Maternal Medical Conditions Flashcards
Breast Cancer in Pregnancy (RCOG 2011)
Prognosis (2)
- Pregnancy does not worsen prognosis of breast cancer
- Pregnancy-associated breast cancer occurs in younger people who may have features of higher risk disease (high grade, ER neg)
Breast Cancer in Pregnancy (RCOG 2011)
Diagnosis (3)
- All patients with a breast lump should be referred to breast specialist
- USS-guided biopsy for histo as pregnancy-related changes renders cytology inconclusive
- Histo-confirmed grade, receptor status and HER2 status
Breast Cancer in Pregnancy (RCOG 2011)
Imaging (4)
- USS firstline
- Mammography with fetal shielding if cancer confirmed to assess extent of disease and contralateral breast
- CXR, liver USS for staging
- Bone scanning/pelvic CT not recommended; prefer XR or MRI
Breast Cancer in Pregnancy (RCOG 2011)
Treatment (5)
- Surgical: all trimesters. Avoid reconstructions until postnatal
- Radiotherapy: only if life or organ-preserving with fetal shielding or early delivery
- Chemotherapy: 2nd and 3rd trimesters. Contraindicated in 1st due to fetal abnormality. Not while breast-feeding
- Tamoxifen/ Herceptin: not in pregnancy/breastfeeding
- GCSF is safe and recommended to avoid neutropenia
Breast Cancer in Pregnancy (RCOG 2011)
Birth (3)
- Can usually deliver at term vaginally
- Should deliver 2-3 weeks after last chemotherapy
- May consider early delivery with steroid cover if needed for treatment
Breast Cancer in Pregnancy (RCOG 2011)
Postnatal Considerations:
- Lactation (3)
- Contraception (2)
Lactation:
- Can breast feed from unaffected breast
- Should not breastfeed on Tamoxifen or Herceptin
- Should wait 14+ days post chemo to avoid fetal leukopenia
Contraception:
- Non-hormonal preferred
- LNG-IUS may decrease endometrial complications on Tamoxifen. No increased risk of recurrence, unless developed breast cancer on LNG-IUS
Breast Cancer in Pregnancy (RCOG 2011)
Future Pregnancies (6)
- Should wait at least 2 years before conception as recurrence is highest in first 3 years
- Avoid if metastatic breast cancer given reduced life expectancy and limitations on treatments
- Tamoxifen should be stopped 3 months before conception
- Long term survival not adversely effected by pregnancy
- No evidence of increased risk of congenital abnormalities/stillbirth
- Echocardiogram in pregnancy if anthracycline chemotherapy to exlude cardiomyopathy
Beta Thalassaemia in Pregnancy (RCOG 2014)
Pre-Conception Care: screening for end-organ dysfunction (6)
- Diabetes: serum fructosamine, aiming for <300nmol/L for 3+ months pre-conception
- Thyroid: hypothyroidism is common
- Cardiac: echocardiogram, ECG, T2 cardiac MRI
- Liver: liver T2 MRI, liver/gall bladder USS
- Bone: bone scan, vitamin D levels
- Group and antibody screen
Beta Thalassaemia in Pregnancy (RCOG 2014)
Pre-conception considerations (7)
- Screening for end-organ damage
- Optimisation of complications
- Aggressive chelation
- Contraception
- Genetic screening: partner (Hb/MCV/MCH +/- haemoglobin electrophoresis), PGD
- Immunisation: hep B, pneumococcal/HiB/meningococcal if splenectomy
- 5mg folic acid
Beta Thalassaemia in Pregnancy (RCOG 2014)
Antenatal Considerations (9)
- Monthly visits until 28/40, then fortnightly
- Diabetes: monthly fructosamine
- Cardiac: echo 28/40 if thalassaemia major
- TFTs if hypothyroid
- Hb 2-3 weekly
- Folic acid 5mg daily
- Aspirin +/- clexane (splenectomy and/or platelets >600)
- Blood transfusions
- Iron chelation
Beta Thalassaemia in Pregnancy (RCOG 2014)
Scan Frequency (4)
- Early pregnancy scan 7-9 weeks
- Nuchal scan 11-14 weeks
- Anatomy 18-20+6
- Growth scans from 24 weeks
Beta Thalassaemia in Pregnancy (RCOG 2014)
Intrapartum Considerations
