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Becks obstetric Qs > Other medical disorders in pregnancy > Flashcards

Other medical disorders in pregnancy Flashcards

1
Q

What is the definition of gestational diabetes?

A

Gestational diabetes is a carbohydrate intolerance which is diagnosed in pregnancy and may or may not resolve after pregnancy.

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2
Q

What levels are required to diagnose gestational diabetes?

A

Glucose levels of >5.6mmol.L or >7.8mmol 2 hours after eating 75g glucose load.

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3
Q

Why is glycosuria not a useful test for gestational diabetes?

A

In normal women, the kidneys will start excreting glucose at blood level around 11mmol/L. In pregnancy this varies more but often decreases, so glycosuria can often occur at physiological blood glucose concentrations.

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4
Q

What is the mechanism that causes diabetic mothers to have babies with increased birthweight?

A

Higher blood glucose in foetus –> pancreatic islet cell hyperplasia –> hyperinsulinaemia –> more fat deposition –> larger baby

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5
Q

What are foetal complications of type 1 and 2 diabetes pre-pregnancy?

A
  • Congenital abnormalities (particularly neural tube defects) due to peri-conceptual glucose control.
  • Preterm labour.
  • Foetal lung maturity at any given gestation is less than with non-diabetic pregnancies.
  • Increased birthweight.
  • Polyhydramnios
  • Dystocia and birth trauma are more common.
  • Foetal compromise, foetal distress in labour and sudden foetal death are more common - especially with poorer control in the 3rd trimester.
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6
Q

What are the foetal complications of diabetes due to?

A

Blood glucose levels and so women with gestational diabetes are less affected than those with type 1 or 2.

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7
Q

How do insulin levels change at the end of pregnancy?

A

They increase by 300% at the end of pregnancy

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8
Q

What are maternal complications of pre-existing diabetes (and less so gestational diabetes)?

A

Hypertension is more common.
Pre-eclampsia risk increased.
UTI and endometrial infection.
C-section or instrumental delivery is more likely.
Diabetic retinopathy often deteriorates during pregnancy.

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9
Q

What is the management approach to pre-existing diabetes in pregnancy?

A

Precise glucose control and foetal monitoring for evidence of compromise.

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10
Q

What diabetic drugs are suitable in pregnancy and pre-conception?

A

Metformin and insulin.

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11
Q

What HbA1c level is recommended and which is not advised for pregnancy?

A

Recommended < 6.5%

Not advised when > 10%

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12
Q

How much folic acid is given to a diabetic woman preconceptually? Why?

A

High dose of 5mg a day because of diabetic increase in congenital abnormalities of the neural tube.

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13
Q

What is the pattern of metformin and insulin usage during pregnancy in type 1 and 2 diabetics?

A

Insulin and metformin doses usually need to be increased as the pregnancy advances.
Those with type 2 using metformin may need to be supplemented with insulin.

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14
Q

What is prescribed to prevent pre-eclampsia in diabetic pregnancies and when?

A

Low dose aspirin (75g) from 12 weeks.

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15
Q

What is scan used to check for pre-eclampsia and IUGR?

A

Umbilical artery Doppler

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16
Q

Why are extra ultrasounds booked towards the end of gestation in diabetic mothers?

A

To check foetal growth and liquor volume (32 and 36 weeks) as polyhydramnios and macrosomia can still develop with good control.

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17
Q

What timing and mode of delivery is advised in diabetes?

A

37-39 weeks and C-section is recommended if estimated foetal weight is over 4kg.

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18
Q

What is a common foetal development after birth regarding blood sugar levels? Why?

A

Hypoglycaemia because they have become accustomed to hyperglycaemia and their insulin levels are too high.

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19
Q

What treatments (conservative and medical) are given to those with gestational diabetes?

A

Diet/exercise
Metformin
Insulin (depending on severity)

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20
Q

What is the treatment for gestational diabetes after birth?

A

They can stop insulin, and have a fasting glucose is taken 6 weeks postnatally due to the increased risk of type 2 diabetes later in life.

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21
Q

What changes are there to the cardiovascular system during pregnancy?

