Ob/gyn Secrets 05: Ob

Front 1

What is optimal wt gain in pregnancy, based on starting BMI?

Back 1

BMI <19.8: 28-40lbs
0.5kg/wk
BMI >26: 15-25lbs
0.3 kg/wk
For normal BMI women: 0.5 kg/wk

Front 2

What is risk for underwt women and women with low pregnancy wt gain?

Back 2

Preterm delivery
Deliver infant weighing <2500gm

Front 3

What is risk for overwt women and women with high pregnancy wt gain?

Back 3

Fetal macrosomia: >4000-4500gm or >90% for GA
Greater risk for HTN and DM of pregnancy
Greater risk for post-op wound infection is get c-sxn

Front 4

What is avg maternal weight gain?
What is this due to? (6)

Back 4

1) ~28lbs
2) Fetal wt + placental wt + amniotic fluid + breast enlargement + volume expansion + fat stores

Front 5

In which trimester is wt gain most important?

Back 5

2nd
-> is protective of fetal growth even if overall wt gain is poor!

Front 6

By what percentage are energy requirements increased during pregnancy?
How many additional kcals/day should a woman therefore consume?

Back 6

1) ~17%
2) 300 - total of about 2500 kcal/day

Front 7

What is RDA of protein for pregnant woman?
What percent of kcals should be fat?
Carbs?

Back 7

1) 60 grams - 20% of diet
2) 30%
3) 50%

Front 8

What are recommendations for multiple gestation in terms of additional kcals/day?

Back 8

Add 300 kcals + 10g of protein per additional fetus

Front 9

Why do we tell women wishing to conceive to take 0.4mg of folic acid/day?

Back 9

Reduces incidence of neural tube defects by 50%
Women with history of neural tube defect pregnancy should take 4mg until end of 1st T

Front 10

What should we counsel women with DM prior to conception?

Back 10

4fold increase in major congenital malformations - related to poorly controlled DM PRIOR to pregnancy.
Control that diabetes!!!

Front 11

What to tell women with PKU prior to conception?

Back 11

You have increased risk of fetal malformation (cardiac defects, microcephaly)
Can reduce risk significantly if start Phe-restricted diet 3mos prior to conception
Normalize Phe levels by GA 8wks to reduce incidence of low birth wt.

Front 12

If pt is on Dilantin, what supplements should she take during pregnancy?
What is outcome if pt follows this diet?

Back 12

1) Folate, Vitamins, Amino acids
2) Greater fetal wt, decreased SQ bleeding, more ossification centers, fewer malformations

Front 13

If pt has risk of lead exposure, what supplements should she take during pregnancy?
What is outcome if pt follows this diet?

Back 13

1) Vit C & E
2) Reduce potentially adverse Pb effects & toxicity

Front 14

If pt has multiple gestation, what supplements should she take during pregnancy?
What is outcome if pt follows this diet?

Back 14

1) Give extract folate
2) Better rbc production

Front 15

If pt is HIV+, what supplements should she take during pregnancy?
What is outcome if pt follows this diet?

Back 15

1) Selenium + antioxidant vitamins
2) Inhibit RT activity of virus, may reduce chance of placental transmission

Front 16

If pt has high EtOH consumption, what supplements should she take during pregnancy?
What is outcome if pt follows this diet?

Back 16

1) B complex & folate
2) Baby is probably still effed. :(

Front 17

If pt has hemoglobinopathy, what supplements should she take during pregnancy?
What is outcome if pt follows this diet?

Back 17

1) Folate
2) helps replenish rbcs

Front 18

If pt has HTN, what supplements should she take during pregnancy?

Back 18

Calcium

Front 19

Megadoses of which supplements have been shown to cause issues in pregnancy?

Back 19

1) Vit A&D - birth defects
2) Selenium - birth defects
3) Zinc - immune suppression & anemia (blocks Fe absorption)
4) Fluoride - mottled teeth
5) Vit C - messes w/ Cu metabolism

Front 20

What is problem w/ "calmatives" or "nervines" (herbal supplements for pregnancy)? (2)

Back 20

Have large amounts of alkalines
May cause hepatic damage.

Front 21

What is the problem with Mate, a tea-like infusion that women might take during pregnancy?

Back 21

May increase risk of digestive tract cancers.

Front 22

What is the problem with a pregnant woman drinking pleurisy root (an herbal tea)?

