MATERNAL MEDICINE Flashcards
Adverse outcomes of untreated hypothyroidism in pregnancy?
Miscarriage or stillbirth
Anaemia
SGA
Pre-eclampsia
Hypothyroidism in baby
What drug is used to manage hypothyroidism in pregnancy?
Levothyroxine - require an increased dose by up to 50% as early as 4-6 weeks of pregnancy but this dose will be titrated based on TSH level
Monitoring of hypothyroidism in pregnancy
Serum TSH is measured in each trimester and 6-8 weeks post-partum
Risks of untreated thyrotoxicosis in pregnancy?
Increased risk of miscarriage
Maternal HF
Premature labour
LBW
Abnormal development
Most common cause of thyrotoxicosis in pregnancy?
Graves’ disease
Activation of TSH receptor by HCG may occur (transient gestational hyperthyroidism)
Drugs to manage thyrotoxicosis in pregnancy?
Propylthiouracil in first trimester
Carbimazole from the beginning of the second trimester
Normal changes to blood pressure in pregnancy>
Blood pressure falls in the first trimester and continues to fall until 20-24 weeks (particuarly diastolic!)
After this the bp will increase to pre-pregnancy levels by term
Definition of hypertension in pregnancy?
Systolic >140
Diastolic >90
(Or… an increase above booking readings of >30mmHg systolic or >15 diastolic)
How common is pre-existing hypertension in pregnancy?
3-5% of pregnancies
More common in older women
How can you distinguish pre-existing hypertension from gestational hypertension or pre-eclampsia?
Starts before 20/40
No proteinuria or oedema like pre-eclampsia
Management of pre-existing hypertension in pregnancy?
advice on weight management, exercise, healthy eating and lowering salt in diet
Continue with existing Antihypertensive Tx if safe in pregnancy
Consider labetalol, nifedipine or methyldopa in this order if not on pre-existing Tx
Offer all women aspirin OD from 12 weeks
Which antihypertensives are unsafe in pregnancies?
ACEi
ARBs
Thiazide and thiazide-like diuretics
Why may pregnancy worsen seizure control in women with epilepsy?
Alterations in medication regimes
Stress
Lack of sleep
Hormonal changes
Managing epilepsy in pregnancy?
Levetiracetam, lamotrigine and carbamazepine are the safer anti-epileptic medication in pregnancy
Aim for mono therapy!
All women considering becoming pregnant should be adsvsed totake folic acid 5mg per day before pregnancy to minimise the risk of neural tube defects
Sodium valproate in pregnancy?
Associated with neural tube defects
Phenytoin in pregnancy?
Can cause cleft palate
When are pregnant women screened for anaemia?
The booking visit
28 weeks
What cut offs do NICE use to determine whether a woman should recieve oral iron therapy?
First trimester <110
Second ans thirds trimester <105
Postpartum <100
Management of anemia in pregnancy?
Oral ferrous sulfate or ferrous fumarate - continue for 3 months after IDA is corrected to allow iron stores to be replenished
Impact of anaemia in pregnancy?
LBW
Premature birth
Stillbirth
Can cause fatigue, reduce milk production and is associated with post-natal depression.
Problems of cardiac disease in pregnancy?
Main risk is having a heart attack which is a rare but is a leading cause of death in pregnancy
There is a >40% increase in the blood circulating in the mother’s body so it can make cardiac conditions worse
Implications of pregnancy and diabetes?
Macrosomia which can increase risk of a diffiuclt birth e.g. labour induction/needing a C-section/prolonged labour, and increases risk of birth trauma (most worryingly shoulder dystocia!!)
Transient neonatal morbidity e.g. hypoglycaemia
Miscarriage
May increase risk of health problems shortly after birth, or developing obesity/diabetes later in life
Slightly higher chance of baby being born with birth defects - particuarly heart and nverous system abnormalities
Slightly higher chance of stillborn or perinatal death
Polyhydramnios as more urine output
Increased chance of pre-eclampsia
Women will then be at higher risk of developing T2DM after pregnancy
Reducing risks that diabetes carries in pregnancy?
