169 GDM & Hypertensive Disorders of Pregnancy: Screening, Severe Features & Magnesium Traps for the PANCE

Hello and welcome to episode 169 of the Physician Assistant Exam Review Podcast. We’ve got some really exciting things coming your way today. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review. And today we have two major major, oh, two major things going on. One is tonight I’m offering a free class on unlocking your potential as a student. What we’re going to do is we’re going to cover the six skill areas and define them for you and show you which ones are holding you back and how to fix them.

Tonight at 8 p.m. Eastern time, if you go to physicianassistantexamreview.com/masterclass, you can register for that. There’s also another. We’re going to do it again on Sunday. So if you can’t make the show tonight, then you can definitely come on Sunday and take a look at that. The other piece is today is the launch of registration for the August cohort of 33 Days to Pass the PANCE. If you are struggling on EORs, if you’re struggling in didactic year, if you can’t figure out why your scores aren’t moving, that’s exactly what we do.

If you’ve taken the PANCE, if you failed the PANCE, if you’re worried about it coming up, exactly what we cover is the skills necessary to learn medicine and to score well on high stakes exams. It’s not just about the content. We’ll talk about that today during the show. But if you’re concerned that you’re not a good test-taker, that you have test-taking anxiety, that you have not retaining the information the way that you would want to be and understanding the questions the way that you think that you should be, all of those things are things we cover inside of 33 Days to Pass the PANCE. And if you’re interested in that, you can go check out physicianassistantexamreview.com/33. It’s going to be open for the next few days. I think it’s into next Wednesday, Tuesday or Wednesday, either way.

You can find out on the website which of those it is, but we do need to get started. I think it’s the 29th. It’s the onboarding call and then we jump into things beginning August 1st. One question I get a lot about that program is one, it’s designed to not take up time on your day. It’s designed for clinical and didactic students to have the biggest impact in the smallest amount of time. So time is something I took very seriously when I designed it. And then the other thing is when should you take it?

Well, you have access to all the videos, all the coursework, everything inside of it indefinitely at this point. So you can use everything that’s in there. So our recommendation is take it early so you can learn these skills and then apply them to your entire journey and get better at them over time before the PANCE. But if you’re concerned and you’re close to the PANCE, that’s a million times better than not doing it. You’re still going to get the skills. You’re still going to get everything. But if you’re concerned about taking it early, we do provide you with access to everything indefinitely.

So that’s not a concern.

All right. Today, we’re going to continue with pregnancy and we’re going to cover gestational diabetes and hypertensive disorders.

Let’s jump right into our priming questions. Right upper quadrant pain with a low platelet count after 20 weeks points to what diagnosis? Right upper quadrant pain with a low platelet count after 20 weeks. What are we talking about? What’s the initial screening test for gestational diabetes? That one might take you a minute. What’s the initial screening test for gestational diabetes?

What’s the preferred medication? When diet and exercise fail to control gestational diabetes, what do we start with? Name three severe features of preeclampsia. Three severe features of preeclampsia. And what’s the earliest sign of magnesium toxicity?

All right. So let’s jump in and get started with gestational diabetes. To begin with, we’ll get into hypertension and those things in a second. Gestational diabetes, glucose intolerance first recognized during pregnancy. That’s the key here. It’s distinct from preexisting diabetes that predates or is present before 20 weeks. That would just be regular diabetes, right?

This is gestational diabetes. Risk factors here are obesity, so BMI greater than 30. This is the strongest modifiable risk factor. As always, prior gestational diabetes is a huge risk factor. Recurrence rate is about 50%. Prior large baby, macrosomia. History of type two diabetes, polycystic ovarian syndrome, PCOS, glucosuria on prenatal urinalysis.

These are all risk factors. Being of Hispanic, black, Asian, Native American, or Pacific Islander descent. That is also included in the list for risks. And advanced maternal age or multiparity. Clinical presentation. So this doesn’t really have a clinical presentation, right? You’re not going to see gestational diabetes.

This is going to be something we’re screening for. Those are the reasons why we do this though, right? So it’s not that you’re seeing the diabetes, you’re seeing what happens because of it. So in moms, it can lead to preeclampsia, polyhydramnios, increased C-section rate, type two diabetes later in life. For the fetus, you can get macrosomia, which might lead to shoulder dystocia or birth trauma, brachial plexus injuries, and so on. One thing I want to point out is that congenital anomalies like cardiac issues or neural tube defects are complications of pre-gestational diabetes, not gestational diabetes. So it happens before gestational diabetes would kick in.

