Medical Complications of
Pregnancy: A Brief Review for
the Internal Medicine Resident
Kristen Amann, MDJuly 9, 2010
Quick Reminders
• Give all pregnant women folate to prevent neural tube defects (most effective in the 1st trimester)
• Treat asymptomatic bacteruria (20% will develop cystitis and/or pyelonephritis)
• hCG doubles every 2 days in the first trimester– Home pregnancy tests: positive ~ 2 weeks after
conception• Gravid uterus: abdomen at 12 weeks, umbilicus at
20 weeks• GP nomenclature:
– G (gravida): # of times pregnant– P (para): # births >20 weeks gestation
• (term), (preterm), (abortions), (living children)
Some Pertinent Teratogens
• Acyclovir• ACE Inhibitors• Diazepam• Fluconazole• Lithium• Warfarin• Aminoglycosides
• Isotretinoin (Accutane)
• Antineoplastic agents
• Carbamazepine• Methotrexate• Trimethoprim• Tetracycline• Phenytoin (Dilantin)
Sheehan’s Syndrome (Postpartum Pituitary Necrosis)• Major obstetric hemorrhage resulting in hypovolemic shock
and subsequent anterior pituitary ischemia and necrosis • Most common cause of anterior pituitary insufficiency in
females– Total: 0.5% of all hypopituitarism cases
• Clinical presentation:– Severe (recognized within the first days to weeks): lethargy,
anorexia, fatigue, agalactorrhea– Less severe (weeks, months, or even years after delivery):
agalactorrhea, failure to resume menses, lethargy• Physiology:
– Hypertrophy and hyperplasia of lactotrophs during pregnancy resulting in enlargement of the anterior pituitary
– Anterior pituitary supplied by low pressure venous system (versus posterior pituitary having direct arterial supply).
– Major hormones secreted: TSH, ACTH, LH, FSH, GH, prolactin• If blood loss is severe, immediately treat for presumed
adrenal insufficiency
Diabetes Mellitus
• Optimization of pre-conceptional DM and during key periods of organogenesis can reduce risk for fetal malformations – Sacral agenesis, caudal dysplasia, renal
agenesis, VSD, hypertrophic cardiomyopathy, etc.
• Increased risk for preeclampsia• DM + microvascular disease: higher risk for
IUGR• Fasting glucose goals: 105-140• Treatment: diet, insulin
– ADA and ACOG do not endorse oral hypoglycemic agents
HELLP• Hemolysis, Elevated Liver enzymes, Low Platelets• Develops in 10-20% of patients with severe
preeclampsia/eclampsia• Overall occurrence: 1-2 per 1,000 pregnancies• Usually occurs in 3rd trimester but can occur in 2nd
and post-partum• Clinical:
– RUQ/epigastric pain, nausea, vomiting, malaise– MAHA, Plt <100,000, AST >70, LDH >600
• Significant morbidity: DIC, AKI, ARDS, subcapsular liver hematoma, etc.
• Treatment: delivery, supportive management, HTN control, magnesium (seizure prevention), platelet transfusion for <20,000 or for significant bleeding
Acute Fatty Liver of Pregnancy
• Usually in the 3rd trimester but may occur in the 2nd • Maternal mortality: <3%• More common with male fetus• Etiology hypothesis: Disordered metabolism of fatty
acids in the patient’s mitochondria caused by LCHAD (long-chain-3-hydroxyl acyl DH) deficiency
• Clinical:– Liver is typically small– Transaminitis (<500 IU/L), elevated bilirubin, elevated
ammonia, hypoglycemia, prolonged INR• Usually necessitates termination of pregnancy due
to fetal distress• Treatment: supportive care, fetal delivery• Recurrence is rare
Thromboembolic Disease• Hypercoagulable state: stasis, changes in venous
capacitance, increase in factor levels, decrease in protein S, progressive protein C resistance in 2nd and 3rd trimesters,
• Pulmonary embolism = most common cause of maternal death in the US
• DVT: more common in LLE versus RLE (left iliac vein compression)– 25%: carriers of the factor V Leiden allele (activated
protein C resistance)– Additional genetic mutations: prothrombin G20210A
mutation (hetero- and homozygotes), methylenetetrahydrofolate reductase C677T mutation (homozygotes)
• Treatment: heparin (or LMWH)– Warfarin contraindicated during pregnancy, but not in
breast-feeding mothers
Gestational Trophoblastic Neoplasia
• Spectrum of lesions arising from the trophoblastic epithelium of the placenta:– Hydatidiform mole (complete or partial)– Invasive mole– Placental-site trophoblastic tumor
• Cytotrophoblast cells arising from placental implantation site– Choriocarcinoma
• Anaplastic trophoblastic tissue with both cytotrophoblastic and syncytiotrophoblastic components, no villi
• Elevated -hCG without an existing pregnancy• Incidence: 1 per 1,500 pregnancies (10-fold higher in Asia)
– Choriocarcinoma: 1 in 25,000 pregnancies• Approximately 50% of patients had a prior molar pregnancy• Frequently metastasizes (lung, brain, vagina)• Think about this in females of child-bearing age with multiple
pulmonary nodules• Add to differential for premenopausal women with irregular
vaginal bleeding
Sources• Dunaif, A. Women’s Health. Harrison’s Principles of Internal Medicine, 16th
edition. McGraw-Hill, New York. 2005.• Snyder, P. Causes of Hypopituitarism. www.uptodate.com. • Teratogens. http://sis.nlm.nih.gov.• The American College of Obstetrics and Gynecology. www.acog.org.• Young, D. Gynecologic Malignancies. Harrison’s Principles of Internal
Medicine, 16th edition. McGraw-Hill, New York. 2005.
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