Transcript Comorbid Diseases in Pregnancy

Comorbid Diseases in Pregnancy
Chapter 105 Tintinalli
Presented by Dr. Kelley
December 6, 2005
Diabetes
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2-3% of all pregnancies
Gestational- 90%
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A1- diet controlled
A2- insulin controlled
Predated Diabetes- 10%
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Always insulin
dependent.
Do NOT use oral
hypoglycemics!!!
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Goals
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<90mg/dL fasting
<140 1º postprandial
 insulin needs as
pregnancy progresses.
Diabetes Complications
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Hypertensive diseases, preterm labor,
spontaneous Ab, pyelonephritis, DKA,
hypoglycemia
DKA
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Rapid occurrence at lower glucose levels.
Same tx as nonpregnant
Diabetes Complications Cont.
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Hypoglycemia
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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
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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
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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
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Divided into chronic or
preeclampsia, however
chronic HTN can lead to
preeclampsia.
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Chronic
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4-5% occurrence
 BP >140/90mmHg
before 12th week gest.
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Tx (indicated when
systolic >160 or diastolic
>100): Aldomet,
Labetalol, nifedipine
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Acute Hypertensive
Crisis
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IV Labetalol (10mg q510 min up to 300 mg
total) or Hydralazine (510mg q 15 min IV)
Goal: 140-150/90-100
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Dysrhytmias
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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
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0.5-0.7% occurrence
Risk factors:
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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:
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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
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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.
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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.
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Peak flow can guide tx.
(should not change with
progression of
pregnancy)
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Normal 380-550L/min
If <100L/min with less
than 10% improvement
with tx are sign of poor
prognosis—aggressive
management!!
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pO2
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101-108 mmHg
early
90-100 mmHg near
term
pH- 7.40-7.45
pCO2- 27-32
Asthma Cont.
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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
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Can use standard agents for rapid sequence
intubation.
Chronic Renal Disease
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Pregnancy rarely occurs with
preconception serum creatinine >3mg/dL.
Complications:
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Preterm delivery
Superimposed preeclampsia
Chronic pyelonephritis pts with  # of
recurrences.
Cystitis/Pyelonephritis
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 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
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3 day course of nitrofurantoin, ampicillin,
or cephalosporin.
Trimethoprim after 1st trimester.
NO SINGLE DOSE ABX THERAPY!!
Pyelonephritis Treatment
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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
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 risk for nutritional and metabolic
abnormalitiesIUGR.
Tx: Same as nonpregnant
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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
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 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)
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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
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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
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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
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Single grand mal
seizure
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(May be followed by
fetal bradycardia for
up to 20 minutes- no
apparent long term
fetal harm.)
Oxygen
Left lateral uterine
displacement
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Status Epilepticus
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Aggressive
management with
intubation/ventilatio
n early because 50%
mortality of fetus
and 33% mortality of
mother.
HIV
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All HIV patients >14 weeks gestation
should be on zidovudine therapy to  risk
of vertical transmission (258%)
Pregnancy does not alter course of disease.
If CD4+ cell counts <200prophylaxis for
pneumocystis carinii pneumonia
Substance Abuse
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Refer to high-risk obstetrics clinic and offer
substance abuse counseling.
Cocaine
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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.
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Opiate Withdrawal
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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
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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
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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
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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
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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
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1. Emergency Medicine: A Comprehensive
Study Guide. Judith Tintinalli Chapter
105
2. Blueprints in Obstetrics and
Gynecology Second Edition Chapters 7
and 8
Questions
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1. It is reasonable to use oral hypoglycemics to
treat gestational diabetes.
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A. True
B. False
2. You should not be concerned about a BP
140/90 or greater in a pregnant patient.
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A. True
B. False
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3. A DVT in a pregnant patient can be
treated with all of the following except:
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A. Heparin
B. LMWH
C. Coumadin
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4. Treatment of pyelonephritis in a
pregnant patient includes all of the
following except:
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A.
B.
C.
D.
Hospitalization
IV Abx.
IV Fluids
Does not require hospitalization
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5. Alcohol use during pregnancy can
increase risk for all of the following except:
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A.
B.
C.
D.
E.
Spontaneous abortion
Low birth weight infants
Fetal ETOH syndrome
Preterm delivery
All of the above are true.
Answers
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1.
2.
3.
4.
5.
F
F
C
D
E