Module 5 Flashcards
What is type 1 diabetes
Insulin dependent diabetes occurs when beta cells in the islets of Langerhans in the pancreas are destroyed, stopping insulin production.
Incidence of thyroid dysfunction
Affects 2-3% of pregnant women
What is hyperthyroidism (thyrotoxicosis)
State of having excess production of free thyroxine and low thyroid stimulating hormone
Incidence of hyperthyroidism in pregnancy
0.2% of pregnancies
What is graves disease
An autoimmune condition that causes an overproduction of thyroid hormones. Accounts for more than 95% of hyperthyroidism
Complications of hyperthyroidism (graves disease)
- Graves ophthalmopathy
- dermopathy
- thyrotoxic storm
- Miscarriage
- SGA
- Prematurity
- FDIU
Treatment of hyperthyroidism (Graves disease) in pregnancy
- Treatment is limited to medication, carbimazole or propylthiouracil (PTU)
- Surgery and radioactive iodine is not recommended in pregnancy, risk of miscarriage
S/S of hyperthyroidism (graves disease)
- Heat intolerance
- Weight loss
- Insomnia
- Agitation
_ Tremor
_Retraction of the upper eyelid - Sweating
- Tachycardia/bounding pulse
- Diarrhoea
- Amenorrhoea
Hyperthyroidism (graves disease) management
- Referral to obstetrics
- Regular T4 and TSH testing
- Serial USS
- CEFM in labour and alert paed
- Postnatally check baby’s bloods, baby may require temporary treatment, check maternal serum levels 6 wks pp.
What is Hypothyroidism
A condition where the thyroid gland doesn’t produce enough thyroid hormone.
What is Hashimoto disease (Autoimmune thyroiditis)
When the immune system attacks the thyroid gland causing preventing the thyroid producing enough hormones. Most common cause of hypothyroidism.
S/S of hypothyroidism (Hashimoto’s disease)
- Weight gain
- Constipation
- Cold intolerance
- Alopecia
- Dry skin
- Hoarseness
- Lethargy
- Ataxia
- Cognitive impairment
- Anaemia
- Bradycardia
- Sometimes asymptomatic
Investigations for hyper and hypothyroidism
Measurement of the circulating thyroid hormones using thyroid function tests.
- Hyperthyroidism TSH will be lowered and free thyroxine T4 will be elevated
- Hypothyroidism TSH will be lowered and free thyroxine t4 will be reduced
Treatment for hypothyroidism (Hashimoto’s)
Thyroxine 50-150 mcg daily (safe in BF)
Complications of hypothyroidism (Hashimotos)
- Myoedema coma
- Reduced fertility
- Pregnancy induced hypertension
- PND
- Failure to lactate
- Increased sensitivity to opioids
- Low birth weight
- Psychomotor retardation
- Anovulation
Preconception care Hypothyrodism (Hashimotos)
- Consider fertility care
- Discuss risk
- check thyroxine levels
- Manage medications
Management of Hypothyrodism (Hashimotos)
- Check T4 and TSH at booking, 4-6 weekly throughout the pregnancy
- adjust the dose of thyroxine to maintain TSH in the lower half of the reference range,
- serial growth scans if hx IUGR
- Postnatally reduce dose of thyroxine
- check T4 and TSH 6 weeks after delivery
What are the elements of blood
- red blood cells (Erythropoiesis is the process by which erythrocytes (red blood cells) are formed
- white blood cells
- platelets (Platelets are important in preventing blood loss by promoting the formation of clots)
Causes of anaemia
- Inadequate production through diet, bone marrow production
- Rapid destruction through hypersplenism, liver disease, malaria, lupus and sickle cell disease
- Blood loss
What is beta thalassaemia
Hereditary blood disorder categorised as major or minor.
Caused by absent or reduced synthesis in beta chains of haemaglobin
Symptoms of beta thalassamia
- pallor
- lethargy
- poor appetite
- development delay
- failure to thrive
- irritability
- anaemia
What is thrombocytopenia, normal range and diagnostic criteria
- Low platelet level
- Normal range 150,000 to 450,000 per microlitre
- Diagnostic <50,000 per microlitre
S/S Thrombocytopenia
- Petechiae
- Bleeding gums
- Nose bleeds
- Malaise
Thrombocytopenia causes
- Decreased platelet production: Leukaemia, anaemia, viral infections, HIV
- Increased destruction: Autoimmune disease, lupus, rheumatoid arthritis, Blood borne infection
- Medication induced
What are coagulapathies
Impaired clotting ability which be be Inherited or Acquired through chronic disease, infection, heparin use, Vit K deficiency
Management of coagulopathies
- Require complete family history/ Detailed medical history
- Pre-pregnancy counselling/Early pregnancy counselling
- Referral to haematology specialists
- Treatment as indicated
What is thrombophilia
The presence of hypercoagulability that increases the risk of thrombosis.
WHAT IS SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
Systemic lupus erythematosus (SLE) is when the body produces autoantibodies against its own connective tissue. Has some of the most serious consequences for pregnancy.
The body is in a thrombophilic state.
Goes through periods of remission and flares often triggered by infection, exposure to sunlight or oestrogen increase.
