1578185 - McGraw-Hill Professional ©PART 19 Consultative M

1578185 - McGraw-Hill Professional ©
PART 19 Consultative Medicine
465 Approach to Medical Consultation
Jack Ende, Jeffrey Berns
Effective health care requires teams of generalists and
specialists with complementary
expertise. Many clinical conditions require the input of more
than one clinical provider,
either because the diagnosis and recommended treatment is
uncertain or because a
patient may have multiple diseases that may be best managed by
involving multiple
specialists.
To consult is to seek advice from someone with expertise in a
particular area, whereas
consultation refers to the meeting or comparable outcome
arising from that request.
Medical consultation takes several forms. Its most traditional
forms include in-hospital
consultation in which physicians provide recommendations or
perform procedures for a
hospitalized patient, and out-patient consultations, in which
patients are seen in the office
setting. More contemporary forms of consultation include e-
consultations, telemedicine
evaluations (see “Consultation Involving Telemedicine,”
below), and remote medical
second opinions. In these forms, the consultant may not actually

see the patient but,
nonetheless, assumes the responsibility of evaluating the
patient’s clinical condition,
assessing and analyzing pertinent clinical data, and offering a
synthesis and appropriate
recommendations.
While forms of medical consultation evolve, basic
responsibilities associated with
medical consultation endure. These responsibilities can be
divided into those that fall to
the requesting physician or non-physician practitioner; the
consultant, who provides the
consultation; and the health system, hospital, or organization
that must support this
important medical encounter (Table 465-1).
TABLE 465-1 Stakeholder Responsibilities in the Medical
Consultation Process
RESPONSIBILITIES OF THE REQUESTING PRACTITIONER
Before requesting a consultation, the provider should ensure
that the patient endorses the
purpose of the consultation, understands the role of the
consultant, and anticipates the
likely outcomes of the encounter. Further responsibilities of the
requesting practitioner
include being specific and communicating clearly the reason for
the consultation. Vague
messages such as, “Please evaluate” are not as helpful as more
specific inquiries such as,
“What is the cause of the declining kidney function?” or, “How

should this asymptomatic
pulmonary nodule be evaluated?” To the extent possible, the
requesting practitioner
should provide the relevant clinical information, summarized as
succinctly as possible.
Urgency should be clearly conveyed, typically with a phone call
or other direct
communication.
The requesting practitioner should be explicit regarding the
intended outcome of the
consultation, i.e., is this for a single evaluation or ongoing co-
management?
Communication between the requesting and the consulting
providers is paramount.
Whether this communication includes direct contact is less
important than that the
relevant information and desired outcome be explicit and clear,
regardless of
communication medium. Consultations should be requested for
clinical purposes and
always directed to qualified consultants; they should not be
driven by entrepreneurial or
relationship-building purposes. Another responsibility of the
referring provider is not to
“over- consult.” Medical care should be focused on value, not
volume.
RESPONSIBILITIES OF THE CONSULTANT
Just as the referring provider should attend to clear and explicit
communication, so too
should the consultant follow the precepts of effective
interactions between professionals,
which include courtesy, availability, and clarity. Particularly on
the inpatient service, where
consultants may receive several requests each day, it is

important that the incoming
consultations are triaged and dispatched as clinically
appropriate. Consultants also need
to determine the requested level of involvement going forward
and not assume that long-
term co- management is being sought. While consultants can
and should make use of
available clinical data, they should also assemble independently
their own database,
including taking a history, performing a physical exam, and
reviewing pertinent clinical
studies. Absent that, they may be unable to provide an
independent and actionable
synthesis. Just as the referring provider needs to be clear and
concise, so too should the
consultant be specific and focused in the recommendations
provided. “Possible malignant
ascites” is less helpful than, “I will arrange for paracentesis to
exclude the possibility of
malignant ascites.” For the most part, recommendations to
“consider” some diagnosis or
test are less helpful than more specific and concrete advi ce.
Some referring practitioners
wish to be called after a patient is seen; others prefer that
communication be handled as
part of the medical record. How this communication is handled
must also align with the
complexity and urgency of the consultation and clinical
circumstances.
RESPONSIBILITIES OF HEALTH SYSTEMS, HOSPITALS,

AND MEDICAL
ORGANIZATIONS
Health systems, hospitals, and medical organizations also have
responsibilities in the
consultation process. This responsibility includes ensuring that
qualified consultants are
accessible and available on the medical staff. Consultations
within a single system are
aided by common shared electronic medical records,
particularly when consultations
originate in the hospital, but can also involve care in the
outpatient setting. Finally, health
care entities should strive to foster a culture of team-based care
and collegiality.
SPECIAL ISSUES IN MEDICAL CONSULTATION
Curbside Consults Curbside consults are requests from one
practitioner to another for
an informal and unwritten opinion about a specific patient care
matter. They are typically
limited in scope, mostly regarding management or questions
regarding procedures, and
developed from information provided by the consulting
practitioner and perhaps the
medical record (such as labs and imaging studies), but without a
comprehensive review of
the record or any direct contact with the patient. Although often
viewed as convenient,
efficient, and a common aspect of clinical care, by their very
nature, curbside consults
have been found to often be incomplete or even flawed. It is not
uncommon for the
question being asked to be deemed too complex for a curbside
consult, or for it not to be
the actual or only issue the consultant feels needs to be

addressed. As a general rule,
curbside consults should be avoided. While medicolegal
liability is often cited as a reason
to limit curbside consults, the risk is actually negligible as U.S.
courts have ruled that
curbside consults do not establish a doctor-patient relationship
necessary for creating the
basis for medical malpractice litigation. An important
exception, however, is when a
curbside consult is provided by a resident or fellow in training;
in this circumstance the
trainee’s supervising physician, whether aware of the curbside
consult or not, is
responsible for the recommendations of the trainee.
Second Opinions Physicians may find themselves providing
consultations requested by
patients who have already been evaluated for the same problem
by another physician. Not
a “consult” in the usual context of one physician referring a
patient to another, the service
provided by the consultant here is, nonetheless, very much
aligned with a physician-
referred consult. Second opinions, which often are encouraged
by the patient’s physician,
may be sought by patients for reassurance that a diagnosis and
treatment
recommendation is correct, out of dissatisfaction with the initial
physician, or with the
hope of an entirely different opinion and recommendation. The
physician providing the

second opinion should strive to understand the patient’s
motivations for seeking the
additional opinion. While a second opinion may have been
initiated by the patient rather
than referral from another physician, it is recommended that the
consulting physician
communicate with the patient’s primary physician or specialist
as would be done
following a standard consultation unless the patient insists
otherwise. In addition,
professional behavior in how the consulting physician refers to
the recommendations or
actions of previously consulted physicians is important, even
when there is disagreement.
Likewise, it is important that a transfer of care from prior
consultants to the one providing
a second opinion be enacted only if specifically requested by
the patient or the physician
who encouraged the second opinion.
Consults Involving Mid-Level Providers Increasingly, specialist
physicians may find
themselves being consulted by nurse practitioners and physician
assistants rather than
other physicians. Whether the quality of the information
provided to the consultant
physician by a mid-level provider is different from physician-
to-physician referrals has not
been studied. Consulting physicians should know whether they
should respond back to
the mid-level provider or to the supervising physician. As with
physician-to-physician
consults, it is also important for the consultant to know whether
the individual calling for
the consult has an ongoing role in the care of the patient or is
simply covering for a limited

period of time. Finally, the consultant, if responding back to the
mid-level provider, should
make sure that the information provided meets the needs of that
provider, and that
questions are answered as they would be if responding back to
another physician.
Consultation Involving Telemedicine Consultations making
use of electronic health
records, patient portals, and various forms of
telecommunication technology, including
video conferencing or cell phone communication, can improve
access to care, reduce cost,
and improve outcomes. This is particularly true when employed
in geographic areas of
health care shortage and when the clinical issues can be handled
without direct contact
with the patient, e.g., radiology or dermatology. However, the
absence of direct contact
between patient and consultant introduces special issues related
to diagnostic accuracy
and physician-patient relationship. Regulatory issues, liability,
security, and confidentiality
issues arise as well. Consultation via telemedicine holds
considerable promise, but the
aforementioned concerns will need to be better understood.
FURTHER READING
DANIEL H, SULMASY LS: Policy recommendations to guide
the use of telemedicine in
primary care: An American College of Physicians Position
Paper. Ann Intern Med
163:787, 2015.
PEARSON SD: Principles of generalist-specialist relationships.

J Gen Intern Med 14(Suppl
1):S13, 1999.
466 Medical Disorders During Pregnancy
Robert L. Barbieri, John T. Repke
Each year, approximately 4 million births occur in the United
States, and more than 130
million births occur worldwide. A significant proportion of
births are complicated by
medical disorders. Advances in medical care and fertility
treatment have increased the
number of women with serious medical problems who attempt to
become pregnant.
Medical problems that interfere with the physiologic
adaptations of pregnancy increase
the risk for poor pregnancy outcome; conversely, in some
instances, pregnancy may
adversely impact an underlying medical disorder.
HYPERTENSION
(See also Chap. 271) In pregnancy, cardiac output increases by
40%, with most of the
increase due to an increase in stroke volume. Heart rate
increases by ~10 beats/min
during the third trimester. In the second trimester, systemic
vascular resistance decreases,
and this decline is associated with a fall in blood pressure.
During pregnancy, a blood
pressure of 140/90 mmHg is considered to be abnormally
elevated and is associated with
an increase in perinatal morbidity and mortality. In all pregnant

