Medical conditions in pregnancy Flashcards
prepregnancy assessment and counselling CF
MDT -Phys, obs, diet, DM team, CF nurse, PT, anaeathetis, MW, respiratory physicians
testing for diabetes
monitor nutritional status and weight gain
monitor lung function and tx exacerbations
individualised plan for delivery
Effects of pregnancy on CF
generally does not shorten survival, but may in severe disease
inadequate weight gain
deteriorating lung function
Effects of CF on pregnancy
GDM PTB HTN IUGR fetal anomalies
Crohns risks to pregnancy
PTB
IUGR
miscarriage
SB
pregnancy effect on crohns
most will not have a flare
most at risk of flare if have active disease at conception or new dx crohns in pregnancy
Risks with obstetric cholestasis
SB PTB GDM PET intractable itch
when to screen for haemoglobinopathy
low MCV
low MCH
Normal iron levels
Ethnicity
Maternal haemoglobinopathy - test to screen in father
CBC (MCV, MCH)
Ferritin level
Haemoglobinopathy screen
both parents haemoglobinopathy carriers - what to do
arrange genetic counselling and molecular testing
beta thalassaemia management in pregnancy
screen for antibodies baseline CBC and blood film ECHO - can have cardiomyopathy Liver USS - can have cirrhosis or cholelithiasis related to iron overload HbA1c - risk DM TFTs - risk hypothyroidism Vitamin D levels
Epilepsy management at booking
MDT approach Aim monotherapy Explain increased risk NTD HD folic acid Refer to neurologist advise medication may need to be increased advise re monitoring levels possibility of increased seizure frequency during pregnancy Advise vit k to bubs to prevent HDN
Cervical cancer in pregnancy management
MDT input
Colposcopy - exclude invasive disease, biopsy if suspicious of invasive disease
Staging procedure or MRI, CT if think lung mets
CXR
Consider laparoscopic lymphadenectomy for accurate staging, enabling further fetal maturation
If positive nodes, consider TOP; if continuing CT after first trimester
Treatment of 1A2 and beyond - gold standard is radical hysterectomy and BS; can do just trachelectomy during pregnancy with cerclage - high risk PTB, steroid baby @ 24 weeks
If adenocarcinoma - take ovaries too
Timing of delivery - C/S; prelabour, aim 34-36 weeks, earlier depending on well-being of mother; vaginal delivery not advised due to risk of bleeding, and recurrence at epis site
BF contraindicated with CT
Psychological support
Chemotherapy in pregnancy
Avoid in first trimester
Monthly growth scans
Monthly MSUs
Avoid CT 3-4 weeks prior to delivery
Myasthenia Gravis and pregnancy
rule of thirds for symptoms
delay pregnancy at least 2 years from outset of disease
risk miscarriage and PTB
can develop transient neonatal MG
C/S only for obstetric indication, may require instrumental delivery
Advise epidural
Ok to continue neostigamine
corticosteroids - increased risk oral clefts
Avoid medications that exacerbate symptoms eg magnesium sulfate
NO mycophenylate
Sickle cell risks in pregnancy
acute pain crisis/sickle crisis
infection
IUGR
PTB
Prepreg care sickle disease
UTD immunisations (pneumococcal, Hep B) Antenatal serology penicillin propylaxis if splenectomy High dose folic acid stop hydroxyurea 3/12 before pregnancy iron chelators to be stopped keep warm and well hydrated to reduce risk of sickle crisis ECG, ECHO Retinal screening renal function (BP and urine checks) Identify partner status - autosomal recessive
Management sickle in pregnancy
Monthly MSUs
VTE prophylaxis from 28 weeks, earlier if other risk factors
CBC, LDH, LFTs checked every two weeks
serial USS
High risk sickle crisis and VTE PP
Consider blood transfusion if anaemic and HCT <0.26
Ferritin check each trimester
Beta thalassaemia pre pregnancy counselling
Tests to order: ECHO, LFTs and liver USS, HbA1c, TFTS, infection screen
Stop bisphosphonates
Ensure Vit D and calcium
