Surgical and Medical Complications of Pregnancy

gestational diabetes mellitus (GDM) is screened at how many weeks?

24-28

why does insulin resistance happen in GDM?

- growing placenta synthesizes human placental lactogen (hPL)

- hPL = insulin resistance

GDM can resolve postpartum but carries what increased risk?

risk of developing type 2 DM in subsequent years

diagnosis of DM (earlier or later)? in pregnancy is more consistent with previously undiagnosed type 2 DM

- early

- late term diagnosis = gestational DM

when screening for GDM (at 24-28 weeks) what approach do we use?

- two-step approach used

what is step 1 and 2 of the two step screening process for GDM?

- step 1: SCREEN all patients

- if first step is positive --> 2nd step: DIAGNOSE GDM if positive

step one of screening for GDM required what components? what is a positive test

- 1-hour glucose tolerance test (GTT)

- 50 g oral glucose solution given (does not need to be fasting, measure serum glucose at 1 hour after administration)

- Glucose >= 135 mg/dL is considered positive and requires patient to complete step two

step two of screening for GDM required what components?

- measure FASTING serum glucose level

- give 100 g oral glucose solution

- measure serum glucose at 1, 2, and 3 hours after administration

- GDM is dxed if 2 or more glucose levels are above threshold (see table)

GDM fetal complications

- macrosomia and LGA

- polyhydramnios

- stillbirth

- childhood obesity

GDM maternal complications

- preeclampsia and gestational HTN

- postpartum: t2DM, metabolic syndrome, CVD

when is glucose monitoring checked when managing GDM?

what are the target glucose levels?

- fasting in AM and 1-2 hours postprandial

- fasting < 95 mg/dL

- 1-hour < 140 mg/dL

- 2-hour < 120 mg/dL

what is the 1st line non-pharm tx for GDM?

- medical nutritional therapy (diet plan)

- most pts can achieve target glucose levels with lifestyle mod alone

those who do not achieve glucose targets with nutritional therapy and exercise alone, or fetal hyperinsulinemia (AC > 75th or EFW > 90th percentile) should consider what?

pharm therapy

what is the first lien pharm treatment of GDM? is it safe for the fetus?

what initial dise do you need?

- insulin (safe for fetus)

(start simple and increase as needed)

- 10-20 units of intermediate-acting insulin and 6-10 units of fast-acting insulin in the morning before breakfast

- add 6-10 units of fast-acting before lunch or before dinner depending on postprandial levels for those meals

SE of insulin?

hypoglycemia

what are second line pharm treatments for GDM?

- metformin and glyburide are the ONLY noninsulin antihyperglycemics used in pregnancy

what are the SE of metformin and glyburide?

- glyburide can cause hypoglycemia (metformin doesn't)

what are the 2 classes of GDM?

- A1: glycemic control achieved WITHOUT medication

- A2: glycemic control achieved WITH medication

when / why do an US for a pt with GDM?

36-39 weeks to screen for macrosomia

when would a cesarean birth be appropriate in a pt with GDM?

- at 39 weeks if EFW is >= 4500 g

for A1 GDM, offer what at 39 weeks? what additional testing is needed

induction

*not at an increased risk for stillbirth

*does not require additional antenatal fetal testing (NST, BPP)

for A2 GDM, what is checked at 32 weeks?

- NST and amniotic fluid check x 2 weeks

- induction at 39 weeks OR between 37 and 38+6 weeks if patient has suboptimal glycemic control

after birth, effects of hPL stop quickly.

do most pt need to continue medication? how do you confirm good glycemic control?

- no most -return to prepregnancy glycemic status shortly after delivery

- can stop antihyperglycemics

- check fasting glucose level to confirm

when does glucose return to pre preg state?

within a week

All patients should have a _______ between 4 and 12 weeks postpartum

2-hour GTT

2-hour GTT:

- pt is FASTING and given a 75 g oral glucose

- measure serum glucose 2 hours after administration

- Prediabetes = ___________ mg/dL

- Diabetes = >= ___________ mg/dL

- If test is abnormal, refer for management as medically indicated

140-199

200

what are the pre-GDM glucose targets for fasting and postprandial

- fasting 70-95 mg/dL

- 1-hour postprandial 110-140 mg/dL or 2-hour postprandial 100-120 mg/dL

how to treat pre-GDM?

- nutritional therapy for all

- insulin if pharmacotherapy is needed

- if already on oral antihyperglycemics at first prenatal visit = discontinue and transition to insulin

what is pre-GDM A1C goals each trimester?

