Comorbid Diseases in Pregnancy

1
Comorbid Diseases in Pregnancy

• Tintinallis Chapter 105

2
Diabetes

• Complicates 2-3 of all pregnancies
• 90 gestational 10 established prior
• All establish diabetics will be managed with
  insulin therapy gestational diabetics will
  attempt diet control 1st (Oral hypoglycemics
  contraindicated)
• Goal is fasting glucose lt 90 mg/dL 1 hour post
  prandial lt 140 mg/dL
• Insulin-Dependents will need increase insulin
  throughout pregnancy 45 will have 1 or more
  hypoglycemic episodes
• Pregnant Diabetics have increased HTN, Preterm
  labor, spontaneous abortion, pyelonephritis, DKA

3
Hyperthyroidism

• Increased risk of preeclampsia and neonatal
  morbidity
• Thyrotoxicosis can present as hyperemesis
• Treated with PTU, but maximum action is at 4-6
  weeks
• If a purpuric rash presents after PTU is given,
  switch to Methimazole (0.3 on PTU will get
  agranulocytosis)
• Thyroid storm
• fever, volume depletion, cardiac decompensation
• Mortality rate up to 25
• IV fluids, O2, antipyretics, PTU sodium iodine
  Propranolol

4
Hypertension

• Divided into chronic preeclampsia (ch 106)
• 4 of all pregnancies and is a sustained BP
  gt140/90 before wk 20
• Therapy initiated if BP gt 160/100
• Labetalol, nifedipine, alpha-methyldopa, and
  hydralazine are all options for treatment
• Treatment goals during HTN crisis is systolic
  140-160 diastolic 90-100

5
Comorbid Diseases of Pregnancy

• Dysrhythmias
• Rare
• Lidocaine, Digoxin, Procainamide, Verapamil are
  all safe. Beta blockers are class C
• Cardioversion is safe in pregnancy
• LMW heparin is the anticoagulant of choice
• Thromboembolism
• Incidence is 0.5-0.7
• DVT PE twice as common antenatal vs. post
  partum
• VQ scans can be performed safely in pregnancy,
  newer literature suggests CTA is safer
• Treatment is IV heparin to PTT 1.5-2 x normal
• Coumadin (NO), LMWs (Okay), Thrombolytics (last
  resort)

6
Asthma

• Complicates 0.4-1.3 1/3 have worsening of
  symptoms
• Presents the same in pregnancy
• Rescue meds Beta agonists IV or PO steroids
  or 0.3mL of 11000 epi SQ
• PO2 should be kept gt 65 mmHg
• Peak flows do not change in pregnancy
• Peak lt 100 L/min or lt 10 improvement is a sign
  of severe disease
• Normal PaCO2 in pregnancy is 27-32 mmHg
• Indications for intubation
• PaO2 lt 65 on supplemental O2
• PaCO2 gt 40
• Maternal exhaustion
• Respiratory acidosis (lt7.2) refractory to
  treatment
• Altered Mental Status

7
Comorbid Diseases of Pregnancy

• Cystitis Pyelonephritis
• Urinary stasis and mild hydronephrosis lead to
  increased UTIs
• Causative organisms are the same, E coli (75)
  Klebsiella Proteus 10-15
• Simple cystitis tx is 3 days of nitrofurantoin,
  ampicillin, or cephalosporin bactrim after first
  trimester
• Pyelonephritis patients should be hospitalized
  due to increased morbidity Tx consists of IV
  2nd/3rd generation cephlo. continued for 48
  hours after afebrile no pain, then 10 day
  course
• Chronic Renal Disease
• Preterm delivery preeclampsia are common

8
Comorbid Diseases of Pregnancy

• Inflammatory Bowel Disease
• Risk of nutritional metabolic abnormalities
• No increase incidence of flare ups
• Treatment mostly the same
• Codeine lomotil are safe
• Sulfasalazine steroids safe
• Azathioprine 6-mercaptopurine are safe
• TPN as a last resort
• Metronidazole for infectious colitis is safe
  after the first trimester

9
Comorbid Diseases of Pregnancy

• Seizure
• Incidence of 0.15-1
• Usually increases in pregnancy due to increase
  plasma volume
• Management is no different for the pregnant
  patient
• Fetal bradycardia is common up to 20 minutes post
  seizure
• 50 fetal 30 maternal mortality rate in status
  
• Migraine
• Usually improve with pregnancy
• Tx acetaminophen, codeine, meperidine,
  antiemetics
• Sickle Cell
• Increased risk of miscarriage and preterm labor
• Increase vascular occlusive events
• Txs are aggressive hydration analgesic therapy
• Narcotics safe NSAIDS before 32 wks transfusion
  if Hb lt 6 g/dL

10
Comorbid Diseases of Pregnancy

• Substance Abuse
• All should be referred to a high risk OB/GYN
• Cocaine has increase risk of placental abruption,
  IU growth restriction, preterm labor, premature
  rupture of membranes, and fetal cerebral
  infarcts HTN, MI, ruptured aneurysms, and
  dysrhythmias common in mothers
• Opiate withdrawal should be treated with
  methadone and clonidine
• EtOH abuse is 1-2 in pregnancy withdrawal
  symptoms should be treated with pentobarbital not
  benzos
• HIV
• All infected women past 14wks should be on
  zidovudine
• CD4 count lt200 should be placed on TMP-SMX

11
Comorbid Diseases of Pregnancy

• Radiation exposure
• 0-2 wks can lead to resorption of the embryo
• 2-8 wks is the most sensitive period for
  teratogenesis to occur
• 8-15 wks is when the CNS is most sensitive to
  radiation (your kid isnt going to Harvard)
• Beyond wks the risk if very low and beyond 25 wks
  no effects have been observed
• 10 rads if the threshold for human teratogenesis
• 10 rads
• 20,000 chest xrays with shielding
• 100 KUBs or single view abdominal film
• 100 Head CTs
• 3 abdominal CTs

12
Resources

• Tintinalli Chapter 104