Vision Changes in Pregnancy

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Today we are joined by Dr. Ben Young. Ben is an ophthalmology resident at Yale New Haven Hospital in Connecticut, and is sharing with us a common complaint that we know very little about - the eye in pregnancy!

Ben also hosts Eyes For Ears, an educational podcast and flashcard reference for ophthalmology residents. If you happen to know any vision sciences students or residents, let them know about it!

We start out talking about the “ocular vital signs,” which are:
- Visual Acuity
- Pupils (“swinging light test”)
- Intraocular pressure
- Visual Fields
- Extra-ocular movements

Image copyright of FOAMCast

The most common reasons for ophthalmology issues in pregnancy relate to either 1) vision changes requiring a new prescription, or 2) dry eye. However, don’t forget some key pearls:

- Monocular (single eye) double vision — dry eye. Binocular (both eye) double vision — badness!
- A Snellen chart and a flashlight are the best tools you have to help out a consultant.
- Check out this video on how to perform a swinging flashlight test.

Further reading from the OBG Project:
Get updates on this and more content, as well as other awesome features for FREE if you’re a PGY-4 — sign up for OBG First!
Is Cataract Surgery in Women Associated with Decreased Mortality?

Hypertension and Pregnancy Trio

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We’ve had an overwhelming response to our Espresso episode on acute treatment of severe hypertension in pregnancy, so today we have a special triple episode release on pregnancy and hypertension! We dive into ACOG PB 202 on Preeclampsia and Gestational Hypertension, and ACOG PB 203 on Chronic Hypertension in Pregnancy (membership required for both).

In our first episode, we dive into risk factors and definitions to set the stage. Recall several risk factors that may raise your suspicion for these disorders:
- Nulliparity
- Multiple gestation
- Chronic hypertension
- History of hypertensive disorder of pregnancy in previous pregnancy
- Pregestational or gestational diabetes mellitus
- Thrombophilia, Anti-phospholipid syndrome, or SLE
- Chronic kidney disease
- Advanced maternal age > 35 years
- Obesity (BMI > 30) or obstructive sleep apnea
- Conception via assisted reproductive technology

In episodes 2 and 3, we dive into the specific definitions and management for each hypertensive disorder. Here are our show notes in table format; we hope that this helps you with your own review!

And in closing, a few postpartum/future health pearls to consider:
- With a history of any of these hypertensive disorders, baby aspirin is indicated in future pregnancies beginning at 12 weeks gestation to reduce risk or delay onset of preeclampsia.
- Women with a history of preeclampsia have 3-4x higher lifetime risk of hypertension, and 2x lifetime risk of heart disease and stroke, thus its important to ask about these even with just the annual physical.
- Best available evidence suggest NSAIDs are OK to use postpartum for patients with hypertensive disorders of pregnancy.
- Best available evidence also supports use of parenteral magnesium for seizure prophylaxis in patients who develop any of these disorders during the postpartum period (generally onsets within first week, but has been reported up to 8 weeks after delivery!).

Further reading from the OBG Project:
And get updates on this and more content, as well as other awesome features for FREE if you’re a PGY-4 — sign up for OBG First!
Diagnosing Preeclampsia: Key Definitions and ACOG Guidelines
ACOG Preeclampsia Guidelines: Antenatal Management and Timing of Delivery
Aspirin Treatment for Women at Risk for Preeclampsia: ACOG and USPSTF Guidelines
Chronic Hypertension in Pregnancy: Diagnosis and BP Measurement
Chronic Hypertension in Pregnancy: Evaluation and Management
The 2017 AHA/ACC Blood Pressure Guidelines
#GrandRounds: Does Hypertension in Pregnancy Predict Hypertension in Later Life?

Espresso: Treatment of Acute Hypertension in Pregnancy and Postpartum

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Our second espresso episode focuses on the acute treatment of severe-range BPs in the pregnant and postpartum patient. More or less, we let the freshly released ACOG CO 767 speak for itself.

Below you’ll find the algorithms we describe in the podcast, which are present in ACOG CO 767. In addition to the below, always remember:

-Obtain IV access and labs (CBC, Creatinine, AST, ALT, urine protein:creatinine ratio) for any newly diagnosed patient with severe-range pressures.
-Avoid labetalol in patients with known asthma, as the beta-blockade effect can trigger respiratory issues, as well as those with CHF or pre-existing cardiac disease. Labetalol may also cause neonatal bradycardia due to beta-blockade.
-Immediate-release nifedipine should not be administered sublingually due to possibility of developing precipitous hypotension. Similarly, parenteral hydralazine may also cause precipitous maternal hypotension.
-IV magnesium sulfate should be given at a 4g or 6g bolus initially, followed by 2g/hr drip for the prevention of eclamptic seizures, if not previously given. Adjusted dosing may be required if renal insufficiency is noted on laboratories. Magnesium sulfate is not an antihypertensive agent.