Obs - Medical disorders in pregnancy Flashcards
why do fetus’ of mothers with diabetes become microsomic?
high fetal blood sugars
fetal islet cell hyperplasia -> hyperinsulinaemia
increased fat deposition
defien gestational diabetes
carbohydrate intolerance which
is diagnosed in pregnancy and may or may not resolve
after pregnancy’
what are the thresholds for gestational diabetes diagnosis ?
fasting glucose level ≥ 5.6 mmol/L
or >7.8 mmol 2 hours after a 75 g glucose load (glucose tolerance test:GTT)
which pregnant women are most likely to suffer from complications as a result of diabetes?
Complications are related to preeconception glucose levels, therefore Gestational DM are less effected
list some fetal complications of DM?
Subclassify into trimester!!
Congenital abnormalities eg cardiac defects
Increased birthweight
10% preterm labour
Polyhydramnios due to increased urine output
Shoulder dystocia
Fetal compromise, fetal distress in labour and sudden fetal death - poor 3rd trimester control
Neonatal hypoglycaemia!
list some maternal complications of DM?
1st trimester:
Miscarriage
2nd trimester:
Pre eclampsia more common
Hypoglycaemic episodes
Generally:
UTI, wound and endometrial infection more common
Diabetic complications accelerate and detriorate:
Diabetic nephropathy
Diabetic retinopathy
Intrapartum:
CS or instrumental delivery more likely
what is the overview of management of DM?
Pre-conceptual care:
- optimise health and sugars for pregnancy
Monitoring & Treating DM:
- Consultant led ANC care
Monitoring Fetus:
Monitoring complications of DM:
Renal function and retinae checked
75mg aspirin daily from 12 weeks
Timing/Mode of Delivery:
- delivery on labour ward with neonatal facilities
Neonate and Puerperium:
- Deliver 37-39 wks
- montor carefully as risk neonatal hypoglycaemia due
to hyperinsulinaemic state in utero
what is the target hba1c in glucose control for diabetics?
HbA1c level 48mmol/mol (6.5%) or below
what consideratoin would a diabetic mother need in labour?
Sliding scale of insulin and dextrose infusion during labour - if required insulin during pregnancy
Monitor capillary glucose every hour during labour and birth and ensure that it is maintained between 4-7 mmol/L
what additional monitoring might a fetus of a diabetic mum reequire?
Echo
Umbilical doppler if PET or IUGR
US - growth and liqour
what are the components of pre-conceptual care for diabetics?
Assess renal function, BP and retina
Optimise glucose control
Folic acid 5mg/day
Labetalol or methyldopa as anti-HTN
what is the screening schedule for gestatoinal diabetees?
Previous GDM screened at 18 weeks
28 week GTT screening test
Also check if polyhydramnios or persistent glycosuria
when is insulin indicated?
Advise diet and exercise then:
If fasting glucose > 7 at diagnosis
If after 2 weeks of Metformin , fasting levels >5.3 before meals,
or >7.8 1 h after meals, go to Step 4 (insulin)
what drugs for DM ar eallowed in pregnancy?
metformin and insulin
what can you say about these drugs;
Warfarin and ACEi
are teratogenic in pregnancy
which types of heart defects are a problem in pregnancy?
Pulmonary hypertension - absolute contraindication
Mitral valve stenosis/regurg - fix before pregnancy
Aortic stenosis - fix before pregnancy
managemnt of epilepsy in pregnancy?
Preconception care:
seizure control with as few drugs as possible
5mg folate a day
Carbamazepine and Lamotrigine are safe
10mg vit K given from 36 weeks onwards
risks of epilepsy in pregnancy?
seizure control worse = more seizures
neural tube defect risk with drugs
3% risk of baby getting epilepsy
most common cause of hypothyroid in pregnancy?
Hashimoto’s thyroiditis or thyroid surgery
risk of hypothyroid in pregnancy?
miscarriage, pre-term delivery and intellectual impairment in childhood
PET if antithyroid antibody
management of hypothyroid and hyperthyroid in pregnacy?
Hypothyroid:
thyroxine 6 weekly monitoring
Hyperthyroid:
propylthiouracil (low dose - can still cross placenta)
risk of graves disease in pregnancy?
Antithyroid antibodies cross placenta -> neonatal thyrotoxicosis and goitre
how does postpartum thyroditis present and risk in pregnancy?
