pregnancy planning and chronic illness mohammad

which hormones change in pregnancy and why

1. human chorionic gonadotropin (hCG): increase

= made by placenta to maintain corpus luteum

2. progesterone: increase

= maintains uterine lining

=helps prepare breast for milk production

3. estrogen: increase

= promotes growth of uterus and development of mammary glands

role of progesterone in pregnancy? estrogen?

progesterone= maintain uterine lining + prepares breasts for milk

estrogen= uterus growth, mammary gland development

how does weight change in pregnancy

1st trimester: 1-5lbs or no weight at all

2nd and 3rd trimester: 1/2 to 1lb per week

how does the endocrine system change in pregnancy

1. thyroid increase

2. insulin sensitivity change

3. hepatic enzyme induction

4. hormone regulating fluid balance alteration (ex: aldosterone, renin)

-> may require change in meds/dose

FITE= fluids, insulin, thyroid, enzymes

how does the cardiovasc system change in pregnancy

1. increase in blood volume (can dilute drugs)

2. change in bp

3. elevated cardiac output (to supply blood flow to placenta)= affects med distribution

how does the GI system change in pregnancy

1. increase/decrease in gastric acid (affects med absorption)

2. N/V (affects intake, adherence, absorption)

3. bile production altered (absorption of fat soluble meds affected)

t/f: preconception care increases the risk of maternal and infant mortality

false. lowers risk

before becoming pregnant it is important to screen for conditions such as

HTN, diabetes, thyroid disorders, depression

when should folic acid be started and how much? what does it help with?

400-1000mg of folic acid 1 month before conception (or earlier)

= reduces risk of neural tube defects

which drugs are known to impact male fertility

cimetidine (stomach acid)

sulfasalazine (UC/Crohns)

nitrofurantoin

steroids

chemo/ radiation

how does GFR change in pregnancy and how does this affect drugs

GFR increases by 50% in first trimester and continues to rise till final week

--->drugs with narrow TI can have greater clearance (less effective)

----> if drug is only eliminated by GF, will be 50% more cleared

what were the FDA pregnancy categories (A,B,C,D,X) replaced with

Pregnancy and Lactation Labeling Rule (PLLR)

what do the old pregnancy categories mean

A= no risk in human studies

B= no risk in animal

C= risk Cant be ruled out

D= eviDence of risk

X= contraindicated

what 3 sections does PLLR require for drugs

1. pregnancy - info on risks to the fetus, data from humans/animals, and whether there's a registry

2. lactation - info on drug transfer into breast milk and potential effects on the infant

3. Females and Males of Reproductive Potential - info on contraception, pregnancy testing, and infertility related to the drug

common contraindicated TERATOGENIC meds to avoid in pregnancy

M WIVES ("michigan wives should avoid")

Methotrexate

Warfarin

Isotretinoin

Valproic Acid

Empagliflozin, Dapagliflozin

Semaglutide, tirzepatide, liraglutide

which meds have a teratogenic risk but might be necessary for the mom and need shared decision making

1. Lithium- Ebsteins anomaly

2. Carbamazepine- neural tube defects

3. Ondansetron- cardiac malformations and cleft palate

how is HTN diagnosed in pregnancy? what is severe HTN?

HTN: 140/90bp measured TWICE at least 4hrs apart

severe HTN: 160/110

t/f: hypertensive disorders are the second cause of maternal mortality after maternal hemorrhage

true

elevated systolic BP is associated with

-increased risk of preterm delivery, small infants, low birth weight

-increases risk of preeclampsia, placental abruption, cesarean birth

risk factors for pregnancy HTN

Age >35

Multiple or multifetal pregnancies

Obesity

Family history

preexisting conditions:

-prior preeclampsia

-chronic stage 2 HTN

- pregestational diabetes

-CKD

chronic HTN vs gestational HTN

Chronic HTN - HTN prior to 20 weeks into the pregnancy

Gestational HTN - bp >140/90 that develops after 20 weeks of gestation WITHOUT proteinuria or other signs of preeclampsia. NO prior HTN dx

how is preeclampsia defined/ diagnosed

-gestational HTN (140/90 develops after 20 weeks)

-high levels of protein in urine

OR end organ damage

onset of preeclampsia can be...

early: <34 weeks

late onset

present up to 6 weeks postpartum

(but remember it cant be before 20 weeks bc atp u wouldnt have gestational HTN)

what is proteinuria in preeclampsia defined as

>300mg per day in urine

protein/creatinine ratio >0.3mg/dL

(note proteinuria is not needed for diagnosis if pt has new onset end organ damage sx)

examples of organ damage sx present in preeclampsia

-thrombocytopenia

-renal insufficiency

-impaired liver fxn

-pulmonary edema

- new onset headache unresponsive to meds

eclampsia

when preeclampsia (HTN + proteinuria/organ damage) progresses to seizures

-> can cause maternal/fetal death

what is given to pts with preeclampsia or severe HTN to prevent transition to eclampsia (seizures)

magnesium sulfate 4-6g IV over 15-20mins followed by maintenance infusion of 1g per day

HELLP syndrome

severe form of preeclampsia

-can damage RBCs and stop blood clotting

-can cause abdominal pain & liver bleeding

hemolysis, elevated liver enzymes, low platelets

Preeclampsia prophylaxis

aspirin 81 to 162mg once daily

started btwn 12-28 weeks of gestation for moms with at least 1 HIGH risk factor or 2+ moderate risk factors

preeclampsia HIGH risk factors

preeclampsia in the past

carrying >1 fetus

chronic HTN

kidney disease

diabetes mellitus

autoimmune conditions (SLE)

multiple mod risk factors

mdpack

preeclampsia moderate risk factors

first time pregnancy

pregnant >10yrs after last pregnancy

BMI>30

family hx (mom or sis)

age 35+

complications in last pregnancy (ex: low birth weight)

in vitro fertilization

black race (racism)

lower income (inequities)

what is the threshold for general HDP (hypertensive disorders of pregnancy)? urgent tx for severe HTN?

general: SBP>140 and/or diastolic >90

urgent: SBP>160 and/or DBP >110

first line agents for HDP (general) + dose

First line:

Labetalol 100-200mg BID

Nifedipine ER 30mg daily

alternate:

Methyldopa 250mg 2-3 times daily

(we dont need to memorize doses)

first line agents for URGENT tx of severe HTN

Labetalol 10-20mg IV, then 20-80mg every 10-30mins [max 300mg]

Hydralazine 5mg IV or IM, then 5-10mg IV every 20-40mins [max 20mg]

Nifedipine IR 10-20mg, repeat in 20mins if needed. then 10-20mg every 2-6hrs [max 180mg]

which antihypertensive meds should you AVOID in pregnancy

1. ACE inhibitors/ ARBs

2. Atenolol

3. mineralocorticoid receptor antags (spironolactone, eplerenone)

4. Nitroprusside (bc of cyanide levels)