Comorbid Diseases in Pregnancy
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Transcript Comorbid Diseases in Pregnancy
Comorbid Diseases in Pregnancy
Chapter 105 Tintinalli
Presented by Dr. Kelley
December 6, 2005
Diabetes
2-3% of all pregnancies
Gestational- 90%
A1- diet controlled
A2- insulin controlled
Predated Diabetes- 10%
Always insulin
dependent.
Do NOT use oral
hypoglycemics!!!
Goals
<90mg/dL fasting
<140 1º postprandial
insulin needs as
pregnancy progresses.
Diabetes Complications
Hypertensive diseases, preterm labor,
spontaneous Ab, pyelonephritis, DKA,
hypoglycemia
DKA
Rapid occurrence at lower glucose levels.
Same tx as nonpregnant
Diabetes Complications Cont.
Hypoglycemia
45% occurrence
Symptoms: swelling, tremors, blurred vision,
diplopia, weakness, hunger, confusion, paresthesias,
anxiety, palpitations, vomiting, HA, stupor
Tx: Levels <70mg/dL & able to talk and follow
commands- 1 cup milk with bread and crackers q 15
min.
Severe- 1 amp D50W IVP or glucagon 1-2mg IM/SQ
with or without D5W IV @ 50-100 cc/hr.
Hyperthyroidism
Associated with risk of preeclampsia,
neonatal morbidity, low birth weight, and
possible congenital malformations.
Symptoms: nervousness, palpitations, heat
intolerance, inability to gain weight
(Thyrotoxicosis may present as
hyperemesis gravidarum.)
Tx: PTU (100-150mg PO TID)
Thyroid Storm
Symptoms: fever, volume depletion, cardiac
decompensation
Mortality rate of 25%
Tx: IVF, Oxygen, antipyretic agents, PTU
400mg PO q8º, sodium iodide 1g in 500mL IVF q
day, propranolol 40mg PO q6º (unless cardiac
failure), cooling blanket.
NO radioactive iodine therapy (congenital
hypothyroidism)!
Hypertension
Divided into chronic or
preeclampsia, however
chronic HTN can lead to
preeclampsia.
Chronic
4-5% occurrence
BP >140/90mmHg
before 12th week gest.
Tx (indicated when
systolic >160 or diastolic
>100): Aldomet,
Labetalol, nifedipine
Acute Hypertensive
Crisis
IV Labetalol (10mg q510 min up to 300 mg
total) or Hydralazine (510mg q 15 min IV)
Goal: 140-150/90-100
Dysrhytmias
Rare
Lidocaine, digoxin, procainamide can be used as
indicated.
Maintenance beta-blockers are category C so prescribe
with consultation with cardiologist/obstetrician.
Verapamil effective for cardioversion of SVT to NSR
without adverse effects.
Anticoagulation for A. Fib- unfractionated or LMWH
Cardioversion safe for fetus
Artificial pacemaker not shown to affect pregnancy
course.
Thromboembolism
0.5-0.7% occurrence
Risk factors:
advanced maternal age,
parity, multiple
gestation, operative
delivery, bed rest,
obesity, h/o previous
clot, antithrombin III def,
protein C&S def, lupus
anticoag syndrome.
Occur 2X more often
during antenatal than post
partum pd.
30% without identifiable
risk
Diagnosis:
doppler studies,
technitium-99m
perfusion lung scans and
lower ext. studies,
ventilation/perfusion
scans, pulmonary
arteriography
NO iodine-125
fibrinogen scanning!
Spiral CT has not been
studied in pregnancy.
Tx: IV Heparin or
LMWH. No coumadin!
Asthma
0.4-1.3% occurrence
Severe asthmatic- poorly controlled with
slight risk of preterm birth, stillbirth, and
low-birth weight babies.
1/3- asthma worsens in pregnancy
1/3- no change
1/3- improve
Asthma Cont.
Symptoms: cough, wheezing, dyspnea
Preventive Therapy: inhaled glucocorticoids such
as beclomethasone & cromolyn sodium via
inhaler.
Acute Exacerbation Tx: beta2 agonists
(salbutamol, metaproterenol, albuterol,
isoproterenol via nebulizer), IV
methylprednisolone or oral prednisone, epi 0.3mL
(1:1000) SQ, O2, fetal monitoring past 20 weeks
gestation, near sitting with leftward tilt position.
Asthma Cont.
Peak flow can guide tx.
(should not change with
progression of
pregnancy)
Normal 380-550L/min
If <100L/min with less
than 10% improvement
with tx are sign of poor
prognosis—aggressive
management!!
pO2
101-108 mmHg
early
90-100 mmHg near
term
pH- 7.40-7.45
pCO2- 27-32
Asthma Cont.
Indication for intubation (status epilepticus):
1. Inability to maintain pO2 >65mmHg
2. Inability to maintain pCO2 <40mmHg
3. Maternal Exhaustion
4. Significant Respiratory Acidosis (pH <7.207.25)
5. AMS
Can use standard agents for rapid sequence
intubation.
Chronic Renal Disease
Pregnancy rarely occurs with
preconception serum creatinine >3mg/dL.
Complications:
Preterm delivery
Superimposed preeclampsia
Chronic pyelonephritis pts with # of
recurrences.
Cystitis/Pyelonephritis
urinary stasis makes urinary tract most
common place of infection during
pregnancy!
Occurrence of both acute cystitis and
pyelonephritis: 1-2%
Organisms: E.coli (75%), Klebsiella
pneumoniae and Proteus (10-15%)
CystitisTreatment
3 day course of nitrofurantoin, ampicillin,
or cephalosporin.