Ensure diabetes is well controlled before you become pregnant - HbA1c should be <48 before you get pregnant and if its >65 its recommended not to get pregnant
Regular BM
5mg folic acid OD until 12 weeks to prevent neural tube defects
Intense antenatal care plan - will likely involve specialist nurses
Weight and other lifestyle measurements
You will be offered regular diabetic eye screening during pregnancy
Kidney function will be monitored also
Blood glucose will be monitored hourly during labour and birth and baby’s BG will be checked a few hours after birth
How common does gestational diabetes complicate pregnancy?
1 in 20!
Second most common medical disorder complicating pregnancy after hypertension
Affect 4% of pregnancies
Whats the breakdown of gestational diabetes, Type 1 diabetes and type 2 diabetes in pregnancy? d
87.5% have gestational diabetes
7.5% have type 1 diabetes
5% have type 2 diabetes
What causes gestational diabetes?
Reduced insulin sensitivity during pregnancy
Risk factors for gestational diabetes?
BMI of > 30 kg/m²
previous macrosomic baby weighing 4.5 kg or above
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
Others:
PCOS
Older maternal age
Polyydramniops
Screening for gestational diabetes?
For women who’ve previously had gestational diabetes: Oral glucose tolerance test as soon as possible after booking and at 24-28 weeks if first test is normal
Women with any other risk factors should be offered OGTT at 24-28 weeks
Diagnostic thresholds for gestational diabetes?
Fasting glucose >=5.6
2 hour glucose >=7.8
How to do an oral glucose tolerance test?
After a fast (i.e in the morning) measure blood sugar level, then give women a 75g glucose drink and then measure again at 2 hours
Management of gestational diabetes?
Once diagnosed see in. A joint diabetes and antenatal clinic within 1 week
Teach how to monitor blood glucose
Advice about diet, exercise, weight
If fasting plasma glucose <7 then start management on diet and exercise. If glucose targets not met within 1-2 weeks then metformin. If glucose targets not met then short acting insulin.
If at the time of diagnosis fasting plasma glucose is >=7 then insulin should be started
If at time of diagnosis fasting plasma glucose is 6-6.9 ans there is evidence of complications e.g. macrosomia then insulin should be offered
Glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment
Antenatal care for women with diabetes?
Advise women to test fasting, pre-meal, 1 hour post meal and bedtime BM daily (with target BM levels fasting 5.3 and 1 hour after meals 7.8)
Measure HbA1c at booking for women with pre-existing diabetes
Insulin treatment
Continuous glucose monitoring if type 1 diabetes
Ketone testing for type 1 diabetics - for DKA
Retinal assessment in pregnancy
Renal assessment at first contact and monitor
Aspirin to prevent pre-eclampsia
Further examination of foetal heart at 20 week scan to detect congenital malformations
USS monitoring of foetal growth and amniotic fluid volume every 4 weeks from 28 weeks
Intrapartum care for gestational diabetes?
Elective birth by induced labour or c-section between 37-38+6 (if complications then earlier!)
Advise women not to give birth later than 40+6
Monitor capillary plasma glucose every hour during labour and birth - maintain between 4-7
Consider IV dextrose and insulin infusion from the onset of established labour for women with T1DM of those whose capillary plasma glucose is not maintained between 4-7mmol/litre
Neonatal care for women with gestational diabetes?
Advise women to birth in hospitals
Blood glucose testing at 2-4 hours after birth
Feed within 30 mins of birth and then every 2-3 hours until feeding maintains pre-feed cap plasma glucose levels >2.0mmol/litre
Admit babies if signs of any complications
Dont transfer babies to community care until at least 24 hours old and satisfied baby is mianting good BM levels and is feeding well
Complications of gestational diabetes on the baby?
Hypoglycaemia due to hyper insulin anemia
Macrosomia
RDS
Congenital heart disease
Neonatal encephalopathy
Polycythemia
Jaundice
Hypocalcaemia and hypomagnasemia
Postnatal care for gestational diabetes?
Women with insulin‑treated pre‑existing diabetes should reduce their insulin immediately after birth and monitor their blood glucose levels to find the appropriate dose - at increased risk of hypoglycaemia so encourage meaning or snacks before baby feeds
Women who have been diagnosed with gestational diabetes should stop blood glucose‑lowering therapy immediately after birth
Women with pre‑existing type 2 diabetes who are breastfeeding can resume or continue metformin immediately after birth, but should avoid other oral blood glucose‑lowering therapy while breastfeeding
For women who were diagnosed with gestational diabetes offer a fasting plasma glucose test 6-13 weeks after birth to exclude diabetes or HbA1c
Offer an annual HbA1c test for women with gestational diabetes who have a negative postnatal test for diabetes
Offer women with gestational diabetes early self-monitoring of blood glucose or an OGTT for future pregnancies!
