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50 Cards in this Set
- Front
- Back
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Hyperemesis Gravidarum
a. what is it b often associated with what condition c. what is important to document c. |
a. Nausea and vomiting in pregnancy due to hormones and disordered motility of upper GI --> electrolyte abnormalities
b. molar pregnancy c. document viable IUP |
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Goals and therapy for hyperemesis gravidarum treatment in short term
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1. Rehydrate, correct electrolyte abnormalities
b. hypochloremic acidosis caused by vomiting --> treat with NS + 5% dextrose, antiemetics for vomiting, ginger, and vit B12 long term - add small, frequent meals |
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anti-emetics used in the setting of hyperemesis gravidarum
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compazine, phenergan, tigan, reglan
second: droperidol, zofran Can treat with corticosteroids, acupuncture, acupressure, nerve stimulation |
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common etiologies why seizure frequency is higher in pregnancy
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1. increased volume of dist for anti-epileptic drugs
2. increased hepatic metabolism of anti-epilepics (increased estrogen increases P450) 3. decreased compliance to ADS 4. increased renal function --> impacts metablism of bamazepine, primidone, nnd benzos |
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How does estrogen level affect seizures in pregnancy
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Higher estrogen decreases seizure threshold
Peak s in third trimester |
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Fetal congenital abnormalities and adverse outcomes
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4x increase in cleft lip/palate, 3-4x increase in cardiac abnormalities, Neural tube defects (carbemazepine, valproic acid)
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How do phenytoin, primidone, and phenobarbital act teratogens
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folate antagonists, can lead to congenital malforms like NTDs
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What is the relationship between teratogenesis and epoxide hydrolase
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Anomalies increase in infants with reduced activity of the enzyme epoxide hydrolase
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What special dosing regimen should be undertaken when taking valproic acid
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Higher peak plasma levels of valproic acid may be teratogenic, so dose at 2-4 times per day to even plasma levels
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Valproic acid, carbemazepine
what should you take to help protect against fetal defects |
folate, these cause NT defects
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What is a level II fetal survey and when is it done
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19-20 weeks - fetal exam w/careful attention to face, CNS, and heart
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6 parts of managing a woman with epilepsy during pregnancy
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-check levels of anti-epileptic drugs
-early genetic counseling -MSAFP -Level II ultrasound -amniocentesis for AFP and acetylcholinesterase -supplement w/oral vit. K (37weeks to delivery) |
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Side effect of benzos in women and newborns
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respiratory depression
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How are siezures treated in a patient with seizure disorder vs. preeclampsia
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seizure disorder - phenytoin
preeclampsia - magnesium sulfate |
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How might AEDs lead to spontaneous hemorrhage
How should you treat |
inhibit vitamin K-dependent clotting factors secondary to increased vit K metabolism and inhibition of placental transport of vit K by AEDs
supplement vit K, deliver FFP if cord blood is deficient in clotting factors |
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Cardiac changes with pregnancy
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50% increase in blood vol.
Decrease in SVR increased Stroke vol. Myocardial remodeling |
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4 conditions w/high maternal mortality (CV)
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Primary pulm HTN
Eisenmenger Mitral/aortic stenosis Marfan's |
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What should you use with patients with cardiac abnormalities in labor
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SBE prophylaxis
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High risk patients with cardiac abnormalities who become pregnant
What interventions |
1. Suggest termination of pregnancy
If they refuse 2. Use an epidural 3. Assisted vaginal delivery to decrease valsalva 4. fluid monitoring, often with a central venous pressure monitor and an arterial line |
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Why are there fluid shifts in the immediate postpartum period that are dangerous for women with congenital heart disease
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increased venous return
clamping down of uterus --> autotransfusion of blood supply |
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Patient has R-L shunt or pulmonary HTN
what should be advised in pregnancy |
1. terminate pregnancy
OR -serial echos (pulm pressure, cardiac function) -inhaled NO -labor and assisted delivery watch out 2-4 weeks postpartum |
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Patient has aortic stenosis/aortic insufficiency
What is an early sequelae |
require decreased afterload to maintain CO
pregnancy --> decrease in SVR --> actually diminished symptoms initially |
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Patient has mitral stenosis
what happens in pregnancy |
heart unable to meet higher demands in pregnancy --> CHF
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Recommendations for a patient with Marfan's in pregnancy
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increased risk of aortic dissection and/or rupture (esp if aortic root dilation)
advise to be sedentary and use b-blockers to decrease CO |
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Peripartum cardiomyopathy
a. signs and symptoms b. treatment if >34weeks c. treatment if <34 weeks |
a. heart failure symptoms, dilated heart with lower ejection fraction
b. beyond 34 weeks --> delivery c. below 34 weeks --> betamethasone treat with diuretics, digoxin, vasodilators |