Back 22

It has digoxin-like effects

Front 23

Is pregnancy tea - with chamomile, mint, and raspberry leaves - safe to drink during pregnancy?

Back 23

Yes - if consumed in moderation

Front 24

How many liters of water does a woman on average gain during pregnancy?

Back 24

9L

Front 25

How much extra fluid per day should a woman drink?

Back 25

30mL/day extra

Calculate: 100mL/kg for 1st 10kg, 50mL/kg for next 10kg, 25mL/kg above 20kg

Front 26

Why is it important for a woman to drink sufficient fluids during pregnancy?

Back 26

Maternal fluid status may affect amniotic fluid volume
Acute changes in maternal osmolality may alter fetal hydration

Front 27

What is % absorption of iron from heme sources vs non-heme sources?

Back 27

10% vs 2%

But, iron deficient pts generally absorb 2x as much iron from a meal as iron replete pts

Front 28

What is relationship btw iron absorption and gestational age - i.e. at wks 7, 24, and 36?

Back 28

wk 12: 7%
wk 24: 36%
wk 36: 66%

Front 29

What are high sources of dietary iron?

Back 29

1) Oysters
2) Red lean meats (esp liver)
3) Tofu
4) Legumes
5) Beans
Note: consume the plant-based w/ acidic sources like oranges, grapefruit, or tomato juice.

Front 30

What are moderate sources of dietary iron?

Back 30

Enriched grains and cereals

Front 31

What are low sources of dietary iron?

Back 31

1) Light & white meats (chicken, salmon, pork)
2) Diary products

Front 32

What is relationship btw iron absorption and acidic foods (orange juice, etc)?
Btw Fe and Ca?

Back 32

1) Acidic food increase Fe absorption
2) Calcium interferes w/ Fe absorption - antacids, tea, & coffee can also do this (esp w/ non-heme iron)

Front 33

With which types of restrictive diets should one advise nutritional supplementation during pregnancy?

Back 33

1) Lactovegetarian (no eggs, fish, or other meat)
2) Vegan

Consider B complex, Ca, and Fe

Front 34

Which types of restrictive diets should one avoid during pregnancy?

Back 34

1) Fruit-only
2) Zen macrobiotic

Front 35

What are risks of pregnancy to pts <17 y/o?
What role does nutrition play in this?

Back 35

1) preterm delivery, perinatal mortality, low birth wt - increased with pregnant girls w/in 2 yrs of their own menarche (body competes w/ fetus for growth materials)
2) Be sure she's getting enough nutrition for both pt and fetus

Front 36

What are risk factors for pica during pregnancy?

Back 36

1) Family history of pica
2) Rural residence
3) African american

Front 37

How common is nausea & vomiting of pregnancy? (NVP)
When is onset?
When is resolution?

Back 37

1) 60-70%
2) As early as prior to 1st missed period (7%)
3) 30% by 10wks
60% by 12wks
99% by 20wks

Front 38

What time of day does NVP most commonly occur?

Back 38

6am-noon

Can xp symptoms throughout the day

Front 39

What are criteria for hyperemesis gravidarum?

Back 39

No universally accepted definition
XS NVP + fluid, electolyte, & nutritional status compromise
Maternal wt loss of 5%
Persistent significant ketonuria
Moderate-severe has HyperCl metabolic alkalosis
If longstanding volume depletion, may have acidosis
May have elevated LFTs, amylase, lipase

Front 40

What is incidence of hyperemesis gravidarum?

Back 40

5:1000 pregnancies

Front 41

What is the DDx of increased NVP in 1st and 2nd trimesters? (3)

Back 41

1) Multiple gestation
2) Gestational trophoblastic disease
3) Fetal aneuploidy (triploidy or t21)

Front 42

What could increased NVP in 3rd trimester indicate?

Back 42

1) Acute fatty liver of pregnancy
2) Preeclampsia

Front 43

When should you consider non-pregnancy-related disorders for increased NVP? (3)

Back 43

1) Vomiting persists
2) Has begun later than 9wks GA
3) Symptoms acutely worsen

Front 44

What are GI disorders to consider for abnormally increased NVP? (6)

Back 44

Biliary tract disease
Hepatitis
SBO or LBO
Pancreatitis
Appy
Gastroenteritis

Front 45

What are endocrine disorders to consider for abnormally increased NVP? (3)

Back 45

HyperTH
DKA
Addison disease

Front 46

What are GU disorders to consider for abnormally increased NVP? (4)

Back 46

Pyelo
Nephro(lithiasis)
Ovarian torsion
Uterine fibroid degeneration

Front 47

What are CNS disorders to consider for abnormally increased NVP? (3)

Back 47

Migraine
Pseudotumor cerebri
Primary CNS lesions

Front 48

What are the fetal complications of hyperemesis gravidarum or NVP if mild to moderate?
If severe?

