Jenna Van Pelt, MDGynecology & Fertility, PC

Lincoln, NE

I have no disclosures

Identify obstetrical concerns related to common complaints in pregnancy

Implement interventions for the obstetrical concerns

Understand updated pregnancy guidelines, adjust primary care plan to align with guidelines

24 yo G1P0 presents to your office with complaints of a headache. Tylenol and sleep haven’t helped. She is 28 weeks along, has had an otherwise uncomplicated pregnancy

PMH: migraines Meds: PNV, Tylenol as needed

A. Pre-eclampsia B. Central venous thrombosis C. Stroke D. Tension headache E. Migraines

A. Pre-eclampsia B. Central venous thrombosis C. Stroke D. A & B E. A, B, & C

Differential diagnosis:◦ Pre-eclampsia◦ Transverse venous sinus thrombosis◦ Hormonal headache◦ Migraine◦ Tension headache◦ Cluster headache◦ Meningitis◦ Stroke◦ Spinal headaches (postpartum)◦ List goes on and on

•Headache with altered mental status, seizures, papilledema, changes in vision, stiff neck, or focal neurological signs/symptoms •Sudden onset of severe headache ("worst headache of my life") •New-onset of migraine-type headache •Headache in an immunosuppressed woman •Change in headache characteristics (eg, pain, pattern, severity) from usual headaches

•Headache associated with/precipitated by fever, head trauma, nonprescription drug use, or toxic exposure

•Headache that awakens one from sleep •Headache unrelieved by pain medication

Usually with MRI◦ Add MRA, MRV if concerned about central venous

thrombosis◦ No radiation/no fetal concern

Can use CT of head (usually faster and more readily available)◦ Avoid gadolinium or iodine contrast◦ CT of head exposes baby to approx. 50 mrad◦ 5000 mrad is limit of radiation exposure to baby

Pregnancy and postpartum period put women at increased risk of stroke compared to non-pregnant women of same age

Relative risk of ischemic stroke postpartum is increased to 8 and 28 for hemorrhagic stroke

Pregnancy specific Risk factors: surgery (c-section), HTN (pre-eclampsia), infection, hypercoagulable state

Dx by imaging (usually non-contrast CT) Usually treatment is same as in non-pregnant

patient

Very rare, but much more common in pregnancy

Usually presents in 3rd trimester Sx: headache, vomiting, possible seizure,

blurred vision, focal neuro deficits Tx: low molecular weight heparin◦ Can change over to warfarin or other agents

postpartum◦ Duration of treatment is at least 6 weeks

postpartum, for at least 6 months after diagnosis

24 yo G1 at 28 weeks presenting with a headache that is unrelieved by Tylenol.◦ BP: 157/102◦ 1+ protein in urine dip

◦ Lab eval: CBC, CMP, urine protein:creatinine ratio wnl, other than UPC of 0.45

◦ She is in your office. What do you do next?

A. Treat with oral nifedipine to bring BP down, to see if that relieves headache

B. Assess baby with a quick ultrasound (i.e. biophysical profile)

C. Send to Labor & Delivery, notifying the OB provider

D. Plan on delivering the baby for severe pre-eclampsia

Hypertension in pregnancy

◦ Plus

Proteinuria◦ Or

Lab abnormalities / Symptoms

Systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg on two occasions at least four hours apart after 20 weeks of gestation in a previously normotensive patient

If systolic blood pressure is ≥160 mmHg or diastolic blood pressure is ≥110 mmHg, confirmation within minutes is sufficient

and

Proteinuria ≥0.3 g in a 24-hour urine specimen or protein/creatinine ratio ≥0.3 (mg/mg) (30 mg/mmol)

Or dipstick ≥1+ if a quantitative measurement is unavailableOR

Systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg on two occasions at least four hours apart after 20 weeks of gestation in a previously normotensive patient with the new onset of any of the following (with or without proteinuria):

Platelet count <100,000/microLSerum creatinine >1.1 mg/dL (97.2 micromol/L) or doubling of the creatinine concentration in the absence of other renal disease

Liver transaminases at least twice the upper limit of the normal concentrations for the local laboratory

Pulmonary edema

Cerebral or visual symptoms (eg, new-onset and persistent headaches not responding to usual doses of analgesics*; blurred vision, flashing lights or sparks, scotomata)

Spectrum of disease◦ Chronic HTN◦ Gestational HTN◦ Pre-eclampsia without severe features◦ Pre-eclampsia with severe features HELLP Syndrome◦ Superimposed pre-eclampsia◦ Eclampsia (pre-E + seizure)

Chronic HTN◦ Pre-pregnancy consultation◦ Avoid ACE-Is and ARBs, change meds as

appropriate◦ Draw baseline labs, as risk for developing super-

imposed pre-eclampsia◦ Growth ultrasounds, antenatal testing starting at 32

weeks◦ If remains stable throughout pregnancy, without

symptoms, delivery is usually 38-39 weeks

Gestational hypertension ◦ Only abnormality is elevated BP after 20 weeks

gestation Pre-eclampsia without severe features◦ >140 SBP; >90 DBP; plus proteinuria

Growth ultrasounds, antenatal testing Early term delivery is indicated (37-38 wks) No Mag Sulfate

