Common Medical Complications
in Pregnancy
Susan M Cox, MD
4.27.2014
Milestone 1
• Basic understanding of the pathophysiology
and management of gestational hypertensive
diseases
• Basic understanding and management of
Diabetes Mellitus complicating pregnancy
Objectives
• Review the diagnosis and treatment of common
medical conditions seen in pregnancy
– Hypertension
– Diabetes
– Hyperthyroidism
• Recognize the maternal and fetal complications
of each
Case 1
• A 23-year-old G1P0 presents at 39 weeks with
concerns for swelling in her face and hands over
the last 3 days. Her blood pressure is 155/99. A
24-hour urine collection shows 440mg of protein.
What is the treatment for her disease?
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Delivery
Furosemide
Hydralazine
Magnesium sulfate
Management of fluids
Epidemiology and Risk Factors
• First Pregnancies
• Multiple Gestations
• Maternal Vascular Disorders
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•
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•
•
Diabetes Mellitus (Types 1 And 2)
Lupus Erythematosus
Renal Disease
Antiphospholipid Antibody Syndrome
Obesity
Advanced Maternal Age
African-American Race
Chronic Hypertension.
Complicates
8% of
pregnancies
Terminology
• Chronic hypertension
• Chronic hypertension with superimposed
preeclampsia
• Gestational hypertension
• Preeclampsia and eclampsia
Hypertensive Disorders in Pregnancy
• Chronic Hypertension
o Dx: BP >140/90
o Prior pregnancy or
o Noted prior to 20th week EGA or
o Persists beyond 12 weeks postpartum
Hypertensive Disorders in Pregnancy
• Chronic HTN
o Treatment Goal: DBP <100 (<90 if end organ
damage)
o Treatment options (starting dose)
Methyldopa 250 mg PO bid
Labetalol 100 mg PO bid
Nifedipine 30 mg PO q day
Hydralazine 10 mg PO qid
Hypertensive Disorders in Pregnancy
• Chronic hypertension with superimposed
preeclampsia
o Gestational age > 20 weeks
o Proteinuria >300 mg / 24 hours (when it didn’t
exist at gestational age < 20 weeks) OR
o BP >160 / 110 (when it was under control at
earlier gestational age )
Hypertensive Disorders in Pregnancy
• Gestational Hypertension
o Dx >140/90 on two occasions
o Gestational age >20 weeks and normal BP earlier
in pregnancy
o No proteinuria (<300 mg / 24 hours on spot urine
estimation)
Hypertensive Disorders in Pregnancy
• Gestational Hypertension
o Treatment Goal: DBP <100 ( <90 with end
organ damage)
o Treatment options
Methyldopa
Labetalol
Nifedipine
Hydralazine
Hypertensive Disorders in Pregnancy
• Pre-eclampsia
o Hypertension >140/90 on two readings
o Proteinuria >300 mg / 24 hours on spot estimation
o Gestational age > 20 weeks
o Normal blood pressures earlier in pregnancy
Hypertensive Disorders in Pregnancy
• Pre-eclampsia
o Treatment options
Depends of gestational age and severity criteria
Hypertensive Disorders of Pregnancy
• Criteria for severe pre-eclampsia
o SBP >160 or DBP >110
o Proteinuria > 5 grams / 24 hours
o Oliguria <500 ml / 24 hours
o Pulmonary edema
o Thrombocytopenia (<100,000)
o Liver dysfunction (AST or ALT > 2x normal) or liver
distention (RUQ pain / N/V )
o Neurologic dysfunction
o IUGR
o Eclampsia
HELLP Syndrome
• Hemolysis
• Elevated Liver Enzymes
• Low Platelets
Deliver the baby!
Dexamethasone not effective
(Am J of Obstet Gynecol 2005 Nov; 193(5):1591-1598)
Clinical Management Pearls
• Pre-eclampsia
o Preterm
Betamethasone 12 mg IM q 24 hours x 2 doses
(EGA < 34 weeks)
Observation if BPP reassuring and no severe
criteria
o Term
Expedite delivery
Clinical Management Pearls
• Eclampsia prevention
o Magnesium Sulfate
4 gram load IV then 2 gram/hr IV
Monitor for
– Oliguria
– Loss of reflexes
– Somnolence
– Respiratory depression
o Continue Mag SO4 for 24 hours post-partum
Maternal Cardiovascular
Consequences
Case 2
• A 34 year old G2 P1 presents for her first prenatal visit at 25 weeks’
gestation. She had no prenatal care during her first pregnancy which
ended in a term stillborn whose birth weight was 10.5 pounds.
