MEDICAL DISORDERS IN PREGNANCY Flashcards
Why are pregnant women more at risk of developing iron deficiency anaemia?
Normal physiological changes result in an increased plasma expansion which dilutes the Hb.
Iron requirements are almost tripled during pregnancy.
At what point would anaemia normally be picked up in a pregnant woman?
FBC is done at booking appointment (within first 10 weeks) and then repeated at 28 weeks
What Hb levels would prompt treatment on FBC at booking appointment and at 28 week check?
Booking: less than 110 g/L
28 weeks: less 105 g/L
What is the main side effect of iron supplements?
Constipation
Other than iron supplements, what else can pregnant women with iron deficiency anaemia be advised to do?
Vitamin C has been shown to increase iron absorption from the gut, therefore fresh orange juice is recommended.
Tannins found in tea and coffee on the other hand reduce absorption so should be avoided.
What are the complications of prolonged iron deficiency anaemia?
Breathlessness
Low birth weight
Preterm delivery
At higher risk of complications from perinatal haemorrhage
What are the complications associated with pre-existing diabetes in pregnancy?
Miscarriage
Congenital anomalies in particular cardiac
Fetal macrosomia
Polyhydramnios
Pre-eclampsia
Prematurity
Needing labour induced
Needing caesarian section
Birth trauma
Shoulder dystocia
Stillbirth
Neonatal hypoglycaemia
Obesity and diabetes later in the baby’s life
How is folic acid supplementation different in pre-existing diabetic women looking to conceive compared to non-diabetic women?
Non-diabetic women advised to have 400 micrograms each day until 12 weeks gestation
Diabetic women are prescribed 5 mg each day until 12 weeks gestation
What additional ultrasound scans will pregnant women with pre-existing diabetes be offered and why?
They are entitled to early USS if they like
In addition, they will have nuchal translucency checked including a detailed assessment of the fetal heart at 20 weeks.
They are then advised to have US growth scans every 4 weeks between 28 and 36 weeks to look for macrosomia and polyhydramnios.
In addition to USS, what monitoring should be done of a pregnant patient with pre-existing diabetes?
Patients should have their eyes checked at booking appointment and then at 28 weeks
They should also have regular blood pressure checks and urine dip for proteinuria.
What factors alter glucose metabolism in pregnancy such that pregnancy itself is a state of impaired glucose tolerance?
Hormones secreted by the placenta include:
Glucagon
Cortisol
Human placental lactogen
What is the gold standard test used to diagnose gestational diabetes?
Oral Glucose Tolerance Test (OGTT) - 75g of glucose administered post fasting and blood glucose levels recorded at 0 and 2 hours
Is there a difference in the definitions (in terms of results from an OGTT) between frank diabetes and gestational diabetes according to NICE?
Frank diabetes:
Fasting glucose of more than 7 mmol/L
2 hour level on OGTT of more than 11 mmol/L
Gestational diabetes:
Fasting glucose of more than 5.6 mmol/L
2 hour level on OGTT of more than 7.8 mmol/L
What are the risk factors for developing gestational diabetes?
BMI above 30
Previous macrosomic baby weighing more than 4.5kg
Previous gestational diabetes
First degree relative with diabetes
Country of family origin being in South Asia, Caribbean, Middle East.
Who is offered an OGTT in pregnancy and when during gestation will they be offered the test?
All those with risk factors should be offered OGTT at 24-28 weeks
All those who have had gestational diabetes previously should be offered OGTT soon after booking and then again at 24-28 weeks if negative
All patients with gestational diabetes should have a fasting plasma glucose arranged 6 weeks post-natally
What are the complications associated with gestational diabetes?
Fetal macrosomia
Polyhydramnios
Pre-eclampsia
Prematurity
Needing labour induced
Needing caesarian section
Birth trauma
Shoulder dystocia
Stillbirth
Neonatal hypoglycaemia
Obesity and diabetes later in the baby’s life
How do we treat patients with newly diagnosed gestational diabetes with a fasting glucose of less than 7 mmol/L?
