Obstetrical Medicine

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    • ASIDE: (Note that Albumin normal is < 2 mg/mmol, and (x15) <30 mg/24h.  
    • Microalbuminuria 2-20mg/mmol  (>30)
    • Macroalbuninuria > 20  (protein > 300)

    Hyperemesis Gravidarum

    • Nausea/vomiting with 5% weight loss from pre-pregnancy weight, dehydration, and ketosis.
    • Resolves in 2nd trimester (10% remain symptomatic)
    • NEEDS workup for trophoblastic disease or multiple gestations
    • IV fluids, malnutrition
    • AST and ALT < 300
    • 1st Line:
      • Diclectin
    • 2nd Line:
      • Anti-Histamines
      • Metoclopramide
      • Ondansetron.
      • ...

    Hypertension

    • Screening Questions
      • Hx of Hypertension
      • Family history of gestational hypertension
      • Previous history of gestational hypertension
      • Complications associated with hypertension
        • Head
          • CVA
          • Retinal Changes
          • Encephalopathy
        • Chest
          • ACS
          • HF
          • Dissection
        • Abdomen
          • Kidneys
            • Proteinuria (> 300mg/24hrs)  --> CKD III/IV > 500mg/24h
              • Proteinuria was validated for pregnancy (not albumin)
            • CKD
            • AKI
          • Pre-Eclampsia
          • Liver
      • Targets for Hypertension in pregnancy
        • Even if has proteinuria, can watch and wait
        • CHIP Trial
        • If proteinuria worsens, then consider treating
        • BP Targets in Pregnancy:

          • 130-155/80-105
    • Pre-Eclampsia Defined as:
      • New or worsening end organ damage.
        OR
      • Proteinuria (new or worsening)
    • Monitoring eclampsia:
      • Look for SEVERE organ damage
      • Liver enzymes, platelets.
      • Fetal (doppler flow reversal, placental abruption)
    • Prevent pre-eclampsia EARLY in pregnancy:
      • ASA
      • Calcium 600mg-1g of Ca++.
    • Indication for delivery:
      • Eclampsia
      • Severe end organ damage markers

     

     

    HELLP

    • Presents 28-36w gestation (can be also in 1st week postpartum)
    • Symptoms (often asymptomatic)
      • Headache
      • N/V
      • RUQ pain
    • Clinical:
      • Hypertension, proteinuria, edema
    • Outcomes
      • Mortality rate 1-3% (hepatic infarcts, subcapsular, hepatic rupture, intraparenchymal hemorrhage, etc..)
      • Fetal outcomes worse (low birth weight, early delivery etc..)
    • Diagnosis
      • Microangiopathic Hemolysis  (schistocytes)
      • Elevated Liver Enzymes (>2x ULN)
      • Low Platelets (plts < 100)
    • Management:
      • Delivery!!! (Cornerstone of therapy)
        • (Labs may get worse in first 48hrs after delivery)
      • Treat HTN (labetalol, hydralazine, nifedipine)
      • MgSO4 for eclampsia prophylaxis (risk of seizure is 10 fold)
      • Steroids (not used)
      • Supportive care:
        • Platelets: (look up numbers) > 50 for neuraxial analgesia

    DMII

     

    VTE

    Guidelines: SOGC and ACCP (CHEST) Guidelines 

    • Higher difference of L-leg clot (b/c R iliac artery crosses over)
    • Diagnosis of PE
      • D-Dimer not helpful (esp in 3rd pregnancy)
      • Cannot use Wells Score --> Use LEFT Score used (but hello okay so what in the yeah
      • Recommended to do leg doppler first
        • If leg doppler positive --> made diagnosis
        • If leg doppler negative, and you still suspect
          • Discuss Risk and Benefits
            • Up to 50 mGY is safe in pregnancy (CT vs. VQ Scan) - CTPE is ~25 mGY (can even lower to 2-3 mGY.  VQ scan is 0.5-1 mGY)
          • IF pre-existing lung disease --> Recommend low dose CT (with contrast)
          • IF no pre-existing lung disease --> VQ Scan
          • NOTE: VQ = less radiation to mother (more to fetus), and CT-PE protocol = less radiation to fetus but more to mother. 
    • SOGC Guidelines 1.pngSOGC Guidelines 2.png
    • Treatment
      • Heparin or Dalteparin (dalteparin in outpatient setting)
      • Weekly weights + increase dose
      • Do anti-Xa level 4hrs post-dose once per month to ensure therapeutic
      • Treat minimum of 3 mo (must include 6w post partum)
      • CAN switch to warfarin post-delivery (safe for breastfeeding)
      • NOTE: Warfarin contraindicated due to spontaneous abortion & fetal embryopathy

     

    • Source: SOGC Guidelines 2016

     


