⚙️ Severe Preeclampsia Workflow
Step 1 — Confirmation:
- BP ≥ 160/110 × 2 (4 h apart) or any severe feature
- CBC, LFT, Cr, LDH, haptoglobin, smear (HELLP?)
- urine P/Cr or 24-h
- Fetal US + NST
Step 2 — Acute BP control (≥ 160/110):
- IV labetalol 20 mg → 40 → 80 → q10 min (max 300 mg)
- IV hydralazine 5-10 mg q20 min
- PO immediate-release nifedipine 10-20 mg q20-30 min
- Target < 160/110 但 not < 130/80 (placental perfusion)
Step 3 — Seizure prophylaxis:
- MgSO4 load 4-6 g IV over 15-20 min
- Maintenance 1-2 g/h IV
- Monitor reflex, RR, Cr, urine output
- Toxicity (areflexia / RR < 12) → calcium gluconate 1 g IV
Step 4 — Fetal lung maturity:
- Betamethasone 12 mg IM × 2 dose 24 h apart (< 34 wk)
Step 5 — Delivery decision:
- ≥ 34 wk → delivery
- < 34 wk + stable → expectant in tertiary center
- < 34 wk + progression → delivery
- HELLP / eclampsia / fetal distress / uncontrollable BP / abruption → immediate delivery 不論 wk
Step 6 — Postpartum:
- BP 在 7-10 d 可惡化
- MgSO4 continue 24 h postpartum
- Antihypertensive continue, taper as BP normalizes
- 6-12 wk follow-up
- Counseling: lifetime CV risk
⚙️ Pre-existing DM Pregnancy Workflow
Pre-conception:
- HbA1c < 6.5% (低 fetal malformation)
- Folate 4 mg/d (高 dose 降 NTD)
- Stop SGLT2i, GLP-1 RA, DPP4i, sulfonylurea
- Switch to insulin (regimen optimization)
- Retinopathy assessment + 治療 if needed
- Nephropathy: baseline Cr + 24-h protein
- Lipid: stop statin (Q1 致畸 unclear ↑)
- BP: stop ACEi/ARB → switch methyldopa / labetalol / nifedipine
Q1 (受孕):
- Confirm preg → adjust insulin (resistance ↓ early)
- Hypoglycemia warning
- Tight glycemia: FBS < 95, 1-h pp < 140, 2-h pp < 120
- SMBG / CGM
- Aspirin 81 mg from 12 wk (preeclampsia 預防)
- Fetal anatomical US 18-20 wk
Q2 / Q3:
- Insulin resistance ↑ → titrate up
- Fetal growth US (macrosomia, polyhydramnios)
- Retinopathy re-check
- Nephropathy follow (proteinuria + Cr trend)
- Anti-thyroid (Hashimoto co-association)
Delivery:
- 39 wk induction if controlled (some 38 wk if HbA1c 不達標)
- C/S if EFW ≥ 4500 g
- Tight glucose 80-130 during labor (insulin drip if needed)
- Neonatal team for hypoglycemia / RDS / hyperbilirubinemia
Postpartum:
- Insulin requirement ↓ immediately (back to pre-pregnancy or less)
- Breastfeeding 鼓勵 (T2DM 風險 ↓)
- 6-12 wk OGTT (if GDM, 確認 normalize or 持續)
- Continue diabetes care, restart non-pregnancy agents
⚙️ Endocrinopathy + Pregnancy 內專特集（盧醫師）
Pheochromocytoma + Pregnancy
Diagnosis:
- 24-h urine metanephrines (gold)
- Plasma metanephrines (alt)
- MRI without gadolinium for localization
- Sympathetic crisis: BP severe spike + headache + 汗 + palpitation
Management:
- α-block first: phenoxybenzamine or doxazosin (14 d, hypotension careful)
- β-block AFTER α-block (avoid unopposed α → crisis)
- Q2 laparoscopic adrenalectomy 偏好 (best timing)
- 若 Q3 too late → cesarean + simultaneous resection vs postpartum resection
- 自然產 / labor catecholamine surge 高 risk → cesarean preferred
- 50% maternal mortality if undiagnosed
Adrenal Insufficiency + Pregnancy
- Pre-conception 確診 (cortisol, ACTH, ACTH stim)
- Hydrocortisone replacement continue (15-25 mg/d divided)
- Mild dose ↑ Q3 may be needed
- Stress dose for labor: hydrocortisone 100 mg IV → 50 mg q6h × 24-48 h → taper
- C/S stress dose: 100 mg IV pre-op → 50 mg q6h × 24-48 h
- Fludrocortisone continue if primary AI
- Neonatal: 如 mother 是 CAH carrier → 寶寶 21-OHD 風險（pre-conception 諮詢）
- Postpartum: 維持劑量；breastfeeding OK
Cushing’s + Pregnancy
- 多 pre-conception 處理
- 若 active during pregnancy:
- Metyrapone (preferred, blocks 11β-hydroxylase)
- Ketoconazole (Q1 致畸 concern)
- Mitotane 禁忌 (teratogenic)
- Surgery (transsphenoidal or adrenalectomy): Q2 preferred
- Complications: GDM、HTN、preeclampsia 高、fetal growth restriction
Prolactinoma + Pregnancy
Micro (< 10 mm):
- Discontinue dopamine agonist when preg confirmed
- Visual field check + clinical monitor
- Symptomatic enlargement <1.5%
- Postpartum resume agonist if needed
Macro (≥ 10 mm):
- Continue dopamine agonist (bromocriptine preferred; cabergoline 數據少 但 used)
- Visual field q3 mo + MRI 若 symptom
- 10-30% enlarge
- Surgery / radiation if vision threat
Agent safety:
- Bromocriptine: 多 safety data
- Cabergoline: less data but emerging safe
Acromegaly + Pregnancy
- Often somatostatin analog (SSA) hold during pregnancy
- Continue if active disease + uncontrolled
- Pegvisomant: limited data
- Pituitary may enlarge (lactotroph hyperplasia + tumor)
- Macroadenoma: visual field + MRI 監測
- GDM 高 risk (GH ↑)
- HTN, cardiomyopathy 風險
- Delivery: vaginal 多 OK; consider cardio risk
Hyperparathyroidism + Pregnancy
- Mild Ca elevation: expectant + hydration
- Severe (Ca > 12 / symptomatic / nephrolithiasis / pancreatitis):
- Surgery preferred Q2 (mid-second trimester safest)
- Avoid bisphosphonates (cross placenta, fetal bone effect)
- Cinacalcet limited data; reserved
- Neonatal hypocalcemia 風險 (parathyroid suppression in utero)
- Postpartum: re-assess + 處理