Maternal Medicine Flashcards
What are the maternal risks of obesity in pregnancy?
Thromboembolism Pre-eclampsia Diabetes C-section Wound infections Difficult surgery PPH Maternal death
What are the risks to the fetus caused by obesity?
Congenital abnormalities
Perinatal mortality increased (due to diabetes and pre eclampsia)
What modifications to drug treatment need to be made in obese women?
Preconceptual weight advice
High dose (5mg) preconceptual folic acid supplementation recommended
Vitamin D
Weight best maintained – loss impractical + can cause malnutrition
Consider high risk pregnancy (esp. if BMI >35)
Screen for gestational diabetes + closer BP surveillance required
Formal anaesthetic risk assessment is recommended if BMI >40
Thromboprophylaxis often used
What are the consequences of HIV on pregnancy?
Main concern is high risk of vertical transmission to baby
<1% if best prophylaxis, 15% with none, up to 40% if breast feeding + under resourced
Increased by early and late disease, high CD4 or low viral load, prematurity, other infection, labour, long rupture of membranes
Increased risk of miscarriage Fetal growth restriction Prematurity Stillbirth Pre-eclampsia
How is HIV in pregnancy managed?
combination therapy elective C-section avoid breastfeeding treat neonate for 6 weeks screen for other infections
What are the main types of thrombophilia?
antiphospholipid syndrome protein S and C deficiency Activated protein C resistance and factor V Leyden Prothrombin gene mutation Antithrombin III deficiency Hyperhomocysteinaemia
What are the effects of thrombophilia in pregnancy?
VTE Miscarriage Preterm delivery Pre-eclampsia Placental abruption IUGR Fetal death
What modifications to drug treatment need to be made in thrombophilia?
high risk pregnancy care
aspirin and LMWH usually only if adverse previous obs history
postnatal LMWH to prevent VTE
What are the risks of epilepsy in pregnancy?
Congenital abnormalities (e.g. neural tube defects) increased – risk dose dependent, higher with multiple drugs + with sodium valproate
Newborn has 3% risk of developing epilepsy
How does pregnancy effect epilepsy?
seizure control deteriorates in pregnancy and labour
antiepileptic treatment is continued
How is drug treatment of epilepsy modified in pregnancy?
Preconceptual assessment preferred – seizure control with as few drugs as possible at lowest dose 5mg/day folic acid throughout pregnancy + 10mg vit K from 36 weeks
Avoid sodium valproate
Carbamazepine + lamotrigine safest
Doses may need to be increased but benefits of routine drug level monitoring
remain debated
20 week scan + fetal echocardiography to exclude fetal abnormalities
What effect does pregnancy have on the CV system?
40% increase in cardiac output, due to increase in stroke volume + HR, 40% increase in blood volume
50% reduction in systemic vascular resistance, BP drops in second trimester but normal by term
Ejection systolic murmur in 90% pregnanct woman
Left axis shit + inverted T waves on ECG
What are the risks of cardiac disease in pregnancy?
depends on cardiac status
most encounter no problems
if acquired and uncorrected then can cause cardiac failure and maternal mortality
How should cardiac disease be managed?
assess before pregnancy
warfarin and ACEI contraindicated
cardiac assessment required
Fetal USS at 20 weeks to exclude abnormalities
Treat HTN
elective forceps to avoid pushing in labour, abx if replacement valves, elective epidural
How is asthma/ resp disease managed in pregnancy?
drugs should be continued
if on long term steroids then increase dose in labour
What liver conditions occur in pregnancy?
Acute fatty liver - malaise, vomiting, jaundice and vague epigastric pain
Intrahepatic cholestasis of pregnancy - itching without skin rash, abnormal LFTs
What are the consequences of urine infection in pregnancy?
associated with preterm labour, anaemia and increased perinatal morbidity and mortality
treat asymptomatic bacteriuria as can lead to pyelonephritis therefore treat
What is the risks associated with sickle cell disease in pregnancy?
perinatal mortality
thrombosis
sickle crises
How is sickle cell disease treated in pregnancy?
exchange transfusions folic acid avoid precipitating factors avoid iron if homozygous test partner and offer prenatal diagnosis
What are the risks of hypothyroidism in pregnancy?
miscarriage preterm delivery intellectual impairment in childhood pre-eclampsia PPH Spontaneous abortion
What are the risks of hyperthyroidism in pregnancy?
causes neonatal thyrotoxicosis and goitre
treat with PTU rather than carbimazole but lowest dose and TFTs
when uncontrolled –> pre-eclampsia, growth restriction, preterm, stillbirths etc
What is postpartum thyroiditis?
can cause postnatal depression
risk factors are T1DM + antithyroid antibodies
What is renal disease managed in pregnancy?
monitor serum creatinine to determine progression
look for presence of HTN and proteinuria
low dose aspirin as prophylaxis for preeclampsia
review current meds
What happens to insulin requirements in pregnancy?
they increase because of the anti-insulin effects of placental hormones
How is diabetes managed in pregnancy?
good glycaemic control and BP control is crucial
avoid ACEIs, take more folic acid
avoid hypos
low dose aspirin
assess fetus for abnormalities
What are the implications of diabetes in pregnancy?
congenital abnormalities e.g. NTDs and CHD Fetal macrosomia IUGR if vascular disease Pre-eclampsia (30%) Early delivery often indicated Risk of neonatal hypoglycaemia
How is hyperthyroidism managed during pregnancy?
TFTs every 4-6 weeks, adjust therapy
serial growth measurements. assess fetal HR
How is hypothyroidism managed in pregnancy?
Increase replacement if indicated
test TFT every trimester, adjust medication
make sure adequate iodine intake
How should thalassaemias be treated in pregnancy?
treat with folic acid, avoid iron, may need transfusions
test partner and offer prenatal diagnosis if carrier
How is SLE managed in pregnancy?
counsel to avoid pregnancy until 5 months after a flare up
low dose aspirin to reduce pre-eclampsia risk, LMWH if concurrent APS
monitor with symptom reviews, regular assessment
immunosuppressants if severe
induce at 37-38 weeks
