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