Comorbid-Diseases-in-Pregnancy课件.ppt

《Comorbid-Diseases-in-Pregnancy课件.ppt》由会员分享，可在线阅读，更多相关《Comorbid-Diseases-in-Pregnancy课件.ppt（35页珍藏版）》请在淘文阁 - 分享文档赚钱的网站上搜索。

1、Comorbid Diseases in PregnancyChapter 105 TintinalliPresented by Dr.KelleyDecember 6,2005Diabetesn2-3%of all pregnanciesnGestational-90%nA1-diet controllednA2-insulin controllednPredated Diabetes-10%nAlways insulin dependent.nDo NOT use oral hypoglycemics!nGoals-n90mg/dL fastingn140 1 postprandialn

2、insulin needs as pregnancy progresses.Diabetes ComplicationsnHypertensive diseases,preterm labor,spontaneous Ab,pyelonephritis,DKA,hypoglycemianDKA-nRapid occurrence at lower glucose levels.nSame tx as nonpregnantDiabetes Complications Cont.nHypoglycemian45%occurrencenSymptoms:swelling,tremors,blurr

3、ed vision,diplopia,weakness,hunger,confusion,paresthesias,anxiety,palpitations,vomiting,HA,stupornTx:Levels 140/90mmHg before 12th week gest.nTx(indicated when systolic 160 or diastolic 100):Aldomet,Labetalol,nifedipinenAcute Hypertensive CrisisnIV Labetalol(10mg q5-10 min up to 300 mg total)or Hydr

4、alazine(5-10mg q 15 min IV)nGoal:140-150/90-100DysrhytmiasnRarenLidocaine,digoxin,procainamide can be used as indicated.nMaintenance beta-blockers are category C so prescribe with consultation with cardiologist/obstetrician.nVerapamil effective for cardioversion of SVT to NSR without adverse effects

5、.nAnticoagulation for A.Fib-unfractionated or LMWHnCardioversion safe for fetusnArtificial pacemaker not shown to affect pregnancy course.Asthman0.4-1.3%occurrencenSevere asthmatic-poorly controlled with slight risk of preterm birth,stillbirth,and low-birth weight babies.n1/3-asthma worsens in pregn

6、ancyn1/3-no changen1/3-improveAsthma Cont.nSymptoms:cough,wheezing,dyspneanPreventive Therapy:inhaled glucocorticoids such as beclomethasone&cromolyn sodium via inhaler.nAcute Exacerbation Tx:beta2 agonists(salbutamol,metaproterenol,albuterol,isoproterenol via nebulizer),IV methylprednisolone or ora

7、l prednisone,epi 0.3mL(1:1000)SQ,O2,fetal monitoring past 20 weeks gestation,near sitting with leftward tilt position.Asthma Cont.nIndication for intubation(status epilepticus):n1.Inability to maintain pO2 65mmHgn2.Inability to maintain pCO2 40mmHgn3.Maternal Exhaustionn4.Significant Respiratory Aci

8、dosis(pH 7.20-7.25)n5.AMSnCan use standard agents for rapid sequence intubation.Cystitis/Pyelonephritisn urinary stasis makes urinary tract most common place of infection during pregnancy!nOccurrence of both acute cystitis and pyelonephritis:1-2%nOrganisms:E.coli(75%),Klebsiella pneumoniae and Prote

9、us(10-15%)CystitisTreatmentn3 day course of nitrofurantoin,ampicillin,or cephalosporin.nTrimethoprim after 1st trimester.nNO SINGLE DOSE ABX THERAPY!Inflammatory Bowel Diseasen risk for nutritional and metabolic abnormalitiesIUGR.nTx:Same as nonpregnantnAntidiarrheals-Codeine,Opium,Paregoric,Lomotil

10、nSulfasalazine and Corticosteroids safe.nNO sulfa drugs in 3rd trimester.nTPN in severe nutritional deficiencies.nMetronidazole after 1st trimester.Sickle Cell Diseasen risk of miscarriage,preterm labor,&other complications due to impaired O2 supply and sickling infarcts in placental circulation.n v

11、ascular occlusive events(3rd trimester and post partum)nTx of painful crisis same as nonpregnant(analgesics and hydration)except NO NSAIDs!nMore severe cases-partial exchange transfusion via automated erythrocytopheresis or simple transfusion 6g/dL.MigrainenPregnancy usually improves classic migrain

12、es.nNO ERGOT ALKALOIDS!nSumatriptan with minimal experience in pregnancy.nAcute Tx:Analgesics&AntiemeticsnProphylactic Tx:beta blockers(propranolol 40-60mg/day or atenolol 50-100mg/day)Seizure Disordersn0.5-1.0%occurrencen slightly in frequency during pregnancynMedication doses may need to maintain

13、therapeutic levels.nValproic Acid general avoided(1-3%risk of neural tube defects)Seizure Disorders TreatmentnSingle grand mal seizure n(May be followed by fetal bradycardia for up to 20 minutes-no apparent long term fetal harm.)nOxygen nLeft lateral uterine displacementnStatus EpilepticusnAggressiv

14、e management with intubation/ventilation early because 50%mortality of fetus and 33%mortality of mother.Substance AbusenRefer to high-risk obstetrics clinic and offer substance abuse counseling.nCocainenFetal complications:risk of placental abruption,fetal death in utero,IUGR,preterm labor,premature

15、 rupture of membranes,spontaneous Ab,cerebral infarctsnMaternal complications:MI,HTN,pulmonary edema,cardiac dysrhythmia,subarachnoid hemorrhage,ruptured aneurysms,strokenTx of acute intoxication handled as in nonpregnant pt.Substance Abuse Cont.nOpiate WithdrawalnAcute Tx:Methadone or clonidine(0.1

16、-0.2mg SL q1 up to 0.8mg)nMaintenance Tx:Clonidine 0.8-1.2mg/day in divided doses X 7 days then taper for 3 days.nAlcohol Abusen1-2%of pregnanciesn2 or more drinks/day risk of spont Ab,low-birth-weight infants,preterm deliveries,perinatal mortality,fetal alcohol syndromenETOH coma/withdrawal treated

17、 like nonpregnant except avoid benzodiazepines in early pregnancy.Domestic Violencen14-17%occurrencen risk associated with late prenatal care,unintended pregnancy,drug and ETOH abuse,depresion,and housing problems.nFetal complications:placental abruption,fetal fractures,uterine rupture,preterm labor

18、nKeep high risk of suspicionnRefer to social services and/or law enforcement.nRhoGam for Rh neg mothers with blunt abd trauma.Complicating Effects of Radiationn10 rad is threshold for human teratogenesis nTable 105-3nVentilation/perfusion scan=0.5 radnUltrasound without known teratogenic effect.nStu

19、dies with MRI have not shown any harmful effects thus far.THE END!QUESTIONS?Questionsn1.It is reasonable to use oral hypoglycemics to treat gestational diabetes.nA.TruenB.Falsen2.You should not be concerned about a BP 140/90 or greater in a pregnant patient.nA.TruenB.False n3.A DVT in a pregnant pat

20、ient can be treated with all of the following except:nA.HeparinnB.LMWHnC.Coumadinn4.Treatment of pyelonephritis in a pregnant patient includes all of the following except:nA.HospitalizationnB.IV Abx.nC.IV FluidsnD.Does not require hospitalizationn5.Alcohol use during pregnancy can increase risk for all of the following except:nA.Spontaneous abortionnB.Low birth weight infantsnC.Fetal ETOH syndromenD.Preterm deliverynE.All of the above are true.Answersn1.Fn2.Fn3.Cn4.Dn5.E