comorbid diseases in pregnancy课件

ComorbidDiseasesinPregnancy Chapter105TintinalliPresentedbyDr KelleyDecember6 2005 Diabetes 2 3 ofallpregnanciesGestational 90 A1 dietcontrolledA2 insulincontrolledPredatedDiabetes 10 Alwaysinsulindependent DoNOTuseoralhypoglycemics Goals 90mg dLfasting 1401 postprandial insulinneedsaspregnancyprogresses DiabetesComplications Hypertensivediseases pretermlabor spontaneousAb pyelonephritis DKA hypoglycemiaDKA Rapidoccurrenceatlowerglucoselevels Sametxasnonpregnant DiabetesComplicationsCont Hypoglycemia45 occurrenceSymptoms swelling tremors blurredvision diplopia weakness hunger confusion paresthesias anxiety palpitations vomiting HA stuporTx Levels 70mg dL abletotalkandfollowcommands 1cupmilkwithbreadandcrackersq15min Severe 1ampD50WIVPorglucagon1 2mgIM SQwithorwithoutD5WIV 50 100cc hr Hyperthyroidism Associatedwith riskofpreeclampsia neonatalmorbidity lowbirthweight andpossiblecongenitalmalformations Symptoms nervousness palpitations heatintolerance inabilitytogainweight Thyrotoxicosismaypresentashyperemesisgravidarum Tx PTU 100 150mgPOTID ThyroidStorm Symptoms fever volumedepletion cardiacdecompensationMortalityrateof25 Tx IVF Oxygen antipyreticagents PTU400mgPOq8 sodiumiodide1gin500mLIVFqday propranolol40mgPOq6 unlesscardiacfailure coolingblanket NOradioactiveiodinetherapy congenitalhypothyroidism Hypertension Dividedintochronicorpreeclampsia howeverchronicHTNcanleadtopreeclampsia Chronic4 5 occurrence BP 140 90mmHgbefore12thweekgest Tx indicatedwhensystolic 160ordiastolic 100 Aldomet Labetalol nifedipineAcuteHypertensiveCrisisIVLabetalol 10mgq5 10minupto300mgtotal orHydralazine 5 10mgq15minIV Goal 140 150 90 100 Dysrhytmias RareLidocaine digoxin procainamidecanbeusedasindicated Maintenancebeta blockersarecategoryCsoprescribewithconsultationwithcardiologist obstetrician VerapamileffectiveforcardioversionofSVTtoNSRwithoutadverseeffects AnticoagulationforA Fib unfractionatedorLMWHCardioversionsafeforfetusArtificialpacemakernotshowntoaffectpregnancycourse Thromboembolism 0 5 0 7 occurrenceRiskfactors advancedmaternalage parity multiplegestation operativedelivery bedrest obesity h opreviousclot antithrombinIIIdef proteinC Sdef lupusanticoagsyndrome Occur2Xmoreoftenduringantenatalthanpostpartumpd 30 withoutidentifiablerisk Diagnosis dopplerstudies technitium 99mperfusionlungscansandlowerext studies ventilation perfusionscans pulmonaryarteriographyNOiodine 125fibrinogenscanning SpiralCThasnotbeenstudiedinpregnancy Tx IVHeparinorLMWH Nocoumadin Asthma 0 4 1 3 occurrenceSevereasthmatic poorlycontrolledwithslight riskofpretermbirth stillbirth andlow birthweightbabies 1 3 asthmaworsensinpregnancy1 3 nochange1 3 improve AsthmaCont Symptoms cough wheezing dyspneaPreventiveTherapy inhaledglucocorticoidssuchasbeclomethasone cromolynsodiumviainhaler AcuteExacerbationTx beta2agonists salbutamol metaproterenol albuterol isoproterenolvianebulizer IVmethylprednisoloneororalprednisone epi0 3mL 1 1000 SQ O2 fetalmonitoringpast20weeksgestation nearsittingwithleftwardtiltposition AsthmaCont Peakflowcanguidetx shouldnotchangewithprogressionofpregnancy Normal380 550L minIf 100L minwithlessthan10 improvementwithtxaresignofpoorprognosis aggressivemanagement pO2101 108mmHgearly90 100mmHgneartermpH 7 40 7 45pCO2 27 32 AsthmaCont Indicationforintubation statusepilepticus 1 InabilitytomaintainpO2 65mmHg2 InabilitytomaintainpCO2 40mmHg3 MaternalExhaustion4 SignificantRespiratoryAcidosis pH 7 20 7 25 5 AMSCanusestandardagentsforrapidsequenceintubation ChronicRenalDisease Pregnancyrarelyoccurswithpreconceptionserumcreatinine 3mg dL Complications PretermdeliverySuperimposedpreeclampsiaChronicpyelonephritisptswith