Trimethoprim after 1st trimester.
NO SINGLE DOSE ABX THERAPY!!
Pyelonephritis Treatment
Must be prompt b/c acute pyelonephritis can
precipitate preterm labor, bacteremia (10-15%),
septic shock, respiratory insufficiency from acute
lung injury (2-8%).
Tx: hospitalization, aggressive IV hydration, IV
Abx. (2nd/3rd gen. Cephalosporin) until afebrile X
48 hrs and no CVA tenderness, then d/c with abx
to complete 10 day course. Possible antibiotic
suppression remainder of pregnancy
(nitrofurantoin 50-100 mg/day).
Inflammatory Bowel Disease
risk for nutritional and metabolic
abnormalitiesIUGR.
Tx: Same as nonpregnant
Antidiarrheals- Codeine, Opium, Paregoric, Lomotil
Sulfasalazine and Corticosteroids safe.
NO sulfa drugs in 3rd trimester.
TPN in severe nutritional deficiencies.
Metronidazole after 1st trimester.
Sickle Cell Disease
risk of miscarriage,
preterm labor, & other
complications due to
impaired O2 supply and
sickling infarcts in
placental circulation.
vascular occlusive
events ( 3rd trimester
and post partum)
Tx of painful crisis same
as nonpregnant
(analgesics and
hydration) except NO
NSAIDs!
More severe casespartial exchange
transfusion via automated
erythrocytopheresis or
simple transfusion
<6g/dL.
Migraine
Pregnancy usually improves classic migraines.
NO ERGOT ALKALOIDS!
Sumatriptan with minimal experience in
pregnancy.
Acute Tx: Analgesics & Antiemetics
Prophylactic Tx: beta blockers (propranolol 4060mg/day or atenolol 50-100mg/day)
Seizure Disorders
0.5-1.0% occurrence
slightly in frequency during pregnancy
Medication doses may need to maintain
therapeutic levels.
Valproic Acid general avoided (1-3% risk
of neural tube defects)
Seizure Disorders Treatment
Single grand mal
seizure
(May be followed by
fetal bradycardia for
up to 20 minutes- no
apparent long term
fetal harm.)
Oxygen
Left lateral uterine
displacement
Status Epilepticus
Aggressive
management with
intubation/ventilatio
n early because 50%
mortality of fetus
and 33% mortality of
mother.
HIV
All HIV patients >14 weeks gestation
should be on zidovudine therapy to risk
of vertical transmission (258%)
Pregnancy does not alter course of disease.
If CD4+ cell counts <200prophylaxis for
pneumocystis carinii pneumonia
Substance Abuse
Refer to high-risk obstetrics clinic and offer
substance abuse counseling.
Cocaine
Fetal complications: risk of placental abruption,
fetal death in utero, IUGR, preterm labor, premature
rupture of membranes, spontaneous Ab, cerebral
infarcts
Maternal complications: MI, HTN, pulmonary
edema, cardiac dysrhythmia, subarachnoid
hemorrhage, ruptured aneurysms, stroke
Tx of acute intoxication handled as in nonpregnant
pt.
Substance Abuse Cont.
Opiate Withdrawal
Acute Tx: Methadone or clonidine (0.1-0.2mg SL
q1º up to 0.8mg)
Maintenance Tx: Clonidine 0.8-1.2mg/day in
divided doses X 7 days then taper for 3 days.
Alcohol Abuse
1-2% of pregnancies
2 or more drinks/day risk of spont Ab, low-birthweight infants, preterm deliveries, perinatal mortality,
fetal alcohol syndrome
ETOH coma/withdrawal treated like nonpregnant
except avoid benzodiazepines in early pregnancy.
Domestic Violence
14-17% occurrence
risk associated with late prenatal care,
unintended pregnancy, drug and ETOH abuse,
depresion, and housing problems.
Fetal complications: placental abruption, fetal
fractures, uterine rupture, preterm labor
Keep high risk of suspicion
Refer to social services and/or law enforcement.
RhoGam for Rh neg mothers with blunt abd
trauma.
Medications for Concurrent
Illness During Pregnancy and
Lactation
Classic teratogenic period: Days 31-71
after last menstrual period (period of
organogenesis)
Before 31 days- all-or-none effect. Fetus
either survives or does not survive.
Table 105-1
Table 105-2
Complicating Effects of
Radiation
10 rad is threshold for human teratogenesis
Table 105-3
Ventilation/perfusion scan=0.5 rad
Ultrasound without known teratogenic
effect.
Studies with MRI have not shown any
harmful effects thus far.
THE END!
QUESTIONS?????
References
1. Emergency Medicine: A Comprehensive
Study Guide. Judith Tintinalli Chapter
105
2. Blueprints in Obstetrics and
Gynecology Second Edition Chapters 7
and 8
Questions
1. It is reasonable to use oral hypoglycemics to
treat gestational diabetes.
A. True
B. False
2. You should not be concerned about a BP
140/90 or greater in a pregnant patient.
A. True
B. False
3. A DVT in a pregnant patient can be
treated with all of the following except:
A. Heparin
B. LMWH
C. Coumadin
4. Treatment of pyelonephritis in a
pregnant patient includes all of the
following except:
A.
B.
C.
D.
Hospitalization
IV Abx.
IV Fluids
Does not require hospitalization
5. Alcohol use during pregnancy can
increase risk for all of the following except:
A.
B.
C.
D.
E.
Spontaneous abortion
Low birth weight infants
Fetal ETOH syndrome
Preterm delivery
All of the above are true.
Answers
1.
2.
3.
4.
5.
F
F
C
D
E