Step 1. Changes to diet and exercise regimes
Step 2. Add metformin
Step 3. Add insulin
NB. insulin should be started as first line treatment if the plasma glucose is 6-6.9 mmol/L and there is evidence of macrosomia or polyhydramnios
How do we treat patients with newly diagnosed gestational diabetes with a fasting glucose of more than 7 mmol/L?
Start insulin as first line treatment - oral hypoglycaemic agents are not indicated
How do we treat pregnant patients with pre-existing diabetes?
All oral hypoglycaemic agents other than metformin should be stopped and insulin should be started
5mg of folic acid should be given from pre-conception to 12 weeks
What is the main concern regarding epilepsy in pregnancy?
The fact that anti-epileptic drugs are for the most part teratogenic.
What supplements do we advise all epileptic women looking to conceive to be on?
5mg of folic acid
What are the guidelines regarding anti-epileptic therapy during pregnancy?
Patients are counselled against stopping medication. Sodium valproate is known to be particularly teratogenic therefore patients may consider swapping medication.
Lamotrigine is recommended for epileptics in pregnancy
Do we change doses of anti-epileptic medications in pregnancy?
Reducing dose is normally advised against, unless seizure control has been good for a long period. Doses may even need to be titrated up as increased hepatic metabolism and renal clearance in pregnancy means that levels of drugs are reduced.
In addition to folic acid, what prophylactic supplements should epileptic pregnant on phenytoin be given?
Patients on hepatic enzyme inducing drugs (carbamazepine and phenytoin) should be given vitamin K 10 mg orally in the last month of pregnancy.
When in pregnancy is the risk of seizures at its highest?
Labour and the 24 hours following delivery. Epileptics women are advised against having home births.
What are the guidelines surrounding breast feeding and anti-epileptic medications?
Breast feeding is considered safe in epileptic mothers taking medications.
What is the incidence of congenital abnormalities in mothers taking anti-epileptics compared to non-epileptic mothers?
Non-epileptic: 1-2%
Epileptic: 3-4%
What percentage of pregnancies are affected by hypothyroidism?
1%
What are the clinical features of hypothyroidism in pregnancy?
May be confused with normal symptoms of pregnancy:
Lethargy and tiredness
Weight gain
Dry skin
Hair loss
Discriminatory symptoms:
Cold intolerance
Slow pulse rate
Slow relaxing tendon reflexes
Goitre
What are the complications of hypothyroidism in pregnancy?
Miscarriage
Reduced intelligence
Neurodevelopmental delay
Brain damage
Up until 12 weeks gestation the fetus relies solely on maternal thyroid hormone.
What is the aetiology of most cases of hypothyroidism in pregnancy?
Autoimmune eg Hashimoto’s
How do we treat hypothyroidism in pregnancy?
Thyroxine is safe in pregnancy and must be adequately titrated. Remember that when interpreting TFTs it is important to use pregnancy adjusted values.
What are the clinical features of hyperthyroidism in pregnancy?
Similar to non-pregnancy related hyperthyroidism:
Sweating
Palpitations
Heat intolerance
Vomiting
Tachycardia
Tremor
Exopthalmos
Goitre
Palmar erythema
What is the main cause of hyperthyroidism in pregnancy?
Graves’ disease
Why might be levels of thyroid hormone be raised in the first trimester of pregnancy?
hCG can activate the TSH receptor
What are the complications of hyperthyroidism in pregnancy?
Miscarriage
Preterm labour
Growth restriction
Neonatal thyrotoxicosis - due to transplacental passage of thyroid antibodies
What are the clinical features of neonatal thyrotoxicosis?
Jaundice
Failure to thrive
Irritability
Heart failure in severe cases
How do we treat pregnant patients with hyperthyroidism?
TFTs measured every trimester - assessed using pregnacy adjusted values
Anti-thyroid medications such as propylthiouracil (PTU) and carbimazole should be continued or started.
How does hyperthyroidism affect breast feeding?
Carbimazole should be avoided in breast feeding mothers. They should be switched to propylthiouracil (PTU).
What is thought to be the cause of obstetric cholestasis?
Cholestatic effects of oestrogen and progesterone
Genetic factors
What are the risk factors for developing obstetric cholestasis?
Family history Chilean descent (up to 5% compared to 0.5% in the UK)
What are the clinical features of obstetric cholestasis?
