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Common Medical Conditions Seen in Pregnancy

Common Medical Conditions Seen in Pregnancy. Justin A. Glass, MD 12.13.07. Objectives. Use a sample clinic schedule to review the diagnosis and treatment of common medical conditions seen in pregnancy. Review the tallest peaks in each of the seven continents. FMC of EJCH 13 Dec 2007.

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Common Medical Conditions Seen in Pregnancy

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  1. Common Medical Conditions Seen in Pregnancy Justin A. Glass, MD 12.13.07

  2. Objectives • Use a sample clinic schedule to review the diagnosis and treatment of common medical conditions seen in pregnancy. • Review the tallest peaks in each of the seven continents

  3. FMC of EJCH 13 Dec 2007 0830 Adams, Betty 12398283 OB @ 24 weeks/ f/u 0845 Markson, Jonette 14728673 Amenorrhea / ? pregnant 0900 Charles, Jenny 23537289 OB @ 32 weeks / leg pain 0915 Jackson, Mary 23287839 OB @ 36 weeks / RUQ pain 0930 Barelas, Tina 19186788 OB @ 32 weeks / Numbness 0945 Davidson, Tammy 11890900 OB @ 14 weeks / Acid issue • Dreyer, Misty 20001378 OB @ 9 weeks / Vomiting • Acute 1 • Acute 2 • Acute 3 • Acute 4 1115 Acute 5

  4. Time to work….

  5. Case 1 • Betty Adams is a 23 yr old African American female G1P0 @ 24 weeks EGA by LMP. She presents for a follow-up prenatal visit. • PMH negative • Pregnancy uncomplicated to date • Labs at intake normal • 20 week ultrasound: Singleton female

  6. My sister had diabetes while pregnant. Do I need to be tested?

  7. Gestational Diabetes Mellitus • Criteria for no screening: • Age <25 • 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)

  8. How do you screen for GDM?

  9. Gestational Diabetes Mellitus • 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 versus 140

  10. What if the 50 gram glucola is abnormal? • Confirmation with a 100 gram glucola (3 hr GTT) • Fasting for 8 hours • Draw fasting glucose level • Drink glucola • Draw 1, 2 and 3 hour PP values

  11. 3 hour GTT cutoffs • Carpenter and Coustan Criteria • Fasting <95 • 1 hour <180 • 2 hour <155 • 3 hour <140 A positive test for GDM is 2 of 4 values abnormal.

  12. GDM Goals of Treatment Fasting <95 AND One hour PP <130 OR Two hour PP <120

  13. What are the treatment options for GDM? • MNT (medical nutritional therapy) • Insulin • NPH and Regular OR • Lantus and Humalog • Glyburide • Metformin

  14. Oral therapy for GDM • Glyburide Single randomized controlled trial of GDM comparing glyburide to insulin (N = 404 ) N Engl J Med 2000;343:1134-8 1. No difference in maternal / neonatal outcomes • Most authorities still cautious about recommending, but gaining acceptance (Grady now using) • Start Glyburide 2.5 mg PO q day • Can titrate to maximum dose 20 mg PO q day

  15. 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. • Randomized trial (Australia) results expected soon

  16. Antepartum Monitoring of GDM Pregnancies • GDM A1 NST / AFI >38 weeks • GDM A2 NST / AFI >32 weeks

  17. What is the risk of future DM 2 after GDM? • GDM = Pre-Diabetes • 75 gram glucola at PP visit and yearly thereafter

  18. Why do we care about diagnosing GDM? • Current pregnancy • Future prognosis for mom • Future prognosis for baby

  19. Denali

  20. Case 2 • Jonette Markson is a 38 yr G4P3 @ 6 weeks EGA presenting following a positive urine home pregnancy test. • Her PMH is negative. • Her exam is significant for BP 150/95.

  21. Is my blood pressure high?

  22. What are the types of HTN in pregnancy? • Chronic Hypertension • Gestational Hypertension (Pregnancy Induced Hypertension) • Preeclampsia • Preeclampsia superimposed on chronic hypertension.