- Timing of birth as per obstetric indications
- G/H +/- X-match
- Peripartum iron chelation
- CEFM
- Active third stage
- Other considerations (cardiac, diabetes)
Beta Thalassaemia in Pregnancy (RCOG 2014)
Postnatal considerations (2)
- High risk of VTE (clexane 7/7 vaginal birth or 6/52 post CS)
- Breast-feeding safe/encouraged
Bleeding Disorders in Pregnancy (RCOG 2017)
Haemophilia Definition (3)
- X-linked recessive condition with reduction or absence in clotting factors causing bleeding
- VIII: haemophilia A
- IX: haemophilia B
Bleeding Disorders in Pregnancy (RCOG 2017)
Haemophilia Inheritance (3)
- 50% neonatal males with severe haemophilia have no family hx
- 90% chance mother is carrier, with risk to next male child
- Different phenotypes and severities of haemophilia
Bleeding Disorders in Pregnancy (RCOG 2017)
Haemophilia Risks to Mother (2)
- Carriers may have low factor VIII/IX levels
- Carriers are at increased risk of bleeding with invasive procedures, TOP/miscarriage and birth
Bleeding Disorders in Pregnancy (RCOG 2017)
Haemophilia risks to neonate (2)
- Male neonates with haemophilia are at increased risk of bleeding, including intra- and extra-cranial haemorrhage
- Male neonates with haemophilia are at risk of iatrogenic bleed following delivery
Bleeding Disorders in Pregnancy (RCOG 2017)
Haemophilia Pre-pregnancy Management (3)
- Baseline factor level and bleeding phenotype prior to onset of pregnancy
- General optimisation of health - weight, iron deficiency
- Pre-conception counselling due to risk of male infant
Bleeding Disorders in Pregnancy (RCOG 2017)
Haemophilia: Prenatal Diagnosis (4)
- Carriers should be offered preimplantation genetic diagnosis
- Carriers with male fetus confirmed to be affected should be counselled
- All carriers should be offered fetal sex determination by NIPT from 9/40
- Pregnant carriers with a male fetus should be offered CVS 11-14/40 or amniocentesis to confirm fetal status to inform delivery
Bleeding Disorders in Pregnancy (RCOG 2017)
Haemophilia: Antepartum Management (9)
- Multidisciplinary
- Check factor levels at booking, before any antenatal procedure and in third trimester
- Aim for factor levels >0.5iu/mL, targetting 1.0iu/mL if tx required
- Consider TXA in combination if <0.5iu/ml or isolation if >0.5iu/mL
- Desmopressin for factor VIII (with fluid restriction 1L until 24h post)
- Recombinant VIII if ineffective desmopressin
- Recombinant IX if levels <0.5iu/ml (haemophilia B)
- If fetal status unknown, manage as if affected
- Avoid ECV for affected males, and in females who are carriers of severe haemophilia B
Bleeding Disorders in Pregnancy (RCOG 2017)
Haemophilia Intrapartum Considerations (10)
- Planned CS >39/40 for affected males, especially if severe or unknown
- If vaginal birth, spont labour is preferred
- Planned IOL may be required if long distance
- Avoid ventouse and midcavity forceps for affected male babies
- Avoid FBS/FSE if expected moderate-severe haemophilia
- Use FBS/FSE judiciously in mld haemophilia only to facilite vaginal birth, with extended pressure haemostasis
- Females at risk of carrying severe haemophilia B may be more at risk of haemorrhage
- Factor levels >0.5iu/ml required for neuraxial anaesthesia
- Avoid IM medications if factor levels <0.5iu/mL
- Consider desmopressin, TXA or factor concentrate peripartum
Bleeding Disorders in Pregnancy (RCOG 2017)
Haemophilia Postpartum management (4)
- Active third stage
- Factor levels should be maintained >0.5iu/mL for 3/7 post vaginal birth, 5/7 post AVD or CS
- TXA should be continued until lochia normal
- Avoid pharmacological thromboprophylaxis if factors ≤0.6iu/mL
Bleeding Disorders in Pregnancy (RCOG 2017)
