maternal medical problems Flashcards
crohns
Risks
If active disease miscarriage IUGR PTB
Flair of disease
Management
reassurance of obstetric outcomes if stable disease
quiescent disease = no worse outcomes
high dose folic acid / iodine / Vit D / B 12
Obs med / obstetrics / gastroenterology input
Care in high risk obs clinic
Review operation notes
Medication review
Serial growth scans
IP
If caesarean needed senior obs as risk of adhesions and bowel injury
If steroids need stress doses intrapartum
Consider LSCS if severe perianal disease
Routine prepregnancy care
Pre preg iodine / folic acid / Vitamin D Booking bloods FBC G+ H antibody screen Rubella symphilis HIV Hep B HBA1c Review prepregnancy vaccination hx MMR varicella genetic carrier screening Smear Smoking drug and alcohol cessation caffiene intake to 300 mg / day
Rheumatoid arthritis
Effect of pregnancy on RA
Higher risk of IUGR and PTB
Cannot use: NSAIDs, MTX, cyclophosphamide, chlorambucil, cyclosporine, penicillamine, gold salts, mycophenolate, leflunamide, rituximab/abatacept
Can use: simple analgesics/splinting/cold packs, corticosteroids, sulfasalazine (5mg folate), hydroxycholorquine, azathioprine, IVIG
Consider atlanto-axial subluxation for GA
Efect of RA on pregnancy
Improves in pregnancy
Relapses post-partum
Management plan Pre-pregnancy Avoid during active RA Avoid NSAIDs (risk of miscarriage) Discontinue teratogenic drugs for 3/12 pre-pregnancy
Pregnancy
Obstetric lead care with MFM team- physicians, rheum, paeds etc
5mg folic acid if taking sulfasalazine
Simple analgesics, steroids rather than NSAIDs (stop NSAIDs 32/40 if must be continued)
Routine care
Regular monitoring of FBC, LFTs (sulfasalazine)
Screen for anti-Ro and anti-La if secondary Sjogren’s syndrome
Growth USS in pregnancy
OGTT (steroids)
Refer to obstetric anaesthetist (atlanto-axial subluxation)
Assess range of motion of hips/knees for vaginal birth
Mode of birth determined by usual obstetric indications
Stress dose hydrocortisone at birth if taking steroids
Warn of risk of post-partum flare
SLE
Effect of SLE on pregnancy Lower risk with quiescent disease Miscarriage IUFD (higher with lupus nephritis) IUGR PET Pre-term birth Neonatal lupus (anti-Ro) VTE (anti-cardiolipin) Cannot use: NSAIDs, MTX, cyclophosphamide, chlorambucil, cyclosporine, penicillamine, gold salts, mycophenolate, leflunamide, rituximab/abatacept
Can use: simple analgesics/splinting/cold packs, corticosteroids, sulfasalazine (5mg folate), hydroxycholorquine, azathioprine, IVIG
Effect of pregnancy on SLE
Flares in pregnancy, lower chance if quiescent disease
Flares more difficult to diagnose
Lupus nephritis high risk of flare (33%) if pre-existing and if flare 21% risk of renal deterioration and 7% risk of permanent deterioration
First presentation of lupus nephritis more common in pregnancy
Management
Pre-pregnancy
Delay pregnancy for 6/12 after flare of lupus nephritis (best outcome with quiescent disease for 6/12 and no renal disease, HTN, thrombocytopenia, antiphospholipid syndrome)
Assess:
Renal status: BP, urinalysis, PCR, UEC
FBC
Maternal/fetal risks: anti-Ro, anti-La, anti-Ds DNA, antiphospholipid screen, complement titres
Discuss maternal/fetal risks and Mx
Avoid NSAIDs/cytotoxics - discontinue for 3/12 pre-pregnancy
Pregnancy
Obs led with MDT input- MFM, obs med, rheum, cardio
Adjust medication, continue hydroxychloroquine (stopping= flare)
Aspirin if lupus nephritis, antiphospholipid, vasculitis and consider Clexane
Baseline values (above) in 1st trimester
Routine care
Monthly serial measurements
Anatomy scan
Uterine artery dopplers 22-24 weeks
OGTT (steroids)
Regular growth scans
Prenatal visits initially 2-4 weeks, then 1-2 weekly in 2nd half of pregnancy with BP checks, urinanalysis
If anti-Ro/La positive: weekly FHR auscultations from 16/40 to screen for complete heart block, fetal ECHO if this is suspected, ECG at birth
Aim for vaginal birth
CEFM
Antiphospholipid syndrome
Anticardiolipin antibodies/lupus anticoagulant PLUS
Clinical criteria:
Thrombosis: venous (unusual sites), arterial, small vessel
Pregnancy:
>/= 3 consecutive miscarriages <10 weeks gestation
>/= 1 fetal death > 10 weeks with normal fetal morphology
>/= 1 preterm birth due to PET or severe placental insufficiency
Effect of APS on pregnancy Miscarriage T2 and T3 fetal death (usually preceded by FGR and oligohydramnios) PET IUGR Placental abruption
Effect of pregnancy on APS
High risk of thrombosis
Pre-existing thrombocytopenia may worsen
Management
Pre-pregnancy
Screen for APS in women with above history
Take a careful history of circumstances of fetal loss to exclude other causes
Screen for anaemia, thrombocytopenia, renal compromise
Transition from warfarin to heparin
Pregnancy
Obs led with MDT input- MFM, obs med, haem, rheum
Anticoagulation:
If lab + pregnancy loss: prophylactic LMWH + aspirin
If lab + VTE: therapeutic LMWH
If VTE + pregnancy loss: therapeutic LMWH + aspirin
If lab + pre-term birth: aspirin and postnatal Clexane 6/52
If lab + no other feature: aspirin, then PN vaginal birth aspirin 6/52 + TEDs, PN LSCS LMWH + aspirin 6/52
Routine care Anatomy scan Uterine artery dopplers at 22-24 weeks Prenatal visits initially 2-4 weeks, then 1-2 weekly in 2nd half of pregnancy with BP checks, urinanalysis Regular growth scans 2-4 weeks Aim for vaginal birth Consider IOL around 40/40 Discontinue LMWH during labour/birth Flotrons during labour CEFM
Postpartum anticoagulation (warfarin can start days 2-3) Avoid COCP
Scleroderma