women, the measurement
of blood pressure should be performed in the sitting position,
because the lateral
recumbent position may result in a lower blood pressure. The
diagnosis of hypertension
requires the measurement of two elevated blood pressures at
least 4 h apart. Hypertension
during pregnancy is usually caused by preeclampsia, chronic
hypertension, gestational
hypertension, or renal disease.
PREECLAMPSIA
Approximately 5–7% of all pregnant women develop
preeclampsia, the new onset of
hypertension (blood pressure >140/90 mmHg) and proteinuria
(either a 24 h urinary
protein >300 mg/24 h, or a protein- creatinine ratio ≥0.3) after
20 weeks of gestation.
Recent revisions to the diagnostic criteria include: proteinuria is
no longer an absolute
requirement for making the diagnosis; the terms mild and severe
preeclampsia have been
replaced; and the disease is now termed preeclampsia either
with or without severe
features and fetal growth restriction is no longer a defining
criterion for preeclampsia with
severe features. Although the precise pathophysiology of
preeclampsia remains unknown,
recent studies show excessive placental production of
antagonists to both vascular
endothelial growth factor (VEGF) and transforming growth
factor β (TGF-β). These
antagonists to VEGF and TGF-β disrupt endothelial and renal
glomerular function resulting
in edema, hypertension, and proteinuria. The renal histological
feature of preeclampsia is

glomerular endotheliosis. Glomerular endothelial cells are
swollen and encroach on the
vascular lumen. Preeclampsia is associated with abnormalities
of cerebral circulatory
autoregulation, which increase the risk of stroke at mildly and
moderately elevated blood
pressures. Risk factors for the development of preeclampsia
include nulliparity, diabetes
mellitus, a history of renal disease or chronic hypertension, a
prior history of preeclampsia,
extremes of maternal age (>35 years or <15 years), obesi ty,
antiphospholipid antibody
syndrome, and multiple gestation. Low-dose aspirin (81 mg
daily, initiated at the end of
the first trimester) modestly reduces the risk of preeclampsia in
pregnant women at high
risk of developing the disease.
Preeclampsia with severe features is the presence of new-onset
hypertension and
proteinuria accompanied by end-organ damage. Features may
include severe elevation of
blood pressure (>160/110 mmHg), evidence of central nervous
system (CNS) dysfunction
(headaches, blurred vision, seizures, coma), renal dysfunction
(oliguria or creatinine >1.5
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mg/dL), pulmonary edema, hepatocellular injury (serum alanine
aminotransferase level
more than twofold the upper limit of normal), hematologic

dysfunction (platelet count
<100,000/L or disseminated intravascular coagulation [DIC]).
The HELLP syndrome
(hemolysis, elevated liver enzymes, low platelets) is a special
subtype of severe
preeclampsia and is a major cause of morbidity and mortality in
this disease. Platelet
dysfunction and coagulation disorders further increase the risk
of stroke.
TREATMENT
Preeclampsia
Preeclampsia resolves within a few weeks after delivery. For
pregnant women with
preeclampsia prior to 37 weeks of gestation, delivery reduces
the mother’s morbidity
but exposes the fetus to the risk of premature birth. The
management of preeclampsia
is challenging because it requires the clinician to balance the
health of the mother and
fetus simultaneously. In general, prior to term, women with
preeclampsia without
severe features may be managed conservatively with limited
physical activity, although
bed rest is not recommended, close monitoring of blood
pressure and renal function,
and careful fetal surveillance. For women with preeclampsia
with severe features,
delivery is recommended unless the patient is eligible for
expectant management in a
tertiary hospital setting. Expectant management of preeclampsia
with severe features
remote from term affords some benefits for the fetus, but
significant risks for the
mother. Postponing delivery beyond 34 weeks gestation in this

group of patients is not
recommended. In preeclampsia without severe features delivery
at 37 weeks is
recommended.
The definitive treatment of preeclampsia is delivery of the fetus
and placenta. For
women with preeclampsia with severe features, aggressive
management of blood
pressures >160/105 mmHg reduces the risk of cerebrovascular
accidents. IV labetalol
or hydralazine is most commonly used to acutely manage severe
hypertension in
preeclampsia; labetalol is associated with fewer episodes of
maternal hypotension.
Elevated arterial pressure should be reduced slowly to avoid
hypotension and a
decrease in blood flow to the fetus.
Magnesium sulfate is the preferred agent for the prevention and
treatment of
eclamptic seizures. Large, randomized clinical trials have
demonstrated the superiority
of magnesium sulfate over phenytoin and diazepam in reducing
the risk of seizure and,
possibly, the risk of maternal death. Magnesium may prevent
seizures by interacting
with N-methyl-D-aspartate (NMDA) receptors in the CNS. The
universal use of
magnesium sulfate for seizure prophylaxis in preeclampsia
without severe features is
no longer recommended by most experts. There is consensus
that magnesium sulfate
should be used in all cases of preeclampsia with severe features,
or in cases of
eclampsia. Women who have had preeclampsia appear to be at

increased risk of
cardiovascular and renal disease later in life.
CHRONIC ESSENTIAL HYPERTENSION
Pregnancy complicated by chronic essential hypertension is
associated with intrauterine
growth restriction and increased perinatal mortality. Pregnant
women with chronic
hypertension are at increased risk for superimposed
preeclampsia and abruptio placentae.
Women with chronic hypertension should have a thorough
prepregnancy evaluation, both
to identify remediable causes of hypertension and to ensure that
the prescribed
antihypertensive agents (e.g., angiotensin-converting enzyme
[ACE] inhibitors, angiotensin-
receptor blockers) are not associated with an adverse outcome
of pregnancy. Labetalol
and nifedipine are the most commonly used medications for the
treatment of chronic
hypertension in pregnancy. The target blood pressure is in the
range of 130–150 mmHg
systolic and 80–100 mmHg diastolic. Should hypertension
worsen during pregnancy,
baseline evaluation of renal function (see below) is necessary to
help differentiate the
effects of chronic hypertension from those of superimposed
preeclampsia. There are no
convincing data that the treatment of mild chronic hypertension
improves perinatal
outcome.

GESTATIONAL HYPERTENSION
The development of elevated blood pressure after 20 weeks of
pregnancy or in the first 24
h post-partum in the absence of preexisting chronic
hypertension or proteinuria is referred
to as gestational hypertension. Mild gestational hypertension
that does not progress to
preeclampsia has not been associated with adverse pregnancy
outcome or adverse long-
term prognosis.
RENAL DISEASE
Normal pregnancy is characterized by an increase in glomerular
filtration rate and
creatinine clearance. This increase occurs secondary to a rise in
renal plasma flow and
increased glomerular filtration pressures. Patients with
underlying renal disease and
hypertension may expect a worsening of hypertension during
pregnancy. If superimposed
preeclampsia develops, the additional endothelial injury results
in a capillary leak
syndrome that may make management challenging. In general,
patients with underlying
renal disease and hypertension benefit from aggressive
management of blood pressure.
Preconception counseling is also essential for these patients so
that accurate risk
assessment and medication changes can occur prior to
pregnancy. In general, a
prepregnancy serum creatinine level <133 μmol/L (<1.5 mg/dL)
is associated with a
favorable prognosis. When renal disease worsens during
pregnancy, close collaboration
between the internist and the maternal-fetal medicine specialist

is essential so that
decisions regarding delivery can be weighed to balance the
sequelae of prematurity for the
neonate versus long-term sequelae for the mother with respect
to future renal function.
CARDIAC DISEASE
VALVULAR HEART DISEASE
(See also Chaps. 256–263) Valvular heart disease is the most
common cardiac problem
complicating pregnancy.
Mitral Stenosis This is the valvular disease most likely to
cause death during pregnancy.
The pregnancy-induced increase in blood volume, cardiac
output, and tachycardia can
increase the transmitral pressure gradient and cause pulmonary
edema in women with
mitral stenosis. Women with moderate to severe mitral stenosis
(mitral valve area ≤1.5
cm2) who are planning pregnancy and have either symptomatic
disease or pulmonary
hypertension should undergo valvuloplasty prior to conception,
preferably with
percutaneous balloon valvotomy (PBV). Pregnancy associated
with long-standing mitral
stenosis may result in pulmonary hypertension. Sudden death
has been reported when
hypovolemia occurs. Careful control of heart rate, especially
during labor and delivery,

minimizes the impact of tachycardia and reduced ventricular
filling times on cardiac
function. Pregnant women with mitral stenosis are at increased
risk for the development
of atrial fibrillation and other tachyarrhythmias. The immediate
postpartum period is a
time of particular concern secondary to rapid volume shifts.
Careful monitoring of cardiac
and fluid status should be observed.
Mitral Regurgitation and Aortic Regurgitation and Stenosis
The pregnancy-induced
decrease in systemic vascular resistance reduces the risk of
cardiac failure with these
conditions, especially in women with chronic lesions. Acute
onset of mitral or aortic
regurgitation may not be well tolerated during pregnancy. For
women with severe aortic
stenosis, treatment before pregnancy should be considered for a
peak-to-peak valve
gradient >50 mmHg. In women with aortic stenosis and a mean
valve gradient <25 mmHg,
pregnancy is likely to be well tolerated. For women with mitral
or aortic regurgitation and
left ventricular dysfunction (LVEF <30%) pregnancy should be
avoided.
CONGENITAL HEART DISEASE
(See also Chap. 264) Reparative surgery has markedly increased
the number of adult
women with surgically repaired congenital heart disease.
Maternal morbidity and mortality
are greater among these women than among those without
surgical cardiac repair. When
pregnant, these patients should be jointly managed by a
cardiologist and an obstetrician

familiar with these problems. The presence of a congenital
cardiac lesion in the mother
increases the risk of congenital cardiac disease in the newborn.
Prenatal screening of the
fetus for congenital cardiac disease with ultrasound is
recommended.
OTHER CARDIAC DISORDERS
Supraventricular tachycardia (Chap. 241) is a common cardiac
complication of
pregnancy. Treatment is the same as in the nonpregnant patient,
and fetal tolerance of
medications such as adenosine and calcium channel blockers is
acceptable. When
necessary, pharmacologic or electric cardioversion may be
performed to improve cardiac
performance and reduce symptoms. This intervention is
generally well tolerated by mother
and fetus.
Peripartum cardiomyopathy (Chap. 254) is an uncommon
disorder of pregnancy and
its etiology remains unknown. Approximately 10% of women
with peripartum
cardiomyopathy carry a truncating mutation in the gene
encoding the titin sarcomere
protein. Treatment is directed toward symptomatic relief and
improvement of cardiac
function. Many patients recover completely; others are left with
progressive dilated
cardiomyopathy. Recurrence in a subsequent pregnancy has
been reported, and women
who do not have normal baseline left-ventricular function after
an episode of peripartum
cardiomyopathy should be counseled to avoid pregnancy.

