medical disorders of pregnancy

Question 1

What are causes of maternal death?

Answer 1

Two thirds of mothers died from medical and mental health problems during pregnancy (cardiac disease, neurological, psychiatric, cancer etc)

one third died from direct complications of pregnancy such a bleeding, thrombosis, pre eclampsia

Question 2

what do woman with pre-excisting medical and mental health problems need?

Answer 2

pre-pregnancy advice

joint specialist and maternity care

Question 3

what are some direct causes of of maternal death

Answer 3

thrombosis
haemorrhage
pre-eclampsia

Question 4

what are some causes of indirect maternal death?

Answer 4

cardiac disease
neurological
psychiatric
malignancies

Question 5

what are some pre-existing medical disorders that affect pregnancy

Answer 5

asthma
epilepsy 
hypertension 
diabetes 
thyroid
renal 
cardiac SLE/RA

Question 6

what are some pregnancy specific medical disorders in pregnancy?

Answer 6

pre-eclampsia 
thromboembolism 
GDM 
obstetric cholestasis
acute fatty liver

Question 7

what are some physiological changes in pregnancy?

Answer 7

Cardiac
Respiratory
Renal
Hepatic
Endocrine

Question 8

what steps are taken pre-pregnancy for woman with exciting conditions?

Answer 8

Optimise disease control, defer pregnancy until medical condition is stable
Rationalise drug therapy to minimise effects on baby – alter medication to drugs “safe” in pregnancy
Advise on risks to mum and baby
Agree a plan of care – multidisciplinary
Effective contraception until ready to conceive

Question 9

what effect can pregnancy have on the existing medical condition?

Answer 9

May cause medical condition to worsen eg mitral stenosis

Some conditions improve in pregnancy eg rheumatoid arthritis

Question 10

what effects can medical conditions have on the mother and baby?

Answer 10

May increase the risk of pregnancy complications eg essential hypertension is associated with risk of superimposed pre-eclampsia

May have detrimental effects on the baby either directly eg teratogenetic drug effects, or indirectly due eg premature delivery

Question 11

what steps are taken for delivery and postpartum care in woman with medical conditions?

Answer 11

"Safest” mode of delivery
Neonatal support
Anaesthetic expertise
HDU/ITU facilities
Ongoing care postpartum – maternal condition may initially deteriorate

Question 12

What is iron deficiency associated with during pregnancy?

Answer 12

Iron deficiency is the commonest anaemia followed by folate deficiency
Iron deficiency is associated with low birthweight and preterm delivery

Question 13

is anaemia common during pregnancy?

Answer 13

Pregnancy is associated with a 2-3 fold increase in requirement for iron and a 10-20 fold increase in folate requirements

Question 14

what is the respiratory physiology during pregnancy?

Answer 14

Increased metabolic rate and 20% increase in O2 consumption
Minute ventilation increases due to increase in tidal volume - respiratory rate unchanged
Arterial pO2 increases and pCO2 decreases
Mild compensated respiratory alkalosis is normal in pregnancy

Question 15

when are the main risk of asthma during pregnancy?

Answer 15

Risk of exacerbation especially in 3rd trimester

Question 16

what affects does asthma have on the fetus?

Answer 16

Risk of fetal growth restriction due to inadequate placental perfusion
Premature delivery - usually due to deterioration in maternal condition

Question 17

what drugs for asthma can be used in pregnancy?

Answer 17

Short acting beta 2 agonist, long acting beta 2 agonist can be used in pregnancy
Inhaled steroids can be used in pregnancy
Theophyllines can be used
Steroid tablets can be used in severe asthma
Leukotriene anatogonist can be used

Question 18

cardiac physiological changes during pregnancy?

Answer 18

Cardiac output rises by 40% mainly due to increased stroke volume (CO=SV x HR)

Question 19

what is the leading cause of maternal death?

Answer 19

Cardiac disease has been the leading cause of maternal death in UK since 2003
Ischaemic heart disease,
In younger women -Congenital heart disease
Joint care with a cardiologist – ideally with pre-pregnancy assessment

Question 20

what are low risk cardiac lesions during pregnancy?

Answer 20

Mitral incompetence
Aortic incompetence
ASD
VSD

Question 21

what are high risk cardiac lesions during pregnancy?

Answer 21

Aortic stenosis
Coarctation of aorta
Prosthetic valves
Cyanosed patients

Question 22

what care during pregnancy and postpartum do woman with cardiac disease need?

Answer 22

Prediction and prevention of heart failure – Echo/ECG
Anticoagulation – mechanical heart valves
Drug therapy – need to alter/add medication
Monitor fetal growth and wellbeing - scan
Timing and mode of delivery -
Postpartum complications – cardiac failure

Question 23

what is the comments liver disease during pregnancy?

Answer 23

obstetric cholestasis

Question 24

what does obstetric cholestasis present with?

what would tests show?

Answer 24

Presents with itching – no rash

Abnormal liver function (raised AST, ALT and bile acid)

Question 25

how is obstetric cholestasis resolved?

what is the risk of recurrence?

Answer 25

Resolves after delivery

Recurrence risk is >80%

Question 26

what risks are associated risks with obstetric cholestasis?

Answer 26

Risk of fetal complications (notably stillbirth and premature labour) is thought to relate to the level of bile acid.

Question 27

what treatment can be given to reduce fetal complications of obstetric cholestasis?