Effect of pregnancy on scleroderma
Those with early systemic sclerosis/renal disease more likely to flare
Oesophagitis may worsen
Raynauds may get better
Pulmonary fibrosis/HTN high risk of postpartum flare
Effect of scleroderma on pregnancy
Preterm birth
PET
IUGR
Perinatal mortality
IVL/venepuncture/BP monitoring may be hard
GA/regional may be difficult (limited movement, lesions on back)
Management
Obs led care with MDT input
Delay pregnancy until disease stable
Pre-pregnancy assessment with lung functions and ECHO (avoid pregnancy with multiple/severe organ involvement)
Care as outlined above
Regular MDT assessment and BP checks
Early assessment by anaesthetist
Avoid steroids for fetal lung maturity as may precipitate a renal crisis
Continue PPI
If renal crisis, ACEi can be given as risk to the mother outweighs risk to baby
EDS
Effect of pregnancy on EDS
Increased risk of aortic and visceral rupture
Increased joint and back pain
Effect of EDS on pregnancy Vascular EDS: Uterine rupture Preterm birth Skin fragility and poor healing Joint hypermobility PPROM and preterm cervical dilatation Precipitous labour PPH Skin fragility and poor healing
Management
Obs led care with MDT input
Refer to geneticist pre-pregnancy for classification
Advise TOP to those with vascular EDS
Routine care/care as described above
LSCS advisable for those with vascular EDS at 34/40 due to risk of uterine/aortic rupture towards the end of the 3rd trimester
Resistance to local anaesthetic- review by anaesthetist to discuss pain relief in labour
Obesity
Overweight BMI 25-29.9
Obese BMI >30
Risks Antenatal: Miscarriage GDM Fetal congenital abnormalities (NTDs) Stillbirth PET VTE OSA Preterm birth Maternal death Intrapartum IOL, prolonged labour and failure to progress Instrumental delivery Failed instrumental delivery Shoulder dystocia Caesarean section Difficulties with FHR monitoring PPH Peripartum death Anaesthetic risks Difficulty with labour analgesia GA Difficulty maintaining adequate airway, failed intubation Increased need for ICU post-operatively Post-partum Delayed wound healing and infection VTE Greater likelihood of needing support with breastfeeding Postnatal depression Long-term neonatal consequences including neonatal body composition, infant weight gain and obesity
Management
Antenatal
Diet and exercise
Advice to lose weight pre-pregnancy and continue with healthy diet and exercise in pregnancy
Dietician review (especially if post-bariatric surgery)
Folic acid 5mg and iodine 150mcg
Consider aspirin
Advise weight gain as per NZ guidelines:
BMI 25-29.9: 7-11kg
Obese: 5-9kg
Offer psychological support if appropriate
Obstetric consultation in pregnancy
Early OGTT with repeat if necessary
Tertiary anatomy scan
Influenza and pertussis vaccines (major morbidity associated with H1N1)
Growth USS every 2-4 weeks from 24 weeks
Anaesthetic consultation for obese women
Advise IOL by 40/40
Intrapartum
IV access in labour
Anaesthetic consultation
Continuous CTG monitoring, consider FSE
Low threshold for instrumental in theatre
Inform OT if weight >120kg to ensure adequate staffing
Active 3rd stage management
Postnatal Consider thromboprophylaxis Offer breastfeeding support Screen for post-natal depression Recommend weight loss Arrange appropriate contraception
Severe restrictive lung disease
Assess each case individually but avoid pregnancy if:
Pulmonary HTN
Cor pulmonale
FEV1 <30-40% predicted
Mx
Pre-pregnancy individualised counselling
Continue immunosuppression for ILD (prednisone or azathioprine)
MDT involvement (especially for those with nocturnal hypoxia
Routine pregnancy care and flu vaccine
Careful obstetric anaesthetic assessment
Regional may be dangerous depending on level of block
GA may be safer
Elective LSCS may be recommended if emergency GA too dangerous
CF
Cystic fibrosis
Effect of pregnancy on CF
Maternal mortality is increased compared to non-pregnant (especially with mod to severe lung disease)
Usually well tolerated (women who get pregnant usually have less severe disease)
Women may deteriorate and die while the child is young
Morbidity from: Poor weight gain Deterioration in lung function Pulmonary infective exacerbations Congestive cardiac failure
Effect of CF on pregnancy No increased risk of congenital abnormalities despite Abx use Predicting factors of poor obstetric outcome: Pulmonary HTN Cyanosis Arterial hypoxaemia Moderate to severe lung disease Poor maternal nutrition Preterm birth IUGR (chronic hypoxia)
Management Pre-pregnancy Safe in mild disease AVOID with: Pulmonary HTN Cor pulmonale (RV failure) FEV1 <30-40% predicted Recent Burkholderia cepacia infection (associated with rapid deterioration in lung x) Screen for DM Determine carrier state of partner Pregnancy Obs led care with MDT input Care in tertiary hospital with experience Routine pregnancy care and flu vaccine Nutrition- high calorie supplements Control infection- chest physio, continue Abx as needed (avoid tetracyclines), aggressively treat exacerbations
Avoid hypoxia- worse in T3, admit for bed rest and O2 therapy
OGTT
Regular growth USS
If slows admit Mum for rest, O2 and nutritional supplements
Mode of birth for usual obstetric indications
Avoid GA if possible
Avoid prolonged second stage (risk of pneumothorax with prolonged Valsalva/pushing)
Encourage breastfeeding
Sarcoidosis
Effect of pregnancy on sarcoidosis Unaffected or improved (due to endogenous corticosteroids) Management Obs led care with MDT input Steroids if extra-pulmonary disease or functional respiratory impairment OGTT Growth USS Counsel re risks of steroids (above) Stress dose steroids for labour/birth Avoid vitamin D
