Maternal Medical Conditions Flashcards
What counts as maternal death?
Death during pregnancy or up to 42 days after end of pregnancy
What is the main cause of INDIRECT maternal death?
Maternal cardiac conditions
Other common causes include renal conditions and non-genital tract sepsis
What is the most common medical condition to cause complication in pregnancy?
Diabetes mellitus
What is there an increased risk of with DM in pregnancy?
-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)
What fetal abnormalities is the woman with DM at risk of?
- Sudden IUD (Intra-Uterine death)
- Shoulder dystocia (due to macrosomic baby)
- Neonatal hypoglycaemia
- Increased risk of baby developing obesity or diabetes later in life
What pre-conception advice should be given to a woman with DM?
Counselling about risks
- Advice on weight loss if BMI above 27
- Tight BM control <40 HbA1c (home testing kit) -All women should be assessed for retinopathy and nephropathty
- Medication - check for teratogenicity
What diabetic medication is generally considered safe and is preferred in pregnancy?
What other drugs should they be prescribed?
Metformin and insulin generally considered safe
- High dose 5mg FOLIC ACID up until 12w pregnancy to avoid NTD
- 75mg aspirin from (12 weeks-birth) to reduce risk of preeclampsia
What are some risk factors for Gestational diabetes?
BMI above 30 Prev macrocosmic baby or baby weighing >4.5kg Prev GDM FH of DM Minority ethnic
How do we diagnose GDM?
Gestational diabetes
GLUCODSE TOLERANCE TEST 5678!
If woman has:
Fasting blood glucose of 5.6mmol/L or above
2 hour plasma glucose of 7.8mmol/L or above
How should GDM be managed?
All seen in specialist clinic within 1 week
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
Fasting plasma glucose level < 7 mmol/l
- trial of diet and exercise
- if not met within 1-2 weeks>start metformin
- if still not met>insulin (short acting)
Fasting glucose level is >= 7 mmol/l
- start on insulin
- also start insulin if glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios
What should women’s target blood glucose levels be?
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)
Will women with diabetes need extra scanning?
YES
at 28 weeks, 32 weeks and 36 weeks to look for fetal growth and liquor volume
How should women with diabetes have their delivery planned?
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)
What neonatal care is necessary for babies born to mothers with diabetes?
Blood glucose checked at 2-4hours post delivery.
Admit babies if they have hypoglycaemia or any signs of respiratory distress
What pre-conception advice should be given to women with epilepsy?
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
What increased risks do women with epilepsy have during pregnancy?
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
What anti-epileptic medications are safest during pregnancy and which ones should be avoided?
SODIUM VALPROATE SHOULD BE AVOIDED (high malformation risk)
The SAFEST options are Lamotrigine and Carbamazepine
How should you manage a woman who is fitting during pregnancy?
SEIZURE MANAGEMENT IN ECLAMPSIA MgSO4 IV immediately THEN Lorazepam 0.1mg/kg bolus (4mg) If not responding consider Phenytoin
Should women with epilepsy be offered extra growth scans?
YES due to their risk of SGA babies
At 28, 3 2 and 36weeks (same schedule as diabetes)
Should women on anti-epileptic drugs be allowed to breastfeed?
Yes - levels in the breast milk are LOW
But monitor for neonatal toxicity…
Lethargy, sedation and withdrawal it the neonate
What should you discuss with the mother with epilepsy about future contraception?
Oral contraceptive pills NOT appropriate due to CYP450 interaction
Offer copper IUD or Depo ink
What are the effects of having a seizure while pregnant?
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
When is the highest risk of seizures?
3 days post-natally
If a woman has essential hypertension and becomes pregnant what change is likely to be made?
She will probably be on ACE-i but these CANNOT be given during pregnancy so she will have to come off this medication
Stop ramipril and switch to labetalol (beta blocker)
(apart from ASTHMA and Afro-Caribbean - nifedipine CCB)
-75mg ASPIRIN (12 weeks-birth) can be given to reduce the chance of woman developing pre-eclampsia
What physiological changes are there to the cardiovascular system during pregnancy?
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)
What kinds of symptoms and signs would make you concerned about a cardiac disorder in pregnancy?
Chest pain Shortness of breath Syncope Fatigue Palpitations Difficulty breathing while sleeping
What are some examples of cardiac problems and how they effect pregnancy?
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
What existing or previous mental health conditions are associated with the development of post-partum psychosis?
Bipolar disorder
What three factors would make you begin considering postpartum psychosis?
New or sudden thoughts of self harm
Feeling of estrangement from baby
Sudden onset or rapidly worsening mood
Why do maternal glucose levels go up in pregnancy normally?
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)
What risks are there to the baby if the mother has uncontrolled diabetes? Why is this?
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
What effects will pregnancy have on a woman’s pre-existing diabetes?
Her insulin requirements will change (drop in the first trimester and then climb again)
Will complicate diabetic retinopathies
How can diabetes in pregnancy be screened for?
Glucose Tolerance Test (GTT) at 24-28weeks IF WOMEN HAVE RISK FACTORS (FH, Prev Hx, raised BMI, prev big baby)
If women have risk factors for VTE, what prophylaxis should they be on?
Important things to remember? (epidural)
How long should they have this?
- LMWH
- 24 hours should pass between regional anaesthesia and last injection of LMWH therapeutic dose (f it is prophylactic dose then 12 hours)
- Continue for 6 weeks (hypercoagubility of pregnancy continues for 6 weeks)
When should you start VTE prophylaxis?
Depends on risk factors
- If prophylactic VTE since had one before - then start prophylaxis as soon as they know it is pregnant
- If 3 risk factors for VTE - start at 28 weeks
