Obstetrical Medicine

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. 
• 
• 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

• 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