Haemophilia Neonatal Management (5)
- Diagnostic testing, including cord bloods
- Coag panel
- Oral vitamin K if low factor levels
- Pressure haemostasis post bloodspot screening
- Consider cranial USS if known moderate-severe haemophilia
- Consider primary prophylaxis if traumatic birth or prematurity
Bleeding Disorders in Pregnancy (RCOG 2017)
vWD risks to mother/baby
Increased risk of APH, 1’ and 2’ PPH, especially in type 1 vWD with factor levels ≤0.5iu/mL at term, or type 2 or 3
Bleeding Disorders in Pregnancy (RCOG 2017)
vWD Preconception (2)
- Genetic counselling about risk of transmission
- Subtype of vWD and response to desmopressin
Bleeding Disorders in Pregnancy (RCOG 2017)
vWD Antenatal Management (5)
- Multidisciplinary approach
- Avoid aspirin/NSAIDs
- Check vWF antigen + activity levels and factor VIII levels at booking and in third trimester
- Desmopressin with fluid restriction
- FFP or cryoprecipitate
Bleeding Disorders in Pregnancy (RCOG 2017)
vWD Intrapartum Management (6)
- Treatment as close to delivery
- Pre- and post-treatment vWF activity/factor VIII levels as well as post-birth
- TXA
- Platelets (type 2B)
- Avoid ECV, FBS, FSE, ventouse or midcavity forceps if fetus may be affected by type 2 or 3
Neuraxial anaesthesia:
- Ok for type 1 with normal vWF levels
- Avoid in type 2 unless activity and factor VIII >0.5iu/mL
- Avoid in type 3
- Consider additional treatment prior to removal of epidural catheter
Bleeding Disorders in Pregnancy (RCOG 2017)
vWD postnatal management (6)
- IM injections/NSAIDs ok if vWF activity/factor VIII >0.5iu/mL
- Maintain levels >0.5iu/mL for 3 days post NVD or 5 days post instrumental/CS
- TXA 1g TDS - QID for 7-14 days postnatally
- Clexane ok if levels >0.5iu/mL
- Risk of delayed bleeding
- May need factor concentrate 2-3 weeks following birth for type 3
Bleeding Disorders in Pregnancy (RCOG 2017)
vWD Neonatal Management (4)
- Diagnostic tersting
- Type 2/3: cord bloods for vWF levels/activity
- Oral vitamin K
- Consider cranial imaging and prophylaxis for type 3
Modified WHO Classification of Maternal Cardiovascular Risk
mWHO I
1. Lesions
2. Risk
3. Maternal cardiac event rate
4. Follow-up
5. Location of birth
- Lesions
- Small or mild PS, PDA, mitral valve prolapse
- Repaired simple lesions (ASD, VSD, PDA, anomalous pulmonary venous drainage)
- Atrial or ventricular ectopic beats - Risk
- No detectable increased maternal mortality
- No/mild increased risk on morbidity - Maternal cardiac event
- 2.5-5% - Once or twice in pregnancy
- Local hospital
Modified WHO Classification of Maternal Cardiovascular Risk
mWHO II
1. Lesions
2. Risk
3. Maternal cardiac event rate
4. Follow-up
5. Location of birth
- Lesions
- Unoperated ASD/VSD
- Repaired ToF
- Most arrhythmias
- Turner syndrome without aortic dilatation - Risk
- Small increased risk of maternal mortality
- Moderate increase in morbidity - Maternal cardiac event rate
- 5.7-10.5% - Once per trimester
- Local hospital
Modified WHO Classification of Maternal Cardiovascular Risk
mWHO II-III
1. Lesions
2. Risk
3. Maternal cardiac event rate
4. Follow-up
5. Location of birth
- Lesions
- Mild LV impairment EF >45%
- Hypertrophic cardiomyopathy
- Native or tissue valve disease not I or IV (mild MS, moderate AS)
- Marfan or other hereditary thoracic aortic disease syndromes without aortic dilation
- Aorta <45mm with bicuspid AV
- Repaired coarctation
- Atrioventricular septal defect - Risk
- Intermediate increased risk of maternal mortality
- Moderate-severe increase in morbidity - Cardiac event rate
- 10-19% - See every two months
- Tertiary hospital
Modified WHO Classification of Maternal Cardiovascular Risk
mWHO III
1. Lesions
2. Risk
3. Maternal cardiac event rate