• Past medical history is negative for hypertension, diabetes, and substance
abuse. She denies alcohol use, smoking, or trauma. Her previous
pregnancy was via Caesarean delivery because of failed induction times 3
and CPD.
• Physical Examination is unremarkable except for a gravid uterus at 26 cm
height with fetal heart tones: 144/min.
• Routine Prenatal Labs:
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Hemoglobin: 12.6 g/dL
WBC: 7800
Creatinine: 0.6 mg/dL
Random blood sugar: 130
One-hour glucola: 165
What is the next step in her
work-up?
100 gram glucola (3 hr GTT)
GDM Risk Factors
• Traditional risk factors
– Family history
– Previous macrosomic infant
– Poor obstetric history
– Glycosuria
identify only 40-60% of cases of GDM
Gestational Diabetes Mellitus
• Criteria for no screening:
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Age <25
No history of GDM / DM 2
No first degree relative with DM 2
Pre-pregnancy body weight normal
No history of poor obstetrical outcome
Not a member of higher risk ethnic group (Hispanic /
African American / Pacific Islander / Native American /
South or East Asian)
Fifth International Workshop Conference on GDM certain features place
women at low risk of GDM, and it may not be cost-effective to screen this
group of women. Represents only 10% of population.
Gestational Diabetes Mellitus
Screening
• 50 gram Glucola (1 hour glucola)
– 24-28 weeks EGA (+/- 1st trimester screen)
– No fasting required
– Nurse can give drink at beginning of encounter
– Single lab draw 1 hour after drinking glucola
– Screening cut-off
• 130 = 23% require 30 GTT and identifies additional 10%
of GDM cases
• 140 = 14% require 30 GTT
GDM Diagnostic Test
• Confirmation with a 100 gram glucola (3 hr
GTT)
– Fasting for 8 – 10 hours
– Draw fasting glucose level
– Drink glucola
– Draw 1, 2 and 3 hour PP values
3 hour GTT cutoffs
• Carpenter and Coustan Criteria
– Fasting <95
– 1 hour <180
– 2 hour <155
– 3 hour <140
A positive test for GDM is 2 of 4 values abnormal
GDM Goals of Treatment
Fasting < 95
AND
One hour PP < 130
OR
Two hour PP < 120
Treatment for GDM
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Diet (medical nutritional therapy)
Insulin
Glyburide
Metformin
Oral therapy for GDM
• Glyburide
1. No difference in maternal / neonatal outcomes
2. Most authorities still cautious about
recommending due to placenta crossing, but
gaining acceptance
3. Start Glyburide 2.5 mg PO q day
3. Titrate to maximum dose 20 mg PO q day
Oral Therapy for GDM
• Metformin
– No randomized trials (i.e. insulin vs. metformin)
– Data comes from cohorts treated into pregnancy
for infertility / PCOS / etc.
– No significant safety concerns at this point
Antepartum Monitoring of GDM
• GDM A1 NST / AFI >38 weeks
• GDM A2 NST / AFI >32 weeks
Risk of future DM 2
• GDM = Pre-Diabetes
– 75 gram glucola at PP visit and yearly thereafter
Maternal And Fetal Consequences
• Current pregnancy
• Future prognosis for mom
• Future prognosis for baby
Case 3
34-year-old G4 P3 at 19 weeks presents to the
emergency department with chest pain, palpitations
and sweating, which began 4 hours ago. She notes
that she has been very anxious lately and is not
sleeping well, which she attributes to the pregnancy.
She reports that she has lost 30 pounds in the last
year while not dieting. She denies significant medical
problems.
Case 3
Examination: patient appears diaphoretic and anxious,
her eyes are wide open, prominent, and you can
easily see the sclera surrounding the pupil. Her
temperature is 38.1; pulse is 132; and her blood
pressure is 162/84. Height is 1.75 meters (70”) and
weight is 58 kg (128 lb.). Her thyroid is palpably
enlarged, with an audible bruit. Electrocardiogram
shows sinus tachycardia. Remaining labs are pending.
