Medical conditions in pregnancy Flashcards
1
Q
Epilepsy in pregnancy - general
A
- 0.6% of pregnancies occur in women with epilepsy; most women have been dx before conception
- Seizure frequency can increase or remain unchanged
- Fetus usually tolerates seizures without long-term sequelae, but there is an increased risk of fetal demise with status epilepticus
- Increased risk of major congenital anomalies, mostly due to anticonvulsant medication
- Multiple drugs + higher doses -> increased risk
2
Q
Epilepsy in pregnancy - mx
A
- Optimise tx, achieve seizure control, educate pt. Use least number of drugs at lowest dose to control seizures
- Once pregnancy dx, the woman should continue on her anticonvulsant drugs and not change, as teratogenic risk exposure has already occurred
- Folic acid 5mg/d for at least 12 weeks before conception; continue until delivery
- Intrapartum = aim for vaginal delivery, control seizures with benzodiazepines
- Risk of epilepsy in child = 4% if one parent affected and 15% if both parents affected
3
Q
Cerebrovascular accidents - overview
A
- Rare in women of reproductive age, but increased risk in post-partum period. 9x risk for infarcts and 28x risk for haemorrhagic stroke in first 6wks post-partum
- Sx = abrupt onset of weakness, sensory loss, dysphasia; RF = smoking, diabetes, HTN, hypercholesterolaemia
- Mx depends on cause
- Mx of SAH due to dilation of AVMs (due to estrogen; common cause of SAH in pregnancy) = surgery usually recommended - excision of AVM, coiling or clipping. Vaginal delivery if lesion successfully treated. Elective CS if lesion inoperable. Epidural anaesthesia contraindicated with recent SAH due to raised ICP
- Involve neurologist in investigation and management
4
Q
Cardiac disease in pregnancy - mx
A
Note: normal pregnancy is associated with significant haemodynamic changes; these may not be tolerated in women with heart disease
- Multidisciplinary management with obstetrician, cardiologist, and occasionally, cardiothoracic surgeon
- Preconception counselling - optimise maternal cardiovascular status, modify medication, discuss maternal and fetal risks of pregnancy; decide if termination recommended (e.g. pulmonary HTN)
- Monitor for signs of heart failure; consider serial maternal echos. Monitor fetal growth by serial US bc risk of IUGR and FDIU
- Intrapartum = aim for vaginal delivery with short active second stage
- In labour, continuous monitoring of fetus (CTG); maternal cardiac monitoring may be required. Strict fluid balance necessary. Minimise blood loss by active management of 3rd stage (use oxytocin, but avoid ergometrine and prostaglandin). Epidural analgesia - may reduce changes in HR and BP associated with pain, but may cause serious complications with restricted cardiac output
5
Q
Marfan’s syndrome in pregnancy - general
A
- Autosomal dominant condition (c/some 15) caused by defect in fibrillin synthesis (genetic testing available). Main risk = aortic dissection and rupture
Mx
- Monthly maternal echo for aortic dimensions until 8 weeks post-partum
- Beta-blockers for HTN or aortic dilatation (reduce rate of dilatation and risk of dissection)
- Aim for vaginal delivery with short second stage (if aortic root dilatation present, deliver by CS)
Mortality
5. 25% if aortic root >4cm, pregnancy contraindicated with aortic root >4.5cm until aortic root replacement
6
Q
Asthma in pregnancy - general
A
- 1/3 of pts show no change in asthma, 1/3 show improvement, 1/3 deteriorate
- Usually no effect on fetus or cause of pregnancy, but poorly controlled asthma may be associated with low birth weight and preterm labour
Mx
- Continue current therapy in pregnancy. Treat as in non-pregnant state. Note - risk of gestational diabetes is increased in women on long-term steroids
- Advise cessation of smoking
- Asthma attacks are rare during labour; can use inhaled beta-agonists (no evidence that they interfere with uterine activity). Women on long-term oral steroids (prednisolone >7.5mg/d for >2 weeks) are at risk of Addisonian collapse during labour - give hydrocortisone 100mg every 8hr. PGF2a should only be used in cases of life-threatening PPH bc bronchoconstrictive action. Encourage breastfeeding
7
Q
Cystic fibrosis in preganncy - general
A
- Offspring will definitely receive one affected gene from mother, so parental status should be ascertained
- Care involves multidisciplinary team with chest physician (CF unit), obstetrician, dietitian and physiotherapist
- Principles of care = control of respiratory infections, avoidance of hypoxia, maintaining nutrition and fetal surveillance