Back 48

1) Does not seem to be any! Actually seems to be associated w/ DECREASED risk of SAB!
2) If mother has wt loss: one study indicates low birth wt (<10%); none if no wt loss. Otherwise no risk of congenital anomalies

Front 49

What are maternal complications of hyperemesis gravidarum or NVP? (6)

Back 49

1) Wernicke's encephalopathy 2/2 thiamine deficiency
Ataxia, confusion, oculomotor sx!!
2) Possible central pontine myelinolysis (2/2 #1)
3) Mallory-Weiss tear
4) esophageal rupture
5) splenic avulsion
6) peripheral neuropathy 2/2 B6 & B12 deficiency

Front 50

What are thought to be the hormonal variables associated with hyperemesis gravidarum?

Back 50

1) HyperTH in some women -> increased circulating/active hCG
2) Progesterone -> delayed gastric emptying
We don't really know for sure!!

Front 51

What are thought to be the gastric motility variables associated with hyperemesis gravidarum? (1)

Back 51

Decreased motility in some pts, but others are okay!

Front 52

What are thought to be the CNS variables associated with hyperemesis gravidarum? (1)

Back 52

Possible CNS changes - especially in the "vomiting center" in response to hormonal triggers

Front 53

What are thought to be the psychosocial variables associated with hyperemesis gravidarum? (3)

Back 53

1) Conversion disorder
2) Heightened maternal perceptions of sensations
3) Mom can't deal with life stress (really?)
VERY LIMITED data to support these notions

Front 54

How to manage NVP and hyperemesis gravidarum initially?

Back 54

1) Symptomatically
2) Adequate hydration
3) Frequent small meals
4) Ginger tea/powdered ginger
5) 30mg B6 daily (one RCT supports efficacy)
6) Some studies support acupressure bands and transcutaneous nerve stimulaiton

Front 55

How to manage intractable NVP and hyperemesis gravidarum?

Back 55

1) If hydration has failed:
Metoclopramide (Reglan)
Ondansetron (Zofran)
Phenothiazine
** All seem safe in pregnancy!
2) If anti-emetics fail:
Systemic corticosteroids (PO methylprednisolone)
** No adverse fetal effects have been described
3) TPN for pts who cannot maintain wt & keep vomiting despite treatment

Front 56

What is circulating toxin theory of preeclampsia?
Support for this?

Back 56

1) Vasoconstrictive substances circulate -> may cause PET
2) These substances have been extracted from blood, amniotic fluid, and placenta from PET women. Have reproduced symptoms in some animal studies

Front 57

What is endogenous vasoconstrictor theory of preeclampsia?

Back 57

Increased sensitivity to vasopressin, Epi, NE have been reported in PET pts, plus loss of 3rd-Tri ang II resistance has been reported.

Front 58

What is endothelial damage theory of preeclampsia?

Back 58

Primary endothelial dmg -> decreased prostacyclin production (a vdltr) & increase in TXA2
Cause of dmg is unclear
Low dose heparin or baby ASA may help prevention

Front 59

What is primary DIC theory of preeclampsia?

Back 59

Microvascular thrombin formation + deposition -> vessel damage (esp in kidney & placenta)

Front 60

What are fetal risks associated w/ preeclampsia? (7)

Back 60

1) IUGR
2) Oligohydramnios
3) Placental infarction
4) Placental abruption
5) Prematurity consequences
6) Uteroplacental insufficiency
7) Perinatal death

Front 61

What are maternal risks associated with preeclampsia? (6)

Back 61

1) CNS: seizures, stroke
2) DIC + its complications
3) Renal failure
4) Hepatic failure/rupture
5) Death - leading cause of maternal mortality!
6) Increased chance of c-sxn

Front 62

What is recurrence risk for preeclampsia in subsequent pregnancies after 1 episode?