So the question stem would likely be about screening, more likely than anything else. Maybe about complications, but usually it’s going to be about screening here.

So let’s talk about screening. Universal screening is at 24 to 28 weeks for all pregnant patients. I would write that down and put it up on a note on my wall because that’s something I would absolutely want to know. Step one is a one-hour glucose challenge test. This is a 50-gram oral glucose load, no fasting required. The cutoff is greater than 130 to 140, depending on where you’re at, sort of, you know, each lab’s a little different. If they’re abnormal, you go on to a three-hour glucose tolerance test.

So the key here is the one hour you don’t have to fast for, and it’s a 50-gram glucose load. And we’re going to measure to 130, 140. Step two is a three-hour glucose tolerance test. This is a 100-gram oral glucose load, and this does require fasting. If two or more values meet or exceed the threshold, we say that the patient has gestational diabetes. So first is at fasting if they’re over 95. Second is one hour past the challenge, if they’re at over 180.

At two hours over 155, and at three hours over 140. I know those are hard to listen to, you should look those up, and I would post those on my wall as well because those are going to be test questions. So you want to understand the first step in the glucose challenge test, and then the second step, and definitely have a good handle on each because you’re going to get asked about them.

Now, if a patient has type 2, I’m sorry, if a patient has gestational diabetes, there’s class A1 and A2. A1 is controlled with diet and exercise. That’s the plan. A2 requires medication, so this insulin is the preferred source here. We’re also going to be looking more at fetal surveillance and early delivery. Next line, of course, is going to be nutritional and exercise, carbohydrate restriction, aerobic exercise. This will work for most patients, like 70 to 80% from what I could find.

So we’re targeting a less than 95 glucose, right? But if after one to two weeks, we can’t get there, I’m sorry, that’s on fasting. If we can’t get there, then we’re going to start talking about insulin, metformin next, glyburide next. Keys here, exam keys, would be just understanding the screening test, the one hour glucose tolerance test, and the three hour test, followed by what it might mean for a patient has gestational diabetes, their increased risks, and the risks of the baby. And that we’re going to try to start with diet and exercise, but if that doesn’t get it under control quickly, we’re going to move to insulin as our mainstay. We’re also going to have to treat postpartum because usually it doesn’t resolve right away. So gestational diabetes always seemed hard to me when I was in school, but the reality is there’s not a whole lot of things you’re going to ask you about, right?

You’re really going to get asked about the screening and some of the risk factors that go into that are for gestational diabetes and some of the risk factors it creates. That’s really all they can ask, so it’s not nearly as complicated as it might seem.

All right, let’s move into hypertensive disorders of pregnancy. So this is a spectrum of blood pressure disorders occurring during pregnancy, classified by timing, presence of proteinuria, and end organ dysfunction. And just like GDM, what are our risk factors for preeclampsia? Well, prior preeclampsia is the highest recurrence risk. Nulliparity, so the first pregnancy, chronic hypertension, chronic kidney disease, diabetes coming in, obesity, multiple gestations, autoimmune disease like SLE, anti-phospholipid syndrome, those kinds of things. And obviously always advanced maternal age and also assisted reproductive technology. So anything where we’re doing donor eggs or things are at an increased risk for preeclampsia.

Let’s define what we’re talking about. Chronic hypertension is BP greater than 140 over 90, present before pregnancy or before 20 weeks, just like GDM, before 20 weeks. This is preexisting and will likely persist postpartum. Gestational hypertension is new onset above 140 over 90. That’s after 20 weeks without proteinuria or severe features. This is gestational hypertension and it usually clears out about 12 weeks after delivery postpartum. Chronic hypertension is just, again, normal hypertension, go over 140 over 90, before 20 weeks.

Gestational hypertension is the same thing but only occurring after 20 weeks.