- Continue chest therapy (same as non-pregnant state); monitor for signs of chest infection and treat aggressively with abx (tailored according to sputum culture results)
- Aim for vaginal delivery (limit 2nd stage bc pneumothoraces can occur with prolonged or repeated Valsalva manoeuvres); breastfeeding recommended
8
Q
Pneumonia in pregnancy - general
A
- Same incidence as in non-pregnant population (1-2:1000 pregnancies), risk factors = smoking, chronic lung disease and immunosuppression
- Clinical features = fever, cough, purulent sputum, chest pain and breathlessness
- Ix = FBE, CRP, CXR, sputum culture, serology (mycoplasma, Legionella and viral titres) +/- ABG
- Fetal risks = preterm labour, possibly IUGR
- Tx = physiotherapy (?), adequate oxygenation, hydration and appropriate antibiotics
Note - varicella infection (chickenpox) causes pneumonia in 10% of cases in pregnancy; mortality 10%. Women who develop varicella in pregnancy should be treated with aciclovir, and be hospitalised if respiratory signs develop
9
Q
TB in pregnancy - general
A
- Uncommon in pregnancy; does not adversely affect outcome if dx and treated appropriately in first 20 weeks or so. Increased risk of prematurity and IUGR if treatment inadequate or delayed (note - transplacental spread of infection is rare)
- Clinical features = cough, haemoptysis, fever, weight loss, chest pain and night sweats)
- Essential to habve respiratory physician and microbiologist involvement
- Ix = CXR (classically calcification and upper lobe abnormalities), sputum microscopy with Ziehl-Nielsen stain (identification of acid-fast bacilli), sputum culture, bronchoscopy if no sputum, tissue biopsies for extrapulmonary TB
- Transmission from mother to baby after delivery can occur if mother remains infective. Women usually become non-infectious within 2 weeks of starting treatment. Baby should be given BCG vaccination, and if smear (?) positive, prophylaxis with isoniazid for 3mo
10
Q
Obstetric cholestasis
A
- Affects 0.5-1% of pregnancies (UK); usually occurs in 3rd trimester and resolves spontaneously after delivery
- Symptoms (3) = pruitus of trunk and limbs without skin rash, anorexia/malaise, epigastric discomfort, steatorrhoea, dark urine (less common)
- Risks = vitamin K deficiency in mother (potentially leading to PPH), preterm labour, stillbirth
- Ix = LFTs and bile acids for all women itching; if normal repeat every 1-2 weeks if symptoms persist (bc itching can predate abnormal LFTs). Exclude other causes of pruritus and liver dysfunction
- Commence water-soluble vitamin K from dx. Symptoms can be alleviated by topical emollients. Establish postnatal resolution of symptoms + LFTs. Intrauterine death (?) is usually sudden and cannot be predicted by biochemical results, CTG findings or on US
11
Q
Acute fatty liver of pregnancy - general
A
- Rare condition affecting 1:10,000 pregnancies; typically presents in 3rd trimester and can occur at any parity. Can progress rapidly to fulminant liver failure, DIC and renal failure
- RF = twin pregnancy, male fetus and mild preeclampsia
- Clinical features (5) = abdominal pain/NV, jaundice, headache, fever, confusion/coma. Hypoglycaemia common
- Dx based on Swansea criteria. Ix = FBE + film, clotting studies, BGL, UEC, urate, LFTs, blood gases
- Mx = correct hypoglyacemia, correct coagulopathy with IV vitamin K and fresh frozen plasma (FFP), strict control of BP and fluid balance, delivery following stabilisation, supportive care following delivery, transfer to specialist liver unit if fulminant hepatic failure
12
Q
Renal tract infections - general
A
- More common in pregnancy bc dilation of upper renal tract and urinary stasis
- Asymptomatic bacteriuria affects 5-10% of pregnant women; if untx can lead to symptomatic infection in 40% of cases
- Cystitis in 1% of pregnancies
- Pyelonephritis in 1-2% of pregnancies; associated with preterm labour - Women should be screened for asymptomatic bacteria with MSU sample at booking
- Symptoms
- Cystitis = urinary frequency, urgency, dysuria, haematuria, suprapubic pain
- Pyelonephritis = fever, rigors, vomiting, loin pain, abdominal pain
*Consider dx of pyelonephritis in women presenting with hyperemesis or threatened preterm labour - Ix (7) = urinalysis, MSU, FBE, UEC, CRP, blood cultures, renal ultrasound (after single episode of pyelonephritis or two or more UTIs - to exclude hydronephrosis, congenital abnormalities and calculi). Monthly MSU in women with culture-proven UTI to prove eradication
- Mx asymptomatic bacteriuria or cystitis (empirical) = cephalexin 500 mg orally BD 5d or nitrofurantoin 100mg orally BD 5d or amoxycillin + clavulanate 500 + 125mg orally BD 5d.