Back 62

25%

Front 63

What factors effect recurrence of preeclampsia? (5)

Back 63

1) Gestational age at onset (greater recurrence risk w/ earlier onset)
2) Severity (more severe = greater recurrence risk)
3) Underlying maternal conditions (chronic HTN, renal disease, etc = greater RR)
4) Underlying obstetric conditions (NO fetal abnormalities = greater RR)
5) Multiparous: RR is 50%!

Front 64

T or F: Preeclampsia increases risk of developing HTN or other chronic diseases later in life

Back 64

FALSE

Note: women with recurrent PET may have underlying HTN or another chronic disease

Front 65

How to prevent preeclampsia?

Back 65

NO KNOWN WAY

Dietary and low-dose ASA studies have repeatedly failed!

Front 66

T or F: Women with preeclampsia CANNOT take OCPs after giving birth

Back 66

FALSE!!

Front 67

What are criteria for SEVERE preeclampsia?

Back 67

1) sBP >160 or dBP >110 at least TWO times, 6H apart!
2) Proteinuria >/= 5g/24H
3) Oliguria
4) Cerebral or visual symptoms
5) Epigastric or RUQ pain
6) Pulmonary edema/cyanosis
7) Low platelets
8) Elevated LFTs
9) Fetal growth restriction

Front 68

What are criteria for MILD preeclampsia?

Back 68

Does not meet requirements for severe.

Front 69

How to manage preeclampsia?

Back 69

Deliver fetus
If preterm (<32wks), conservative mgmt - 48hrs of steroids, hospitalize, bed rest.
Prophylactic MgSO4: 4-6g bolus + 2g cont infusion

Front 70

When to do c-section for preeclampsia pt?

Back 70

If pt's condition requires urgent delivery and vaginal birth is not progressing fast enough.

Front 71

What is Mag goal in preeclampsia treatment?

Back 71

4-8mg/dL

Front 72

How long to give Mg for in treating preeclampsia?

Back 72

During labor and for 24hrs postpartum

Front 73

When to use antihypertensives in treatment of preeclampsia?
Which ones to use?

Back 73

1. Usually if dBP>110 or MAP >125 (+ proceed to delivery!!)
2. Hydralazine or labetalol (both have rapid onset)

Front 74

Why avoid diuretics in preeclampsia treatment?

Back 74

PET pt has vasoconstriction and intravascular depletion - diuretics make this WORSE!!

Front 75

When to use antihypertensives in a pregnant pt with mild-to-moderate HTN?

Back 75

If pt has known chronic HTN & elevated BP is known to be caused by disease & not by PET

Front 76

Definition of eclampsia?

Back 76

PET + seizure activity
Is most severe form of PET!

Front 77

What percent of pts with preeclampsia will develop eclampsia?

Back 77

~1%

Front 78

What is best mgmt of eclampsia?

Back 78

1. Stabilize pt - airway, O2, circulation, control seizures
2. Consider delivery options - #1 often stabilizes fetal status & can permit vaginal delivery

Front 79

What is best agent to prevent seizure recurrence in eclampsia?

Back 79

MgSO4 (based on RCT)

Front 80

Define HELLP syndrome

Back 80

H emolysis
E levated L iver function tests
L ow P latelets
+/- other PET signs

Is subcategory of severe PET
Often has rapidly accelerating downhill course.
Treatment: delivery asap

Front 81

What causes midepigastric pain in HELLP syndrome?

Back 81

Liver capsule distention

Can also cause n/v, hepatic rupture

Front 82

What is DDx of pt at 18wks GA w/ increased BP? (4)

Back 82

1. Hydatidiform mole (+hyperemesis, fetal size>dates, hydropic changes in placenta on US)
2. Fetal chromosomal abnormalities (triploidy)
3. Chronic HTN: be sure to exclude renal disease, pheochromocytoma, Cushing, coarctation of aorta
4. Drug use: cocaine; or drug withdrawal (heroin)

Front 83

Definition of HTN in pregnancy?

