5. Common medical problems in pregnancy

Question 1

What is gestational diabetes?

When does this develop?

Answer 1

‘Carbohydrate intolerance of variable severity with onset or first presentation in pregnancy’

This is the development of temporary diabetes once the woman falls pregnant - effects about 3% of the women in the UK

This tends to happen just slightly more than halfway through the pregnancy

Question 2

What is the aetiology of gestational diabetes?

Answer 2

Pregnancy - intrinsically, this is a state of insulin resistance and glucose intolerance
This is thought to be due to the placental secretion of anti-insulin hormones e.g. HPL, cortisol, glucagon
Gestational diabetes can then occur as an exaggerated form of this physiological condition

Question 3

What are the risk factors for gestational diabetes?

Answer 3

Previous GDM
Family history of diabetes 
Previous macrosomic baby 
Previous unexplained stillbirth 
Obesity 
Glucosuria 
Polyhydramnios - excess amniotic fluid in the amniotic sac 
Large for gestational age in the current pregnancy

Question 4

What are the maternal complications that arise as a result of gestational diabetes?

Answer 4

Generally, gestational diabetes does not cause massive problems for the mother but the following can occur:
Hyperglycaemia/hypoglycaemia 
Pre-eclampsia - hypertension
Infection
Thromboembolic disease

Question 5

What are the foetal complications that arise as a result of gestational diabetes?

Answer 5

Macrosomia - birth aphyxia and traumatic birth injury
Respiratory distress syndrome
Hypoglycaemia - when they’re born, they are used to having so much glucose so then enough is not provided in the breast or bottle milk
Hyperbilirubinaemia (jaundice)

Question 6

What is the issue if a woman falls pregnant whilst she already has diabetes?

Answer 6

If you fall pregnant whilst you already have the disease, then the complications of the disease get worse quicker

Question 7

What is the management for gestational diabetes?

Answer 7

Dietary modification including calorie reduction
Insulin provision if persistant fasting or postpradial hyperglycaemia despite adequate dietary modification
Intrapartum monitoring
Regular ultrasound scan every two weeks during pregnancy to monitor foetal growth and wellbeing
Glucose tolerance test 6 weeks following delivery

Question 8

Why should a woman have a glucose tolerance test 6 weeks following delivery?

Answer 8

Because in some instances, some women have diabetes but they have no symptoms of this and are not aware of their disease
When they fall pregnant, the disease becomes evident and they then realise they require lifelong management

Question 9

Why are non-viral infections an issue in pregnancy?

Answer 9

The vagina contains many bacteria which do not cause any harm in the vagina normally
BUT when the waters break, this results in access for the bacteria to go up through the cervix to infect the placenta and can then infect the baby itself
Therefore, there is an increased risk of non-viral infection in the baby once the waters break

Question 10

What are the different non-viral infections that can occur in pregnancy?

Answer 10

Group B streptococcus
Urinary tract infections 
Listeriosis
Syphilis 
Chlamydia and Gonorrhoea

Question 11

Why can a Group B streptococcus (GBS) infection easily occur in pregnancy?

How common in this?

Answer 11

25% of women contain Group B streptococcus bacteria within the normal flora of their vagina - this is normally harmless
BUT when their waters break, there is access and potential for an ascending movement and infection by these bacteria - can infect the placenta and then infect the baby
In most cases this does not occur but if it does take place and the baby is infected then this can prove to be life threatening

Question 12

What can GBS Infection lead to?

Answer 12

Pneumonia
Meningitis
Non-focal sepsis
Death

Question 13

How are GBS infections in the mother and baby prevented?

Answer 13

There may be opportunistic detection of the GBS antenatally via swabs or urine
Cannot treat during pregnancy as it will just return but can give benzylpenicillin whilst the woman is in labour

Question 14

Why is there an increased risk of contracting a UTI during pregnancy?

Answer 14

There is increased pressure on the bladder, urethra, ureters during pregnancy and this can result in stasis of urine - stasis of bacteria within - more prone to infect

During pregnancy, there is an increased release of progesterone and relaxin - these act on smooth muscle via the bloodstream to ensure that it does not contract e.g. bladder, urethra, ureters, blood vessels

Question 15

What is the treatment for a UTI in pregnancy?

Answer 15

Penicillins
Cephalosporins
Nitrofurantoin

NB. The normal first line treatment for a UTI is trimethoprim but this is teratogenic in the first trimester of pregnancy

Question 16

What is listeriosis and how is it prevented?

Answer 16

Bacterial infection which is rare but fatal for the baby
This is gained via food poisoning so women should be wary of the foods they consume
This is asymptomatic and cannot be diagnosed during pregnancy - only after via placental investigations and post mortem

Question 17

What is the risk and effect of syphilis on a foetus and new born?

Answer 17

If untreated in the mother, there is a 50% chance of congenital syphilis 
Primary - chancre
Secondary - rash
Latent - nothing
Tertiary - neurosyphilis

Question 18

What are the treatment and management options for syphilis?

Answer 18

Early routine screening during pregnancy

Treatment with penicillin

Question 19

What is the effect of chlamydia and gonorrhoea on the mother and on the baby and how are these infections treated?

Answer 19

Mother: endometritis
Baby: Opthalmia neoatorum, pneumonia
Treatment: Azithromycin (tetracyclines are teratogenic)

Question 20

What is the effect of iron deficiency anaemia on the mother and baby and what is the problem with diagnosing this?

Answer 20

There are no foetal complications linked to this but the maternal problems are linked to bleeding at the time of delivery

Symptoms paradox - the symptoms of iron deficiency anaemia are very similar to those of pregnancy so the history will not tell you whether iron deficiency anaemia is present or not

Question 21

What is the treatment for iron deficiency anaemia during pregnancy?

Answer 21

Oral iron via tablets or syrup
Iron infusion
Blood transfusion

Question 22

What is the effect of sickle cell anaemia on pregnancy?

Answer 22

More severe and more frequent pain crises
Hypertension leading to pre-eclampsia
Growth restriction, preterm birth