  23. Hypertensive Disorders in Pregnancy • Chronic Hypertension • Dx: BP >140/>90 • Preceding pregnancy OR • Preceding 20th week EGA OR • Persists beyond 12 weeks postpartum

  24. Hypertensive Disorders in Pregnancy • Chronic HTN • Treatment Goal: DBP <100 ( <90 with 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

  25. Hypertensive Disorders in Pregnancy • Gestational Hypertension • Dx >140/>90 on two occasions • Gestational age >20 weeks and normal bp’s earlier in pregnancy • No proteinuria (<300 mg / 24 hours on spot urine estimation

  26. Hypertensive Disorders in Pregnancy • Gestational Hypertension • Treatment Goal: DBP <100 ( <90 with end organ damage) • Treatment options • Methyldopa • Labetalol • Nifedipine • Hydralazine

  27. Hypertensive Disorders of Pregnancy • Pre-eclampsia • Hypertension >140/>90 on two readings • Proteinuria >300 mg / 24 hours on spot estimation • Gestational age >20 weeks • Normal blood pressures earlier in pregnancy

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

  29. Hypertensive Disorders of Pregnancy • Criteria for severe pre-eclampsia • SBP >160 or DBP >110 • Proteinuria > 5 grams / 24 hours • Oliguria (<500 ml / 24 hours • Pulmonary edema • Thrombocytopenia (<100,000) • Liver dysfunction (AST or ALT > 2x normal) or liver distention (RUQ pain / N/V ) • Neurologic dysfunction (scotomata / Blurred vision / AMS / severe HA) • IUGR • Eclampsia

  30. HELLP Syndrome • Hemolysis • Elevated Liver Enzymes • Low Platelets Deliver the baby! Dexamethasone not effective in a recent trial (Am J of Obstet Gynecol 2005 Nov; 193(5):1591-1598)

  31. Hypertensive Disorders in Pregnancy • Pre-eclampsia Management Pearls • Preterm • Betamethasone 12 mg IM q 24 hours x 2 doses (EGA < 34 weeks) • Observation if BPP reassuring and no severe criteria • Term • Expedite delivery

  32. Hypertensive Disorders of Pregnancy • Eclampsia prevention • Magnesium Sulfate • 4 gram load IV then 2 gram/hr IV gtt • Monitor for • Oliguria • Loss of reflexes • Somnolence • Respiratory depression Continue Magnesium SO4 for 24 hours post-partum.

  33. Hypertensive Disorders of Pregnancy • Superimposed Pre-eclampsia on Chronic Hypertension • Gestational age > 20 weeks • Proteinuria >300 mg / 24 hours (when it didn’t exist at gestational age < 20 weeks) OR • BP >160 / >110 (when it was under control at earlier gestational age )

  34. Mt. Kilimanjaro

  35. Case 3 • Jenny Charles is a G1PO female at 32 weeks EGA. She presents with increased swelling in her L leg x 2 days. She has had mild edema bilat for about a month. She had trouble sleeping due to pain in the L leg last night • PMH Neg • BP 115/78 UA Neg protein

  36. Case 3 • Can I take quinine for this leg cramp doctor?

  37. Thrombotic Disease in Pregnancy • Incidence: 0.5 -1 case / 1000 pregnancies • Relative risk (RR) = 5.0 • Factors • Postpartum • C-section

  38. Thrombotic Disease in Pregnancy • Diagnosis of VTE D-Dimer Duplex scan MRI Spiral CT VQ scan

  39. Thrombotic Disease in Pregnancy • Treatment • LMWH • Need to monitor anti-factor Xa levels q 4 weeks • Goal: 0.6 – 1.0 IU/ml (bid dosing) or 1 -2 IU/ml for q day dosing • Heparin bridge • Stop LMWH 2 weeks before delivery. • Start Unfractionated Heparin with goal PTT 1.5-2.3 normal • Hold for delivery with restart 6 hours after vaginal delivery or 12 hours after C-section • Coumadin in the post-partum period

  40. Thrombotic Disease in Pregnancy • Coumadin is teratogenic • Nasal hypoplasia • Limb hypoplasia • Optic disc atrophy • Neurodevelopmental delays • However, ok with nursing.

  41. Thrombotic Disease in Pregnancy • Duration of therapy • Three to Six months • Need to cover at least six weeks post-partum

  42. Mt Everest

  43. Case 4 • Mary Jackson is a 20 year old G1P0 female at 36 weeks EGA. She comes in complaining of RUQ pain and nausea. Present x 3 days. No appetite. Ill appearing. Jaundiced. • BP 120/80 Urine protein negative • Tbili 8 / SGOT and SGPT in 200’s • RUQ U/S shows no gallstones.

  44. Acute Fatty Liver of Pregnancy • Rare (1:10,000) • 3rd trimester presentation • N/V • RUQ Abdominal Pain • Anorexia • Jaundice

  45. Acute Fatty Liver of Pregnancy • Differential Diagnosis • Cholelithiasis / Cholecystitis • HELLP Syndrome • Viral Hepatitis • Intrahepatic Cholestasis of Pregnancy

  46. Acute Fatty Liver of Pregnancy • Treatment Delivery!

  47. Aconcagua

  48. Case 5 • Tina Barelas is a 28 G3P2 female at 36 weeks EGA who presents with numbness in R hand. Worse in early AM hours. Better during day. Hand feels “weak” in AM.

  49. Case 5 • Am I having a stroke?

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