4. Follow-up
5. Location of birth
- Lesions
- Moderate LV impairment EF 30-45%
- Previous peripartum cardiomyopathy without any residual LV impairment
- Mechanical valve
- Systemic RV with good or mildly decreased ventricular function
- Fontan circulation if otherwise well
- Unrepaired cyanotic heart disease
- Other complex heart disease
- Moderate MS
- Severe asymptomatic AS
- Moderate aortic dilatation (40-45mm in Marfan or other HTAD, 45-50mm in bicuspid aortic valve, Turner syndrome aortic size index 20-25mm, ToF <50mm)
- VT - Risk
- Significantly increased risk of maternal mortality
- Severe morbidity - Maternal cardiac event rate
- 19-27% - See monthly
- Tertiary centre with specialist obstetric cardiac input
Modified WHO Classification of Maternal Cardiovascular Risk
mWHO IV
1. Lesions
2. Risk
3. Maternal cardiac event rate
4. Follow-up
5. Location of birth
- Lesions
- Pulmonary arterial hypertension
- Severe ventricular dysfunction EF <30%, NYHA III-IV
- Previous peripartum cardiomyopathy with residual LV impairment
- Severe MS
- Severe symptomatic AS
- Systemic RV with moderate or severely decreased ventricular function
- Severe aortic dilatation (>45mm Marfan or other HTAD, >50mm in bicuspid aortic valve, Turner aortic size index >25mm, ToF >50mm)
- Vascular EDS
- Severe (re) coarctation
- Fontan with any complication - Risk
- Pregnancy contraindicated
- Extremely high risk of maternal mortality
- Severe morbidity - Maternal cardiac event rate
- 40-100% - See monthly
- Tertiary centre with specialist obstetric cardiac input
ESC Recommendations for Management of Heart Disease in Pregnancy
Pre-Conception (3)
- Pre-pregnancy risk assessment/counselling for all known or suspected patients with heart disease
- Risk assessment before and after conception using mWHO classification
- Genetic counselling for congenital heart disease/arrhythmias, cardiomyopathies, aortic disease or genetic malformations associated with cardiovascular disease
ESC Recommendations for Management of Heart Disease in Pregnancy
Antenatal (9)
- High-risk patients managed in tertiary unit with MDT approach
- Steroids recommended if mother is for cardiac surgery 24 - <37/40
- Fetal echo if elevated risk of fetal abnormalities
- Coronary bypass surgery or valve surgery may be considered when conservative/medical therapy has failed in life-threatening conditions not amenable to PCI
Imaging:
- CXR when investigating dyspnoea
- Echo is recommended for pregnant patients with unexplained or new cardiovascular signs in pregnancy
- Consider MRI (without gadolinium) if echo insufficient
- CT and electrophysiological studies in select patients
- Cardiac catheterisation can be considered with strict indications
ESC Recommendations for Management of Heart Disease in Pregnancy
Intrapartum (6)
- Antibiotic prophylaxis to prevent endocarditis during delivery not recommended
- Vaginal delivery recommended for most
- Consider delivery before surgery if >26/40
- IOL should be considered at 40/40 for all women with cardiovascular disease
- If hypertensive, recommend epidural and consider elective instrumental
Caesarean should be considered for:
- Standard obstetric indications
- Dilated ascending aorta >45mm
- Severe AS
- Pre-term labour on anticoagulation
- Eisenmenger’s syndrome
- Severe heart failure
ESC Management of Aortic Disease
Preconception (4)
- Preconception counselling about aortic dissection risk if known aortic disease
- Imaging of entire aorta (CT/MRI) prior to pregnancy with genetically proven aortic syndrome/known aortic disease
- Imaging of ascending aorta recommended if bicuspid AV
Pregnancy not recommended:
- Patients with/history of aortic dissection
- Vascular EDS
