Complications of Pregnancy

Hyperemesis Gravidarum

Persistent nausea and vomiting in pregnancy leading to dehydration and malnutrition, associated with HCG levels, requires IV fluids and medications like Zofran, Phenergan, Reglan, and vitamin B6

Signs and Symptoms of Hyperemesis Gravidarum

Severe and persistent vomiting (often projectile) and severe nausea

Treatment of Hyperemesis Gravidarum

IV fluids (NS, D5LR, LR, Banana Bag), check blood glucose levels, check orthostatic vital signs, obtain ECG, check thyroid levels, medications (Zofran, Phenergan, Reglan - IM, IV, PO, vitamin B6)

Asthma in Pregnancy

1/3 will experience worsening symptoms, 1/3 will experience lessening symptoms, 1/3 will have no change, may use rescue inhaler if needed, often keep current regimen if working well

Seizure Disorders in Pregnancy

May worsen, get better or remain the same, 2/3 of women remain seizure free during pregnancy, 70% have no change in seizure frequency, 12% have fewer seizures, 18% have more seizures

Safe Seizure Medications in Pregnancy

Phenobarbital, valproic acid, lamotrigine (Lamictal), continue to draw titers at least once per trimester (more in last weeks of pregnancy) to maintain therapeutic levels

Appendicitis in Pregnancy

Diagnosis is difficult

Acute Cholecystitis in Pregnancy

Try to manage medically

Acute Pancreatitis in Pregnancy

Supportive care

Bowel Obstruction in Pregnancy

Bowel rest and support, if no resolution after 48-96 hrs need to operate

Adnexal Torsion in Pregnancy

Remove infarcted organ, ovary or corpus luteal cyst

Trauma in Pregnancy

Most common cause is MVA

Ovarian Tumors in Pregnancy

Over 8cm need to be biopsied immediately

Gestational Diabetes Mellitus Incidence

2-3% of pregnant women are affected

Gestational Diabetes Screening Protocol

All patients tested between 24 and 28 weeks gestation, 1hr glucose tolerance test with 50gm oral glucose (abnormal >140), 3hr glucose tolerance test with 100gm glucose load (abnormal when 2 or more levels equal or exceed: Fasting 105, 1 hour 190, 2 hours 165, 3 hours 145)

Diabetes Monitoring in Pregnancy

Monitor FBS (<105) and 2hr PP (<120)

Diabetes Treatment in Pregnancy

Diet control, oral hypoglycemic medications (Glyburide does not cross placental/fetal barrier), insulin is best choice, may need to adjust dosages, monitor for hyperglycemic or hypoglycemic episodes

Maternal Complications of Diabetes in Pregnancy

Polyhydramnios (increased amniotic fluid), preeclampsia (increased blood pressure), hypoglycemia, ketoacidosis and coma, cardiac/renal/ophthalmic/peripheral vascular complications

Fetal Complications of Diabetes in Pregnancy

Cardiovascular (atrial and ventricular septal defects, transposition of great arteries, coarctation of aorta, PDA), macrosomia, CNS issues (neural tube defects, microcephaly), intrauterine growth restriction

Shoulder Dystocia Definition

Difficulty in delivering the shoulders when they cannot clear birth canal, fetus gets stuck, major concern is brachial nerve plexus damage, may result in clavicle or humerus fracture

McRoberts Maneuver

Hyperflex the woman's legs tightly to the abdomen, may need to apply pressure to the lower abdomen and gently pull on the fetus' head to manage shoulder dystocia

Preexisting Diabetes Fetal Complications

Increased likelihood of perinatal mortality (especially when not managed appropriately), perinatal morbidity from birth injury, neonatal hypocalcemia/hypoglycemia, congenital abnormalities (cardiac, neural tube defects), intrauterine growth restriction

Management of Preexisting Diabetes in Pregnancy

Obtain HbA1c at first prenatal visit, high levels should prompt fetal ultrasound, give combination of short-acting regular insulin with intermediate-acting NPH and long-acting insulin, watch for hypoglycemia (especially with N/V), control glucose tightly during labor and delivery

Anemia in Pregnancy

Natural decrease in hematocrit during second half of pregnancy because newly formed hemoglobin and red cell mass don't keep pace with expansion of maternal blood volume

Iron Deficiency Anemia in Pregnancy

Most common anemia in pregnancy, pregnant women need additional 800mg of iron (300mg to fetus, 500mg to expand maternal red cell mass)

Types of Anemia in Pregnancy

Iron deficiency anemia (most common), megaloblastic anemia (generally caused by folic acid deficiency), sickle cell anemia

Treatment for Iron Deficiency Anemia

Oral iron therapy (ferrous sulfate 300mg TID, consider adding stool softener), parenteral iron therapy (iron dextran IM or IV, each 2-ml vial provides 100mg of iron, 0.5ml test dose to monitor for anaphylactic reaction - 1% risk), blood transfusion for operative delivery or PPH

Urinary Tract Infections in Pregnancy

5% of pregnant women have bacteriuria at first prenatal visit, treated even if asymptomatic

Cystitis vs Acute Pyelonephritis

Cystitis: lower urinary tract infection

Treatment of Pyelonephritis in Pregnancy

Inpatient admission, IV fluids, IV antibiotics

UTI Complications for Newborns

Respiratory problems, pneumonia, septic shock, meningitis

UTI Pathogens and Treatment in Pregnancy

E. Coli causes ~90% of cases, Proteus mirabilis and Klebsiella pneumoniae less frequent, amoxicillin is safe but E. Coli increasingly resistant, cephalosporins and nitrofurantoin are safe

