492.2 ๐ ๅ่็๏ผ้ซๅธซๅ่ / PGY OSCE๏ผ
492.2.0.1 ๐ Cram Sheet
492.2.0.1.1 ๐ฅ ้ซ yield 20
- ๅญๆ CO โ 30-50% (stroke volume + HR)
- ๅญๆ GFR โ 50%๏ผCr ไธ้ < 0.8
- TBG โ โ total T4 โ๏ผไฝ free T4 ๅคง่ดๆญฃๅธธ๏ผtrimester-specific TSH
- Hypercoagulable๏ผVTE 6 ๅใpostpartum > pregnancy
- HDP ๅๅ้ก๏ผChronicใGestationalใPreeclampsiaใEclampsia
- Preeclampsia ่จบๆท๏ผBP โฅ 140/90 + proteinuria OR end-organ damage๏ผthrombocytopeniaใLFTใCrใ่บๆฐด่ ซใ็ฅ็ถ๏ผ
- HELLP๏ผHemolysisใElevated LFTใLow Platelets
- MgSO4 for severe preeclampsia / eclampsia
- Delivery ๆฏๅฏไธๆ นๆฒป preeclampsia
- ้ฟ ACEi / ARB ๅ จๅญๆ๏ผ็จ methyldopa / labetalol / nifedipine
- ASA 81 mg ้ ้ฒ preeclampsia๏ผ้ซ้ขจ้ช 12-28 ้ฑ่ตท๏ผ
- GDM ็ฏฉๆฅ 24-28 ้ฑ๏ผone-step 75g ๆ two-step 50gโ100g
- GDM ็ฎๆจ๏ผFBS < 95ใ1-h < 140ใ2-h < 120๏ผๆฒป็้ๆขฏ MNT โ insulin
- Q1 PTUใQ2/Q3 methimazole๏ผๅญๆ hyperthyroid๏ผ
- ้ฟ RAI ๅ จๅญๆ
- LT4 + 25-30% ไธๆทๅญๅพ็ซๅป่ชฟ๏ผ็ฎๆจ TSH < 2.5 (Q1)
- VTE ๆฒป็ LMWH๏ผwarfarin Q1 ็ฆๅฟใDOAC ๅ จ็จ็ฆๅฟ
- AFLP Q3ใhypoglycemia + AKI + ๅ่ก็ฐๅธธ โ ๆฅ็ข
- Intrahepatic cholestasis Q3 ๆ็ข + bile acid โ โ UDCA
- Pre-existing DM๏ผHbA1c < 6.5%ใfolate 4 mg/dใๅ SGLT2i/GLP-1/DPP4i โ insulin
492.2.0.1.2 ๐ข ๅฟ ่ๆธๅญ
| ้ ็ฎ | ๆธๅผ |
|---|---|
| Cardiac output โ | 30-50% |
| GFR โ | 50% |
| Plasma volume โ | 45% |
| BP ็ฐๅธธ (ๅญๅฉฆ) | โฅ 140/90 (ร 2, 4 h apart) |
| Severe BP | โฅ 160/110 |
| Proteinuria threshold | 300 mg/24h or P/Cr โฅ 0.3 |
| Platelet (preeclampsia severe) | < 100K |
| GDM ็ฏฉๆฅ้ฑๆธ | 24-28 wk |
| GDM ๆฉๆ้ซ้ขจ้ชๆ็พค | ็ฌฌไธๆฌก็ขๆชข |
| GDM fasting target | < 95 mg/dL |
| GDM 1-h pp target | < 140 mg/dL |
| GDM 2-h pp target | < 120 mg/dL |
| Pre-existing DM HbA1c | < 6.5% (pre-conception) |
| Folate DM ๅญๅฉฆ | 4 mg/d |
| TSH target Q1 | < 2.5 |
| TSH target Q2/Q3 | < 3.0 |
| LT4 dose โ (ๅญๆ) | 25-30% (ๅ ฉ้กๅค pill/้ฑ) |
| ASA preeclampsia ้ ้ฒ | 81 mg 12-28 wk |
| MgSO4 loading | 4-6 g IV over 15-20 min |
| MgSO4 maintenance | 1-2 g/h IV |
