Preexisting Risk in Pregnancy

What is the most common endocrine disorder associated with pregnancy?

Diabetes mellitus.

What causes diabetes mellitus?

Impaired insulin secretion, inadequate insulin action, or both.

What is pre-gestational diabetes?

Diabetes that exists prior to pregnancy.

Why is hyperglycemia dangerous in pregnancy?

It is teratogenic and causes congenital malformations, miscarriage, macrosomia, and birth trauma.

What neonatal complications are associated with uncontrolled DM?

Respiratory distress, microvascular damage, hypoglycemia.

Why is pre-pregnancy glucose control important?

To reduce congenital anomalies and complications.

What is gestational diabetes mellitus (GDM)?

Carbohydrate intolerance with onset or first recognition during pregnancy.

What are White's classifications for GDM?

A1 (diet controlled) and A2 (requires insulin).

Which type of GDM is most common?

A1 (diet controlled).

First trimester DM risk for mom?

Hypoglycemia and miscarriage.

Why hypoglycemia occurs early pregnancy?

Glucose is shunted to fetus.

Later pregnancy risks with DM?

IUFD, macrosomia, HTN, preeclampsia, polyhydramnios, infections.

What defines macrosomia?

>4000 g or >90th percentile.

Why does macrosomia occur?

Insulin acts as growth hormone.

What causes polyhydramnios in DM?

Fetal hyperglycemia → polyuria.

What infections are common with DM?

Yeast infections and UTIs.

What is DKA range in pregnancy?

Blood glucose ~200-250 mg/dL.

First trimester fetal risk?

Congenital anomalies (CV and CNS).

Later pregnancy fetal risks?

Placental insufficiency, macrosomia, birth trauma.

Common birth injuries with macrosomia?

Brachial plexus injury, fractures, facial nerve injury.

Neonatal risks with DM?

Prematurity, respiratory distress, hypoglycemia.

Why respiratory distress occurs?

Insulin inhibits surfactant production.

Why neonatal hypoglycemia occurs?

Loss of maternal glucose after cord cut.

Ideal A1C in pregnancy?

6-6.5%.

Fasting glucose goal?

60-105 mg/dL.

1-hour postprandial goal?

<140 mg/dL.

2-hour postprandial goal?

<120 mg/dL.

Early morning glucose goal?

>60 mg/dL (2-6 AM).

What labs assess kidney function?

24-hour urine protein and creatinine clearance.

Why check thyroid labs in DM?

Thyroid disorders are associated with DM.

How often prenatal visits?

1-2 weeks early; 1-2x/week in 3rd trimester.

Exercise recommendation?

Walking or swimming 20-30 min/day.

Who should NOT exercise?

Patients with vascular compromise, ketosis, neuropathy.

Why check urine ketones instead of glucose?

Glucose normally present in pregnancy urine.

Preferred delivery timing?

39-40 weeks.

Why induction may occur?

Placenta does not last long; risk increases.

Major complications requiring hospitalization?

Poor control, DKA, infection, preeclampsia.

When screen for NTDs in DM pregnancy?

15 weeks (AFP test).

When perform fetal echo?

20-22 weeks.

When start NSTs?

By 32 weeks (biweekly).

How often ultrasound for growth?

Every 3-4 weeks.

What daily monitoring is required?

Fetal kick counts.

How does glucose cross placenta?

Facilitated diffusion.

Does insulin cross placenta?

No.

When does fetus produce insulin?

Around 20 weeks.

First trimester metabolic state?

Anabolic (stores nutrients).

What happens to maternal glucose early?

Decreases (hypoglycemia).

Second/third trimester effect?

Diabetogenic state (insulin resistance).

Why insulin resistance occurs?

Hormonal changes.

What happens postpartum to baby glucose?

Drops rapidly after cord cut.

When screen for GDM?

24-28 weeks.

High-risk screening timing?

24-26 weeks.

Diet recommendation?

2000-2500 kcal/day.

Exercise recommendation?

45 min/day.

Medications used?

Insulin, metformin, glyburide (PO not FDA approved).

Postpartum insulin needs?

Decrease significantly.

Long-term risk after GDM?

Type 2 DM (20% within 10-20 years).

Breastfeeding effect on glucose?

May reduce insulin needs.

What happens to thyroid hormones in pregnancy?

T3 and T4 increase.

What stimulates TSH?

hCG.

Most common cause of hyperthyroidism?

Graves' disease.

Hyperthyroid S/Sx?

Goiter, weight loss, pulse >100 bpm.

1st trimester drug for hyperthyroid?

PTU.

2nd/3rd trimester drug?

Methimazole.

Why switch drugs?

PTU → liver risk; MMI → teratogenic early.

Untreated hyperthyroid risks?

Preterm birth, miscarriage, heart failure.

Most common cause of hypothyroidism (US)?

Hashimoto's thyroiditis.

Hypothyroid lab finding?

Increased TSH.

Treatment for hypothyroidism?

Levothyroxine.

How to take levothyroxine?

Empty stomach, separate from iron.

What causes PKU?

Deficiency of phenylalanine hydroxylase.

What happens in PKU?

Cannot metabolize phenylalanine → toxic buildup.

Effects of untreated PKU?

Intellectual disability, microcephaly.

Preconception PKU management?

Restrict phenylalanine before conception.

Target phenylalanine level?

<6 mg/dL.

Can PKU moms breastfeed?

Yes, unless baby also has PKU.

When should SLE patient conceive?

After 6 months remission.

Maternal risks with SLE?

Miscarriage, preeclampsia, preterm birth.

Fetal risks?

IUGR, stillbirth, preterm birth.

Safer medication in pregnancy?

Hydroxychloroquine.

Why avoid prolonged NSAIDs?

Premature ductus arteriosus closure.

Delivery timing for SLE?

Around 39 weeks.

What is MG?

Muscle weakness disorder affecting skeletal muscles.

Does MG affect labor muscles?

No (smooth muscle unaffected).

Medications to avoid in MG?

Magnesium sulfate, opioids (caution).

Neonatal risk?

Neonatal myasthenia (temporary).

Resolution time?

Usually resolves by 72 hours (up to 6 weeks).

What increases in pregnancy?

Blood volume (~50%).

Cardiac output increase?

30-45%.

When CO peaks?

25-30 weeks.

Early sign of cardiac decompensation?

HR >100 bpm, RR >25.

Goal of cardiac care?

Minimize cardiac stress.

Contraindicated meds?

ACE inhibitors, warfarin.

Safe anticoagulants?

Heparin, Lovenox.

Preferred birth method?

Vaginal.

Preferred position?

Left lateral.

Avoid during labor?

Valsalva, supine, stirrups.

Pain control?

Epidural.

Avoid meds?

Terbutaline, methergine.

Subjective signs?

Fatigue, dyspnea, cough, palpitations.