A 30-year-old G1 at 6 weeks’ gestation by last menstrual period presents for prenatal care. Her past medical history is significant for type 1 diabetes, which was diagnosed at the age of 14.
Which of the following is the most common birth defect associated with diabetes?
Major congenital anomalies are the leading cause of perinatal mortality in pregnancies complicated by type 1 diabetes, occurring in 6% to 12% of infants of women with diabetes. It is believed that the increased risk of congenital anomalies is a consequence of poor glucose control in the preconception and early pregnancy period. Glycosylated hemoglobin (Hgb A1c) level correlates directly with the frequency of anomalies. A HbA1c around 6% is associated with a fetal anomaly rate close to that of the general population (2%-3%), whereas an HbA1c of 10% is associated with a fetal anomaly rate of 20%-25%. The most common single organ system anomalies are complex cardiac (38%), musculoskeletal (15%), and central nervous system (anencephaly and/or spina bifida) (10%). Sacral agenesis is a rare malformation seen in severely diabetic women.
Which of the following diabetic complications is most likely to be permanently worsened by pregnancy?
Pregnancy has been associated with exacerbation of many diabetes-related complications. The rapid institution of strict glycemic control in women with diabetes during pregnancy has been associated with acute worsening of diabetic proliferative retinopathy, especially in women with coexisting hypertensive disorders. Pregnant women with diabetes should undergo a complete eye examination at the beginning of pregnancy, and should be monitored closely throughout. Most studies have failed to demonstrate permanent worsening in renal function in women with mild to moderate diabetic nephropathy. CAD does not necessarily worsen during pregnancy, but in women with preexisting symptomatic CAD, the pregnancy-associated hemodynamic changes may lead to an increased risk of myocardial infarction and death. Diabetic neuropathy is not very well studied during pregnancy, but may manifest as gastroparesis causing intractable nausea and vomiting.
A 33-year-old woman at 10 weeks’ gestation presents for her first prenatal visit. Routine laboratory findings are drawn, and her hepatitis B surface antigen is positive. Liver function tests are normal and her hepatitis B core and surface antibody tests are negative.
Which of the following is the best way to prevent neonatal infection?
Hepatitis B is transmitted by parenteral and sexual contact. Women with multiple sex partners, those who engage in intravenous drug use, and those who have sexual partners who engage in these risky behaviors are at highest risk to acquire this infection. Infection of the newborn whose mother chronically carries the hepatitis B virus can usually be prevented by the administration of hepatitis B immune globulin very soon after birth, followed promptly by the hepatitis B vaccine.
A 38-year-old G1P0 presents to the obstetrician’s office at 37 weeks’ gestation complaining of a rash on her abdomen that is becoming increasingly pruritic. The rash started on her abdomen, and is starting to spread downward to her thighs. She reports no previous history of any skin disorders or problems, and she reports no malaise or fever. On physical examination, she is afebrile and her physician notes that her abdomen, and most notably her stretch marks, is covered with red papules and plaques. No excoriations or bullae are present. The patient’s face, arms, and legs are unaffected by the rash.
Which of the following is this patient’s most likely diagnosis?
PUPPP is the most common dermatologic condition of pregnancy. It is more common in nulliparous women and occurs most often in the second and third trimesters of pregnancy. PUPPP is characterized by erythematous papules and plaques that are intensely pruritic and appear first on the abdomen. The lesions then commonly spread to the buttocks, thighs, and extremities with sparing of the face.
Herpes gestationis is a blistering skin eruption that occurs more commonly in multiparous patients in the second or third trimester of pregnancy. The presence of vesicles and bullae help differentiate this skin condition from PUPPP. Immunologically, it is indistinguishable from bullous pemphigoid. Prurigo gestationis is a very rare dermatosis of pregnancy that is characterized by small, pruritic excoriated lesions that occur between 25 and 30 weeks. The lesions first appear on the trunk and forearms and can spread throughout the body as well. In cholestasis of pregnancy, bile acids are cleared incompletely and accumulate in the dermis, which causes intense itching. These patients develop pruritus in late pregnancy; there are no characteristic skin changes or rashes except in women who develop excoriations from scratching. Impetigo herpetiformis is a rare pustular eruption that forms along the margins of erythematous patches. This skin condition usually occurs in late pregnancy. The skin lesions usually begin at points of flexure and extend peripherally; mucous membranes are commonly involved. Patients with impetigo herpetiformis usually do not have intense pruritus, but more commonly have systemic symptoms of nausea, vomiting, diarrhea, chills, and fever.
A 25-year-old G2P0 at 30 weeks’ gestation presents with the complaint of intense itching that is worse on the palms and soles of her feet, and is worse at night. Her physical examination does not show any evidence of rash, but she has obvious excoriations from scratching on her abdomen.
Which of the following tests would be most likely to confirm your suspected diagnosis?
The hallmark of intrahepatic cholestasis of pregnancy is elevated serum bile acids. This may be accompanied by elevated liver enzymes, but there are other diseases, such as preeclampsia, that could cause this. Liver biopsy is typically not needed to confirm the diagnosis, but if performed, it would show mild cholestasis with intracellular bile pigments and canalicular bile plugging without necrosis. Liver ultrasound would usually be normal, but may serve to exclude other diagnoses, such as biliary obstruction due to gallstones. Skin biopsy is not used to diagnose cholestasis of pregnancy.