Medical Conditions in Pregnancy Flashcards
What are the physiological thyroid changes during pregnancy?
Pregnancy may mimic hyperthyroidism as hCG is a TSH analogue
↑ TBG and T4 output to ↑ free T4
TSH may ↓ to below pre-pregnancy levels in T1 (due to ↑hCG)
Which are the best tests to order to monitor thyroid function during pregnancy?
Free T4, free T3, TSH
Which is the most common thyroid disorder during pregnancy?
Grave’s Disease
What are the risk of hyperthyroidism during pregnancy?
↑ risk of prematurity
Foetal loss
Malformations
Thyroid Storm
What is a thyroid storm?
Fever, tachycardia, change in mental state that may be precipitated by labour, delivery or surgery
What are the causes of foetal thyrotoxicosis?
Premature delivery
Foetal goitre = polyhydramnios
Extended neck in labour
F. Tachycardia
What are the consequences of hypothyroidism during pregnancy?
Increased rates of miscarriage, stillbirth, PROM
What is the management of hyperthyroidism during pregnancy?
Prophylthiouracil
Low dose + monthly monitoring as can cross placenta
What is the management of hypothyroidism during pregnancy?
↑ levothyroxine by 30% once pregnant and monitor 6 weekly
Optimise T4 before conception
When is a women at the greatest risk of cardiomyopathy?
1 month before and 5 month after delivery
What are the risk factors for cardiomyopathy?
> 35
Afrocarribean
Multiple gestations
What are some symptoms of cardiac disease during pregnancy?
Dyspnoea, fatigue and ankle oedema (also symptoms of pregnancy).
SO nocturnal dyspnoea and cough and chest pain = 🚩 🚩 🚩 🚩 🚩 🚩 🚩 🚩
What is the general management of cardiac disease during pregnancy?
MDT management with both cardiologists and obstetricians
Prevention of things that could exacerbate e.g. anaemia, smoking, obesity, hypertension
Vasodilators e.g. hydralazine can be given to ↓ after load due to ventricular dysfunction
Diuretics to get rid of pulmonary oedema
Which anticonvulsants are to be avoided during pregnancy?
Valproate has biggest risk of congenital malformations
Carbamezapine also has big risk
Lamotrigine also has big risk but smallest risk overall
All are to be avoided in breastfeeding
What are is the management of epilepsy pre-conception?
Specialist referral
Take folic acid 5mg before conceiving
What are is the antenatal management of epilepsy?
Assess for eclampsia if having seizures in 2nd half of pregnancy
Concentration of medication in plasma can change
Foetus may be at relatively higher risk of harm during a generalised tonic-clonic seizure
↑ chance of difficulties during labour and delivery e.g. failure to progress, chance of c-section
What is the antepartum management of epilepsy?
Continue to take AEDs
Not birthing pool
IV access - can give IV Benzos if seizing
Avoid maternal exhaustion
What is the postpartum management of epilepsy?
Neonatal withdrawal might happen
Routine injections of vitamin K to baby = ↓ risk of neonatal haemorrhage
Breastfeeding encouraged
Enough Sleep!
How can the risk of vertical transmission of HIV be increased? (5)
Vaginal delivery
Breast feeding
ROM for >4hours
PROM
Viral load >400
What is the antenatal management of a mother with HIV?
Offer testing at booking
Have to inform staff of HIV status + MDT management
Vaccines: influenze, hep b, pneumococcal
Bloods for other infections: hep b&c, TORCH, measles
Maternal Antiretroviral therapy from week 24 (HAART)
What is the intrapartum management of a mother with HIV?
Offer caesarean if maternal viral load is >50copies/ml. Offer at 38 weeks.
Give Zidovudine infusion 4 hours BEFORE caesarean
Can a vaginal delivery be offered to a pregnant mother with HIV?
Yes if maternal viral load is <50copies/ml
Have to minimise trauma to baby as much as poss
Continue HAART during labour
Can a mother with HIV breastfeed?
Not recommended!!
Give Cabergline PO to suppress lactation
What is the management of a baby born to a mother with HIV?
Zidovudine for baby twice a day for 2 weeks.
Give baby zidovudine if maternal viral load is below 50.
Otherwise give triple therapy for 4-6 weeks
What happens if a mother with HIV has PROM?