Case 3
• What is the most likely diagnosis?
– Anxiety
– Heatstroke
– Serotonin Syndrome
– Thyroid Storm
– Anticholinergic toxicity
Hyperthyroidism
• Affects 0.2% of pregnancies
• Prevalence 0.1% to 0.4%, with 85% Graves’
disease
– Single toxic adenoma, multinodular toxic goiter,
and subacute thyroiditis
– gestational trophoblastic disease, viral thyroiditis
and tumors of the pituitary gland or ovary (Struma
Ovarii)
Physiologic Changes in Thyroid Function
During Pregnancy
Maternal
Status
TSH
Free T4
Free
Thyroxine
Index
(FTI)
Total T4
Total T3
Resin
Triiodothyronine
Uptake
(RT3U)
**initial
screening
test**
Pregnancy
No
change
No
change
No
change
Increase
Increase
Decrease
Hyperthyroidism
Decrease
Increase
Increase
Increase
Increase
or no
change
Increase
Hypothyroidism
Increase
Decrease
Decrease
Decrease
Decrease
or no
change
Decrease
Graves’ disease
• 95% of thyrotoxicosis during pregnancy
• Activity level fluctuate during gestation
– exacerbation during the first trimester
– gradual improvement during the latter half
– exacerbation shortly after delivery
• Clinical scenarios
– stable Graves’ disease receiving thionamide therapy
with exacerbation during early pregnancy.
– in remission with a relapse of disease.
– without prior history diagnosed with Graves’ disease
de novo during pregnancy.
Graves’ disease
• Diagnosis
– difficult: hypermetabolic symptoms in normal
pregnancy
– thyroid examination: goiter (with or without bruit)
– suppressed serum TSH level and usually elevated free
and total T4 serum concentrations
– TSH receptor antibodies
• complications related to the duration and control of
maternal hyperthyroidism
• autoantibodies mimic TSH and can cross the placenta
and cause neonatal Graves’ disease
Graves’ disease
• Pregnancy outcome
– preterm labor
• untreated (88%)/partially treated(25%) /adequately
treated (8%)
– preeclampsia
• untreated twice the risk
– stillbirth
• untreated (50%) /partially treated (16%) /adequately
treated (0%)
– small for gestational age
– congenital malformations
Thyroid storm
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Obstetric emergency
Extreme metabolic state
10% of pregnant women with hyperthyroidism
High risk of maternal cardiac failure.
Fever, change in mental status, seizures, nausea,
diarrhea, and cardiac arrhythmias.
• Inciting event (e.g., infection, surgery, labor/delivery)
and a source of infection
• Treatment immediately, even if serum free t4, free
t3, and TSH levels are not known.
• Untreated thyroid storm can cause shock, stupor,
and coma.
Treatment of Hyperthyroidism
• Goal is to maintain FT4/FTI in high normal range using
lowest possible dose (minimize fetal exposure)
• Measure FT4/FTI q2-4 weeks and titrate
• Thioamides (PTU/methimazole) ->
– decrease thyroid hormone synthesis blocks I organification
– PTU also reduces T4->T3 and may work more quickly
– PTU traditionally preferred (methimazole crossed placenta and
associated with fetal aplasia cutis; newer studies refute this)
Treatment of Hyperthyroidism
• Median time to normalization of maternal
thyroid function
– 7 weeks with PTU
– 8 weeks with methimazole
• Breastfeeding safe when taking PTU/
methimazole
Treatment of Hyperthyroidism
• Beta-blockers can be used for symptomatic
relief (usually Propanolol)
• Reserve thyroidectomy for women in whom
thioamide treatment unsuccessful
• Iodine 131 contraindicated (risk of fetal
thyroid ablation especially if exposed after 10
weeks); avoid pregnancy/breastfeeding for 4
months after radioactive ablation
Maternal Complications
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Increased risk of stillbirth
Preterm delivery
Intrauterine growth restriction
Preeclampsia
Heart failure
Spontaneous abortion
Increased maternal mortality
Fetal Complications
• Fetal thyroid hyperfunction or hypofunction
caused by TSH abs
• Fetal goiter from excessive antithyroid drug
treatment
• Neonatal thyrotoxicosis
• Increased perinatal maternal mortality
• Decreased IQ of offspring because of excessive
use of antithyroid drugs
Good Luck!