Asthma
Effect of pregnancy on asthma
Variable: may improve, stay stable, get worse
Women with severe disease more likely to deteriorate, especially late in pregnancy
Risk of post-natal deterioration
Acute asthma in labour uncommon (endogenous steroid production)
Effect of asthma on pregnancy
Usually no adverse effects
Severe asthma with subsequent hypoxaemia may affect the fetus
Some association with:
HTN/PET
Preterm birth/labour
Low birth weight
IUGR
Neonatal morbidity (TTN, hypoglycaemia, seizures, NICU admit)
Long term steroids: PPROM, infection, GDM, poor glucose control
Management
MDT input
Emphasis on prevention rather than Rx of acute attacks
Mild asthma: salbutamol inhaler
If reliever >3/week then use regular steroid preventer + reliever
Next step is a LABA or higher steroid dose
Next includes monteluklast or high dose inhaled steroids
Next step is oral steroids
Advise smoking cessation
Advise action plan and home peak flow monitoring
Routine obstetric care
Caution with aspirin
Growth scans if on long-term steroids
OGTT
Flu vaccine
Acute severe asthma
MDT input- ICU, physicians, obstetrics
High flow O2
Nebulised salbutamol
Pulse therapy of salbutamol
Nebulised ipatropium bromide
Steroids
CXR
Continue inhalers in labour
Stress dose hydrocortisone in labour if taking long-term steroids
Avoid carboprost (bronchospasm) and plain ergometrine Avoid opiates for pain relief (eg Remifentanyl)
Recommend breastfeeding
Renal transplant
Effect of pregnancy on renal transplants
No adverse long-term effects if creatinine <100
Increased risk of deterioration with creatinine >130 and HTN
Can use: prednisolone, azathioprine, tacrolimus, ciclosporin
Can’t use: mycophenalate mofetil, sirolimus
Effect of renal transplants on pregnancy
Good outcomes for those with no HTN, proteinuria, recent graft rejection and normal renal fx
Worse with diabetes, HTN and poor graft function
HTN/PET
IUGR
Preterm birth
Infection (UTI)
Graft rejection
Management
Pre-pregnancy
Delay pregnancy for 1 year after transplantation so that graft function has stabilised and immunosuppressives are at maintenance levels
Oral contraceptives and Mirena OK
Wait 3 months after switching from MMF
Pregnancy
Obs led care with MDT input- nephrologists, experienced obs
Routine pregnancy care
Monitoring and control of BP, urinary protein, FBC, LFTs, calcium status, MSU each visit
Regular growth assessment of the fetus and uterine/umbilical dopplers
Proteinuria is not an indication for delivery unless accompanied by worsening HTN or renal function
DDx of worsening renal function: UTI, dehydration, obstruction, PET, Rx nephrotoxicity, acute/chronic rejection
Mode of birth as per usual obstetric complications, ideally avoid LSCS due to pelvic kidney (if needs then discuss with transplant team)
Prophylactic abx with any procedure (including episiotomy)
Stress dose steroids in labour
Dialysis
Poor prognostic factors for pregnancy
Age >35 years
>5 years on dialysis
Delayed diagnosis of pregnancy (late increase in dialysis times)
Effect of pregnancy on renal replacement therapy
Anaemia exacerbated (need more transfusions, EPO and IV iron)
Marked increase in dialysis requirements
Increased doses of IV herparin to avoid clotting of dialysis lines
Fluctuations in fluid balance and BP
Reduced doses of calcium and Vit D
Effect of renal replacement therapy on pregnancy
Miscarriage
IUD
HTN and PET
Preterm labour
PPROM
Polyhydramnios (uraemia)
Placental abruption
Management Obstetric lead care with MDT team input Routine pregnancy care Increase dialysis Reduce dietary restrictions but keep fluid restrictions Uterine artery dopplers at 22-24 weeks Regular growth scans Monitor closely for deterioration Mode of birth for usual obstetric indications (but avoid crash GA)
CKD
Effect of pregnancy on CKD
Accelerated decline in renal function (worse with severe CKD)
Escalating HTN
Worsening proteinuria
Flare/relapse of glomerulonephritis (esp with lupus)
Effect of CKD on pregnancy Miscarriage PET FGR Preterm birth Fetal death Polyhydramnios (when urea >10 due to fetal polyuria)
Factors influencing outcome
Presence and degree of renal impairment- avoid pregnancy with CKD 5 (Cr >250)
Presence and severity of HTN
Presence and degree of proteinuria
Underlying cause of CKD - much worse with SLE and diabetic nephropathy
Management
Pre-pregnancy
Counselling
Baseline renal function, proteinuria and BP
Pregnancy
Obs led care with MDT input- MFM, renal, physicians
Regular screening for UTI
Aspirin
1-2 weekly BP checks and treat if BP >130/80
Regular assessment of renal function, proteinuria
Routine pregnancy care
Regular growth scans
Uterine artery dopplers at 22-24 weeks
Admit during pregnancy if: worsening HTN, worsening renal function or proteinuria, superimposed PET or polyhydramnios
Mode of birth as per usual obstetric indications
UTI in pregnancy
UTI
Asymptomatic bacteruria= treat
Acute cystitis= treat, increase fluids, empty bladder after sex, double voiding, clean front to back
Prophylactic Abx with recurrent UTIs= cephalosporins, amoxycillin, 50mg nitrofurantoin OD, renal USS if two or more UTIs in pregnancy
Acute pyelonephritis
Increased risk of PTL
Increased risk of LBW
Manage in hospital, take MSU, then start antibiotics penicillin or cephalosporin) for 24 hours and then change to orals, ensure renal function checked regularly given risk of AKI
Hyperthyroidism
