Other Medical Complications Of Pregnancy

Front 1

Define: Hyperemesis Gravidarum

Back 1

"Morning Sickness." Seen in >90% of pregnancies. Patients can become dehydrated.

Front 2

Discuss Seizure frequency in epileptic pts w/r/t/ pregnancy

-list 4 possible mechanisms

Back 2

Seizure frequency increases. Etiologies include
1) Estrogen activates P450, which degrades AEDs (Antiepileptic drugs more)
2) Higher renal function clears the drugs faster
3) Lowered seizure threshold due to stress of pregnancy
4) Noncompliance w/ AED's

Front 3

What is the mechanism of teratogenicity for Phenobarbitol, primidone, and phenytoin?

Back 3

These AEDs are folate antagonists. Folate antagonism leads to Neural Tube Defects

Front 4

What should a patient taking multiple AEDs be counseled to do upon becoming pregnant

-special case: valproic acid

Back 4

Reduce down to 1 AED. If they haven't had seizures in 2-5, may want to totally withdraw from AEDs.

-for valproic acid, change dosing to 2-4 times per day because teratogenicity is related to peak plasma levels

Front 5

What maternal markers can be used to manage pregnant women w/ epilepsy?

Back 5

-msAFP (rising levels indicated NTD, I *think*)
-AED levels

Front 6

What vitamin should be absolutely sure to give a mom w/ seizures disorders?

-mechanism
-consideration of giving AEDs or not...

Back 6

Vitamin K! Here's why:

-AEDs can inhibit vitamin K
-vitamin K is needed for clotting factor development in babies
-babies of moms on AEDs have an increased risk of spontaneous hemorrhage

**HOWEVER, there can be serious trauma and hypoxia if the mom has a seizure. So make sure to give vitamin K**

Front 7

By how much does blood volume increase maternally during pregnancy

Back 7

50%

Front 8

Name what happens to the following cardiac levels:
-blood volume
-systemic vascular resistance
-stroke volume

Back 8

-blood volume increases 50%
-SVR decreases
-stroke volume increases

Front 9

Discuss: Eisenmenger Syndrome and its effects on pregnancy

Back 9

Moms w/ Eisenmenger syndrome have R to L shunts and Pulmonary HTN.

What happens is that Eisenmenger starts off as a L to R shunt, ,usually due to a VSD. This leads to excessive blood on the R ventricle, which then sends it to the pulmonary vasculature. This leads to rising pulmonary HTN, so much so that eventually the shunt reverses and DE-oxygenated bloods gets shunted to the left side (R-->L shunt).

These patients become hypoxic during the cardiac stress of pregnancy and are encouraged to terminate pregnancies as mortality rates are >50%

Front 10

What is a big fear for a pregnant patient with Marfan's syndrome?

-syndrome
-complications
-treatment

Back 10

Marfans syndrome is a deficiency in elastin that leads to *dilation of the aortic root.* During the hyperdynamic pregnancy state, this can lead to *aortic dissection/rupture.*

Tx: Beta blockers to decrease cardiac output

Front 11

When should betamethasone be given to mature the lungs?

Back 11

Before 34 weeks

Front 12

In a patient with peripartum cardiomyopathy (PPCM), when should the mother deliver?

Back 12

After 34 weeks, the risks to the mother are greater than the risks to the fetus w/r/t/ prematurity.

Front 13

In a patient with PPCM...
-what causes it
-how to treat it?

Back 13

-low ejection fraction (20-40%) caused by pregnancy and a dilated heart
-treat w/ diuretics, digoxin, vasodilators

Front 14

T/F: a patient with mild (Cr<1.5) renal disease will experience an increase in RBF and creatinine clearance during pregnancy

Back 14

True! pregnancy increases RBG and creatinine clearance.


*pts with moderate (Cr 1.5-2.8) or severe (Cr>2.8) chronic renal disease will have renal fxn decrease though*

Front 15

Patients with chronic renal disease are at an increased risk for which 3 conditions?

Back 15

-IUGR
-Pre-eclampsia
-preterm delivery

Front 16

In a patient with baseline HTN and renal disease, what can be used to make a dx of pre-E?

Back 16

uric acid levels. if nl at baseline, it can help to make the dx of pre-E

Front 17

Define: Fetal fibronectin test

Back 17

Positive value isn't great, but NEGATIVE test means you won't deliver for a week

Front 18

Discuss Pregnancy w/r/t/ coagulability

Back 18

It is considered a hypercoaguable state.

Possible mecahanisms
1) intrinsic increase in coagulability of the serum (more clotting factors)
2) more subendothelial collagen exposed due to damage during pregnancy
3) venous stasis

Front 19

Pelvic vein thromboses can be attributed to what, primarily?

-2 theories
-which is more likely?

Back 19

Venous stasis. There are actually two sources of venous stasis:

1) progesterone relaxes smcs
2)*** as the uterus enlarges, it compresses the IVC, iliac, and pelvic veins.**

The compression point is the money point here!

Front 20

Difference between SVT and DVT?

