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INTRODUCTION

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This chapter reviews the most common comorbid conditions encountered in pregnant women in the ED environment: diabetes and hypoglycemia; thyroid disorders; hypertensive disorders; cardiac arrhythmias; thromboembolism; asthma; renal disease; urinary tract infections; sickle cell disease; headache; seizures; substance abuse; and intimate partner violence. Drug risk during pregnancy, lactation, and fetal effects of radiation are summarized based on currently available data. Resuscitation is covered in chapter 25, "Resuscitation in Pregnancy."

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DIABETES IN PREGNANCY

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Maternal diabetes affects >8% of the 4 million live births annually in the United States.1 Three fourths of pregnant patients with diabetes have either gestational diabetes or type 2 diabetes diagnosed through prenatal screening. Of the remaining 25%, 1% have preexisting type 1 diabetes, and the remaining are type 2 diabetics. Pregnant diabetic women are at increased risk for spontaneous abortion, particularly patients with poor glycemic control early in pregnancy, preexisting vascular disease, and pre-eclampsia. Pregnant diabetics are also at increased risk for several pregnancy complications, including pregnancy-induced hypertension, preterm labor, spontaneous abortion, pyelonephritis, and diabetic ketoacidosis (DKA). The goal of treatment during pregnancy is to prevent spontaneous abortions, hyperglycemia-induced congenital abnormalities and ketoacidosis, and hypoglycemia.

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Oral hypoglycemic agents, such as metformin and glyburide, are occasionally used in select patients with gestational diabetes.2 A significant portion of gestational diabetics can be managed with diet alone if they can maintain glycemic goals with frequent glucose monitoring.

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The American College of Obstetricians and Gynecologists recommends the following goals for maintaining euglycemia in pregnant diabetic patients: a fasting blood glucose concentration of ≤95 milligrams/dL and a 2-hour postprandial glucose concentration ≤120 milligrams/dL.3 Patients with gestational diabetes who are managed by diet alone rarely develop acute hyperglycemic complications because glucose values rarely reach levels consistent with DKA. Among patients with preexisting type 1 and type 2 diabetes, the need for insulin increases throughout the course of pregnancy. Historically, all type 2 diabetics were switched to insulin as soon as possible (even prior to conception) to ensure appropriate glycemic control and due to concerns over the safety of oral hypoglycemic agents in pregnancy. Recent studies in gestational diabetes have not shown metformin or glyburide to have any harmful fetal effects, but long-term studies are needed. Although metformin may be continued in select patients, there is no consensus on the use of these oral agents alone in the pregnant patient with type 2 diabetes.2,3,4,5

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In general, during the first trimester, the initial insulin requirement is 0.7 units/kg/day. By late pregnancy, patients generally require 1 unit/kg/day.6

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Neutral protamine Hagedorn (NPH)/regular insulin combinations are still first-line insulin therapy, but the long-acting analog insulin detemir (Levemir) is approved by the U.S. Food and Drug Administration for use in pregnancy and is category B. Compared to NPH, insulin detemir improves fasting plasma glucose and decreases hypoglycemic events. There ...

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