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MBBS IV - Junior Clerkship WCS > JC110 (O&G) - Medical disorders in Pregnancy > Flashcards

JC110 (O&G) - Medical disorders in Pregnancy Flashcards

1
Q

List chronic medical conditions that must be optimized before pregnancy

A 
 Pre-existing hypertension
 Diabetes
 Autoimmune diseases
 Renal disease
 Cardiac diseases
 Asthma
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2
Q

List medical conditions that is caused by pregnancy

A 
 Hyperemesis gravidarum
 Gestational hypertension
 Gestational diabetes
 Acute fatty liver of pregnancy
 Acute renal failure
 DIC secondary to obstetrics complications (e.g. postpartum hemorrhage)
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3
Q

List medical conditions aggravated by pregnancy

A

 Iron deficiency anaemia

 Thromboembolism

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4
Q

Management of maternal health before pregnancy

A

 Optimize her medical disorder
 Substitute teratogenic medications if possible
 Advise on whether she is medically fit to get pregnant
 Contraceptive advice if needed

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5
Q

Management of maternal health during pregnancy

A

 Assess whether medically fit to continue pregnancy
 Monitor her and her fetus throughout the pregnancy
 Detect fetal congenital abnormalities/ growth problem with ultrasound
 Monitor and control her medical disorder

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6
Q

Management of maternal health during delivery

A

 Plan/ decide on the timing and mode of delivery ahead of time
 Consider early delivery if her medical disorder is uncontrolled/ complications arise
 Make an individualized intrapartum and postpartum management plan when necessary
 In labor, monitor her medical disorder, fetal well-being and progress of labor

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7
Q

Management of maternal health after delivary

A

Assess her baby by a paediatrician

Encourage breastfeeding, except where lactation is contraindicated for certain maternal drugs

Optimize medical disorders and medications

Discuss contraception:
 May need to avoid another pregnancy shortly or in the long term
 Some medical disorders may affect her eligibility to some contraceptive methods

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8
Q

4 types of hypertension during pregnancy

A

Pre-existing:

  • Hypertension: high BP before 20 weeks
  • Renal disease: proteinuria before 20 weeks

Gestational: high BP first detected after 20 weeks
 Without proteinuria = Gestational HT
 With proteinuria = pre- eclampsia (hypertension + proteinuria + oedema)

Pre-existing hypertension with superimposed pre-eclampsia

Unclassified: No antenatal care before (unknown whether HT occurred before 20 weeks)

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9
Q

Management of maternal hypertension in pregnancy

  • Purpose of optimizing control
  • Investigations
  • Drugs
A

Purpose:

  • Optimize drugs to prevent intracerebral hemorrhage or uterine hypoperfusion/ fetal hypoxia
  • Prevent eclampsia

Ix: (screen and manage associated complication: HELLP, coagulopathy, renal failure)
 Complete blood picture
 Renal/liver function tests
 Coagulation tests’

Drugs:

  • Most antihypertensive except ACEi and Propranolol
  • IV labetalol
  • Pre-eclampsia: Vasodilators - hydralazine
  • Eclampsia: Magnesium sulphate (antiepileptic)
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10
Q

Describe the effects of pregnancy on blood glucose control and DM

A

Pregnancy alters carbohydrate metabolism, more difficult to control blood glucose:

  1. Insulin resistance increases with gestation period:
    - Placental hormones antagonize insulin (e.g. cortisol, oestrogens, progesterone, human placental lactogen)
    - Placenta degrades insulin
  2. Increase stress and end-organ damage on cardiovascular and renal system, increase diabetic retinopathy
  3. Increase metabolic demand: Fasting hypoglycaemia
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11
Q

Complications of DM on mother during pregnancy

A

Increase risk of:

  • Pre-eclampsia
  • UTI
  • Pre-term labor

Increase incidence of C-section and instrumental delivery

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12
Q

Complications of maternal DM on fetus

A

Antenatal

  1. Increase risk of congenital malformations: E.g. neural tube, skeletal, cardiac, renal, gastrointestinal
  2. Polyhydramnios
  3. Spontaneous miscarriage, stillbirth, Preterm delivery
  4. Large-for-gestational age/ macrosomia