SPECIFIC HIGH-RISK CARDIAC LESIONS
Marfan Syndrome (See also Chap. 406) This autosomal
dominant disease is
associated with an increased risk of aortic dissection and
rupture. An aortic root diameter
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<40 mm is associated with a favorable outcome of pregnancy;
conversely, an aortic root
diameter >40 mm is associated with an increased risk of aortic
dissection. Prophylactic
therapy with beta blockers has been advocated to reduce aortic
dilation and the risk of
dissection. A “cardiac delivery” with reduced pushing and early
intervention with operative
delivery is often recommended to reduce increases in aortic wall
stress caused by the
Valsalva maneuver.
Ehlers-Danlos syndrome (EDS) may be associated with
premature labor, and in type IV
EDS there is increased risk of organ or vascular rupture that
may cause death. For women
with vascular EDS, pregnancy is relatively contraindicated

because of the high risk of
vascular and uterine rupture.
Pulmonary Hypertension (See also Chap. 277) Maternal
mortality in the setting of
severe pulmonary hypertension is high, and primary pulmonary
hypertension is a
contraindication to pregnancy. Termination of pregnancy may
be advisable in these
circumstances to preserve the life of the mother. In the
Eisenmenger syndrome, i.e., the
combination of pulmonary hypertension with right-to-left
shunting due to congenital
abnormalities (Chap. 264), maternal and fetal deaths occur
frequently. Systemic
hypotension may occur after blood loss, prolonged Valsalva
maneuver, or regional
anesthesia; sudden death secondary to hypotension is a dreaded
complication.
Management of these patients is challenging, and invasive
hemodynamic monitoring
during labor and delivery is recommended in severe cases.
In patients with pulmonary hypertension, vaginal delivery is
less stressful
hemodynamically than cesarean section, which should be
reserved for accepted obstetric
indications.
DEEP VENOUS THROMBOSIS AND PULMONARY
EMBOLISM
(See also Chap. 273) Pregnancy is associated with venous
stasis, endothelial injury and a
hypercoagulable state. Inherited thrombophilias and the
presence of antiphospholipid
antibodies increase the risk of venous thromboembolism (VTE)

in pregnancy. Deep
venous thrombosis (DVT) or pulmonary embolism (PE) occurs
in about 1 in 500
pregnancies, with DVT being three times more common than
PE. VTE occurs more
commonly in the 6 weeks post-partum than antepartum. In
pregnant women, most
unilateral DVTs occur in the left leg because the left iliac vein
is compressed by the right
iliac artery and the uterus compresses the inferior vena cava.
TREATMENT
Deep Venous Thrombosis
Aggressive diagnosis and management of DVT and suspected
pulmonary embolism
optimize the outcome for mother and fetus. In general, all
diagnostic and therapeutic
modalities afforded that the nonpregnant patient should be
utilized in pregnancy
except for D-dimer measurement, in which values are elevated
in normal pregnancy.
Anticoagulant therapy with low-molecular-weight heparin
(LMWH) or unfractionated
heparin is indicated in pregnant women with DVT. LMWH may
be associated with an
increased risk of epidural hematoma in women receiving an
epidural anesthetic in
labor and must be discontinued at least 24 h before placement of
an epidural catheter.
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Warfarin therapy is contraindicated in the first trimester due to
its association with fetal
chondrodysplasia punctata. In the second and third trimesters,
warfarin may cause
fetal optic atrophy and mental retardation. In pregnancy the use
of warfarin is
restricted to women with mechanical heart valves. Warfarin is
not contraindicated in
breast-feeding women. For women at moderate or high risk of
DVT who have a
cesarean delivery, mechanical and/or pharmacologic
prophylaxis is warranted.
ENDOCRINE DISORDERS
DIABETES MELLITUS
(See also Chaps. 396–398) In pregnancy, the fetoplacental unit
induces major metabolic
changes, the purpose of which is to shunt glucose and amino
acids to the fetus while the
mother uses ketones and triglycerides to fuel her metabolic
needs. These metabolic
changes are accompanied by maternal insulin resistance caused
in part by placental
production of steroids, a growth hormone variant, and placental
lactogen. Although
pregnancy has been referred to as a state of “accelerated
starvation,” it is better
characterized as “accelerated ketosis.” In pregnancy, after an
overnight fast, plasma
glucose is lower by 0.8–1.1 mmol/L (15–20 mg/dL) than in the

nonpregnant state. This
difference is due to the use of glucose by the fetus. In early
pregnancy, fasting may result
in circulating glucose concentrations in the range of 2.2 mmol/L
(40 mg/dL) and may be
associated with symptoms of hypoglycemia. In contrast to the
decrease in maternal
glucose concentration, plasma hydroxybutyrate and acetoacetate
levels rise to two to four
times normal after a fast.
TREATMENT
Diabetes Mellitus in Pregnancy
Pregnancy complicated by diabetes mellitus is associated with
higher maternal and
perinatal morbidity and mortality rates. Preconception
counseling and treatment are
important for the diabetic patient contemplating pregnancy and
can reduce the risk of
congenital malformations and improve pregnancy outcome.
Folate supplementation
reduces the incidence of fetal neural tube defects, which occur
with greater frequency
in fetuses of diabetic mothers. In addition, optimizing glucose
control during key
periods of organogenesis reduces other congenital anomalies,
including sacral
agenesis, caudal dysplasia, renal agenesis, and ventricular
septal defect.
Once pregnancy is established, glucose control should be
managed more
aggressively than in the nonpregnant state. In addition to
dietary changes, this
enhanced management requires more frequent blood glucose

monitoring and often
involves additional injections of insulin or conversion to an
insulin pump. Fasting
blood glucose levels should be maintained at <5.8 mmol/L
(<105 mg/dL), with
avoidance of values >7.8 mmol/L (140 mg/dL). Sequential
measurement of
hemoglobin A1c is of minimal value for monitoring glucose
control during pregnancy
because of the higher rate of red blood cell turnover during
pregnancy. Commencing in
the third trimester, regular surveillance of maternal glucose
control as well as
assessment of fetal growth (obstetric sonography) and
fetoplacental oxygenation
(fetal heart rate monitoring or biophysical profile) optimize
pregnancy outcome.
Pregnant diabetic patients without vascular disease are at
greater risk for delivering a
macrosomic fetus, and attention to fetal growth via clinical and
ultrasound
examination is important. Fetal macrosomia is associated with
an increased risk of
maternal and fetal birth trauma, including permanent injury to
the brachial plexus.
Pregnant women with diabetes have an increased risk of
developing preeclampsia, and
those with vascular disease are at greater risk for developing
intrauterine growth
restriction, which is associated with an increased risk of fetal
and neonatal death.

Excellent pregnancy outcomes in patients with diabetic
nephropathy and proliferative
retinopathy have been reported with aggressive glucose control
and intensive maternal
and fetal surveillance.
As pregnancy progresses, glycemic control may become more
difficult to achieve
due to an increase in insulin resistance. In pregnant women with
Type 1 diabetes,
closed-loop insulin delivery with both continuous interstitial
glucose monitoring and
sensor-augmented insulin pump therapy is helpful in
normalizing circulating glucose
with few episodes of hypoglycemia. In general, efforts to
control glucose and avoid
preterm delivery result in the best overall outcome for both
mother and newborn.
Preterm delivery is generally performed only for the usual
obstetric indications (e.g.,
preeclampsia, fetal growth restriction, non-reassuring fetal
testing) or for worsening
maternal renal or active proliferative retinopathy.
GESTATIONAL DIABETES (GDM)
GDM occurs in ~4% of pregnancies. Because about 90% of
women have at least one risk
factor for GDM, all pregnant women should be screened for
GDM. A typical two-step
strategy for establishing the diagnosis of GDM is performed at
24–28 weeks of gestation
and involves administration of a 50-g oral glucose challenge
with a single serum glucose
measurement at 60 min. If the plasma glucose is <7.8 mmol/L
(<130 mg/dL) the test is
considered normal. Plasma glucose >7.8 mmol/L (>130 mg/dL)

warrants administration
of a 100-g oral glucose challenge with plasma glucose
measurements obtained in the
fasting state and at 1, 2, and 3 h. Normal plasma glucose
concentrations at these time
points are <5.3 mmol/L (<95 mg/dL), <10 mmol/L (<180
mg/dL), <8.6 mmol/L (<155
mg/dL), and <7.8 mmol/L (<140 mg/dL) as the upper norms for
a 3-h glucose tolerance
test. Two elevated glucose values indicate a positive test.
Adverse pregnancy outcomes
for mother and fetus appear to increase with glucose as a
continuous variable; thus it is
challenging to define the optimal threshold for establishing the
diagnosis of GDM.
Pregnant women with GDM are at increased risk of stillbirth,
preeclampsia, and delivery
of infants who are large for their gestational age, with resulting
birth lacerations, shoulder
dystocia, and birth trauma including brachial plexus injury.
These fetuses are at risk of
hypoglycemia, hyperbilirubinemia, and polycythemia. Tight
control of blood sugar during
pregnancy and labor can reduce these risks.
TREATMENT
Gestational Diabetes
Treatment of GDM with a two-step strategy—dietary
intervention followed by insulin