Back 83

SBP > 140 or
dBP > 90

Front 84

What are categories of HTN in pregnancy? (4)

Back 84

Chronic
Gestational
Preeclampsia (PET)
Chronic with superimposed PET

Front 85

Define chronic HTN in pregnancy

Back 85

HTN that:
1) predates pregnancy or is IDed prior to 20wks
2) If PNC starts after 20wks, is chronic if it persists >12wks postpartum

Front 86

Define preeclampsia

Back 86

HTN (>140 sBP or >90 dBP)
Proteinuria (>300mg in 24H urine)
In practice, proteinuria is defined as >trace protein on urine dipstick

Note: edema is no longer part of definition, b/c of poor predictive value

Front 87

What additional signs/symptoms might women with preeclampsia have? (6)

Back 87

1) H/a
2) Visual disturbances
3) Epigastric pain
4) Elevated liver enzymes
5) Increased or decreased Hct
6) Decreased platelets

Front 88

Define gestational HTN

Back 88

HTN after 20wks
LACK of proteinuria

Front 89

Define chronic HTN with superimposed preeclampsia

Back 89

Pt has known chronic HTN
Gets increased BP plus proteinuria
Presence of other PET signs/symptoms helps diagnosis

Front 90

Why are women with chronic HTN considered to be high-risk pregnancies?

Back 90

Poor placental vascular development + ongoing BP elevations → increased risk for IUGR, abruption, stillbirth, and superimposed PET

Front 91

How to prevent complications in pregnant pt w/ chronic HTN? (3)

Back 91

1) Mild: have BP under control prior to conception, continue BP meds while pregnant (avoid ACEi). If dx during pregnancy, monitor only.
2) Moderate-severe: Labetolol, CCBs
3) All: follow w/ serial US, fetal NSTs or BPPs, usually induce @40wks

Front 92

How often does preeclampsia occur?

Back 92

6-8% of all live births

Front 93

What are preeclampsia risk factors? (9)

Back 93

Nulliparity
<15 or >35 y/o
African American
H/o PET in 1st degree female relative
H/o PET in prior pregnancy
DM
chronic renal or vascular disease
chronic HTN
Multiple gestations

Front 94

What are systemic effects of preeclampsia?

Back 94

Vasoconstriction
Hypovolemia
All organs (fetoplacental unit included) show e/o poor perfusion

Front 95

What is the immunologic theory of preeclampsia's cause?
What support is there?

Back 95

1) Inadequate maternal antibody response to fetal allograft → vascular damage from circulating immune complexes
2) Increased disease prevalence in young nulliparas (ltd prior antigen exposure) and in pts w/ increased fetal antigens (twins, moles, hydropic pregnancies, diabetics w/ big placentas)

NOTE: measurement of immune complexes has been inconsistent.

Front 96

What TH functions increase during pregnancy? (3)

Back 96

TBG (estrogen mediated)
Total T4
Total T3

Front 97

Which TH functions decrease during pregnancy?

Back 97

T3 resin uptake (T3RU)

Front 98

Which TH functions remain the same during pregnancy? (3)

Back 98

TSH
Free T4
Free T3

Front 99

What are indications for ordering TH function tests during pregnancy? (5)

Back 99

Pt on TH
FHx of autoimmune thyroiditis
Goiter
PMH of rads to thyroid
DM type 1

Front 100

What is hyperthyroidism in pregnancy incidence?

Back 100

1:2000

Front 101

What are MCC of hyperthyroidism in pregnancy? (6)

Back 101

Grave's
toxic adenoma
subacute thyroiditis
iatrogenic
transient 2/2 hyperemesis gravidarum
gestational trophoblastic disease

Front 102

What are lab findings in Grave's? (autoantibodies -> hyperTH)

Back 102

Increased total & free T3 & T4
Low TSH

Front 103

What can result from untreated Grave's in pregnancy in mom?
In fetus?

Back 103

1) Increased PET risk
Congestive heart failure
2) Stimulation of fetal thyroid -> in utero demise, prematurity, IUGR, autoimmune rxn (lymphatic hypertrophy + thrombocytopenia), goiter, exophthalamos
Can last 1-5mos postpartum in newborn

Front 104

When to do diagnostic iodine studies in pregnant pt w/ suspected new-onset Graves?

Back 104

POSTPARTUM!!

Study uses rads; crosses placenta and can cause fetal hypothyroidism

Front 105

What is treatment of choice for Grave's during pregnancy?

Back 105

PTU

Some evidence of fetal hypothyroidism, delayed bone growth, CNS effects, though.

Front 106

What are alternative treatments for Grave's in pregnancy?

Back 106

1) Methimazole - can cause aplasia cutis in fetal scalp
2) Propronolol to diminish thyrotoxicosis symptoms

Front 107

How to administer PTU for Grave's in pregnancy?

