Common Medical Complications in Pregnancy

Susan M Cox, MD4.27.2014

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?– Delivery– Furosemide– Hydralazine– Magnesium sulfate– Management of fluids

Epidemiology and Risk Factors

• First Pregnancies• Multiple Gestations• Maternal Vascular Disorders

– 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 >140/90o Prior pregnancy oro Noted prior to 20th week EGA oro Persists beyond 12 weeks postpartum

Hypertensive Disorders in Pregnancy

• Chronic HTNoTreatment Goal: DBP <100 (<90 if end organ

damage)oTreatment options (starting dose)

Methyldopa 250 mg PO bidLabetalol 100 mg PO bid Nifedipine 30 mg PO q day Hydralazine 10 mg PO qid

Hypertensive Disorders in Pregnancy• Chronic hypertension with superimposed

preeclampsiao Gestational age > 20 weekso Proteinuria >300 mg / 24 hours (when it didn’t

exist at gestational age < 20 weeks) ORo BP >160 / 110 (when it was under control at

earlier gestational age )

Hypertensive Disorders in Pregnancy• Gestational Hypertension

o Dx >140/90 on two occasionso Gestational age >20 weeks and normal BP earlier

in pregnancyo No proteinuria (<300 mg / 24 hours on spot urine

estimation)

Hypertensive Disorders in Pregnancy

• Gestational HypertensionoTreatment Goal: DBP <100 ( <90 with end

organ damage)oTreatment options

MethyldopaLabetalolNifedipineHydralazine

Hypertensive Disorders in Pregnancy• Pre-eclampsia

o Hypertension >140/90 on two readingso Proteinuria >300 mg / 24 hours on spot estimationo Gestational age > 20 weekso Normal blood pressures earlier in pregnancy

Hypertensive Disorders in Pregnancy

• Pre-eclampsiaoTreatment options

Depends of gestational age and severity criteria

Hypertensive Disorders of Pregnancy• Criteria for severe pre-eclampsia

o SBP >160 or DBP >110o Proteinuria > 5 grams / 24 hourso Oliguria <500 ml / 24 hourso Pulmonary edemao Thrombocytopenia (<100,000)o Liver dysfunction (AST or ALT > 2x normal) or liver distention (RUQ

pain / N/V )o Neurologic dysfunction o IUGRo 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 oPreterm

Betamethasone 12 mg IM q 24 hours x 2 doses (EGA < 34 weeks)

Observation if BPP reassuring and no severe criteria

oTermExpedite delivery

Clinical Management Pearls

• Eclampsia preventionoMagnesium Sulfate

4 gram load IV then 2 gram/hr IV Monitor for –Oliguria– Loss of reflexes– Somnolence–Respiratory depression

oContinue 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:– 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:– 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 MellitusScreening

• 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 < 130OR

Two hour PP < 120

Treatment for GDM

• Diet (medical nutritional therapy)• Insulin• Glyburide• Metformin

Oral therapy for GDM• Glyburide

1. No difference in maternal / neonatal outcomes2.Most authorities still cautious about

recommending due to placenta crossing, but gaining acceptance

3.Start Glyburide 2.5 mg PO q day3.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 334-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

**initial screening

test**

Free T4 Free Thyroxine Index (FTI)

Total T4 Total T3 Resin Triiodo-

thyronine Uptake (RT3U)

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 n

ovo 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• 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• 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!