Medical disorders in pregnancy Flashcards
What are common conditions seen in women of reproductive age?
- Asthma
- Diabetes
- Epilepsy
- Cardiac Disease
- UTI
What medications should not be started in a pregnant woman for treatment of asthma?
Leukotriene receptor antagonists
What measures should be taken pre-conception in a woman with epilepsy?
- Folic acid 5mg for >3 months prior
- Optimise treatment - avoid ppolypharmacy
What are other causes of seizures during pregnancy beside epilepsy?
- Pre-eclampsia
- Cerebral venous thrombosis
- Intracranial mass
- Stroke
- Hypoglycaemia
- Migraine
- Hyponatraemia
- Drugs/Withdrawal
- Infection
- Postdural puncture
- Pseudoseizures
What epileptic medication has highest risk of foetal abnormality associated with it?
Sodium valproate
When should a pregnant woman with epilepsy be started on Vit K in the last 4 weeks of pregnancy, and why?
If on following antiepileptic drugs - All enzyme inducers - clotting factors may be reduced in the newborn
- Carbemazepine
- Phenytoin
- Primidone
- Phenobarbitol
- Ethosuximide
When is fitting in labour indicative for a C-section?
Only if in status epilepticus - otherwise
Should you continue anti-epileptic drugs during labour?
Yes
Are epidurals safe in epileptic women going through labour?
Yes
How would you manage seizures during labour that were not self-limiting?
Benzodiazepines - lorazepam, diazepam
Why are seizures in epilptic pregnant women common intrapartum and postpartum?
- Sleep deprivation
- Reduced drug efficacy - increased volume of distribution, increased serum binding
- Hyperventilation
- Hormonal changes
- Nausea and vomiting
Why would you give vitamin K to a child post birth?
To reduce risk of haemorrhagic disease of the newborn
What might you have to do with the dose of oral contraception in post natal epileptic women if they are on enzyme inducing drugs?
Increase dose of oral contraceptive
What cardiopulmonary disease carries a high risk of mortality in pregnant women?
Pulmonary hypertension
What might you think of if you saw sinus tachycardia in a pregnant woman?
- Anxiety
- Anaemia
- Hyperthyroidism
- Infection
- Hypovolaemia
What psychiatric medication should be avoided in pregnany?
- Valproate
- Carbemazepine
- Paroxetine - 1st trimester
- Lithium
- Benzodiazepines
What is gestational diabetes?
Diabetes which develops during pregnancy which reverts to normal after pregnancy
What are risk factors for gestational diabetes?
- BMI > 30
- Previous macrosomic baby
- Previous GDM
- FH of diabetes
- High risk groups - asian origin
- Previous polyhydramnios
Why can insulin requirements of pregnant type I/type II diabetics increase?
Increase in:
- Human plcaental lactogen
- Progesterone
- B-HCG
- Cortisol
Why can foetal hyperinsulinaemia occur in pregnancy of diabetic women?
Maternal glucose crosses the placenta and induces increased insulin production in the foetus -> Causes macrosomia
What complications are those who have type I/II diabetes at risk of during pregnancy?
- Foetal congenital abnormalities - especially if blood sugars high peri-conception
- Miscarriage
- Pre-eclampsia
- Macrosomia
- Polyhydramios
- Operative delivery
- Shoulder dystocia
- Worsening maternal nephropathy, retinopathy, hypoglycaemia, reduced awareness of hypoglycaemia
- Infections
- Stillbirth
- Neonatal - impaired maturity, neonatal hypoglycaemia, jaundice
Complications of diabetes in pregnancy
- Shoulder dystocia
- Macrosoma
- Amniotic fluid excess
- Stillbirth
- Hypertension and neonatal hypoglycaemia
What measures would you take preconception when managing someone who wants to get pregnant and has diabetes?
Better glycaemic control
- 4-7mmol/l pre-conception
- HbA1c <6.1% (<43 mmol/mol)
- Folic acid 5mg
- Dietary advice/Weight reduction
- Retinal assessment
- Renal assessment
What antenatal measures would you want to take during pregnancy when managing a diabetic woman?
