Medical disorders of pregnancy Flashcards
What are the general principles of medical disorders in pregnancy
Pregnant women more predisposed to acute medical problems
Chronic medical problems can worsen/flare in pregnancy
What are the causes of maternal deaths
Direct, indirect, late, coincidental
2/3 indirect, 1/3 direct
What pre-existing conditions are worsened by pregnancy
Asthma, epilepsy, hypertension, diabetes, thyroid, renal, lupus, arthritis
What are pregnancy specific medical conditions
Pre-eclampsia, thromboembolism, gestational diabetes, obstetric cholestasis, acute fatty liver
How are medical disorders managed in pregnancy
Be aware of normal physiological changes
Preconceptual counselling
Pregnancy-safe medication or contraception until ready to conceive
Assess effects of pregnancy on medial condition + effects of medical condition on pregnancy
Decide safest mode of delivery
How is essential hypertension managed in pregnancy
Pregnancy-safe medication
Risk of superimposed preeclampsia- aspirin to reduce risk
Serial growth scans to monitor risk of poor placental function
Possible early delivery
What are the pathophysiological processes underlying preeclampsia
Genetic predisposition Inadequate trophoblast invasion of spiral arteries Reduced uteroplacental perfusion Placental damage + apoptosis Release of circulating factors Endothelial cell dysfunction
What are the symptoms of preeclampsia
Headache, visual disturbance, epigastric/liver pain, vomiting
Brisk refleces, clonus, oedema
What are the complications of preeclampsia
Renal failure, pulmonary oedema, eclampsia, HELLP syndrome
How is preeclampsia treated
Antihypertensives- Labetalol, Nifedipine, Methyldopa
Fluid restriction
Diuretics if pulmonary oedema
MgSO4
What haematological conditions occur in pregnancy
Anaemia- iron deficiency, folate deficiency, associated with LBW, prematurity
Thrombophilia- major cause of maternal death, pregnancy = prothrombotic state. Manage anticoagulation around deliveru
Venous thromboembolism, bleeding disorders, thrombocytopenia
What respiratory conditions occur in pregnancy
Asthma- optimise control pre-pregnancy, pregnancy safe medication. Risk of FGR due to inadequate placental perfusion, prematurity due to deterioration in maternal condition
Treat with short or long acting beta 2 agonists, inhaled steroids, theophyllines, steroid tablets, Leukotriene antagonist
What are low risk cardiac disease conditions
Mitral regurg, Aortic regurge, ASD, VSD
What are high risk cardiac disease conditions
Aortic stenosis
Coarctation of aorta
Metallic valves
Cyanosis
How is cardiac disease managed during pregnancy
Prepregnancy- assess risk of complications, ensure safe medication
Predict + prevent heart failure using echo/ECG
Anticoagulation with mechanical heart valves
Monitor fetal growth + wellbeing
Timing + mode of delivery
What is obstetric cholestasis
Most common liver disease in pregnancy Genetic predisposition Presents with itching but no rash Abnormal liver function Resolves after delivery Risk of fetal complications related to level of bile acids Risk of recurrence >80% Treatment- Ursodeoxycolic acid. Doesnt reduce fetal complications but improved biochemical abnormalities
What is hyperthyroidism
Uncommon
Maternal risk of thyroid crisis with cardiac failure
Medication- Propylthiouracil for maternal liver fialure, Carbimazole for fetal abnormalities
What is hypothyroidism
Common
Untreated can cause miscarriage and impaired neurodevelopment
Aim for adequate thyroxine replacement in 1st trimester
How is diabetes managed preconception
HbA, Folic acid 5mg
Stop ACE inhibitors and statins
Retinal screening
Renal function + microalbuminuria
What are the maternal risks of diabetes
Diabetic ketoacidosis Hypoglycaemia Progression of retinopathy Preeclampsia Premature labour
What are the fetal/neonatal risks of diabetes
Miscarriage Macrosomia, shoulder dystocia Fetal abnormality Stillbirth Neonatal hypoglycaemia, respiratory distress, hypeocalcaemia
Why does maternal diabetes affect fetus
Maternal hyperglycaemia causes excessive glucose transfer across placenta, secondary fetal hyperinsulinaemia
How can maternal diabetes be treated
Insulin- Basal bolus regime, carbohydrate counting, insulin pump
Metformin
Glibenclamide
How does renal disease occur in pregnancy
In healthy kidneys pregnancy causes 50% increase in renal blood flow + GFR
Serum creatinine, urate + albumin fall
Pelvicalyceal system + ureters dilate, predisposition to ascending infection + pyelonephritis
What are the maternal risks of renal disease
Severe hypertension, deterioration in renal function, preeclampsia, caesarean section
What are the fetal risk of renal disease
Premature delivery, growth restriction, stillbirth, abnormalities due to maternal drug therapy
Outcome depends on degree of renal dysfunction, maternal blood pressure, creatinine level, proteinuria
What is the antenatal care for renal disease
Risk assessment pre pregnancy
Multidisciplinary care
Close monitoring of renal function + BP
Regular assessment of fetal growth
How does pregnancy affect neuroendocrine disorders
Epilepsy- increase in seizure frequency 25-33%
SUDEP 1/500-1000 people. More common when not taking anticonvulsants- sometimes avoided in pregnancy
Anticonvulsants associated with risk of fetal abnormalities
What are the safest anitconvulsant medications
Keppra
Lamotrigine
Cabemezipine
(sodium valproate highest risk)
How is epilepsy managed in pregnancy
Proconception assessment Screening for fetal anomalies Control seizures Plan for delivery Postpartum support
What effect does epilepsy have on fetus
Hypoxia associated with maternal seizures
Injury from falling