Bacterial Vaginosis in Pregnancy

Normal vaginal bacteria replaced by other bacteria, untreated can lead to premature birth, low birth weight, pelvic inflammatory disease, consider testing/screening for gonorrhea and chlamydia

Syphilis in Pregnancy

May remain asymptomatic for years, primary stage (single sore), stage two (lesions, skin rash), late stage (no signs, disease attacks body), can cause stillbirth, blindness, developmental delays in babies, requires testing at 1st prenatal visit, 28 weeks, and hospital admission

HSV Management in Pregnancy

Take thorough history, culture suspicious lesions, use suppression medication around 34/36 weeks, C-section required if active lesions present during delivery

Trichomoniasis in Pregnancy

May be asymptomatic or have frothy yellow-green discharge, irritation, itching, discomfort during intercourse, dysuria, lower abdominal pain

HIV Transmission in Pregnancy

Pregnant women may infect fetuses during pregnancy, delivery, or breastfeeding, risk of vertical transmission is 20-30% (>50% occur at delivery), treatment includes multiple agents to reduce viral load and prevent transmission, women with >1000 copies should have cesarean, multiple drugs IV during labor and delivery

Candidiasis in Pregnancy

Risk factors include poorly controlled diabetes, taking antibiotics, wearing tight-fitting clothing

Thromboembolic Disease in Pregnancy

Pregnancy is a hypercoagulable state, gravid uterus may cause venous stasis

DVT Signs and Treatment in Pregnancy

S/S: Calf pain, unilateral edema of the leg, Homan's sign

Pulmonary Embolism Signs in Pregnancy

Tachypnea, dyspnea, tachycardia, pleuritic pain, cough, anxiety

Pulmonary Embolism Diagnosis in Pregnancy

Ventilation/perfusion scan or spiral CT or pulmonary angiogram (safe in pregnancy)

Pulmonary Embolism Treatment in Pregnancy

High-flow oxygen and ventilation support as needed, establish IV-NS, cardiac monitoring/vital signs/O2 sat, anticoagulation with heparin for 6-12 months (including labor and delivery)

Rh Isoimmunization

Caused by maternal antibody production in response to exposure to fetal red blood cell antigens of the Rh group

Rh Negative Mother Management

If mother is Rh negative, determine father's blood type

Chronic Hypertension in Pregnancy

Persistent HTN >140/90 before 20th week of pregnancy, increased risk for stroke or other cardiovascular problems

Pregnancy-Induced Hypertension

Develops after the 20th week of pregnancy, resolves spontaneously after delivery

Preeclampsia Risk Factors

First pregnancy before age 20, advanced maternal age, history of multiple pregnancies, diabetes

Preeclampsia Symptoms

Manifests after 20th week with triad: edema, gradual onset of hypertension, protein in urine

Eclampsia Definition

Presence of tonic-clonic seizures in a woman not attributable to any other cause, 25% happen before labor, 50% during labor, 25% after delivery

Preeclampsia Seizure Treatment

Magnesium sulfate is recommended, Ativan or valium if available quickly

Preeclampsia Complications

Placental abruption, hemorrhage, disseminated intravascular coagulation

HELLP Syndrome

Variant of pre-eclampsia categorized by Hemolysis, Elevated Liver Enzymes, Low platelets, Increased Uric Acid

Preeclampsia Renal Effects

Decreased clearance of uric acid, proteinuria >300/24 hours, acute kidney injury with oliguria

Preeclampsia Neurologic Effects

Hyperreflexia, grand mal seizures

Preeclampsia Pulmonary Effects

Pulmonary edema related to capillary leak, fluid overload or left heart failure

Preeclampsia Liver Involvement

Symptoms include epigastric or right upper quadrant pain, nausea/vomiting

Fetal Effects of Hypertension

Decreased placental perfusion from maternal vascular spasm may cause increased injury, uteroplacental insufficiency may cause fetal death or IUGR, placental abruption is common

Treatment for Hypertensive Disorders

Delivery is the only definitive treatment, magnesium sulfate during labor and post-partum to prevent seizures (anticonvulsant of choice in eclampsia)

Antihypertensive Medications in Pregnancy

Methyldopa is safest, use smallest dose to keep pressure around 140/90, may discontinue after 1st trimester, calcium channel blockers (Nifedipine) are safe, AVOID ACE inhibitors and angiotensin II receptor blockers, Labetalol is drug of choice (be careful with beta blockers), perform serial ultrasounds to assess fetal growth

Delivery Criteria in Preeclampsia

Women with oliguria, renal failure or HELLP syndrome should always be delivered regardless of gestational age, weigh risks/benefits of delivery vs surveillance

Preeclampsia Hospital Management

Admission for close observation and fetal surveillance, daily fetal monitoring, daily labs, daily weight, regular ultrasounds (daily/weekly/biweekly)

Magnesium Sulfate Side Effects

Respiratory depression, hypotension, circulatory collapse, must be administered slowly through IV, may be given IM for acute eclampsia

Tobacco Effects in Pregnancy

Placental abruption, placenta previa, prematurity, SIDS, low birth weight

Cocaine Effects in Pregnancy

Placental abruption, low birth weight, preterm labor, neonatal withdrawal

Opiate Effects in Pregnancy

Neonatal withdrawal, low birth weight, fetal death

Marijuana Effects in Pregnancy

Low birth weight, congenital anomalies

Alcohol Effects in Pregnancy

Fetal alcohol syndrome

```