Medical conditions in pregnancy

Question 1

Anti-phospholipid syndrome (APLS)

Answer 1

Definition: autoimmune disease causing venous or arterial thrombus; can be diagnosis alone or with SLE
Suspect with Hx of multiple unprovoked thrombus or multiple miscarriages
Untreated has 10% livebirth rate

Diagnostic Criteria: 
- CLINICAL Hx of
Vascular Thrombosis  (arterial, venous, small vessel eg microangiopathy in kidney)
OR
≥3 miscarriages <10/40
OR
≥1 late miscarriage (>10/40)
OR
PET/IUGR with delivery <34/40
AND
Presence of: (2 positive results >12 weeks apart)
Anti-cardiolipin antibodies
OR
Anti-β-2 glycoprotein I antibodies
OR
Lupus anticoagulant

Ix: (MUST be on two or more occasions at least 12 weeks apart and BEFORE anticoagulants; only ONE of these need to be positive for diagnosis of APLS)

• Anti cardiolipin Ab IgG and IgM - >40
• Lupus anticoagulant - present
• Anti-beta2-glycoprotein Ab IgG and IgM - positive if >99th centile

In pregnancy, increases risk of:

• Thrombosis
• Thrombocytopaenia
• PET
• IUGR
• Preterm birth
• Miscarriage
• Abruption
• FDIU
• Non obstetric complications (DVT, stroke, livedo reticularis, cutaneous ulcers, transverse myelitis)

Treatment:

• LMWH once IUP confirmed + aspirin -> decreases miscarriage rate by 54%
• Multidisciplinary care (MFM, Rheum, Haem, anaesthetics, Paeds)
• Serial growth US
• Baseline PET bloods
• Monitor platelets
• Monitor BP and UA
• IOL at term
• LMWH for 6weeks postpartum
• No oestrogen containing contraception

NO IVIg or steroids (increases morbidity)

Question 2

Hypertension

Answer 2

Definition: sBP>140, dBP>90

Types:

• Gestational HTN: BP>140/90 after 20wks
• PET: BP>140/90 after 20wks + end organ damage
• Essential HTN: HTN <20wks or secondary to other cause (renal disease, renal artery stenosis, Phaeo, coarctation of aorta)
• Essential HTN with superimposed PET

Risk factors:

• Primigravida
• New partner
• GDM
• Obesity
• Previous PET
• Family Hx PET
• Pre-existing HTN, renal disease, APLS
• Multiple pregnancy
• Molar pregnancy
• IVF
• Advanced maternal age
• Long interpregnancy interval >10yrs

Criteria for PET:
RENAL
- Urine PCR>= 30
- Cr >90
HAEM
- Platelets <100
- Haemolysis: increased bili, high LDH>600, reduced haptoglobin
- DIC
HEPATIC
- Increase transaminases
NEURO
- Eclampsia
- Hyperreflexia with clonus
- Headache, visual disturbance
PLACENTA
- FGR

Prevention of PET
LOW DOSE ASPIRIN
- If commenced <=16/40 and doses >=75mg daily
- CLASP trial: non-significant reduction in incidence of PET and less PTB
- Cochrane review: reduces PET, PTB, SGA, perinatal mortality
CALCIUM
- Only benefit if low calcium intake
- Caution in renal impairment
- Sys review: reduces PET especially if high risk PET + low dietary Ca, reduces risk of PET

Mangement

• Pre-conception - age, parity, history, BP, renal function, secondary causes of HTN, weight, diabetes, change meds to pregnancy appropriate meds
• Antenatal - accurate dating (increase of FGR later), baseline BP/bloods, urine PCR, PIGF, commence aspirin <16/40, assess BP/urine dipstick every visit

Question 3

Cystic fibrosis

Answer 3

Autosomal recessive
Mutation in CFTR gene -> leads to abnormal movement of water and elctrolytes across epithelial surfaces -> thick secretions -> prone to infection

Pregnancy with CF:

• Can tolerate pregnancy unless severe respiratory dysfunction, CCF, pulm HTN
• Pregnancy does not usually worsen lung function but can
• Need to screen partner
• Need baseline heart/lung function - spirometry, TTE
• Need MDT care
• Supplements - creon, vit A/D/E/K (fat soluble)
• Fetal growth US
• Can have NVB - consider shorten 2nd stage to limit prolonged valsalva and increased risk of pneumothorax
• Screen neonate for CF

Ix:

• Parents known to be affected or carriers - screen most common mutations
• CVS or amnio
• NIPT is useful only if the mother and father carry different mutations: absence of the paternal mutation in the fetus means that infant will not have CF; if both parents carry the same mutation, NIPT is unable to determine whether the infant is an unaffected carrier or an affected homozygote
• Echogenic bowel on US

Complications:

• Meconium ileus
• Recurrent lung infections
• Malabsorption
• GDM
• Pancreatic insufficiency
• Chronic sinusitis
• Osteoporosis
• Males - infertility (absent vas deferens)
• Pulmonary hypertension
• Cardiac failure
• Miscarriage
• Preterm birth
• FDIU
• IUGR
• In 3rd trimester, worsening respiratory symptoms, dyspnoea