Pregnancy and Lactation (L6)

chronic conditions and lactation

approximately 7% of pregnancies are complicated by DM and ~9-% of those patients are diagnosed with GDM

other risk factors: sedentary lifestyle, ________, and maternal _______

obesity, age (>35 y/o)

diabetes in pregnancy: GDM

fetal/neonatal complications: macrosomia (big baby), neonatal hypoglycemia, hyperbilirubinemia, shoulder dystocia, other birth trauma

maternal complications: ___________, _______ delivery, preterm labor and delivery, and increased risk of _________

pre-eclampsia, cesarean, T2DM

GDM screening in pregnancy

oral glucose tolerance test (OGTT) done between __________ weeks gestation is recommended for ALL women

24-28

GDM screening in pregnancy

oral glucose tolerance test (OGTT) done between 24-28 weeks gestation is recommended for ________ women

ALL (earlier OGTT is indicated for overweight/obese (BMI >25) women with 1 additional risk factor)

GDM screening in pregnancy

oral glucose tolerance test (OGTT) done between 24-28 weeks gestation is recommended for ALL women

early OGTT indicated for _________/_________ women with 1 additional risk factor

overweight, obese (BMI >25)

GDM screening in pregnancy

oral glucose tolerance test (OGTT) done between 24-28 weeks gestation is recommended for ALL women

early OGTT indicated for overweight/obese (BMI >25) women with 1 additional risk factor

if this early test is normal, do these women still need to get screened at the regular 24-28 week time?

YES

GDM screening in pregnancy

one-step 2-hour 75g OGTT: diagnosis made if any of the following are elevated

- fasting >____mg/dL

- 1-hour >180mg/dL

- 2-hour >153mg/dL

92

GDM screening in pregnancy

________-step 2-hour 75g OGTT: diagnosis made if any of the following are elevated

- fasting >92mg/dL/dL

- 1-hour >180mg/dL

- 2-hour >153mg/dL

one

GDM screening in pregnancy

one-step 2-hour 75g OGTT: diagnosis made if _______ (how many) of the following are elevated

- fasting >92mg/dL/dL

- 1-hour >180mg/dL

- 2-hour >153mg/dL

any (1 is enough)

GDM screening in pregnancy

two-step 1-hour 50g OGTT

- if 1hr is >______mg/dL, we must perform the further 3-hour 100g OGTT

- if 1hr is >______mg/dL, the diagnosis can be made and no further testing is required

180, 200

GDM screening in pregnancy

_______-step 1-hour 50g OGTT

- if 1hr is >180mg/dL, we must perform the further 3-hour 100g OGTT

- if 1hr is >200mg/dL, the diagnosis can be made and no further testing is required

two

GDM screening in pregnancy

two-step 1-hour 50g OGTT

if 1hr is >180mg/dL, we must perform the further 3-hour 100g OGTT

diagnosis made if _______ (how many) readings are elevated from the 3 hour 100g OGTT

- fasting >95mg/dL

- 1-hour >180mg/dL

- 2-hour >155mg/dL

- 3-hour >140mg/dL

>2

GDM screening in pregnancy

two-step 1-hour 50g OGTT

if 1hr is >180mg/dL, we must perform the further 3-hour 100g OGTT

diagnosis made if >2 readings are elevated from the 3 hour 100g OGTT

- fasting >_____mg/dL

- 1-hour >180mg/dL

- 2-hour >155mg/dL

- 3-hour >140mg/dL

95

GDM: non-pharm management

~80% of women diagnosed with GDM can control their blood glucose with _____ and _________

diet, exercise (be sure the dieting isn’t too extreme tho cuz the baby needs to stay fed)

GDM: pharm management

1st-line: __________ replacement

insulin

GDM: pharm management

1st-line: Insulin replacement (indicated for all patients with elevated blood glucose)

- 0.7-1.0 units/kg/day divided

does insulin cross the placenta?

NO🙂

GDM: pharm management

1st-line: Insulin replacement

2nd-line: __________

Metformin

GDM: pharm management

1st-line: Insulin replacement

2nd-line: Metformin (max daily dose= ______mg)

2000

GDM: pharm management

1st-line: Insulin replacement

2nd-line: Metformin (max daily dose= 2000mg)

- this option is only indicated for women with an intolerance to insulin, a good __________ BG and an impaired _______ BG

post-prandial, fasting

GDM: pharm management

1st-line: Insulin replacement

2nd-line: Metformin (max daily dose= 2000mg)

- this option is only indicated for women with an intolerance to insulin, a good post-prandial BG and an impaired fasting BG

does Metformin cross the placenta?