ofrecurrences Cystitis Pyelonephritis urinarystasismakesurinarytractmostcommonplaceofinfectionduringpregnancy Occurrenceofbothacutecystitisandpyelonephritis 1 2 Organisms E coli 75 KlebsiellapneumoniaeandProteus 10 15 CystitisTreatment 3daycourseofnitrofurantoin ampicillin orcephalosporin Trimethoprimafter1sttrimester NOSINGLEDOSEABXTHERAPY PyelonephritisTreatment Mustbepromptb cacutepyelonephritiscanprecipitatepretermlabor bacteremia 10 15 septicshock respiratoryinsufficiencyfromacutelunginjury 2 8 Tx hospitalization aggressiveIVhydration IVAbx 2nd 3rdgen Cephalosporin untilafebrileX48hrsandnoCVAtenderness thend cwithabxtocomplete10daycourse Possibleantibioticsuppressionremainderofpregnancy nitrofurantoin50 100mg day InflammatoryBowelDisease riskfornutritionalandmetabolicabnormalities IUGR Tx SameasnonpregnantAntidiarrheals Codeine Opium Paregoric LomotilSulfasalazineandCorticosteroidssafe NOsulfadrugsin3rdtrimester TPNinseverenutritionaldeficiencies Metronidazoleafter1sttrimester SickleCellDisease riskofmiscarriage pretermlabor othercomplicationsduetoimpairedO2supplyandsicklinginfarctsinplacentalcirculation vascularocclusiveevents 3rdtrimesterandpostpartum Txofpainfulcrisissameasnonpregnant analgesicsandhydration exceptNONSAIDs Moreseverecases partialexchangetransfusionviaautomatederythrocytopheresisorsimpletransfusion 6g dL Migraine Pregnancyusuallyimprovesclassicmigraines NOERGOTALKALOIDS Sumatriptanwithminimalexperienceinpregnancy AcuteTx Analgesics AntiemeticsProphylacticTx betablockers propranolol40 60mg dayoratenolol50 100mg day SeizureDisorders 0 5 1 0 occurrence slightlyinfrequencyduringpregnancyMedicationdosesmayneed tomaintaintherapeuticlevels ValproicAcidgeneralavoided 1 3 riskofneuraltubedefects SeizureDisordersTreatment Singlegrandmalseizure Maybefollowedbyfetalbradycardiaforupto20minutes noapparentlongtermfetalharm OxygenLeftlateraluterinedisplacement StatusEpilepticusAggressivemanagementwithintubation ventilationearlybecause50 mortalityoffetusand33 mortalityofmother HIV AllHIVpatients 14weeksgestationshouldbeonzidovudinetherapyto riskofverticaltransmission 25 8 Pregnancydoesnotaltercourseofdisease IfCD4 cellcounts 200 prophylaxisforpneumocystiscariniipneumonia SubstanceAbuse Refertohigh riskobstetricsclinicandoffersubstanceabusecounseling CocaineFetalcomplications riskofplacentalabruption fetaldeathinutero IUGR pretermlabor prematureruptureofmembranes spontaneousAb cerebralinfarctsMaternalcomplications MI HTN pulmonaryedema cardiacdysrhythmia subarachnoidhemorrhage rupturedaneurysms strokeTxofacuteintoxicationhandledasinnonpregnantpt SubstanceAbuseCont OpiateWithdrawalAcuteTx Methadoneorclonidine 0 1 0 2mgSLq1 upto0 8mg MaintenanceTx Clonidine0 8 1 2mg dayindivideddosesX7daysthentaperfor3days AlcoholAbuse1 2 ofpregnancies2ormoredrinks day riskofspontAb low birth weightinfants pretermdeliveries perinatalmortality fetalalcoholsyndromeETOHcoma withdrawaltreatedlikenonpregnantexceptavoidbenzodiazepinesinearlypregnancy DomesticViolence 14 17 occurrence riskassociatedwithlateprenatalcare unintendedpregnancy drugandETOHabuse depresion andhousingproblems Fetalcomplications placentalabruption fetalfractures uterinerupture pretermlaborKeephighriskofsuspicionRefertosocialservicesand orlawenforcement RhoGamforRhnegmotherswithbluntabdtrauma MedicationsforConcurrentIllnessDuringPregnancyandLactation Classicteratogenicperiod Days31 71afterlastmenstrualperiod periodoforganogenesis Before31days all or noneeffect Fetuseithersurvivesordoesnotsurvive Table105 1Table105 2 ComplicatingEffectsofRadiation 10radisthresholdforhumanteratogenesisTable105 3Ventilation perfusionscan 0 5radUltrasoundwithoutknownteratogeniceffect