Medical problems in pregnancy Flashcards
Pre-eclampsia
One of several hypertensive disorders that can occur during pregnancy
Placental disease, affects up to 5% of women in their first pregnancy
Most severe form → catastrophic maternal and/or fetal compromise
Pre-eclampsia pathophysiology
Abnormal placentation
Pre-eclampsia → remodelling of spiral arteries in incomplete; high resistance, low-flow uteroplacental circulation develops, as the constrictive muscular walls of the spiral arterioles are maintained
- increase in BP, combined with hypoxia and oxidative stress from inadequate uteroplacental perfusion → systemic inflammatory response & endothelial cell dysfunction
Pre-eclampsia risk factors
Moderate
- nuliparity
- maternal age > 40
- maternal BMI > 35 at initial presentation
- FHx
- pregnancy interval > 10 years
- multiple pregnancy
High
- chronic HTN
- HTN, pre-eclampsia or eclampsia in previous pregnancy
- pre-existing CKD
- DM
- autoimmune diseases eg. SLE, antiphospholipid syndrome
Prophylaxis with aspirin 150mg a day for women with 1 high risk factor or > 2 moderate risk factors; continued from 12 weeks until birth
Pre-eclampsia criteria
Three criteria:
1) HTN (systolic BP > 140 mmHg or diastolic BP > 90 mmHg), on two occasions at least 4 hours apart
2) significant proteinuria - >300mg protein in a 24 hours urine sample or > 30mg/mmol urinary protein:creatinine
3) women > 20 weeks gestation
Pre-eclampsia clinical features
Asymptomatic
Headaches (frontal)
Visual disturbances - blurred/double vision, halos, flashing lights
Epigastric pain (due to hepatic capsule distension/infarction)
Sudden onset non-dependent oedema
Hyper-reflexia
Pre-eclampsia ix
Urine dipstick
BP
FBC - decreased Hb, decreased platelets
U&Es - increased urea, increased creatinine, increased urate & decreased urine output
LFTs - increased ALT, AST
Pre-eclampsia differential diagnosis
Essential HTN - HTN prior to 20 weeks’ gestation
Pregnancy induced HTN - new onset HTN presenting after 20 weeks’ gestation, without significant proteinuria
Eclampsia - pre-eclampsia + seizure → emergency
Pre-eclampsia mx
Monitoring of maternal & fetal wellbeing → BP, urinalysis, blood tests, fetal growth scans & CTG
VTE prevention - LMWH
Antihypertensives - labetalol (avoid in asthma + diabetes), nifedipine, methyldopa
Delivery → only definitive cure
Pre-eclampsia postnatal care
Pre-eclampsia resolves following delivery of the placenta
Important to monitor mother for at least 24 hours post-partum → still at risk of having eclamptic seizures
BP should be monitored daily for the first 2 days post-partum & at least once 3-5 days after
Advised about risk of developing pregnancy-induced HTN & pre-eclampsia in subsequent pregnancies
Pre-eclampsia complications
Maternal
- HELLP - haemolysis, elevated liver enzymes, low platelets
- eclampsia
- AKI
- DIC
- ARDS
- HTN
- cerebrovascular haemorrhage
- death
Fetal
- prematurity
- intrauterine growth restriction
- placental abruption
- intrauterine fetal death
Obstetric cholestasis
Characterised by the reduced outflow of bile acids from the liver
Condition resolves after delivery of the baby
Obstetric cholestasis clinical features
Typically present later, particularly in third trimester
Pruritis, particularly affecting the palms of the hands & soles of the feet
Other symptoms: fatigue, dark urine, pale & greasy stools, jaundice
No rash
Obstetric cholestasis differentials
Gallstones
Acute fatty liver
Autoimmune hepatitis
Viral hepatitis
Obstetric cholestasis ix
LFTs & bile acids
- abnormal LFTs, mainly ALT, AST & GGT
- raised bile acids
Obstetric cholestasis mx
Symptomatic management of itching:
- ursodeoxycholic acid
- antihistamine
- calamine lotion
Neonatal vitamin K & maternal vitamin K → if clotting deranged
Weekly LFTs & bile acids
Gestational diabetes
Any degree of glucose intolerance with onset or first recognition during pregnancy
Gestational diabetes risk factors
BMI > 30
Asian ethnicity
Previous gestational diabetes
1st degree relative with diabetes
PCOS
Previous macrosomic baby (>4.5kg)
Gestational diabetes fetal complications
Macrosomia
Organomegaly - particularly cardiomegaly
Erythropoiesis - polycythaemia
Polyhydramnios
Increased rates of pre-term delivery
Increased risk of hypoglycaemia
Increased risk of transient tachypnoea → high insulin can cause a reduction in pulmonary phospholipids
Gestational diabetes ix
Oral glucose tolerance test
- fasting glucose > 5.6
