Medical Problems in Pregnancy Flashcards
1
Q
Which couples are at high risk of conceiving a child with a NTD?
A
- Either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family hx of NTD.
- The woman is taking anti-epileptic medication.
- The woman has coeliac disease or other malabsorption state, diabetes mellitus, sickle-cell anaemia, or thalassaemia.
- The woman is obese (BMI >30).
2
Q
What are the daily dosages of folic acid which should be taken by pregnant women at normal risk of neural tube defects?
And those at high risk?
A
- Normal risk for a NTD - folic acid 400µg daily, to continue until the 12th week of pragnancy.
- High risk of a NTD - folic acid 5mg daily, to continue until the 12th week of pregnancy.
- Women with sickle cell disease, thalassaemia, or thalassaemia trait should take folic acid 5mg daily throughout pregnancy.
3
Q
What issues must be addressed in a pre-conception discussion with a woman who has a pre-existing medical condition?
A
- Healthy weight
- Folic acid
- Quit smoking
- Alcohol and drugs
- Nutrition and anaemia
- Encourage women to continue to use contraception and their regular medication until they have had a full review with their specialised team, as well as other routine preconceptual care.
4
Q
What are the common pre-existing conditions which cause concern when a woman becomes pregnant?
A
- Anaemia
- Hypertension
- Endocrine disorders - thyroid disease, diabetes
- Psychotic disorders
- Epilepsy
- Autoimmune diseases
- Heart disease
- Coagulation disorders
- Renal diseases
- Respiratory diseases
5
Q
How is asthma managed in pregnancy?
A
- There is little need for modification of treatment in pregnancy.
- The risk of uncontrolled asthma outweighs and risk from medication.
- Steroids should be used as needed in the usual way and not withheld due to pregnancy.
6
Q
Describe the management of CF in pregnancy.
A
- Autosomal recessive
- CF team speak to every woman diagnosed with CF as soon as she turns 16 about which kind of contraception she is using and counsel her on the risk of offspring having CF; partner is also screened to check if they are a carrier of CF.
- Preconception counselling and planned pregnancy:
- Woman must be reminded of the importance of continuing physiotherapy throughout and beyond pregnancy (if neglected, lungs will clog).
- Can have IVF and use a donor to prevent risk of baby having CF.
- Maternal nutrition, control of pulmonary infection and avoidance of hypoxia and fetal surveillance.
- MDT management
7
Q
Describe the concerns and management in a woman who is pregnant and epileptic.
A
- Majority of women have diagnosis before pregnancy.
- 1/3 improve; 1/3 deteriorate; 1/3 remain the same.
- In general, fetus is resistant to short episodes of hypoxia but status epilepticus is dangerous to both mother and fetus.
- Main concern - teratogenic potential of the anticonvulsant medications (sodium valproate = high risk).
- Lamotrigine and Levetiracetam are commonly used and are safe in pregnancy.
- All women with a hx. of epilepsy should take high dose folic acid - 5mg / day.
- Planned pregnancy and discussion with neurologist is recommended.
8
Q
Describe the management of a woman with diabetes who is considering pregnancy.
A
- Planned pregnancy recommended.
- HbA1c should be kept below 48 mmol/mol to reduce risk of congenital malformation.
- Women with HbA1c of above 86 mmol/mol should avoid pregnancy until better control has been established.
- Blood glucose targets, monitoring and control should be discussed prior to pregnancy.
- Individualised targets for self-monitoring of blood glucose should be agreed, taking into account the risk of hypoglycaemia.
- Metformin can be used as an adjunct or alternative to insulin in those with T2DM but other oral hypoglyaemics should be discontinued prior to pregnancy.
- Many with T2DM will be converted to insulin during this period.
- Good glycaemic control before conception and throughout pregnancy will reduce, but not eliminate the risk of miscarriage, congenital malformation, stillbirth and neonatal death.
- Structured educational programmes should be offered where women have not previously attended one.
- Provide advice on diet, exercise and weight loss (prior to pregnancy).
9
Q
What are the complications which occur in pregnancy secondary to DM?
Describe how to manage these.
A
- Check for retinal and renal complications.
- Retinal screening should be done unless it has been done in the previous 6 months.
- Refer to nephrology where eGFR <45 mL/min, creatinine is abnormal or the UACR >30 mg/mmol.
- Review concurrent medication and stop ACE-Is, ARBs and statins.
- Check for co-existing thyroid disease in those with T1DM (TSH, free T4 and thyroid peroxidase antibodies).
- Treat as high risk for NTD with a dose of 5mg folic acid pre-conception and up to 12 weeks.
10
Q
Describe how to manage thyroid disorders during pregnancy.
A
- Hypothyroidism common (1%).
- Increase the thyroxine dose by 25µg at positive pregnancy test.
- Because of changes in maternal physiology.
- Repeat TFTs every 12 weeks / trimester (should be 2-4).
- Postnatally 6-12 weeks repeat TFT.
- Increase the thyroxine dose by 25µg at positive pregnancy test.
- Subclinical hypothyroidism
- Should commence treatment and be referred to an endocrinologist if contemplating pregnancy.
- Hyperthyroidism - Grave’s disease
- Specialist review
- Anti-thyroid treatment
- Fetal monitoring
- The use of radioactive iodine is contraindicated in pregnancy.
11
Q
Describe the management of hypertension in pregnancy.
A
- Increases the risk of pre-eclampsia during pregnancy.
- It also increases the risk of placental abruption and neonatal morbidity and mortality.
- ACE-Is and ARBs are contraindicated in pregnancy, so ideally should be changed prior to pregnancy.
- If the woman becomes pregnant, substitute with an alternative agent suitable for use during pregnancy.
- Labetalol is usually first-line.
- Drugs of choice are methyldopa, beta-blockers (labetalol, propanolol, metoprolol) and nifedipine.
- If uncomplicated hypertension, target BP will be below 140/90mmHg.
12
Q
Describe the management of cardiac disease in pregnancy.
A
- MDT
- All women with congenital or acquired heart disease should discuss future pregnancies with a cardiologist.
- Advise women to continue contraception until this discussion has taken place.
- The risk of fetus having congenital heart disease is higher if mother has CHD.
- Statins are contraindicated in pregnancy and should be stopped prior to conception.
13
Q
What are the cardiac abnormalities with minimal risk (<1%) to maternal mortality?
A
- Atrial septal defect
- Ventricular septal defect
- Patent ductus arteriosus - corrected and uncorrected
- Corrected Fallot’s tetralogy
- Benign arrhythmias
14
Q
What are the cardiac abnormalities which carry high risk of maternal mortality?
A
- Primary pulmonary hypertension
- Eisenmenger’s syndrome
15
Q
Describe puerperal cardiomyopathy in pregnancy.
A
- Usually occurs from 24 weeks gestation to 6/12 postnatally.
- Risk factors:
- Maternal age
- Hypertension
- Multiparity
- Multiple pregnancy
- Symptoms:
- SOB
- Poor exercise tolerance
- Palpitations
- Peripheral and pulmonary oedema
- Prognosis is variable - difficult to predict so is potentially fatal.