Back 107

Give same dose for 4wks, then gradually decrease to keep mom's T4 at upper limit of normal

Front 108

Does treating mom with PTU guarantee that her baby will avoid neonatal Grave's?

Back 108

NO!! Happens in ~1% of babies of moms with Grave's regardless of history of treatment.

Front 109

T or F: Breastfeeding is absolutely contraindicated if pt is on PTU

Back 109

FALSE

Small amounts of PTU are excreted in breastmilk, but is okay if monitor newborn's thyroid function

Front 110

What characterizes thyroid storm?

Back 110

1. Hypermetabolic state
2. Fever
3. Altered mental status

Front 111

When does thyroid storm usually happen during pregnancy?

Back 111

1. During labor or c-sxn
2. Ante- or postpartum infxn
3. Gestational trophoblastic disease
4. Women with unrecognized hyperthyroidism

Front 112

How to manage thyroid storm during pregnancy?

Back 112

1. Symptomatic, supportive treatment of pyrexia, tachycardia, severe dehydration
2. Thionamide, PTU, beta-blockers, steroids, iodines, ipodate
3. Treat any HTN, infection, anemia

Front 113

What are common causes of HYPOthyroidism in pregnancy?

Back 113

1. Hashimoto's
2. Previous Grave's treatment (rads or surgery)
3. xs PTU sdose

Front 114

What are possible maternal complications of untreated hypothyroidism?

Back 114

Subfertility (2/2 elevated PRL)
Anemia
Preeclampsia
Abruption
PPH
Cardiac dysfunction

Front 115

What are possible fetal complications of untreated hypothyroidism?

Back 115

Low birth wt
Perinatal demiase

Lesser degrees: pregnancy loss, prolonged gestation

Front 116

How to treat hypothyroidism in pregnancy?

Back 116

1.6ug/kg levothyroxine, adjust dose as needed
Assess TSH in 1st Tri and adjust meds as needed
Also assess TSH 6-12 wks postpartum

Front 117

What is link btw hyperemesis gravidarum and thyroid problems?

Back 117

Think that elevated hCG levels may have TSH-like effects. Usually don't treat for hyperthyroidism in these pts.
Can clarify w/ free T4 by equilibrium dialysis

Front 118

What is postpartum thyroiditis?

Back 118

1-8mos postpartum, affecting 5%
1-4mos = hyperthyroidism
5-8mos hypothyridism
Anti-TH abs may be present
May be misdiagnosed as postpartum depression or psychosis.10-30% of these pts have permanent hypothyroidism
Tends to recur w/ subsequent pregnancies

Front 119

What test to order on pregnant pt w/ thyroid nodule?

Back 119

US (see if it's cystic or solid)
Confirm by FNA or biopsy

Solid = more likely to be malignant.

Front 120

What is the relation btw epilepsy treatment and fertility?

Back 120

NONE!

However, it can decrease OCP effectiveness b/c increased SHBG decreases unbound, active OCP hormonal agents
(hepatic p450 metabolism of epilepsy meds)

Front 121

What is gestational epilepsy?

Back 121

Epilepsy that occurs only during pregnancy.
But if occurs in one pregnancy, this doesn't mean it will recur in subsequent pregnancies

Front 122

How do seizures affect course of pregnancy?

Back 122

Nothing has been demonstrated clearly, except vaginal bleeding (likely 2/2 med-induced Vit K deficiency)

Front 123

What anticonvulsants are commonly used in pregnancy?

Back 123

Phenytoin
Phenobarbital
Carbamazepine
Less often: Primidone or Valproic acid

Note: each med has specific side fetal and neonatal risks
Monotherapy is preferred!

Front 124

How does pregnancy affect blood levels of anticonvulsants?

Back 124

Decreases them, 2/2 increased blood volume, delayed GI absorption, increased hepatic clearance

Folic acid may lower phenytoin levels
However, amount bound may DECREASE as albumin falls during pregnancy

Front 125

How much folic acid to give to pregnant women on anticonvulsant meds?

Back 125

4mg/day

Front 126

Which anticonvulsant is absolutely contraindicated in pregnancy?

Back 126

Trimethadone

Syndrome: DD, low ears, abn palate, irreg teeth, speech problems, V-eyebrows
+/- IUGR, short, cardiac abn, ocular defects, simian creases, hypospasias, microcephaly
~2/3 of exposed infants develop anomalies

Front 127

What does fetal hydantoin (phenytoin) syndrome consist of?