ROM <34 weeks = Give steroids and erythromycin
> 34 weeks = Deliver baby regardless of viral load
MDT management
Ensure HAART still taken
What are the physiological haematological changes that occur during pregnancy? (2)
↑ plasma volume. More than red cell volume
Dilutional anaemia = ↓ in Hb and ↓ haematocrit. This is at maximum effect at 28-30/40.
Also may have neutrophilia, thrombocytopenia, ↓cell-mediated immunity = PREDISPOSES TO SEPSIS
What are the adverse effects of an increase in plasma volume during pregnancy?
Net fluid gain = too much oxytocin used can cause fluid overload as is similar to ADH
What is the main cause of anaemia during pregnancy?
Iron deficiency anaemia is the most common - baby needs A LOT of Iron.
Significant if menorrhagia is baseline.
What are the effects of anaemia on mam?
normal anaemia signs e.g.
fatigue,
immunosuppression
poor concentration
low mood
What are the foetal effects of anaemia?
Low birth weight
preterm delivery
What is the management of anaemia during pregnancy?
Routine supplementation not recommended
Eat lots of iron rich food
If have to, treat with 100-200mg or oral elemental iron per day for 3 months and continue fr 6 weeks postpartum
How does pregnancy predispose VTE?
Blood stickier anyway
Baby can compress veins therefore predisposing stasis
Commonly compresses the left ileofemoral.
Common iliac artery crosses over common iliac vein on right more than left so left is more exposed to be compressed.
What are the issues with diagnosing VTE during pregnancy?
Big symptom cross over
What are the signs and symptoms of a DVT?
Signs = ↑ temp and WCC
Symptoms = Swollen leg +/- pain, abdominal pain
What are the signs and symptoms of a PE?
Signs = tachypnoea + tachycardia
Symptoms = pleuritic chest pain, haemoptysis, dyspnoea (exertion → rest)
What are the investigations for DVT during pregnancy?
Well’s Score
LMWH before diagnosis unless CI e.g. epidural
Urgent duplex doppler scan
Based on the results of a duplex doppler scan, when would a DVT be treated during pregnancy?
- Negative + low suspicion of DVT = discontinue treatment
- Negative + high suspicion of DVT = continue to anticoagulate and repeat in 1 week
What are the investigations of a PE during pregnancy?
Well’s Score
CXR
= Normal - do a doppler
= normal but still suspect a PE = VQ scan or CTPA but watch radiation
Why are D-dimers shit in pregnancy?
Raised during pregnancy anyway. Do clinical assessment and imaging. Always do a Well’s score.
What is the management of VTE during pregnancy?
LMWH
NOT WARFARIN AS TERATOGENIC
IV unfractionated heparin can be used if massive PE
What are the rules for using LMWH in pregnancy?
Use throughout and for 3 months after
Should you ever stop anticoagulating during pregnancy?
Yes have to stop for labour to reduce PPH risk and so anaesthesia can be used
Stop at first signs of labour or 24 hours before morning of admission if elective
What is the definition of chronic hypertension during pregnancy?
HTN >140/90 but is present before pregnancy OR during the first 20 weeks
What is the definition of pre-eclampsia?
Pre-eclampsia = NEW hypertension after first 20 weeks and proteinuria (>300mg/24hrs) +/- oedema
What is the definition of gestational hypertension?
ew-onset and after 20 weeks. Often leads to pre-eclampsia.
What are the physiological changes in pregnancy that relate to blood pressure?
⬆️ blood volume by 50%
⬆️ cardiac output ( ⬆️ HR and SV)
Initial ⬇️ in blood pressure due to: ⬆️ progesterone = vasodilation. Returns to what it was before pregnancy @ 36 weeks.
What is the pathophysiology of pre-eclampsia?
Abnormal remodelling of the spiral arteries (T1-20/40).
Cytotrophoblasts in the placenta don’t penetrate the myometrial segment of the spiral arteries properly = narrow and high resistance within the blood vessels
Mam produces ↓PIGF and ↑sFLT-1 = less angiogenesis. PIGF might be new test?
Which IUGR is associated with pre-eclampsia and why?
Asymmetrical IUGR - blood shunted to vital bits
What are the maternal symptoms of pre-eclampsia? (5)
Severe headache - throbbing/pounding. Do they suffer from migraines anyway?
Severe epigastric pain
Can move to R flank + back
Tender liver on palpation (stretching Glisson’s capsule)
N&V
Sudden swelling of hands and feet
Visual Changes
Flashing lights
End stage PE
What are the maternal signs of pre-eclampsia? (5)
Hypertension
Hyperreflexia (about to seize!!)