- goal of < 6 or < 7 percent depending on risk of causing hypoglycemia

what are 2 other pharm management options for pre-GDM for preeclampsia prophylaxis? when do they start?

- folic acid

- aspirin 81mg --> 12 weeks -(for preeclampsia prophylaxis)

for pre-GDM, use an US at ________ weeks and repeat q 4 weeks (to assess fetal growth)

what other test do you use in pt is at increased risk of a still birth at 32 weeks?

28

- twice weekly NST/BPP starting at 32 weeks

Fetal effects of maternal HTN

- preterm birth, low birth weight, reduced placental perfusion, oligohydramnios, placental abruption

New onset HTN WITH proteinuria > 20 weeks OR with s/sx of end-organ dysfunction

Preeclampsia

what is the typical vs severe presentation of preeclampsia?

- typical = new onset HTN and proteinuria (90% of cases occur >= 34 weeks)

- severe = new onset HTN >= 160/110 mmHg + headache/blurred vision/abd pain/AMS/dyspnea

what labs will stand out for preeclampsia?

- UA = protein/Cr ratio >= 0.3 or >= 2+ protein on a dipstick

- platelets < 100,000 cells/microL

- serum Cr > 1.1 mg/dL

- liver transaminases > 2x the upper limit of normal (ULN)

how to manage preeclampsia with severe HTN?

- antihypertensive tx -(labetalol, hydralazine, nifedipine)

what do you give for seizure prophylaxis?

- magnesium sulfate

what is the definitive treatment of preeclampsia

Delivery

if pt is > 37 weeks gestation with preeclampsia, delivery or expectant management?

delivery

if pt is < 37 weeks gestation with preeclampsia, delivery or expectant management?

- severe = delivery regardless of gestational age

- typical = expectant management, deliver once 37 weeks

what is the protocol for expectant management in preeclampsia < 37 weeks

- CBC/CMP at least twice weekly

- BP check at least twice DAILY

- daily kick counts and twice weekly NST/BPP

- corticosteroids if < 34 weeks gestation

onset of seizures or coma in a patient with preeclampsia

Eclampsia

presentation of eclampsia

- prodrome: HTN, headache, visual disturbances, RUQ/epigastric pain (minutes/hours before initial seizure)

- seizure: self-limited tonic-clonic, usually resolves within a few minutes

- on exam: brisk DTRs, vision deficits, AMS, cranial nerve deficits

how to diagnose eclampsia?

clinical diagnosis based on new onset seizures in preeclampsia and absence of other causative conditions

how to manage eclampsia?

- maternal ABCs

- IV lorazepam or midazolam if initial seizure does not resolve within 5 minutes

- treatment of severe HTN

- magnesium sulfate for prevention of recurrent seizures

-Evaluate for delivery

What is HELLP syndrome in pregnancy?

H- Hemolysis

E- Elevated liver enz

L- Liver enzymes

L - Low Platelets

how does HELLP present?

- RUQ/epigastric pain, proteinuria, malaise, HTN, N/V, headache, vision changes, jaundice

how to dx HELLP

- hemolysis: schistocytes/burr cells on peripheral smear, serum bilirubin >= 1.2 mg/dL, hgb < 8 g/dL

- liver enzymes: AST or ALT >= 2x ULN

- low platelets: < 100,000 cells/microL

how to manage HELLP

- hepatic imaging: for bleeding

- IV Mg sulfate: for seizure preventions

- prompt delivery: for severe or if > 34 weeks

*vaginal birth preferred unless hepatic bleeding present

New onset BP >= 140/90 mmHg on at least 2 occasions 4 hours apart after 20 weeks gestation

- NO proteinuria or s/sx of end-organ dysfunction

Gestational HTN

when should HTN resolve?

within 12 weeks postpartum

persist = chronic

what labs stand out for HTN?

UA = no proteinuria

- no signs of end organ damage

how to manage severe htn

same as preeclampsia

how to manage htn < 160/110 mmHg

- BP check twice weekly and UA/CBC/liver panel weekly

- BPP or NST twice weekly

- deliver at 37 to 39 weeks

HTN present before conception or first recognized before 20 weeks gestation

Chronic HTN

early pregnancy management of chronic HTN

- labetalol or nifedipine

- aspirin 81mg daily starting at 12 weeks (prevention of preeclampsia)

- review and optimize antihypertensives (avoid ACEIs/ARBs) and monitor BP at home

what are the 2 antenatal surveillance of chronic HTN?