- Aim to stay normoglycaemic
- Increase BM monitoring - Provide kits for hypo’s
- Detailed scan at 18-20 weeks - look for foetal abnormality
- Insulin increase - can be 50-100%, but may need to decrease towards end
- Monitor foetal growth
- Regular U+E’s, MSSU, HbA1c, Eye exam
- Aim for tight control
What are the cut-offs for the following in diabetic control in pregnancy:
- Fasting glucose
- Post - Prandial glucose
- Before bedtime
- Fasting - <5.3 mmol/L
- Post-prandial - < 7.8mmol/L
- Before bedtime - < 6mmol/L
Can metformin be used in pregnancy?
Yes
When is labour usually induced in diabetes?
38-40 weeks
How would you control blood sugar in gestational diabetes?
- Diet
- Metformin/insulin
Is a new onset Ejection systolic murmur normal in pregnancy?
Yes - 96% of women develop it
What post-natal measures should you take with someone with GDM?
Do OGTT 6 weeks post-delivery
What CNS problem can sodium valproate cause?
Neural tube defect
What ENT problem can phenytoin cause?
Cleft lip/palate
What cardiovascular problem can phenytoin/sodium valproate cause?
VSD
How would you manage someone who is epileptic who wanted to get pregnant (e.g. pre-conception advice etc.)?
- Assess epilepsy
- Change from poly to monotherapy
- Smallest possible dose
- High dose folate
- Advise strongly against stopping AED without medical advise
What are the most commonly recommended forms of contraception in someone with epilepsy?
- Barrier
- IUD
Why might oral contraceptives be less effective in someone with epilepsy?
Many AEDs induce liver enzymes, leading to rapid clearence of steroid hormones and allow ovulation in women taking OCP or other hormonal forms of birth control
What epileptic drugs drugs have an anti-folate effect on the foetus?
- Phenytoins
- Carbemazepines
- Barbituates
What endocrine disorder can normal pregnancy mimic?
Hyperthyroidism
What changes occur in thyroid physiology during pregnancy?
- Thyroid binding globulin + T4 output rise to maintain free t4 levels
- High levels of HCG mimic TSH
- Redued iodine availibility - increased urinary excretion and active transport to feto-placental unit
- T3/T4 increased
Why might TSH fall below normal in first trimester?
Suppressed by BHCG
What might happen to symptoms of hyperthyroidism in someone who is pregnant?
May improve as it can be autoimmune cause - autoimmune disorder tend to improve in pregnancy as it is an immunosuppressed state
What problems can hyperthyroidism cause in pregnancy?
- Risk of miscarriage
- IUGR
- Thyroid storm
- Preterm labour
How would you manage hyperthyroidism in pregnancy?
- Propylthiouracil
- Carbimazole
- Beta blockers - symptom control
What problems can severe hypothyroidism cause?
- Misscarriage
- Foetal loss
- IUGR
What foetal congenital abnormalities can occur in diabetes?
- Sacral agenesis
- Congenital heart disease
- Neural tube defects
What is important in terms of manage the neonate following delivery of a baby with diabetes?
Early feeding and regular BMs - risk of hypoglycaemia
Why does polyhydramnios occur in pregnant women with diabetes?
Causes fetal hyperglycemia and resulting polyuria (fetal urine is a major source of amniotic fluid).
How would you manage blood sugars during labour?
Sliding scale of insulin
What scans would you do in someone who had type I/II diabetes?
- First visit
- Detailed
- Cardiac Scan
- Growth scan
What complications can occur as a result of polyhydramnios?
- Cord prolapse
- Placental abruption
- Malpresentation of baby
- Preterm birth
If a pregnant woman was found to be on sodium valproate at 12 weeks, what advise would you give them?
Delicately say there is no point in changing meds, as most important period is within first 12 weeks, and risks of complications from changing meds then outweigh risks to the baby
