What are the three effects of hPL on maternal metabolism?
- Decreases insulin sensitivity
- Decreases maternal glucose utilization
- Increases lipolysis
Are opioids contraindicated in pregnancy?
Yes
What is the most common medical condition in pregnancy?
HTN
What percent of all women in pregnancy have HTN?
6-8%
What happens to maternal BP early in pregnancy? Why? (2)
Decreases in the first trimester, d/t increased maternal blood volume, and decreased colloid oncotic pressure
The lowest maternal BP occurs when in pregnancy?
13-20 weeks gestation
Why is it particularly important to take BP readings early in the pregnancy?
To distinguish chronic HTN from HTN causes in pregnancy
What are the four types of pregnancy related HTN?
- Chronic HTN
- Gestational HTN
- Preeclampsia
- Preeclampsia superimposed on chronic HTN
What is the definition of chronic HTN? (2)
- BP more than 140/90 prior to the first 20 weeks of pregnancy
- BP remains elevated more than 12 weeks postpartum
Is there proteinuria with chronic HTN?
No
Chronic HTN is defined as having high BP how many weeks postpartum?
More than 12
What is mild HTN defined as? What are the complications that can arise from this in pregnancy?
DBP 90-110
No increase risk
What defines severe HTN in pregnancy?
DBP more than 110
Over what age is maternal HTN particularly concerning?
40 years
What percent of women with gestational HTN have a premature birth?
66%
What percent of women with gestational HTN have IUGR?
33%
What is the RR of fetal demise with maternal HTN?
3x
What is the RR of mortality of pregnant women if they have severe HTN in the first trimester?
50% increase
What placental abnormality can occur with HTN?
Placental abruption
What is placental abruption?
When the placenta separates before delivery
When (particularly) should lifestyle modifications be considered with maternal HTN?
When BP is “low” in first half of pregnancy with no renal insufficiencies
When do you start to treat HTN in pregnancy with meds?
If BP is more than 160/110
When should antiHTN meds be continued into pregnancy?
- Multiple meds needed
- End organ dysfunction
What are the two major signs of preeclampsia? (2)
- Proteinuria
- Sudden increase in BP
When a woman develops preeclampsia, what aspects of the fetus should be measured? How often should this be done?
- Fundal height
- US 1 4 weeks starting at 28-32 weeks
What is the definition of gestational HTN? Is there proteinuria with this?
Nonproteinuric HTN after 20 weeks
What defines mild gestational HTN? Severe?
Less than 160/110
More than 160/110
Is transient HTN of pregnancy concerning?
As long as does not develop into preeclampsia
What is the treatment for mild gestational HTN?
Expectant
What is the treatment for severe gestational HTN?
Same management as for severe preeclampsia
What percent of US pregnancies have preeclampsia?
5-7%
What is the definition of gestational HTN?
New onset HTN and proteinuria after 20 weeks gestation, in a previously normotensive woman
What is the BP range that defines MILD preeclampsia? What amount of protein in the urine?
More than 140/90
0.3 g in a 24 hour urine
What are the signs of severe preeclampsia? (6)
- BP more than 160/110
- Thrombocytopenia
- Impaired liver function
- Progressive renal insufficiency
- Pulmonary edema
- New onset cerebral or visual disturbances
When does preeclampsia present?
At any point in the pregnancy
What is eclampsia?
Seizures
What are the age ranges that are a risk factor for preeclampsia?
Less than 20 or more than 35
What ethnicity has an increased risk for developing preeclampsia? What is the RR?
Black
2x higher than white
Is nulliparity or multiparity a risk factor for the development of preeclampsia?
Nulliparity
What is the role of stress with preeclampsia? Obesity?
Increases the risk
What are the hematological abnormalities that can increase the risk for preeclampsia? (2)
- Thrombophilias
- Antiphospholipid antibody syndrome
True or false: having preeclampsia in a previous pregnancy is a risk factor for developing it again
True
Are multifetal pregnancies at an increased risk for preeclampsia?
Yes
Is there an increased or decreased risk for preeclampsia for the following:
- Chromosome abnormalities
- Hydrops fetalis
- Oocyte donation
- Structural congenital abnormalities
All increased
What is the prevalence of eclampsia in the US?
1 in 2000
What is HELLP syndrome?
Preeclamptic s/sx with:
- Hemolysis
- elevated LFTs
- Low platelets
When are most cases of HELLP syndrome diagnosed?
antepartum
What defines a thrombocytopenia with HELLP syndrome?
Less than 100,000
What defines elevated LFTs with HELLP syndrome?
More than 100
LDH greater than what value indicates hemolysis?
600
Bili of more than what indicates hemolysis?
1.2 mg/dL
True or false: the abnormal PBS can be seen with hemolysis in HELLP syndrome
True
What are the prevention measures for preeclampsia?
None known
What is the ultimate cure for preeclampsia?
-Delivery
When is inpatient management indicated for preeclampsia? (3)
- Noncompliant pt
- No ready access to medical care
- Progressive s/sx
What are the two key goals of treating preeclampsia?
Control HTN
Prevent seizures
What is the treatment for seizures 2/2 preeclampsia?
MgSO4, then pre for delivery after seizure stopped
What are the three fetal indications for a delivery with preeclampsia?
- severe IUGR
- Nonreassuring fetal surveillance
- Oligohydramnios
Over how many weeks gestation is delivery indicated for preeclampsia?
More than 37 weeks
What is the preventative treatment for seizures after delivery?
MgSO4
What are the four major postpartum complications that can occur with preeclampsia?
- Pulmonary edema
- Heart failure
- HTN encephalopathy
- Renal failure
What is the definition of IUGR?
Estimated fetal weight less than the 10th percentile
What is needed to diagnose IUGR?
Serial US
What is asymmetric IUGR?
IUGR is disproportionately lagging in abdominal growth (HC more than Abdominal circumference)
True or false: asymmetric IUGR is “abdomen sparing”
False–“head sparing”
What is symmetric IUGR?
All parts of the baby are small
True or false: symmetric IUGR can sometimes be caused by constitutionally small parents
True
How can DM mothers have IUGR?
Vascular disease causing growth restriction
Is HTN or preeclampsia a risk factor for the development of IUGR?
Yes
What is AFP used as a screen for? What relative value of this indicates a risk for IUGR?
Neural cord defects
Elevated
True or false: Multiple gestations is a protective factor against IUGR
False–risk factor
What are the three major infectious agents that can cause IUGR?
- CMV
- Toxo
- Rubella
What is a key finding on US that may concern you for IUGR?
Placental abnormalities
How do you screen for IUGR?
- Measure maternal fundal height
- AFP
What are the US findings that are used to diagnose IUGR? (3)
- Absolute measurements
- Percentile rank
- Rate of growth
Estimated fetal weight and/or an abdominal circumference of less than what percentile suggests IUGR?
10th
True or false: serial USs allow for definitive diagnosis of IUGR
False–only at delivery
What is the treatment for IUGR before 34 weeks? after
Expectant if before
Delivery if after
True or false: you need to have both retarded HC and AC to diagnose IUGR
True
What are the three antenatal tests that can be used to assess for IUGR?
- Biophysical profile
- Nonstress test
- Umbilical artery doppler
What are the risks of IUGR?
- Meconium aspiration
- Hypoglycemia
- Hyperbilirubinemia
- Seizures