injections if diet alone does not adequately control blood sugar
(fasting glucose <5.6
mmol/L [<100 mg/dL] and 2-h postprandial glucose <7.0
mmol/L [<126 mg/dL])—is
associated with a decreased risk of birth trauma for the fetus.
Oral hypoglycemic
agents such as glyburide and metformin have become more
commonly utilized for
managing GDM refractory to nutritional management, but most
experts favor insulin
therapy. For women with GDM, there is a 40% risk of being
diagnosed with diabetes
within the 10 years after the index pregnancy. All women with
GDM should have a
formal glucose tolerance test (GTT) to screen for T2DM at ~6
weeks post-partum. In
women with a history of GDM, exercise, weight loss, and
treatment with metformin
reduce the risk of developing diabetes. Lactation also reduces
the risk of GDM
progressing to T2DM. All women with a history of GDM should
be counseled about
prevention strategies and evaluated regularly for diabetes.
OBESITY
(See also Chap. 395) Pregnant women who are obese have an
increased risk of stillbirth,
congenital fetal malformations, GDM, preeclampsia, urinary
tract infections, preterm and
post-date delivery, and cesarean delivery. Women
contemplating pregnancy should
attempt to attain a healthy weight prior to conception. For
morbidly obese women who
have not been able to lose weight with lifestyle changes,
bariatric surgery reduces the risks
for GDM, macrosomia, and preterm delivery. Following

bariatric surgery, women should
delay conception for 1 year to avoid pregnancy during an
interval of rapid metabolic
changes. The National Academy of Medicine guidelines for
weight gain during pregnancy
recommend that for BMI ranges of <18.5, 18.5–24.9, 25.0–29.9,
and ≥30 kg/m2, weight
gain targets should be 12.5–18 kg, 11.5–16 kg, 7–11.5 kg, and
5–9 kg, respectively.
THYROID DISEASE
(See also Chap. 375) In pregnancy, the estrogen-induced
increase in thyroxine-binding
globulin increases circulating levels of total T3 and total T4.
Placental human chorionic
gonadotropin (hCG) directly stimulates the thyroid causing an
increase in free T3 and T4.
Interpretation of the measurement of free T4, free T3, and
thyroid-stimulating hormone
(TSH) should use trimester-specific ranges.
TREATMENT
Hyperthyroidism in Pregnancy
HYPERTHYROIDISM
Methimazole crosses the placenta to a greater degree than
propylthiouracil and has
been associated with fetal aplasia cutis. However,
propylthiouracil can be associated
with liver failure. Some experts recommend propylthiouracil in
the first trimester and
methimazole thereafter. Radioiodine should not be used during
pregnancy, either for
scanning or for treatment, because of effects on the fetal
thyroid. In emergent

circumstances, additional treatment with beta blockers may be
necessary.
Hyperthyroidism is most difficult to control in the first
trimester of pregnancy and
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easiest to control in the third trimester. In women with high-
titer thyroid stimulating
antibodies, the newborn may be born with neonatal Graves’
disease.
HYPOTHYROIDISM
The goal of therapy for hypothyroidism is to maintain the serum
TSH in the normal
range, and thyroxine is the drug of choice. During pregnancy,
the dose of thyroxine
required to keep the TSH in the normal range rises. In one
study, the mean replacement
dose of thyroxine required to maintain the TSH in the normal
range was 0.1 mg daily
before pregnancy and increased to 0.15 mg daily during
pregnancy. Since the
increased thyroxine requirement occurs as early as the fifth
week of pregnancy, one
approach is to increase the thyroxine dose by 30% (two
additional pills weekly) as soon
as pregnancy is diagnosed and then adjust the dose by serial
measurements of TSH.

HEMATOLOGIC DISORDERS
Pregnancy has been described as a state of physiologic anemia.
Part of the reduction in
hemoglobin concentration is dilutional, but iron and folate
deficiencies are major causes
of correctable anemia during pregnancy.
In populations at high risk for hemoglobinopathies (Chap. 94),
hemoglobin
electrophoresis should be performed as part of the prenatal
screen. Hemoglobinopathies
can be associated with increased maternal and fetal morbidity
and mortality.
Management is tailored to the specific hemoglobinopathy and is
generally the same for
both pregnant and nonpregnant women. Prenatal diagnosis of
hemoglobinopathies in the
fetus is readily available and should be discussed with
prospective parents either prior to
or early in pregnancy.
Thrombocytopenia occurs commonly during pregnancy. The
majority of cases are
benign gestational thrombocytopenias, but the differential
diagnosis should include
immune thrombocytopenia (Chap. 111), preeclampsia, and
thrombotic thrombocytopenic
purpura. Benign gestational thrombocytopenia is unlikely if the
platelet count is <100,000
per μL.
NEOPLASIA
Cancer complicates ~1 in every 1000 pregnancies. Of all the
cancers that occur in women,
<1% complicate pregnancies. The four cancers that occur most
commonly in pregnancy

are cervical cancer, breast cancer, melanoma, and lymphomas
(particularly Hodgkin’s
lymphoma); however, virtually every form of cancer has been
reported in pregnant women
(Table 466-1). In addition to cancers developing in other organs
of the mother, gestational
trophoblastic tumors can arise from the placenta.
TABLE 466-1 Incidence of Malignant Tumors During Gestation
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aThese are estimates based on extrapolations from a review of
more than 3 million pregnancies (LH Smith et al:
Am J Obstet Gynecol 184:1504, 2001).
bBased on accumulating case reports from the literature; the
precision of these data is not high.
Managing cancer in a pregnant woman is complex. One must
take into account (1) the
possible influence of the pregnancy on the natural history of the
cancer, (2) effects on the
mother and fetus of complications from the malignancy (e.g.,
anorexia, nausea, vomiting,
malnutrition), (3) potential effects of diagnostic and staging
procedures, and (4) potential
effects of cancer treatments on both the mother and the
developing fetus. Generally, the
management that optimizes maternal physiology is also best for
the fetus. The dilemma

occasionally arises that what is best for the mother may be
harmful to the fetus, and what
is best for the fetus may compromise the ultimate prognosis for
the mother. The best way
to approach management of a pregnant woman with cancer is to
ask, “What would one do
in this clinical situation if she was not pregnant? Then, which,
if any aspect of those plans
need to be modified because she is pregnant?”
TREATMENT
Special Therapeutic Considerations in Pregnancy
Exposure of developing fetuses to ionizing radiation may cause
adverse fetal effects;
awareness of this potential toxicity has resulted in a
disproportionate aversion to
diagnostic imaging in pregnancy. The fetus is most sensitive to
teratogenesis during
organogenesis in the first trimester. Imaging that uses ionizing
radiation should not be
done without a compelling reason and due consideration to
obtaining the necessary
information by alternative imaging modalities. Exposure to
diagnostic and therapeutic
radionuclides, especially radioactive iodine, poses unique risks,
but a full discussion of
these is beyond the scope of this chapter.
Generally, toxic chemotherapy should be avoided during
pregnancy, if at all possible.
It should virtually never be given in the first trimester. A
variety of single agents and
combinations have been administered in the second and third
trimesters, without a
high frequency of toxic effects to the pregnancy or the fetus,

but data on safety are
sparse. A database on the risks associated with individual
chemotherapy agents is
available
(http://ntp.niehs.nih.gov/ntp/ohat/cancer_chemo_preg/chemopre
gnancy_monofinal_50
8.pdf). If the malignancy is slowly progressive, and if the
patient is near her delivery
date, and if waiting until delivery to begin treatment is not
anticipated to compromise
maternal prognosis, then delaying treatment until after delivery
to avoid fetal exposure
to chemotherapy is desirable. If there is a greater sense of
urgency to begin definitive
http://ntp.niehs.nih.gov/ntp/ohat/cancer_chemo_preg/chemopreg
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treatment to avoid compromising maternal prognosis, and the
patient is beyond 24
weeks of gestation but remote from her delivery date, then
treatment (surgical, medical,
or both) might be initiated during pregnancy and plans made to
deliver the fetus early
to avoid exposure to more chemotherapy than absolutely
necessary. Since neonatal
prognosis is most closely linked to gestational age at delivery,
decisions regarding
timing of delivery should include input from Maternal-Fetal
Medicine, Neonatology, and
Oncology. Finally, if the patient is in her first trimester and
toxic chemotherapy must be
initiated promptly to avoid a very poor maternal outcome, then

it may be necessary to
consider therapeutic abortion to avoid maternal disaster and
fetal survival with injury
resulting in long-term morbid sequelae. In general, pregnancy
has relatively little or no
impact on the natural history of malignancies, despite the
hormonal influences. Spread
of the mother’s cancer to the fetus (so-called vertical
transmission) is exceedingly rare.
NEUROLOGIC DISORDERS
For women with epilepsy planning pregnancy, consideration
should be given to switching
from valproate, a known teratogen, to another medication. If
valproate is continued during
pregnancy, folic acid supplementation should be increased to 4
mg daily.
Patients with preexisting multiple sclerosis (Chap. 436)
experience a gradual decrease
in the risk of relapses as pregnancy progresses and, conversely,
an increase in attack risk
during the postpartum period. Disease-modifying agents,
including interferon β, should not
be administered to pregnant multiple sclerosis patients, but
moderate or severe relapses
can be safely treated with pulse glucocorticoid therapy. Finally,
certain tumors, particularly
pituitary adenoma and meningioma (Chap. 373), may manifest
during pregnancy
because of accelerated growth, possibly driven by hormonal
factors.
Peripheral nerve disorders associated with pregnancy include
Bell’s palsy (idiopathic
facial paralysis) (Chap. 438), which is approximately threefold

more likely to occur during
the third trimester and immediate postpartum period than in the
general population.
Therapy with glucocorticoids should follow the guidelines
established for nonpregnant
patients. Entrapment neuropathies are common in the later
stages of pregnancy,
presumably as a result of fluid retention. Carpal tunnel
syndrome (median nerve) presents
first as pain and paresthesia in the hand (often worse at night)
and later with weakness in
the thenar muscles. Treatment is generally conservative; wrist
splints may be helpful, and
glucocorticoid injections or surgical section of the carpal tunnel
can usually be postponed.
Meralgia paresthetica (lateral femoral cutaneous nerve
entrapment) consists of pain and
numbness in the lateral aspect of the thigh without weakness.
Patients are usually
reassured to learn that these symptoms are benign and can be
expected to remit
spontaneously after the pregnancy has been completed. Restless
leg syndrome is the
most common peripheral nerve and movement disorder in
pregnancy. Disordered iron
metabolism is the suspected etiology. Management is expectant
in most cases.
GASTROINTESTINAL AND LIVER DISEASE
Up to 90% of pregnant women experience nausea and vomiting
during the first trimester
of pregnancy. Hyperemesis gravidarum is a severe form that
prevents adequate fluid and
nutritional intake and may require hospitalization to prevent
dehydration and malnutrition.

