Medical Complications of Pregnancy

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Transcription:

Medical Complications of Pregnancy

Systems Cardiovascular Pulmonary Endocrine Gastrointestinal Urologic Neurologic

Cardiovascular System Physiologic anemia 3:1 increase of plasma volume:rbc mass Treat <10 g/dl iron deficiency anemia (90%) Ferrous sulfate 325 mg BID megaloblastic anemia Folic acid 1 mg daily, rarely B12

Cardiovascular System Hemoglobinopathies Sickle cell trait (HbSA), Sickle cell β- thalassemia (HbSβthal) Sickle cell disease (HbSS), Sickle cell hemoglobin C (HbSC)

Cardiovascular system physiologic changes Cardiac output increases ~50% Peak second trimester Stroke volume Heart rate Physiologic systolic murmur Blood pressure decreases through second trimester, normalizes at term

Cardiovascular system Rheumatic Heart Disease (50%) Mitral stenosis Congenital Heart Disease New York Heart Association Functional Classification (I-IV) Correct anemia, treat infections, decrease physical activity, and ensure proper weight gain Risk low birth weight, prematurity, congenital heart disease

Cardiovascular system Cardiac arrhythmias Paroxysmal atrial tachycardia Atrial fibrillation and atrial flutter Peripartum and postpartum cardiomyopathy (30, Af Am, multiparous, twins/preeclampsia)

Thromboembolic disorders Superficial thrombophlebitis Erythema and tenderness, usually calves Deep venous thrombosis Acute erythema, tenderness, edema Venous doppler, *venography Anticoagulation Risk pulmonary embolism

Thromboembolic disorders Pulmonary embolism Chest pain, dyspnea, palpitations, tachypnea, tachycardia Maternal mortality 80% if untreated 70% from DVT ABG, V-Q scan, pulmonary angiography Septic pelvic thrombophlebitis Infection and thrombosis within ovarian veins Postpartum Anticoagulation vs. antibiotics

Urinary System Urinary tract infection Pyelonephritis Urinary calculi 50% increase in glomerular filtration Gravid Cr: 0.6 BUN: 9 mg/100 ml Chronic renal failure

Respiratory System Dyspnea of pregnancy Asthma Avoid dehydration, treat infections, avoid causes of exacerbations PEFR Chronic mild, moderate, severe Smoking If severe, risk abortion, fetal demise growth retardation Low birth weight, growth restriction, placental abruption

Endocrine system: Diabetes mellitus Human placental lactogen (hpl) increases fat metabolism, inhibits glucose uptake and gluconeogenesis Glucosuria of pregnancy

Diabetes Mellitus White s Classification Class Onset Duration Vascular Dx A any any none B >20 yr <10yr none C 10-19yr 10-19yr none D <10yr >20yr benign retinopathy EF any any nephropathy R any any prolif. Retinopathy H any any heart disease RT any any renal transplant GDM A1 - Fasting <105, post-prandial >120, diet controlled GDM A2 - Fasting <105, post-prandial <120, insulin requiring

Fetal Complications of Diabetes Congenital anomalies Cardiac and limb Macrosomia Neonatal hypoglycemia Polyhydramnios Preterm labor, abruptio placentae, postpartum atony Spontaneous abortion and fetal demise Respiratory distress syndrome

Diabetes Mellitus Screening Nonfasting 50 g oral glucose at 24-28 weeks Glucose level at 1 hr, >140 mg/dl need GTT Diagnosis Fasting 100 g oral glucose load Glucose level fasting, 1 hr, 2 hr, 3 hr 105/190/165/145 Two + abnormal values =gestational diabetes

Diabetes Management Glucose monitoring Fasting <90 Postprandial <120 Oral hypoglycemics Insulin (short and long-acting)

Diabetes Management Baseline Hgb A1c Monthly urine cultures CPS anatomical assessment and fetal growth 24 hr urine for total protein and creatinine clearance Fundoscopic exam Fetal echocardiogram Antepartum testing 38 week delivery?

Endocrine System: thyroid disease Increased total T4, T3, TBG Free T4, T3, TSH unchanged Minimal transfer of T4 and T3 across placenta Hyperthyroidism PTU

Neurological system Seizures Risk congenital anomalies, seizure disorders, abruption, uteroplacental insufficiency? Continue medications Folate supplementation Preferred meds: carbamazepine, phenytoin, phenobarbitol

Gastrointestinal System Nausea and vomiting Hyperemesis gravidarum Reflux Peptic ulcer disease Pica Appendicitis

Gastrointestinal system Hepatitis A gamma-globulin B most common (80%) C D Universal screening Active and passive fetal immunization E high maternal mortality

Gastrointestinal system Cholestasis Pruritis, fatigue, jaundice Elevated bile acids Cholelithiasis and cholecystitis Food-associated colic ultrasonography

Questions?

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