A

Increased cardiac output (40%) –> increased stroke volume, heart rate and blood volume (40%).
There is also a decrease (50%) in systemic vascular resistance.
Increased blood flow produces a flow murmur in 90% of pregnant women.

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22
Q

When does heart disease usually manifest as a problem in pregnancy?

A

Usually manifests after 28 weeks or soon after labour, with decompensation particularly in associated with fluid overload or blood loss.

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23
Q

What can cause fluid overload at birth? And what can be the consequence?

A

In the early puerperium, as the uterine involution ‘squeezes’ a large ‘fluid load’ into the circulation, this can cause fluid overload. In a woman with heart disease, this can cause decompensation.

24
Q

What cardiac drugs are used and which are contraindicated in pregnancy?

A

Used:
Low dose low molecular weight heparin
Beta blockers - labetalol
Nifedipine

Contraindicated:
ACE inhibitors
Warfarin

25
Q

What heart conditions are dangerous in pregnancy?

A 
Aortic stenosis
Pulmonary hypertension
Mitral valve disease
Cyanotic heart disease without pulmonary hypertension
Myocardial infarction
Peripartum cardiomyopathy
26
Q

What do women on long term steroids require during labour?

A

They require an increased dose in labour because the chronically suppressed adrenal cortex is unable to produce adequate steroids for the stress of labour.

27
Q

What are the risk factors in pregnancy for epilepsy and its medication?

A

Epilepsy –> increased risk of epilepsy in child

Medication –> increased risk of neural tube defects (so the mother has 5mg folic acid supplementation)

28
Q

What is the management of epilepsy drugs and prophylaxis in pregnancy?

A

Lowest dose and fewest drugs possible to control seizure.
Sodium valproate is contraindicated in any woman of reproductive age.
Carbamazepine and lamotrigine are safest.
High dose folic acid (5mg/day) before and during pregnancy helps to prevent neural tube defects.

29
Q

What are hypothyroidism and subclinical hypothyroidism associated with in pregnancy?

A

Hypothyroid - rare due to anovulatory cycles but associated with high perinatal death. Higher risk of pre-eclampsia if antithyroid antibodies are present.
Sub clinical hypothyroidism - associated with miscarriage, preterm delivery and intellectual impairment in childhood.

30
Q

What are the consequences of hyperthyroidism in pregnancy?

A

Antithyroid antibodies cross the placenta and rarely this causes neonatal thyrotoxicosis and goitre.
Poorly controlled disease in the mother can cause ‘thyroid storm’ and heart failure.
Inadequately treated disease increases perinatal mortality.

31
Q

What medication is used to treat hyperthyroidism in pregnancy?

A

Propylthiouracil (PTU) in the first trimester rather than carbimazole. The lowest possible dose is used as it can cross the placental barrier and may cause neonatal hypothyroidism.

32
Q

What is postpartum thyroiditis and how common is it?

A

5-10% get this.
Initially there is a transient, subclinical hyperthyroidism (around 3 months postpartum), followed after by about 4 month of hypothyroidism. This is permanent in 20%.

33
Q

What characterises intrahepatic cholestasis of pregnancy?

A

Unexplained pruritus and abnormal LFTs and/or raised bile acids in pregnancy which resolve after delivery.

34
Q

What treatments are given for intrahepatic cholestasis of pregnancy?

A

Ursodeoxycholic acid (UDCA) - helps with pruritus and reduce bile acid levels (to reduce foetal and maternal risk).
Vitamin K at 36 weeks - due to an increased maternal and foetal haemorrhage tendency.
Induction of labour.

35
Q

Why are UTIs tested for in the booking visit?

A

5% of women have asymptomatic bacteriuria but is more likely to lead to pyelonephritis in pregnancy.
UTI is associated with preterm labour, anaemia and increased perinatal morbidity and mortality.

36
Q

How is antiphospholipid syndrome (APS) diagnosed?

A

When lupus anticoagulant and/or anticardiolipin antibodies occur (measured on 2 separate ocassions 3 months apart) in association with adverse pregnancy complications or thrombotic events.