Crohn’s disease may be associated with exacerbations in the
second and third
trimesters. Ulcerative colitis is associated with disease
exacerbations in the first trimester
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438
and during the early postpartum period. Medical management of
these diseases during
pregnancy is similar to management in the nonpregnant state
(Chap. 319).
Exacerbation of gallbladder disease is common during
pregnancy. In part, this
aggravation may be due to pregnancy-induced alteration in the
metabolism of bile and
fatty acids. Intrahepatic cholestasis of pregnancy is generally a
third-trimester event.
Profound pruritus may accompany this condition, and it may be
associated with increased
fetal mortality. Placental bile salt deposition may contribute to
progressive uteroplacental
insufficiency. Therefore, regular fetal surveillance should be
undertaken once the
diagnosis of intrahepatic cholestasis is made, and delivery
should be planned once the
fetus reaches about 37 weeks of gestation. Favorable results
with ursodiol have been

reported.
Acute fatty liver is a rare complication of pregnancy.
Frequently confused with the
HELLP syndrome (see “Preeclampsia” above) and severe
preeclampsia, the diagnosis of
acute fatty liver of pregnancy may be facilitated by imaging
studies and laboratory
evaluation. Acute fatty liver of pregnancy is generally
characterized by markedly increased
serum levels of bilirubin and ammonia and by hypoglycemia.
Management of acute fatty
liver of pregnancy is supportive; recurrence in subsequent
pregnancies has been reported.
All pregnant women should be screened for hepatitis B. This
information is important
for pediatricians after delivery of the infant. All infants receive
hepatitis B vaccine. Infants
born to mothers who are carriers of hepatitis B surface antigen
should also receive
hepatitis B immune globulin as soon after birth as possible and
preferably within the first
72 h. Screening for hepatitis C is recommended for individuals
at high risk for exposure.
INFECTIONS
BACTERIAL INFECTIONS
Other than bacterial vaginosis, the most common bacterial
infections during pregnancy
involve the urinary tract (Chap. 130). Many pregnant women
have asymptomatic
bacteriuria, most likely due to stasis caused by progestational
effects on ureteral and
bladder smooth muscle and later in pregnancy due to

compression effects of the
enlarging uterus. In itself, this condition is not associated with
an adverse outcome of
pregnancy. If asymptomatic bacteriuria is left untreated,
symptomatic pyelonephritis may
occur. Indeed, ~75% of pregnancy-associated pyelonephritis
cases are the result of
untreated asymptomatic bacteriuria. All pregnant women should
be screened with a urine
culture for asymptomatic bacteriuria at the first prenatal visit.
Subsequent screening with
nitrite/leukocyte esterase strips is indicated for high-risk
women, such as those with sickle
cell trait or a history of urinary tract infections. All women with
positive screens should be
treated. Pregnant women who develop pyelonephritis need
inpatient IV antibiotic
administration due to the elevated risk of urosepsis and acute
respiratory distress
syndrome in pregnancy. Pregnant women with recurrent urinary
tract infections, or one
episode of pyelonephritis, should be considered for daily
antibiotic suppressive treatment
throughout the remainder of their pregnancy.
All pregnant patients are screened prenatally for syphilis,
gonorrhea, and chlamydial
infections, and the detection of any of these should result in
prompt evaluation and
treatment (Chaps. 151 and 184).
VIRAL INFECTIONS
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Zika Virus (ZV) ZV can be transmitted from mother to
fetus throughout gestation and
often results in fetal death, severe microcephaly, or other
malformations of the central
nervous system. Pregnant symptomatic women with relevant
epidemiologic exposure
within 2 weeks of symptom onset should have serum and urine
tested for ZV ribonucleic
acid by real-time reverse transcriptase-polymerase chain
reaction (RT-PCR). Testing 2–12
weeks after symptom onset utilizes serum measurement of Zika
and dengue virus IgM.
Sequential obstetrical ultrasound is recommended to assess for
fetal growth and
anomalies. Couples considering pregnancy should avoid travel
to areas with known
mosquito transmission of ZV.
Influenza (See also Chap. 195) Pregnant women with influenza
are at increased risk of
serious complications and death. All women who are pregnant
or plan to become
pregnant in the near future should receive inactivated influenza
vaccine. The prompt
initiation of antiviral treatment is recommended for pregnant
women in whom influenza is
suspected. Treatment can be reconsidered once the results of
high- sensitivity tests are
available. Prompt initiation of treatment lowers the risk of
admission to an intensive care
unit and death.

Cytomegalovirus Infection The most common cause of
congenital viral infection in the
United States is cytomegalovirus (CMV) (Chap. 190). As many
as 50–90% of women of
childbearing age have antibodies to CMV, but only rarely does
CMV reactivation result in
neonatal infection. More commonly, primary CMV infection
during pregnancy creates a
risk of congenital CMV. No currently accepted treatment of
CMV infection during
pregnancy has been demonstrated to protect the fetus
effectively. Moreover, it is difficult
to predict which fetus will sustain a life-threatening CMV
infection. Severe CMV disease in
the newborn is characterized most often by petechiae,
hepatosplenomegaly, and jaundice.
Chorioretinitis, microcephaly, intracranial calcifications,
hepatitis, hemolytic anemia, and
purpura may also develop. CNS involvement, resulting in the
development of psychomotor,
ocular, auditory, and dental abnormalities over time, has been
described. Women with a
primary CMV infection should delay conception for 6 months.
Rubella (See also Chap. 201) Rubella virus is a known
teratogen; first-trimester rubella
carries a high risk of fetal anomalies, though the risk
significantly decreases later in
pregnancy. Congenital rubella may be diagnosed by
percutaneous umbilical-blood
sampling with the detection of IgM antibodies in fetal blood.
All pregnant women and all
women of childbearing age should be tested for their immune
status to rubella. All women
who might become pregnant and who are not immune to rubella

should be vaccinated at
least 3 months before conception.
Herpesvirus Infection (See also Chap. 187) The acquisition of
genital herpes during
pregnancy is associated with spontaneous abortion, prematurity,
and congenital and
neonatal herpes. A cohort study of pregnant women without
evidence of previous
herpesvirus infection demonstrated that ~2% acquired a new
herpesvirus infection during
the pregnancy. Approximately 60% of the newly infected
women had no clinical
symptoms. Infection occurred with equal frequency in all three
trimesters. If herpesvirus
seroconversion occurred early in pregnancy, the risk of
transmission to the newborn was
very low. In women who acquired genital herpes shortly before
delivery, the risk of
transmission was high. The risk of active genital herpes lesions
at term can be reduced by
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prescribing acyclovir for the last 4 weeks of pregnancy to all
women who had an episode

of genital herpes during the pregnancy.
Herpesvirus infection in the newborn can be devastating.
Disseminated neonatal
herpes carries with it high mortality and morbidity rates from
CNS involvement. It is
recommended that pregnant women with active genital herpes
lesions at the time of
presentation in labor be delivered by cesarean section.
Parvovirus Infection (See also Chap. 192) Parvovirus
infection (caused by human
parvovirus B19) may occur during pregnancy. It rarely causes
sequelae, but susceptible
women infected during pregnancy may be at risk for fetal
hydrops secondary to erythroid
aplasia and profound anemia.
HIV Infection (See also Chap. 197) The predominant cause of
HIV infection in children
is transmission of the virus from mother to newborn during the
perinatal period. All
pregnant women should be screened for HIV infection. Factors
that increase the risk of
mother-to-newborn transmission include high maternal viral
load, low maternal CD4+ T
cell count, prolonged labor, prolonged duration of membrane
rupture, and the presence of
other genital tract infections, such as syphilis or herpes. Prior to
the widespread use of
antiretroviral treatment, the perinatal transmission rate was in
the range of 20%. In women
with a good response to antiretroviral treatment, the
transmission rate is about 1%.
Measurement of maternal plasma HIV RNA copy number guides
the decision for vaginal

versus cesarean delivery. For women with <1000 copies of
plasma HIV RNA/mL who are
receiving combination antiretroviral therapy, the risk of
transmission to the newborn is
~1% regardless of mode of delivery or duration of membrane
rupture. These women may
elect to attempt a vaginal birth following the spontaneous onset
of labor. For women with
a viral load of ≥1000 copies/mL prior to 38 weeks of gestation,
a scheduled prelabor
cesarean at 38 weeks is recommended to reduce the risk of HIV
transmission to the
newborn.
VACCINATIONS
(See also Chap. 118) For rubella-nonimmune individuals
contemplating pregnancy,
measles-mumps-rubella vaccine should be administered, ideally
at least 3 months prior to
conception, but otherwise in the immediate postpartum period.
In addition, pregnancy is
not a contraindication for vaccination against influenza, tetanus,
diphtheria, and pertussis
(Tdap), and these vaccines are recommended for appropriate
individuals.
MATERNAL MORTALITY
Maternal death is defined as death occurring during pregnancy
or within 42 days of
completion of pregnancy from a cause related to or aggravated
by pregnancy, but not due
to accident or incidental causes. The maternal mortality ratio is
the number of maternal
deaths per 100,000 live births. From 1935 to 2007, the U.S.
maternal mortality ratio
decreased from nearly 600/100,000 births to 12.7/100,000

