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Comorbid Diseases in Pregnancy

Comorbid Diseases in Pregnancy. Chapter 105 Tintinalli Presented by Dr. Kelley December 6, 2005. 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-

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Comorbid Diseases in Pregnancy

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  1. Comorbid Diseases in Pregnancy Chapter 105 Tintinalli Presented by Dr. Kelley December 6, 2005

  2. 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

  3. Diabetes Complications • Hypertensive diseases, preterm labor, spontaneous Ab, pyelonephritis, DKA, hypoglycemia • DKA- • Rapid occurrence at lower glucose levels. • Same tx as nonpregnant

  4. 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.

  5. 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)

  6. 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)!

  7. 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 q5-10 min up to 300 mg total) or Hydralazine (5-10mg q 15 min IV) Goal: 140-150/90-100 Hypertension

  8. 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.

  9. 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! Thromboembolism

  10. 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

  11. 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.

  12. 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.

  13. 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 <7.20-7.25) • 5. AMS • Can use standard agents for rapid sequence intubation.

  14. Chronic Renal Disease • Pregnancy rarely occurs with preconception serum creatinine >3mg/dL. • Complications: • Preterm delivery • Superimposed preeclampsia • Chronic pyelonephritis pts with  # of recurrences.

  15. 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%)

  16. CystitisTreatment • 3 day course of nitrofurantoin, ampicillin, or cephalosporin. • Trimethoprim after 1st trimester. • NO SINGLE DOSE ABX THERAPY!!

  17. 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).

  18. Inflammatory Bowel Disease •  risk for nutritional and metabolic abnormalitiesIUGR. • 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.

  19.  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 cases- partial exchange transfusion via automated erythrocytopheresis or simple transfusion <6g/dL. Sickle Cell Disease

  20. Migraine • Pregnancy usually improves classic migraines. • NO ERGOT ALKALOIDS! • Sumatriptan with minimal experience in pregnancy. • Acute Tx: Analgesics & Antiemetics • Prophylactic Tx: beta blockers (propranolol 40-60mg/day or atenolol 50-100mg/day)

  21. 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)

  22. 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/ventilation early because 50% mortality of fetus and 33% mortality of mother. Seizure Disorders Treatment

  23. HIV • 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

  24. 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.

  25. 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-birth-weight infants, preterm deliveries, perinatal mortality, fetal alcohol syndrome • ETOH coma/withdrawal treated like nonpregnant except avoid benzodiazepines in early pregnancy.

  26. 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.

  27. 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

  28. 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.

  29. THE END! QUESTIONS?????

  30. References • 1. Emergency Medicine: A Comprehensive Study Guide. Judith Tintinalli Chapter 105 • 2. Blueprints in Obstetrics and Gynecology Second Edition Chapters 7 and 8

  31. 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

  32. 3. A DVT in a pregnant patient can be treated with all of the following except: • A. Heparin • B. LMWH • C. Coumadin

  33. 4. Treatment of pyelonephritis in a pregnant patient includes all of the following except: • A. Hospitalization • B. IV Abx. • C. IV Fluids • D. Does not require hospitalization

  34. 5. Alcohol use during pregnancy can increase risk for all of the following except: • A. Spontaneous abortion • B. Low birth weight infants • C. Fetal ETOH syndrome • D. Preterm delivery • E. All of the above are true.

  35. Answers • 1. F • 2. F • 3. C • 4. D • 5. E

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