5.1 Pregnancy - Terrell

what are the most important recs for preconception planning?

stop smoking, drinking, and doing illicit drugs

limit caffeine

exercise

have a balanced diet

increase iron in diet

what are the consequences of being iron deficient while pregnant? (4)

Anemia during infancy, spontaneous abortion, premature delivery, low birth weight at delivery

What is the recommended iron intake during pregnancy? and eating iron rich foods with ____ leads to better absorption

30 mg/day

vitamin C

all women who ever plan on having a child should take ___ supplements. why is this?

folic acid; prevents neural tube defects

folic acid:

1. recommended daily dose in women

2. when to take it

1. 0.4-0.8 mg

2. prior to and during the first trimester

Why is calcium important during pregnancy?

Needed for adequate mineralization of fetal skeleton and teeth

when is calcium supplementation most important for women and how much should they have in one day?

3rd trimester

1000 mg

What happens if calcium intake is not adequate during pregnancy?

the baby will take the mothers calcium increasing the risk of osteoporosis later in life

where does fertilization occur?

fallopian tubes

What happens during the first 2 days after fertilization?

Cell division while traveling down the tube

When do the fertilized cells reach the uterine cavity?

about day 3

What happens after reaching the uterine cavity?

More cell division for 2–3 days, then implantation begins

When does the blastocyte form?

about day 6

What hormone is produced at the blastocyte stage?

hCG

What happens after full implantation of cells?

receives nutrition from the maternal blood forming the embryo

what produces hCG?

trophoblasts

____ eventually become part of the placenta. which are responsible for producing hCG.

trophoblasts

What are the two subunits of hCG? and describe each

alpha: identical to other pitutiary hormones (LH, FSH, and TSH)

beta: specific to hCG

What is the main function of hCG?

Maintains the synthesis of progesterone until the placenta is able

when is the placenta able to maintain the synthesis of progesterone?

about 8 weeks pregnant

when is hCG detectable in material circulation and urine?

about 11 days post conception

How do hCG levels change early in pregnancy?

Increase rapidly (doubling ~every 2–4 days)

When do hCG levels peak?

60-70 days (decrease after that)

how is pregnancy confirmed?

2 at home pregnancy tests and then a blood test at the dr office

when is the heartbeat usually first seen?

about week 6

what foods should be avoided during pregnancy?

food with mercury (fish)

eggs

cold deli meat

unpasteurized milk and cheese

name two things that pregnant women cant do

change cat litter and get in the hot tub

(win some lose some)

when is the embryonic period of pregnancy and what occurs during this phase?

2-8 weeks after fertilization; most body structures are formed

when is the fetal period and what occurs during this phase?

8-40 weeks; body structures grow and mature

how long is the typical pregnancy? and how is this determined?

40 weeks (9-10 m)

from day of last period to birth

what is gestational age

Age of embryo or fetus beginning with the 1st day of last period

How is the due date calculated of a preg woman

add 7 days to the 1st day of the last period and subtract 3 months

or just do an ultrasound

what are the weeks assoc with each trimester

0–12 weeks; 13–26 weeks; 27 weeks to end

signs of pregnancy

no period

changes in discharge

increased skin pigmentation

anatomic breast changes (get bigger)

symptoms of pregnancy

fatigue

increased urination

breast tenderness

nausea

vomitting

fetal movement in abdomen

when does N/V begin and end with pregnancy

begins around week 6

resolves around weeks 12-18

when does the baby start kickin

about 16-20 weeks along

function of the placenta

Gas exchange; transfer of nutrients and waste

Transfer of immunity

Secretion of hormones

Physical protection

how do substances cross the placenta

Simple diffusion (O2 and CO2)

Active transport (amino acids, glucose)

Facilitated diffusion

what characteristics makes it easier for things to diffuse across the placenta?

nonionized

lipophilic

low molecular weight

low protein binding

limit taking medications during organogenesis of pregnancy, when is this? and why?

weeks 2-10

can cause loss of pregnancy, structural abnormalities, and impaired growth

name some problematic drugs to take during pregnancy for infectious diseases

fluroquinolones (-floxacin)

sulfonamides (bactrim)

tetracyclines (minocycline etc)

trimethoprim (bactrim)

name some problematic drugs to take during pregnancy for heme/onc diseases

chemotherapy

thalidomide

SERMs (raloxefine, tamoxifen etc)

name some problematic drugs to take during pregnancy for cardio diseases

ACEi (-prils)

ARBs (-sartans)

HMG CoA reductase inhibitors (- statins)

name some problematic drugs to take during pregnancy for CNS diseases

anticonvulsants (keppra etc)

benzodiazepines (lorazepam etc)

name some problematic drugs to take during pregnancy for random diseases (not anything mentioned yet)

NSAIDs

methotrexate

methimazole and propylthiouracil

5 alpha reductase inhibitors

retinoic acid derivatives

live vaccines

how to treat N/V in pregnancy (nonpharma)

small frequent meals with low fat, dry, and blandness #ew

avoid spicy and highly smelly foods

take naps and work less #yay

hyperemeis gravidarum

1. what is it

2. characteristics/signs/symps

3. what do pts have to do for tx

1. intractable vomitting

2. weight loss of 5% or more of prepregnancy weight, ketonuria and ketonemia, electrolyte abnormalites

3. hospital stay

medications for N/V in pregnancy

doxylamine and vitamin B6 (pyridoxine)

diphenhydramine

meclizine

hydrozyzine

what are the types of DM during preg

pregestational DM

preDM

gestational DM

define the following

1. pregestational DM

2. preDM

3. gestational DM

1. already diagnosed with DM or at first screening presumed to have undiagnosed DM

2. looking for undiagnosed DM

3. DM only during later portion of preg

What is the ideal A1c prior to pregnancy to prevent pregestational DM

<6.5%

describe glucose levels during the first trimester

fluctuating bc insulin resistance increases in preg due to hormones

What complication risk is increased in pregestational diabetes?

development and progression of retinopathy

What eye exam is recommended for patients with pregestational diabetes? and when?

