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Medical Illness In Pregnancy

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Mohammad Zaher

on 20 May 2015

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Transcript of Medical Illness In Pregnancy

Medical Illness In Pregnancy
Mohammad Zaher
"Horrors of the D-Side"
28 y/o Lady, PG
C/O Headache / Blurred Vision
K/C of Multiple Sclerosis
As you interview her, She says
Her right hand is weak for the last 30 minutes
 Acute ischemic stroke
 Hemorrhagic Stroke
 Cerebral venous thrombosis
 MS Relapse

Acute Ischemic Strokes in pregnancy
Increased risk, especially peri/postpartum

Same risk factors as non-pregnant women, plus:
Hypercoagulable state
Preeclampsia, Eclampsia, and HELLP
Thrombotic thrombocytopenic purpura (TTP)
Postpartum cerebral angiopathy
Rarely, Amniotic fluid embolism
Same increased Risk

Most commonly:
Subarachnoid Hemorrhage - Ruptured Aneurysms
Preeclampsia / eclampsia
Decreased risk of relapse during Pregnancy
Increased risk postpartum
Hemorrhagic Strokes in Pregnancy
Multiple Sclerosis In Pregnancy
Right UL: 0/5
Right LL: 2/5
Stroke Code!

TPA? But She's Pregnant!
Back to your patient..
What would you do next?

Does Not Cross Placenta
No controlled trials investigating harm
Case Series: 8% risk of complications

2013 AHA Ischemic Stroke Guidelines:
Pregnancy is a Relative Contraindication
TPA in Pregnancy
"Under some circumstances —with careful consideration and weighting of risk to benefit—patients may receive fibrinolytic therapy despite 1 or more relative contraindications."
While Deciding what to do..
Patient Starts Seizing.
Same workup as non-pregnants
Consider Eclampsia (proteinurea / High BP)

Same treatment as non-pregnants
Consider Magnesium Sulfate
New Seizures in Pregnancy
Pregnancy has a variable effect on seizure disorders
Altered drug metabolism, Lower drug levels
AEDs are teratogenic, especially with:
Classical agents (Especially Valproic Acid)
Use of multiple antiepileptics
Benefit of switching meds after established pregnancy is questionable (Except Valproic Acid).
Folic Acid / Vitamin K prohpylaxis
Seizure Disorders in Pregnancy
Antiepileptics in Pregnancy
Misc. Neurological Disorders
Mysthenia Gravis:
Pregnancy has variable effect
Infections, Stress can exacerbate condition
Dyspnea might signal impeding crisis
Magnesium Sulfate is CONTRAINDICATED
Labor could be complicated by fatigue

Spinal Cord Injuries
Higher risk of infections, thomboembolism
Difficult to detect labor if lesion above T10
Autonomic dysreflexia if lesion above T5-6
28 y/o Lady, PG
C/O Generalized Fatigue at Sunday 3 am
Triage unfortunately ordered labs.
Only significant result
TSH is High
Free T4 is Normal
Thyroid Physiology in Pregnancy
HCG structure resembles TSH
TSH receptors stimulated by HCG
More T3/T4 production --> Low TSH

TBG raises during pregnancy
Less free T3-T4 measured in lab
Total T3-T4 more accurate
Hypothyroidism in Pregnancy
Subclinical Hypothyroidism should be treated
Myxedema Coma is rare
Same Treatment as non-pregnants

