PHP 328 Final Women's Health I

How is gestational or pregnancy-induced hypertension defined? (mmHg and time)

>140/90 after 20 weeks

What are some complications of gestational or pregnancy-induced hypertension?

Low risk for mild C-section rate increases

How is chronic hypertension defined? (mmHg and time)

>140/90, pre-existing or onset <20 weeks

What are some complications of chronic hypertension?

IUGR, low birth weight, premature birth, target organ damage (TOD)

How is pre-eclampsia hypertension defined?

>140/90 and >300mg proteinuria in 24 hours

What are some complications of pre-eclampsia hypertension?

Headache, visual disturbances, oliguria, upper quadrant pain, increased LFT, HELLP

How is eclampsia hypertension defined?

Pre-eclampsia + seizures

What are some complications of eclampsia hypertension?

Headache, visual disturbances, oliguria, upper quadrant pain, increased LFT, HELLP

How is superimposed hypertension defined?

Chronic + pre-eclampsia

What are some complications of superimposed hypertension?

Headache, visual disturbances, oliguria, upper quadrant pain, increased LFT, HELLP

Severe complications of any pregnancy hypertension type include:

Maternal death, fetal death, TOD (CVA, MI, renal, retinopathy), pulmonary edema, cyanosis, placental abruption, hemorrhage

Hypertension in pregnancy is defined as SBP of ___+ OR DBP of ___+, measured on ___ separate occasions ___(how long)___ apart.

140+; 90+; 2; 4 hours

Severe hypertension is defined as SBP of ___+ AND/OR DBP of ___+, measured twice at least ___(how long)___ apart

160+; 110+; 15 minutes

For chronic hypertension: Treat/titrate/maintain BP at ___/___ based on the _____ study. This study showed that the primary composite of pre-eclampsia with severe features, preterm birth, placental abruption, or fetal/neonatal death was lower in the 140/90 group versus the 160/105 group

140/90; CHAP

Gestational hypertension: Lack of data supporting use of _____ to treat BP, unless it is severe (___/___). Compelling indications that indicate lower thresholds include ________ and _____

antihypertensives; 160/110; renal impairment; comorbidities

The treatment goal is higher during pregnancy: SBP ___-___ OR DBP ___-___. Target BP is higher in pregnant women because of the increased risk for decreased _____ blood flow and impaired _____ development or demise

120-160; 80-110; uteroplacental; fetal

Drugs commonly used to treat hypertension in pregnancy include: (4)

Labetalol, nifedipine, methyldopa, and hydrochlorothiazide

Ward's question she told us to look up in class:

"Why is labetalol different from other beta blockers?"

Labetalol is a mixed antagonist, blocking both alpha-1 and beta-adrenergic receptors (beta-1 and beta-2). While other b-blockers primarily lower heart rate, labetalol's unique alpha-1 blockade reduces peripheral resistance (dilating blood vessels) without decreasing cardiac output.

Is labetalol selective or non-selective?

non-selective

Labetalol: Initial dose

100-200mg BID

Labetalol: Usual dose

200-2400mg/day divided into 2-3x/day

Nifedipine: Initial dose

30-60mg/day BID

Nifedipine: Usual dose

30-120mg/day

HCTZ: Dose

12.5-50mg/day

Labetalol: Avoid in _____, ________, and _____

asthma, heart block, and bradycardia

Nifedipine: Do not use ___ or ___ unless hospitalized. Avoid in _____

SL; IR; tachycardia

HCTZ: 1st, 2nd, or 3rd line?