births. Since 2007, the U.S.
maternal mortality ratio has increased to 21.5/100,000 births.
There are significant health
disparities in the maternal mortality ratio. In the United States,
in the period from 2005 to
2014, the maternal mortality ratios (per 100,000 live births) by
race were 11.3 among
Hispanic women, 14.1 among non-Hispanic white women, and
40.2 among non-Hispanic
black women. The most common causes of maternal death in the
United States today are
pulmonary embolism, obstetric hemorrhage, hypertension,
sepsis, cardiovascular
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conditions (including peripartum cardiomyopathy and stroke),
and ectopic pregnancy.
Specialists in internal medicine play an important role in
national efforts to reduce the
maternal mortality ratio.
As stated above, the maternal mortality ratio in the United
States is about
21.5/100,000 live births. In some countries in sub-Saharan
Africa and southern Asia, the
maternal mortality ratio is >500/100,000 live births. The most
common causes of

maternal death in these countries are maternal hemorrhage,
hypertensive disorders,
infection, obstructed labor, and complications from unsafe
pregnancy termination. The
health interventions that would have the greatest impact on
maternal health include
improving the following components of the health system: (1)
access to contraceptive
services in order to space births and limit total family size; (2)
access to safe pregnancy
termination; (3) presence of trained birth attendants at all
deliveries; and (4) transportation
to emergency obstetrical centers that can provide intensive
medical and surgical services,
including cesarean delivery. Maternal death is a global public -
health tragedy that could be
mitigated with the application of modest resources.
SUMMARY
With improved diagnostic and therapeutic modalities as well as
advances in the treatment
of infertility, more patients with serious medical complications
will be seeking to become
pregnant and will require complex obstetric care. Improved
outcomes of pregnancy in
these women will be best attained by a team of internists,
maternal- fetal medicine (high-
risk obstetrics) specialists, pediatricians and anesthesiologists
assembled to counsel
these patients about the risks of pregnancy and to plan their
treatment prior to, and
following, conception. The importance of preconception
counseling cannot be overstated.
It is the responsibility of all physicians caring for women in the
reproductive age group to
assess their patients’ reproductive plans as part of their overall

health evaluation.
ACKNOWLDGEMENT
The authors are grateful to Michael F. Greene and Dan L. Longo
for their contributions to
the content on neoplasia in pregnancy based upon material from
previous editions of
Harrison’s.
FURTHER READING
BRASIL P et al: Zika virus infection in pregnant women in Rio
de Janeiro-preliminary report.
N Engl J Med 375:2321, 2016.
ESPOSITO S et al: Chemotherapy against cancer during
pregnancy: A systematic review on
neonatal outcomes. Medicine (Baltimore) 95:e4899, 2016.
LEFEVRE ML et al: Low-dose aspirin use for the prevention of
morbidity and mortality from
preeclampsia: U.S. Preventive Services Task Force
recommendations statement. Ann
Int Med 161:819, 2014.
MOADDAB A et al: Health care disparities and state-specific
pregnancy- related mortality in
the United States, 2005–2014. Obstet Gynecol 126:869, 2016.
STEWART ZA et al: Closed-loop insulin delivery during
pregnancy in women with Type 1
Diabetes. N Engl J Med 375:644, 2016.
WARE JS et al: Shared genetic predisposition in peripartum and
dilated cardiomyopathies.
N Engl J Med 374:233, 2016.

467 Medical Evaluation of the Surgical Patient
Prashant Vaishnava, Kim A. Eagle
Cardiovascular and pulmonary complications continue to
account for major morbidity
and mortality in patients undergoing noncardiac surgery.
Emerging evidence-based
practices dictate that the internist should perform an
individualized evaluation of the
surgical patient to provide an accurate preoperative risk
assessment and stratification that
will guide optimal perioperative risk-reduction strategies. This
chapter reviews
cardiovascular and pulmonary preoperative risk assessment,
emphasizing the goal-
directed management of patients at elevated risk for adverse
cardiovascular outcomes in
the perioperative period. In addition, perioperative management
of diabetes mellitus and
prophylaxis of endocarditis and for venous thromboembolism
are reviewed.
EVALUATION OF INTERMEDIATE- AND HIGH-RISK
PATIENTS
Simple, standardized preoperative screening questionnaires,
such as the one shown in
Table 467-1, have been developed for the purpose of identifying
patients at intermediate
or high risk who may benefit from a more detailed clinical
evaluation. Evaluation of such
patients for surgery should always begin with a thorough history

and physical
examination and with a 12-lead resting electrocardiogram, in
accordance with the
American College of Cardiology/American Heart Association
guidelines. The history
should focus on symptoms of occult cardiac or pulmonary
disease. The urgency of the
surgery should be determined, as true emergency procedures are
associated with
unavoidably higher morbidity and mortality risk. Preoperative
laboratory testing should be
carried out only for specific clinical conditions, as noted during
clinical examination. Thus,
healthy patients of any age who are undergoing elective surgical
procedures without
coexisting medical conditions should not require any testing
unless the degree of surgical
stress may result in unusual changes from the baseline state.
TABLE 467-1 Standardized Preoperative Questionnairea
aUniversity of Michigan Health System patient information
report. Patients who answer yes to any of questions
2–9 should receive a more detailed clinical evaluation.
Source: Adapted from KK Tremper, P Benedict: Anesthesiology
92:1212, 2000; with permission.
PREOPERATIVE CARDIAC RISK ASSESSMENT
A stepwise approach to cardiac risk assessment and
stratification in patients undergoing
noncardiac surgery is illustrated in Fig. 467-1. The evaluation

begins with characterization
of the combined surgical and clinical risk into categories of low
(<1%) and elevated risk for
major adverse cardiovascular events (MACE). Select surgeries
are associated with very
low risk for MACE; these surgeries and procedures include
select ophthalmologic surgeries
(e.g., cataract surgery), select endoscopic procedures, and select
superficial procedures.
Patients undergoing these low-risk procedures should proceed to
surgery without further
testing. Clinical risk may be estimated with the American
College of Surgeons National
Surgical Quality Improvement Program (NSQIP) risk calculator
(http://www.riskcalculator.facs.org) or with calculation of the
Revised Cardiac Risk Index
(RCRI).
http://www.riskcalculator.facs.org/
FIGURE 467-1 Composite algorithm for cardiac risk assessment
and stratification in patients
undergoing noncardiac surgery. Preoperative evaluation
involves a stepwise clinical evaluation. Those
individuals requiring emergency surgery should proceed without
further risk stratification. Acute
coronary syndrome (step 2) should be evaluated and treated,
accordingly to goal-directed medical

therapy. For patients awaiting non-emergent surgeries and
without acute coronary syndrome,
perioperative risk is a combination of clinical and surgical risk.
Select procedures and surgeries (e.g.,
select endoscopic procedures) are associated with low
perioperative (<1%) risk and no further clinical
testing is generally necessary. For those procedures associated
with elevated risk, an assessment of
functional capacity informs the decision for further testing.
Those individuals with moderate or greater
functional capacity do not require further testing and should
proceed to surgery. Individuals with poor
or unknown functional capacity may require pharmacologic
stress testing if it would change decision-
making or perioperative care. (From LA Fleisher et al:
Circulation 2014;130:e278-e333, with permission.)
Previous studies have compared several cardiac risk indices.
The American College of
Surgeons’ National Surgical Quality Improvement Program
prospective database has
identified five predictors of perioperative myocardial infarction
(MI) and cardiac arrest
based on increasing age, American Society of Anesthesiologists
class, type of surgery,
dependent functional status, and abnormal serum creatinine
level. However, given its
accuracy and simplicity, the RCRI (Table 467-2) is often the
favored risk index. The RCRI
relies on the presence or absence of six identifiable predictive
factors: high-risk surgery,
ischemic heart disease, congestive heart failure, cerebrovascular
disease, diabetes
mellitus treated with insulin, and renal insufficiency with a
creatinine >2.0 mg/dL. Each of
these predictors is assigned one point. The risk of major cardiac

events—defined as MI,
pulmonary edema, ventricular fibrillation or primary cardiac
arrest, and complete heart
block—can then be predicted. Based on the presence of none,
one, two, three, or more of
these clinical predictors, the rate of development of one of these
four major cardiac events
is estimated to be 0.4, 0.9, 7, and 11%, respectively (Fig. 467-
2). An RCRI score of 0
signifies a 0.4–0.5% risk of cardiac events; RCRI 1, 0.9–1.3%;
RCRI 2, 4–7%; and RCRI ≥3,
9–11%. The clinical utility of the RCRI is to identify patients
with three or more predictors
who are at very high risk (≥11%) for cardiac complications and
who may benefit from
further risk stratification with noninvasive cardiac testing,
initiation of preoperative
preventive medical management, or avoidance of surgery.
FIGURE 467-2 Risk stratification based on the revised cardiac
risk index; derivation and prospective
validation of a simple index for prediction of cardiac risk in
patients undergoing major noncardiac
surgery. Cardiac events include myocardial infarction,
pulmonary edema, ventricular fibrillation, cardiac
asystole, and complete heart block. (Adapted from TH Lee et al:
Circulation 100:1043, 1999.)
TABLE 467-2 Clinical Markers Included in the Revised Cardiac
Risk Index
High-Risk Surgical Procedures

Vascular surgery (except carotid endarterectomy)
Major intraperitoneal or intrathoracic procedures
Ischemic Heart Disease
History of myocardial infarction
Current angina considered to be ischemic
Requirement for sublingual nitroglycerin
Positive exercise test
Pathological Q-waves on ECG
History of PCI and/or CABG with current angina considered to
be ischemic
Congestive Heart Failure
Left ventricular failure by physical examination
History of paroxysmal nocturnal dyspnea
History of pulmonary edema
S3 gallop on cardiac auscultation
Bilateral rales on pulmonary auscultation
Pulmonary edema on chest x-ray
Cerebrovascular Disease
History of transient ischemic attack
History of cerebrovascular accident
Diabetes Mellitus
Treatment with insulin
Chronic Renal Insufficiency
Serum creatinine >2 mg/dL
Abbreviations: CABG, coronary artery bypass grafting; ECG,
electrocardiogram; PCI, percutaneous coronary
interventions.
Source: Adapted from TH Lee et al: Circulation 100:1043,
1999.