Hyperthyroidism in Pregnancy
Pregnancy symptoms can mask hyperthyroidism
HCG Mediates Hyperthyroidism
Associated with Hyperemesis Gravidarum
Postpartum Thyroiditis
Up to 9% of Postpartum women within 9 months
Could present with Hypo/hyperthyroidism
T4 for Hypo, Beta blockers for Hyper
Treatment is the same as non-pregnants
PTU is preferable
Iodide reserved for refractory cases
Plasmaphoresis / Thyroidectomy are last resorts
Radioactive Iodine is contraindicated
Hyperthyroidism / Thyroid Storm in Pregnancy
28 y/o Lady, PG
C/O difficulty breathing
When you arrive at the room:
Patient in respiratory distress
Not improving with 100% O2
You shift the patient to a monitored bed
RSI in Pregnancy
Factors that affect RSI in pregnant females:
They become hypoxic quicker
Difficult positioning
Gravid Uterus = Obesity
Supine hypotension syndrome
Airway is hyperemic and friable
Bleeding with Minimal Manpuation
More likely to vomit / aspirate
Pregnant Airway = Difficult Airway
Pregnant Airway = Difficult Airway
Call for help
Attempt by the most experienced staff
Tube size 0.5-1mm smaller than usual
Short Handled Blade
Smaller tubes, bougie, LMA
Video Laryngeoscopy
Anticipate Surgical Airway
Need longer times than usual
No paralysis if any doubt about success
RSI in Pregnancy
Ventilator Settings
Based on physiological changes
Lower tidal volumes
Higher respiratory rates
PaO2 >70 (O2 Sat >95%)
PaCO2 ~ 35
Now, Back to that's patient's presentation..
Lung Changes During Pregnancy
Airway erythema / Friability
More epistaxis
Higher diaphragm, increased chest diameter
Increased oxygen consumption
Progesterone stimulates respiratory center
Physiological Dyspnea
Increased Tidal Volume, Minute Ventilation, PaO2
Decreased Residual Volume, PaCO2 (~27-33)
Exploring the Differential
Dyspnea with..
Normal vital signs, H&P, and labs?
Productive cough and fever?
Persistant Basal Crackles?
Chest pain and a Swollen lower limb?
Low Hemoglobin?
Shock, ARDS, and DIC?
Pulm. Edema
Pulm. Embolism
Amniotic Fluid
Dyspnea of Pregancy
Asthma In Pregnancy
Pneumonia in Pregnancy
Experienced by 60-70% of pregnants
Sensation of dyspnea (described as "air hunger")
Starts during the first or second trimester
Not Exertional, usually worse with sitting
Diagnosis of exclusion

Fetal hypoxia is the concern
Same treatment as non-pregnants
Inhaled Steroids preferred over systemic steroids
Fetal monitoring during exacerbations after 3rd Trimester
Mother: Preterm labor and delivery, Pulmonary Edema
Fetus: Low birth weight

Low threshold for admission
Varicalla Zoster with any degree of dyspnea -> Admission

Similar antibiotic choices to Non-Pregnants, Except:
Avoid fluoroquinolones, Doxycycline, & clarithromycin.
PE/DVT in Pregnancy
First cause of maternal mortality in developed world
Typical Symptoms/Signs less specific in pregnants
D-Dimer not helpful
Amniotic Fluid Embolism
Release of amniotic fluid into maternal circulation
Severe, rapidly fatal Anaphylactoid reaction

Occurs during labor (most common), or with abortions, amniocentesis, abruptio placentae, or spontaneously

Sudden hypotension, hypoxia, and coagulopathy

Supportive treatment in intensive care setting
45 y/o Lady, G6P4+1
C/O Chest pain
ACS in Pregnancy: Diagnosis
Hyperdynamic State of pregnancy increases risk


ECG changes could be a part of pregnancy
T wave flattening / inversion (mainly lead III)
Nonspecific ST changes
Early Echocardiography is advised
ACS in Pregnancy: Treatment
Same as non-pregnants
Nitroglycerin-induced hypotension -> Fetal distress
Very limited experience with fibrinolysis -> PCI Preferred
Valvular Heart Disease in Pregnancy
Lesions assoicated with high risk:
Advanced Aortic / Mitral Stenosis
Any grade of AS/MS with Heart Failure / Pulm HTN
Maximum medical management
Baloon Valvotomy if refractory
Prosthetic Heart valves requiring anticoagulation
Warfarin should be switched to heparin
Aortic / Mitral Regurgitation Well tolerated (Except acute)
Pulmonary Hypertension in Pregnancy
Poorly tolerated regardless of type
Mortality up to 50%
Even with aggressive monitoring and treatment, mortality still unacceptably high.
Patients advised not to get pregnant, and offered termination if they do.
Cardiac Arrest in Pregnancy
Needs involvement of neonatal resuscitation team as well
BLS / ACLS. Shocks delivered as usual
Uterine displacement to the left, or ramping.
IV lines above the diaphragm

