKG

2. prescribe labetalol or nifedipine

3. aspirin 81 mg starting at 12 weeks gestation

what antenatal surveillance can be done for chronic hypertension in pregnancy?

1. monitor for FGR starting at 28 weeks

2. weekly NST/BPP starting at 32 weeks

when would you typically induce pregnancy in a patient with chronic hypertension?

around 39 weeks

what is hyperemesis gravidarum?

a severe form of nausea/vomiting in pregnancy

what is the presentation of hyperemesis gravidarum?

1. associated with hypovolemia

2. electrolyte abnormalities

3. abdominal pain, diarrhea, or fever

why would you obtain a CMP in a patient with hyperemesis gravidarum?

assess for electrolytes abnormalities, specifically hypokalemia

what would you assess when obtaining a UA in a patient with hyperemesis gravidarum?

1. ketones

2. specific gravity

how is a diagnosis of hyperemesis gravidarum made?

persistent vomiting accompanied by ketonuria and weight loss > 5% of pre-pregnancy weight

how is hyperemesis gravidarum managed?

1. ER or L&D if hypovolemic

2. PPIs + antiemetics

3. short period of gut rest

what is acute fatty liver of pregnancy?

maternal liver dysfunction and microvesicular fatty infiltration of hepatocytes leading to liver failure

acute fatty liver of pregnancy is a rare but obstetric emergency

true

2 multiple choice options

what is the presentation of acute fatty liver of pregnancy?

1. presents between 30-38 weeks gestation

2. nausea/vomiting

3. abdominal pain

4. malaise

5. anorexia

how is a diagnosis of acute fatty liver of pregnancy made?

1. clinical diagnosis

2. LFTs are 5-10x ULN

3. elevated bilirubin, ammonia, creatinine, and WBCs

how is acute fatty liver of pregnancy managed?

1. prompt delivery regardless of gestational age

2. supportive maternal care -- liver function normalizes within 7-10 days postpartum

what are some complications of acute fatty liver of pregnancy?

1. maternal hemorrhage

2. liver failure

3. acute kidney injury

4. death

what is intrahepatic cholestasis of pregnancy?

the most common liver disease unique to pregnancy

what is the presentation of intrahepatic cholestasis of pregnancy?

generalized pruritus in the 2nd/3rd trimester

how is a diagnosis of intrahepatic cholestasis of pregnancy made?

1. pruritus

2. elevated total serum bile acid levels

how is intrahepatic cholestasis of pregnancy managed?

1. ursodiol until delivery

2. delivery is based on the highest total bile acid level, but usually between 36-38 weeks gestation

what are the complications of intrahepatic cholestasis of pregnancy?

1. intrauterine demise

2. meconium-stained amniotic fluid

3. preterm birth

4. neonatal respiratory distress

what is the etiology of asymptomatic bacteriuria and uncomplicated UTIs?

E. coli

bacteriuria is common in pregnancy, with 30-40% cases progressing to a UTI

true

1 multiple choice option

how is a diagnosis of asymptomatic bacteriuria and uncomplicated UTIs made?

1. urine culture to screen for bacteriuria at the first prenatal visit

2. UA will show hematuria, +/- leukocytes or nitrites

how is bacteriuria in pregnancy managed?

antibiotics tailored to the culture results x 5-7 days

how is cystitis in pregnancy managed?

1. empiric cefpodoxime, Augmentin, or fosfomycin

2. tailor antibiotics to culture results

what are the complications of asymptomatic bacteriuria and uncomplicated UTIs?

1. untreated bacteriuria, leading to preterm birth

2. low birth weight

what is pyelonephritis?

1. a complicated UTI

2. involves the upper urinary tract and kidneys

what is the presentation of pyelonephritis in pregnancy?

1. fever and nausea/vomiting

2. flank pain +/- CVA tenderness

3. typical symptoms of cystitis

how is pyelonephritis in pregnancy confirmed?

1. UA

2. urine culture

in which patients might you order a renal US to diagnose pyelonephritis in pregnancy?

1. severely ill

2. history of renal issues

how is pyelonephritis in pregnancy managed?

1. hospital admission for IV antibiotics until afebrile for 24-48 hours

2. ceftriaxone for initial empiric therapy

3. switch to PO antibiotics once afebrile for 48 hours

4. continue a low-dose antimicrobial for the remainder of the pregnancy to prevent recurrence

what is the presentation of nephrolithiasis in pregnancy?

1. acute flank pain

2. radiates to the lower abdomen/groin

3. hematuria

how is nephrolithiasis in pregnancy diagnosed?

1. UA shows hematuria +/- pyuria

2. BMP to assess kidney function

3. renal US to assess for stones and hydronephrosis