| Aortic root surgery cutoff (Marfan) | > 45 mm |
| AFLP delivery timing | urgent (ไปปไฝ GA) |
| Cholestasis delivery | 36-37 wk |
| sFlt-1/PlGF preeclampsia | โฅ 40 |
492.2.0.2 โญ ้ซ yield ่กจ
492.2.0.2.1 HDP Classification
| ๅ้ก | ๆ้ | BP | Proteinuria | Severe features |
|---|---|---|---|---|
| Chronic HTN | < 20 wk ๆ pre-preg | โฅ 140/90 | ๅฏๆ | ็ไฝต็ผ |
| Gestational HTN | > 20 wk | โฅ 140/90 | ็ก | ็ก |
| Preeclampsia | > 20 wk | โฅ 140/90 | ๆ / end-organ | ็ features |
| Eclampsia | > 20 wk | preeclampsia + seizure | โ | ไธๅพ severe |
492.2.0.2.2 Severe Features of Preeclampsia (ไปป 1)
- BP โฅ 160/110
- ้ ญ็ / ่ฆ่ฆบ็็
- ไธ่ น / RUQ pain
- Platelet < 100K
- LFT โฅ 2ร ULN
- Cr > 1.1
- ่บๆฐด่ ซ
492.2.0.2.3 Antihypertensive in Pregnancy
| ่ฅ | ๅฎๅ จ | ๆณจๆ |
|---|---|---|
| Methyldopa | ๅฎๅ จ (ๆไน data) | ๆ ขๆ ข่ตทๆ |
| Labetalol | ๅฎๅ จ (PO + IV) | ฮฒ-blocker ้ฟๅ high dose (FGR) |
| Nifedipine ER | ๅฎๅ จ | IR ็จๆผๆฅ BP control |
| Hydralazine IV | ๆฅๆง severe BP | ็ถญๆไธๅปบ่ญฐ |
| ACEi / ARB | ็ฆๅฟ (่ด็ธ) | Q1 ๅฟ่ใQ2/3 renal failure |
| Diuretic | ไธ่ฌไธ็จ | volume contraction concern |
492.2.0.2.4 GDM Diagnosis Criteria
Two-step๏ผACOG๏ผ: - Step 1: 50 g GCT 1-h โฅ 130-140 โ step 2 - Step 2: 100 g OGTT 3-h - Fasting < 95 - 1-h < 180 - 2-h < 155 - 3-h < 140 - โฅ 2 abnormal = GDM
One-step๏ผIADPSG๏ผ: - 75 g OGTT 2-h - Fasting < 92ใ1-h < 180ใ2-h < 153 - ไปป 1 abnormal = GDM
492.2.0.2.5 Thyroid in Pregnancy
| ็ๆณ | ่็ฝฎ |
|---|---|
| Hyperthyroid Q1 | PTU (้ฟ methimazole ่ด็ธ) |
| Hyperthyroid Q2/Q3 | methimazole (PTU ่ๆฏๆง) |
| Hyperthyroid ็ฃๆธฌ | q4 wk free T4 + TSH๏ผTRAb |
| Hypothyroid ๆทๅญๅพ | LT4 + 25-30% |
| TSH Q1 target | < 2.5 |
| TSH Q2/Q3 target | < 3.0 |
| Postpartum thyroiditis | hyper โ hypo โ recover; 20% ๆฐธไน |
| ๅ จ็จ avoid | RAIใsurgery ้ค้ๅฟ ่ฆ |
492.2.0.2.6 Pre-existing DM in Pregnancy
| Pre-conception | ่็ฝฎ |
|---|---|
| HbA1c target | < 6.5% |