- monitor for FGR starting at 28 weeks

- weekly NSTs or BPPs starting at 32 weeks

when is delivery induced for a pt with chronic HTN?

39 weeks

severe form of nausea/vomiting in pregnancy

-N/V associated with hypovolemia (hypotension, dizziness, thirst, tachycardia, decreased urine volume, weight loss)

Hyperemesis Gravidarum

what do you check on the CMP for a pt with hyperemesis gravidarum?

CMP for electrolyte abnormalities (low K+) and UA for ketones and specific gravity

If sxs of hyperemesis gravidarum start AFTER the 1st trimester, what should you do?

assess for other causes

what sxs would prompt eval for an alternative eti?

abdominal pain, diarrhea, fever

how to manage hyperemesis gravidarum?

- ER or L&D unit if evidence of hypovolemia = baseline EKG, aggressive rehydration, thiamine, electrolyte replacement

- PPIs + antiemetics (typically ondansetron if hospitalized)

- short period of gut rest followed by reintroduction with liquids and bland/low-fat foods

Rare but OBSTETRIC EMERGENCY

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

Acute Fatty Liver of Pregnancy

when does acute fatty liver of pregnancy present?

30 - 38 weeks

how to dx acute fatty liver of pregnancy present?

- clinical diagnosis based on symptoms and supporting lab findings

- aminotransferases 5-10x ULN

how to manage acute fatty liver of pregnancy?

- delivery REGARDLESS of gestational age

-

when does liver function normalize in acute fatty liver of pregnancy?

within 7-10 days postpartum

what is the most common liver disease unique to pregnancy?

presents with generalized pruritus in the 2nd or 3rd trimester

Intrahepatic Cholestasis of Pregnancy

how to manage intrahepatic cholestasis of pregnancy?

ursodiol until delivery

what is the MC pathogen in Asymptomatic Bacteriuria and Uncomplicated UTI?

e. coli

how to dx Asymptomatic Bacteriuria and Uncomplicated UTI?

- urine culture to screen for bacteriuria at first prenatal visit

how to manage bacteriuria?

cystitis?

- bacteriuria = antibiotics tailored to culture results (amoxicillin, cephalexin) x 5-7 days

- cystitis = empiric cefpodoxime, amoxicillin-clavulanate, or fosfomycin, then tailor to culture results

untreated bacteriuria can lead to what complication?

preterm birth, low birth weight

complicated UTI = involves upper urinary tract and kidneys

- fever, flank pain, N/V, +/- CVA tenderness or typical symptoms of cystitis

- UA and culture confirm bacteriuria

- Renal US not routinely ordered but consider in severely ill patients or hx renal issues

Pyelonephritis

how to manage pyelonephritis

- hospitalize for IV antibiotics until afebrile for 24-48 hours

- ceftriaxone or piperacillin-tazobactam for initial empiric therapy

- low-dose antimicrobial for remainder of pregnancy to prevent recurrence (INFECTION IN THE KIDNEYS)

Rare but incidence increases in 2nd and 3rd trimesters

- Acute flank pain with radiation to lower abdomen/groin, hematuria

-UA showing hematuria, +/- pyuria

-BMP to assess kidney function (KIDNEY STONES)

Nephrolithiasis

how to dx gestational nephrolithiasis

Renal US to check for stone and hydronephrosis

how to manage nephrolithiasis

- most stones pass spontaneously

- If obstructing/septic/acute kidney injury -> emergent surgical management regardless of gestational age

pregnancy can increase progression of what dz?

Chronic Kidney Disease

what are the complications of CKD?

worsening renal function

how to manage CKD

- monitor by nephrologist and maternal-fetal medicine subspecialist

- daily BP checks

- aspirin 81mg starting at 12 weeks to reduce risk of preeclampsia

-Increased routine prenatal visits:

- 1st trimester - monthly

- 2nd trimester - every 2 weeks

- 3rd trimester - weekly

for surgical conditions in pregnancy, is radiation treatment ok?

low dose radiation is okay for fetus

in the perioperative period, what about the fetus do you monitor

fetal heart tone

what position should surgeons avoid in a preg pt operation?

avoid supine

what is a GI complication of sx?

delayed gastric emptying --> aspiration during sx

what pt prep is needed for all preg pt operations?

pneumatic compression devices for all preg pt

what prophylaxis is needed 24-34 weeks before sx to reduce perinatal morbidity and mortality?

glucocorticoids

_____________ is more common in pregnancy than in not preg

actuate cholecystitis

how to dx