Effect of pregnancy on hyperthyroidism Exacerbations in first trimester Improvement in graves disease in T2/T3 No progression of Graves ophthalmopathy Exacerbation post-partum
Effect of hyperthryoidism on pregnancy Minimal effect of well controlled disease HTN PET Placental abruption Thyroid storm= maternal mortality of 25% Tracheal obstruction Miscarriage IUGR Preterm birth Perinatal mortality Neonatal thyrotoxicosis
Management Pre-pregnancy MDT Avoid pregnancy 4 months after radioactive iodine Wait 3 months once euthyroid Pregnancy Obs led care with MDT team input Continue: PTU or carbimazole at the lowest dose that maintains the euthyroid state (avoid high doses as they cause fetal hypothyroidism)
New diagnosis: use PTU
Patients stable on carbimazole: continue
Propranolol for symptoms
Monthly TFTs + FBC (risk of neutropenia)
Check anti-thyroid antibodies- if positive, check at 18-22/40 and 30-34/40
Routine obstetric care
Serial USS for growth, FHR, goitre (suspect thyrotoxicosis with tachycardia)
Consider cordocentesis if features of fetal thyrotoxicosis for TSH
Labour and delivery may precipitate thyroid storm, Mx: IVF, O2, temp and glycaemic controrl, high dose PTU, iodide therapy, dexamethasone and propanolol
Postpartum take cord blood for TFTs
Encourage breastfeeding
Risk of flare post-partum, especially with Graves
Hypothyroidism
Effect of hypothyroidism on pregnancy Good outcome for euthyroid women Thyroid peroxidase autoantibodies do not affect the fetus Undertreated: Miscarriage PET Abruption LBW Stillbirth Impaired neurodevelopment and low IQ Effect of pregnancy on hypothyroidism Does not improve or exacerbate hypothyroidism Management Pre-pregnancy MDT care Check TFTS and optimise thyroxine doses pre-regnancy
Good control = normal pregnancy
Pregnancy
Obs led care with MDT input
Routine care
Euthyroid women may not need dose adjustments, but otherwise 30-50% increases usually needed from T1
New diagnosis: start on 100mcg of thyroxine
Monthly TFTs if thyroxine dose adjusted, otherwise once a trimester
If secondary to Graves, monitor auto-antibodies
Serial growth scans checking growth and for goitre
Check FTFs post-partum, be aware of high risk postpartum thyroiditis
Check TSH on Guthrie card
Thyroid cancer
Effect of pregnancy on thyroid cancer
No adverse effects
Effect of thyroid cancer on pregnancy
Adverse effect depends on severity of hyperthyroidism
Retrosternal extension of disease may cause airway obstruction
Management
Prepregnancy
Avoid pregnancy for 1 year after radioactive iodine
Pregnancy
MDT care
Routine care
Biopsy and treat- do not delay surgery unless very near term
Treated thyroid ca- continue thyroxine to maintain TSH suppression
Avoid radioactive iodine
Be very careful with intubating
Breastfeeding contraindicated with radioactive iodine
Postpartum thyroiditis
Destructive autoimmune thyroiditis
75% of patients with TPA antibodies
3-6 months post-delivery, presents with vague Sx
Dx: TFTs, anti-thyroid antibodies (distinguish from Graves)
Stop breastfeeding for 24 hours after radioactive scan
Most women recover within 1 year
Thyroxine can be withdrawn from some women at 6-9 months, then repeat TFTs
Long-term annual TFTs
Pre-existing diabetes
Effect of pregnancy on diabetes
Increased risk hypoglycaemia
Increased insulin requirement, especially 28-32 weeks
Increased risk diabetic ketoacidosis (hyperemesis, infections, B-agonists, steroids)
Progression in retinopathy (2 fold)
Progression in nephropathy
Progression in autonomic neuropathy and gastric paresis
Normochromic normocyic anaemia
Effect of diabetes on pregnancy
Maternal Increased risk infection Increased risk HTN Increased risk PET Increased risk obstetric intervention (IOL, LSCS, emergency CS)
Fetal Miscarriage Major congenital abnormality (3x risk CHD, 3x risk NTD, situs inversus, renal abnormalities, sacral agenesis) Macrosomia Preterm birth Perinatal mortality and morbidity Unexplained stillbirth
Management
Pre-pregnancy
MDT team care
Optimise HbA1c pre-pregnancy to reduce risk of congenital abnormalities, miscarriage and PET
Contraception until glycaemic control optimised
Dietary advice
5mg folic acid for 3/12
Retinal assessment- treat proliferative retinopathy
Assess renal function- BP, UEC, ACR, ACEi for nephropathy until pregnancy
Advise against pregnancy if Cr >150 due to risk of progressive nephropathy
Assess CV risk
Assess TFTs
Change 2DM to insulin or metformin
General measures- stop smoking, lose weight etc
Discuss risk of DM in offspring
Avoid pregnancy if:
IHD
Untreated proliferative retinopathy
Severe gastroparesis
Severe renal impairment
Pregnancy
MDT team care (high risk pregnancy)
Routine pregnancy care
First trimester USS to accurately date
Screening NIPT or MSS1
Detailed anatomy scan + ECHO (esp if bad glycaemic control)
Serial growth scans
Retinal assessment each trimester
BSLs to target (ADIPS):
Fasting: <5
Postprandial: <6.7
Different for 1DM, individualised targets to minimise hypos
Dietician advice- avoid starvation and calorie restriction
Adjust insulin as required through trimester 2-3
Be wary of reducing insulin requirements
Discuss hypoglycaemia management and ensure has glucagon kit
Check TFTs (1DM)
Regular visits for BP, urinanalysis, check of BSLs
HbA1c in T2 and T3
If nephropathy- regular UEC, protein dip, strict BP control aiming 130/80 to avoid renal damage
Aim for SVB by 40/40 to minimise stillbirth risk
If EFW >4.5kg offer LSCS
GIK during labour
Preterm labour- give steroids with increase in insulin
Continuous CTG in labour
