Medical Conditions and Pregnancy part 2 Flashcards
What are the teratogenic effects of sodium valproate
Neurocognitive impairment,
Autism spectrum disorders,
Attention deficit disorders,
Neural tube defects - even if not on AED there is still a higher risk of neural tube defects with maternal epilepsy.
Hypospadias,
Heart defects,
Craniofacial anomalies,
Skeletal anomalies,
Developmental delay
What are the effects AEDs on fetal vitamin K
AEDs induce fetal hepatic activity which lower vitamin K and then results neonatal bleeding.
It is recomended to give all neonates konakion
What are the effects of pregnancy on epilepsy
Often seizure activity isn’t changed but it can deteriorate. Potentially due to reduced absorption (N+V), impaired sleep and reduced drug levels due to the increased vol of distribution and metabolism.
What is the management of epilepsy in pregnancy
Counselling - Monotherapy and requires folate supplement.
AED dose - lamotrigine increases.
Detailed ultrasound - neural tube, cardiac and cariofacial abnormalities.
Vitamin K for women on enzyme inducing AEDs.
Seizures - most will be self limiting but if prolonged then give diazepam/loraz.
Postnatal - breastfeeding safe
Contraception - Need higher dose oestrogen or alternative
What is the antenatal, intraoartum and postpartum management for epilepsy
Antenatal - Drug monitoring and screen for birth defects at 11-13wk and 20wks.
Intrapartum - IV acess, continue AEDs at normal time, avoid maternal exhaustion, CTG monitoring, Benzos for seizure termination.
Postnatal - May need to modify doses, however most are safe with breastfeeding
Describe the considerations around contraception and epilepsy
IUD, LNG-IUS and progesterone injections are not affected by enzyme inducing AEDs so promoted as most reliable
What are the potential complications of Varicella Zoster virus in pregnancy?
Maternal chickenpox - pneumonia, hepatitis, encephalitis and mortality.
Fetal varicellar syndrome - Occurs if a non-immune women contracts VZV in the first week of pregnancy
What are the features of congenital varicella syndrome?
Low birth weight, limp hypodysplasia, skin scarring, microcephaly, eye defects, learning disabilities
What are the precaustions and management of varicella infections in pregnancy
If women has history of chickenpox/shingles or had to doses of vaccine and is not immunocompromised then not at risk.
If no history of VZV and has history of significant contact then test for VZV IgG. If positive then woman is immune. If negative then may need antiviral treatment of VZV immunoglobulin (VZIG)
HIV and pregnancy
Highest risk of transmission during birth but can have prenatal transmission.
ART recommended during pregnancy.
If viral load < 50 copies/mL at 36 weeks then a planned vaginal delivery recommended.
If viral load > 50 copes/mL at 36wks then planned caesarian at 38weks.
Neonate started on PEP (zidovudine) within first 4 hrs and given for 4 weeks.
Avoid breastfeeding
Neonatal testing for HIV
- During first 48hrs before discharge.
- 6 weeks of age
- 12 weeks of age
- 18 months
Explain rhesus isoimmunisation
Occurs when rhesus negative mother carries a rhesus positive baby. Rh antigens from baby enter maternal circulation in delivery. Mother generates anti-Rh antibodies which with attack a subsequent Rh+ baby - HDN.
What are the signs and symptoms of haemolytic disease of the newborn
Antenatally - Polyhydramnios, theickened placentas, hydrops (subcut oedema) and in-utero demise.
Postnatally - Jaundice, hepato-splenomegally, pallor, kernicterus (billirubin encephalopathy) and hypoglycaemia
What are the investigations and management of rhesus incompatibility
Ix - check maternal blood groups and fetal blood group amnio
Rx - Anti-D after ectopic pregnancy, molar pregnancy, surgical TOP, medical/surgical miscarrage > 12 wks, severe bleeding < 12weks, after sensitising event >12wks. Also offer prophylaxis at 28 wks. After delivery test infant cord blood (blood group) and maternal blood (dose of Anti-D required)
WHat are normal skin changes in pregnancy?
