General Medical Disorders in Pregnancy

Question 1

Hypertension

Answer 1

Common, especially in older mother – exclude secondary causes
BP will decrease in early stages but rises after 28weeks
Assess risk of pre-eclampsia with dopplers at 20wks

Question 2

Epilepsy (4)

Answer 2

Most older AEDs are pregnancy friendly (except valproate) – some have risk of fetal cardiac abnormalities
drug levels will fall during pregnancy (lamotrigine, levatiracetam
Risk of seizures is high to mother and baby (highest in 48hrs post-partum)
Can be enzyme inducers (carbamazepine)

Question 3

SLE

Answer 3

Risk of flares if active less than 6month before conception
–> flares occur in 30% of pregnancies but doesnt worsen SLE progression — Risk of nephritis or PET
Risk of miscarriages if secondary APS

Question 4

Renal Disease

Answer 4

Creatinine 220
Risk of maternal KI 1/10 3/10 ESRF likely
Chance of live birth >90% 85% (60% prem) IUD likely

Question 5

Effects of existing disease on pregnancy

Answer 5

Infertility or PET
IUGR, Macrosomia or Fetal abnormality
Prematurity, IUD or miscarriage

Question 6

Sickle cell disease in pregnancy

Answer 6

Fertility is generally unaffected - no contraception contraindications
General increased risk of pregnancy complications with sickle cell - 9.23 for maternal mortality and 2.8 perinatal mortality, 1.92 PE risk

Question 7

Thalassaemia in pregnancy

Answer 7

Iron accumulation in endocrine glands can impact fertility

should screen for diabetes and check up for anaemia

Question 8

Maternal deaths in the UK

Answer 8

50% are due to pre-existing medical conditions - particularly obesity and older mothers
substandard care is the case of 55% of deaths

Question 9

Points to consider when managing a chronic condition in a pregnant lady

Answer 9

Will the disease get better or worse with pregnancy?
Will termination improve the outcome of the disease?
Will changing the medications to more pregnancy friendly ones affect the outcome of the disease?

Question 10

Obesity in pregnancy

Answer 10

common and there is associated subfertility – increased risk of structural abnormalities
Increase exercise, aim for no weight gain in pregnancy

Question 11

How many pregnant women are infected with HIV?

Answer 11

1.4million in low to middle income countries in 2012
Very rare in developed countries (was 1200/yr in UK in 2005, now lower)
– 2% of global transmission is vertical

Question 12

Prevention of vertical tranmission of HIV

Answer 12

ARTs in pregnancy (20-32wks) – planned C-section and do not breast feed.
Also treat baby for the first month as well
May not need a Cs if viral load <50/ml, above this pre-labour CS is recommended

Question 13

Impact of Obesity on birth (3,4)

Answer 13

Antenatal –> prolonged labour, failure to induce, Increased C-section rate,
Post-partum –> DVT risk, wound infection/Dehisence, continuing diabetes, problems breastfeeding

Question 14

Hyperemesis gravidarium

Answer 14

80% of women will have vomiting in pregnancy but only 1-2% will have HG. Linked to BhCG levels it is worse 8-12wks but can persist to 20wks. associated with multiple pregnancy, trophoblastic disease, obesity (smoking is protective).

Question 15

Management of Hyperemesis gravidarium

Answer 15

Reducing spicy or fatty food may help. Promethazine is first line but admission for IV fluids may be needed. Can then be treated with metacloprimide or ondansetron. May need vitamin/thiamine supplements.

Question 16

Pubis symphysis dysfunction

Answer 16

Common cause of pain in pregnancy due to hormonally induced ligament laxity. There will be pain over the pubis symphysis radiation to the groin and medial thighs. A waddling gait may be seen.

Question 17

Round ligament pain in pregnancy

Answer 17

A common discomfort of pregnancy usually starting in the second trimester and continuing until delivery (can last a few days after). Can present as a sudden or shooting pain in the pelvic area on movements or exercise. Generally treat with paracetamol or rest.

Question 18

Risks of Epilepsy in pregnancy

Answer 18

The risks of uncontrolled epilepsy generally outweigh the risks of medication. 3-4% risk of cogenital defects from 1-2% in non-epileptic mothers.

Question 19

Treating Epilepsy in pregnancy

Answer 19

Aim for monotherapy but there is no need to monitor drug levels.
Valproate is associated with NTDs
Carbamazepine is considered largely safe
Phenytoin is associated with cleft palate. Give Vit K in final month.
Lamotrigine is safe but the dose may need to be increased in pregnancy.