Common:
Itchy palms and soles of feet and abdomen
No rash (this is important) but excoriations from scratching
Itching often increases in the evening
Less common:
Jaundice
Darker urine
Lighter stools, that are harder to flush
Upper right quadrant pain
Vomiting
What investigations would you do in someone who presents with features of obstetric cholestasis?
LFTs - show raised ALT
Bile acids - raised
Rule out other causes of deranged LFTs such as doing hepatitis screen, hepatic autoimmune screen, liver ultrasound.
Occasionally patients have symptoms but normal LFTs. These patients should have regular blood tests.
How do we diagnose obstetric cholestasis?
It is a diagnosis of exclusion. All other causes of deranged LFTs and jaundice should be ruled out first.
How do we treat obstetric cholestasis?
Ursodeoxycholic acid for symptom control
Sedating anti-histamines such as chlorphenamine and promethazine can be used.
Aqueous skin gels can help itch
What supplements may be given to pregnant women with obstetric cholestasis if the LFTs are deranged?
Vitamin K supplementation should be provided for those with abnormal clotting, this is to try and reduce PPH
What are the risk associated with obstetric cholestasis?
Bile acid levels of more than 40 mmol/L are associated with:
Stillbirth
Preterm delivery
Passage of meconium
Fetal anoxia
How might a diagnosis of obstetric cholestasis change the management of labour and delivery?
Early induction of labour at 37/38 weeks may be considered on an individual basis.
What post-natal care is needed for someone who had obstetric cholestasis?
Ensure LFTs have normalised 10 days post-partum.
Warn patients of likelihood of recurrence in future pregnancy
Advised to avoid oestrogen containing contraceptive pill as these may trigger cholestasis.
What are the risk factors for acute fatty liver of pregnancy?
Primip
Carrying male fetus
Multiple pregnancy
What are the clinical features of acute fatty liver of pregnancy?
Nausea and vomiting
Anorexia
Malaise
Abdominal pain
Polyruria
Jaundice
Ascites
Encephalopathy
Mild proteinuric hypertension
What syndrome is acute fatty liver of pregnancy sometimes difficult to distinguish from?
HELLP syndrome (pre-eclampsia spectrum)
What would blood tests of someone with acute fatty liver of pregnancy show?
Raised ALT
Raised ALP
Raised bilirubin
Raised WCC
Hypoglycaemia
Raised uric acid
Coagulopathy
How do we treat people with acute fatty liver of pregnancy?
Stabilisation including correction of hypoglycaemia and coagulopathy and fluid resuscitation.
Followed by urgent delivery
When in pregnancy does acute fatty liver of pregnancy occur?
Third trimester
What are the complications of acute fatty liver of pregnancy if not treated?
Death
Is pregnancy a pro-thrombotic or anti-thrombotic state?
Pro-thrombotic
What makes pregnancy a pro-thrombotic state?
Increase in certain clotting factors
Increase in fibrinogen levels
Decrease in fibrinolytic activity
Decrease in protein S and antithrombin
Increased venous stasis in lower limbs (left more than right)
What are the risk factors for VTE in pregnancy?
Thrombophilia (Factor V Leiden, Protein C deficiency, antiphospholipid syndrome)
Age over 35
BMI over 30
Parity over 3
Smoker
Immobility eg surgery or disability
Gross varicose veins
Multiple pregnancy
Medical comorbidities
Systemic infection
How long after delivery does the risk of VTE remain elevated?
6 weeks
What prophylactic steps can be taken to avoid VTE in pregnant women?
LMWH if admitted to hospital or if high risk (eg thrombophilia)
Compression stockings if admitted to hospital or travelling
What prophylactic treatment do we give women who have had a caesarian section?
7 days of LMWH.
How might you investigate a suspected DVT in a pregnant lady?
Dopplers - remember that may be found higher than the calf. This is particularly true in pregnancy.
How might you investigate a suspected PE in a pregnant lady?
ECG - sinus tachy
ABG - hypoxia and hypercapnia or may reveal respiratory alkalosis
FBC - rules out anaemia
CXR - rules out other causes of breathlessness
What further investigations would you do in a pregnant lady with suspected PE if the chest x-ray was normal?
