Saturday, May 16, 2009
Managing the pregnant patient
When speaker Anna Kho, MD, asked the audience today how many people had done a consult on a pregnant patient, nearly every hand in the room shot up. Yet only about 1/4 of people kept their hands raised when asked if they'd had any training for such consults.
Dr. Kho made quick work of correcting that, by outlining the symptoms and treatment for the four main conditions pregnant women present with: asthma, hypertension, VTE and diabetes. Following are some key points from her lecture:
- When considering drug therapy, think about whether lifestyle changes can be recommended, and whether there's a similar drug that's safer. Avoid new medications, think twice when prescribing medication in the first trimester, and never use a drug without an indication.
- You don't need to treat chronic hypertension until the diastolic blood pressure goes above 105. The evidence shows no added benefit to mother or child for treating when DBP is below this mark. Methyldopa is the drug of choice for hypertension; avoid ACE inhibitors and ARBS, because they can lead to renal agenesis and fetal demise.
- Treat asthma the same way you would in a non-pregnant patient. Avoid epinephrine. It's fine to order radiologic studies when needed, as long as the cumulative exposure during pregnancy is less than 5 rads. A single dose of iodine is unlikely to be harmful.
- Pregnant women are at higher risk of VTEs; it's the leading cause of non-OB maternal mortality in the U.S. The rate is pretty much the same in all three trimesters. To diagnose, look for unilateral leg edema and pain, and note that 90% of DVTs occur on the left side in pregnant women.
- Treatment for DVTs in pregnant women should be unfractionated heparain, and low molecular weight heparin. Avoid warfarin due to extreme teratogenicity.
- Oral hypoglycemics should almost never be used with pregnant patients with diabetes. Insulin is pretty much the only treatment.
Labels: Hospital Medicine 2009, pregnancy
posted by Jessica Berthold at
5:23 PM
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