medical disorders of pregnancy Flashcards
What are causes of maternal death?
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
what do woman with pre-excisting medical and mental health problems need?
pre-pregnancy advice
joint specialist and maternity care
what are some direct causes of of maternal death
thrombosis
haemorrhage
pre-eclampsia
what are some causes of indirect maternal death?
cardiac disease
neurological
psychiatric
malignancies
what are some pre-existing medical disorders that affect pregnancy
asthma epilepsy hypertension diabetes thyroid renal cardiac SLE/RA
what are some pregnancy specific medical disorders in pregnancy?
pre-eclampsia thromboembolism GDM obstetric cholestasis acute fatty liver
what are some physiological changes in pregnancy?
Cardiac Respiratory Renal Hepatic Endocrine
what steps are taken pre-pregnancy for woman with exciting conditions?
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
what effect can pregnancy have on the existing medical condition?
May cause medical condition to worsen eg mitral stenosis
Some conditions improve in pregnancy eg rheumatoid arthritis
what effects can medical conditions have on the mother and baby?
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
what steps are taken for delivery and postpartum care in woman with medical conditions?
"Safest” mode of delivery Neonatal support Anaesthetic expertise HDU/ITU facilities Ongoing care postpartum – maternal condition may initially deteriorate
What is iron deficiency associated with during pregnancy?
Iron deficiency is the commonest anaemia followed by folate deficiency
Iron deficiency is associated with low birthweight and preterm delivery
is anaemia common during pregnancy?
Pregnancy is associated with a 2-3 fold increase in requirement for iron and a 10-20 fold increase in folate requirements
what is the respiratory physiology during pregnancy?
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
when are the main risk of asthma during pregnancy?
Risk of exacerbation especially in 3rd trimester
what affects does asthma have on the fetus?
Risk of fetal growth restriction due to inadequate placental perfusion
Premature delivery - usually due to deterioration in maternal condition
what drugs for asthma can be used in pregnancy?
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
cardiac physiological changes during pregnancy?
Cardiac output rises by 40% mainly due to increased stroke volume (CO=SV x HR)
what is the leading cause of maternal death?
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
what are low risk cardiac lesions during pregnancy?
Mitral incompetence
Aortic incompetence
ASD
VSD
what are high risk cardiac lesions during pregnancy?
Aortic stenosis
Coarctation of aorta
Prosthetic valves
Cyanosed patients
what care during pregnancy and postpartum do woman with cardiac disease need?
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
what is the comments liver disease during pregnancy?
obstetric cholestasis
what does obstetric cholestasis present with?
what would tests show?
Presents with itching – no rash
Abnormal liver function (raised AST, ALT and bile acid)
how is obstetric cholestasis resolved?
what is the risk of recurrence?
Resolves after delivery
Recurrence risk is >80%
what risks are associated risks with obstetric cholestasis?
Risk of fetal complications (notably stillbirth and premature labour) is thought to relate to the level of bile acid.
what treatment can be given to reduce fetal complications of obstetric cholestasis?
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)
hyperthyroidism in pregnancy?
maternal risks?
fetal/neonatal risks?
treatment?
monitoring?
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
Hypothyroidism during pregnancy
It is common
Untreated – early fetal loss and impaired neurodevelopment
Aim for adequate replacement with thyroxine especially in 1st trimester
gestational diabetes
Gestational diabetes – carbohydrate intolerance first recognised in pregnancy – risk of developing type 2 diabetes within 10-15 years
what needs to be done for woman with diabetes pre-conception?
HbA 1c < 48 mmol/l Folic acid 5 mg Stop ACE inhibitors and statins Retinal screening Renal function and microalbuminuria
maternal risks with diabetes during pregnancy?
Maternal risks Diabetic ketoacidosis Hypoglycaemia (common) Progression of retinopathy Pre-eclampsia Premature labour
fetal/neonatal risk associated with diabetes during pregnancy?
Fetal/Neonatal risks Miscarriage Macrosomia, shoulder dystocia Fetal abnormality Stillbirth Neonatal hypoglyaemia, respiratory distress, hypocalcaemia, polycycaemia
what are the most fatal complications of diabetes during pregnancy though to be related to?
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
what drugs can be used for diabetes during pregnancy?
Insulin – basal bolus regime
Metformin
Glibenclamide
( All other hypoglycaemics are contraindicated)
Statins and ACE inhibitors are contraindicated.
what physiological changes are there to rent system during pregnancy?
Pregnancy with healthy kidneys is associated with a 50% increase in renal blood flow and GFR.
what are maternal risks associated with chronic renal disease?
Maternal risks Severe hypertension Deterioration in renal function Pre-eclampsia Caesarean section
what are the fetal/neonatal risk associated with chronic renal disease?
Fetal/Neonatal risks: Premature delivery Growth restriction Stillbirth Abnormalities due to maternal drug therapy
what do the outcomes of chronic renal disease during pregnancy depend upon?
Outcome mainly depends on degree of renal dysfunction, maternal blood pressure, creatinine level and proteinuria.
what is needed pre- and during pregnancy for woman with chronic renal disease?
Risk assessment pre-pregnancy, multidisciplinary care, close monitoring of renal function and Bp during pregnancy and regular assessment of fetal growth and wellbeing.
neurological disorders that affect pregnancy?
migraine epilepsy MS eclampsia cerebral vein thrombosis myasthenia graves malignant brain tumour
maternal risks of epilepsy during pregnancy
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
fetal/neonatal risk of epilepsy during pregnancy
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
management of epilepsy during pregnancy
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
thromboembolism during pregnancy?
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
what to do if thromboembolism suspected during pregnancy?
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)