- 2hrs postprandial glucose > 7.8
OGTT offered:
- booking - if previous GDM
- 24-28 weeks - RFs present or previous GDM
- any point in pregnancy - 2+ glycosuria on one occasion, 1+ on two occasions
Gestational diabetes mx
Lifestyle advice given regarding diet and exercise
Medication:
- metformin
- glibenclamide - if metformin not tolerated & insulin declined
- insulin - consider started if fasting glucose > 7
Consultant led care, additional growth scans at 28, 32 & 36 weeks
Aim to deliver at 37-38 weeks if on treatment
Gestational diabetes postnatal care
All medication stopped after delivery
6-13 weeks post-partum, a fasting glucose test recommended; yearly tests offered if normal to check for diabetes
In subsequent pregnancies → OGTT offered at booking & at 24-28 weeks gestation
Asthma in pregnancy
Medicines used to treat asthma are safe in pregnancy → includes reliever inhalers, preventer inhalers, long-acting & combined relievers, theophylline & steroid tablets
Still taking steroid tablets when go into labour → v important these are not stopped suddenly → make sure continued in labour
Epilepsy in pregnancy
Should take folic acid 5mg daily from before conception
Ideally, epilepsy should be controlled with a single anti-epileptic drug before becoming pregnant
Levetiracetam, lamotrigine and carbamazepine are safer anti-epileptic medications in pregnancy
Existing HTN in pregnancy
Existing HTN → may need changing to current medications
Need to be stopped:
- ACE inhibitors
- ARBs
- thiazide & thiazide-like diuretics
Not known to be harmful:
- labetalol
- CCBs eg. nifedipine
- alpha-blockers e.g. doxazosin
Rubella mx in pregnancy
<12 weeks - high likelihood of defects, reasonable to consider a TOP
12-20 weeks - prenatal diagnosis of fetal rubella infection required
- if confirmed → TOP or USS surveillance to identify features of congenital rubella syndrome
> 20 weeks - no action required
Congenital rubella syndrome
Neonatal manifestation of infection with the rubella virus during pregnancy
Present at birth - auditory problems (sensorineural deafness), cardiac defects, ophthalmic defects, CNS abnormalities, haematological
Late onset - diabetes mellitus, thyroiditis, growth hormone abnormalities, behavioural disorders
CMV in pregnancy
Most cases of CMV in pregnancy do not cause congenital CMV
Features of congenital CMV:
- fetal growth restriction
- microcephaly
- hearing loss
- vision loss
- LD
- seizures
Parvovirus in pregnancy
Can lead to several complications, particularly in the first & second trimesters
Complications: miscarriage/fetal death, severe fetal anaemia, hydrops fetalis, maternal pre-eclampsia-like syndrome
Ix - IgM, IgG, rubella antibodies
Mx - supportive, referral to fetal medicine to monitor for complications & malformations
Chickenpox in pregnancy
Exposure to chickenpox in pregnancy
- previously had chickenpox → safe
- not sure → test VZV IgG levels, if positive = safe
- not immune → treated with IV varicella immunoglobulins → 10 days within exposure
Chickenpox rash in pregnancy can be treated with oral aciclovir if present within 24 hours & > 20 weeks gestation
Congenital varicella syndrome
Occurs when infection occurs in first 28 weeks of gestation
Typical features
- fetal growth restriction
- microcephaly, hydrocephalus & LD
- scars and significant skin changes located in specific dermatomes
- limb hypoplasia
- chorioretinitis → cataracts and inflammation in the eye
Syphilis in pregnancy
Offered antenatal screening at booking
Has potential to cross the placenta/infect the baby during delivery
Important to treat pregnant women early
Untreated → miscarriage, stillbirth, pre-term labour or congenital syphilis (saddle nose, rashes, fever & failure to gain weight)
Zika in pregnancy
Can lead to congenital Zika syndrome:
- microcephaly
- fetal growth restriction
- other intracranial abnormalities → ventriculomegaly & cerebellar atrophy
Ix - viral PCR & antibodies to Zika virus
Mx - no treatment, referral to fetal medicine for close monitoring
HIV in pregnancy
Viral load determines the mode of delivery:
- under 50 copies = normal vaginal delivery
- over 50 copies = consider a pre-labour CS
- over 400 copies = pre-labour CS recommended
IV zidovudine - infusion during labour & delivery if viral load unknown/above 1000 copies/ml
Prophylaxis may be given to baby:
- low-risk babies - zidovudine for 2-4 weeks
- high risk babies - zidovudine, lamivudine & nevirapine for 4 weeks
Avoid breastfeeding