Okay, let’s talk about preeclampsia. This is new onset with blood pressure over 140 over 90 after 20 weeks with proteinuria or any severe feature even without proteinuria. So BP greater than 160 over 110, thrombocytopenia, so platelets under 100,000. Renal insufficiency, so creatinine greater than 1.1 or doubling from baseline, impaired liver function or severe right upper quadrant or epigastric pain, pulmonary edema, new onset headaches, unresponsive to medication or visual disturbances. All of that would be classified as preeclampsia. Let me talk about that again just to make sure that we’re clear. So preeclampsia has a sort of a spectrum.

You have to have a blood pressure of 140 over 90, right? Bigger than that, after 20 weeks. But in addition to that, if you have proteinuria, then we’re calling it preeclampsia. If a 24-hour urine protein is greater than 300 milligrams or a dipstick is 2 plus, then we’re calling it preeclampsia. Or even without proteinuria, if they have a really high BP, if they have a really low platelet count, if they have renal insufficiency, if they have impaired liver function, if they have pulmonary edema or new onset headaches that can’t be resolved or visual disturbances, we’re calling this preeclampsia.

Now, what’s the difference to the step of eclampsia rather than preeclampsia? Eclampsia is all of those factors above, plus new onset generalized seizures with no seizure history. So for obvious reasons, we do not want to progress to eclampsia. We want to avoid having seizures, but that’s the delineating mark. The next step here is HELLP syndrome. Hemolysis, elevated liver enzymes, low platelets. Consider a variant of severe preeclampsia.

This may present with right upper quadrant pain or epigastric pain, so we said that earlier, but you want to turn up the dial a little when you see this. You may have nausea, malaise, and bruising, sometimes without classic hypertension or proteinuria, so don’t miss it. This is definitely something that can be missed both in the clinic and on your exams. So if you have high blood pressure and right upper quadrant pain, we need to stop and think. You can also have hyperreflexia and clonus. These are warning signs of impending eclampsia. These are not… diagnostic, but something they’ll just look for. So our question stem would likely be a patient with hypertension, proteinuria, or a question about what constitutes a severe feature? So you need to know the different pieces to this and be able to pull it together and take it apart again. How do we diagnose it? Well, we just pretty much went through that, right? Blood pressure. You have to do two readings at least four hours apart to confirm a sustained elevation.

Urinalysis would be a spot protein and creatinine ratio or 24-hour urine protein. You’re going to do a CBC, metabolic panels, LDH, uric acids, continuous fetal monitoring, of course. Treatment. The only definitive treatment is delivery. This is important, right? The only definitive treatment is delivery of the child. But if you have gestational hypertension or mild preeclampsia, you can just kind of watch with close monitoring to get greater than 160 over 110 as well.

When they recommend you start introducing antihypertensives, I don’t work in OB, so you might want to double-check that. If a patient has preeclampsia over 37 weeks, sorry, after 37 weeks, the idea is you just deliver the baby because this is going to solve the problem after 37 weeks. We’re far enough along in development.

Now, if you have preeclampsia with severe features, you’re going to consider delivery at greater than 34 weeks. If less than 34 weeks maternal and fetal status allows, you want to try to get rid of it. It sort of comes into this gray zone at under 34 weeks, but you have to balance everyone’s health with the risk of delivering early. What about if you have true seizures and true preeclampsia? What medications do you give at this point? Well, magnesium sulfate IV should help with the seizures so that you can stabilize for delivery. One concern with magnesium is the toxicity level.

So you lose deep tendon reflexes, then respiratory depression, then cardiac arrest. So you’re giving IV, and then you’re giving it magnesium sulfate to break seizures. It’s something to keep an eye on. So you want to monitor deep tendon reflexes, respiratory depression, and cardiac arrest. This is an interesting just side note. I don’t think you’ll get this, but what’s the antidote for a magnesium toxicity? Calcium gluconate, IV.

If you have acute severe hypertension, so greater than 160 over 110, we really need to start treating this, and we want to be giving IV labetalol or IV hydralazine. You can also do oral nifedipine. We’re concerned about strokes and end-organ damage when we start getting above those levels. What do we want to avoid from a hypertension medication standpoint in a pregnant woman? If you studied this, hopefully you retained it because it is important. You want to avoid ACE inhibitors and ARBs in pregnancy because it can cause fetal renal toxicity. For HELLP syndrome, again, it’s delivery is the treatment.