Management of pre-existing diabetes in pregnancy?
weight loss for women with BMI of > 27 kg/m^2
stop oral hypoglycaemic agents, apart from metformin, and commence insulin
folic acid 5 mg/day from pre-conception to 12 weeks gestation
detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
tight glycaemic control reduces complication rates
treat retinopathy as can worsen during pregnancy
What is asymptomatic bacteruria?
Implications in pregnancy?
Testing for it?
Bacteria present in the urine without symptoms of infection
Pregnant women who have this are at higher risk of developing lower urinary tract infections and pyelonephritis, and subsequently preterm birth
Pregnant women are tested fore it at booking and routinely throughout pregnancy - send MSU for culture and sensitivities
Management of UTI in pregnancy?
7 day course of antibiotics and follow up - nitrofurantoin (avoid at term)
Offer immediate antibiotic prescription!!
RCOG guidelines on starting VTE prophylaxis?
Start at 28 weeks if 3 risk factors
Start in first trimester if 4 or more risk factors
Consider if admitted to hospital, any surgical procedures, previous VTE, medical conditions etc.g. Cancer, high-risk thrombophilia or ovarian hyperstimulation syndrome
Risk factors for VTE in pregnancy and the puerperium?
Previous VTE
Thrombophilia
Medical conditions e.g. cancer, nephrotic syndrome, SCD, current IV drug user, SLE
Age >35
BMI >30
Parity >=3
Smoking
Gross varicose veins
Paraplegia
Multiple pregnancy
Pre-eclampsia
C-section
Prolonged labour >24 hours
Midcavity or rotational operative delivery
Stillbirth
Preterm birth
PPH
Any surgical procedure during pregnancy or peurperium
Hyperemesis or dehydration
Ovarian hyperstimulation syndrome
Admission or immobility >3 days of bed rest
Current systemic infection
Long distance travel >4 hours
Investigation for DVT in pregnant women?
Compression duplex ultrasound
Investigations. For PE in pregnant woman?
ECG and CXR
Consider CTPA or V/Q scanning
Why is D-dimer not used in pregnancy to investigate for DVT or PE?
Often raised in pregnancy anyway so its of limited use
Prophylaxis of VTE in pregnancy?
LMWH for at least 3 months
(If contraindicated consider intermittent pneumatic compression or anti-embolic compression stockings)
Why are pregnant women 5 x more likely to get a VTE than non-pregnant women?
Pregnancy is a prothrombotic state:
venous stasis - obstruction of venous flow by enlarging uterus
endothelial damage - in delivery or from venous hypertension
hypercoaguability - increased clotting factors and hormonal changes
What is obstetric cholestasis?
How common?
Intrahepatic cholestasis of pregnancy - reduced outflow of bile acids from the liver
Affects 1% of pregnancies in UK
Features of intrahepatic cholestasis of pregnancy?
Pruritus which may be intense - typically worse on palms, soles, abdomen
Clinically detectable jaundice in 20% of pt
Raised bilirubin in >90% of cases
Problem with intrahepatic cholestasis of pregnancy?
Increase the risk of premature or stillbirth
Management of intrahepatic cholestasis of pregnancy?
induction of labour at 37-38 weeks - particuarly if LFTs and bile acids are severely deranged as risk of stillbirth
ursodeoxycholic acid
Symptoms of itching can be managed with emollients e.g. calamine lotion, and antihistamines to help with sleeping (note they actually dont help the itching!!)
vitamin K supplementation if prothrombin time is deranged. (Lack of bile acids can lead to vit K deficiency as cannot be absorbed in intestines)
Investigtaions for obstetric cholestasis?
LFTs - ALT, AST and GGT abnormal (note placenta produces ALP so likely to be abnormal anyway)
Bile acids raised
Recurrence rate of intrahepatic cholestasis of pregnancy in subsequent pregnancies?
45-90%
What is acute fatty liver of pregnancy?