Test partner - could test cffdna or cordocentesis during pregnancy
Vaccination status (pneumococcal)
beta thal during preg
stop chelation therapy
follow as per pre preg counselling
?prophylactic antibiotics (if splenectomy)
Review vaccination status
Early diabetes screen
ECHO third trimester is previous one normal
VTE prophylaxis for 6/52 PP; not given antenatally unless personal history
iron chelation therapy ok in BF
alpha thal
fetus would be severely anaemic with risk of hydrops and SB
usually also complicated by pre-eclampsia
HbA1c pre diabetes
41-49
Pre-existing diabetes pre preg counselling investigations
HbA1c PET screen TFTs with antibodies booking bloods coeliac screen for Type 1 smear/swabs MSU/urine PCR electrolytes lipids last eye review ECG if DM>10yrs Dietary advice/exercise
glucose targets in pregnancy
fasting <5
post prandial <7
Fetal complications with GDM
macrosomia IUGR SB misc PTL
Maternal complications with Diabetes
Birth trauma
UTI
C/S
PET/GTN HTN
primary adrenal insufficiency in pregnancy
nausea vomiting weight loss skin darkening hypoglycaemia hyponatraemia hyperkalaemia
management acute adrenal crisis in pregnancy
IV line Hydrocortisione cover in labour test ACTH, cortisol, glucose and serum electrolytes Identify cause tapering steroid once PP fetal assessment and monitoring
Differentiating features of Cushings compared to pregnancy
proximal myopathy easy bruising osteopenia/# hirsuitism early onset HTN
Work up of Cushings
urinary cortisol
Risks of Cushings in pregnancy
SB IUGR PTL misc GDM PET/GTN HTN wound infection CCF psychiatric disorders neonatal adrenal insufficiency Infertility Post op wound dehiscence
Treatment Cushings
adrenalectomy (unilateral) for adrenal cause
Transphenoidal surgery for pituitary cause
perform in second trimester
or metyrapone or cabergoline
Screening for VWD
VWD screen
Factor VIII
Management of VWD
Risk of major APH and PPH
Labour in hospital
Refer/involve haematology and anaesthesia
Obtain/review Factor VIII/vWF levels, aim 50/IU/dL close to delivery.
Have a plan drawn up for antenatal/intrapartum and postpartum care
May need TXA, DDAVP, vWF concentrates recombinant
,vWF + FVIII if severe bleeding
Refer to haematologist, anaesthetist and care ideally through multidisciplinary highrisk pregnancy clinic
Thrombocytopaenia screen
FBC reticulocyte count Peripheral blood film coag screen U/Es LFTs TFTs Direct Coombs test APL antibodies ANA Hep B, Hep C, HIV Immunoglobulins Vitamin B12/folate H. Pylori
Risks with thrombocytopaenia
Haemorrhage
Neonatal thrombocytopaenia
DDx thrombocytopaenia
ITP Gestational Pregnancy induced - HELLP syndrome Other - haemotological malignancy AFLP HUS
Management of thrombocytopaenia antepartum
iron/diet monitor platelets monthly IOL by term MDT approach further investigations if platelets <70 Treatment if platelets <50 Consider trial of steroids for response +/- immunoglobulin birth in hospital
intrapartum management of thrombocytopaenia
Anticipate PPH FBC, G&H, platelets Anaesthetics Neuraxial issues <70 Avoid instrumental/FBS/clip Platelets >50 (>20 likely safe) Stress steroids IV hydrocortisone 50 mg Q6H from established labour to 6 hours after birth For CS, give 100 mg IV hydrocortisone at time of anaesthesia, then 6 hours post birth Neonatal platelets and repeat Possible platelet transfusion Active management of third stage
Risks of hypothyroidism in pregnancy
miscarriage PIH/PET Anaemia PPH Abruption Preterm birth Cognitive impairment Developmental delay Low birthweight Increased risk of perinatal mortality
Treatment of hyperthyroidism in pregnancy
prophylthiouracil
Risks to fetus in mum on tx hyperthyrodism
fetus can be hypothyroid due to mum’s drug crossing placenta
if TRABs, then risk of fetal hyperthyroidism
Management of maternal hyperthyroidism
treat with meds
Monitor TSH and T4 and TRABs monthly
