Endocrine in Pregnancy Flashcards
what are the stages of the of the ovarian cycle
menstruation starts
follicular growth
ovulation
luteal function
what happens in follicular growth
variable in length
when follicules grow with maturing egg inside them
what hormone is produced in the follicular growth phase
oestradiol and oestrogen
what hormone peaks just before ovulation
LH- luteinising hormone
what happens in the luteal phase
last 14 days
after ovulation, either fertilised egg implants and grows in endometrium or shedding of endometrial wall occurs
what hormones are increased in the luteal phase
progesterone and oestradiol
when should you measure progesterone
7 days before mentruation (e.g. if cycle is 30 days, 30 - 7 = 23, measure on the 23rd day)
what hormone is increase by a follicle produce
oestradiol
what is created when a implanted follicles becomes a fertilised ovum
corpus leteum
what hormone is produced when a corpus luteum is produced
progesterone
what hormone is produced when a corpus luteum implants
HCG
what hormone is measured in a pregnancy test
HCG
what hormones does the placenta produce
human placenta lactogen ((hPL)
placenta progesterone
placental oestrogens
what pregnancy hormone is produced by the pituitary gland
prolactin (lactogen)
what is the role of prolactin
develops breast tissue and milk production after delivery
what happens to insulin resistance in pregnancy
progesterone and hPL increase insulin resistance
what can result from increased insulin resistance in pregnancy (if predisposed)
raised blood glucose causing gestational diabetes
what is the adaptive reason for increased insulin resistance in pregnancy
so more glucose ans nutrients go through the placenta to the baby
when does gestational diabetes usually develop
in the 3rd trimester as when hormones at greatest concentration
when does foetal organogensis develop
starts at 5 week (possibly earlier)
what are the complications seen in pre existing diabetes
congential malformation pre maturity intra-uterine growth retardation macrosomia (>90th centile for size) polyhydramnios intrauterine death
what complications are seen in gestational diabetes
macrosomia
polyhydramnios
intrauterine death
what is polyhydraminios
increases fluid around babies
what are complication seen in neonates from diabetic mothers
respiratory distress (immature lungs), hypoglycaemia and hypocalcaemia
why do neonates from diabetic mothers get hypos
If mother has high blood sugar at time of delivery- this goes to baby who has normal insulin response to this and stores it. If difficulty feeding then still have high insulin so at risk of hypos
what CNS defects are seen in diabetic pregnancies
anecephaly, spina bifida
what skeletal defects are seen in diabetic pregnancies
caudal regression syndrome
what GI/GU defects are seen in diabetic pregnancies
utereric duplication (duplication of collecting duct if kidney)
what causes macrosomia in diabetic pregancies
maternal hyperglycaemia- foetal hyperglycaemia- foetal hyperinsulinaemia
(insulin produced by foetus in 3rd trimester is a major growth factor
what defines macrosomia
new born greater than 90 percentile or more than 4 kg
what should be done pre pregnancies for both type 1 and type 2
3 months prior to conception
counselling- good sugar control to limit congenital malformation
folic acid (5mg instead of 400 micrograms for diabetics)
consider changes from tablets to insulin
what diabetic complication is accelerated in pregnancy
retinopathy
what BP meds should you avoid in pregnancy
ACE inhibitor, statin (use labetalol, nifedipine, methyldopa instead)
what are the blood pressure targets for diabetes in pregnancy
pre-meal <4- 5.5 mmol/l 2h post meal <6.5-7 mmol/l
what should be giving for BG during labour
IV insulin and IV dextrose
what is the pregnancy management for T1DM
insulin
what is the pregnancy management for T2DM
metformin, will probably need insulin later
what is the pregnancy management for gestation diabetes
lifestyle (reduce carbs and calories), metformin, may need insulin
why is it important to check 6 week post natal fasting glucose or GTT in GDM
to ensure resolution of GDM- if not resolved by a year- may turn into T2DM
what are the long term implications of GDM
50% resolve
50% develop T2DM after 10-15 yrs (higher is obese)
<5% T1DM (slim)
how do you prevent T2DM GDM
keep healthy weight healthy diet (low refined sugar, predominant starch, low sat fat, low energy foods) aerobic exercise annual fasting glucose
true or false: Gestational diabetes usually presents in the first trimester
false- usually in third
true or false: Methyldopa in pregnancy is the preferred treatment for blood pressure
false labetalol
true or false: Maternal hyperinsulinaemia causes increased foetal growth?