- HTAD with aortic root >45mm
- Biscuspid AV with aortic root >50mm (or >27mm/mm2 BSA)
- Turner syndrome with aortic size index >25mm/mm2 BSA
ESC Management of Aortic Disease
Antenatal Management (6)
- Strict BP management with known aortic dilatation, history of dissection or genetic predisposition
- Echo monitoring every 4-12 weeks during pregnancy/6 months postnatal if ascending aortic dilation
- Imaging with MRI if known dilatation of distal ascending aorta, aortic arch or descending aorta
- Prophylactic surgery should be considered if aorta diameter >45mm and increasing rapidly
- ß-blockers should be considered in women with Marfan syndrome/other HTAD
- Vascular EDS patients should have celiprolol
ESC Management of Aortic Disease
Intrapartum (8)
- Deliver in a tertiary centre where cardiothoracics is available
- If fetus is viable, deliver prior to surgery
- Vaginal delivery recommended if diameter <40mm
- Epidural anaesthesia
- Expedited second stage
- Consider caesarean section if aorta diameter 40-45mm
- Recommend caesarean section with ascending aorta >45mm or history of aortic dissection
- Avoid ergometrine where possible
ESC Management of Native Valvular Heart Disease
Pre-Pregnancy (1)
Pre-pregnancy evaluation including echo and counselling
ESC Management of Native Valvular Heart Disease
Mitral Stenosis (5)
- Restricted activities and ß-blockers recommended if symptomatic or pulmonary hypertension
- Diuretics recommended when CHF sx persist despite ß-blockers
- Intervention recommended pre-pregnancy with MS and valve area <1.0cm2 and considered <1.5cm2
- Anticoagulation is recommended for AF, LA thrombosis or prior embolism
- Percutaneous intervention should be considered with severe symptoms or systolic pulmonary pressure >50mmHg despite medical therapy
ESC Management of Native Valvular Heart Disease
Aortic Stenosis (3)
Intervention recommended before pregnancy with severe AS if:
- Symptomatic
- LVEF <50%
- Symptoms from exercise testing
Intervention should be considered if asymptomatic with severe AS when a fall in BP below baseline during exercise testing occurs
Balloon valvuloplasty should be considered with severe AS and severe sx
ESC Management of Native Valvular Heart Disease
Regurgitant Lesions (2)
Surgical treatment recommended before pregnancy in patients with severe AR or MR with symptoms of impaired function or ventricular dilatation
Medical therapy is recommended in pregnancy when symptoms occur
ESC Management of Prosthetic Heart Valves
Antenatal Care (6)
- Mechanical heart valve patients should be managed with tertiary obs/cardiac team
- Recommend discontinuing warfarin and start on heparin at 36/40
- Consider continuing warfarin in 1st trimester if <5mg/day, otherwise change to 1mg/kg/BD clexane
- Weekly anti-Xa for those on heparin, targeting 0.8-1.2U/L for AV or 1.0-1.2 IU/ML for mitral and RV replacements
- 1-2 weekly INR on warfarin
- Echocardiogram with mechanical vales and dyspnoea or embolic event
ESC Management of Prosthetic Heart Valves
Intrapartum (2)
- Caesarean recommended if labour starts while on warfarin or <2 weeks after discontinuation
- Recommend changing LMWH to UFH >36/40 before planned delivery. UFH continued until 4-6h pre-birth and restarted 4-6h after if no bleeding
ESC Management of CAD (5)
- ECG and troponin recommended when a pregnant woman has chest pain
- Primary coronary angioplasty is recommended as preferred re-perfusion for STEMI
- Consider invasive reperfusion for NSTEMI with high risk criteria
- Conservative management for stable NSTEMI with low risk criteria
- Breastfeeding not recommended in mothers who take antiplatelets other than aspirin due to lack of evidence
ESC Management of Cardiomyopathies and Heart Failure
