HIV in the Pregnant Patient

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Today we go into part 2 of our HIV series, this time focusing on pregnancy and HIV. Check out ACOG CO 752 (Prenatal and Perinatal HIV Screening) and CO 751 (Labor and Delivery Management of Women with HIV).

However, we have to give a major shout out to the OBG Project — their editors have put out an awesome summary of HIV in pregnancy and preventing vertical transmission: Check it out here.

(c) OBG Project

One of the important CREOG points on HIV in pregnancy includes drug interactions. Methergine is metabolized by CYP3A4 enzymes, which may be inhibited by certain antiretrovirals. Thus, methergine should be avoided if possible if encountering postpartum hemorrhage.

Lastly, we wanted to drive home the point again about patient autonomy, especially regarding risk of cesarean delivery. We put the ACOG CO text below for you to chew on!

ACOG CO 751

Cardiotocography/EFM Part II: Management

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Today we are back with our midwifery colleagues Linda Steinhardt and Liz Kettyle, who shepherd us through the management of cardiotocography in labor.

We start this episode by quickly reviewing definitions, and defining categories of tracings, reviewed below:

Copyright UpToDate

Recall that category I tracings virtually exclude fetal acidemia, while category III tracings are associated with acidemia 25% of the time, but also have higher risk of cerebral palsy, neurologic injury, or fetal death. That said, the positive predictive value for bad outcomes of CTG is overall poor.

We review a number of scenarios and resuscitative measures for category II and III tracings. However, much of this episode draws on the 2013 Clark et al. article to describe the management of category II tracings. The algorithm is below:

Clark et al. (AJOG 2013)

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?

Interpreting Cardiotocography/EFM Part I: Definitions

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Today we take a break from STIs to jump back into obstetrics, and are joined by two very special guests: Liz Kettyle and Linda Steinhardt, both of whom are certified nurse midwives (CNMs) and clinical educators at the Warren Alpert Brown School of Medicine.

ACOG PB 106 (membership required) forms the basis for this episode and in a future episode, we will discuss management of cardiotocography (CTG). Also, for a recent article surrounding the naming of CTG vs. EFM vs. all the other names for this technology, check out a recent AJOG article on its now 50-year history.

We also are using some special sound effects for these episodes! As you listen to the various sounds for different types of decelerations, keep in mind that the higher-pitched sound represents a contraction pattern, and the lower-pitched sound represents the fetal heart rate response.