Neonatal:

  1. Asphyxia, birth trauma
  2. Jaundice, needing phototherapy
  3. Metabolic, respiratory distress syndrome
  4. Sepsis
  5. Fetal programming effect on metabolic and cardiovascular diseases
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13
Q

Management of maternal DM before pregnancy

A

Pre-pregnancy counseling:

  1. Better glycaemic control (need home blood glucose monitoring, optimize drugs)
    - Hyperglycaemia is teratogenic
    - Incidence of major congenital abnormality correlates with HbA1c level
  2. Avoid OC pills (risk of stroke), may use IUCD
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14
Q

Management of maternal DM during pregnancy

DM, Diet, Obstetrics management

A

DM control:

  • Strict glycaemic control with oral hypoglycaemic agents
  • Insulin dosage adjustment in type 1 DM
  • Hotline for glycaemic control with regular follow-up

Diet:
- Increase caloric intake for baby’s demand

Obstetrics:

  • Fetal ultrasound for fetal growth, exclude congenital abnormalities
  • Monitor maternal and fetal complications
  • Intra-partum: tight glucose control with Insulin-dextrose drip and potassium replacement (prevent RDS, fetal hypoglycemia)
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15
Q

Post-partum management of fetus born from mother with DM

A

 Neonatal assessment

 Regular blood glucose monitoring by dextrostix (e.g. hypoglycaemia)

 Neonatal jaundice and phototherapy

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16
Q

Thyroid diseases associated with pregnancy

A

Maternal Grave’s disease causing neonatal thyrotoxicosis

Transient biochemical hyperthyroidism in mother, a/w hyperemesis gravidarum

Subclinical hypothyroidism (High TSH, Normal fT4) in mother
- Causes preterm labor, delayed neurological development in offsprings
17
Q

Treatment of hyperthyroidism and hypothyroidism during pregnancy

A

Hyperthyroidism:

  • Radioactive iodine contraindicated in pregnancy***
  • Propylthiouracil (PTU) and carbimazole are commonly used: no teratogenicity
  • Risk: PTU liver failure, transient neonatal hypothyroidism

Hypothyroidism:
- Thyroxine replacement

18
Q

Autoimmune diseases associated with pregnancy

Maternal diseases and effects on fetus

A

Autoantibodies crossing placenta:

  • idiopathic thrombocytopenia purpura/ ITP&raquo_space; fetal thrombocytopenia and excessive bleeding during delivery
  • Anti-Ro antibodies&raquo_space; Congenital heart block
  • SLE&raquo_space; Neonatal lupus
  • Lupus anticoagulant, anticardiolipin&raquo_space; IUGR, pregnancy loss

End organ damage:

  • Autoimmune thyroiditis&raquo_space; Delayed fetal neurological development
  • Autoimmune renal disease&raquo_space; IUGR, superimposed pre-eclampsia
19
Q

Describe the effect of pregnancy on maternal autoimmune diseases

A
  1. Pregnancy modulates immune system: alleviate or worsen autoimmune diseases
  2. Pregnancy increases metabolic demand and stress on end-organs: exacerbate end-organ damage by autoimmune diseases
  3. Pregnancy is contraindicated during acute flare of autoimmune diseases
20
Q

Describe the effect of autoimmune disease treatment on fetus

A

Steroids: IUGR, Cleft lip
Immunosuppressants: Teratogenic (azathioprine is safe)
Cytotoxic drugs: Teratogenic, pregnancy loss

21
Q

Describe the effects of pregnancy on maternal cardiac conditions

Explain why pregnancy exacerbates cardiac conditions

A

Heart failure during pregnancy due to:
- Increase cardiac output for fetus
- Antenatal anemia
- Drug-use in pregnancy (β-adrenergics for arresting preterm labour)

Delivery:
- Stress and physical demand during labour and delivery
- Excessive intravenous fluids during labor (congestive HF)

Postpartum Volume overload due to resorption of uterine blood into systemic circulation
- Right heart failure
- Increase R to L shunt with pulmonary hypertension