Usually subclinical hyperthyroidism (3m post partum) followed by 4m of hypothyroidism
this hypothyroidism can be permanent in 20%
can cause post natal depression
how does obstetric cholestasis present?
itching WITHOUT skin rash WITH abnormal LFTs
and/or raised serum bile acid
Both resovle post delivery
(itching - soles of feet and palms of hand typical)
what are the complications of obstetric cholestasis?
Fetal fetal arrhythmia - > stillbirth Premature birth Meconium passage IUGR
Maternal:
Intense itching affects sleep and overall well-being
Maternal PP haemorrhage (uncharacterised)
rx of obstetric cholestasis?
- Bile acids <40 symptomatic
Monitor lfts weekly form diagnosis till delivery
Medical: Topical emollients for itch e.g. Diprobase Antihistamines • Cholestyramine + Vit K • Ursodeoxycholic Acid
- Bile acids >40 micromol/L (severe cholestasis) and gestational age <37 weeks
§ Medical
• Ursodeoxycholic Acid or phenobarbital (sedative side-effects)
• Dexamethasone (DM excluded) for symptom relief and prepare foetal lung development for potential preterm delivery - dont give unless in an RCT!
• VitAMIN K daily from 36 wks - if PT prolonged
Intrapartum:
o Offer induction of labour (IOL) at 37 weeks
MONITORING:
LFTS, doppler+ctg
pregnant woman presents with
Malaise, vomiting, jaundice and vague epigastric pain and thirst.
what is the dfx?
Acute fatty liver of pregnancy
what is the rx of acute fatty liver of pregnancy?
Critical care support
o IV fluids
o 10% dextrose IV
o Coagulopathy screen every 4-6 hours to asses for DIC
o Continuous foetal monitoring
o Dexamethasone if <37 weeks gestation
o Magnesium sulphate if <32 weeks gestation
• Delivery as soon as possible
presence of lupus anticoagulant and/or anticardiolipin antibodies indicates?
Antiphospholipid Syndrome
list some complications of Antiphospholipid Syndrome and why
Placental thrombosis recurrent miscarriage, IUGR and early preeclampsia
high fetal loss
how is Antiphospholipid Syndrome managed?
Aspirin and LMWH - only if high antibody level - low levels normal
high risk pregnancy - consultant led care
postnatal LMWH
what are the diagnostic criteria for APLS?
1 or more of Clinical criteria:
o Vascular thrombosis
o 1+ death of fetus >10 weeks
o PET or IUGR requiring delivery <34 weeks
o 3+ fetal loss <10 weeks, otherwise unexplained
+ laboratory criteria measured twice >3 months apart
o Lupus anticoagulant
o High anticardiolipin antibodies
o Anti-B2 Glp I ab
what are the common sites of thromboses in pregnancy?
Thromboses
are normally ileofemoral and more common in the left than the right.
how would you ivx and mx a patient with suspected dvt?
basic ivx on everyone -> cxr, ecg, bloods,
start lmwh
clinical sx and signs of dvt :
Yes - compression duplex ultrasound leg
No:
CXR abnormal - CTPA
CXR normal - V/Q scan
if nothing found but still high suspicion DVT -continue LMWH whilst lookinig for alternate diagnosis
how is obesity ivx/ managed in pregnancy?
Preconception:
diet and exercisie advise for weight reduction
5mg folate
viitamin d
Pregnancy:
do not lose weight pregnancy - malnutrition
high riisk bmi >35
how should BPAD be managed in pregnancy ?
Lithium frequently used and associated with increased rate of cardiac abnormalities
Discontinuation risks relapse – only stopped in those well or low risk
Monthly monitoring of lithium levels during pregnancy as increased excretion during pregnancy
which antidepressant is contraindicated in pregnancy ?
paroxetine - cardiiac defects
which treatments can you NOT use in schizophrenia?
clozapine and olanzapine
how would you help some1 with opiate dependency?
opiate replacement: Methadone maintenance
what is the risk of benzo use in pregnancy?
cleft lip
neonatal hypotonia and withdrawal sx
A woman comes in to ANC, their bloods show that they are anaemic
list the causes of a anemia in pregnancy?
o Inadequate intake
o Poor absorption - coeliac etc
o Haemolysis e.g. sickle cell
o Excessive demands e.g. twins
o Vaginal loss or pre-existing haemorrhage
how is anaemia managed?
Considier folate and B12 deficiency (prescribe if so)
Antenatal
o 100-200 mg oral iron (ferrous sulphate)
- iV iron in severe cases
§ Re-check Hb in 2-3 weeks
• Intrapartum may require
o Active management of 3rd stage
o Active management of PPH
o Consider prophylactic syntocinon infusion
what is the aetiology of sickle cell?