Sustained ankle clonus
Papilloedma
Weight gain due to fluid retention/ sudden oedema/ pulmonary oedema
What are the foetal signs of pre-elampsia?
Asymmetrical IUGR
Foetal Distress
Reduced foetal movements
What are the maternal investigations for pre-eclampsia?
- Bed - urinalysis = +1 is diagnostic then do a protein:creatinine ratio
Bloods
FBC - ↓ platelets and WBC
U&E - ↑ creatinine, monitor kidney function
LFT - deranged if severe PE + ↑bili = ?haemolysis
What are the foetal investigations for pre-eclampsia?
CTG
Uterine artery doppler - identifying high risk women
USS - oligohydramnios for growth restriction
What is the preventative management of pre-eclampsia?
75mg aspirin daily from 12 weeks to birth IF one high risk or two low risk so you’d have to bloody take it
Aspirin prevents platelet aggregation and is pro-angiogenic
What is the conservative management of pre-eclampsia and when should you do it?
Manage conservatively until 34/40. Can deliver after this if given corticosteroids and deliver after 37/40 if mild-mod.
What is the management of severe pre-eclampsia?
Delivery after 34 weeks or give steroids and antihypertensives until they can make it to this
Magnesium Sulphate if severe (seizure prevention)
What is the postnatal management of pre-eclampsia?
Measure BP QDS whilst in
Then, day 3 and 5 if no anti-HTN taken or 1-2 for 2/52 if taken
BP >150/100mmHg = start meds UNLESS methyldopa (PN depression)
Which antihypertensives should be avoided during pregnancy?
ACEI and ARBs!!!! Teratogenic!!! Effect on foetal kidneys!! (can use enalapril after when breastfeeding though)
What is the management of chronic hypertension during pregnancy?
Labetalol
B blocker - not for asthmatics
Also not for T1DM as palpitations are a warning for hypoglycaemia so will stop this. AND NOT pheochromocytoma AND NOT afro-carribean
Nifedipine
Calcium Channel Blocker
Good for afrocarribean women
Methyldopa
Asthmatic and already on ACEI. Good in early pregnancy.
Not if depressed and STOP within 2 days of delivery
Hydralazine
Only if IV labetalol or if other CI
GIVE IV - NOT IF severe tachy / recent MI/ SLE / before T3
What are the side effects of nifedipine?
Can stop contractions/labour
Headaches.
flushing/dizzy
Fluid retention
NO GRAPEFRUIT JUICE AFFECTED BY CYP
What are the maternal complications of pre-eclampsia? (5)
Eclampsia
Placental Abruption
Haemorrhage ⇢ AKI
HELLP
↑ risk C-seciton
What is HELLP?
Haemolysis
Elevated Liver Enzymes
Low Platelets
Deliver baby ASAP
What is eclampsia?
Seizures during pregnancy
What are the foetal complications of pre-eclampsia? (4)
Preterm
Asymmetrical IUGR
Placental abruption
Stillbirth
What is the definition of gestational diabetes?
Glucose intolerance with onset/diagnosis during pregnancy (24 to 28 weeks). Usually resolves after delivery.
What are the endocrine changes during trimester 1?
↓ insulin requirement.
Human Placental Lactogen causes maternal insulin resistance so that there is a big enough glucose gradient for foetal uptake @ placenta via facilitated diffusion.
hPL = increase blood glucose.
Human somatomammotropin = decrease blood glucose.
What are the insulin changes during trimester 2?
↑ insulin requirement
What are the insulin changes during trimester 3?
↓ insulin requirement (late on)
What is the pathophysiology of gestational diabetes?
Insufficient insulin production from maternal pancreatic beta cells = gestational diabetes
What are the complications of hyperglycaemia during trimester 1?
Foetal hyperglycaemia in T1 is teratogenic (NTD, Cardiac, renal)
What are the complications of hyperglycaemia after T1?
hyperinsulinaemia and as insulin is anabolic leads to macrosomia and organomegaly
↑ o2 demand of foetus = hypoxia + acidosis
Macrosomia = ↑ risk of birth complications
Enlarged kidneys = ↑ erythropoiesis and neonatal polycythaemia (blood gets stickier)
What are the risk factors for gestational diabetes?
Non-modifiable
- Previous macrocosmic baby
- Previous GD
- South asian
- Multip (bigger placenta)
Modifiable
- BMI >30kg/m2
What are the symptoms of gestational diabetes?
usually asymptomatic but may come about if hyperglycaemic
polydipsia, polyuria, thirsty/dry mouth, fatigued
What are the signs of gestational diabetes?