For patients at elevated combined clinical and surgical risk for
MACE, the stepwise
perioperative cardiac assessment for coronary artery disease
(CAD) proceeds with
consideration of functional capacity. Participation in activities
of daily living offers an
expression of functional capacity, often expressed in terms of
metabolic equivalents
(METs). For predicting perioperative events, poor exercise
tolerance has been defined as
the inability to walk four blocks or climb two flights of stairs at
a normal pace or to meet a
MET level of 4 (e.g., carrying objects of 15–20 lb or playing
golf or doubles tennis)
because of the development of dyspnea, angina, or excessive
fatigue (Table 467-3).
Patients with moderate or greater (≥4 METs) functional capacity
(e.g., climbing up a flight
of stairs, walking up a hill, or walking on level ground at 4
mph) generally should not
undergo further non-invasive cardiac testing prior to elective
non-cardiac surgery. Those
patients with poor (<4 METs) or unknown functional capacity
should undergo
pharmacological stress testing if the results of such testing
would impact decision-
making or perioperative care.
TABLE 467-3 Assessment of Cardiac Risk by Functional Status
PREOPERATIVE NONINVASIVE CARDIAC TESTING FOR
RISK
STRATIFICATION
There is little evidence to support widespread application of
preoperative noninvasive
cardiac testing for all patients undergoing major surgery. The

current paradigm to guide
the need for noninvasive cardiac testing is to perform such
testing in patients with poor or
unknown capacity if it would alter clinical management or
modify perioperative care.
Options for pharmacological stress testing include dobutamine
stress echocardiography
or myocardial perfusion imaging with coronary vasodilator
stress (dipyridamole,
adenosine, or regadenoson) with thallium-201 and/or
technetium-99m. Routine screening
with noninvasive stress testing is not recommended in patients
at low risk for noncardiac
surgery. Furthermore, coronary revascularization before
noncardiac surgery is not
recommended for the express purpose of reducing perioperative
cardiac events. That said,
revascularization before noncardiac surgery should be
considered in patients if it would be
indicated regardless of the surgery planned and instead
according to clinical practice
guidelines. In the Coronary Artery Revascular Prophylaxis tri al,
there were no differences in
perioperative and long-term cardiac outcomes with or without
preoperative coronary
revascularization; of note, patients with left main disease were
excluded.
RISK MODIFICATION: PREVENTIVE STRATEGIES TO
REDUCE CARDIAC RISK

Perioperative Coronary Revascularization Prophylactic
coronary revascularization with
either coronary artery bypass grafting (CABG) or percutaneous
coronary intervention (PCI)
provides no short- or mid-term survival benefit for patients
without left main CAD or three-
vessel CAD in the presence of poor left ventricular systolic
function and is not
recommended for patients with stable CAD before noncardiac
surgery. Although PCI is
associated with lower procedural risk than is CABG in the
perioperative setting, the
placement of a coronary artery stent soon before noncardiac
surgery may increase the risk
of bleeding during surgery if dual antiplatelet therapy (DAPT)
(aspirin and thienopyridine)
is administered; moreover, stent placement shortly before
noncardiac surgery increases
the perioperative risk of MI and cardiac death due to stent
thrombosis if such therapy is
withdrawn prematurely (Chap. 270). It is recommended that, if
possible, elective
noncardiac surgery be delayed 30 days after placement of a bare
metal intracoronary
stent and ideally for 6 months after deployment of a drug-
eluting stent. Contemporary
stent platforms allow for greater flexibility in the earlier
interruption of DAPT; current
clinical practice guidelines do suggest consideration of elective
noncardiac surgery 6
months after drug eluting stent (DES) implantation if the risk of
further delaying surgery
exceeds the risk of stent thrombosis/myocardial ischemia. For
patients who must undergo
noncardiac surgery early (>14 days) after PCI, balloon
angioplasty without stent

placement appears to be a reasonable alternative because DAPT
is not necessary in such
patients.
PERIOPERATIVE PREVENTIVE MEDICAL
THERAPIES The goal of perioperative preventive medical
therapies with β-adrenergic antagonists, hydroxymethylglutaryl-
coenzyme A (HMG-CoA)
reductase inhibitors (statins), and antiplatelet agents is to
reduce perioperative adrenergic
stimulation, ischemia, and inflammation, all of which are
heightened during the
perioperative period.
B-ADRENERGIC ANTAGONISTS The use of perioperative
beta blockade should be based on a
thorough assessment of a patient’s perioperative clinical and
surgery-specific cardiac risk
(e.g., as with the RCRI). The paradigm for beta blockade in the
perioperative period has
shifted in recent years owing, firstly, to the publication of the
PeriOperative Ischemic
Evaluation (POISE) trial demonstrating that, while
perioperative beta blockade reduces the
perioperative risk for MI, this is at the expense of increased
death and stroke. Regarding
POISE, this trial has been criticized for the use of an excessive
dose of beta blocker in the
perioperative period and one that may not be reflective of
clinical practice, nor one that
was titrated in the days or weeks preceding the procedure or
surgery. Secondly, research
misconduct has discredited the Dutch Echocardiographic
Cardiac Risk Evaluation
Applying Stress Echocardiography (DECREASE) family of
studies, which previously

file://view/books/9781259644047/epub/OEBPS/part6f.html#c h2
70
contributed to the bedrock of data supporting the use of
perioperative beta blockade but
have now been retracted.
Current guidelines emphasize the following key points:
1. Continuation of beta blockade in patients undergoing surgery
and who have been
receiving such therapy chronically.
2. Avoidance of beta-blocker withdrawal or initiation on the day
of surgery.
3. Consideration of initiation of beta-blocker therapy
perioperatively (ideally far enough in
advance to assess safety and tolerability) in very select high-
risk patients, namely,
those with intermediate- or high-risk ischemia or three more
RCRI risk factors.
HMG-COA REDUCTASE INHIBITORS (STATINS) A
number of prospective and retrospective
studies support the perioperative prophylactic use of statins for
reduction of cardiac
complications in patients with established atherosclerosis. For
patients undergoing
noncardiac surgery and currently taking statins, statin therapy
should be continued to
reduce perioperative cardiac risk. Initiation of statin therapy is
reasonable for patients

undergoing vascular surgery independent of clinical risk.
Perioperative initiation of statin
therapy should be considered in patients undergoing elevated
risk procedures if there is an
indication for such therapy separate from the surgery and
according to clinical practice
guidelines.
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
It is important to maintain continuity of
therapy with ACE inhibitors (when such therapy is used for the
treatment of heart failure or
hypertension).
ORAL ANTIPLATELET AGENTS The 4- to 6-week period
following implantation of an
intracoronary stent (bare metal or drug eluting) constitutes the
period of time of greatest
risk for the development of stent thrombosis. If possible,
noncardiac surgery should be
avoided in this vulnerable period. The duration of DAPT
thereafter is dictated by the
circumstances in which PCI was performed and whether the
indication was stable
ischemic heart disease or acute coronary syndrome. For the
former among patients
treated with a drug eluting stent, dual anti-platelet therapy
should be given for at least 6
months. For the latter, dual anti-platelet therapy should be
given for at least 12 months.
However, DAPT may be interrupted to allow for noncardiac
surgery 30 days after BMS and
6 months after DES, respectively. If P2Y12 inhibitor therapy
(clopidogrel, prasugrel, or
ticagrelor) is interrupted or discontinued in patients who have
received intracoronary

stents, aspirin should be continued perioperatively (save select
circumstances where the
risk of bleeding may be catastrophic as in neurosurgical or
spinal procedures) and the
P2Y12 receptor inhibitor should be restarted as soon as possible
post-operatively.
Decisions surrounding antiplatelet management in the
perioperative setting among
patients who have received intracoronary stents are complex and
should involve
multidisciplinary decision-making.
α2 AGONISTS Based on the results of POISE-2 (a large
multicenter, international, blinded
randomized clinical trial of aspirin and clonidine), α2 agonists
for prevention of cardiac
events are not recommended in patients who are undergoing
noncardiac surgery. In this
trial, clonidine increased the rate of nonfatal cardiac arres t and
clinically important
hypotension, while reducing the rate of death or nonfatal MI.
CALCIUM CHANNEL BLOCKERS Evidence is lacking to
support the use of calcium channel
blockers as a prophylactic strategy to decrease perioperative
risk in major noncardiac
surgery.
ANESTHETICS Mortality risk is low with safe delivery of
modern anesthesia, especially
among low-risk patients undergoing low-risk surgery (Table
467-4). Inhaled anesthetics

have predictable circulatory and respiratory effects: all decrease
arterial pressure in a
dose- dependent manner by reducing sympathetic tone and
causing systemic
vasodilation, myocardial depression, and decreased cardiac
output. Inhaled anesthetics
also cause respiratory depression, with diminished responses to
both hypercapnia and
hypoxemia, in a dose-dependent manner; in addition, these
agents have a variable effect
on heart rate. Prolonged residual neuromuscular blockade also
increases the risk of
postoperative pulmonary complications due to reduction in
functional residual lung
capacity, loss of diaphragmatic and intercostal muscle function,
atelectasis, and arterial
hypoxemia from ventilation-perfusion mismatch.
TABLE 467-4 Gradation of Mortality Risk of Common
Noncardiac Surgical Procedures
Several meta-analyses have shown that rates of pneumonia and
respiratory failure are
lower among patients receiving neuroaxial anesthesia (epidural
or spinal) rather than
general anesthesia. However, there were no significant
differences in cardiac events
between the two approaches. Evidence from a meta-analysis of
randomized controlled
trials supports postoperative epidural analgesia for >24 h for the
purpose of pain relief.
However, the risk of epidural hematoma in the setting of
systemic anticoagulation for
venous thromboembolism prophylaxis (see below) and
postoperative epidural
catheterization must be considered.