YES

GDM: pharm management

1st-line: Insulin replacement

2nd-line: Metformin (max daily dose= 2000mg)

- this option is only indicated for women with an intolerance to insulin, a good post-prandial BG and an impaired fasting BG

after how many weeks will insulin-resistance improve?

it will not improve until the baby is delivered

GDM: monitoring

antenatal self-monitored blood glucose (SMBG)

- testing at least _____ times daily (fasting and 2-hr post-prandial)

4

GDM: monitoring

antenatal self-monitored blood glucose (SMBG)

- testing >4 times daily (_________ and ______ ______ ________)

fasting, 2-hr post-prandial

GDM: monitoring

antenatal self-monitored blood glucose (SMBG)

- testing >4 times daily (fasting and 2-hr post-prandial)

fasting goal= ____-____ mg/dL

2-hr PP goal= <____ mg/dL

65-95, 120 (these are the same goals for all diabetic pts)

GDM: post-partum monitoring

screen for persistent _____ at 6-12 weeks postpartum

DM

HTN in pregnancy: hypertensive disorders complicate up to 10% of pregnancies

incidence of __________ is increasing worldwide

pre-eclampsia

HTN in pregnancy

chronic HTN is defined as…

- a HTN diagnosis _______ ____ pregnancy

- BP >140/90mmHg (two readings) BEFORE ____ weeks gestation

prior to, 20

HTN in pregnancy

chronic HTN is defined as…

- a HTN diagnosis prior to pregnancy

- BP >____/___mmHg (two readings) BEFORE 20 weeks gestation

140/90

HTN in pregnancy

chronic HTN is defined as…

- a HTN diagnosis prior to pregnancy

- BP >140/90mmHg (_____ readings) BEFORE 20 weeks gestation

two

HTN in pregnancy

_________ HTN is defined as…

- a HTN diagnosis prior to pregnancy

- BP >140/90mmHg (two readings) BEFORE 20 weeks gestation

chronic

HTN in pregnancy

chronic HTN is defined as…

- a HTN diagnosis prior to pregnancy

- BP >140/90mmHg (two readings) ________ 20 weeks gestation

before

HTN in pregnancy

gestational HTN is defined as…

- BP >140/90mmHg (two readings) on or AFTER _____ weeks gestation

20

HTN in pregnancy

gestational HTN is defined as…

- BP >140/90mmHg (two readings) ________ 20 weeks gestation

after

HTN in pregnancy

gestational HTN is defined as…

- BP >____/___mmHg (two readings) AFTER 20 weeks gestation

140/90

HTN in pregnancy

__________ HTN is defined as…

- BP >140/90mmHg (two readings) AFTER 20 weeks gestation

gestational

HTN in pregnancy: goals of therapy

goal is <140/90 for most patients with gestational HTN and chronic HTN

goal is <130/80 for chronic HTN and pre-existing _______ (more aggressive goal with that added risk factor)

DM

HTN in pregnancy: goals of therapy

goal is <140/90 for most patients with gestational HTN and chronic HTN

goal is <130/80 for ________ HTN and pre-existing DM (more aggressive goal with that added risk factor)

chronic

HTN in pregnancy: goals of therapy

goal is <140/90 for most patients with gestational HTN and chronic HTN

goal is <____/___ for chronic HTN and pre-existing DM (more aggressive goal with that added risk factor)

130/90

HTN in pregnancy: pharmacotherapy

chronic HTN: if medication controlled prior to pregnancy, either continue medication or change to a preferred agent

gestational HTN: initiate therapy when BP >____/___ or when BP >____/___ if pre-existing cardiac hx, vascular dx, or DM

15/100, 140/90

HTN in pregnancy: pharmacotherapy

1st-line: _________ (alpha-beta blocker) or __________ (calcium-channel blocker)

labetalol, nifedipine

HTN in pregnancy: pharmacotherapy

1st-line: Labetalol (alpha-beta blocker) or Nifedipine XR (calcium-channel blocker)

2nd-line: _________ diuretics or _________ calcium-channel blockers

thiazide, non-DHP

HTN in pregnancy: pharmacotherapy

1st-line: Labetalol (alpha-beta blocker) or Nifedipine XR (calcium-channel blocker)

2nd-line: thiazide diuretics (concerns for _________ abnormalities) or non-DHP CCB (concerns for _______ defects)

electrolyte, CV

HTN in pregnancy: pharmacotherapy

1st-line: Labetalol (alpha-beta blocker) or Nifedipine XR (calcium-channel blocker)

2nd-line: thiazide diuretics (concerns for electrolyte abnormalities) or non-DHP CCB (concerns for CV defects)

AVOID _________ and _________ due to VC/CNS defects in the 1st trimester and nephrotoxicity in the 2nd and 3rd trimester

AVOID Atenolol due to increased fetal mortality

ACE-inhibitors, ARBs

HTN in pregnancy: pharmacotherapy

1st-line: Labetalol (alpha-beta blocker) or Nifedipine XR (calcium-channel blocker)

2nd-line: thiazide diuretics (concerns for electrolyte abnormalities) or non-DHP CCB (concerns for CV defects)

AVOID ACE-Is and ARBs due to VC/CNS defects in the 1st trimester and nephrotoxicity in the 2nd and 3rd trimester