V/Q scan
What further investigations would you do in a pregnant lady with suspected PE if the chest x-ray was abnormal?
CTPA
What is the treatment for a pregnant women found to have a DVT or PE?
Therapeutic doses of LMWH
Do not use warfarin in a pregnant women as known to cross placenta and be teratogenic
What is the treatment for a puerperium women found to have a DVT or PE?
Therapeutic doses of LMWH can then be converted to warfarin. Warfarin is safe in breast feeding
At what point will pregnant women be screened for HIV?
At booking appointment
What is the risk of vertical transmission of HIV in an untreated HIV positive women?
25%
What is the risk of vertical transmission of HIV is a treated HIV positive women?
1%
What additional screening tests will be done in HIV positive women?
Hep C
Genital infections - screened in 1st trimester and at 28 weeks
Also offer Hep B vaccination
Screened for gestational diabetes as is a risk factor of HAART (Highly Active Anti-retroviral Treatment)
How should delivery and post natal care of a pregnant patient with HIV be adapted?
Avoid performing invasive procedures such as fetal blood sampling
If viral load is less than 50 copies/ml then vaginal delivery will not increase risk.
Planned caesarian section is offered though as in general it reduces risk of transmission
Those with a high viral load (above 50 copies/ml) will have planned caesarian section with zidovudine cover 4 hours prior to delivery and continued until cord is clamped.
Once delivered all neonates started on anti-retrovirals
Should not be breastfed
Regular tests of baby - negative at 18 months means definitely not affected.
What are the risk factors for depression during and after pregnancy?
History of post-natal depression
History of depression
IVF pregnancy
History of abuse
Multiple pregnancy
Drug misuse
Poor social support
Low SES
Low education
Poor pregnancy outcome eg illness, prematurity, stillbirth, neonatal death, congenital abnormality
What is the incidence of puerperal psychosis?
1 in every 500 births
When does puerperal psychosis usually start?
2 weeks postnatally
What are the features of puerperal psychosis?
Mania
Delusions
Hallucinations (both auditory and visual)
Agitation
Disinhibited behaviour
How do we treat patients with puerperal psychosis?
Admission to hospital for mother and baby to prevent separation.
Rule out organic cause
Anti-psychotic medication such as haloperidol.
Are anti-psychotic medications safe in pregnancy?
It is not fully known. In practice the lowest dose is used with a reduction in dose towards term to prevent toxicity in neonates.
Is breastfeeding on antipsychotics safe?
Most of them are fine. Clozapine is contraindicated.
What are the congenital abnormality associated with Lithium use in bipolar mothers?
Cardiac defects
What are the complications associated with maternal cocaine use during gestation?
Growth restriction
Placental abruption
Stillbirth
Neonatal death
What are the complications associated with maternal opioid abuse during gestation?
Growth restriction
Preterm labour
Neonatal dependence
What are the complications associated with smoking during pregnancy?
VTE
Growth restriction
Placental abruption
Cot death
Childhood asthma
What are the features of fetal alcohol syndrome?
Short palpebral fissure
Thin vermillion border/hypoplastic upper lip
Smooth/absent filtrum
Learning difficulties
Microcephaly
Growth retardation
Epicanthic folds
When in pregnancy do women tend to be affected by hyperemesis gravidarum?
Most common between 8 and 12 weeks gestation but may continue until 20 weeks
What percentage of pregnant women are affected by hyperemesis gravidarum?
1%
What is the cause of hyperemesis gravidarum?
Thought to be related to the raised levels of hCG.
What are the risk factors for hyperemesis gravidarum?
Multiple pregnancies
Trophoblastic disease
Hyperthyroidism
Nulliparity
Obesity
What is a recognised preventative factor for hyperemesis gravidarum that should not really be recommended by physicians?
Smoking
How do you manage hyperemesis gravidarum?
First line: Promethazine (anti-histamine)
Ginger and P6 (wrist) acupressure can also be tried
Admit and give fluids if showing signs of dehydration
What are the complications of hyperemesis gravidarum?
Wernicke’s encephalopathy
Mallory-Weiss tear
Central pontine myelinolysis
Acute tubular necrosis
Small for gestational age (SGA)
Pre-term birth