Answer 27

Treatment with ursodeoxycolic acid has not been shown to reduce fetal complications although it appears to be associated with improved biochemical abnormalities (bile acid level and liver function tests)

Question 28

hyperthyroidism in pregnancy?

maternal risks?
fetal/neonatal risks?

treatment?
monitoring?

Answer 28

Often improves in pregnancy after 1st trimester
Maternal risk – thyroid crisis with cardiac failure
Fetal/neonatal risk – thyrotoxicosis due to transfer of thyroid stimulating antibodies

Antithyroid drugs - Propylthiouracil (maternal liver failure) cf carbimazole (fetal abnormalities)
If mother has stimulating antibodies monitor fetal growth with ultrasound

Question 29

Hypothyroidism during pregnancy

Answer 29

It is common

Untreated – early fetal loss and impaired neurodevelopment

Aim for adequate replacement with thyroxine especially in 1st trimester

Question 30

gestational diabetes

Answer 30

Gestational diabetes – carbohydrate intolerance first recognised in pregnancy – risk of developing type 2 diabetes within 10-15 years

Question 31

what needs to be done for woman with diabetes pre-conception?

Answer 31

HbA 1c < 48 mmol/l
Folic acid 5 mg
Stop ACE inhibitors and statins
Retinal screening
Renal function and microalbuminuria

Question 32

maternal risks with diabetes during pregnancy?

Answer 32

Maternal risks 
Diabetic ketoacidosis
Hypoglycaemia (common)
Progression of retinopathy  
Pre-eclampsia
Premature labour

Question 33

fetal/neonatal risk associated with diabetes during pregnancy?

Answer 33

Fetal/Neonatal risks 
Miscarriage
Macrosomia, shoulder dystocia
Fetal abnormality
Stillbirth
Neonatal hypoglyaemia, respiratory distress, hypocalcaemia, polycycaemia

Question 34

what are the most fatal complications of diabetes during pregnancy though to be related to?

Answer 34

Most fetal complications are thought to relate to maternal hyperglycaemia, excessive glucose transfer across the placenta and secondary fetal hyperinsulinaemia
Key to optimising outcome is good glycaemic control from conception
Cause of late stillbirth

Question 35

what drugs can be used for diabetes during pregnancy?

Answer 35

Insulin – basal bolus regime
Metformin
Glibenclamide
( All other hypoglycaemics are contraindicated)
Statins and ACE inhibitors are contraindicated.

Question 36

what physiological changes are there to rent system during pregnancy?

Answer 36

Pregnancy with healthy kidneys is associated with a 50% increase in renal blood flow and GFR.

Question 37

what are maternal risks associated with chronic renal disease?

Answer 37

Maternal risks
Severe hypertension
Deterioration in renal function
Pre-eclampsia 
Caesarean section

Question 38

what are the fetal/neonatal risk associated with chronic renal disease?

Answer 38

Fetal/Neonatal risks:
Premature delivery
Growth restriction
Stillbirth
Abnormalities due to maternal drug therapy

Question 39

what do the outcomes of chronic renal disease during pregnancy depend upon?

Answer 39

Outcome mainly depends on degree of renal dysfunction, maternal blood pressure, creatinine level and proteinuria.

Question 40

what is needed pre- and during pregnancy for woman with chronic renal disease?

Answer 40

Risk assessment pre-pregnancy, multidisciplinary care, close monitoring of renal function and Bp during pregnancy and regular assessment of fetal growth and wellbeing.

Question 41

neurological disorders that affect pregnancy?

Answer 41

migraine
epilepsy 
MS
eclampsia
cerebral vein thrombosis 
myasthenia graves 
malignant brain tumour

Question 42

maternal risks of epilepsy during pregnancy

Answer 42

Increase in seizure frequency – 25-33%
Sudden Unexpected Death in Epilepsy (SUDEP) occurs in about 1 in 500-1000 people with epilepsy).
SUDEP is more common in patients who do not take their prescribed anticonvulsants. Pregnant and breastfeeding women are often reluctant to take anticonvulsants for fear of harming their baby

Question 43

fetal/neonatal risk of epilepsy during pregnancy

Answer 43

Fetal/Neonatal abnormality - epilepsy is associated with a risk of fetal abnormality - mainly due to anticonvulsant medication, may also be due to epilepsy itself
All anticonvulsants are associated with a risk of fetal abnormalities – Sodium Valporate has the highest risk - 7-9%
Inheritance of epilepsy
Risk of fetal hypoxia associated with maternal seizures

Question 44

management of epilepsy during pregnancy

Answer 44

Preconception assessment – offer high dose folic acid and determine if medication required or if it can be rationalised?
Once pregnant - offer screening for fetal anomalies
Control seizures
Plan for delivery – pain relief, avoid prolonged labour
Postpartum support

Question 45

thromboembolism during pregnancy?

Answer 45

Major cause of maternal death in UK
Risk factors include maternal age, BMI and operative delivery
Haematological changes in pregnancy predispose to VTE
Recent NICE & Dept of Health thromboprophylaxis guidelines

Question 46

what to do if thromboembolism suspected during pregnancy?

Answer 46

If suspect DVT/PE investigate
Investigation of DVT – doppler ultrasound
Investigation of PE – VQ scan or CTPA
LMWH treatment of choice for VTE in pregnancy (warfarin crosses the placenta and may cause fetal abnormalities and intracranial bleeding)