Hyperpigmentation,
Striae gravidarum,
Hair and nail changes,
Vascular - angiomas and spider naevia,
Greasier skin,
Pruritis
What are some common skin diseases in pregnancy?
Atopic eruption of pregnancy,
Polymorphic eruption of pregancy.
Acne vulgaris or rosacea,
Psoriasis - give emmolients/steroids/dithranol/UVB.
Infections - Candida, warts or varicella.
Infestations - scabies.
Autoimmune - SLE or pemphigus gestationis
Describe features of actopic eruption of pregnancy
Most common and presents before 3rd trimester.
E- type (eczema) - rough and red patches, typically on face, neck, elbows and knees.
P-Type (Prurigo) - Bumps develop and affect abdomen, arms and legs.
Treatment - Emollients, aqueous creams, topical steroids, antihistamines, UVB and oral steroids if severe.
Describe features of polymorphic eruption of pregnancy
Pruritic eruption of lower abdomen and striae with umbilical sparing.
Fetal prognosis is normal.
Treatment - emollients, topical steroids and offer sedating antihistamine if itch causing sleep difficulties
Describe features of pemphigus gestationis
Occurs in 2nd or 3rd trimester. Autoimmune disease which can cause urticarial lesions, wheals and bullae in umbilical area.
Risks (rare) - premature delivery FGR, transient blistering on infant, secondary infection.
Treatment - refer to dermatology. Treat with topical steroids, antihistamines and if severe then oral steroids.
Rubella and pregnancy
Women planning to get pregnant should get MMR vaccine.
If in doubt then test for rubella immunity. If not immune then give two doses of MMR vaccine, three months apart.
If already pregnant then do not give vaccine as it is live. Instead give after birth
What is congenital rubella syndrome and its features
Caused by maternal infection with rubella virus within first 20wks of pregnancy.
Features - congenital deafness, cataracts, congenital heart disease and learning difficulties
Describe features of listeria in pregnancy
Listeria = gram +ve bacteria which causes listeriosis. 3x more likely in pregnant women.
Infection can be asymptomatic or cause flu-like illness, pneumonia or meningoencephalitis. it can increase risk of miscarrage or fetal death.
Describe features of congenital CMV infection
Occurs when mother is infected with CMV in pregnancy.
Features - FGR, microcephaly, hearing and vision loss, learning difficulties and seizures.
Describe features of congenital toxoplasmosis
Occurs when mother is infected with toxoplasma gondii.
Classic triad of congenital toxo: intracranial calcification, hydrocephalus and chorioretinitis (inflammation of choriod and retina)
Describe features of parvovirus B19 infection normally
Self limiting viral infection which causes a diffuse bright red rash on both cheeks (Slapped cheek syndrome). It later causes a reticular erythematous rash on trunk.
Supportive treatment. No longer infectious once rash has appeared
Describe features of parvovirus B19 in pregnancy
Can lead to several complications eg, miscarriage or fetal death, severe fetal anaemia which then leads to heart failure (hydrops fetalis) which can then lead to maternal pre-eclampsia-like syndrome
Describe features of mirror syndrome
Maternal pre-eclampsia-like syndrome which is a rare complication of hydrops fetalis. Involves triad of hydrops fetalis, placental oedema and oedema in mother.
Also HTN and proteinuria.
Ix - IgM and IgG to parvovirus, rubella antibodies.
Treat supportively.
Describe features of congenital zika virus
Occurs when women are infected with zika virus (spread by aedes mosquitos).
Features: Microcephaly, FGR and intracranial abnormalities (ventriculomegaly and cerebellar atrophy).
Ix - viral PCR and antibodies to Zika virus. No treatment.
What is the managment of chickenpox in pregnancy?
Give oral aciclovir if she is >20wks and presents within 24 hours onset of rash.