    • Age of VTE

      Untreated daily fatal PE risk

      Mx

      1-14 days

      1%

      Retrievable IVC filter

      LMWH post partum day 1

      2-4 weeks

      0.1%

      IV heparin until cervix 3 cm

      Restart 6 hrs pp

      > 4 weeks

      0.01%

      Stop split dose LMWH 12 h prior

      Restart post partum > 6 h

     

    DVT Prophylaxis in pregnancy

    • More thrombogenic post-partum.
    •   ANTEPARTUM

      POSTPARTUM

      (lower threshold)

      Personal hx of VTE YES YES

      1st Degree Family Member

      + Any thrombophilia on genetic screen

        YES

      Family History + Homozygous for

      Factor V leiden OR Promthrombin Mutation

      YES YES

    Imaging

    • >100rad = teratogenic  (<5rad is safe)
      • CT is 3.5 rad
      • CXR is 5mrad

     

    Liver Abnormalities

    SOURCE: ACG Clinical Practice Guidelines

     

    Pregnancy Liver Disease chart.jpg

     

    • Workup the same as non-pregnant patient - always send off liver workup
    • Be mindful that HSV hepatitis (detected by PCR! not serology) is more common and severe in pregnancy
    • ALP Elevation --> does not need workup
    • If ALP + Bilirubin --> needs further workup

     

    • Intrahepatic Cholestasis of Pregnancy
      • Most common liver disease (0.3-5.6%)
      • Risk Factor: Advanced  Maternal Age
      • Mechanism: MDR3 gene mutation - unable to transport bile acids. Environmental/hormonal factors also. 
      • Features:
        • Pruritis (palms/soles)
        • NO rash
        • Jaundice is rare (<25%)
      • Workup:
        • ALP modestly elevated
        • Transaminitis may reach > 1000 (do full w/u to rule out other pathology)
        • Elevated Bile Acid Levels (>40 umol/L = more complications)
        • MUST do abdo u/s (rule out biliary pathology)
          • Bile ducts should look NORMAL 
      • Complications
        • Fetal distress, stillbirth
      • Treatment:
        • Ursodeoxycholic acid 10-15mg/kg
          • Increases bile acid export pumps
          • Increases placental transporters (Bacq et al 2012)
        • Can also use: antihistamines and benzodiazepines
        • Cholestyramine and dexamethasone can be used (but UDCA is better)
        • Early Delivery (at 37w)
        • Educate on worse fetal outcomes (early death, prematurity, etc..)
      • Recurrence rate 60-70% high for subsequent pregnancies
         
    • Acute Fatty Liver of Pregnancy
      • Rare, but life threatening
      • Mechanism: unclear.  Appears to have inherited defects with beta-oxidation of fatty acids
      • Presentation:
        • Presents 3rd trimester after 20w
        • Non-specific
        • Nausea, vomiting, abdo pain, anorexia, jaundice
      • Diagnosis:
        • Swansea criteria (need 4 or more criteria)
        • Biopsy often needed (liver) --> microvesicular steatosis, absence of periportal hemorrhage/fibrin (as seen in HELLP and pre-eclampsia)
      • Treatment:
        • Immediate delivery
        • Supportive Care
        • Survival 100% if prompt dx made, delivery, and ICU care.
        • Liver abnormalities resolve post-partum. 

     

    • Hepatitis B During pregnancy
      • Big question: Will there be transmission to fetus? 
      • Risk of Transmission:
        • Chronic HBV --> 90% in infancy
        • HBeAg status --> transmission risk
          • Positive = 70-90%
          • Negative = 10-40%
        • Ri
      • Active-passive immunoprophylaxis
        • HBIG + vaccinations
      • Review of data 1975-2012
        • Risks Factors
        • Viral Load = biggest risk factors for transmission
      • Treatment:
        • If DNA level > 2x10^5 IU/mL --> need treatment
          • Can stop treatment post-partum. 
        • Delivery method?  --> unclear, not enough data. 
        • Breastfeeding transmission is LOW. 
        • Telbivudine 600mg/d week 20-32 gestation (n=134) vs. untreated control (n=94)
          • All infants got vaccination
          • Less risk of chronic infection

    Other

    Asthma

    • Treat as non-pregnant
    • Little literature of cleft palate and cleft lip and due to steroid.
      • Cochrane review --> almost disproved.
    • Montelukast --> safety not proven.

     

    CKD

     

    Liver

    • Cholestasis of pregnancy
      • Premature delivery & intrauterine death
      • Cholestyramine  (ursodiol safer??) - check "mother risk"
      • Follow fasting bile acids
    • HELP (subcapsular hemorrhages)
    • Acute fatty liver of pregnancy
      • Polyuria

     

    HF

    • Avoid ACE inhibitors (renal agenesis)
    • Atenolol (IUGR sometimes)
    • Hydralazine is safe

     

    Thyroid

    • Graves
      • best option is 2nd trimester surgery (can't use radiation)
      • PTU preferred
    • Subclinical Hypothyroidism
      • Keep TSH under 2.5
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