PREOPERATIVE PULMONARY RISK ASSESSMENT
Perioperative pulmonary complications occur frequently and
lead to significant morbidity
and mortality. Clinical practice guidelines recommend the
following:
1. All patients undergoing noncardiac surgery should be
assessed for risk of pulmonary
complications (Table 467-5).
TABLE 467-5 Predisposing Risk Factors for Pulmonary
Complications
1. Upper respiratory tract infection: cough, dyspnea
2. Age >60 years
3. Chronic obstructive pulmonary disease
4. Cigarette use
5. American Society of Anesthesiologists Class ≥2
6. Functional dependence
7. Congestive heart failure
8. Serum albumin <3.5 g/dL
9. Obstructive sleep apnea
10. Impaired sensorium (confusion, delirium, or mental status
changes)
11. Abnormal findings on chest examination
12. Alcohol use
13. Weight loss
14. Spirometry threshold before lung resection
a. FEV1 <2 L
b. MVV <50% of predicted

c. PEF <100 L or 50% predicted value
d. PCO2 ≥45 mmHg
e. PO2 ≤50 mmHg
2. Patients undergoing emergency or prolonged (3–4 h) surgery;
aortic aneurysm repair;
vascular surgery; major abdominal, thoracic, neurologic, head,
or neck surgery; and
general anesthesia should be considered to be at elevated risk
for postoperative
pulmonary complications.
3. Patients at higher risk of pulmonary complications should
undergo incentive
spirometry, deep-breathing exercises, cough encouragement,
postural drainage,
percussion and vibration, suctioning and ambulation,
intermittent positive-pressure
breathing, continuous positive airway pressure, and selective
use of a nasogastric tube
for postoperative nausea, vomiting, or sympto matic abdominal
distention to reduce
postoperative risk. Multiple pulmonary risk indices are
available to estimate the
postoperative risk of respiratory failure, pneumonia, and other
pulmonary
complications; among these is the ARISCAT risk index, which
accounts for the
following seven risk factors: age, low preoperative oxygen
saturation, respiratory
infection within the preceding month, upper abdominal or
thoracic surgery, surgery
lasting >2 h, and emergency surgery (Table 467-6).
TABLE 467-6 Risk Modification to Reduce Perioperative

Pulmonary Complications
Preoperatively
• Cessation of smoking for at least 8 weeks before and until at
least 10 days after
surgery
• Training in proper lung expansion techniques
• Inhalation bronchodilator and/or steroid therapy, when
indicated
• Control of infection and secretion, when indicated
• Weight reduction, when appropriate
Intraoperatively
• Limited duration of anesthesia
• Avoidance of long-acting neuromuscular blocking drugs, when
indicated
• Prevention of aspiration and maintenance of optimal
bronchodilation
Postoperatively
• Optimization of inspiratory capacity maneuvers, with attention
to:
• Mobilization of secretions
• Early ambulation
• Encouragement of coughing
• Selective use of a nasogastric tube
• Adequate pain control without excessive narcotics
4. Preoperative spirometry and chest radiography should not be
used routinely for
predicting risk of postoperative pulmonary complications but
may be appropriate for

patients with chronic obstructive pulmonary disease or asthma.
5. Spirometry is of value before lung resection in determining
candidacy for coronary
artery bypass; however, it does not provide a spirometric
threshold for extrathoracic
surgery below which the risks of surgery are unacceptable.
6. Pulmonary artery catheterization, administration of total
parenteral nutrition (as
opposed to no supplementation), or total enteral nutrition have
no consistent benefit in
reducing postoperative pulmonary complications.
PERIOPERATIVE MANAGEMENT AND PROPHYLAXIS
DIABETES MELLITUS
(See also Chaps. 396–398) Many patients with diabetes mellitus
have significant
symptomatic or asymptomatic CAD and may have silent
myocardial ischemia due to
autonomic dysfunction. Intensive (versus lenient) glycemic
control in the perioperative
period is generally not associated with improved outcomes, and
may increase the risk of
hypoglycemia. Practice guidelines advocate a target glucose
range from 100 to 180
mg/dL in the perioperative period. Oral hypoglycemic agonists
should not be given on the
morning of surgery. Perioperative hyperglycemia should be
treated with IV infusion of
short-acting insulin or SC sliding-scale insulin. Patients whose
diabetes is diet controlled
may proceed to surgery with close postoperative monitoring.
INFECTIVE ENDOCARDITIS

(See also Chap. 123) Prophylactic antibiotics should be
administered to the following
patients before dental procedures that involve manipulation of
gingival tissue,
manipulation of the periapical region of teeth, or perforation of
the oral mucosa: those
with prosthetic cardiac valves (including transcatheter
prosthetic valves); prosthetic
material used in valve repair (annuloplasty ring or artificial
chord); previous infective
endocarditis; cardiac transplant recipients with valvular
regurgitation from a structurally
abnormal valve; and unrepaired cyanotic congenital heart
disease or repaired congenital
file://view/books/9781259644047/epub/OEBPS/part5b.html#ch1
23
heart disease, with residual shunts or valvular regurgitation at
the site of adjacent to the
site of a prosthetic patch or prosthetic device.
VENOUS THROMBOEMBOLISM
(See also Chap. 273) Perioperative prophylaxis of venous
thromboembolism should
follow established guidelines of the American College of Chest
Physicians. Aspirin is not
supported as a single agent for thromboprophylaxis. Low -dose
unfractionated heparin
(≤5000 units SC bid), low-molecular weight heparin (e.g.,
enoxaparin, 30 mg bid or 40 mg
qd), or a pentasaccharide (fondaparinux, 2.5 mg qd) is
appropriate for patients at

moderate risk; unfractionated heparin (5000 units SC tid) is
appropriate for patients at
high risk. Graduated compression stockings and pneumatic
compression devices are
useful supplements to anticoagulant therapy or in patients at
excessive bleeding risk.
FURTHER READING
FLEISHER LA et al: 2014 ACC/AHA Guideline on
perioperative cardiovascular evaluation
and management of patients undergoing noncardiac surgery.
Circulation 130:e278,
2014.
LEVINE GN et al: 2016 ACC/AHA guideline focused update on
duration of dual antiplatelet
therapy in patients with coronary artery disease. A Report of the
American College of
Cardiology/American Heart Association Task Force on Clinical
Practice Guidelines. J
Am Coll Cardiol 68:1082, 2016.
NISHIMURA RA et al: 2017 AHA/ACC focused update of the
2014 AHA/ACC guideline for
the management of patients with valvular heart disease. A
report of the American
College of Cardiology/American Heart Association Task Force
on clinical practice
guidelines. Circulation 135:1, 2017.
SMETANA GW et al: American College of Physicians.
Preoperative pulmonary risk
stratification for noncardiothoracic surgery: Systematic review
for the American
College of Physicians. Ann Intern Med 144:581, 2006.

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73
Grader - Instructions Access 2019
ProjectGO19_AC_CH02_GRADER_2E_HW - Biology Supplies
1.1
Project Description:
In this project, you will use a database to answer questions
about biology laboratory supplies at a college. You will open
and save an existing database, create a relationship between two
tables, sort records in a table, create queries in Design view,
create queries from existing queries, sort query results, and
specify criteria in a query.
Steps to Perform:
Step
Instructions
Points Possible
1
Start Access. Open the downloaded file named
Student_Access_2E_Biology_Supplies.accdb, and enable the
content.
0
2
Using Vendor ID as the common field, create a one-to-many
relationship between the 2E Vendors table and the 2E Biology
Lab Supplies table. Enforce referential integrity and enable both
cascade options.
6
3
Create a relationship report with normal margins. Save it as 2E
Relationships Close all open objects.
6
4
In the last record of the 2E Vendors table, change the data in
the Vendor ID field from V-100 to V-001, save and then close

the table. (The related records in the 2E Biology Lab Supplies
table will automatically update.)
3
5
Open your 2E Biology Lab Supplies table. Sort the records first
in Descending order by Price Per Item and then in Ascending
order by Category. Close the table, saving changes to the table.
5
6
Create a query in Query Design view based on the 2E Biology
Lab Supplies table to answer the question: What is the item ID,
item name, room, location, and quantity in stock for all of the
items, sorted in ascending order by the Room field and the
Location field? Display the fields in the order listed in the
question. Save the query as 2E Items by Room Query. Close the
query.
15
7
Copy the 2E Items by Room Query to create a new query with
the name 2E Item Categories Query. Redesign the query to
answer the question: What is the item ID, item name, category,
vendor ID, and quantity in stock for all items, sorted in
ascending order by the Category field and the Vendor ID field?
Display only the fields necessary to answer the question and in
the order listed in the question. Be sure that the fields are sorted
in the correct order in Design view, so that the results display
the categories in ascending order, then the Vendor IDs within
each category in ascending order. Close the query, saving the
design changes.
16
8
Copy the 2E Items by Room Query to create a new query with
the name 2E Supplies Sort Query. Redesign the query to answer
the question: What is the item name, category, price per item,
and quantity in stock for all supplies, sorted in ascending order
by the Category field and then in descending order by the Price

Per Item field? Display only the fields necessary to answer the
question and in the order listed in the question. Close the query,
saving the design changes.
16
9
Copy the 2E Supplies Sort Query to create a new query with the
name 2E Kits Query. Redesign the query to answer the question:
What is item name, category, price per item, quantity in stock,
and vendor ID for all items that have a category of kits, sorted
in ascending order by the Item Name field? Do not display the
Category field in the query results, and display the rest of the
fields in the order listed in the question. Run the query; six
records match the criteria. Close the query, saving the design
changes
20
10
Create a query in Query Design view based on the 2E Vendors
table to answer the question: What is the vendor ID, vendor
name, and phone number where the phone number is blank,
sorted in ascending order by the Vendor Name field? Display
the fields in the order listed in the question. Run the query; two
records match the criteria. Save the query as 2E Missing Phone
Query. Close the query.
13
11
Be sure that all database objects are closed, open the Navigation
Pane, and then close Access. Submit the
Student_Access_2E_Biology_Supplies.accdb database as
directed.
0
Total Points
100
Created On: 07/11/2019 1
GO19_AC_CH02_GRADER_2E_HW - Biology Supplies
1.1

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