Okay, so what are our exam keys for today? Pre-eclampsia is hypertension after 20 weeks plus proteinuria or severe features? No, the severe features. Eclampsia is pre-eclampsia plus seizures. How do we treat it? Magnesium. HELLP syndrome is hemolysis, elevated LFTs, low platelets, right upper quadrant pain, thrombocytopenia.

This you have to keep an eye out for because it may present kind of weird. How do we treat magnesium toxicity? What are we looking for? Deep tendon reflexes. Calcium gluconate, we’ll reverse it. And again, the mainstay of treatment here is deliver the baby. Deliver the baby.

Perfect. I know that was a lot, so I don’t want to go much deeper into content today. That was just a big section, gestational diabetes and hypertension in pregnancy. It’s a lot to remember. So I’m not going to take this any further. We’re going to quit there.

So let’s talk about our study tip for today. Our study tip for today is going to be really simple. And in light of registration for 33 Days to Pass the PANCE, in light of the Master Class I’m hosting tonight, I also did a workshop for a university program today this morning on a similar topic. And I’m going to share a little bit of that with you. And the main topic of all of these things is to understand that there’s more to high stakes exams than knowing the content. I like to think of the equation as content multiplied by skills gives you your score. All the content in the world and no skills in test taking, no skills in anxiety management, no skills in studying to retain information well for exams, and you’ll wind up not doing well.

No content and all the skills in the world and you won’t do well. These two go together and you can know a little and have high skills and pass. You can know a lot and have low skills and pass, but they have to cross somewhere. So the point of this is when you’re studying, when you’re getting ready for things, when you’re preparing for your high stakes exams, when you’re preparing for end of rotation exams, even in didactic year, consider the whole picture. Take some percentage of the time, maybe 15%, maybe 20%, and look at your approach to studying. Some people will do that. A lot of good students find out that they’re not strong studiers.

They don’t want to admit it, but eventually they’re forced to like I was in PA school and they start finding new ways to study. But very few people take the next step and evaluate how they are at test taking. They say I’m bad at test taking, but they do no thought into what they’re actually doing. They do no post-game analysis on what they did well, what they didn’t do well, how to improve, how to get better. They don’t stop and think about different techniques, different resources for test taking, for helping the information come to top of mind, for staying calm, for performing at their very best. So I’m asking for our study tip for today. It’s consider the whole picture, consider the whole package.

Don’t just rely on content alone. You can do it on content alone, but it’s hard. It’s so much easier if you just incorporate a few skills and learn a few techniques.

All right, let’s answer our priming questions. Right upper quadrant pain with low platelet count after 20 weeks points to what diagnosis? Hopefully this jumps out now. It’s HELLP syndrome, hemolysis, elevated liver enzymes, and low platelets. What’s the initial screening test for gestational diabetes? What’s the one hour glucose challenge test? What was that, do you remember?

50 grams of glucose load, no fasting. When do we do it? 24 to 28 weeks. What’s the preferred medication when diet and exercise fail to control gestational diabetes? Insulin. Name three severe features for preeclampsia, any three of blood pressure over 160 over 110, higher platelets, I’m sorry, or higher, I read that wrong, 160 over 110 or higher, platelets under 100,000, I thought that sounded funny, platelets under 100,000, or creatinine over 1.1, liver enzymes doubled, pulmonary edema, severe headaches, or visual changes that you can’t control. What’s the earliest sign of magnesium toxicity?

We just said this one, loss of deep tendon reflexes.

Excellent work today, excellent work.

All right, so if this helped you in any way, please pass it along to your faculty, please pass it around to your classmates, anyone you think that this might be helpful for. If you are not already planning on joining us this evening or on Sunday, please go ahead and register at physicianassistantexamreview.com/masterclass, where we’re going to go in deep on some of the skills that are really going to move for you, I think it’s going to be really, really helpful. Absolutely free, just show up, bring a friend. I would love to see you there. If you are looking for help, direct help, on your next exam, on what’s going forward for you, if you’re struggling, if you’re having any kind of problems, physicianassistantexamreview.com/33, we start the August cohort on August 1st of that program, and I would love to have you in it, and I’d love to hear the impact it’s going to have on you and be able to share your success story amongst the other success stories that I often share from that program.

All right, everybody, take care, have a great day, and I look forward to working with some of you moving forward. If I hope to see you on Thursday or Sunday, those of you coming to the class, if not, we’ll talk to you next week, take care.