Medical Conditions and Pregnancy part 1

Question 1

What are the different types of hypertension in pregnancy?

Answer 1

Chronic hypertension: HTN before 20wks in absence of hydratidiform mole or persistent HTN beyond 6 weeks post partum.
Gestational - Gestational hypertension (without proteinuria), Gestation proteinuria (withouthypertension) or gestation proteinuric hypertension

Question 2

What is the definition of pre-eclampsia?

Answer 2

HTN developing after 20 weeks gestation with 1+: prtoeinuria, maternal organ dysfunction FGR

Question 3

What are some potential forms of maternal organ dysfunction in pre-eclampsia?

Answer 3

Renal insufficency (cr >90).
Liver involvement
Neurological complications (eclampsia, blindness, stroke, hyperreflexia with clonus or severe headaches).
Haematological complications (thrombocytopenia, DIC, haemolysis)

Question 4

What is eclampsia?

Answer 4

Generliased tonic-clonic seizures in women with pre-eclampsia, if seizures cannot be attributed to other causes

Question 5

What is the pathophysiology of pre-eclampsia

Answer 5

Phase 1: abnormal placentation - inadequate trophoblast invasion of maternal spiral arteries causing inadequate placental perfusion.
Phase 2: Widespread endothelial damage and dysfunction, likely to be mediated by oxidative stress originating from ischaemic placenta.

Question 6

What are the risk factors for pre-eclampsia?

Answer 6

First pregnancy,
Family history,
Extremes of maternal age,
Obesity,
HTN,
renal disease,
diabetes,
antiphopholipid syndrome,
inherited thrombophilia,
CTD eg, SLE
Multiple pregnancy,
previous pre-eclampsia,
hydrops fetalis,
hydatidiform mole,

Question 7

What are the symptoms and signs of pre-eclampsia?

Answer 7

Symptoms - severe headache, RUQ pain, swelling of hands, face or feet, visual disturbence, vomiting, restlessness or agitation
Signs - HTN and prtoeinuria, hyperreflexia, raised serum creatinine, reduced platelets, clonus, haemolytic anaemia, elevated liver enzymes, retinal haemorrhages and papilloedema.

Question 8

What are the investigations for pre-eclampsia?

Answer 8

BP,
Urinalysis for proteinuria >30mL/dL or +.
Bloods:FBC, UEs, prolonged coag, transaminitis.
Fetal assessment - SFH, ultrasound

Question 9

How can you prevent pre-eclampsia?

Answer 9

75mg of aspirin from 12 weeks gestation.

Question 10

How do you manage pre-eclampsia?

Answer 10

Control BP: <150/100.
Prevent seizures with magnesium sulphate.
Assess fluid palance.
Consider delivery - maternal or detal deterioration.
Optimise postnatal care.

Question 11

What types of drugs can be used for HTN in pregnancy?

Answer 11

Labetalol - widely used.
Methyldopa (oral only)- Sade but not suitible if history of depression.
Hydralazine - Widely used in hypertensive crisis.
Nidefipine - BP can fall when using MgSO4

Question 12

What are the maternal and fetal complications of pre-eclampsia?

Answer 12

Maternal - placental rupture, DIC, HELLP, pulmonary oedema, Aspiration, Eclampsia, Liver Failure, Stroke, Death, long term- cardiovascular morbidity.

Fetal - Pre-term delivery, IUGR, hypoxia-neurological injury, perinatal death, long term CV morbidity.

Question 13

Describe features of hyperglycaemia in pregnancy

Answer 13

Placenta produces hormones eg, human placental lactogen which increases insulin resistance. If pancreatic beta cells are unable to produced sufficient insulin then the mother can develop GD.
Glucose crosses placenta but insulin does not so more maternal glucose=increased fetal glucose.

Question 14

How do the insulin requirements change with gestation?

Answer 14

1st trimester - static or decreased.
2 trimester - Increased.
3rd trimester - increased and may reduce slightly towards term

Question 15

What are the risks of diabetes in pregnancy?

Answer 15

Pre-exisiting diabetes- miscarriage, congenital malformations, stillbirth, neonatal death
Gestational - neonatal hypoglycaemia, perinatal death.
Both - fetal macrosomia, birth trauma, induction of labour/C-section, obesity and or diabetes later in babies life, hypocalcaemia, hyperbilirubinaemia, RDS

Question 16

What is the pre-pregnancy advice given with regards to diabetes?

Answer 16

Good glycaemic control before conception as high glucose at time of organogenesis increases risk of congenital abnormalities.
Folic acid supplements,
Retinal and renal assessment at booking and 28 weeks,
Fasting glucose of 5-7mmol/l on waking.
BM of 4-7mmol/l at other times of the daty
HbA1c of 48

Question 17

What is the antenatal care for diabetes in pregnancy?

Answer 17

Early booking appointment to confirm viability.
4 weekly obstetric review until 28 weeks, 2 weekly until 36 weeks, then weekly.
Offer serum screening, anomaly and cardiac scan.
Retinal and renal screening at booking and 28 weeks.
Planned delivery for 37-38 weeks

Question 18

What is the intrapartum and post-partum care for diabetes in pregnancy?

Answer 18

Inta - sliding scale with aims of 4-7mmol/l
Post - Encourage breastfeeding, re-intriduce insulin from pre-pregnancy regime.

Question 19

RFs for gestational diabetes

Answer 19

BMI > 30,
Previous macrosomic baby > 4.5kg.
Previous GD,
Family history of diabetes,
Ethnicity.

Question 20

What are the investigations and diagnosis for GD?

Answer 20

OGTT at 24-28 weeks.
diagnostic if:
fasting glucose of 5.6 or above.
2-hour plasma glucose of 7.8 or above

Question 21

Explain the effects of pregnancy on thyroid hormones

Answer 21

In pregnancy iodine is lost in the urine and feto-placental unit which leads to state of iodine deficiency.
Total thyroid hormone concentrations in blood are increased in pregnancy - due to oestrogen and hCG which acts like TSH. T4 levels rise.
At 12 weeks the fetal thyroid function is independant.

Question 22

What are the effects of untreated thyrotoxicosis in pregnancy?

Answer 22

Increased risk of fetal loss, miscariiage, perinatal mortality maternal heart failure and premature labour

Question 23

Hypothyroidism and pregnancy

Answer 23

Thyroxine is safe during pregnancy.
WOmen require an increase by up to 50% as early as 4-6 weeks.

Question 24

How can you differentiate hyperthyroidism and pregnancy?

Answer 24

Presents similarly but best discriminators are weight loss, eye signs, pre-tibial myxoedema and tremor

Question 25

What is the management of hyperthyroidism in pregnancy?

Answer 25

1st trimester - Propylthiouracil.
2nd and 3rd trimester - carbimazole.
Beta-blockade with propanolol - make sure to monitor fetal growth.
Surgery is very rarely used.
Radioactive iodine is CI

Question 26

Describe features of post-partum thyroiditis

Answer 26

Tends to occur 1-3 months. There is a transient hyperthyroidism with subsequent hypothyroidism.