22
Q

Describe effects of maternal cardiac conditions on fetus

A

Effects on fetus:

  1. Smaller fetal size (IUGR)
  2. More frequent preterm labour

Reasons:
 Cardiac condition may limit the normal physiological increase in the cardiac output
 Hypoxia in cyanotic heart disease affects growth of fetus

23
Q

Cardiac drugs contraindicated during pregnancy

A

Diuretics (e.g. frusemide) - limits physiological volume expansion, IUGR

Warfarin:

  • Warfarin embryopathy in 1st trimester
  • Intracranial hemorrhage and fetal loss in 2nd trimester

ACEi:
- Fetal loss, oligohydramnios, fetal renal hypoperfusion

Propranolol

24
Q

Management of cardiac conditions during pregnancy

A

General:

  • Regular assessment by cardiologist - every 4 weeks till 32 weeks then every 2 weeks
  • Monitor fetal growth every 4 weeks
  • Induce labor +/- C-section if necessary

Drugs:

  • Stop and substitute all teratogenic drugs before 1st trimester
  • Adjust Digoxin dosage

Surgical:
- Postpone cardiac catheterization, open-heart surgery and valve replacements

Heart valve diseases:

  • Antibiotic prophylaxis against bacterial IE during delivery
  • Prevent thromboembolism
25
Q

Management of epilepsy during pregnancy

A

Continue control of epilepsy despite teratogenic potential (e.g. cleft lip, cleft palate, neural tube defects)

  • Keep antiepileptic drugs
  • Switch to monotherapy if possible
  • Increase folic acid supplement dose (protect against neural defect)
  • Prenatal US exam for fetal morphology
26
Q

Describe the effects of pregnancy on venous thromboembolism

A

Pregnancy increases Virchow’s triad/ risk factors for thromboembolism
1. Immobility : relatively less mobile during pregnancy, bed rest

  1. Hypercoagulability: aggravated by pre-clampsia and hyperemesis
  2. Obstruction to blood flow: Gravid uterus
27
Q

Risk factors of venous thromboembolism during pregnancy

A

Pre-existing risks:
 Demographic (advanced age, obesity, ethnicity (Caucasian))
 Smoking
 Congenital/ acquired thrombophilia
 Family history/ past history of thromboembolism

Pregnancy:

  • Pre-eclampsia and hyperemesis (increase blood viscosity)
  • Long bed rests, injuries causing immobilization
  • C-section delivery
  • Post-partum genital infection
28
Q

Prevention of venous thromboembolism during pregnancy

A
  1. Minimize immobility: especially for threatened miscarriage, IUGR
  2. Adequate hydration
  3. High risk of thromboembolism:
    - Compression stocking
    - Prophylactic anticoagulants:
    LMWH/ heparin for antenatal and short-term post-natal.
    Warfarin for post-natal ONLY.
29
Q

Regimens of prophylactic anticoagulation for pregnant women at risk of thromboembolism

A

High risk:
- continue anticoagulant for 10 days after Caesarean section in pt with preeclampsia
- continue during immobilization

very high risk (e.g. previous DVT)
- Cover 6 weeks postpartum

very very high risk (e.g. antiphospholipid syndrome, previous pulmonary embolism)
- Cover throughout pregnancy + 6 weeks postpartum

Prophylaxis with heparin/ LMWH, only use warfain post-partum

30
Q

Warfarin is safe for use during pregnancy

True or False?

A

Warfarin (oral):
 Crosses placenta, teratogenic (warfarin embryopathy) - avoided in 1st (and 2nd) trimester
 Long half-life - avoided in 3rd trimester (after 36 weeks) to prepare for delivery (should use heparin instead)
Only safe for breastfeeding, post-partum use

31
Q

Liver disease associated with pregnancy

A

 Deranged liver function (HELLP in pre-eclampsia)
 Acute fatty liver of pregnancy
 Cholestasis of pregnancy
 reactivation of hepatitis B due to altered immunity and increase stress post-partum

MBBS IV - Junior Clerkship WCS (131 decks)

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