Pathophysiology?
A rare complication that may occur in the third trimester or in the immediate peurperal period
Genetic condition in foetus impairs fatty acid metabolism e.g. LCHAD = impaired processing of fatty acids in the placenta = fatty acids enter maternal circulation and accumulation in the liver = acute hepatitis
Features of acute fatty liver of pregnancy?
abdominal pain
nausea & vomiting
headache
jaundice
hypoglycaemia
severe disease may result in pre-eclampsia
Investigtaions for acute fatty liver of pregnancy?
LFTs - elevated ALT and AST
Raised bilirubin
Raised WBC
Deranged clotting
Low platelets
(Think of HELLP syndrome before this if low platelets and elevated liver enzymes as it’s more common!!)
Mabagement of acute fatty liver of pregnancy?
Stabilise pt ans then delivery of baby
An obstetrics emergency
Treat acute liver failure if it occurs
Causes of jaundice in pregnancy?
Intrahepatic cholestasis of pregnancy
Acute fatty liver of pregnancy
Gilberts - may be exacerbated
Dubin-Johnson syndrome - may be exacerbated
HELLP syndrome
Others:
Acute viral or autoimmune hepatitis
Cholelithiasis
Chronic liver disease
What are the reversible causes of adult cardiac arrest?
4Ts and 4Hs:
Thrombosis - PE or MI
Tension pneumothorax
Toxins
Tamponade cardiac
Hypoxia
Hypovolaemia
Hypothermia
Hyperkalaemia, hypoglycaemia and other metabolic disturbances
Others: eclampsia and intracranial haemorrhage
Top 3 causes of cardiac arrest in pregnancy?
Obstetric haemorrhage
PE
Sepsis
Causes of obstetric haemorrhage?
Ectopic pregnancy (early pregnancy)
Placental abruption (including concealed haemorrhage)
Placenta praevia
Placenta accreta
Uterine rupture
Aortocaval compression in pregnancy
> 20/40, the uterus is a significant size. When a pregnant woman lies supine, the mass of the uterus can compress the IVC + aorta. The compression on the IVC reduces venous return = reduces the cardiac output = hypotension.
In some instances, this can be enough to lead to the loss of CO and cardiac arrest.
The vena cava is slightly to the right side of the body. The solution to aortocaval compression is to place the woman in the left lateral position, lying on her left side, with the pregnant uterus positioned away from the inferior vena cava. This should relieve the compression on the inferior vena cava and improve venous return and cardiac output.
The differences to standard resuscitation: pregnancy?
A 15 degree tilt to the left side for CPR, to relieve compression of the inferior vena cava and aorta
Early intubation to protect the airway
Early supplementary oxygen
Aggressive fluid resuscitation (caution in pre-eclampsia)
Delivery of the baby after 4 minutes, and within 5 minutes of starting CPR - delivery will improve the venous return to the heart improving CO = increases chances of baby and mother of surviving
Risks of smoking in pregnancy?
Increased risk of miscarriage 47%
Increased risk of preterm labour
Increased risk of stillbirth
IUGR
Increased risk of SUDI
Risks of alcohol in pregnancy>
Foetal alcohol syndrome - learning diffiuclties, characteristic facies, IUGR and postnatal restricted growth
Risks of cannabis in pregnancy
Similar to smoking risks due to tobacco content- miscarriage, preterm labour, stillbirth, IUGR, SUDI
May also be a risk to mother for triggering onset of mental health problems for the first time or heightening any pre-existing mental health issues
Risks of cocaine use in pregnancy?
Maternal risks:
hypertension in pregnancy including pre-eclampsia
placental abruption
Fetal risks:
prematurity
LBW
neonatal abstinence syndrome
Risks of heroin in pregnancy?
Neonatal withdrawal syndrome
SUDI risk increases
Managing smoking in pregnancy?
Hi to nine replacement therapy
Avoid liquorice-flavoured nicotine products, E-cigs if possible although better than smoking
When should delivery be arranged for and why in a woman with intrahepatuc cholestasis?
Induction of labour at 37-38 weeks gestation due to the increased risk of stillbirth
A woman with a previous history of gestational diabetes comes in pregnant with a normal OGTT at 12 weeks. What do you do?
Repeat the OGTT at 24-28 weeks
