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mcatmemoranda · 4 months

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I'm on OB rotation again. I asked the attending what are things the PCP should know about prenatal and postpartum pts. Stuff we discussed:

SSRIs can be continued during pregnancy. I often see patients on Zoloft during pregnancy if they need an antidepressant. In fact, I just started a prenatal patient on Zoloft the other day in clinic. It is safe to continue SSRIs during pregnancy because you should treat the patient's depression. Babies can come out sort of jittery because of the SSRI, but that goes away.

Postpartum patients will have bleeding somewhat similar to a menstrual period right after giving birth. It starts to decrease and becomes like a brownish color and can last up to 6 weeks postpartum. Any bleeding beyond that point is abnormal.

There is some evidence that if you have estrogen-containing birth control, it can decrease milk supply. Actually, I had a patient in clinic recently who was seen by an attending and he started her on a progesterone only birth control so that it would not affect her milk supply. Estrogen decreases the patient's milk supply, so patients who plan to breast-feed should not be started on estrogen-containing birth control. Right after giving birth, your body has increased amounts of estrogen, so you would not start estrogen containing birth control until at least 6 weeks postpartum anyway. Increasing estrogen immediately postpartum increases risk of blood clots. For patients who plan to breastfeed and want to be on an oral contraceptive, use progesterone only oral contraceptives until she stops breastfeeding.

If the mother is breastfeeding at least every 4 hours, then this can be used for contraception. It's about 80% effective. Once baby starts sleeping through the night or once baby starts feeding more than every 4 hours, this method won't work! If you go more than 4 hours without breastfeeding, breastfeeding will not protect you from pregnancy! You can also ovulate before your menstrual period returns, so you can't say you can't get pregnant because your period has not returned yet!

I asked the attending I worked with today about how she goes about prescribing birth control. She said she will usually start with Sprintec. It's usually covered by insurance and if it's not covered, it's pretty affordable. She also said Junel is pretty well tolerated. Certain progestins in certain brands of birth control may work better for certain things like acne control, but she didn't have as much knowledge on that. I'll ask another attending again about that. I usually start people on Sprintec as well.

PCP should know that alkaline phosphatase is high in pregnant patients. It comes from the placenta. So don't be freaked out by that.

You should know HTN in pregnancy and preeclampsia workup. High BP is 140/90. Severely high BP is 160/110. Swelling occurs in many pregnant pts, but that should also alert you to start preeclampsia workup.

[Preeclampsia w/u from UpToDate:

Diagnostic evaluation

•Laboratory – Patients with suspected preeclampsia should have a complete blood count with platelets, creatinine level, liver chemistries, and determination of urinary protein excretion.

•Fetal status – Fetal status is assessed concurrently or postdiagnosis, depending on the degree of concern during maternal evaluation. At a minimum, a nonstress test or biophysical profile is performed if appropriate for gestational age. Ultrasound is used to evaluate amniotic fluid volume and estimate fetal weight, given the increased risk for oligohydramnios and growth restriction.

•Consultation with the neurology service is generally indicated in patients with neurologic deficits/abnormal neurologic examination, which may include ocular symptoms or a severe persistent headache that does not respond to initial routine management of preeclampsia.]

An important thing to review is physiology of pregnancy. Blood volume increases during pregnancy, so there are lots of new RBCs and that will throw off a HgbA1c reading, therefore HgbA1c is not measured during pregnancy and will not be accurate! My attending today told me there was a midwife who offered pts either HgbA1c or oral glucose tolerance tests to screen for gestational DM. The HgbA1c is not accurate in pregnancy, so this should not be done. That would be bad to miss a diagnosis of gestational diabetes. You have to wait until 3 months postpartum to measure HgbA1c to get an accurate reading. Had a pt who did not have a PCP prior to getting pregnant, was on insulin during the pregnancy, and after giving birth, still needs to establish with PCP for diabetes f/u. After you give birth, you insulin needs drastically change, so you don't need as much as you did when you were pregnant. So I stopped her insulin and advised that she f/u with her new PCP for diabetes care.