False- FOETAL hyperinsulinaemia causes the increased growth
true or false: Implanted fertilised ovum cells secretes HCG?
True what you measure in pregnancy test
true or false: After a pregnancy with GDM, the risk of type 2 diabetes is 25% within the next 10 years?
False 50%
how does hypo and hyper thyroidism affect fertility
anovulatory cycles- reduced fertility
why are thyroid hormones important in pregnancy
maternal thyroxine important for neonatal development (especially CNS and brain)
why do thyroid problems gets worse in pregnancy
increased demand on thyroid during pregnancy
plasma protein binding increases (need to thyroxine during pregnancy to populate these)
why does the thyroid increase in size during pregnancy
increased T4 production to maintain normal concentration
what happens to patients already on thyroxine in pregnancy
relative thyroid deficiency (thyroid cant meet demands)
what should you do to meds in pre exisiting
hypothyroidism during pregnancy
increase thyroxine dose by 25 mcg as soon as pregnancy suspected
what should the TSH goal be for patients in thyroxine in pregnancy
<3 mU/I
measure TFTs months for first 20 weeks then 2 monthly until term
what are the risks of untreated hypothyroidism in pregnancy
increased abortion, preeclampsia, abruption, postpartum haemorrhage, preterm labour, foetal neuropsychological development, increased risk of low IQ
what role does hCG have on the thyroid
hCG - increases thyroxine - suppress TSH
what causes morning sickness (hyperemesis gravidarum)
hCG
what does hyperemesis mimic biologically
hyperthyroidism
how do you distinguish hyperemesis from hyperthyroidism
hyperemesis resolves 20 weeks gestation
hyperthyroid:
- nausea and vomiting - tachycardia - warm and sweaty - lack of wt gain
when should you treat Gestational hCG-asscociated Thyrotoxicosis
if persists past 20 weeks
how does hyperthyroidism affect reproduction
Infertility- lack of periods and ovulatory cycle
Spontaneous miscarriage
Stillbirth
Thyroid crisis in labour- esp in c sections
Transient Neonatal thyrotoxicosis
what maternal hyperthyroidism cause in a new born
babies thyroid to be overactive in first few weeks- fidgety, weight loss
what can cause thyrotoxucosis in pregnancy
Graves’ disease
toxic multinodular goitre, toxic adenoma
Thyroiditis
what is the management for hyperthryoid in pregnancy
wait and see if hyperemesis (will settle)
graves may also settle as pregnancy suppresses autoimmunity
Beta blockers needed
LOSE DOSE anti-thyroid drugs
-propylthiouracil 1st trimester
-carbimazole 2/3rd trimester
explain the prescription of anti thyroid drugs in pregnancy
use propylthioyracil in first trimester as less risk of embryopathy (scalp and GI abnormalities, choanal and oesophageal atresia)
Risks for liver toxicity with PTU much greater than carbimazole- why you switch after first trimester
what is the relevance of TRAb antibodies in pregnancy
if present alert neonatalogist
TRAb antibodies can cross the placenta and cause neonatal transient hyperthryoidism
what is post partum thyroiditis
2-4 months become thyroid over active- transient thyrotoxic
Then 4-10 months becomes underactive- Hypothyroid
small diffuse nontender goitre
should return to normal at 10-12 months
what should you give in post partum thyroiditis
Don’t give carbinazole in over active phase as will make crash down a lot worse
If crash down produces symptoms then give thyroxine
what is post partum depression closely linked to
post partum hypothyroidism
what happens if post partum thyroiditis lasts longer than 1 year
becomes persistent hypothyroidism
What is the thyroid status of this pregnant woman at 10 weeks gestation?fT4 22 (10-20); TT3 3.4 (up to 2.6); TSH 0.2 (0.4-4)
hyperemesis
true or false: All antithyroid drugs should be avoided in pregnancy
False (avoid in first trimester if you can, rest of pregnancy okay)
true or false: A woman in early pregnancy with known hypothyroidism should double her thyroxine dose when she finds she is pregnant
false- increase by 25 micrograms
true or false: If a patient still needs thyroxine one year after delivery she is likely to need it life-long
true