MANAGEMENT OF SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
- No cure
- Treatment aims to manage symptoms and prevent progression, survival rate to 15 years
COMPLICATIONS OF SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
- acute and chronic infection
- nausea
- vomiting
- diarrhea
- alopecia
- photosensitivity
- arthritis
- ulcers
- fatigues
- myalgia
- renal disease (>50%, 60% hypertension)
- heart disease
- hypertension
- pericarditis
- anaemia
- thrombocytopenia
- increases risk of miscarriage 40-80% (pregnancy loss in 20-30% of cases)
- FDIU 8%
Incidence of systemic lupus erythematosus (SLE) in pregnancy
1:1000
EFFECT OF SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) ON PREGNANCY
1/3 improve
1/3 stabilise
1/3 deteriorate
DIAGNOSIS AND TESTING OF SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
Women must fulfil at least one clinical and one laboratory feature at some time during the course of their disease
Clinical features:
- Recurrent pregnancy loss (MORE THAN 3 CONSIDER OBSTETRIC LUPUS ANTIBODY SCREEN)
- fetal death
- venous or arterial thrombosis
- autoimmune thrombocytopenia
- coombs positive
- haemolytic anaemia
Laboratory features:
- ANA, ACA, LAC, Anti-Ro, Anti-La
- Antiphospholipid antibodies are seen in 50% cases
PRECONCEPTION CARE FOR SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
Preconception care:
- discuss complications
- refer to obstetrician and rheumatologist
- discuss conception during a period of remission
- does not appear to affect fertility
MANAGEMENT AND TREATMENT SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
- individual to the woman based on condition
- antibody screening preconception
- renal function testing
- serial USS
- low dose aspirin
- patient education, preparation for hospitalisation, prem delivery, outcomes,
- emotional support
- obstetric involvement
- assess proteinuria
- treat flares with steroids
- review medication
- consider timing of delivery
- steroids if preterm
- CEFM, often can delivery vaginally
- increased risk of flare postpartum
- return to prepregnancy drug regime
- lactation may be suppressed
COMPLICATIONS OF ANTIPHOSPHOLIPID SYNDROME AKA HUGHES SYNDROME
- placental insufficiency
- recurrent miscarriage
- fetal loss
- preeclampsia/ HELLP
- preterm delivery
- placental abruption
ANTIPHOSPHOLIPID SYNDROME AKA HUGHES SYNDROME
A disorder in which the immune system mistakenly attacks normal proteins in the blood.
The condition is an acquired thrombophilia (clotting disorder), making women prone to thrombotic disorders.
DAIGNOSIS OF ANTIPHOSPHOLIPID SYNDROME AKA HUGHES SYNDROME
Diagnosis on one clinical and one laboratory criteria
Clinical criteria:
- vascular thrombosis
- one or more unexplained death of a normal fetus after 10 wks
- one or more preterm birth before 34 weeks due to preeclampsia or placental insufficiency
- three or more unexplained miscarriages before 10 wks.
Laboratory criteria:
- LA, aCL, IgG, IgM, Anti-B2 present on at least two occasions at least 12 weeks apart
PRECONCEPTION CONSIDERATIONS FOR ANTIPHOSPHOLIPID SYNDROME AKA HUGHES SYNDROME
- women with a history of SLE, thrombosis, recurrent miscarriage, severe IUGR, early onset pre-eclampsia, FDIU or prem delivery associated with IUGR should be offered screening for antiphospholipid antibodies,
- discuss risks and pregnancy care
- confirm antibody levels
- advise aspirin, commence heparin, discontinue warfarin
MANAGEMENT OF ANTIPHOSPHOLIPID SYNDROME AKA HUGHES SYNDROME
- obstetrician involvement
- regular growth USS, dating scan,
- aspirin
- monitor of signs of pre-eclampsia
- blood tests
- heparin.
- CEFM
- review by anaesthetist early
- in labour adequate hydration, TED stockings, encourage mobility, active management, prompt suturing
- Postpartum, increased risk of thrombosis,
- admission to NICU if associated complications occur.
What is multiple sclerosis
Inflammatory disease of the CNS that mostly affects women and those in the childbearing age group
Characterised by plaques of tissue in the brain and spinal cord and a variety of classification types
S/S of multiple sclerosis
- diplopia
- vertigo
- bladder incontinence
- loss of vision
- fatigue
- muscular weakness
Complications of multiple sclerosis
- optic neuritis
- transverse myelitis
- increase chance of relapses postnatally when physical and emotional stressors are greater
Effect of pregnancy on multiple sclerosis
pregnancy has a protective benefit against relapses
Treatment for multiple sclerosis
- Treatment aimed at symptoms and improving everyday life rather than the disease itself,
- acute episodes treated with high dose corticosteroids
Preconception care of multiple sclerosis
- fertility is not affected
- plan pregnancy during remission
- review medications and discontinue where appropriate 3 months prior to conception
- continuity of care
- obstetric involvement
Management of multiple sclerosis
- Immunomodulatory agents are not recommended in pregnancy and lactation
- Spinal epidural and GA can be used in MS
- Exclusive breastfeeding and concomitant suppression of menses significantly reduces the risk of postpartum relapses in MS
- Pregnancy does not affect the long term course or progression of the disease
- Postnatal support should be available
WHAT IS INTRAHEPATIC CHOLESTASIS
- Characterised by increased serum bile acid and gestational pruritus
COMPLICATIONS OF INTRAHEPATIC CHOLESTASIS
- stillbirth
- preterm delivery
- MSL
- fetal distress
- asphyxia
- increased risk where serum levels are above 100umol
MANAGEMENT AND TREATMENT OF INTRAHEPATIC CHOLESTASIS
- symptomatic relief with topical ointments and lukewarm bath,
- timing of delivery 36-40 wks
- close fetal monitoring
- CEFM in labour
- Treatment using ursodeoxycholic acid - a naturally occurring bile acid derivative with an anti cholestatic effect in the human body.