Preconception (3)
- Counsel women with reduced EF about risk of deterioration during pregnancy and peripartum
- Risk of recurrence in subsequent pregnancies of peripartum/dilated cardiomyopathies, even if LV function has recovered
- Pregnancy should be avoided in peripartum/DCM if LV hasn’t recovered
ESC Management of Cardiomyopathies and Heart Failure
Antenatal (5)
- Anticoagulation recommended for patients with intracardiac thrombus or systemic embolism or AF
- Treat women with heart failure using non-pregnancy guidelines, omitting contraindicated drugs
- Continue ß-blockers or commence them if indicated for women with reduced EF
- Cardiogenic shock/inotrope requirement should be transferred to a facility where mechanical circulatory support is available
- Bromocriptine may be considered to stop lactation and enhance recovery in peripartum cardiomyopathy (with anticoagulation)
ESC Management of HCM (4)
- Same risk stratifications as non-pregnant women
- ß-blockers should be continued
- ß-blockers should be started if develop symptoms of LVOT or arrhythmia
- Cardioversion should be considered for persistent AF
ESC Management of Arrhythmias
Acute Management of SVT/AF (4)
- Vagal manoeuvres or adenosine for acute conversion of PSVT
- Electrical cardioversion for any tachycardia with haemodynamic instability or AF
- ß-1 selective ß-blockers for acute conversion of PSVT
- Flecainide for termination of atrial flutterAF in stable patients with normal hearts
ESC Management of Arrhythmias
Long-term management of SVT/AF (6)
- ß1-blockers or Verapamil for prevention of SVT
- Flecainide for prevent of SVVT with WPW
- ß-blockers recommended for rate control of atrial tachycardia/AF
- Flecainide or Sotalol should be considered for prevention of SVT, atrial tachycardia or AF if AV nodal blocking agents fail
- Digoxin or Verapamil should be considered for atrial tachycardia or AF if ß-blockers fail
- Catheter ablation should be considered if drug-refractory and poorly tolerated SVT
ESC Management of Arrhythmias
Acute Management of ventricular tachyarrhythmias (2)
- Immediate electrical cardioversion for sustained unstable and stable VT
- Can consider ß-blocker, Sotalol, Flecainide or pacing if stable monomorphic VT
ESC Management of Arrhythmias
Long term management of VT
- ICD recommended pre-pregnancy if
Hypothyroidism (RANZCOG)
Thyroid Hormone in Pregnancy (5)
- ßhCG similar to TSH, so there may be a transient increase in T4 with suppression of TSH
- Increased GFR = increased iodine clearance = increased iodine intake in pregnancy
- If pre-existing thyroid disease, cannot respond to physiological demands of pregnancy = increased thyroid replacement required
- Fetus is reliant on transplacental maternal thyroid hormone until 12/4-
- Fetus and fully breastfed infant is dependent on maternal iodine for thyroid hormone synthesis
Hypothyroidism (RANZCOG)
Diagnosis in pregnancy (4)
Use local pregnancy-specific ranges for TSH and T4
- TSH can be 0.5mU/L than non-pregnancy range for 1st trimester, then the same in 2nd and 3rd trimesters
- 4mU/L is the upper limit of normal throughout pregnancy
Hypothyroidism is defined as:
- Increased TSH and low T4
- Or TSH >10mU/L regardless of T4 level
Hypothyroidism (RANZCOG)
Overt hypothyroidism
- Adverse effects (8)
- Testing (3)
- Treatment and monitoring (3)
Adverse effects (untreated):
- Anovulation and miscarriage
- PET
- Placental abruption
- Anaemia
- PPH
- Prematurity
- Perinatal mortality
- Neurodevelopmental delay in children
Target Testing recommended:
- Symptoms of thyroid disease
- T1DM
- Personal hx thyroid disease
Treatment and Monitoring
- Pre-existing thyroid disease: 30-50% increase in thyroxine (2x doses per week)
