Medical Disorders and Pregnancy Flashcards
Can insulin cross the placenta?
No
Can glucose cross the placenta?
Yes
If the head is delivered but the shoulders aren’t, how quickly do you need to deliver the shoulders and what happens if this is not done?
5 minutes
Death due to hypoxia or brain damage due to hypoxia
What can shoulder dystocia result in?
Stuck
Erb’s palsy
Effects of T1DM in first trimester
Miscarriage More prone to developing DKA Congenital defects - cardiac - neural tube
What is the risk of miscarriage in the general population?
6 - 8%
What type of condition is pregnancy?
Diabetogenic
Which weeks are the second trimester?
12 - 28 weeks
Effects of T1DM in second trimester
Polyhydramnios
What can be done after 28 weeks gestation to monitor growth?
Serial scans
Management of a diabetic woman wanting to get pregnant
HbA1c < 48
Folic acid (5mg)
Make sure aware of hypo symptoms
How much time before pregnancy should folic acid be taken?
3 months before
Effects of T1DM in third trimester
Stillbirth (macrosomic babies)
Placental insufficiency
When are scans done in a normal pregnancy?
12 - 14 weeks first scan
20 weeks anomaly scan
28 weeks onwards growth scans
Effects of polyhydramnios
Pre term labour
Pre term rupture of membranes
PPH
How does polyhydramnios cause its complications?
It stretches the uterus
What can T1DM result in post delivery?
Neonatal hypoglycaemia
3 - 5% of the babies develop DM
Usually sugar levels of mum drop
Usually need pre pregnancy levels of insulin
What is used to prevent respiratory distress syndrome of the neonate in DM?
Steriods
Effects of DM in pregnancy to the mother
Increased insulin requirments Miscarriage Worsening of maternal DM Infections Jaundice
Effects of DM on the foetus
Macrosomnia (foetal hypersinsulinaemia) Neonatal hypoglycaemia Resp distress Cardiac abnormalities Pre eclampsia Polyhydramnios Stillbirth Shoulder dystocia Impaired lung maturity of neonate
What do steriods do to sugar levels?
Increase them and therefore need increased insulin dose
How many doses of steriods are administered in DM and what steriods can be used?
2 doses
Bethamexasone or dexamethasone
In T2DM, when do oral hypoglycaemics affect the foetus?
1st and 2nd trimester
What is the only oral hypoglycaemic allowed in pregnancy? What has to be done if the diabetes is not well controlled on this?
Metformin
If cannot tolerate then need to be switched to insulin
Risk factors for gestational DM
Multiple pregnancy Previous GDM in previous pregnancy FH of GDM FH of T2DM Obesity
What causes gestational DM?
The body cannot cope with the diabetogenic nature of the pregnancy
What 2 things are checked for every pregnant women?
BP
Urine dipstick
What things are checked for high risk women for GDM?
Bloods
OGTT
When is OGTT done in pregnant women?
28 weeks
Treatment of hyperthyroidism
PKU / Carbemazole
RAI
Surgery
Possible teratogenic effects of PKU? How common is this?
Failure to close scalp properly
Very rare
If the mother is on PKU as a treatment in pregnancy, what is usually done?
Change to carbemazole
Is a hyperthyroid mother in pregnancy high risk or low risk?
High
Effects of hyperthyroid in pregnancy
Hyperemesis more common (itself can also cause hyperthyroisim)
Thyroid more stimulated in pregnancy
If already on medication, requirements may increase
Growth of baby altered
Placental problems
What is a thyroid storm?
Once the baby is delivered, there can be drastic changes in hormones which can lead to MI etc
What needs to be done in a thyroid storm?
Antibodies need to be measured
Effects of hypothyroidism in pregnancy
Fertility problems
Neural tube problems (low IQ)
What is the most sensitive part of the babys body effected by the thyroid?
Brain tissue
What happens to the required dose of levothyroxine in the 1st trimester?
Increases
When do babies start producing their own thyroid hormones?
16 weeks
When is the skeletal form of the baby completed?
16 weeks
What is the risk of a controlled seziure free woman for 2 years during pregnancy and delivery?
Very low - 1 - 5% risk of seziure
What are all anti epileptic medications?
