Case Study 7 - Medical disorders in pregnancy Flashcards
Why should women have an antenatal appointment early in pregnancy?
1) To confirm and date the pregnancy
2) For general antenatal advice
3) Clinical assessment - To identify and plan mx of medical conditions which may impact upon the pregancy
EDD may be calculated by
1) LNMP - 1st day plus 280 days
2) Dating USS 7-12 weeks - after 13 weeks CRL no longer accurate due to fetal positioning
General antenatal advice should cover
1) Teratogens - medications, alcohol, radiation
2) Lifestyle - smoking cessation, dietary precautions (listeria - soft cheeses, cook meats well, wash fresh produce), GWG (12-16kg, 7-12 if o/wt, 5-9 obese), exercise, work
3) Vitamin and mineral supplementation (folic acid 0.4mg, or 5mg for high risk i.e. previous NTD, DM, multiple pregnancy, obesity)
4) Models of care and antenatal education
What are the risk factors for GDM?
Maternal age >35
PHx GDM, or FHx DM
Obesity
Clinical assessment should include
Thorough hx and examination including pre-pregnancy BMI
Antenatal blood tests
What blood tests are routinely recommended?
FBE, blood gp and ab Rubella ab Syphilis HIV, Hep B and C Varicella MSU for M/C/S Pap smear
What about vaccination in pregancy?
Influenza vaccine is strongly recommended
Pre-conception immunisation of Hep B, MMR, DTP, varicella if uncertain
Live attenuated vaccines are contraindicated in pregancy
What are obese women at increased risk of in pregnancy?
1) Preconception - reduced fertility
2) Antenatal -
GDM, PET, VTE, OSA, maternal death
miscarriage, stillbirth, abnormal fetal growth and development
3) Intrapartum -
IOL, prolonged labour, failure to progress
Instrumental delivery, CS, PPH
Shoulder dystocia
Difficult fetal monitoring
4) Anaesthetic - difficult epidural, airway, ICU
5) Post-partum
Wound infection and delayed healing
Breastfeeding difficulty
Post-natal depression
What are the major risk factors for DVT in pregancy, and what should be done?
When do we stop treatment for delivery? Restart again?
Highest risk: Past DVT Family hx Thrombophilia SLE Cancer (others - obesity, smoking, age>35, immobility) High risk women will require LMWH - refer to colleague
Stop LMWH at earliest sign of labour to minimise bleeding complications. Restart 4 hours post delivery/CS assuming no PPH. High risk women will need treatment continued for 1-6 weeks post partum.
What thrombophilias should be screened for?
Which may not be reliable in pregnancy?
Heritable -
antithrombin, Protein C or S deficiency, Factor V Leiden
Acquired - antiphospholipid syndrome - persistent lupus anticoagulant or anticardiolipin abs
Note that Protein S and antithrombin are decreased in pregnancy
Why do WTU in pregnancy?
Asymptomatic bacteruria should be treated?
Proteinuria?
What happens to blood pressure in pregnancy?
How should it be measured?
The primary cardiovascular event in pregnancy is peripheral vasodilation which leads to fall in systemic resistance - BP falls in the 2nd trimester to 22-24 weeks, then steadily increases to pre-pregnant levels at term as increase in blood volume (preload) increases cardiac output.
Measure BP sitting wait for disappearance of sounds (Korsakoff 5)
Be aware of the supine hypotensive effect of maternal position in late pregnancy!
What are the guidelines for GDM screening and follow-up?
75g OGTT at 26-28 weeks
Earlier (20 weeks - placental lactogen) for high risk - hx GDM, obesity
For GDM patients - repeat 6 weeks post-delivery, these women are at higher risk (50%) of developing type II DM later in life and should be screened by GP
What are the diagnostic values for GDM?
Current
Fast >=5.5 or 2hr >=8 mmol/L
Jan 2015
Fast >=5.1 or 2hr >=8.5
How is GDM managed?
Multidisciplinary approach - dietician, diabetic educator and obs med
pre and post-prandial glucose monitoring
Manage with diet, or insulin if poor control
Fetal surveillance - risk of LGA/macrosomia - shoulder dystocia, or FGR
Neonatal hypoglycaemia
What is pre-eclampsia?
A multiorgan disorder of gestational hypertension + evidence of renal (proteinuria and PCR) or liver damage (check transaminases)
What are the risk factors for PET?
Risk factors - hx GHTN renal disease diabetes or GDM smoking age >35 BMI >35 FHx multiple pregnancy
How does a woman with PET present?
Headache Blurred vision Severe epigastric pain Oedema Feeling unwell
What PET signs should I look for on examination?
BP > 140/90 peripheral/pulmonary oedema Neuro- hyperreflexia papilloedema on fundoscopy Abdo - Tender liver - subcapsular haematoma Less than expected SFH - FGR WTU - protein
What PET investigations should be ordered?
MSU - PCR >=30mg/mmol
FBE - thrombocytopenia, haemolysis or DIC
U+E - renal function and uric acid
LFTs - transaminases
What is HELLP syndrome?
The combination of Haemolysis, Elevated Liver enzymes, Low Platelets - this indicates more PET of more severe end of spectrum
How is PET managed?
Admit for treatment and monitoring
Antihypertensive - nifedipine, labetalol, hydralazine
MgSO4 to prevent eccampsia (halves risk)
USS fetal growth and wellbeing and doppler
Delivery at latest 37 weeks indicated
What antihypertensives are used in pregnancy?
For acute lowering of BP - hydralazine IV or nifedipine immediate release tablets If delivery can be safely delayed, control with labetolol or nifedipine
How would you manage thromboprophylaxis for an anticoagulated patient at delivery/CS?
Cease enoxaparin at first sign of labour/ —- hours before CS
Use of heparin infusion?
Mechanical prophylaxis with TEDS and SCDs
Recommence anticoagulation min 4hrs post, for 1-6 weeks based on high risk
How do you maximise fetal condition for preterm delivery?
Give steroids to promote fetal lung maturity for delivery 24-34weeks (possibly up to 36 weeks) - 2 x 11.4mg IM doses of betamethasone, 24 hrs apart
