In the Pregnancy: Managing Chronic Conditions Flashcards
What are key points regarding epilepsy in pregnancy?
Risk of uncontrolled epilepsy during pregnancy outweigh risks of medication to the foetus.
- Advice is to take 5mg folic acid per day well before pregnancy to minimised neural tube defects.
- 3-4% of new-borns have congenital defects if mother take antiepileptic medication compared to 1-2% without.
What medications are used for Epilepsy?
Risk of uncontrolled epilepsy during pregnancy outweigh risks of medication to the foetus. Aim for monotherapy and no indication to monitor antiepileptic drug levels
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Avoid
- Sodium valproate: Associated with neural tube defects. Without specialist neurological or psychiatric advice, prgnant women or women of childbearing should not be started on it.
- Phenytoin: associated with cleft palate
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Safe drugs
- Lamotrigine: low rates of congenital malformation. Dose may increase in pregnancy
- Carbamazepine
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Adjuvant
- 5mg folic acid per day well before pregnancy to minimised neural tube defects.
What is the procedure for breast feeding in pregnancy for epileptics?
- Breast feeding is generally considered safe for mothers taking antiepileptics with the possible exception of the barbiturates
- Advised that pregnant women taking phenytoin are given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn
What advice should be given pre-conception for those suffering with Rheumatoid Arthritis?
- Those with early or poorly controlled RA advised to defer conception till stable disease
- RA may improve in pregnancy but only resolves in small minority. Often flares up following delivery
Which medications used for Rheumatoid Arthritis are safe and unsafe in pregnancy?
Safe:
- Sulfasalazine and hydroxychloroquine are considered safe in pregnancy
- Low-dose corticosteroids may be used in pregnancy to control symptoms
Unsafe:
- Methotrexate is unsafe and needs stopping at least 6 months before conception. Leflunomide is also not safe in pregnancy
- NSAIDs should be withdrawn after 32 weeks due to risk of early closure of the ductus arteriosus
What is fibroid degeneration?
- Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy.
- Degeneration occurs due to excessive growth that out matches blood supply and mechanical compression of feeder arteries
What are signs and symptoms of Friboid Degeneration?
- Usually presents with low-grade fever, pain and vomiting.
- Inflammatory markers raised
How is Fibroid Degeneration managed?
- Conservative management with rest, hydration analgesia and if needed antibiotics. It should resolve within 4-7 days.
- Emergency surgery due to pedunculated fibroid
- Hysterectomy if suspicious of sarcoma
What is Zyosity?
- Refers to genetic make-up of a pregnancy. Multiple gestations can be monozygotic or dizygotic.
- Monozygotic twins result from division of zygote arising from fertilisation of one ovum by one sperm.
- Dizygotic twins result from fertilisation of separate ova by separate sperm
What is Chorionicity?
Refers to membrane composition of the pregnancy - the chorion and amnion.
- Determined by the mechanism of fertilisation and by the occurrence and timing of embryo division
What are the types of twins?
- Dizygotic Twins (80%): non-identical, develop from two separate ova that were fertilized at the same time
- Monozygotic Twins: identical, develop from a single ovum which has divided to form two embryos
What are predisposing factors for dizygotic twins?
- Previous twins
- Family history
- Increasing maternal age
- Multigravida
- Induced ovulation and in-vitro fertilisation
- Race e.g. Afro-Caribbean
What are risks associated with Monoamniotic monozygotic twins?
- Increased spontaneous miscarriage, perinatal mortality rate
- Increased malformations, IUGR, prematurity
- Twin-to-twin transfusions
What are antenatal complications of Twin births?
- Polyhydramnios
- Pregnancy induced hypertension
- Anaemia
- Antepartum haemorrhage
What are foetal complications of Twin births?
- Prematurity (mean twins = 37 weeks, triplets = 33)
- Light-for date babies
- Malformation (*3, especially monozygotic)
- Miscarriage
- Twin to twin transfusion syndrome
What is twin to twin transfusion syndrome?
- Blood vessels connect within the placenta and divert blood from one foetus to other.
- Recipient twin receives too much blood causing overloaded cardiovascular system and too much amniotic fluid (polyhydramnios).
- Smaller donor foetus does not get enough blood and low amounts of amniotic fluid
- Managed with laser ablation of interconnecting vessels
What are complications of labour for Twin pregnancies?
- PPH increased (*2)
- Malpresentation
- Cord prolapses, entanglement
- Caesarean delivery
How are twin pregnancies managed?
- Rest advised
- Ultrasound for diagnosis and monthly check
- Additional iron and folate given
- More antenatal care (e.g., weekly after 30 weeks)
- Precautions at labour (e.g., 2 obstetricians present)
- 75% of twins deliver by 38 weeks, if longer most twins are induced at 38-40 weeks
- Test for maternal hypertension and anaemia
- Screening for preterm birth
How is Hepatitis B managed in pregnancy?
- All pregnant women are offered screening for hepatitis B
- Babies born to mothers who are chronically infected with hepatitis B or to mothers who’ve had acute hepatitis B during pregnancy should receive a complete course of vaccination + hepatitis B immunoglobulin
- Little evidence to suggest c-section reduces vertical transmission rate
What is the aim of managing HIV in pregnancy?
- To minimise harm to both the mother and foetus, and to reduce the chance of vertical transmission.
What factors reduce vertical transmission of HIV in pregnancy?
- Maternal antiretroviral therapy (start between 14 and 24 weeks)
- Mode of delivery - Caesarean section
- Neonatal antiretroviral therapy
- Infant feeding (bottle feeding)
How is HIV screened and managed in Pregnancy?
- Screening: NICE guidelines recommend offering HIV screening to all pregnant women
- Antiretroviral therapy: All pregnant women should be offered antiretroviral therapy regardless of whether they were taking it previously
What is the mode of delivery used for patients with HIV?
- Vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarean section is recommended
- Zidovudine infusion should be started four hours before beginning the caesarean section
How should neonates be managed after delivery?
- Zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml otherwise triple ART should be used. Therapy should be continued for 4-6 weeks.
- Test child for HIV in first 2 day, on discharge, at 6 weeks and 12 weeks. Further test will be done at 18 months