2nd or 3rd

ACEi and ARB should be _____ in pregnancy, due to fetal and neonatal _____ impairment, _____, congenital malformations, and neonatal death

avoided; renal; oligohydramnios

Diuretics have a ________ in pregnancy, except for patients with ________. There is a diuretic use concern because of decreased plasma volume by 5-10% and decreased uteroplacental blood flow

theoretical concern; heart disease

Atenolol can cause _____ which can cause low ________

IUGR; birth weight

For other hypertension agents in pregnancy, we would _____ the patients. Two other possible agents include _____ and _____

refer; clonidine; a blockers

Preeclampsia can occur in ___(how many)___ different ways

2

Preeclampsia is _____ + _____ (300+mg/24h urine collection or protein creatinine ratio of 0.3+). Usually occurs after ___ weeks' gestation

hypertension + proteinuria; 20

If there is no proteinuria but there is new onset hypertension, the following are indicative of preeclampsia:

- Thrombocytopenia: Platelets <___ cells/uL

- Elevated SCr: >___ mg/dL or doubling

- Increased LFTs (___x ULN)

- Pulmonary edema

- New unresponsive headache and visual signs/symptoms

100000; 1.1; 2

Preeclampsia maternal risks include:

- HELLP: _____, ________, ________

- Disseminated intravascular coagulopathy (DIC)

- Acute _____ failure

- _____ venous thrombosis

- Eclampsia (_____ + _____)

hemolysis, elevated LFTs, lowered platelets; renal; Intracerebral; preeclampsia + seizures

T/F: Eclampsia is a medical emergency

True

Preeclampsia fetal risks include:

- _____ retardation

- Hypoxemia (limited ___)

- Acidosis

- Prematurity

- Death

Growth; O2

Preeclampsia prevention:

___(this drug)___ ___mg/day for high-risk. Start this medication at 12-28 weeks. It decreases risk of severe preeclampsia by ___% and decreases risk of IUGR by ___%

Aspirin 81mg/day; 53%; 44%

Preeclampsia high risk: ___+ of the following:

- Previous _____

- Multifetal gestation

- _____ disease

- _____ disease

- T1DM, T2DM

- Chronic _____

1; preeclampsia; Renal; Autoimmune; hypertension

Preeclampsia moderate risk: ___+ of the following:

- Nulliparity

- Age ___+

- BMI >___

- _____ history

- Sociodemographics

2; 35; 30; Family

Severe preeclampsia is characterized by SBP ___+ OR DBP ___+, worsening signs/symptoms of: Proteinuria, HELLP, SCr, epigastric or RUQ pain, persistent headache

160+; 110+

The only cure for severe preeclampsia is _____. For a preterm baby, use ________

delivery; antenatal corticosteroids

For preeclampsia, IV hypertensives are indicated if BP reaches ___/___. The drug of choice is _____ or an alternative is _____

160/110; labetalol; hydralazine

Preeclampsia treatment:

For labetalol, dose at ___-___mg to start. Then, give ___-___mg Q10min to a max of ___mg or BP control. Can give as a ________, 1-2mg/min with max 300mg

10-20; 20-40; 20; continuous infusion

Preeclampsia treatment:

For hydralazine, give ___mg IV/IM. Then, give ___-___mg IV/IM Q20-40min to a max of ___mg or BP control. Can give as a ________, 0.5-10mg/hr with max 20mg

5; 5-10; 20; continuous infusion

Preeclampsia treatment:

For nifedipine _____, give ___-___mg PO. Repeat ___(how many times?)___ in 20 minutes if necessary, then ___-___mg Q2-6H to a max of ___mg/day.

IR; 10-20; once; 10-20; 180

Preeclampsia treatment:

2nd line options are?

Nicardipine or esmolol continuous infusions

IV _____ is administered for seizure/eclampsia prevention. The dose is ___-___g IV load over 15 minutes. Then, ___g per hour continuous infusion, until ___-___hrs post-delivery

MgSO4; 4-6; 2; 12-24

Cochrane Review:

Study of 11444 preeclamptic women found a ___% decreased rate in progression to eclampsia in those who received MgSO4. ________ was also decreased.

59%; Placental abruption

Signs of magnesium toxicity include: Loss of ________, decreased respiratory rate. Decreased ________ can add to toxicity (cleared renally)

patellar reflex; urine output

Use ___(this drug)___ or ___(this drug)___ for seizure prevention if contraindicated for MgSO4

diazepam; phenytoin (DPH)

_____ stimulates the production of vitamin K dependent clotting factors (___, ___, ___, ___). This causes a decrease in ________ and an increase in ________. It's important to continue treatment for women with a history of DVT/PE, MVR, clotting factor deficiencies, or antiphospholipid antibodies

Estrogen; II, VII, IX, X; antithrombin III; platelet function

Does heparin cross the placenta?