Back 127

Craniofacial and limb abn

Major anomalies, microcephaly, midface & digital hypoplasia = aka "anticonvulsant ambryopathy"

Front 128

What is the major risk associated with phenobarbital?

Back 128

Neonatal addiction, withdrawal syndrome

Less commonly associated w/ birth defects

Front 129

What has carbamazepine use during pregnancy been linked to recently?

Back 129

Craniofacial defects
DD
NTDs

But is considered to be the safest

Front 130

What is valproate use during pregnancy associated with?

Back 130

Cardiac, orofacial, limb abn
Major: NTDs (risk is 1-2% is exposed 17-30d post conception)

Should consider this a human teratogen

Front 131

What is risk of congenital malformations with anticonvulsant therapy?

Back 131

2-3 times that of population

However, epilepsy itself may contribute some to risk

Front 132

Which drug may be of use in preventing congenital malformations in fetus, if mom is on anticonvulsants?

Back 132

Epoxide hydrolase

However, genetic heterogeneity within the enzyme may lower its effectiveness

Front 133

Which anticonvulsant meds are linked to hemorrhagic disease of the newborn? (3)

Back 133

Phenytoin
Phenobarbital
Primidone

Related to Vit K deficiency

Front 134

With all the bad fetal side effects of anti-convulsants, shouldn't mom just stop taking them when pregnant?

Back 134

NO!!

Uncontrolled seizures may result in greater harm to the fetus
If pt has been seizure free for 2 yrs, suggest trial withdrawal. If successful, expectant mgmt during pregnancy

Front 135

What is risk of kid having seizures if a parent has them?

Back 135

3%

May increase if it's the mom, if it's idiopathic, or febrile seizures

Front 136

T or F It is safe to breast feed when mom is on anticonvulsants

Back 136

True, but, phenobarbital and primidone may accumulate and make infant lethargic, feed poorly, inadequate wt gain
Newer anticonvulsants are untested, so advise against.

Front 137

How much does maternal blood volume increase?
Until which week does it increase?

Back 137

1) 50%
2) wk 32, then stays steady until delivery

Front 138

How much does maternal plasma volume increase vs rbc mass?

Back 138

50% vs 20%
Note: this is behind the dilutional anemia of pregnancy

Front 139

What is behind the blood volume increase of pregnancy?

Back 139

1) Steroid hormones of pregnancy
2) Increased plasma renin activity
3) Hyperaldosteronism

Front 140

How much does maternal cardiac output increase?
Until which week does it increase?

Back 140

1) 30-50%
2) 20wks, stays steady, then decreases at 38-40wks

Front 141

What is behind the increased maternal cardiac output of pregnancy?

Back 141

Early pregnancy: increased stroke volume
Later: increased heart rate

Front 142

What BP changes occur in pregnancy?

Back 142

1) sBP: slight decrease
2) dBP: moderate decrease

Note: nadir is in 3rd Tri, then slow increase back to non-pregnant BP

Front 143

What are normal maternal cardiac changes during labor and delivery?

Back 143

1) During uterine contraction, shift 300-500cc from uterus to maternal circulation
2) This causes systemic venous pressure increase + reflex bradycardia
3) Pain + anxiety -> Epi release -> BP + HR increase
4) Post delivery: decreased vena cava compression + increased blood volume -> 10-20% cardiac output increase

Front 144

What hemodynamic changes can regional anesthesia cause?

Back 144

1) Peripheral vasodilation
2) Preload decreases
3) Possible cardiac output + BP decrease

To prevent, hydrate pt beforehand!

Front 145

Which symptoms merit a cardiac eval during pregnancy?

Back 145

Progressive limitation of physical activity caused by shortness of breth, chest pain with exercise or physical activity, and syncope following palpitations or physical exertion

Front 146

How to treat pregnant pt with ASD?

Back 146

Pts usually do well. May have paroxysmal atrial flutter, which may be difficult to control.
Treatment = catheter ablation AFTER delivery (b/c has extensive radiation exposure)

Front 147

How to treat pregnant pt w/ VSD?

Back 147

Usually do well.
Less prone to arrhythmia, but have significant risk for bacterial endocarditis.
Need ABX prophylaxis during pregnancy

Front 148

Which pregnant pt is prone to bacterial endocarditis: ASD or VSD?

Back 148

VSD