- Monitor TSH at least once per trimester
- Target TSH lower half of trimster-specific ranges
Hypothyroidism (RANZCOG)
Subclinical Hypothyroidism and TPO-abs (4)
- Inconsistent data between SCH and adverse pregnancy outcomes
- Treatment not recommended, even if TPO-ab positive
Recurrent Miscarriage:
- No proven benefit in treating euthyroid TPO-positive women to prevent miscarriage
- Mixed evidence in treating SCH to reduce miscarriage
Epilepsy in Pregnancy (RCOG)
AEDs and Congenital Anomalies (9)
No AEDs: 2.8%
Carbamazepine: 2%
- Neural tube defects: 0.5-15
- Cleft palate
- Enzyme-inducing
- Least risk <400mg/d
Lamotrigine: 3.4%
- Least risk <300mg/d
Levetiracetam: 0.7%
Phenobarbitol: 6.5%
- Cardiac malformations
- Enzyme-inducing
Phenytoin: ~3%
- Cardiac malformations
- Cleft palate
- Enzyme-inducing
- Phenytoin syndrome (3-5%: mental retardation, SGA, craniofacial anomalies, limb defects
Sodium valproate: 10.7%
- NTD: 1-2%
- Facial cleft
- Hypospadias
- Polydactyly
- Kidney malformations
- Cardiac malformations
- Long-term neurodevelopmental issues
- Childhood autism
- Generally avoid
Polytherapy: 16.8%
Previous child with major malformation: 16.8%
Epilepsy in Pregnancy (RCOG)
Pre-conception (4)
- Consider stopping AED if seizure free for 2-5 years
- Change AED to one safer in pregnancy
- Pre-conception counselling about likelihood of fetal anomalies with each drug
- High dose folic acid at least 3 months pre-conception until at least the end of the first trimester
Epilepsy in Pregnancy (RCOG)
Antenatal (5)
- MDT input
- 5mg folic acid until end of first trimester
- No clear evidence routine monitoring of AED levels improves outcome (case-by-case)
- Fetal anomaly scan 18-20+6
- Serial growth scans from 28/40
Epilepsy in Pregnancy (RCOG)
Intrapartum (7)
Pain relief (4)
- Birth in centre with obstetrics/neonates
- Mode of birth as per usual obstetric indications
- One-to-one midwifery care
- Consider IV access
- Avoid triggers
- Continue AEDs
- CEFM if high risk of seizure or following intrapartum seizure
Pain relief:
- Early epidural to minimise triggers
- TENS, entonox, morphine all safe
- Avoid pethidine, ketamine, sevoflurane
- Consider water birth if seizure-free for significant period of time
Epilepsy in Pregnancy (RCOG)
Termination of Intrapartum Seizure (6)
- Left lateral tilt
- Airway management/oxygenation
- Benzodiazepines +/- phenytoin as per local protocols
- Consider tocolysis if uterine hypertonis
- CTG following stabilisation of mother
- If seizure >5 minutes or recurrent, consider expediting delivery
Epilepsy in Pregnancy (RCOG)
Postnatal considerations (5)
- Higher risk of seizure immediately after delivery compared to antenatal (still low risk)
- Minimise triggers (sleep deprivation)
- Review AED dose within 10 days to avoid postpartum toxicity
- Education around seizure and infant safety
- Screening for depressive disorders
Epilepsy in Pregnancy (RCOG)
Contraception (3)
- IUD/IUS reliable and not affected by enzyme-inducing AEDs
- POP, COCP and jadelle at increased risk of failure on enzyme-inducing AEDs
- COCP and lamotrigine is associated with decreased lamotrigine levels = increased seizure risk
Epilepsy in Pregnancy (RCOG)
Neonatal considerations (3)
- Alert neonatal team due to risk of neonatal withdrawal syndrome from benzodiazepines and AEDs
- Vitamin K IM to prevent haemorrhagic disease of the newborn on enzyme-inducing AEDs
- Benefits of breastfeeding generally outweigh small risk to infant; monitor for sedation and poor feeding
SOMANZ Hypertension in Pregnancy
Definitions
- Hypertension (5)
- GHTN (3)
- PET (2)
- CHTN (3)
- Whitecoat HTN (3)
- Masked HTN (3)
Hypertension in pregnancy:
- sBP ≥140mmHg
- dBP ≥90mmHg