I still need to review fetal heart tracings. The attending today said the first thing to look at is the baseline (the baseline HR should be about 160 beats/min), then the variability, then look for accelerations and decelerations. If more than 32 weeks GA, accelerations are 15 beats/min above the baseline lasting at least 15 seconds. Early decelerations are representative of compression of the fetal head, which is normal during labor as baby moves down the pelvis/birth canal. Variable decelerations look sharper like a "V" and can represent compression of the umbilical cord. Late decelerations represent placental insufficiency.

ACOG has very helpful practice bulletins.

I can't take screen shots on my work laptop, so I'm just going to summarize gestational HTN w/u from UpToDate:

Gestational HTN: New onset of systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg on at least 2 occasions 4 hours apart after 20 weeks of gestation in a previously normotensive individual

And:

No proteinuria

No signs/symptoms of preeclampsia-related end-organ dysfunction (eg, thrombocytopenia, renal insufficiency, elevated liver transaminases, pulmonary edema, cerebral or visual symptoms)

Preeclampsia: New onset of systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg on at least 2 occasions at least 4 hours apart after 20 weeks of gestation in a previously normotensive individual. Patients with systolic blood pressure ≥160 mmHg and/or diastolic blood pressure ≥110 mmHg should have blood pressure confirmed within a short interval (minutes) to facilitate timely administration of antihypertensive therapy.

And:

Proteinuria (≥300 mg per 24-hour urine collection [or this amount extrapolated from a timed collection], or protein:creatinine ratio ≥0.3, or urine dipstick reading ≥2+ [if other quantitative methods are not available]).

In a patient with new-onset hypertension without proteinuria, the diagnosis of preeclampsia can still be made if any features of severe disease are present.

Preeclampsia with severe features: In a patient with preeclampsia, presence of any of the following findings are features of severe disease:

Systolic blood pressure ≥160 mmHg and/or diastolic blood pressure ≥110 mmHg on 2 occasions at least 4 hours apart (unless antihypertensive therapy is initiated before this time)

Thrombocytopenia (platelet count <100,000/microL)

Impaired liver function as indicated by liver transaminase levels at least twice the normal concentration or severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by alternative diagnoses, or both

Progressive renal insufficiency (serum creatinine concentration >1.1 mg/dL [97 micromol/L] or doubling of the serum creatinine concentration in the absence of other renal disease)

Pulmonary edema

Persistent cerebral or visual disturbances

Eclampsia: A generalized seizure in a pt with preeclampsia that cannot be attributed to other causes.

HELLP syndrome: hemolysis, elevated liver enzymes, low platelets. Hypertension may be present (HELLP in such cases is often considered a variant of preeclampsia).

Chronic (pre-existing) hypertension: hypertension diagnosed or present before pregnancy or on at least 2 occasions before 20 weeks of gestation. Hypertension that is first diagnosed during pregnancy and persists for at least 12 weeks postpartum is also consider chronic hypertension.

Blood pressure criteria during pregnancy are:

Systolic ≥140 mmHg and/or diastolic ≥90 mmHg

Prepregnancy and 12 weeks postpartum blood pressure criteria are:

Stage 1 – Systolic 130 to 139 mmHg or diastolic 80 to 89 mmHg

Stage 2 – Systolic ≥140 mmHg or diastolic ≥90 mmHg

Chronic HTN with superimposed preeclampsia*:

Any of these findings in a patient with chronic hypertension:

A sudden increase in blood pressure that was previously well-controlled or an escalation of antihypertensive therapy to control blood pressure

New onset of proteinuria or a sudden increase in proteinuria in a patient with known proteinuria before or early in pregnancy

Significant new end-organ dysfunction consistent with preeclampsia after 20 weeks of gestation or postpartum

*Precise diagnosis is often challenging. High clinical suspicion is warranted given the increase in maternal and fetal-neonatal risks associated with superimposed preeclampsia.