Inherit 2 abnormal copies of B globin gene on chromosome 11.
Abnormal beta chain formation (S chain)
-> Abnormal Hb molecule: 2 alpha and 2 S
what is the screening for sickle cell and thalssaemia?
all pregant women get elctrophoresis
if are heterozygote - get prenatal diagnosis i.e. amniocentesis or CVS to see if baby has it.
what is the prognosis and rx of alpha thalssaemia?
Four gene deletions -> death in utero
Heterozygous one or two deletions -> anaemic and require folate + iron
what is the prognosis and rx of beta thalssaemia?
Homozygous: affected by iron overload and pregnancy unusual, give folate, NO iron
Heterozygous: chronic anaemia, worsens during pregnancy
what are the types of FGM?
• Type 1: Clitoridectomy: partial or total removal of
the clitoris, or of the prepuce.
• Type 2: Excision: partial or total removal of the clitoris
and the labia minora, ± the labia majora.
• Type 3: Infibulation: narrowing of the vaginal opening
by cutting and repositioning the labia, with or without
removal of the clitoris.
• Type 4: Other: all other non-medical procedures to
the female genitalia for non-medical purposes.
When is LMWH given in pregnancy based on VTE score?
Vte of 4 = lmwh from start of pregnancy
Vte of 3 = lmwh from 28 weeks
Vte < 3 = mobilisation and hydration
Lmwh used is clexane
Postpartum - reassess
Vte 2+ = lmwh for 10days
High risk eg previous vte = lwmh for 6 weeks
Which kind of monitoring is needed in the following:
- 1st plot below 10th centile
- Static fundal height
- Fundal height slowly decreasing
- Steep rise in fundal height centile
1-3 growth scan
4 - obstetric ANC referral
Obviously all your basic things eg : CTG
Lady comes in and is pregnant, she has hx of severe depression, is not currently on any meds. How would you approach?
Take hx - screen current mood -
Current risk assessment - whooley questions: any thoughts to harm yourself
NICE - (May need to:) start psychological intervention - assess need for for meds
Refer to prenatal mental health team
Refer to obstetrician for appointments
how do you screen for and manage mental health in pregnant women?
At booking, ask:
Whooley questions (depression) GAD-2 (anxiety)
If yes to any of above questions do PHQ9, Edinburgh PNDS.
Then refer to GP or mental health personnel
What are the crucial questoins to ask if suspecting mental health (or to incorporate into any hx)
- Hx and fox mental health
- Physical health problems
- Alcohol and drug use
- Atttude and experience of pregnancy
- Relationship with baby
- Current or past rx for mental health
A woman books for pregnancy at 13 weeks. she is currently on lithium and has been for some months. how would you counciil her?
Confirm pregnancy
May be able to continue drug, often not - seek psychiatry input.
Explain: stopping or changing drug may not remove risk of malformation
Offer screening for fetal anomalies
Offer councelling about continuing pregnancy
what counts as severe cholestasis?
Bile acids >40micromol/L
what are the risks in severe cholestasis?
all the risks associated with IHCP are increased so risk of preterm birth etc.
what is the prognosis of Obstetriic cholestasis? how can it be predicted?
poor outcome cannot be predicted by the biochemical results.
Fetal monitoring isnt particularly predictive of its outcome either. continuous ctg recommended.
all the treatments given are for symptomatic relief, rather than to solve the issue. there is no evidence that theese therapies help prevent fetal stillbirth eetc
how do you different a diagnosis of GDM from pre-existing diabetes?
why do we need to do this?
Measure HbA1c at the time of diagnosis in newly diagnosed GDM to identify those with pre-existing undiagnosed T2DM
Women with preexisting DM likely to fair less well.
Intrapartum:
o Advise women with T1DM or T2DM to have elective birth by induction
of labour or elective C-section between 37-39 weeks
o Consider birth < 37 weeks if there are complications
o Advise women with GDM to give birth no later than 40+6 weeks
complications of vq scan vs ctpa?
CTPA - increased risk of breast cancer
VQ scan - increased risk of childhood cancer
what is Ebsteins anomaly?
Ebstein anomaly is a rare heart defect in which the tricuspid valve — As a result, blood leaks back through the valve and into the right atrium.
symptoms; cyanosis, breathlessness
child adviised to avoid sports but mainly well.
