Maternal Medical Conditions

Question 1

What counts as maternal death?

Answer 1

Death during pregnancy or up to 42 days after

Question 2

What is the main cause of indirect maternal death?

Answer 2

Maternal cardiac conditions

Other common causes include renal conditions and non-genital tract sepsis

Question 3

What is the most common medical condition to cause complication in pregnancy?

Answer 3

Diabetes mellitus

Question 4

What is there an increased risk of with DM in pregnancy?

Answer 4

Episodes of hypo or hyperglycaemia 
Keto-acidosis 
HTN, pre-eclampsia and eclampsia 
Fetal abnormalities
IUGR (due to placental insufficiency because of glycosylation of placental vessels)

Question 5

What fetal abnormalities is the woman with DM at risk of?

Answer 5

Sudden IUD (Intra-Uterine death)
Shoulder dystocia (due to macrosomic baby)
Neonatal hypoglycaemia
Increased risk of baby developing obesity or diabetes later in life

Question 6

What pre-conception advice should be given to a woman with DM?

Answer 6

Counselling about risks
Advice on weight loss if BMI above 27
Monitor HbA1c regularly
5mg FOLIC ACID up until 12w pregnancy to avoid NTD
Offer her home test glucose kit and home test ketone strips
All women should be assessed for retinopathy and nephropatht

Question 7

What diabetic medication is generally considered safe and is preferred in pregnancy?

Answer 7

Metformin and insulin generally considered safe

Question 8

What are some risk factors for GDM?

Answer 8

BMI above 30
Prev macrocosmic baby or baby weighing >4.5kg
Prev GDM
FH of DM
Minority ethnic

Question 9

How do we diagnose GDM?

Answer 9

If woman has
Fasting blood glucose of 5.6mmol/L or above
2 hour plasma glucose of 7.8mmol/L or above

Question 10

How should GDM be managed?

Answer 10

All seen in specialist clinic
All see dietician
Give lifestyle and diet advice (offered as sole management for woman with fasting plasma glucose <7mmol/L at diagnosis)
Offer METFORMIN to women in whom blood glucose targets are not met within 1-2 weeks of diet and lifestyle changes
Monitor renal function and regularly check fundi for signs of retinopathy

Question 11

What should women’s target blood glucose levels be?

Answer 11

Fasting blood glucose: 5.3mmol/L
One hour post-meal: 7.8mmol/L
Two hours post-meal: 6.4mmol/L

Also make women aware of the risks of hypoglycaemia (especially women on insulin therapy)

Question 12

Will women with diabetes need extra scanning?

Answer 12

YES

at 28 weeks, 32 weeks and 36 weeks to look for fetal growth and liquor volume

Question 13

How should women with diabetes have their delivery planned?

Answer 13

Offered induction of labour at 38w (or C/S if desired) can be earlier if signs of fetal abnormality
Not in itself a contraindication for vaginal birth
Maintain plasma glucose between 4mmol/L and 7mmol/L during delivery (insulin and dextrose given if necessary)

Question 14

What neonatal care is necessary for babies born to mothers with diabetes?

Answer 14

Blood glucose checked at 2-4hours post delivery.

Admit babies if they have hypoglycaemia or any signs of respiratory distress

Question 15

What pre-conception advice should be given to women with epilepsy?

Answer 15

5mg folic acid necessary
They will be seen in obstetric epilepsy clinic
Counsel them about the risk of genetic malformations
Review anti-convulsant medications
Pregnancy should be postponed until seizures are well controlled

Question 16

What increased risks do women with epilepsy have during pregnancy?

Answer 16

Slight increased risk of still birth miscarriage
Slight increased risk of epilepsy in baby
Women on anti-epileptic drugs have a THREE TIMES higher risk of having babies that are SGA

Question 17

What anti-epileptic medications are safest during pregnancy and which ones should be avoided?

Answer 17

SODIUM VALPROATE SHOULD BE AVOIDED (high malformation risk)

The SAFEST options are Lamotrigine and Carbamazepine

Question 18

How should you manage a woman who is fitting during pregnancy?

