General medical disorders Flashcards
Effects of pregnancy on CVS
40% increase in CO and blood volume (90% will have ejection systolic murmur due to increased blood flow)
50% drop in SVR
BP - initial drop, starts to rise in second trimester —> normal at term
Pre-existing cardiac problems
Increased CO acts as ‘exercise test’
Manifests >28 weeks (particularly labour)
Decompensation with blood loss and fluid overload
Management:
Assessment before pregnancy - echo
Control HTN and fluid balance
Elective epidural analgesia - reduces afterload
Elective forceps - reduces stress of pushing
Epilepsy
0.5% - seizure control reduced during pregnancy, esp. labour
Management:
lamotrigine and carbemazapine safest (avoid SV)
5mg folic acid
36 weeks - 10mg vit k orally
Hypothyroid
1% pregnant women
Untreated –> miscarriage, preterm delivery, intellectual impairment of child
Management:
Thyroxine (TSH lowered in pregnancy so expect to increase dose)
TSH levels measured every 6 weeks
Hyperthyroidism
0.2%
Antithyroid Ab can cross -placenta –> neonatal thyrotoxicosis
Poor control –> thyroid storm (+++ symptoms and HF), esp. near delivery date
Management: Propylthiouracil (PTU) instead of carbimazole
Postpartum thyroiditis
5-10% (can cause postnatal depression)
RF: antithyroid Ab, DMTI
Subclinical hyperthyroidism - usually 3 months postpartum, then ~4 months hypothyroid (permanant in 20%)
Acute fatty liver of pregnancy presentation
Acute hepatorenal failure, DIC and hypoglycaemia:
- Abdo pain
- N+V
- Jaundice
- Headache
- Fever
- Confusion or coma
Investigations into acute fatty liver of pregnancy
FBC and film LFT - ALT raised Clotting U+E Urate Blood gas
Management of acute fatty liver of pregnancy?
ICU setting:
Treat hypoglycaemia
Correct coagulopathy with IV vit K and fresh frozen plasma
Delivery
Intrahepatic cholestasis in pregnancy
0.7% pregnancies - more common in asians (1/3 have FH)
Occurs in 3rd trimester - resolves after pregnancy
Symptoms: Pruritus without a rash (often worse at night) Anorexia and malaise Epigastric discomfort Steatorrhoea and dark urine Jaundice
Investigations for obstetric cholestasis
LFTs - abnormal
Bloods - raised bilirubin and bile acids
USS of liver and biliary tree
Viral serology
Autoimmune screen
Management of cholestasis?
Vit K supplementation
Ursodeoxycholic acid (UDCA) - reduces itching
Topical emolients
Foetal surveillance - USS and CTG
Pregnancy specific causes of jaundice in pregnancy
Hyperemesis gravidarum
Pre-eclampsia/HELLP
Acute fatty liver
Obstetric cholestasis
Affect of pregnancy on renal system?
Increase in eGFR (40%) –> decreased urea + creatinine
0.2% pregnant women - pregnancy not advised if creatinine is >200mmol/L
Chronic renal disease complications
Dependant on HTN and renal function:
- Pre-eclampsia
- IUGR
- polyhydramnios
- preterm delivery
NB. Protein urea may lead to confusion with pre-eclampsia
Management of CKD
USS for foetal growth Measure renal function Screen for urinary infection Control HTN vaginal delivery is appropriate
Obesity comoplications
20% have BMI >30
Maternal:
- VTE
- Pre-eclampsia
- DM
- C-section
- Wound infections
- PPH
Foetal:
- NTD abnomailities
- Perinatal moratlity
Management for obese patients
5mg folic acid Vit D Screen for GDM and close BP monitoring If BMI>40 - formal anaesthetic assessment VTE prophylaxis
Mental illness
Bipolar - 1%
Depression - 3% taking A/D (paroxetine not advised)
Schizophrenia - 1% (avoid clozapine and olanzapine)
Lithium
Teratogenic but can be continued if required
Close monitoring of levels as pregnancy increases excretion
Recreational drugs
Increased risk of STIs, HIV, HepC and maternal death
MDT and social support
- child may need care order
Cocaine and ecstasy = teratogenic
Alcohol
Avoid in first 12 weeks
Foetal alcohol syndrome: IUGR, small/abnormal brain (>18 units a day)
Tobacco
Increased risk of miscarriage, IUGR, preterm birth, placental abruption, stillbirth + SIDS
Encourage women to stop, at least cut-down
Nicotine replacement therapy
Pregnancy is considered high risk
Medications for:
- N+V
- Epilepsy
- Hyperthyroid
- HTN
- UTI
N+V: prochlorperazine and cyclizine (st line oral), metaclopramide, domperidone, odeansatron
Epilepsy: lamotrigine, carbemazapine (CI = SV)
Hyperthyroid: Proplythiouracil (PTU) (CI = carbimazole)
HTN: labetalol, methyldopa, nifedepine (CI = AC Ei)
UTI: Nitrofurantoin 1st trimester (avoid at term), Trimethoprim after 1st trimester