Fasting plasma glucose = >5.6 mmol/L
2-hour plasma glucose = >7.8 mmol/L at 2 hours
Do a fasting plasma glucose then an oral glucose tolerance test
What are the investigations for gestational diabetes?
OGTT
In the morning after an overnight fast (8 hours)
1 abnormality is enough to diagnose
what is the conservative management of gestational diabetes?
self monitoring of blood glucose
diet + exercise
Offer IOL or c-section at term (37-38+6/40)
What is the medical management of gestational diabetes?
Metformin is first line
Offer if blood sugar are uncontrolled 1-2 weeks after diet and exercise OR > 7 mmol/L fasting
Insulin Therapy
If metformin is contraindicated
BG >7 mmol/L + complications e.g. macrosomia/hydramnios
Can also give Glibenclamide (sulfonylurea) if don’t want insulin
What is the conservative management of pre-existing diabetes during pregnancy?
Self monitoring
Healthy lifestyle
Aim for HbA1c of <6.5% before pregnancy
Monitor BM TDS, urine for ketones, optic funds at booking & 20/40 and growth chart
What is the medical management of pre-existing diabetes during pregnancy?
Insulin
short acting @ mealtime TDS and long acting in background BD
What are the maternal complications of pre-existing diabetes during pregnancy? (3)
miscarriage
pre-eclampsia
↑ risk T2DM in later life
What are the foetal complications of pre-existing diabetes during pregnancy? (4)
↑ risk stillbirth
↑ risk congenital malformations
macrosomia + associated complications
preterm birth + RDS
How is obstetric cholestasis diagnosed?
Diagnosis of exclusion so have to exclude other causes of liver disease first
What is the main symptom of obstetric cholestasis?
Generalised itching
Worse on palms and soles of feet
Commonly in third trimester and worsens with gestation
NO RASH
What are other symptoms of obstetric cholestasis? (5)
Insomnia Malaise Abdominal Pain Pale stools +/ Steatorrhoea Dark urine
What is the pattern of jaundice associated with obstetric cholestasis?
Jaundice
Unusual
If it does happen then it’ll be around 2 weeks after pruritus develops and has quick onset with a rapid plateau. Constant til delivery.
Give 3 differentials for similar presentations to obstetric cholestasis
Acute fatty liver disease of pregnancy (v rare but serious & associated with pre-eclampsia)
Hepatitis - viral/autoimmune/drug induced
extra hepatic obstruction from gallstones
What are the blood tests for obstetric cholestasis and why?
LFTs - measure weekly until delivery
Moderately high ALT & AST
ALP IS VERY HIGH (high anyway in pregnancy so has to be ABNORMALLY high)
Increased serum total bile acid x10
Mild bili increase
What is the maternal management of obstetric cholestasis?
inform of ↑ risk of passage of meconium and prematurity
oral vitamin k
ursodeoxycholic acid
topical calamine lotion or aqueous creams for symptom relief
What is the role of vitamin K in the management of obstetric cholestasis?
Vit K is a fat soluble and have fat malabsorption in liver disease/ biliary dysfunction.
Vitamin K is needed for clotting and so is protective for PPH
What is the role of ursodeoxycholic acid?
Displaces bile salts and protects hepatocytes
What is the foetal management of obstetric cholestasis?
Increased foetal monitoring
What are the maternal complications of obstetric cholestasis?
Liver disease
PPH
↑ prothrombin time
What are the foetal complications of obstetric cholestasis?
Foetal distress
increased risk of intrauterine death, preterm birth
Which anticonvulsant is the best to use in pregnancy?
Lamotrigine?
What are the foetal abnormalities associated with sodium valproate and lithium?
Valproate = Neural tube defects
Lithium = Epstein’s abnormality (tricuspid valve doesn’t form properly)
Define sensitisation (in the contest of RhD)
A process whereby fetal red blood cells (RhD-positive) enter the maternal circulation, where the mother is RhD-negative
The fetomaternal haemorrhage (FMH) can cause antibodies to form in the maternal circulation that can haemolyse fetal red blood cells.
Affects next pregnancies if baby is RhD+
Give 5 potentially sensitising events during pregnancy
Ectopic pregnancy
CVS, amniocentesis
APH
Evacuation of retained products etc
Vag bleeding <12 if really heavy or painful OR just >12 weeks