Mx pyelonephritis (empirical, mild) = amoxicillin + clavulanate 875 + 125mg orally BD 10-14d, cephalexin 500mg orally QID 10-14d.
Mx pyelonephritis (empirical, severe) = gentamicin IV + amoxicillin IV
13
Q
Chronic renal disease in pregnancy - mx
A
- Multidisciplinary care involving a renal physician
- Baseline ix before conception = FBE, UEC, urate, 24h protein, creatinine clearance
- Early and regular antenatal care with tight control of BP, monitoring of renal function and proteinuria, ax fetal size and well-being with serial growth scans + Doppler, early detection of complications (anaemia, UTI, pre-eclampsia, IUGR)
- Review medications. ACEIs stopped as soon as pregnancy confirmed. Prophylactic low-dose aspirin may reduce risk of pre-eclampsia
- Hospital admission if increased proteinuria, HTN, deteriorating renal function or sx of preeclampsia
14
Q
SLE in pregnancy - general
A
- Incidence = 1:1000, onset during reproductive age is common. CTD of relapses (flares) and remissions
- Relapses difficult to dx as similar symptoms occur in normal preganncy (e.g. fatigue, hair loss, joint aches, anaemia). ESR raised in normal pregnancy and CRP not a marker of disease activity. Reduced C3 or increased anti-DNA levels are an objective index of disease activity. Use raised urate + deranged LFTs, and falling C3 + rising anti-DNA levels to distinguish lupus nephritis from pre-eclampsia
- Maternal risks - long-term prognosis not affected by pregnancy. Increased risk of flare-up, especially in puerperium. HTN, pre-eclampsia and placental abruption more common
- Fetal risks (5) = increased risk of miscarriage, preterm delivery, PPROM, IUGR and FDIU. These risks are due to anticardiolipin antibodies, lupus anticoagulant, renal impairment or HTN; risk is low all if these are absent.
- Multidisciplinary team mx. Prepregnancy counselling of maternal and fetal risks based on BP, renal function, anti-Ro and antiphospholipid antibody status. Tx HTN and modify medication if necessary. Tx flareups by starting or increasing dose of medication, or steroids. Ax fetal growth and wellbeing
15
Q
Antiphospholipid antibody syndrome - general
A
Note on pathophysiology: lupus anticoagulant is an inhibitor of the coagulation pathway, and anticardiolipins are antibodies against the phospholipid components of cell walls
- Dx based on one or more clinical features and one or more positive laboratory findings.
- Clinical criteria = vascular thrombosis (arterial or venous), three or more consecutive miscarriages (10 weeks, one or more preterm delivery (6 wks apart, lupus anticoagulant present on at least two occasions >6 weeks apart - Can be complicated by hypertension, pulmonary HTN, epilepsy, thrombocytopenia, leg ulcers and valvular problems
- Termed primary if features of connective tissue disease are absent, or it can occur secondary to established CTD
- Maternal risks = placental abruption, pre-eclampsia
- Fetal risks = early and late miscarriage, FDIU, IUGR