| Folate | 4 mg/d |
| ๅ่ฅ | SGLT2iใGLP-1 RAใDPP4iใPO sulfonylurea |
| ็จ่ฅ | Insulin |
| ็ฃๆธฌ | Retinopathyใnephropathyใneuropathy |
492.2.0.2.7 VTE in Pregnancy
| ่ฅ | ็จ |
|---|---|
| LMWH | ้ฆ้ธ๏ผไธ้่็ค๏ผprophylactic 12 h ๅๅใtherapeutic 24 h ๅๅ (epidural) |
| Unfractionated heparin | ๅฏๆฅ epidural ็ญ |
| Warfarin | Q1 ็ฆๅฟ๏ผQ2/Q3 mechanical valve ไพๅค๏ผ36 wk bridge |
| DOAC | ๅ จๅญๆ็ฆๅฟ |
| Fondaparinux | ้ๅฎ HIT |
492.2.0.3 ๐ฏ ่ชๆๆชขๆธฌ
- ๅญๆ GFR ๅ้ซๅคๅฐ๏ผโ 50%
- ๅญๆ Cr ไธ้๏ผโ < 0.8 mg/dL
- ๅญๆ TBG โ ็ๅๅ ๏ผโ Estrogen
- Preeclampsia ่จบๆท๏ผโ BP โฅ 140/90 + proteinuria ๆ end-organ damage > 20 wk
- Severe features ไปป 1๏ผโ BP โฅ 160/110ใ้ ญ็ใไธ่ น็ใplatelet < 100KใLFT โใCr โใ่บๆฐด่ ซ
- HELLP๏ผโ HemolysisใElevated LFTใLow Platelets
- Preeclampsia ๅฏไธๆ นๆฒป๏ผโ Delivery
- Severe preeclampsia / eclampsia seizure ้ ้ฒ่ฅ๏ผโ MgSO4
- MgSO4 ไธญๆฏ่งฃ่ฅ๏ผโ Calcium gluconate
- ้ ้ฒ preeclampsia ่ฅ + ๆๆฉ๏ผโ ASA 81 mgใ12-28 wk (้ซ้ขจ้ช)
- GDM ็ฏฉๆฅๆ้ป๏ผโ 24-28 wk
- GDM target FBS / 1-h / 2-h๏ผโ < 95 / < 140 / < 120
- ๅญๆ hyperthyroid Q1 ็จ๏ผโ PTU
- ๅญๆ hyperthyroid Q2/Q3 ็จ๏ผโ Methimazole
- Q1 methimazole ่ด็ธ๏ผโ Aplasia cutisใchoanal/esophageal atresia
- ๅญๆ hypothyroid LT4 ่ชฟๆด๏ผโ + 25-30%
- TSH Q1 / Q2 / Q3 target๏ผโ < 2.5 / < 3.0 / < 3.0
- VTE ๆฒป็้ฆ้ธ๏ผโ LMWH
- Warfarin ๅญๆ็ฆๅฟๆ้ป๏ผโ Q1๏ผ่ด็ธ๏ผ+ DOAC ๅ จ็จ็ฆๅฟ
- AFLP ็นๅพต๏ผโ Q3ใhypoglycemia + AKI + ๅ่ก็ฐๅธธ โ ๆฅ็ข
- Intrahepatic cholestasis ็นๅพต่ฅ๏ผโ ๆ็ข + bile acid โใUDCA
- Pre-existing DM HbA1c pre-conception goal๏ผโ < 6.5%
- DM ๅญๅฉฆ folate๏ผโ 4 mg/d
- DM ๅญๅฉฆๅๅชไบๅฃๆ้่ก็ณ่ฅ๏ผโ SGLT2iใGLP-1ใDPP4iใsulfonylurea๏ผๆน insulin
- ACEi / ARB ๅญๆๆๆ๏ผโ Q1 ๅฟ่่ด็ธใQ2/3 fetal renal failure + oligohydramnios
492.2.0.4 ๐ OSCE ้้ป
492.2.0.4.1 ๅ ดๆฏ 1๏ผ26 wk preeclampsia
- ๅ BP ร 2ใneuro examใabdomen tenderness
- Lab๏ผCBCใLFTใCrใurine P/CrใLDH
- IV labetalol if โฅ 160/110
- MgSO4 load + maintenance
- 24h fetal monitoring
- Betamethasone < 34 wk