Maternal Pregnancy ComplicationsJason Ryan, MD, MPH

• Nausea and/or vomiting common in early pregnancy • Mild cases: “morning sickness”• Severe cases: hyperemesis gravidarum

• Vomiting causing hypovolemia• May lead to weight loss

• Check electrolytes and urinalysis• May see alkalosis or hypokalemia• Urinary ketones may be present

Hyperemesis Gravidarum

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• Intravenous fluids• Thiamine

• Rare cases of maternal Wernicke’s encephalopathy reported

• Correct magnesium, calcium and phosphorus if low

Hyperemesis GravidarumTreatment

• Lifestyle changes• Eat when hungry – avoid empty stomach• Avoid triggers: odors, lying down after eating

• Usual first-line medical treatment: doxylamine-pyridoxine• Doxylamine: anti-histamine• Pyridoxine: vitamin B6 (improves nausea through unknown mechanism)

• Severe cases: other antihistamines, dopamine agonists, ondansetron

Hyperemesis GravidarumTreatment

Diabetes in Pregnancy

• Pregnancy is an insulin-resistant state• Decreased maternal response to insulin• Diabetes mellitus: worsened by pregnancy• Gestational diabetes: onset of diabetes during pregnancy• May adversely affect fetus• Screening with serum glucose testing• Glycosuria occurs in normal pregnancy• Hemoglobin A1c limited use in pregnancy

Zapyon/Wikipedia

C-peptide

α chain

β chain

Insulin

Diabetes in PregnancyAdverse effects

• Many potential adverse effects for mother and baby• Large for gestational age• Macrosomia • Birth trauma (shoulder dystocia)• Cesarean delivery• Polyhydramnios• Spontaneous abortion or stillbirth• Preeclampsia • Neonatal hypoglycemia

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Diabetes in PregnancyRisks

• Congenital heart defects: 3-9% of babies• Transposition of the great arteries (TGA)• Ventricular septal defects (VSDs)• Truncus arteriosus• Tricuspid atresia• Patent ductus arteriosus (PDA)

Wikipedia/Public Domain

Caudal Regression SyndromeSacral Agenesis

• Classically associated with maternal diabetes• Usually children of insulin-dependent mothers

• Incomplete development of sacrum• May include sirenomelia

• “Mermaid syndrome”• Fusion of legs

• Often includes a neural tube defect

H. Aslan et a. Prenatal diagnosis ofCaudal Regression Syndrome: a case report. BMC Pregnancy and Childbirth. 1, 8. 2001.

Stanislav Kozlovskiy/Wikipedia

• Mainstay of treatment: diet plus exercise• Controlled carbohydrate intake to meet caloric needs• Medical therapy if > 30% of glucose values above threshold• Mainstay of medical treatment: insulin• Can use metformin in selected patients (2nd/3rd trimester)

Gestational DiabetesTreatment

Time Glucose (mg/dL)

Fasting < 95

1 hr Postprandial < 140

2 hr Postprandial < 120

Glucose Targets

• Consider induction to avoid macrosomia • Consider cesarean delivery if large baby• Diabetes usually resolves postpartum • Increased risk of type II DM after delivery• Screening 2hr GTT at 6 to 12 weeks postpartum

Gestational DiabetesFurther Management

Type Details

A1 Diet controlled

A2 Insulin controlled

B through D Pregestational diabetes

White’s Classification of Diabetes in Pregnancy

• Rare cause of acute liver failure in 3rd trimester of pregnancy• Fatty infiltration of hepatocytes• Classic presentation: persistent nausea and vomiting• Other features: jaundice or encephalopathy• Abnormal labs: LFTs, bilirubin• Treatment: immediate delivery plus supportive care

• Progression of pregnancy may lead to fulminant liver failure

• Most cases recover after delivery

Acute Fatty Liver of Pregnancy

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• Diffuse pruritus with elevated serum bile acids• Occurs in 2nd half of pregnancy due to unknown cause• Diagnosis: ↑ serum total bile acids• Mild abnormalities LFTs or bilirubin • Treatment: ursodeoxycholic acid • Risk to fetus: fetal demise, preterm delivery • Deliver at term

Intrahepatic Cholestasis of Pregnancy

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• Abdominal pain, nausea, vomiting• Pain may occur in RUQ due to pregnancy• Diagnosis: ultrasound • Inconclusive US: MRI• Treatment: surgery

Appendicitis in Pregnancy

Case courtesy of Dr Matthew Lukies, Radiopaedia.org, rID: 51979

Appendicitis

• Progesterone → urinary stasis• Relaxation of smooth muscle in urinary tract• Asymptomatic bacteriuria, cystitis, or pyelonephritis• Most common bacteria: E. coli• Others: S. saprophyticus, GBS, enterococcus

Urinary Infections

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E. Coli

• Asymptomatic bacteriuria • Screening at first prenatal visit with urine culture• High risk of pyelonephritis and preterm birth• Treat positive culture with antibiotics for 7 days• Drug choice based on bacteria sensitivity• Up to 30% do not clear bacteriuria after antibiotics• Repeat culture is usually done for test of cure

• Acute cystitis: empiric antibiotics• Nitrofurantoin• Fosfomycin • Modify when culture results available

Urinary Infections

Wikipedia/Public Domain

• Pyelonephritis• Occurs in 2% of pregnancies• Common indication for hospitalization

• Treatment:• IV fluids• Parenteral, broad spectrum antibiotics• Ceftriaxone, Cefepime, ampicillin-gentamicin

• Recurrence common• Suppressive antibiotics often used until delivery

Urinary Infections

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• Hyperthyroidism or hypothyroidism may complicate pregnancy• Routine screening not recommended• Hyperemesis gravidum

• Associated with high hCG→ stimulates thyroid• Low TSH and possibly high T4• Thyroid studies avoided in HG patients

Thyroid Disease

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