Pregnancy Complications Pt. 2

What pregnancy complication occurs when Glucose crosses placental barrier (facilitated diffusion) --> the higher the maternal glucose, the higher the fetal glucose?

gestational DM

What are some RFs for gestational DM?

1.Age

2.Ethnicity

3.Previous GDM

4.Previous large for gestational age infant

5.Obesity

6.Strong FH DM

What is the management for gestational DM?

•Home glucose monitoring

•MAINSTAY is diet

•Fasting glucose of < 95mg/DL

•1hr postprandial levels < 140mg/dL

•2hr postprandial < 120mg/dL

•Medications: combo of intermediate acting neutral protamine Hagedorn (NPH) & fast acting insulin (lispro)

If a pt has a results of glucose intolerance test of >140-- what is next?

proceed to 3hr test

If a pt has a results of glucose intolerance test of >190-- what is next?

dx of gestational DM

What are the expectations for glucose intolerances test that is 3hrs?

•If 1 of the results is ↑ than normal, you'll likely need to test again in 4 wks.

•If ≥ 2 of the results are ↑ than normal, you'll be dx w/ GDM

•1hr < 180 : normal

•2hrs < 155 : normal

•3hrs < 140 : normal

What occurs as Swelling/inflammation of the thyroid causing low or high levels of thyroid hormones?

postpartum thyroiditis

What is the MC reason for hospitalization in the 1st half of pregnancy?

hyperemesis gravidarum

What is the 1st line tx for N/V in pregnancy?

Vit. B6 +/- doxylamine (Diclegis)

What is the tx for GERD in pregnancy?

•Typically resolves after birth

•Lying down w/in 3hrs of eating

•Avoid eating w/in 3hrs of bedtime

•Avoid tight fitting clothing

•Avoid acidic foods

•Wedge pillow

•Antacids OTC (avoid NaHCO3)

•H2RAs, PPIs

What is the tx for PUD in pregnancy?

•Histamine antagonists are 1st line treatments

•Tx for H. Pylori (if present) should be delayed until after pregnancy/breastfeeding are completed

What can occur in pregnancy with intense itching of palms and soles with NO rash?

intrahepatic choletasis

What is the tx for intrahepatic cholestasis of pregnancy?

ursodeoxycholic acid (↓ plasma bile acids), antepartum fetal surveillance, delivery at 37wks

What are the diagnostics for acute fatty liver?

•Difficult to dx from preeclampsia, Dx: liver bx

•**↑bilirubin, ↓fibrinogen & liver dysfunction less common in preeclampsia

What is the tx for acute fatty liver?

•intensive supportive care & prompt delivery

What is the common organism causing UTI's in pregnancy?

Ecoli

If a pregnant pt is asymp with a UTI how are you treating them?

ampicillin, cephalexin or Macrobid (nitrofurantoin) x 3 days

What type of HTN:

•present before pregnancy or before 20th week of gestation or that persists > than postpartum period (12 weeks after delivery)

chronic

What type of HTN:

•develops for the 1st time > 20 weeks of gestation in the absence of proteinuria

gestational

What type of HTN:

•development of hypertension with proteinuria > 20 weeks of gestation

preeclampsia

What type of HTN:

•additional presence of convulsions in a women w/ preeclampsia that isn't explained by a neurologic disorder

eclampsia

What type of HTN:

•presence of hemolysis, elevated liver enzymes, and low platelet count

HELLP syndrome

What type of HTN:

•sudden constriction of a blood vessel

maternal vasospasm

What are the 1st line agents for chronic HTN in pregnancy?

•Labetalol (combined α & β-blocker)

•CCB's - nifedipine or amlodipine

•Methyldopa has been widely used for decades, however not as effective.

•Diuretics can be cont'd if pt. already taking

What will be absent in a dx of gestational HTN?

proteinuria

What is preeclampsia?

1) Refers to new onset of HTN & proteinuria

OR

2) new onset of HTN + significant end organ dysfunction w/ or w/o proteinuria after 20wks gestation or postpartum

What medication can be used to prevent eclamptic convulsions?

Magnesium Sulfate IV

What antihypertensive medications can be used to tx eclampsia if systolic BP is >160?

•Hydralazine initially

•Labetalol

What does HELLP syndrome stand for?