BSL monitoring in labour
Postpartum- half insulin infusion
Recommence SC insulin at pre-pregnancy dose when eating, or lower if breastfeeding
Check baby’s BSLs
Gestational diabetes
HbA1c at booking Early OGTT (16-18 weeks) to be considered with high risk women (eg previous GDM etc) OGTT at 24-28 weeks + HbA1c Fasting plasma glucose 5.1-6.9 1 hour post glucose >/= 10mmol/L 2 hours post glucose >/= 8.5-11.0mmol/L Treatment targets (ADIPS): Fasting: <5 Postprandial: <6.7 Dietician review and dietary measures Metformin Insulin Regular growth scans Monitoring for PET HbA1c T2 and T3 Aim for SVB by 40/40 Offer LSCS if EFW >4.5kg BSL monitoring in labour Stop treatment after birth of baby Post-natal HbA1c at 6 weeks
Bipolar disorder
Effect of mania on pregnancy
Increased risk of poor outcome, probably related to risk-taking behaviour, poor nutrition and lack of AN care
Lithium is effective but raises risk of cardiac defects
Carbamazepine and valproate are also effective for control of aggressive behaviour and mood stabilisation but are also implicated in neural tube defects
Management
MDT with psychiatrist
Options are: continuing medication, stopping medication in first trimester, or stopping through pregnancy and the best option will depend on the severity of the disease
Use the lowest effective dose
High dose folic acid
Routine pregnancy care
Detailed anatomy scan at 20/40 looking for cardiac defects
Monitor growth
Observe for post-partum relapse (risk is 25-30%)
Prompt admission to mother and baby unit
Paeds examination of baby
Schizophrenia
Effect of pregnancy on schizophrenia
Severity of illness varies
16% risk of postpartum psychosis, ?due to oestrogen withdrawal
Effect of schizophrenia on pregnancy
Stillbirth
Low birth weight
SGA and prematurity
Mainly due to lack of self-care, poor nutrition and drug use
Offspring have a predisposition to schizophrenia
Effect of anti-psychotics on pregnancy
Older classes reduce fertility due to hyperprolactinaemia
Phenothiazines may increase the risk of congenital abnormalities (4 in 1000)
Management
MDT with psychiatrist, support workers, case workers, social work, family services, etc
Pharmacological therapy is essential
CONTINUE treatment and aim for lowest dose of single medication
Avoid depot preparations (neonatal extrapyramidal side effects)
Stopping treatment can lead to relapse
Offer psychosocial support and encourage AN care
Routine care
Serial growth USS
Psychotic relapse- admit to mother and baby unit
Assess suitability of mother to care for baby
Postnatal be aware of risk of pueperal psychosis
Pueperal psychosis
Very rare
30% have pre-existing mental illness
Usually presents in first month after birth
25% risk of recurrence
Timely diagnosis important- suicide rate 5%, infanticide 4%
Important to be admitted to specialised perinatal unit
Heroin
Fetal effects (non-teratogenic) Acute placental infection IUGR Preterm birth Stillbirth
Crosses blood-brain barrier leading to fast “high” in the fetus. During periods of abstinence, fetal activity and oxygen demand increase. If this coincides with labour and placenta insufficiency, then death may result
Neonatal abstinence syndrome- gives 3x risk of SIDS, mothers have childcare problems and there are more behavioural problems and delayed cognitive development amongst offspring
Mx
MDT care- alcohol/drug rehab, psychologist etc
Switch to methadone- titrate to the lowest dose that prevents withdrawal Sx (the goal is risk reduction), dose is the same outside of pregnancy
Safety of buprenorphine uncertain
Cocaine
Fetal effects
Potent vasoconstriction (fetal vascular disruption)
Transplacental passage greatest T1 and T3 and it limits gas and nutrient exchange
Placental abruption
Meconium liquor
PPROM
Fetal hypoxia
IUGR
Preterm birth
Stillbirth
Intestinal atresia, limb reduction defects, aplasia cutis
Restricts head circumference
Prune-belly syndrome, hydronephrosis, hypospadias, heart defects, gastroschisis
Neonatal withdrawal syndrome (peak at 3 days of life and may persist for 3 weeks, increased risk of mild ICH in babies with LBW)
Long term effects on children: reduced HC, developmental delay, reduced verbal and visual reasoning, more likely to live with relatives or in foster homes, more likely to be aggressive
Mx- recommend cessation, give support
Marijuana
Commonest illicit drug used in pregnancy
Increased chance of gastroschisis
No evidence of abnormal developmental outcome at 1 month
However negative effect on performance present at 3 years
Amphetamines
Maternal risks Increased risk HTN and PET Fetal risks Cleft palate and gastroschisis Vasoconstriction leads to: Fetal hypoxia IUGR Stillbirth Placental abruption Preterm birth Neonatal withdrawal Effect on children: 80% brought up in stable foster homes Impaired long-term growth Poor school performance with significant deficits in maths and languages
Mx MDT care Encourage stopping drug use Frequent BP and urine checks Monitor fetal growth CEFM in labour Inform paeds of impending delivery
Major depression
Effect of depression on pregnancy Maternal risks: Substance abuse Postpartum depression PET Fetal risks: Low birthweight Pre-term birth Effect of pregnancy on depression N/A
Risk factors for depression in pregnancy
Previous depression (5x risk)
Family history of mood disorder
Marital conflict
Younger age
Limited social support with greater numbers of children
Tobacco or alcohol use
Unemployed
Lower educational attainment
Management
MDT with maternal mental health