AVOID ___________ (beta-blocker) due to increased fetal mortality

atenolol

HTN in pregnancy

pre-eclampsia diagnosis if…

- BP >____/___mmHg (two readings 20 mins apart) plus one of the following

- proteinuria, thrombocytopenia, renal dysfunction, hepatic dysfunction, pulmonary edema, cerebral/visual symptoms

OR

- BP >____/___mmHg (two readings 1-2 mins apart) sufficient for BP target

140/90, 160/110

HTN in pregnancy

eclampsia diagnosis if…

pre-eclampsia + _________

seizures (grand mal)

HTN in pregnancy: clinical risk assessment for pre-eclampsia

risk level high: recommend low-dose _________ if the patient has one or more of those high-risk factors

risk level moderate: recommend low-dose ________ if the patient has more than one of those moderate-risk factors

Aspirin

HTN in pregnancy: clinical risk assessment for pre-eclampsia

risk level high: 81mg ASA if >____ of the high-risk factors (start it after the 1st trimester= 12wga)

risk level moderate: 81mg ASA if >____ of the moderate-risk factors (start it after the 1st trimester= 12wga)

1, 2

HTN in pregnancy: clinical risk assessment for pre-eclampsia (to use 81mg ASA or not)

high risk factors include history of __________, multifetal gestation (twins/triplets), chronic ______, T1DM or T2DM, _______ disease, or __________ disease

pre-eclampsia, HTN, renal, autoimmune

HTN in pregnancy: clinical risk assessment for pre-eclampsia (to use 81mg ASA or not)

moderate risk factors include nulliparity (first pregnancy), _________, family history of ________, sociodemographic factors, age >____y/o, and personal history factors

obesity, pre-eclampsia, 35

asthma in pregnancy

it may improve, worsen, or have no change in pregnancy

important: help patients differentiate between SOB secondary to __________ and SOB that’s related to __________

pregnancy, asthma (ex: a bronchodilator will not help a patient with SOB d/t pregnancy)

anticoagulation in pregnancy

pregnancy is considered a ____________ state

hypercoagulable (recommend treatment/prevention throughout pregnancy and at minimum 6-weeks post-partum)

anticoagulation in pregnancy: VTE management

1st-line: _________ and ______________ since they do not cross the placenta

LMWH, unfractionated heparin

anticoagulation in pregnancy: VTE management

1st-line: LMWH and unfractionated heparin, since they do not cross the placenta

__________ (LMWH) can be used as prophylaxis (40mg subQ QD) or as therapy (1mg/kg subQ BID)

Enoxaparin

anticoagulation in pregnancy: VTE management

1st-line: LMWH and unfractionated heparin, since they do not cross the placenta

Enoxaparin (LMWH) can be used as prophylaxis or as therapy (______ daily dosing is preferred when possible, because of PK)

twice (BID)

anticoagulation in pregnancy: VTE management

1st-line: LMWH and unfractionated heparin, since they do not cross the placenta

AVOID _________ (unless its the 2nd or 3rd trimester of a patient with mechanical heart valves)

Warfarin

anticoagulation in pregnancy: VTE management

1st-line: LMWH and unfractionated heparin, since they do not cross the placenta

consider monitoring __________ ____ levels (particularity for patients being therapeutically anticoagulated)

anti-factor Xa

thyroid disorder in pregnancy

physiological changes in pregnancy: increased thyroid binding globulin, decreased iodide levels, and ______ and placental changes (since ______ is structurally similar to TSH)

hCG

thyroid disorder in pregnancy: management

hyperthyroidism: ____________ in the 1st trimester and __________ in the 2nd-3rd trimester

Propylthiouracil, Methimazole

thyroid disorder in pregnancy: management

hypothyroidism: _____________ (typically requires a 30% dose increase and may require titration throughout pregnancy)

levothyroxine

thyroid disorder in pregnancy: management

hypothyroidism: levothyroxine (typically requires a 30% dose __________ and may require titration throughout pregnancy)

increase

thyroid disorder in pregnancy: monitoring

symptoms consistent with hyper and hypo thyroidism

labs: trimester specific goals ________ and ______

TSH, free T4

lactation is primarily controlled by ________ (PRL)

prolactin

lactation: medication transfer

the most common method of transfer is ________ _________

simple diffusion (ionization, lipophilicity, protein binding, and molecular weight)

lactation: medication transfer

_______/________ ratio= drugs excreted in breast milk (<1 indicates low levels in milk)

________ _______ ________= how much medication will be exposed to the baby (infant dose divided by maternal dose) (<10% is generally safe)

milk/plasma, Relative Infant Dose (RID)

lactation: minimizing infant exposure

evaluate the duration of treatment

AVOID ______ _______ formulations and mediations with _______ half lives

extended-release, long

lactation: minimizing infant exposure

evaluate the duration of treatment

AVOID extended-release formulations and mediations with long half lives

consider feeding times and schedule doses immediately after ________ or before a long sleep period

feeding