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Common Medical Complications in Pregnancy

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Inciting event (e.g., infection, surgery, labor/delivery) ... Her previous pregnancy was via Caesarean delivery because of failed induction times 3 and CPD. – PowerPoint PPT presentation

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Title: Common Medical Complications in Pregnancy


1
Common Medical Complications in Pregnancy
  • Susan M Cox, MD
  • 4.27.2014

2
Milestone 1
  • Basic understanding of the pathophysiology and
    management of gestational hypertensive diseases
  • Basic understanding and management of Diabetes
    Mellitus complicating pregnancy

3
Objectives
  • Review the diagnosis and treatment of common
    medical conditions seen in pregnancy
  • Hypertension
  • Diabetes
  • Hyperthyroidism
  • Recognize the maternal and fetal complications of
    each

4
Case 1
  • A 23-year-old G1P0 presents at 39 weeks with
    concerns for swelling in her face and hands over
    the last 3 days. Her blood pressure is 155/99. A
    24-hour urine collection shows 440mg of protein.
    What is the treatment for her disease?
  • Delivery
  • Furosemide
  • Hydralazine
  • Magnesium sulfate
  • Management of fluids

5
Epidemiology and Risk Factors
  • First Pregnancies
  • Multiple Gestations
  • Maternal Vascular Disorders
  • Diabetes Mellitus (Types 1 And 2)
  • Lupus Erythematosus
  • Renal Disease
  • Antiphospholipid Antibody Syndrome
  • Obesity
  • Advanced Maternal Age
  • African-American Race
  • Chronic Hypertension.

Complicates 8 of pregnancies
6
(No Transcript)
7
Terminology
  • Chronic hypertension
  • Chronic hypertension with superimposed
    preeclampsia
  • Gestational hypertension
  • Preeclampsia and eclampsia

8
Hypertensive Disorders in Pregnancy
  • Chronic Hypertension
  • Dx BP gt140/90
  • Prior pregnancy or
  • Noted prior to 20th week EGA or
  • Persists beyond 12 weeks postpartum

9
Hypertensive Disorders in Pregnancy
  • Chronic HTN
  • Treatment Goal DBP lt100 (lt90 if end organ
    damage)
  • Treatment options (starting dose)
  • Methyldopa 250 mg PO bid
  • Labetalol 100 mg PO bid
  • Nifedipine 30 mg PO q day
  • Hydralazine 10 mg PO qid

10
Hypertensive Disorders in Pregnancy
  • Chronic hypertension with superimposed
    preeclampsia
  • Gestational age gt 20 weeks
  • Proteinuria gt300 mg / 24 hours (when it didnt
    exist at gestational age lt 20 weeks) OR
  • BP gt160 / 110 (when it was under control at
    earlier gestational age )

11
Hypertensive Disorders in Pregnancy
  • Gestational Hypertension
  • Dx gt140/90 on two occasions
  • Gestational age gt20 weeks and normal BP earlier
    in pregnancy
  • No proteinuria (lt300 mg / 24 hours on spot urine
    estimation)

12
Hypertensive Disorders in Pregnancy
  • Gestational Hypertension
  • Treatment Goal DBP lt100 ( lt90 with end organ
    damage)
  • Treatment options
  • Methyldopa
  • Labetalol
  • Nifedipine
  • Hydralazine

13
Hypertensive Disorders in Pregnancy
  • Pre-eclampsia
  • Hypertension gt140/90 on two readings
  • Proteinuria gt300 mg / 24 hours on spot estimation
  • Gestational age gt 20 weeks
  • Normal blood pressures earlier in pregnancy

14
Hypertensive Disorders in Pregnancy
  • Pre-eclampsia
  • Treatment options
  • Depends of gestational age and severity criteria

15
Hypertensive Disorders of Pregnancy
  • Criteria for severe pre-eclampsia
  • SBP gt160 or DBP gt110
  • Proteinuria gt 5 grams / 24 hours
  • Oliguria lt500 ml / 24 hours
  • Pulmonary edema
  • Thrombocytopenia (lt100,000)
  • Liver dysfunction (AST or ALT gt 2x normal) or
    liver distention (RUQ pain / N/V )
  • Neurologic dysfunction
  • IUGR
  • Eclampsia

16
HELLP Syndrome
  • Hemolysis
  • Elevated Liver Enzymes
  • Low Platelets
  • Deliver the baby!
  • Dexamethasone not effective
  • (Am J of Obstet Gynecol 2005 Nov
    193(5)1591-1598)

17
Clinical Management Pearls
  • Pre-eclampsia
  • Preterm
  • Betamethasone 12 mg IM q 24 hours x 2 doses (EGA
    lt 34 weeks)
  • Observation if BPP reassuring and no severe
    criteria
  • Term
  • Expedite delivery