37
Q

Who is treated for APS and with what?

A

Low levels of these antibodies are present in 2% of pregnant women, so treatment is saved for those with the syndrome.
Treatment is with aspirin and LMWH.

38
Q

What does APS cause?

A

Because of placental thrombosis, recurrent miscarriage, IUGR and early pre-eclampsia are common and foetal loss in high.

39
Q

What risks to diseases which have a high risk of venous thromboembolism increase?

A

Because of placental thrombosis, recurrent miscarriage, IUGR and early pre-eclampsia are common and foetal loss in high.

40
Q

What happens to the levels of urea and creatinine in pregnancy and why?

A

They decrease due to increased GFR

41
Q

Why is the incidence of venous thromboembolism increased in pregnancy?

A

Due to increased clotting factors, decreased fibrinolytic activity and blood flow is altered my mechanical obstruction.

42
Q

What venous thromboembolism diseases are common in pregnancy and how are they diagnosed?

A

Pulmonary embolism. Diagnosed by X-ray, arterial blood gas and CT. Note that the ECG changes of normal pregnancy can mimic pulmonary embolism.
DVT - more often on the left. Diagnosis is with Doppler or MRI.
Cerebral venous thrombosis - MRI.

43
Q

What is the treatment of venous thromboembolism in pregnancy?

A

Subcutaneous LMWH. Treatment is stopped during labour and then continued.

Do not use warfarin due to it being teratogenic, but can use either in breastfeeding.

44
Q

When is thromboprophylaxis used? What is used?

A

Used antenatally in those women at high risk.
Used postnatally in more women (lower risk but still some risk than antenatal) for around 10 days after birth. This includes C-section.
Low molecular weight heparin is usually used.

45
Q

What are the maternal risk factors for obesity?

A

Obese women have a higher risk of thromboembolism, pre-eclampsia, diabetes, C-section, wound infection, postpartum haemorrhage and maternal death.

46
Q

What are the foetal risk factors for maternal obesity?

A

Congenital abnormalities such as NTD and an increased risk of perinatal death.

47
Q

What is the management of obese pregnant women?

A

High dose preconceptual folic acid (5mg) and vitamin D is recommended. As is preconceptual weight loss.
BMI>40 and LMWH is recommended to reduce the risk of venous thromboembolism.

48
Q

Why are benzodiazepines not recommended in pregnancy?

A

Due to risks of dependency, neonatal withdrawal and over-sedation. Also associated with facial clefts and cause neonatal hypotonia.

49
Q

What are the treatments for depression and anxiety during pregnancy?

A

Talking therapy first for both.

Antidepressants for both if severe.

50
Q

What is bipolar disorder treated with in pregnancy? Which drugs are contraindicated?

A

Anti-psychotics –> although quetiapine and olanzapine are associated with weight gain and therefore gestational diabetes.
Contraindicated: Lithium (cardiac defects), sodium valproate and carbamazepine.

51
Q

What are the complications of alcohol during pregnancy?

A

Miscarriage in the first 12 weeks.
IUGR and birth defects with increasing amounts.
Foetal alcohol syndrome (facial abnormalities, growth restriction, a small or abnormal brain and developmental delay).

52
Q

What are the risks of smoking during pregnancy?

A

Not teratogenic.

Associated with an increased risk of miscarriage, IUGR, preterm birth, placental abruption, stillbirth and SIDs.

53
Q

What happens to haemoglobin levels in pregnancy and why?

A

Blood volume increased by more than RBC mass and therefore there is a net fall in haemoglobin so a lower net haemoglobin level is normal (lower limit 11.0g/dL).

54
Q

What types of anaemia are common in pregnancy and how do you tell them apart? How are they treated?

A

Iron deficiency - low corpuscular volume anaemia. Given IV iron.
B12/folate deficiency - large corpuscular volume anaemia. Treatment is with oral B12 or folate.

55
Q

What are the most common haemoglobinopathies and what is the disease they cause?

A

Sickle cell and thalassaemia - they cause haemolytic anaemia.

Becks obstetric Qs (18 decks)

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