Dilated eye exam before pregnancy or during 1st trimester, then each trimester and for 1 year postpartum

What type of malformations are associated with pregestational diabetes? and when does this occur?

Neural tube defects (NTDs) before week 7

What A1C level carries the same risk as giving teratogens?

>12%

What is macrosomia? and why does it occur

Birth weight >4 kg;

Fetal hyperglycemia and hyperinsulinemia with disproportional fat distribution

What happens to the baby after delivery in pregestational diabetes?

hypoglycemia

What are other risks associated with pregestational diabetes?

preeclampsia

congenital anomalies

how to prevent preeclampsia

give ASA at 12 weeks preg

When should screening for early abnormal glucose metabolism occur?

prior to 15 weeks

What indicates early abnormal glucose metabolism?

fasting glucose of >/- 110

or

A1C >/- 5.9%

What are patients with early abnormal glucose metabolism at higher risk for?

Adverse pregnancy and neonatal outcomes; needing insulin treatment; later gestational diabetes diagnosis

RF to gestational DM

age >25

obesity

fam hx of DM

When should patients with risk factors be tested for undiagnosed diabetes if preg?

At first prenatal appointment

When should screening for gestational diabetes occur?

24-28 weeks

What is the 1-step method for gestational diabetes testing?

75 g, 2-hour glucose challenge

Fasting, 1-hour, and 2-hour readings; cannot fail any readings

What is the 2-step method for gestational diabetes testing?

50 g non-fasting (test at 1 hour);

then 100 g fasting (fasting, 1-hour, 2-hour, 3-hour; must pass 3 readings)

What follow-up is needed after gestational diabetes positive diagnosis?

test for prDM or overt DM at 4-12 weeks postpartum then every 3 years after

What is the first-line treatment approach for gestational diabetes in obese pts

nutritional intervention and caloric restrictions

What type of glucose monitoring is recommended in gestational diabetes?

daily BGM or CGM

What is the main pharmacologic treatment for gestational diabetes?

insulin

What oral medications may be considered for gestational diabetes?

glyburide or metformin (but they both cross placenta)

What medication is used to lower risk of preeclampsia in gestational diabetes? dose? and when?

ASA 100–150 mg/day starting at 12–16 weeks until delivery

When does gestational hypertension typically begin? and what is it characterized by?

After 20 weeks

BP of >140/>90

What physiologic changes occur in pregnancy related to hypertension?

Increase in total body water, increase in RAAS, increased cardiac output

What is first line treatment option for hypertension in pregnancy? what are its ADE?

methyldopa at 500-3000 mg per day divided BID

dizzy, sedation, loss of energy

alternative option to methyldopa for gestational HTN?

dose?

potential ADE?

nifedipine 10-30 mg per day

could inhibit labor

What are the key features of pre-eclampsia?

Hypertension, proteinuria, swelling of face, hands, and feet

What should be monitored in pre-eclampsia?

BP, urine, ultrasound

What are treatment options for pre-eclampsia?

Bedrest + IV hydralazine, labetalol, Na nitroprusside, steroids, magnesium sulfate (to prevent seizures)

What are risks of pre-eclampsia to mom and baby?

C-section delivery (possibly emergent), fetal growth restriction, placental abruption, HELLP syndrome, eclampsia, organ damage

What is eclampsia

Pre-eclampsia + seizures

What happens to thromboembolism risk after age 35?

Incidence doubles

What is the treatment for thromboembolism in pregnancy?

LMWH or heparin throughout pregnancy + 6 weeks

What is the most common infection in pregnant women?
and what can happen if it is left untreated?

UTI —> pyelonephritis

How often should urine be checked in pregnancy

At every prenatal visit

What organism causes most UTIs in pregnancy?

e coli

What antibiotics are safe and effective for UTI in pregnancy?

Cephalexin and nitrofurantoin

What is a risk of sulfa-containing drugs in pregnancy?

Newborn kernicterus

How long is typical UTI treatment in pregnancy?

7–14 days

What is dinoprostone used for?

Cervical ripening

What is misoprostol used for?

Cervical ripening and labor induction

What is oxytocin used for?

Labor induction

What is magnesium sulfate used for?

Tocolytic (stops contractions/ delays contractions)

What are betamethasone and dexamethasone used for?

Fetal lung maturation

What happens to plasma volume, cardiac output, and heart rate in pregnancy?

they all increase

What happens to serum albumin in pregnancy and why does it matter?

it decreases and leads to increased free drug concentration

what happens to renal function in pregnancy?

increased renal blood flow and increased GFR