•Hemolysis

•Elevated Liver enzymes

•Low Platelet count

What is the diagnostic criteria for HELLP?

LDH >=600

AST and LT >=2x upper limit

plt <100,000

What is the tx for HELLP syndrome?

•Anti-hypertensive medication (IV labetalol)

•IV corticosteroids

•Delivery ASAP

What is the first line therapy for asthma?

•Inhaled corticosteroid, budesonide

What = Rh incompatibility

?

woman is Rh- & fetus Rh+

What is the term for when bilirubin deposits on basal ganglia and can cause permanent neurologic symptoms/ death?

Kernicterus

A diagnosis of hydrops fetalis needs at least two of what criteria?

1.Pericardial effusion

2.Pleural effusion

3.Ascites

4.Subcutaneous edema

What medication stops the body from making Rh antibodies if it has not already made them, is given as an injection, and destroys Rh + cells in woman's body to prevent Rh +Abs from being made?

rhogam

When is Rhogam administered?

•300 mcg IM x 1 at 28 wks gestation

•300 mcg IM x 1 within 72h of delivery

How does a fetus with hemolytic disease present?

•Elevated bilirubin at birth --> Kernicterus

•Anemia à Erythroblastosis (increased immature RBCs in circulation) --> high-output cardiac failure --> hydrops fetalis (fluid accumulation)

•Hepatosplenomegaly

What is the management for a newborn with hemolytic disease?

•Transfusion of Rh-negative donor blood to the fetus

•UV light (phototherapy) used to correct hyperbilirubinemia

What is the follow up for a newborn with hemolytic disease?

•Monitor infants Hgb 1-2x a wk until 3 months of life

What is a Systemic autoimmune disorder characterized by venous or arterial thrombosis &/or an adverse pregnancy outcome in the presence of persistent laboratory evidence of antiphospholipid antibodies (aPL)?

antiphospholipid syndrome (APS)

What are the two ALP detection tests?

•lupus anticoagulant (LA), anticardiolipin antibodies (aCL)

What is the tx for antiphospholipid syndrome? (APS)

81mg Aspirin or unfractionated Heparin when pregnancy begins

What is an Autoimmune condition in which anti-platelet autoantibodies interfere w/ platelet production & cause destruction of circulating platelets?

idiopathic/immune thombocyptopenia

What presents with pain, tenderness, induration, & erythema along the course of a superficial vein? And how are you treating it?

superficial thrombophlebitis

•Tx: Can be self limiting, compression stockings, warm compress

What is one of the leading causes of maternal mortality and occurs with venous stasis, endothelial injury, and hypercoagulability?

DVT

What is the tx for DVT?

heparin

What can present with SOB/CP and how are you treating it?

PE

•Tx: LMWH, oral anticoags not safe, may perform IVC filter

What does TORCH stand for?

toxoplasmosis

zika, syphillis, varicella

rubella

cytomegalo

herpes

What infection can occur from cleaning a liter box and presents with fever, chills, LAD?

toxoplasmosis

What are these fetal outcomes associated with ?

•Intracranial calcifications, hydrocephalus, IUGR, ascites, fetal demise, severe mental retardation

•blindness

toxoplasmosis

What are the diagnostic tests for toxoplasmosis?

•Fetal US for prognostic info

•Serologic testing IgM & IgG

•Amniocentesis 18wks w/ PCR of amniotic fluid confirms

What is the tx for toxoplasmsosis?

•Spiramycin*

•Wash/handle/cook food thoroughly

What is an RNA virus that is typically mild/self limiting and can have the fetus present with a blueberry muffin rash?

rubella (german measles)

What are these fetal outcomes associated with ?

•Deafness, cataracts, Cardiac malformations (PDA)

•“blueberry Muffin” lesions

•IUGR/hepatosplenomegaly

rubella

What is the diagnostic test for rubella?

PCR

What is the tx for rubella?

vaccination, APAP

What is a DNA herpes virus that is MC congenital and transferred via daycares?

CMV

What are these fetal outcomes associated with ?

•Cerebral palsy

•Vision impairment

•Seizures

•Intellectual disability

•Leading cause of nonhereditary sensorineural hearing loss

CMV

What are the diagnostics for cytomegalo?

•Serology of CMV specific IgG

•Amniocentesis to perform PCR of fluid**

•US markers and monitoring

What is the tx for CMV?

supporative

What is a double stranded DNA virus that can present with tender vesicles w/ ulceration followed by crusting?