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Thresholds for chronic renal disease
a. mild b. mod c. severe |
a. Cr<1.5
b. Cr 1.5-2.8 c. Cr > 2.8 |
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What happens to RBF and Cr clearance in pregnancy
What happens in the latter half |
RBF and Cr clearance increase in pregnancy
decreasing renal func in latter half in those with moderate to severe renal disease |
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3 conditions that chronic renal disease puts you at risk for
How should you screen these patients |
preeclampsia
pre-term delivery IUGR Once per trimester with a 24hr urine for creatinine clearance and protein, antenatal fetal testing 32-34 weeks gestation |
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How do you diagnose preeclampsia in a patient with baseline HTN and proteinuria
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Uric acid levels increase from baseline
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Patient with renal transplant gets pregnant
What must be monitored and why |
medication levels b/c increased metabolism and Vd of immunosuppressants like prednisone and Imuran
Cr clearance and creatinine |
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Woman with thrombophilia gets pregnant
she is at increased risk for what |
DVT, PE
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3 etiologies of hypercoagulability in pregnancy
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1. Intrinsic increase in coagulability of serum - increased production of clotting factors, decreased fibrinogen turnover time, increased fibrinopeptide A, increased fibrin monomers
2. Increased endothelial damage --> thrombogenesis 3. Venous stasis -progesterone --> decreased venous tone -uterus compresses IVC, iliac, pelvic veins |
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Superficial vein thrombosis
a. diagnosis b. treatment c. increases risk for what |
a. palpable, visible venous cords, tender, with local erythema and edema
b. warm compress, analgesics c. DVT, PE |
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DVT in pregnancy
a. diagnosis b. Treatment c. contraindicated in pregnancy |
a. lower extremity pain/swelling (unilateral) + edema, erythema, tenderness, venous distension, palpable cord
Confirm w/doppler or venography b. Treat with heparin (IV), continue subcut. into pospartum c. coumadin - causes nasal hypoplasia, skeletal abnormalities, optic atrophy |
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Pulmonary embolus
a. what can it lead to b. diagnosis -clinical -CXR -EEG - |
a. pulm HTN, hypoxia, right-sided heart failure, death
b. acute SOB + pleuritic chest pain, hemoptysis +/- DVT -CXR - abrupt termination of vessel, area of radiolucency in lung beyond the PE -EEG - RH strain, Right axis deviation, nonspecific ST changes, peak T waves -Spiral CT -pulmonary angiography |
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Gold standard for diangoisng PE
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pulmonary angiography
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Treatment for PE
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IV heparin, subcut or LMW heparin
switched to unfractioned heparin at 36 weeks (so epidural can be placed w/o risk of hematoma) Streptokinase Postpartum - coumadin |
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3 factors that affect thyroid disease in pregnancy
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increaed Vd
increased SHBG (due to estrogen) increased metabolic demands --> TSH, FT4 levels increased |
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Hyperthyroidism and pregnancy
can lead to what in pregnancy |
fetal goiter - result of increased TSI (check levels, fetal survey at 18-20 weeks, ultrasound in third trimester)
fetal hyperthyroidism (fetal tachy, monitor serial NSTs) fetal goiter from PTU or methimazole therapy |
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Patient with Hashimoto's is pregnant
what should be done if they are on levothyroxine What should you follow What if history of thyroid cancer |
due to increased Vd, SHBG, basal metabolic rate, and clearance, increase dosage by 25-30%
Follow TSH level If history of thyroid cancer, keep TSH below normal |
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Patient with SLE + HTN or renal disease are at greater risk of developing what?
Natural history of SLE in pregnancy |
preeclampsia, IUGR, preterm deliveries
1/3 worsen, 1/3 same, 1/3 improve |
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2 drugs for collagen vascular disease that are discontinued in pregnancy
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cyclophosphamide, methotrexate
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Patient has SLE or anti-phospholipid syndrome
a. increased risk of what b. pathogenesis c. hallmark of disease d. treatment |
a. first and second trimester pregnancy loss
b. placental thrombosis c. IUGR at 18-20wks d. aspiring, heparin, corticosteroids |
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Placental thrombosis in the third trimester
a. increased risk for what b. monitoring c. treatment |
a. IUGR, IUFD, preeclampsia
b. antenatal testing at week 32 c. heparin prophylaxis, low dose aspirin |
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Lupus flare vs. preeclampsia
a. similarity in pathophys b. how do you tell the difference |
a. both have circulating antigen-antibody complexes or tissue-specific antibodies that cause a vasculitis
b. Lupus has reduced C3 and C4 complement, preeclamptics have normal levels Lupus flares have active urine sediment |
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How do you treat lupus flare?
Severe preeclampsia? |
high dose corticosteroids, cyclophosphamide
deliver baby! |
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2 complications of neonatal lupus
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lupus flares, irreversible congenital heart block
Rx: corticosteroids, plasmapheresis, IVIG |
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Cigarette smoking in pregnancy increases risk of what conditions
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spontaneous abortions, preterm birth, abruptio placentae, decreased birth wt., SIDS, respiratory illness of childhood
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Cocaine + pregnant
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abruptio placentae, IUGR, increased risk for preterm labor and delivery (causes vasoconstriction and HTN)
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heroin withdrawal in a fetus
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miscarriage, preterm delivery, fetal death
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