Depends on severity and woman’s preference
First line is CBT
Antidepressants if this fails, or severe symptoms, or functional impairment
SSRI or SNRI
Ideally avoid paroxetine in the first trimester (minor congenital heart disease) and not in pregnancy if possible (neonatal toxicity- lethargy, hypotonia, anticholinergic Sx and withdrawal Sx)
Discuss the risk of relapse of 75% if antidepressant is discontinued in pregnancy
Postnatally observe for postnatal depression
Cushings
Effect of pregnancy on Cushings
None
Effect of Cushings on pregnancy
Fetal Miscarriage IUR Prematurity Mortality High maternal cortisol may suppress fetal corticosteroid secreation and cause neonatal adrenal insufficiency Maternal Mortality CHF due to HTN PET GDM Wound breakdown Infections Emotional lability Pscyhosis
Management Pre-pregnancy Well controlled women do well Advise complete treatment pre-pregnancy Optimise HTN and DM
Pregnancy
MDT care with MFM and obs med etc
First line treatment for adrenal tumours is surgery and this should be timed in the second trimester (safe in pregnancy and reduces risk of fetal loss, prematurity and maternal morbidity)
Second line treatment is medical and there is no evidence for safety
Routine care
UA dopplers at 22-24 weeks
Regular growth USS
Vaginal delivery preferred due to poor wound healing
Monitor mother and baby for cortisol withdrawal
Parathyroid disease
Maternal consequences Most asymptomatic Rarely have features of increased calcium Fetal consequences High perinatal complication rate Fetal loss and neonatal tetany
Mx
Maternal parathyroidectomy
Prolactinomas
Effect of pregnancy on prolactinomas
Microprolactinomas <1cm: less than 3% have symptomatic growth in pregnancy
Macroprolactinomas >1cm: 30% have symptomatic growth, highest in T3
Effect of prolactinomas on pregnancy
No adverse effects
Mx Pre-pregnancy MDT Avoid pregnancy until treated MRI Pituitary function Folic acid Bromocriptine/cabergoline Surgery for macroprolactinomas Radiotherapy Pregnancy Obs led care with MDT input Routine pregnancy care Microprolactinoma: monitor Sx each trimester and stop meds Macroprolactinoma: give cabergoline and review monthly If symptoms check visual fields and get MRI If tumour enlarged: Elective delivery if fetus mature Medical treatment with cabergoline if premature Surgery if failed medical treatment
Delay radiation until after surgery
Mode of birth as per usual obstetric indications
Cabergoline may suppress lactation
MRI to monitor size
Acromegaly
Effect of acromegaly on pregnancy
No adverse effect as growth hormone does not cross the placenta Effect of pregnancy on acromegaly Tumour growth may cause visual field defects Pregnancy does not alter the course Management Prepregnancy MDT input MRI to evaluate size of tumour Pituitary function tests Screen for DM, HTN and cardiomyopathy Surgery +/- radiotherapy +/- cabergoline/bromocriptine Folic acid
Pregnancy
MDT team
Treatment can usually be delayed until after pregnancy unless significant tumour growth
Observe for signs of tumour growth
Routine care
Mode of birth as per usual obstetric indications
Breastfeeding fine (lactation may be suppressed by cabergoline)
DVT/PE
Objective testing and treatment without delay when suspected
Management
Involve haematology
Check: FBC, UEC, thrombophilia screen, coags and LFTS
Consider fetal risks (but minimal as heparin does not cross the placenta)
Start LMWH 1mg/kg BD (preferred in pregnancy)
Monitor platelets 7-10 days after starting
Arrange antenatal anaesthetics review
Plan for labour
When in labour, withhold LMWH, restart post-partum (6 hours post vaginal birth, 12 hours post LSCS)
For an IOL administer a prophylactic dose on the day prior and continue this until labour has established
To avoid epidural haematoma, no LMWH for 12 hours after prophylactic dose and 24 hours after treatment dose
Do not give LMWH for 4 hours after epidural catheter inserted/removed
For LSCS
Thromboprophylactic dose on day prior to delivery and omit on morning of delivery
Thromboprophylactic dose 3-4 hours after delivery and treatment dose that evening
Consider UF heparin in high risk of bleeding
Start warfarin postnatally
Day 2-3
Check INR daily and target INR 2.0-3.0
ITP (due to autoantibodies)
Effect of pregnancy on ITP Nil Detected in the first trimester Effect of ITP in pregnancy Mother Relates to platelet count Baby Antiplatelet antibodies cross the placenta causing thrombocytopenia in 20-30% of cases Risk of bleeding is low (ICH risk 2%) Blood sampling not needed Management Pre-pregnancy MDT care- haem and obstetricians Advise women with severe refractory ITP to avoid pregnancy
Consider splenectomy and give women penicillin V 250mg BD and pneumococcus and meningococcal, H. Influenzae vaccines
Pregnancy
Platelets every 2-4 weeks
Aim for platelets >80 for delivery
Treat: prednisone, IvIG, splenectomy, azathioprine, platelet transfusion
Review by anaesthetics to discuss plan for analgesia
Inform anaesthetics/paeds regarding delivery
If platelets <80 avoid regional
If platelets <50 have platelets available
Avoid FSE, FBS, ventouse, difficult forceps
Repair perineal trauma promptly
Observe wound sites
Avoid NSAIDS, can give Clexane if platelets >50
Cord blood for neonatal platelet count and monitor
Gestational thrombocytopenia
Effect on pregnancy Haemodilution, increased platelet activation and clearance Maternal risks relate to platelet count No adverse fetal effects Management No adverse consequences Monthly platelet counts Ensure ITP excluded
