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Comorbid Diseases in Pregnancy

Comorbid Diseases in Pregnancy. Tintinalli’s Chapter 105. Diabetes. Complicates 2-3% of all pregnancies 90% gestational & 10% established prior

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Comorbid Diseases in Pregnancy

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  1. Comorbid Diseases in Pregnancy Tintinalli’s Chapter 105

  2. Diabetes • Complicates 2-3% of all pregnancies • 90% gestational & 10% established prior • All establish diabetics will be managed with insulin therapy & gestational diabetics will attempt diet control 1st(Oral hypoglycemics contraindicated) • Goal is fasting glucose < 90 mg/dL & 1 hour post prandial < 140 mg/dL • Insulin-Dependents will need increase insulin throughout pregnancy & 45% will have 1 or more hypoglycemic episodes • Pregnant Diabetics have increased HTN, Preterm labor, spontaneous abortion, pyelonephritis, & DKA

  3. Hyperthyroidism • Increased risk of preeclampsia and neonatal morbidity • Thyrotoxicosis can present as hyperemesis • Treated with PTU, but maximum action is at 4-6 weeks • If a purpuric rash presents after PTU is given, switch to Methimazole (0.3% on PTU will get agranulocytosis) • Thyroid storm: • fever, volume depletion, cardiac decompensation • Mortality rate up to 25% • IV fluids, O2, antipyretics, PTU & sodium iodine & Propranolol

  4. Hypertension • Divided into chronic & preeclampsia (ch 106) • 4% of all pregnancies and is a sustained BP >140/90 before wk 20 • Therapy initiated if BP > 160/100 • Labetalol, nifedipine, alpha-methyldopa, and hydralazine are all options for treatment • Treatment goals during HTN crisis is systolic 140-160 & diastolic 90-100

  5. Comorbid Diseases of Pregnancy • Dysrhythmias • Rare • Lidocaine, Digoxin, Procainamide, Verapamil are all safe. Beta blockers are class C • Cardioversion is safe in pregnancy • LMW heparin is the anticoagulant of choice • Thromboembolism • Incidence is 0.5-0.7% • DVT & PE twice as common antenatal vs. post partum • VQ scans can be performed safely in pregnancy, newer literature suggests CTA is safer • Treatment is IV heparin to PTT 1.5-2 x normal • Coumadin (NO), LMWs (Okay), Thrombolytics (last resort)

  6. Asthma • Complicates 0.4-1.3% & 1/3 have worsening of symptoms • Presents the same in pregnancy • Rescue meds: Beta agonists & IV or PO steroids or 0.3mL of 1:1000 epi SQ • PO2 should be kept > 65 mmHg • Peak flows do not change in pregnancy • Peak < 100 L/min or < 10% improvement is a sign of severe disease • Normal PaCO2 in pregnancy is 27-32 mmHg • Indications for intubation: • PaO2 < 65 on supplemental O2 • PaCO2 > 40 • Maternal exhaustion • Respiratory acidosis (<7.2) refractory to treatment • Altered Mental Status

  7. Comorbid Diseases of Pregnancy • Cystitis & Pyelonephritis • Urinary stasis and mild hydronephrosis lead to increased UTIs • Causative organisms are the same, E coli (75%) & Klebsiella & Proteus 10-15% • Simple cystitis tx is 3 days of nitrofurantoin, ampicillin, or cephalosporin; bactrim after first trimester • Pyelonephritis patients should be hospitalized due to increased morbidity & Tx consists of IV 2nd/3rd generation cephlo. & continued for 48 hours after afebrile & no pain, then 10 day course • Chronic Renal Disease • Preterm delivery & preeclampsia are common

  8. Comorbid Diseases of Pregnancy • Inflammatory Bowel Disease • Risk of nutritional & metabolic abnormalities • No increase incidence of flare ups • Treatment mostly the same • Codeine & lomotil are safe • Sulfasalazine & steroids safe • Azathioprine & 6-mercaptopurine are safe • TPN as a last resort • Metronidazole for infectious colitis is safe after the first trimester

  9. Comorbid Diseases of Pregnancy • Seizure • Incidence of 0.15-1% • Usually increases in pregnancy due to increase plasma volume • Management is no different for the pregnant patient • Fetal bradycardia is common up to 20 minutes post seizure • 50% fetal & 30% maternal mortality rate in status • Migraine • Usually improve with pregnancy • Tx: acetaminophen, codeine, meperidine, antiemetics • Sickle Cell • Increased risk of miscarriage and preterm labor • Increase vascular occlusive events • Txs are aggressive hydration & analgesic therapy • Narcotics safe; NSAIDS before 32 wks; transfusion if Hb < 6 g/dL

  10. Comorbid Diseases of Pregnancy • Substance Abuse • All should be referred to a high risk OB/GYN • Cocaine has increase risk of placental abruption, IU growth restriction, preterm labor, premature rupture of membranes, and fetal cerebral infarcts; HTN, MI, ruptured aneurysms, and dysrhythmias common in mothers • Opiate withdrawal should be treated with methadone and clonidine • EtOH abuse is 1-2% in pregnancy & withdrawal symptoms should be treated with pentobarbital not benzos • HIV • All infected women past 14wks should be on zidovudine • CD4 count <200 should be placed on TMP-SMX

  11. Comorbid Diseases of Pregnancy • Radiation exposure • 0-2 wks can lead to resorption of the embryo • 2-8 wks is the most sensitive period for teratogenesis to occur • 8-15 wks is when the CNS is most sensitive to radiation (your kid isn’t going to Harvard) • Beyond wks the risk if very low and beyond 25 wks no effects have been observed • 10 rads if the threshold for human teratogenesis • 10 rads = • 20,000 chest xrays with shielding • 100 KUBs or single view abdominal film • 100 Head CTs • 3 abdominal CTs

  12. Resources • Tintinalli Chapter 104

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