No

Heparin:

- Rapid reversal with ________

- (Less/More) frequent dosing

- _____ should be 2x the control value

aPTT

Prophylactic LMWH: Dosing

Enoxaparin 40mg SC QD

Intermediate LMWH: Dosing

Enoxaparin 40mg SC Q12H

Adjusted-dose LMWH: Dosing

Enoxaparin 1mg/kg Q12H

LMWH:

- (First?/Second?) line for coagulation disorders

- QD or BID dosing

- (Lesser/Greater) cost compared to heparin

- _____ monitoring may be needed

First; Greater; Anti-Xa

Warfarin is not recommended because of ________ and other abnormalities. 30% of exposed pregnancies will result in _____. The highest risk is during the ___ trimester. Still use low-dose warfarin _____ for _____. ________ and intellectual disability associated with 2nd and 3rd trimester use.

fetal warfarin syndrome; malformations; 1st; (<5mg/day); pregnant women with mechanical heart valves; Ophthalmic abnormalities

Pain management/HA:

_____ is the drug of choice because it is safe and not teratogenic at usual doses. Toxic maternal doses may cause fetal _____

Acetaminophen; hepatotoxicity

T/F: ALL NSAIDs cross the placenta

True

NSAIDs:

- May increase risk of early ________ in 1st trimester

- Small, absolute risk for ________, _____, but no _____ in malformations across studies

pregnancy loss; congenital anomaly; gastroschisis; increase

Avoid NSAIDs ___+ weeks because it can cause oligohydramnois and neonatal renal impairment. Use may cause constriction of the ________ in the 3rd trimester

20+; ductus arteriosus

Aspirin can (shorten/prolong) labor and constrict the ________. Analgesic doses (>___mg/day) are NOT recommended. Lower doses (<___mg/day) are fine

prolong; ductus arteriosus; 650; 150

Opioids are associated with ________ syndrome if prolonged use or high doses near term

neonatal abstinence

Opioid withdrawal starts ___(how long)___ after birth, but it can take up to 5-10 days to appear. There is a small absolute risk of congenital anomalies if used during _____. Can cause neonatal ________ when used in labor and delivery

1-3 days; 1st trimester; respiratory depression

For opioid use disorder, both _____ and _____ have been used

methadone and buprenorphine

(None/Some/All) UTIs in pregnancy require antibiotics

All

Asymptomatic bacteriuria is present in ___-___% of pregnancies. If untreated, it progresses to symptomatic in ___-___%. Because of this, screening should be done at <___ weeks gestation

2-15%; 20-35%; <16

Acute cystitis affects ___-___% of pregnancies. This should be treated to prevent progression to _____

1-2%; pyelonephritis

Pyelonephritis affects up to ___% of pregnancies. It's associated with preterm birth, ________, and respiratory distress. Hospitalization for ________ is standard of care

2%; septic shock; IV antibiotics

What to use to treat asymptomatic bacteriuria in pregnancy?

B-lactams (penicillins, cephalosporins) commonly used, but growing resistance to ampicillin, amoxicillin, and fosfomycin (single dose)

What to use to treat pyelonephritis in pregnancy?

Use broad-spectrum B-lactams (ceftriaxone, cefepime, amp/gent). Avoid nitrofurantoin and fosfomycin.

For all UTIs in pregnancy, avoid these:

- Nitrofurantoin ___+ weeks, for patients with G6PD deficiency because of risk for ________

- Sulfas: Avoid at the _____ of gestation. Causes newborn _____

- Trimethroprim is contraindicated in the ___ trimester. It's a folate antagonist which is associated with _____

- Fluoroquinolones are _____

- Tetracyclines are _____ due to ________

37+; hemolytic anemia; end; kernicterus; 1st; malformations; contraindicated; contraindicated; teeth discoloration

Preterm labor is defined as labor before ___ weeks gestation

37

Major risk factors for preterm labor:

- Prior _____ birth

- _____ gestations

- Race/ethnicity

preterm; Multiple

Modifiable minor risk factors:

- Poor maternal ________

- Smoking

- Anemia

- Bacteruria

- BV

- _____

weight gain; Pyelonephritis

Non-modifiable minor risk factors:

- _____ extremes

- Multiple _____

- Uterine abnormality

- _____ stature

- Low pre-pregnancy weight

- History of _____ exposure

Age; abortions; Short; DES

Treatment for preterm labor:

Antenatal _____ for lung maturation and prevention of respiratory distress syndrome if 24-34 weeks. These drugs include _____ and _____

corticosteroids; betamethasone; dexamethasone

Betamethasone dose

12mg IM Q24H x 2 doses

Dexamethasone dose

6mg IM Q12H x 4 doses

Treatment for preterm labor in addition to antenatal corticosteroids:

- ________ continuous infusion for neuroprotection (<32 weeks)

- _____ for short-term prolongation (48 hr or less). This temporarily suppresses preterm labor, delaying delivery to allow for antenatal corticosteroid administration, which improves neonatal outcomes

Magnesium sulfate; Tocolysis

Tocolysis drugs: (4)

Nifedipine, indomethacin, magnesium sulfate, terbutaline

Labor induction and cervical ripening:

- Needed if late-term/post-term (beyond ___/___ weeks) or premature membrane rupture

- Based on increase in uterine _____ receptors. Treatment is synthetic _____ infusion to induce contractions

- Labor induction may not be successful if the cervix is not ready to open/won't open

- May require softening of cervix

41/42; oxytocin; oxytocin

Cervical ripening: Nonpharm:

- ________

- _____ catheter

- LOW evidence: Castor oil, hot baths, intercourse, nipple stimulation

Membrane stripping; Foley

Cervical ripening: What drugs to use?

Dinoprost and misoprostol (both are prostaglandins)

Labor pain is caused by _____ dilation, uterine _____, distention/tearing of vagina, vulva, perineum

cervical; contraction

Nonpharm for labor pain: (3)

Massage, water baths, doula

For labor pain, systemic opioids like meperidine are ________. But, you can use these 5 drugs:

NOT recommended. Can use: Fentanyl, morphine, nalbuphine, butorphanol, remifentanil

Labor pain: Fentanyl regimen:

Onset; Duration; Maternal/Neonatal t1/2

2-4min; 30-60min; 3hr/5.3hr

Labor pain: Morphine regimen:

Onset; Duration; Maternal/Neonatal t1/2

10min; 1-3hr; 2hr/7.1hr

Labor pain: Nalbuphine regimen:

Onset; Duration; Maternal/Neonatal t1/2

2-3min; 2-4hr; 2-5hr/4.1hr

Labor pain: Butorphanol regimen:

Onset; Duration; Maternal/Neonatal t1/2

5-10min; 4-6hr; 2-5hr/unknown

Labor pain: Remifentanil regimen:

Onset; Duration; Maternal/Neonatal t1/2

20-90sec; 3-4min; 9-10min/3-8min

Epidural (slows down/speeds up) labor progression. An epidural or "spinal" is an injection into the ________ and is for regional pain

slows down; epidural space

Regional pain management in addition to epidural:

- Local anesthetics, like amides (_____, _____, _____) or esters (_____)

- Opioids (3)

lidocaine, bupivicaine, ropivacaine; chloroprocaine; fentanyl, sufentanil, hydromorphone

Post-partum hemorrhage: Cumulative blood loss of over ___mL/___L or blood loss with signs/symptoms of _____. Many causes include uterine atony (most common cause), retained placenta, coagulopathy, and birth trauma

1000mL/1L; hypovolemia

Post-partum hemorrhage: Treatment of hypovolemic shock includes:

- _____ (ex: 0.9% NaCl)

- _____

Crystalloid; PRBCs

For pain with breastfeeding, for nonpharm relief try: ________ or ________

ice packs or cold cabbage leaves

Mature milk is 88% _____, 6-7% _____, 3-4% _____, and 1-2% _____. Term infants ingest 800mL or ~___mL/kg/day

water; CHO; lipids; protein; 150