Answer 18

SEIZURE MANAGEMENT IN ECLAMPSIA 
MgSO4 IV immediately 
THEN 
Lorazepam 0.1mg/kg bolus (4mg)
If not responding consider Phenytoin

Question 19

Should women with epilepsy be offered extra growth scans?

Answer 19

YES due to their risk of SGA babies

At 28, 3 2 and 36weeks (same schedule as diabetes)

Question 20

Should women on anti-epileptic drugs be allowed to breastfeed?

Answer 20

Yes - levels in the breast milk are LOW
But monitor for neonatal toxicity…
Lethargy, sedation and withdrawal it the neonate

Question 21

What should you discuss with the mother with epilepsy about future contraception?

Answer 21

Oral contraceptive pills NOT appropriate due to CYP450 interaction
Offer copper IUD or Depo ink

Question 22

What are the effects of having a seizure while pregnant?

Answer 22

Causes fetal hypoxia (as well as the possible harm caused by falling to floor or dropping objects on bump)
There is also a risk of SUDEP
Sudden Unexplained Death from Epilepsy in Pregnancy

Question 23

When is the highest risk of seizures?

Answer 23

3 days post-natally

Question 24

If a woman has essential hypertension and becomes pregnant what change is likely to be made?

Answer 24

She will probably be on ACE-i but these CANNOT be given during pregnancy so she will have to come off this medication

Question 25

Which anti-hypertensives are most appropriate during pregnancy?

Answer 25

BETA-BLOCKERS because they do not cross the placental boundary
LABETALOL - most common
NIFEDIPINE (a CCB that is also used when B-B are contraindicated)
ASPIRIN can be given to reduce the chance of woman developing pre-eclampsia

Question 26

What physiological changes are there to the cardiovascular system during pregnancy?

Answer 26

Increase circulating volume (40%)
Increased CO (d/t increased SV and HR)
50% drop in SVR (blood pressure drops in second trimester but then recovers by term)
Ejection systolic murmur in 90% women (due to increased blood flow)

Question 27

What kinds of symptoms and signs would make you concerned about a cardiac disorder in pregnancy?

Answer 27

Chest pain 
Shortness of breath 
Syncope 
Fatigue 
Palpitations
Difficulty breathing while sleeping

Question 28

What are some examples of cardiac problems and how they effect pregnancy?

Answer 28

More likely to get aneurysm of major vessel
Cardiomyopathies might reduce woman’s ability to cope with labour because she has reduced cardiac reserve
High risk of pulmonary oedema from right sided heart failure

Question 29

What existing or previous mental health conditions are associated with the development of post-partum psychosis?

Answer 29

Bipolar disorder

Question 30

What three factors would make you begin considering postpartum psychosis?

Answer 30

New or sudden thoughts of self harm
Feeling of estrangement from baby
Sudden onset or rapidly worsening mood

Question 31

Why do maternal glucose levels go up in pregnancy normally?

Answer 31

Placenta produces a wide range of hormones such as cortisol, hCG, progesterone and placental lactogen all of which are insulin antagonists so prevent glucose form being take up out of the blood
- if the beta islet cells in the pancreas cannot produce enough insulin to overcome this effect then this leads to GESTATION DIABETES (diabetes specific to pregnancy)

Question 32

What risks are there to the baby if the mother has uncontrolled diabetes? Why is this?

Answer 32

Cardiac defects, NTDs, renal defects, IUD, macrosomia
Baby does not start producing its own insulin and thus controlled its own blood glucose until week 10 and so the majority of complications will be due to hyperglycaemia in the first trimester (when organogenesis occurs)

Also rusk of polyhydramnios due to fetal polyuria

Question 33

What effects will pregnancy have on a woman’s pre-existing diabetes?

Answer 33

Her insulin requirements will change (drop in the first trimester and then climb again)
Will complicate diabetic retinopathies

Question 34

How can diabetes in pregnancy be screened for?

Answer 34

Glucose Tolerance Test (GTT) at 24-28weeks IF WOMEN HAVE RISK FACTORS (FH, Prev Hx, raised BMI, prev big baby)