Medical complications and infections in pregnancy Flashcards
What are the risks of poor glycaemic control in pregnancy?
Neural tube defects Cardiac anomalies Foetal macrosomia Stillbirth Risk of pre-eclampsia Hyper/Hypoglycaemia DKA Increased risk of miscarriage Increased risk of infection
What is the management of diabetes in pregnancy?
MDT approach: Specialist diabetes midwife, dietician, obstetrician
Blood glucose monitoring 7 times a day (before meal and 1 hour after meal)
Aim is to maintain blood glucose of:
<5.3 mmol/l pre-meal
<7.8 mmol/l 1 hour post meal
Serial growth scans to detect macrosomia and polyhydramnios
Aim for delivery by 39 weeks, 50% end up having C-section
How is hyperthyroidism treated in pregnancy?
Medical treatment only
Carbimazole and propylthiouracil at lowest dose
What are the risks of suboptimal thyroid hormone replacement?
Developmental delay
Pregnancy loss
What are the three criteria required to diagnose postpartum thyroiditis?
< 12 months of giving birth
Clinical manifestations of hypothyroidism
TFTs to support
NOTE: TPO antibodies present in 90%
How is post-partum thyroiditis managed?
Thyrotoxic phase: propanolol
Hypothyroid phase: thyroxine
What measures are taken during labour in a patient with heart disease?
Aim to wait for spontaneous labour
Epidural anaesthesia usually recommended (reduces pain-related stress/increase in CO)
Prophylactic antibiotics (Prevent bacterial endocarditis)
Use syntocinon (ergometrine CI in hypertension/CHD)
Consider instrumental delivery to keep second stage short
Avoid supine position
Which medications that are commonly used in labour/delivery should be avoided in asthmatic patients?
Ergometrine
Carboprost (Prostaglandin F2a)
Labetalol
What advice should be given to a woman with epilepsy considering getting pregnant?
Start folic acid 5mg/day 3 months before getting pregnant
Explain that epilepsy is associated with much greater risk of congenital abnormalities due to anticonvulsant medications
- Neural tube defects
- Cardiac defects
- Facial clefts
Sodium valproate should be avoided unless no other AED is affective
Lamotrigine is the safest antiepileptic drug to give
Breastfeeding is safe whilst on AEDs
What are the risks of sickle cell in pregnancy?
Miscarriage Pre-eclampsia Increased risk of sickle cell crises FGR Preterm labour VTE
What is the management of sickle cell in pregnancy?
5mg Folic Acid daily preconception
75mg Aspirin daily in early pregnancy
What infections are screened for antenatally?
Syphillis
HIV
Hepatitis B
Note: Rubella is no longer screened for because the incidence rate is so low
What are the features of congenital rubella syndrome?
If infected before 20 weeks, there is a risk of having congenital rubella syndrome, features include:
Cataracts
Deafness
Congenital cardiac defect (Most commonly PDA)
If infected in 3rd trimester, main risk is diabetes
What is the management of congenital rubella syndrome?
If infected, CRS should be screened for
If infected <16 weeks, then termination of pregnancy offered
What are the features of syphilis?
In mother:
Painless genital ulcer 3-6 weeks after infection
Maculopapular rash 6 weeks-6 months later
Risk to foetus: 25% stillbirth FGR Congenital syphilis Preterm birth
How is syphilis managed in pregnancy?
Benzathine penicilin (parenteral)
What is the management of HIV in pregnancy?
Reduce risk of vertical transmission:
- Antiretroviral therapy to keep viral load low
- Delivery by C-Section
- Breastfeeding
Women with a high viral load should receive Azidothymidine (IV) before C-section or following SROM
Management of infant:
Should be given Azidothymidine for 6 weeks after birth
Direct Viral PCR at birth, 3 weeks, 6 weeks and 6 months (Can’t test antibodies because mother’s antibodies cross placenta)
What is the management of hepatitis B in pregnancy?
After birth, baby should receive:
Hep B immunoglobins at birth
Hep B vaccine at birth, 1 month and 6 months
How is a diagnosis of toxoplasmosis made?