Chronic hypertension with superimposed preeclampsia with severe features:

Any of these findings in a patient with chronic hypertension and superimposed preeclampsia:

Systolic blood pressure ≥160 mmHg and/or diastolic blood pressure ≥110 mmHg despite escalation of antihypertensive therapy

Thrombocytopenia (platelet count <100,000/microL)

New-onset or worsening renal insufficiency

Pulmonary edema

Persistent cerebral or visual disturbances

A reduction in blood pressure early in pregnancy is a normal physiologic occurrence. For this reason, women with chronic hypertension may be normotensive at their first few prenatal visits. Later in pregnancy, when their blood pressure returns to its prepregnancy baseline, they may appear to be developing preeclampsia or gestational hypertension if there are no documented prepregnancy blood pressure measurements.

BP: blood pressure.

* Blood pressure should be elevated on at least two occasions at least four hours apart. However, if systolic pressure is ≥160 mmHg or diastolic pressure is ≥110 mmHg, confirmation after a short interval, even within a few minutes, is acceptable to facilitate timely initiation of antihypertensive therapy.

¶ The onset of preeclampsia and gestational hypertension is almost always after 20 weeks of gestation. Preeclampsia before 20 weeks of gestation may be associated with a complete or partial molar pregnancy or fetal hydrops. Postpartum preeclampsia usually presents within two days of delivery. The term "delayed postpartum preeclampsia" is used for signs and symptoms of the disease leading to readmission more than two days but less than six weeks after delivery.

Δ Significant proteinuria is defined as ≥0.3 g in a 24-hour urine specimen or protein/creatinine ratio ≥0.3 (mg/mg) (34 mg/mmol) in a random urine specimen or dipstick ≥1+ if a quantitative measurement is unavailable.

◊ Almost all women with the new onset of hypertension and proteinuria at this gestational age or postpartum have preeclampsia, but a rare patient may have occult renal disease exacerbated by the physiologic changes of pregnancy. An active urine sediment (red and white cells and/or cellular casts) is consistent with a proliferative glomerular disorder but not a feature of preeclampsia. Women with chronic hypertension who had proteinuria prior to or in early pregnancy may develop superimposed preeclampsia. This can be difficult to diagnose definitively, but should be suspected when blood pressure increases significantly (especially acutely) in the last half of pregnancy/postpartum or signs/symptoms associated with the severe end of the disease spectrum develop.

§ Photopsia (flashes of light), scotomata (dark areas or gaps in the visual field), blurred vision, or temporary blindness (rare); severe headache (ie, incapacitating, "the worst headache I've ever had") or headache that persists and progresses despite analgesic therapy; altered mental status. Seizure occurrence upgrades the diagnosis to eclampsia.¥ The differential diagnosis of preeclampsia with severe features includes but is not limited to:

Antiphospholipid syndrome

Acute fatty liver of pregnancy

Thrombotic thrombocytopenic purpura (TTP)

Hemolytic uremic syndrome (HUS)

The laboratory findings in these disorders overlap with those in preeclampsia with severe features. (Refer to table in the UpToDate topic on the clinical manifestations and diagnosis of preeclampsia.) The prepregnancy history, magnitude and spectrum of laboratory abnormalities, and additional presence of signs and symptoms not typically associated with preeclampsia help in making the correct diagnosis, which is not always possible during pregnancy.

In addition, a variety of medical disorders may be associated with hypertension and one or more of the signs and symptoms that occur in women with preeclampsia with severe features. These patients can usually be distinguished from patients with preeclampsia by taking a detailed history, performing a thorough physical examination, and obtaining relevant laboratory studies.‡ In contrast to preeclampsia, gestational hypertension is not associated with end-organ involvement, so neither proteinuria nor the symptoms or laboratory findings of preeclampsia are present.

#OB #OBGYN #birth control #gestational HTN #preeclampsia #eclampsia #breastfeeding #gestational diabetes #fetal heart tracing #FHT

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