Teratogenic
How to change anti epileptic medications in pregnancy
Slowly
Contraception until medication is sorted - do not rush pregnancy
Need to have good control of epilepsy on new medication
What folic acid requirements do epileptic women trying to get pregnant need?
Very high dose
What can epilepsy itself increase the risk of?
NT defects
Effects of epilepsy in the 1st trimester
Miscarriage
Foetal abnormalities
Hyperemesis
Seizure frequency changes in pregnancy
60% remain the same
10% decrease
30% increase
Effects of epilepsy in the 2nd trimester
Growth restriction
Placenta affected
Effects of epilepsy in the 3rd trimester
Pre term labour
Placental abruption
Is epilepsy an indication for a C section?
No
What are women with epilepsy more prone to and why?
PPH
Can affect vitamin K factors etc
Is epileptic medication safe in breast feeding?
Yes (benefits > risks)
What type of medication can reduce the effectiveness of anti epileptic drugs?
COCP
What can sodium valproate reduce the effectiveness of?
COCP
What are the best contraceptive methods for a women with epilepsy?
Barrier methods
Coil
Post partum thyroiditis can be definitively diagnosed based on what 3 criteria?
- Patient is within 12 months of giving birth
- Clinical manifestations are suggestive of hypothyroidism
- TFTs support the diagnosis
What is found in 90% of the patients with post partum thyroiditis?
Thyroid peroxidase antibodies
What are the 3 stages of post partum thyroiditis?
- Thyrotoxicosis
- Hypothyroidism
- Normal thyroid function (but high recurrence rate in future pregnancies)
Treatment of post partum thyroiditis
Thyrotoxic phase - propanolol for symptom control
Hypothyroid phase - levothyroxine
What is the main presenting feature of obstetric cholestasis?
An intense itch
What is the most sensitive marker for obstetric cholestasis?
A rise in serum bile acids
What is the commonest cause of cardiac abnormality in pregnant women?
Mitral valve stenosis
What trimester of pregnancy is aortic dissection assosiated with?
3rd
Differential diagnosis of chest pain in pregnancy
Mitral stenosis
Pulmonary embolism
Aortic dissection
Most cases of MVS in pregnancy are assosiated with what?
Rheumatic heart disease
Predisposing factors in pregnancy for aortic dissection
HTN
Congenital heart disease
Marfans syndrome
What is the first line antihypertensive treatment for pregnant women with severe asthma?
Nifedipine
Which particular drug to treat UTI is contraindicated in the first trimester of pregnancy?
Trimethoprim
Treatment for obstetric cholestasis
Ursodeoxycholic acid
Vit K supplementation
Induction of labour at 37 weeks
When should anti-Xa activity be measured if a pregnant woman is on LWMH due to suspected DVT or PE?
Extremes of body weight
Complicating factors e.g.
- renal impairment
- recurrent VTE
What does obstetric cholestasis increase the risk of?
Stillbirth
Another name for obstetric cholestasis
Intrahepatic cholestasis
Presentation of obstetric cholestasis
Pruritis - may be intense - typically on palms, soles and abdomen Jaundice (20%) Raised bilirubin (90%)
Effects of HTN in the eye
Diabetic retinopathy
Papilloedema in severe
What drugs are used to treat HTN in pregnancy?
Labetolol
Nifedipine
Methydopa
Contraindications to labetolol
Diabetes
Asthma
Why is labetolol contraindicated in DM?
It masks hypos
Why is labetolol contraindicated in asthma?
Causes wheeze
S/E of methyldopa
Depression
Side effects of nifedipine
Headaches
Oedema
Effects of mag sulphate in babies
Cerebral protective of the babies
How to monitor the treatment of VTE in pregnant women on LWMH if they are at extremes of body weight or have complicating factors (e.g. renal failure, recurrent VTE)?
Measurement of peak anti-Xa activity
When do pregnancy induced BP problems NOT occur before?
20 weeks
What should be done if a pregnant women is exposed to chickenpox in pregnancy?
Check VZV Antibodies
If VZV Abs are -ve during pregnancy, what must be done and in what time frame?
Give VZIGs
Only effective up to 10 days post exposure
Criteria for post partum thyroiditis
- Within 12 months of giving birth
- Clinical manifestation of hypothyroid
- TFTs support diagnosis