Pre-eclampsia with severe features◦ >160 SBP; >110 DBP◦ Lab abnormalities or persistent symptoms◦ HELLP Syndrome – hemolysis, elevated liver enzymes, low

platelets Management – IN THE HOSPITAL◦ Daily monitoring of fetus, growth ultrasounds◦ Betamethasone◦ Magnesium sulfate for labor, delivery, and at least 24 hours

postpartum◦ Prolonged use of mag is not recommended if mom is stable

and expectant management in hospital is occurring Delivery – anytime if mom or baby is unstable◦ Otherwise, by 34 weeks or at time of diagnosis◦ Can try induction, not necessarily reason for immediate c-

section

ACOG has protocols that should be followed Use Nifedipine (oral), Hydralazine (IV), or

Labetalol (IV) as first line therapy Should “max out” one agent before going to

the next With each agent, repeat blood pressure in 20

mins, if BP remains high, give the next dose Fetal monitoring should be continuous,

nursing should be one-to-one if able Consider starting magnesium sulfate

Changing Gears…

28 yo G3P2002 at 32 weeks presents to your office with complaints of back pain. What is most likely diagnosis?

A. Musculo-skeletal pain B. Preterm labor C. Kidney stone D. Pyelonephritis

In general, MSK treatment options are:

◦ Stretching/exercise◦ Heat/ice on the back◦ Warm baths◦ Tylenol◦ Chiropractor◦ Massage◦ Pregnancy support belts◦ Physical therapy can be very helpful

What is the minimal work-up for an obstetrics patient presenting with back pain?

A. Physical exam, fetal monitoring B. Exam, UA, cervical check, possible fetal

fibronectin swab/cervical length ultrasound C. Cervical length ultrasound, exam D. No work-up needed, send home with

Tylenol and heat pad

Specific Obstetrical Concerns◦ Preterm labor◦ Pyelonephritis◦ Placental abruption◦ Amniotic infection

But also consider causes of back pain outside of pregnancy◦ MSK◦ Kidney stones◦ Disc issues◦ AAA◦ The list goes on and on

Cervical change prior to 37 weeks gestation Often present with contractions, but

especially early on, may not complain of painful contractions, and just notice pressure/discharge or vaginal bleeding

Significant cause of NICU admission

Work-up◦ Fetal monitoring – toco for contractions, fetal heart

tones to assess fetal well-being◦ Fetal Fibronectin (done prior to cervical checks) If positive, increased risk of preterm birth If negative, 99% chance of not delivering in next 2

weeks◦ Cervical length ultrasound◦ Consider getting cultures as well – beta strep,

ua/urine culture

Management◦ If truly in PTL, management is on L&D◦ If <37 weeks, give BMZ course ALPS study showed improvement in neonatal outcomes

in the late preterm group that was given steroids◦ If <32 weeks, need magnesium sulfate for

neuroprotection Magpie trial showed significant decrease in cerebral

palsy◦ Antibiotics for GBS unknown status to all laboring

patients <37 weeks

28 yo G3P2002 at 32 weeks presents to your office with complaints of back pain. Temp 101 F. Physical exam reveals CVA tenderness. UA with bacteria, +nitrates. What is appropriate management for pyelonephritis in pregnancy?

A. Outpatient oral antibiotics x 7 days B. Outpatient oral antibiotics x 7 days with

suppression for rest of pregnancy C. Inpatient IV antibiotics D. Inpatient IV antibiotics with suppression for

rest of pregnancy

Asymptomatic bacteriuria – treated in pregnancy◦ Increased risk of pyelonephritis, Preterm birth, low

birth weight infants Acute cystitis ◦ 7 day course of antibiotics, tailored to the culture

results Pyelonephritis◦ Inpatient IV antibiotics, until 24-48 hours afebrile

and improvement of symptoms is seen◦ Suppression therapy for remainder of pregnancy

Keflex 250 mg po qid x 7 days Macrobid 100 mg po bid x 7 days (not for

pyelo, avoid in 1st trim if able) Bactrim DS po bid x 5 days (mid-trimester)

Macrobid 50-100 mg po daily is commonly used for suppression

Penicillins, Cephalosporins Ertapenem Fosfomycin Nitrofurantoin – avoid in first trimester

(possible birth defects); avoid if G-6PD deficiency

Trimethoprim-sulfamethoxazole – avoid in first trim (folic acid antagonist) and right before delivery (theoretical risk of fetal kernicterus)

Aminoglycosides – associated with ototoxicity with prolonged exposure

Tetracyclines – discoloring of teeth

Fluoroquinolones – no known risk of teratogenicity based on human/animal data; theoretical risk of bone/cartilage damage based on animal data

ASCCP App – pap smear guidelines, management of abnormal paps -$10

Menopro App – hormone replacement therapy candidates, medications – free

CDC Contraception guidelines – contraindications to contraception for different medical conditions – free

Lactmed App – guidelines for medications in lactation - free

Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period. ACOG. Committee Opinion 692. April 2017.

Urinary tract infections and asymptomatic bacteriuria in pregnancy. Hooton T, Gupta K. UpToDate. Aug 2017.

Hypertension in Pregnancy. ACOG Task Force on Hypertension in Pregnancy. 2013.

Sulfonamides, Nitrofurantoin, and Risk of Birth Defects. ACOG Committee Opinion. Sept 2017

Antnatal Corticosteroid Therapy for Fetal Maturation. ACOG Committee Opinon. Aug 2017.

Management of Preterm Labor. ACOG Practice Bulletin. Oct 2016. Headache in pregnant and postpartum women. Lee MJ et al.

UpToDate. Jan 2018. Cerebrovascular disorders complicating pregnancy. Lee MJ et al.

UpToDate. Aug 2017.

Questions???