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.
What is the best next step in treatment for this pregnancy complication?
Intrahepatic cholestasis of pregnancy is best treated with oral ursodeoxycholic acid therapy, which has been shown to quickly and safely relieve pruritis, lower hepatic enzyme levels, and decrease serum bile acid concentrations. It primarily works by increasing bile flow. Topical steroids and oral antihistamines may be used in conjunction with ursodeoxycholic acid. The data about oral steroids has not shown consistent improvement in symptoms. Cholestyramine may be used, but has been shown to impair fat soluble vitamin absorption, with potential to cause impaired coagulation due to vitamin K deficiency. There is an increased risk of adverse pregnancy outcomes in women who have cholestasis of pregnancy, but this does not require delivery at 30 weeks. Instead, patients should be followed closely with antenatal testing and delivered at 36 to 37 weeks gestation, balancing risks of adverse outcomes such as fetal death with risks of prematurity.
A 23-year-old G3P2002 presents for a routine visit at 34 weeks’ gestation. She reports a history of genital herpes for 5 years. She says that she has had only two outbreaks during the pregnancy, but is very concerned about the possibility of transmitting this infection to her baby.
How should you counsel this patient regarding her management during this pregnancy?
A maternal HSV infection can be passed to the fetus via vertical transmission. If a pregnant woman with a history of herpes has no lesions present at the time she goes into labor, vaginal delivery is permitted. If lesions are present at the time of labor, then there is a 3% to 5% risk of transmitting the infection to the fetus, and cesarean delivery is recommended. Viral shedding can occur without the presence of a lesion. It is not recommended that a patient with a history of herpes be scheduled for an elective cesarean section. It is not recommended that weekly genital viral cultures be performed because such cultures do not predict whether a patient will be shedding the virus at the time of delivery. For patients at or beyond 36 weeks’ gestation, daily suppressive therapy with an antiviral medication such as acyclovir can be used to try to decrease the risk of viral shedding and outbreaks and the likelihood of a cesarean section.
A 37-year-old G3P2 presents to your office for her first OB visit at 10 weeks’ gestation. She has a history of Graves disease and has been maintained on propylthiouracil (PTU) as treatment for her hyperthyroidism. She is currently euthyroid but asks you if her condition poses any problems for the pregnancy.
Which of the following statements should be included in your counseling session with the patient?
Hyperthyroidism in pregnancy is treated with thionamides, namely, PTU and methimazole. Transient leukopenia occurs in about 10% of patients taking thionamide drugs, but does not necessitate stopping the medication. Agranulocytosis, which is a rare complication, necessitates discontinuation of the drug. Fetal exposure to thionamides, which can cross the placenta, may cause goitrous hypothyroidism. Women who remain hyperthyroid despite therapy have a higher incidence of preeclampsia and heart failure. Thyroid storm occurs only rarely in untreated women with Graves disease. This emergent medical condition involves thyrotoxicosis, which is characterized by fever, tachycardia, altered mental status, vomiting, diarrhea, and cardiac arrhythmia.
A 40-year-old P2002 at 37 weeks presents for her routine OB visit. Her pregnancy has been complicated by obesity and gestational diabetes mellitus (GDM) that has been well controlled with diet. Her blood sugar log shows that her fasting and postprandial values have all been within the normal range. Her fetus has an estimated fetal weight of 6½ lb by Leopold maneuvers.
Which of the following is the best next step in her management?
In general, women with gestational diabetes, who do not require insulin, seldom need early delivery or other interventions. There is no consensus on whether antepartum fetal testing is necessary in women with well-controlled gestational diabetes. Antepartum fetal testing is recommended for women with preexisting diabetes mellitus and those who require insulin therapy, due to an increased risk of fetal demise. There is no good evidence to support routine delivery before 40 weeks when glucose control is good and no other complications supervene. Cesarean delivery may be considered in women with GDM if the estimated fetal weight is 4500 g or more.
This patient asks you if GDM has any long-term implications for her.
Which of the following statements should be included in your counseling?
It has been estimated that 15% to 50% of women who have GDM will develop type 2 diabetes later in life. Women with a history of GDM have a sevenfold increased risk of developing type 2 diabetes compared to women without a history of GDM. Postpartum screening at 6 to 12 weeks is recommended to identify women with type 2 diabetes, impaired fasting glucose levels, or impaired glucose tolerance. A fasting plasma glucose test OR the 2-hour 75-g oral glucose tolerance test may be used to screen. Although the fasting glucose is easier to perform, it would be less likely to detect other forms of impaired glucose metabolism.
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