Disorders in pregnancy 2

Question 1

How does anti-epileptic medication affect pregnancy?

Answer 1

risk of congential abnormalities (NTD) is increased (4% overall)
risk as dose dependent, higher with multiple drug usage and certain drugs (eg. sodium valproate)
• The new born has a 3% risk of developing epilepsy

Question 2

What is the management for epilepsy in pregnancy?

Answer 2

seizure control with as few drugs as possible at the lowest dose
folic acid (5mg/day)
carbamazepine and lamotrigine are safest
vitamin K is given orally from 36 weeks for women on enzyme-inducing anti-epileptics

Question 3

How does the thyroid change in pregnancy?

Answer 3

• Thyroid status does not alter
iodine clearance is increased
goitre is more common
• Foetal thyroxine production starts at 12 weeks, before it is dependent on maternal thyroxine- maternal TSH is increased in early pregnancy

Question 4

What occurs with hypothyroidism in pregnancy?

Answer 4

affect 1% of pregnant women and commonly due to Hashimoto’s thyroiditis or thyroid surgery
untreated disease is rare as it leads to anovulation, but is associated with a high perinatal morality
Even subclinical levels are associated with miscarriage, preterm delivery and intellectual impairment in childhood
increased risk of pre-eclampsia, particularly in anti- thryoxine antibodies are present
TSH levels are measured every 6 weeks- in normal pregnancy the TSH levels are decreased

Question 5

What occurs with hyperthyroidism is pregnancy?

Answer 5

affects 0.2% of pregnant women and commonly due to Graves’ disease
anovulation is usual, but inadequately treated disease increases perinatal mortality
anti- thyroid antibodies can cross the placenta and cause neonatal thyrotoxicosis and goitre
Thyroid storm can occur

Question 6

What is the management for hyperthyroidism in pregnancy?

Answer 6

propylthiouracil (PTU) in the 1st trimester rather than carbimazole, but it can cross the placenta and cause neonatal hypothyroidism
Graves’ disease often worsens postpartum

Question 7

What is postpartum thyroiditis?

Answer 7

this is common (5-10%) and cause postnatal depression
risk factors include anti- thyroid antibodies and T1DM
Transient and subclinical hyperthyroidism at about 3 months postpartum followed by 4 months of hypothyroidism- permanent in 20%

Question 8

What is acute fatty liver?

Answer 8

• Very rare (1 in 9000) but serious condition that is part of the spectrum of pre-eclampsia
• Acute hepatorenal failure, DIC and hypoglycaemia lead to a high maternal and foetal mortality
Presents with malaise, vomiting, jaundice and vague epigastric pain (thirst in earlier weeks)
correction of clotting defects and hypoglycaemia are needed first

Question 9

What is the management for acute fatty liver?

Answer 9

Supportive
further dextrose, blood products, careful fluid balance
Occasionally dialysis

Question 10

What is intrahepatic cholestasis of pregnancy?

Answer 10

o Unexplained pruritus
o Abnormal LFTs
o Raised bile acids
o Resolves after delivery
• Due to abnormal sensitivity to the cholestatic effects of oestrogen- occurs in 0.7% of women, is familial and tends to reoccur (50%)
Associated with stillbirth toxic bile salts), meconium passage, postpartum haemorrhage

Question 11

What is the management for intrahepatic cholestasis of pregnancy?

Answer 11

• Ursodeoxycholic acid (UDCA) helps relieve itching and may reduce the obstetric risks by reducing bile acid levels
vitamin K 10mg/day is given form 36 weeks (haemorrhage risk)
• Induction of labour is often offered (38 weeks if bile acid levels are high)
• Six week follow up is indicated to ensure liver function returns to normal

Question 12

What is chronic kidney disease?

Answer 12

pregnancy is considered very high risk if the creatinine level is
>200mmol/L
Proteinuria normally present <20 weeks 
Foetal complications:
Preterm 
Pre-eclampsa
IUGR
Polyhydraminos

Question 13

What is the management for chronic kidney disease?

Answer 13

USS for foetal growth, measurement of renal function, screening for urinary infection and control of hypertension
in severe cases, dialysis is necessary

Question 14

What are UTIs associated with?

Answer 14

o Preterm labour
o Anaemia
o Increased perinatal morbidity & mortality
• Asymptomatic bacteriuria affects 5% of women, but in pregnancy it is more likely to leads to pyelonephritis (20%)
• Urine should be cultured at booking visit (12 weeks) and asymptomatic bacteriuria treated
(E.coli is often amoxicillin resistant)

Question 15

What is antiphospholipid syndrome?

Answer 15

• This is when the lupus anticoagulant and/or anticardiolipin antibodies (ACA) occur in association with adverse pregnancy complications or thrombotic events- foetal loss is high
• Low levels of antibodies are present in 2% of all pregnant women

Question 16

How is antiphospholipid syndrome managed?

Answer 16

• The pregnancy is managed as ‘high risk’
with serial USS and elective induction of labour at least by term
treatment with aspirin & LMWH
postnatal anti-coagulation is recommended to prevent venous thromboembolism

Question 17

How is hyperhomocysteinaemia managed?

Answer 17

associated with increased pregnancy loss and pre-eclampsia
high-dose folic acid
women with prothrombin tendencies and an adverse pregnancy history are usually treated as for antiphospholipid syndrome
postnatal anticoagulation is advised

Question 18

How does SLE present in pregnancy?

Answer 18

• SLE affects 0.1-0.2% of pregnant women
in the absence of lupus anticoagulant or anticardiolipin antibodies, the risks to pregnancy are largely confined to those with active disease or associated hypertension, renal or cerebral disease
• Maternal symptoms often relapse after delivery