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 q5-10 min up to 300 mg total) or Hydralazine (5-10mg 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 <7.20-

7.25) 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 cases- partial 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 40-

60mg/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/ventilation 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-birth-weight

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. Hospitalization B. IV Abx. C. IV Fluids D. Does not require hospitalization

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.

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