In the Pregnancy: Managing Chronic Conditions

Question 1

What are key points regarding epilepsy in pregnancy?

Answer 1

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.

Question 2

What medications are used for Epilepsy?

Answer 2

Risk of uncontrolled epilepsy during pregnancy outweigh risks of medication to the foetus. Aim for monotherapy and no indication to monitor antiepileptic drug levels

• 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
• Safe drugs
  
  • Lamotrigine: low rates of congenital malformation. Dose may increase in pregnancy
  • Carbamazepine
• Adjuvant
  
  • 5mg folic acid per day well before pregnancy to minimised neural tube defects.

Question 3

What is the procedure for breast feeding in pregnancy for epileptics?

Answer 3

• 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

Question 4

What advice should be given pre-conception for those suffering with Rheumatoid Arthritis?

Answer 4

• 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

Question 5

Which medications used for Rheumatoid Arthritis are safe and unsafe in pregnancy?

Answer 5

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• NSAIDs should be withdrawn after 32 weeks due to risk of early closure of the ductus arteriosus

Question 6

What is fibroid degeneration?

Answer 6

• 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

Question 7

What are signs and symptoms of Friboid Degeneration?

Answer 7

• Usually presents with low-grade fever, pain and vomiting.
• Inflammatory markers raised

Question 8

How is Fibroid Degeneration managed?

Answer 8

• 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

Question 9

What is Zyosity?

Answer 9

• 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

Question 10

What is Chorionicity?

Answer 10

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

Question 11

What are the types of twins?

Answer 11

• 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

Question 12

What are predisposing factors for dizygotic twins?

Answer 12

• Previous twins
• Family history
• Increasing maternal age
• Multigravida
• Induced ovulation and in-vitro fertilisation
• Race e.g. Afro-Caribbean

Question 13

What are risks associated with Monoamniotic monozygotic twins?

Answer 13

• Increased spontaneous miscarriage, perinatal mortality rate
• Increased malformations, IUGR, prematurity
• Twin-to-twin transfusions

Question 14

What are antenatal complications of Twin births?

Answer 14

• Polyhydramnios
• Pregnancy induced hypertension
• Anaemia
• Antepartum haemorrhage

Question 15

What are foetal complications of Twin births?

Answer 15

• Prematurity (mean twins = 37 weeks, triplets = 33)
• Light-for date babies
• Malformation (*3, especially monozygotic)
• Miscarriage
• Twin to twin transfusion syndrome

Question 16

What is twin to twin transfusion syndrome?

Answer 16

• 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

Question 17

What are complications of labour for Twin pregnancies?

Answer 17

• PPH increased (*2)
• Malpresentation
• Cord prolapses, entanglement
• Caesarean delivery

Question 18

How are twin pregnancies managed?

Answer 18

• 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

Question 19

How is Hepatitis B managed in pregnancy?

Answer 19

• 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

Question 20

What is the aim of managing HIV in pregnancy?

Answer 20

• To minimise harm to both the mother and foetus, and to reduce the chance of vertical transmission.

Question 21

What factors reduce vertical transmission of HIV in pregnancy?

Answer 21

• Maternal antiretroviral therapy (start between 14 and 24 weeks)
• Mode of delivery - Caesarean section
• Neonatal antiretroviral therapy
• Infant feeding (bottle feeding)

Question 22

How is HIV screened and managed in Pregnancy?

Answer 22

• 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

Question 23

What is the mode of delivery used for patients with HIV?

Answer 23

• 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

Question 24

How should neonates be managed after delivery?

Answer 24

• 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