- 3 consecutive readings at least two minutes apart, repeated again >4h to confirm
- Mild: 140-159/90-109mmHg
- Severe: ≥160/110mmHg
GHTN
- Elevated BP ≥140/90mmHg on two readings at least 4h apart
- Diagnosed for the first time >20/40
- Absence of any features suggestive of PET
PET
- Hypertension
- Evidence of end-organ dysfunction
CHTN
- Elevated BP pre-pregnancy or <20/40
- Retrospective diagnosis if GHTN persists >3/12 postnatal
Whitecoat HTN
- Elevated BP in clinical setting
- Normal ambulatory or home BP readings
- Progression to persistent HTN/PET: 8%
Masked HTN
- Normal BP in clinical setting
- Raised BP on ambulatory or home monitoring
- Outcomes for those presenting >20/40 equate to GHTN
SOMANZ Hypertension in Pregnancy
Initial Assessment for HTN in Pregnancy (4)
- Signs/symptoms of pre-eclampsia
- BP monitoring
- Day unit
- Home BP monitoring
- Inpatient admission - Investigations
- CBC +/- ix for haemolysis
- UECs
- LFTs
- uPCR
- sFlt-1/PlGF as per local availability
- Fetal growth assessment - Inpatient admission indicated for:
- Severe HTN
- Symptoms associated with adverse outcomes: headache, neurological irritability, epigastric/chest pain, dyspnoea, nausea/vomiting
SOMANZ Hypertension in Pregnancy
On-going Antenatal Assessment
- Whitecoat
- Chronic HTN
- GHTN
- PET
SOMANZ Hypertension in Pregnancy
Screening for PET (4)
Women should be screened for their risk of PET early in pregnancy
Combined first trimester screening to identify women at risk is conditionally recommended based on local availability
- Maternal features
- Biomarkers
- Sonography: UtA-PI
High risk: 1 or more risk factors
- Previous hypertensive disorder in pregnancy
- CKD or renal impairment
- Multi-fetal gestation
- Pre-existing CHTN
- Pre-existing diabetes mellitus
- Autoimmune disorders (SLE, APS)
Moderate risk: 2 or more risk factors
- AMA 40y
- BMI ≥35
- Fhx PET
- Interpregnancy interval >10y
- ART
- sBP >130mmHg or dBP >80mmHg at booking
SOMANZ Hypertension in Pregnancy
Aspirin for Prevention of PET
- Mechanism (4)
- Recommendations (6)
- Benefits (6)
Mechanism:
- Non-selective irreversible COX-1 inhibitor
- Decreases TXA concentration
- Mediation of unbalanced TXA/PGI-2 ratio
- Reduces platelet aggregation and inhibits vasoconstriction when there is enhanced uterine blood flow
Recommendations
- Aspirin recommended in women at high risk of PET <16/40
- 150mg/day strongly recommended
- Bedtime aspirin conditionally recommended
- Cessation between 34/40 and birth based on clinical judgement and shared decision making
- Universal aspirin in low-risk nulliparous population not recommended
- Counselling on use of aspirin in pregnancy recommended to improve adherence
Benefits:
- PET: RR 0.67
- Early onset PET: RR 0.29
- Preterm birth: RR 0.51
- SGA: RR 0.52
- No statistically significant difference in placental abruption, APH, PPH or neonatal intra-cerebral haemorrhage
- Small benefit in reducing risk of PTB when commenced >16/40 but nil else
SOMANZ Hypertension in Pregnancy
Use of Calcium in Prevention of PET (3)
- Recommended in women with low dietary intake of calcium to prevent PET, PTB and GHTN <1g/day
- Assess dietary intake prior to recommending oral calcium
- Consider assessing serum calcium level in those taking calcium to avoid hypercalcaemia
SOMANZ Hypertension in Pregnancy
Proteinuria (5)
- Urine dipstick can be used for screening but is inadequate to diagnose proteinuria
- Confirmatory testing with uPCR/ACR recommended if clinical suspicion of PET
- uPCR >30mg/mmol, uACR ≥8mg/mmol
- Cut-off for multiple gestation is unclear
- Repeated urinary protein assessment in women with proteinuria from established PET not recommended in the absence of other indications