18
Clinical Management Pearls
  • Eclampsia prevention
  • Magnesium Sulfate
  • 4 gram load IV then 2 gram/hr IV
  • Monitor for
  • Oliguria
  • Loss of reflexes
  • Somnolence
  • Respiratory depression
  • Continue Mag SO4 for 24 hours post-partum

19
Maternal Cardiovascular Consequences
20
Case 2
  • A 34 year old G2 P1 presents for her first
    prenatal visit at 25 weeks gestation. She had
    no prenatal care during her first pregnancy which
    ended in a term stillborn whose birth weight was
    10.5 pounds.  
  • Past medical history is negative for
    hypertension, diabetes, and substance abuse. She
    denies alcohol use, smoking, or trauma. Her
    previous pregnancy was via Caesarean delivery
    because of failed induction times 3 and CPD.
  • Physical Examination is unremarkable except for a
    gravid uterus at 26 cm height with fetal heart
    tones 144/min.
  • Routine Prenatal Labs
  • Hemoglobin 12.6 g/dL
  • WBC 7800
  • Creatinine 0.6 mg/dL
  • Random blood sugar 130
  • One-hour glucola 165

21
What is the next step in her work-up?
  • 100 gram glucola (3 hr GTT)

22
GDM Risk Factors
  • Traditional risk factors
  • Family history
  • Previous macrosomic infant
  • Poor obstetric history
  • Glycosuria
  • identify only 40-60 of cases of GDM

23
Gestational Diabetes Mellitus
  • Criteria for no screening
  • Age lt25
  • No history of GDM / DM 2
  • No first degree relative with DM 2
  • Pre-pregnancy body weight normal
  • No history of poor obstetrical outcome
  • Not a member of higher risk ethnic group
    (Hispanic / African American / Pacific Islander /
    Native American / South or East Asian)
  • Fifth International Workshop Conference on GDM
    certain features place women at low risk of GDM,
    and it may not be cost-effective to screen this
    group of women. Represents only 10 of
    population.

24
Gestational Diabetes MellitusScreening
  • 50 gram Glucola (1 hour glucola)
  • 24-28 weeks EGA (/- 1st trimester screen)
  • No fasting required
  • Nurse can give drink at beginning of encounter
  • Single lab draw 1 hour after drinking glucola
  • Screening cut-off
  • 130 23 require 30 GTT and identifies
    additional 10 of GDM cases
  • 140 14 require 30 GTT

25
GDM Diagnostic Test
  • Confirmation with a 100 gram glucola (3 hr GTT)
  • Fasting for 8 10 hours
  • Draw fasting glucose level
  • Drink glucola
  • Draw 1, 2 and 3 hour PP values

26
3 hour GTT cutoffs
  • Carpenter and Coustan Criteria
  • Fasting lt95
  • 1 hour lt180
  • 2 hour lt155
  • 3 hour lt140
  • A positive test for GDM is 2 of 4 values abnormal

27
GDM Goals of Treatment
  • Fasting lt 95
  • AND
  • One hour PP lt 130
  • OR
  • Two hour PP lt 120

28
Treatment for GDM
  • Diet (medical nutritional therapy)
  • Insulin
  • Glyburide
  • Metformin

29
Oral therapy for GDM
  • Glyburide
  • 1. No difference in maternal / neonatal outcomes
  • Most authorities still cautious about
    recommending due to placenta crossing, but
    gaining acceptance
  • Start Glyburide 2.5 mg PO q day
  • Titrate to maximum dose 20 mg PO q day

30
Oral Therapy for GDM
  • Metformin
  • No randomized trials (i.e. insulin vs.
    metformin)
  • Data comes from cohorts treated into pregnancy
    for infertility / PCOS / etc.
  • No significant safety concerns at this point

31
Antepartum Monitoring of GDM
  • GDM A1 NST / AFI gt38 weeks
  • GDM A2 NST / AFI gt32 weeks

32
Risk of future DM 2
  • GDM Pre-Diabetes
  • 75 gram glucola at PP visit and yearly thereafter

33
Maternal And Fetal Consequences
  • Current pregnancy
  • Future prognosis for mom
  • Future prognosis for baby

34
Case 3
34-year-old G4 P3 at 19 weeks presents to the
emergency department with chest pain,
palpitations and sweating, which began 4 hours
ago. She notes that she has been very anxious
lately and is not sleeping well, which she
attributes to the pregnancy. She reports that she
has lost 30 pounds in the last year while not
dieting. She denies significant medical
problems.
35
Case 3
Examination patient appears diaphoretic and
anxious, her eyes are wide open, prominent, and
you can easily see the sclera surrounding the
pupil. Her temperature is 38.1 pulse is 132 and
her blood pressure is 162/84. Height is 1.75
meters (70) and weight is 58 kg (128 lb.). Her
thyroid is palpably enlarged, with an audible
bruit. Electrocardiogram shows sinus tachycardia.
Remaining labs are pending.
36
Case 3
  • What is the most likely diagnosis?
  • Anxiety
  • Heatstroke
  • Serotonin Syndrome
  • Thyroid Storm
  • Anticholinergic toxicity  