Sabin Feldman dye test
Treated with spiramycin, to prevent transplacental infection
Which test should be performed if an ultrasound suggests that there is a risk of congenital toxoplasmosis?
Amniocentesis followed by PCR of amniotic fluid for T. gondii.
Termination of pregnancy should be offered if there are abnormalities found in ultrasound and toxoplasmosis infection is confirmed on scan
What are the features of toxoplasmosis infection in infants?
Ventriculomegaly Microcephaly Chorioretinitis Cerebral calcification Normally asymptomatic at birth
What are the features of CMV infection in infants?
Deafness Cataracts IUGR Microcephaly Hepatosplenomegaly Ascites
How is CMV investigated?
If abnormalities are seen on ultrasound, PCR of amniotic fluid may be conducted
If CMV confirmed, TOP offered
What are the features of VZV infection in pregnancy?
Risk to the mother: pneumonia/encephalitis
Risk to the infant: Congenital Varicella Syndrome ○ Low birth weight ○ Cutaneous scarring (In dermatomal pattern) ○ Limb hypoplasia ○ Microcephaly ○ Cortical atrophy ○ Chorioretinitis ○ Cataracts
If infected 7 days before delivery, there is a risk of neonatal varicella infection: Pneumonia, disseminated skin lesion, high risk of mortality. Delivery should be postponed till 7 days of infection to allow time for maternal antibodies to protect child. If birth occurs within 7 days of rash onset, baby should be given VZIG and monitored for 1 month
What is the management of VZV infection in pregnancy?
If the mother has not had the vaccine or previously had chickenpox, she should be given VZIG within 10 days of exposure
If she presents with a rash, oral aciclovir for 7 days should be given within 24 hours
How can VZV immunity be confirmed?
Detection of VZV IgG
What is the main risk of parvovirus B19 infection in pregnancy? At what point in pregnancy does it pose the greatest risk to the foetus?
Aplastic anaemia leading to hydrops fetalis and intrauterine death
May resolve spontaneously or may need intrauterine blood transfusion
Poses the greatest risk at < 20 weeks
What are the risks of listeria in pregnancy?
Miscarriage
Stillbirth
Sepsis
How is listeria treated?
IV antibiotics (Ampicillin 2g every 6 hours and erythromycin)
How should first-episode genital herpes in pregnancy be diagnosed and treated?
Refer to GUM
Viral culture and PCR
Aciclovir 400 mg TDS
No matter when they were initially infected, from 36 weeks gestation, they should receive aciclovir TDS till delivery
How should women with primary herpes infection in the 3rd trimester be managed?
C-section should be recommended (especially if within 6 weeks of onset)
Give intrapartum IV aciclovir
How should recurrent episodes of herpes simplex infection in pregnancy be managed?
NOT an indication for C-section
Consider oral aciclovir from 36 weeks
Avoid invasive procedures if there are genital lesions
How would you manage a woman who is found to have GBS in her genital tract?
Intrapartum antibiotics (IV benzylpenicillin) as soon as possible after the onset of labour
Penicillin allergy: clindamycin
List some indications for GBS prophylaxis
Intrapartum fever PROM Prematurity Previous infant with GBS Incidental detection of GBS in pregnancy GBS bacteriuria
Outline the management of the newborn with risk factors for early-onset GBS disease.
1 minor risk factor = remain in hospital for observation for 24 hours
2 or more minor risk factors = full septic screen AND IV penicillin + gentamicin
What are the consequences of neonatal GBS infection?
Neonatal sepsis immediately after birth: Collapse Tachypnoea Nasal flaring Poor tone Jaundice
What are the clinical features of malaria in pregnancy?
Cyclical spiking pyrexia Jaundice Pulmonary oedema (High mortality) Hypoglycaemia Associated with preterm birth and miscarriage
Managed with antimalarials
What are the clinical features of TB in pregnancy?
May lead to miscarriage, preterm labour, LBW
Anti-TB medications are safe to use in pregnancy