Perimortum C-Section if:
No ROSC in 4 mins of CPR
Viable fetus (Uterus > umbilicus)
Hypertension in Pregnancy
Chronic Hypertension
Gestational Hypertension
Chronic Hypertension with superimposed Preeclampsia
Hypertensive Emergencies in Pregnancy
First line agents
Sodium nitroprusside is the second line
Fetal cyanide toxicity after hours of use
Chronic Hypertension Pregnancy
Hypertension diagnosed before 20 weeks of gestation


Mildly elevated BP does not need to be emergently treated, if superimposed preeclampsia is ruled out:
New proteinurea >20 weeks
Proteinurea <20 weeks with:
Platelet or Liver enzyme changes
New increase in BP or Proteinurea above baseline
While Cardiology and Obstetrics are arguing...
Your patient goes into Ventricular Fibrillation.
How Much Radiation is Safe in Pregnancy?

Radiation causes 2 types of effects of fetus:
Dose Dependent: Malformations
Dose Independent: Childhood cancers

Atomic Bomb Survivor Followup
Dose Dependent effect at >10 Rad
Other studies and consensus:
Effect at >5 Rad
28 y/o Lady, PG
C/O lower abdominal pain, no dysurea
RBS 10.4 mmol
Urine Dipstick: + Glucose, ++ LE
Effect of Pregnancy on Diabetes
Management of IDDM / NIDDM in Pregnancy
Stirct control
HB1c Goal = 6% (near normal)
Oral hypoglycemics changed to insulin
Frequent checks and follow ups
Vaginal Delivery prefered with good compliance
C-Section for poor control, complications or macrosomia
DKA Managed as non-pregnants
Control achieved in most by diet modification
Insulin / some oral hypoglycemics if not improving
Effect of Diabetes on Pregnancy
Pregnancy is associated with insulin resistance
Mostly mediated by placental hormones
Complications are related to glucose control and organ damage more than type of diabetes
Diabetic end-organ damage worsens during pregnancy
CAD progresses to ACS (pregnancy not advised)
Diabetic Nephropathy may advance
Retinopathy can acutely get worse
Hyperemesis /Insulin resistance precipitates DKA
Could have DKA with almost normal PH
Management of Gestational Diabetes
But what about that urine dip?
UTIs in Pregnancy
Pregnants are predisposed to Urinary tract infections
Uterine pressure exerted on the bladder and ureters
Poor emptying of the bladder with voiding
Progesterone-induced inhibition of ureteral peristalsis

Untreated Bacteriurea affects pregnancy outcomes
Increased risk of preterm birth, low birth weight, and perinatal mortality

Screening for Urinary tract pathogens is recommended on the first prenatal visit
Asymptomatic Bacteriurea
Two consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts of 10^5 colony forming units (cfu)/mL
Single catheterized urine specimen with one bacterial species isolated in a quantitative count of 10^2 cfu/mL
Dipsticks don't count!

30% chance to progress to Pyelonephritis
Asymptomatic Bacteriurea / Acute Cystitis Tx
Most recommendations follow local resistance patterns
Repeat cultures to confirm eradication.
Leads to maternal sepsis, permanent renal injury, and premature labor
Fever, N/V, flank pain (commonly right sided) +- Dysurea
Consider other differentials.

Unlike non-pregnants, Admission + IV antibiotics are the rule, then switched to oral antibiotics after being afebrile for 48 hours, to continue for 10-14 days
Cochrane review shows success with oral antibiotics in selected populations
Full transcript