Haemophilia and Von Willebrand’s disease
Haemophilia A (factor 8): severity constant in a family
Haemophilia B (factor 9): more mild
vWD type 1: mild vWF and Factor VIII deficiency
vWD type 2: qualitative defect, type 2b associated with thrombocytopenia
vWD type 3: severe
Effect of pregnancy on haemophilia and vWD
FVIII and vWF increase with increasing gestation so there is an improvement in both
Both rapidly fall after delivery
No increase in F IX levels in pregnancy (haemophilia B)
2b vWD thrombocytopenia worsens in pregnancy
3 vWD no increase in vWF with gestation
Effect of haemophilia and vWD on pregnancy
Risk of excessive bleeding with early pregnancy miscarriage, ectopic, CVS
Increased risk PPH (20% in vWD, mainly secondary)
Spontaneous bleeding in affected fetus is rare
Traumatic delivery may cause ICH and cephalohaematoma
Severity of disease:
Bleeding disorder correlates with factor level: factor level >/= 40 is safe tor vaginal birth
If <40 then need Rx at the onset of labour
Management
Pre-pregnancy
MDT care, management with haematologists, haemophilia team
Genetic counselling
For haemophilia: confirm history and carrier status, consider PIGD
For vWD: assess subtype, avoid aspirin and NSAIDs in type 2b, offer hep A and B vaccine, assess the effect of DDAVP
Pregnancy
Test factor XIII and vWF levels in early pregnancy, 2nd and 3rd trimesters, and prior to delivery as may not need treatment if factor levels rise in pregnancy
Anaesthetic review to discuss regional analgesia
In labour- FBC and G&H, factor XIII and vWF
If levels <50 then start treatment at the onset of labour
DDAVP
Recombinant factor 8
TXA
If levels <40 then avoid IM injection
Avoid regional if factor levels not in normal range
When risk of affected baby:
Atraumatic unassisted vaginal delivery
Avoid FSE and FBS
Avoid ventouse and difficult forceps delivery
Low cavity forceps by an experienced operator is preferable to a difficult LSCS
Repair perineal trauma promptly
Monitor for bleeding from wound sites and for primary/secondary PPH
Maintain factor levels >40 for 3-4 days after vaginal delivery and 4-5 days after LSCS
Contraceptive advice
Cord bloods from baby for factor assay and avoid IM injections until haemophilila/vWD status known
Sickle cell anaemia
Effect of pregnancy on sickle cell Increased frequency of sickling Increased frequency of painful crises Increased susceptibility to infection (hest, urinary tract) Effect of sickle cell on pregnancy Fetal risks Miscarriage FGR PTB Fetal distress Perinatal mortality 4x
Maternal risks PET Placental abruption Thromboembolism Bone marrow embolism (acute chest syndrome) Increased mortality Management MDT team Partner screening 5mg folic acid throughout pregnancy Prophylactic penicillin 250mg BD Regular Hb, urinanalysis and BP Regular growth scans Thromboprophylaxis if needed Uterine artery dopplers at 20 weeks then from 24 weeks Urine dip and BP each visit
Mode of birth for obstetric indications Continue penicillin Ensure adequate pain relief Continuous CTG Maintain hydration Consider post-partum thromboprophylaxis
Beta thalassemia
Effect of pregnancy on beta thal
Trait: mild anaemia in pregnancy
Major: worsened disease and transfusion requirement
Effect of beta thal on pregnancy
Trait: normal outcome
Major: if Hb maintained >100, well chelated and no bone abnormalities, then good outcome
If maternal anaemia or inadequate transfusion: IUGR, preterm birth, fetal hypoxia
Maternal complications of iron overload
If short stature with bone abnormality then increased risk of cephalopelvic disproportion and LSCS
Alpha thalassemia
Effect of pregnancy on alpha thal trait Nil Effect of alpha thal trait on pregnancy If the fetus is unaffected- normal outcome If fetus is affected- alpha thal major Fetal risks 4 gene deletion: incompatible with life Severe anaemia Hydrops fetalis Hepatosplenomegaly Abnormal organogenesis Cardiac failure Polyhydramnios Placentomegaly Stillbirth Maternal risks (secondary to fetal and placental hydrops) HTN PET Placental abruption Obstructed labour APH and PPH DIC
Transfusion dependent anaemias
work up and management
Pre-pregnancy
Bloods: FBC, reticulocytes, ferritin, folate
Hb electrophoresis
First AN bloods (check antibody status)
Screen for iron overload: ECHO, fibroscan, TFTs glucose, ECG, LFTs
Check renal fx
Hep A & B vaccines
Folic acid 5mg/day
Stop iron chelation therapy 3/12 prepregnancy after aggressive chelation (desferrioxamine in T2-T3 is potentially OK but aim to avoid)
Don’t give iron
Screen the partner
Alpha thal: fetal risk 25% if partner has alpha thal trait
Beta thal: fetal risk 25% if partner has beta thal trait, sickle cell trait or HbE
Counsel on maternal/fetal risks
Sickling disorders: check for pulmonary HTN, discontinue hydroxyurea, give pneumococcal, meningococcal and h. Influenzae vaccine, prophylactic
Abx
Consider spinal Xray
Antenatal
If partner screening positive offer prenatal diagnosis
Continue folate 5mg/day through pregnancy
In splenectomy: give prophylactic penicillin and consider thromboprophylaxis
Regular Hb checks and blood transfusions
Low platelets in pregnancy
ddx and initial work up
**
Ddx gestational hypertensive immune haemolytic causes other - sepssi, lvier disease, drugs infection HIV malaria If less then 50 suspect non gestational FBC HIV Infection screen Screen for B symptoms Review bloods before
IITP
Avoid invasive procedures
20 antenetally, >50 intrapartum >90 for epidural/spinal
Avoid fetal trauma/invasive monitoring