37
Hyperthyroidism
  • Affects 0.2 of pregnancies
  • Prevalence 0.1 to 0.4, with 85 Graves disease
  • Single toxic adenoma, multinodular toxic goiter,
    and subacute thyroiditis
  • gestational trophoblastic disease, viral
    thyroiditis and tumors of the pituitary gland or
    ovary (Struma Ovarii)

38
Physiologic Changes in Thyroid Function During
Pregnancy
Maternal Status TSH initial screening test Free T4 Free Thyroxine Index (FTI) Total T4 Total T3 Resin Triiodo-thyronine Uptake (RT3U)
Pregnancy No change No change No change Increase Increase Decrease
Hyperthyroidism Decrease Increase Increase Increase Increase or no change Increase
Hypothyroidism Increase Decrease Decrease Decrease Decrease or no change Decrease
39
Graves disease
  • 95 of thyrotoxicosis during pregnancy
  • Activity level fluctuate during gestation
  • exacerbation during the first trimester
  • gradual improvement during the latter half
  • exacerbation shortly after delivery
  • Clinical scenarios
  • stable Graves disease receiving thionamide
    therapy with exacerbation during early pregnancy.
  • in remission with a relapse of disease.
  • without prior history diagnosed with Graves
    disease de novo during pregnancy.

40
Graves disease
  • Diagnosis
  • difficult hypermetabolic symptoms in normal
    pregnancy
  • thyroid examination goiter (with or without
    bruit)
  • suppressed serum TSH level and usually elevated
    free and total T4 serum concentrations
  • TSH receptor antibodies
  • complications related to the duration and control
    of maternal hyperthyroidism
  • autoantibodies mimic TSH and can cross the
    placenta and cause neonatal Graves disease

41
Graves disease
  • Pregnancy outcome
  • preterm labor
  • untreated (88)/partially treated(25)
    /adequately treated (8)
  • preeclampsia
  • untreated twice the risk
  • stillbirth
  • untreated (50) /partially treated (16)
    /adequately treated (0)
  • small for gestational age
  • congenital malformations

42
Thyroid storm
  • Obstetric emergency
  • Extreme metabolic state
  • 10 of pregnant women with hyperthyroidism
  • High risk of maternal cardiac failure.
  • Fever, change in mental status, seizures, nausea,
    diarrhea, and cardiac arrhythmias.
  • Inciting event (e.g., infection, surgery,
    labor/delivery) and a source of infection
  • Treatment immediately, even if serum free t4,
    free t3, and TSH levels are not known.
  • Untreated thyroid storm can cause shock, stupor,
    and coma.

43
Treatment of Hyperthyroidism
  • Goal is to maintain FT4/FTI in high normal range
    using lowest possible dose (minimize fetal
    exposure)
  • Measure FT4/FTI q2-4 weeks and titrate
  • Thioamides (PTU/methimazole) -gt
  • decrease thyroid hormone synthesis blocks I
    organification
  • PTU also reduces T4-gtT3 and may work more quickly
  • PTU traditionally preferred (methimazole crossed
    placenta and associated with fetal aplasia cutis
    newer studies refute this)

44
Treatment of Hyperthyroidism
  • Median time to normalization of maternal thyroid
    function
  • 7 weeks with PTU
  • 8 weeks with methimazole
  • Breastfeeding safe when taking PTU/ methimazole

45
Treatment of Hyperthyroidism
  • Beta-blockers can be used for symptomatic relief
    (usually Propanolol)
  • Reserve thyroidectomy for women in whom thioamide
    treatment unsuccessful
  • Iodine 131 contraindicated (risk of fetal thyroid
    ablation especially if exposed after 10 weeks)
    avoid pregnancy/breastfeeding for 4 months after
    radioactive ablation

46
Maternal Complications
  • Increased risk of stillbirth
  • Preterm delivery
  • Intrauterine growth restriction
  • Preeclampsia
  • Heart failure
  • Spontaneous abortion
  • Increased maternal mortality

47
Fetal Complications
  • Fetal thyroid hyperfunction or hypofunction
    caused by TSH abs
  • Fetal goiter from excessive antithyroid drug
    treatment
  • Neonatal thyrotoxicosis
  • Increased perinatal maternal mortality
  • Decreased IQ of offspring because of excessive
    use of antithyroid drugs

48
Good Luck!
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