Many medical conditions can present in the context of pregnancy, either as a preexisting condition or arising during pregnancy. This chapter will focus 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 62), and cardiac rhythm disturbances (Chapter 2). Of note, when managing any acute complication of pregnancy, supplemental oxygen therapy and left lateral decubitus positioning are recommended to optimize oxygen delivery to the fetus.
Diabetics are at increased risk for complications of pregnancy and acute complications of diabetes. Many patients with gestational diabetes (GD) are managed with diet alone, with a few requiring oral hypoglycemics (metformin or glyburide). Insulin therapy is necessary for some patients with GD and nearly all patients with Type I or II diabetes. Insulin requirements increase as a pregnancy progresses, from 0.7 to 1.0 units/kg/d at term.
Pregnant patients are at increased risk of diabetic ketoacidosis (DKA), especially those who are noncomplaint, have hyperemesis, or are on sympathomimetic agents for tocolysis. Treatment of DKA is the same for pregnant and nonpregnant patients: isotonic fluid resuscitation to correct volume deficits, administration of continuous insulin, correction of electrolyte abnormalities (potassium and magnesium,) and treatment of the underlying cause (see Chapter 129).
Mild hypoglycemia is treated with a snack of milk and crackers, with care to avoid subsequent hyperglycemia. IV dextrose and/or IM glucagon is used in the obtunded patient, followed by an IV 5% dextrose solution at 50 to 100 mL/h.
Hyperthyroidism in pregnancy increases the risk of preeclampsia, congenital anomalies, and neonatal morbidity. Clinical features may be subtle and may include hyperemesis gravidarum. Hyperthyroidism in pregnancy is treated with propylthiouracil (PTU), started at 50 milligrams PO 3 times daily (may be increased to 200 milligrams 3 times daily). Patients on PTU are at risk for purpuric rash and agranulocytosis. The use of radioactive iodine is contraindicated in pregnancy. Thyroid storm presents with fever, volume depletion, and cardiac decompensation. Management is similar to nonpregnant patients and includes PTU, sodium iodide, propranolol, cooling measures, and supportive care (see Chapter 131).
Dysrhythmias may be precipitated by pregnancy. Supraventricuar tachycardias are treated with β-blockers, adenosine, verapamil, diltiazem, and digoxin at usual dosages. Patients with atrial fibrillation who require anti-coagulation should be managed with unfractionated or low molecular weight heparin (LMWH). Electrical cardioversion may be used to treat tachyarrthymias when indicated and have not been shown to be harmful to the fetus. Amiodarone should only be used to treat resistant, life-threatening dysrhythmias.
Factors associated with increased risk of thromboembolism include advanced maternal age, increasing parity, multiple gestations, operative delivery, bedrest, and obesity. Symptoms of deep venous thrombosis (DVT) and pulmonary embolism (PE) may be mistaken for symptoms of normal pregnancy. Diagnosis of DVT is usually made by ...