Cord platelets and neonatal review – risk of falling over 3-5/7
10-30% affected
<1% morbidity
Postnatal TEDS – careful consideration of LMWH as per risk of bleed
Consider Tx acid
No NSAIDs
B thalassaemia
Pre pregnancy
Ongoing discussions around pregnancy intentions
Contraception if not desired
COCP ok
Risks
Maternal
Complications of Iron overload
Fetal
Miscarriage (especially thalassaemia + diabetes)
IUGR inheritance of disease IUFD
Plan: High dose folic acid and Vit D Screen hep B/c/HIV Partner Genetic screening and referral Immunisations pneumococcal and H influenza
Optimise iron stores
Compliance with chelation – aggressive pre pregnancy chelation can reduce and optimise body iron burden and reduce end organ damage
Optimising iron burden pre pregnancy is critical as ongoing iron accumulation from transfusion exposes her to disease progression
Screen for end organ damage
Hypothyroid is associated with maternal morbidity and perinatal morbidity and mortality
Screen for hypothyroid
Liver
Iron load assessed with Ferriscan or liver T2
Should be <7 mg/g
If over 15mg/g the risk of myocardial load increases so chelation is indicated from 20 weeks
If high iron burden then should have aggressive chelation pre pregnancy
If iron load very high then cardiac load will be present, and therefore may need chelation in pregnancy 20-28 weeks
USS liver and gall bladder for cholelithiasis and liver cirrhosis or transfusion related viral hepatitis
Risk of cholecystitis in pregnancy
Liver cirrhosis and hep C make increase pregnancy risk and should have lvier team involved
Heart
ECHO and ECG
T2 cardiac MRI to assess for iron overload
Aim is no cardiac iron but this can take years to achieve – so maybe aim for minimal iron
Level of iron on T2 weighted MRI dictates chelation
High iron related to increased risk of cardiac failure
Iron causes myocyte apoptosis and fibrosis
Reduced EF is a relative contraindication to pregnancy
MDT input
Bone density scanning
Pre existing OP should be documented
Pathology complex – maybe chelation of calcium, hypogonadism, Vit D deficiency and thalassaemia itself
Serum Vit D optimised with supplements as needed
Deficiency common
Red cell antibodies
ABO and full group genotype and antibody titres should be measures
Alloimmunity occurs in 16.5% of woman with thalassaemia
Limit blood for transfusion
Medication review
Iron chelators should be reviewed
Deferasirox and deferiprone ideally discontinued 3 months before conception
Desferrioxamine has a short half life and can be used during ovulation induction but then avoided in T1
Safe at low dose after 20 weeks
Bisphosphonates are contraindicated in pregnancyand should be discontinued 3 months pre preg
Ovarian stimulation may be needed
MDT counselling pre pregnancy
Genetic screening Partner testing Genetic counselling Options for testing IVF / ICSI with PGD should be considered in the presence of haemoglobinopathies
Egg and sperm donors considering IVF should be screened for haemoglobinopathies
Immunisation
Hep B vaccination if not already
If prev splenectomy should have vaccination for pneumococcus (every 5 years) and haemophilus influenza and meningococcal
Annual influenza
Infections If previous splenectomy then should have penicillin prophylaxis (erythromycin if allergic) Hep C status should be assessed Supplements 5 mg folic acid High demand for folic acid
Antenatal
MDT
Close monitoring with increase High risk obstetrician, haematologist, high risk MW, other specialties as indicated
Individualised
Specific to thalassaemia
Receive blood transfusions on a regular basis aiming for pretransfusion Hb of 100
For intermedia
Clinical decision when to start transfusions
If worsening anaemia, FGR then consider regular transfusions
Same target – pretransfusion 100
Initially a 2-3 unit then top up the next week – until Hb 120
Hb checked in 2 weeks
Hb of 80 is about the threshold for transfusion but this is a clinical multifactorial decision
Reviewed monthly until 28 weeks and fortnightly thereafter
If diabetic – monthly fructosamine concentrations
28 week cardiac assessment(thalassaemia major)
Monitoring iron load
Myocardial iron load should have close cardio follow up with careful monitoring of EF – cardiac decompensation is a primary indication for chelation
Severe hepatic iron loading should be reviewed and consideration given to chelation
VTE prophylaxis
Splenectomy or platelets over 600 – aspirin
Splenectomy and platelets over 600 – aspirin and heparin
At least if admitted
Monitor TFTs Fetal monitoring Early dating scan Routine T1 scan 11-14 weeks Anatomy 18-20 Serial biometry 4 weeks from 24 weeks
Intrapartum
MDT
If there are antibodies, cross match blood
If Hb below 100 – then cross match 2 untis
Peripartum chelation
If transfusion dependant and not being chelated then will have a toxic iron species called non transferrin bound iron. This causes free radical damage and cardiac dysrhythmia when the woman is in the active stress of labour
If major – IV desferrioxamine 2 g over 24 hours should be administered for the duration of the labour
CEFM
Increased risk fetal hypoxia and possible operative delivery
Active management of third stage to minimise blood loss
No specific evidence for timing or MOD
Postpartum
High risk for VTE
LMWH while in hospital
6 weeks post lscs
7 days post NVD
Breast feeding is safe and should be encouraged
If breastfeeding can start desferrioxamine – not harmful to baby
If not breastfeeding – IV or sc desferrioxamine is continued until discharge and resumption of previous chelation
