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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