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INTRODUCTION

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Many medical conditions can present in the context of pregnancy, either as a preexisting condition or arising during pregnancy. This chapter focuses on conditions that require different management when encountered in the pregnant patient. Some disorders are covered in other chapters within this text, including hypertension (Chapters 26 and 61), HIV infection (Chapter 92), and cardiac rhythm disturbances (Chapter 2).

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DIABETES

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Diabetics are at increased risk for complications of pregnancy and acute complications of diabetes. Many patients with gestational diabetes are managed with diet alone, though some patients require oral hypoglycemics such as metformin or glyburide. Insulin therapy is necessary for some patients with gestational diabetes and nearly all patients with type I or II diabetes. Insulin requirements increase as a pregnancy progresses, from 0.7 U/kg/d during the first trimester to 1.0 U/kg/d at term.

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Pregnant patients are at increased risk of diabetic ketoacidosis (DKA), and DKA can occur more rapidly, and at lower glucose levels, than in nonpregnant patients. DKA should be considered for any pregnant diabetic patient who is ill appearing and/or has a blood glucose level ≥180 mg/dL. Treatment of DKA includes supplemental oxygen, left lateral decubitus positioning, and usual DKA care: isotonic fluid resuscitation to correct volume deficits, administration of continuous insulin, correction of electrolyte abnormalities, and treatment of the underlying cause (see Chapter 129).

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Mild hypoglycemia (glucose <70 mg/dL and able to follow commands) is treated with a snack of milk and crackers. Severe hypoglycemia (glucose <70 mg/dL and unable to follow commands) should be treated with 50 mL of 50% dextrose in water IV, with 1 to 2 mg of glucagon given IM or subcutaneous if IV access is delayed. Subsequently, the patient should be given 5% dextrose solution IV at 50 to 100 mL/h.

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HYPERTHYROIDISM

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Hyperthyroidism in pregnancy increases the risk of preeclampsia, congenital anomalies, and neonatal morbidity. Clinical features may be subtle and may mimic normal pregnancy. Treatment is with propylthiouracil (PTU). Patients on PTU are at risk for purpuric rash and agranulocytosis.

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Thyroid storm presents with fever, volume depletion, or cardiac decompensation manifesting as high-output heart failure. Management is similar to nonpregnant patients (see Table 60-1).

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Table Graphic Jump Location
Table 60-1

Principles of Treatment of Thyroid Storm during Pregnancy

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