HSV

What are these fetal outcomes associated with ?

•Most appear normal at birth

•Localized to skin/eyes & mouth

•Localized CNS

•Disseminated disease involving organs

HSV

What are the diagnostics for HSV?

•Cell culture confirms

•PCR more sensitive

•Serologic testing

•Vertical transmission during birth

What is the tx for HSV?

•no lesions present during labor - vaginal can be safe

•Active - C-section

•Antiviral suppressive tx leading up to delivery for those with hx

What is a spirochete (treponella pallidum) caused infection that is transferred via vertical transmission and the mom will present with a macular lesion?

syphillis

What are these fetal outcomes associated with ?

•Stillbirth

•Hydrops fetalis

•Prematurity

•Spontaneous abortion

•Jaundice

•LAD/HSM

syphillis

What are the diagnostic tests for sphyillis?

•Routine screening on all women at 1st visit

•High risk recheck 28-32wks

•DX serologic testing

•VDRL, RPR test

What virus is an arthropod borne falvivirus transmitted by mosquitos that can have a mother present with a maculopapular rash, arthralgia, conjunctivitis, and fever?

zika

What are these fetal outcomes associated with ?

•Severe anomalies

•Microcephaly

•Facial disproportion

•Seizures

•Hypertonia

•Sensorineural hearing loss

Zika

What is the diagnostic tool for zika?

US

What are these fetal outcomes associated with ?

•Cutaneous scars

•Cataracts

•Hypoplastic limbs

•Cortical atrophy

•Nystagmus

VZV

What is the tx for zika virus?

rest and symp. tx

What causes vesicular lesions along a dermatome to form?

VZV

What is the tx for syphillis?

PCN G

What is the dx for VZV?

clinical

PCR

What is the tx for VZV?

PO Acyclovir

When is strep B screening done?

36-37wks

What is the tx/prophylaxis for group B strep?

Abx prophylaxis in labor/rupture of membranes

•PCN, Ampicillin or cefazolin.

•Allergy: Clindamycin

What sti can be acquired during delivery and the mom can have symptoms of cervicitis, urethritis, PID, and discharge?

gonorrhea

What are these fetal outcomes associated with?

•Ophthalmia (newborn purulent conjunctivitis) – can cause blindness

•IUGR, PROM

gonorrhea

What are these fetal outcomes associated with?

•Purulent conjunctivitis (not the same as gonorrhea)

•Pneumonia

chlamydia

What is the MC sti that is often associated with postpartum endometritis and infertility?

chlamydia

What are these fetal outcomes associated with?

•laryngeal papillomatosis

HPV

What virus is an STI or can be obtained thru IV drug use, doesnt affect pregnancy, and has perinatal transmission?

HIV

What can be diagnosed via an abnormal pap during pregnancy and can present with genital warts?

HPV

What is the tx for gonorrhea?

•Ceftriaxone + azithromycin

•Azithro > doxy

What is the tx for chlamydia?

•Azithromycin* or amoxicillin

What is the tx for HIV?

•Anti-viral

•Delivery precautions - planned c-section

•Avoid breast feeding

What is the tx for HPV?

•CIN 1: defer tx until PP

•CIN 2-3: may tx

•Warts: TCA or cryo

What is the MCC of jaundice in pregnancy?

acute viral hep

If a mother is Hep B surface antigen + or detectable serum---- what should the baby receive at birth?

1st dose of hep B vaccine at birth

What is the HBV transmission to a fetus?

vertical transmission

Infants who received hepatitis B immune globulin (HBIG) & the 1st dose of hepatitis B vaccine at birth ____ be breastfed

can

Can a HCV + mother breast feed?

yes- as long as no open cuts or sores

What can occur with an increase in gallstones and RUQ pain?

cholecystitis

What are some causes of pancreatitis?

•Gallstones

•ETOH

•Triglycerides

•Acute fatty liver

What are the causes of bowel obstruction?

•Adhesions

•Hernias

What are the 2 leading causes of trauma that can lead to abruption, rupture, or hemorrhage?

1.MVA

2.Violence (partner)

What can present with severe pain, vomiting, and peritonitis? What is the tx?

adnexal torsion

surgery in 2nd trimester (laproscopy)