Fetal USS for signs hyperthyroidism
antibodies associated with hypothyroidism
TPO
Thyroglobulin
fetal thyrotoxicosis
Clinical Presentation: fetal sinus-tachycardia (around 180-200 bpm) holosystolic tricuspid insufficiency IUGR Goiter Oligo- or Polyhydramnios microcephaly hydrops fetalis premature delivery intrauterine fetal demise Diagnosis: patient history biochemical examination (fT4, TSH, TSHR-Ab) targeted ultrasound examination
BPAD risks on pregnancy
IUGR
PTB
poor bonding
Psychosis
Risk with lithium
NTD
Epstein’s anomaly
other cardiac anomalies
GDM
Management of lithium use in pregnancy
Monthly lithium levels (weekly from 36 weeks), TFTs, U/Es
HD folic acid - ideally preconception
iodine, vit d
early anatomy scan and fetal echo
GDM
?child welfare agency
serial growth scans
active management of the 3rd stage
withhold lithium in labour (high placental transfer)
check lithium level 12 hours post delivery before restarting
Not to be used in BFing
Postpartum psychosis
Psych liason risk of infanticide - ensure baby is safe/remove Ensure safe from self/risk of self harm transfer to acute mental health unit ongoing lithium use sedation if required
Spinal cord injury considerations
injury t4 or above - ventilation assessment in pregnancy
injury T6 or above - risk of autonomic dyreflexia - rise in BP 20-40mmHg is indicative
above T10-altered perception of fetal movements, unable to feel labour pains, risk late preterm labour and UTI
above T12 - malpresentation
above L2-L4 - scar tissue in epidural space can make epidural analgesia difficult
Effect of pregnancy on spinal cord injury
worsening mobility
worsening breathing
possible change of bladder care ?IDC towards end of pregnancy
C/S only if indicated by injury at young age or pelvic trauma
pre preg assessment spinal cord injury
support groups pelvimetry if indicated Respiratory function assessment if injury T4 or above; chest physiotherapy avoid constipation (risk AD) maintain good bladder cares (risk AD) Baseline CXR Consider imaging of head and spine
Autonomic dysreflexia
uncontrolled sympathetic outflow
rise in BP 20-40mmHg
medical emergency
remove noxious stimuli (even constipation, bladder cares)
complication=ICH, death, fetal bradycardia due to paroxysmal HTN episodes
treat with nifedipine sublingual, GTN, or IV labetalol or hydralazine
Intrapartum management SCI
good bladder care - place IDC
monitor observations - rises from baseline should be flagged
prophylactic epidural
continuous CTG
If AD in second stage - instrumental - if don’t have pain relief, then they must be given some!!!
tx of spasticity in pregnancy
baclofen (intrathecal)
otherwise oxybutinin for bladder spasms
diazepam
Covid in pregnancy risks
Pneumonia, ARDS, resp failure AKI, VTE, myocarditis strokes, vasculitis PTL IUGR SB
Covid vaccine explanation
higher risk in pregnancy due to reduced lung function, , increased oxygen consumpton, and reduced immune function
mRNA vaccine does not contain live virus
may offer passive immunity to baby
vaccination best way to prevent these risks and can be given in any trimester
does not effect miscarriage or fertility rates
does not increase VTE
Risks uncontrolled hyperthyroidism in pregnancy
PET thyroid storm thyrotoxic heart failure FGR prematurity stillbirth fetal thyrotoxicosis fetal hypothyroidism
Management thyrotoxicosis
PTU - ok in first trimester and BFing, risk maternal liver function damage
carbimazole - risk aplasia cutis, ok in 2nd and 3rd trimester
No radioactive iodine
surgery rarely required - if need to do, aim second trimester
Rates of depression and anxiety
approx 12-15%
Risk of postpartum psychosis with BPAD
20-30%
Neonatal Adaption syndrome
irritability, sleep disturbance, hypoglycaemia
self-limiting, supportive cares
neonate at risk if SSRI use or benzos
CF investigations
ECHO
baseline lung function tests