Back 20

SVT's are painful but bot likely to cause emboli, and are low risk.

DVT's present in lower extremities w/ pain and swelling and palpable cords underyling the region. Tx: heparin.

Front 21

Define: Pumonary Emobolus

-definition
-three things it can lead to

Back 21

When a DVT travels to the right side of the heart then lodges in the pulmonary arterial system.

-pulmonary HTN
-hypoxia
-RH failure
-(death)

Front 22

A patient presents with acute shortness of breath, pleuritic chest pain, hemoptysis, and signs of a DVT. They are most likely experiencing?

Back 22

A pulmonary embolus

Front 23

Tx of Pulmonary embolsim?

Back 23

Like DVT, treated with Heparin

Front 24

How to Dx a PE?

-4 ways

Back 24

1) Arteriogram (pulmonary angiography): look for filling defects and unperfused lung segments by the absence of contast dye
2) Ventilation/perfusion scans: look for defects in similar areas on both.
3) CXR normal
4) CT scan

Front 25

What does pregnancy do to the body's regulation of thyroid hormone?

-4 things

Back 25

-increased TBG
-increased SHBG
-increased VD
-increased metabolism

Front 26

What is Propylthiouracil?

-mechanism
-used to treat?

Back 26

PTU decreases T4 production.

-used in the treatment of Grave's Disease

Front 27

How do we manage Grave's disease during pregnancy?

Back 27

Check for thyroid-stimulating immunoglobulin levels. fetus is at risk for a goiter if they're too high.

Front 28

What is methimazole?

Back 28

blocks conversion of T4--> T3

-used in tx of Grave's Disease

Front 29

Fetal hyperthyroidism can be dx'd how?

Back 29

Fetal tachycardia

Front 30

What is the most common etiology of hypothyroidism?

Back 30

Hashimoto thyroiditis.

Front 31

A woman who is hypothyroid is currently taking levothyroxine supplementation, She then becomes pregnant. What will happen to her drug regimen?

Back 31

She should take 25% more.
Reasons:
-increased SHBG and TBG
-increased clearance
-increased volume of distribution

Front 32

Regarding SLE and pregnancy, what is the general outlook?

Back 32

Rule of 1/3s:
-1/3 get worse
-1/3 get better
-1/3 stay the same

Front 33

Discuss early pregnancy SLE complications vs. late pregnancy SLE complications

Back 33

early: thrombosis in the placenta that leads to early IUGR and pregnancy loss

late: thrombosed placenta that leads to IUGR, IUFD.

Front 34

Treatment options for SLE?

-drugs to use
-drugs to not use

Back 34

-aspirin and corticosteroids are continued during pregnancy

-methotrexate and cyclophosphamide are not used during pregnancy as they are teratogenic

Front 35

How to differentiate between a SLE flareup and pre-eclampsia?

-similarities
-diferences
-why do we care?

Back 35

similarities: both are antigen/antibody complexes that can cause a vasculitis

different: complement levels
-lupus flareup: reduced C3/C4
-pre-E: normal C3/C4

tx options differ greatly
-lupus: high dose steroids, cyclophosphamide
-pre-E: delivery

Front 36

Describe the 2 forms of neonatal lupus

Back 36

1) maternal antibody/antigen complexes cross placenta, cause lupus in the neonate
2) SLE pts produce anti-Ro and anti-La antbodies that are specific to the fetal cardiac conduction system --> irreversible congenital heartblock

**anti-Ro more likely to cause than anti-La**

Front 37

Define: Fetal Alcohol syndrome

Back 37

syndrome in mothers who consume 2-5 drinks/day during pregnancy

-growth retardation
-CNS effects
-abnormal facies

Front 38

Sudden Infant Death Syndrome and respiratory illnesses are more likely to occur in babies of patients who...

Back 38

,,,smoke cigarrettes during pregnancy

Front 39

A clear link exists between placental abruption and which elicit drug?

Back 39

cocaine

*cocaine causes vasoconstriction and HTN*

Front 40

What is the most damaging aspect of taking narotics during pregnancy

Back 40

actually, it is the withdrawal effects. narcotics like heroin and methadone have no known teratogenic effects

Front 41

Patient with renal disease are at highest risk for?

Back 41

Pre-E and IUGR, plus worsening renal dz after pregnancy

Front 42

Is caffeine risky to have during pregnancy?

Back 42

more than 150 mg/day increases SAB risk

Front 43

What type of thyroid state is pregnancy?

Back 43

Euthyroid! Even though TBG and SHBG go up, Total T4 increases as well, so Free T4 remains unchanged

Front 44

What is an antimicrosomal antibody?

Back 44

These are usually seen after pregnancy and are indicative of thyrotoxicosis due to thyroiditis (destruction of thyroid gland where you have leaking of T4). Starts off as hyperthyroid but will turn into hypothyroid in 4-10 weeks

Front 45

Artery used to assess for fetal anemia on doppler u/s

Back 45

Middle Cerebral Artery

Front 46

Artery used to assess for IUGR on doppler u/s?

Back 46

Umbilical Artery