Other Medical Disorders in Pregnancy Flashcards
Why does glucose tolerance decrease in pregnancy?
Due to altered carbohydrate metabolism and the antagonistic effects of human placental lactogen, progesterone and cortisol
What do we mean when we say pregnancy is ‘diabetogenic’?
women without diabetes, but with impaired or potentially impaired glucose tolerance often deteriorate enough to be classified as diabetic in pregnancy
Even slightly increased glucose levels have adverse pregnancy effects - they are reduced by treatment
at what threshold do the kidneys of non-pregnant women start to excrete glucose?
How does this change in pregnancy?
11mmol/L
Varies more, but often decreases, so glycosuria may occur at physiological blood glucose concentrations
urinalysis for glycosuria is not a useful diagnostic test
What is the result of raised foetal blood glucose levels?
Foetal hyperinsulinaemia
causing foetal fat deposition and excessive growth - macrosomia
What % of pregnant women are affected by pre-existing diabetes?
1%
In those on insulin, increasing amounts will be required in these pregnancies to maintain normoglycaemia
What is gestational diabetes?
Gestational diabetes refers to diabetes triggered by pregnancy. It is caused by reduced insulin sensitivity during pregnancy, and resolves after birth.
What is the NICE threshold for gestational diabetes?
normal:
Fasting: < 5.6 mmol/l
At 2 hours: < 7.8 mmol/l
Results higher than these values are used to diagnose gestational diabetes.
It is really easy to remember the cutoff for gestational diabetes as simply 5 – 6 – 7 – 8.
What are the foetal complications of gestational diabetes?
Congenital abnormalities - NTD (2-4 Ames more common in women with established diabetes and are related to periconceptual glucose control)
Preterm labour (natural or induced) occurs in >10% women with established diabetes
Fetal lung maturity - less than with non-diabetic pregnancies
Birthweight - increased
Dystocia - and birth trauma: baby larger. related particularly to poor 3rd trimester glucose control
Why does gestational diabetes result in large babies?
foetal pancreatic islet cell hyperplasia leads to hyperinsulinaemia and fat deposition - this leads to increased urine polyhydramnios
What are the maternal complications of gestational diabetes?
Insulin requirements - increase by up to 300% by the end of pregnancy
Ketoacidosis - rate but hypoglycaemia may result
UTI
Wound or endometrial infection
Hypertension and pre-eclampsia
Pre-existing ischaemic heart disease
C-section or instrumental delivery
Diabetic nephropathy (5-10%)
can lead to massive proteinuria and deterioration of maternal renal function
Diabetic retinopathy - often deteriorates in pregnancy - may need to be treated
What is the preconceptual care of diabetes?
Glucose levels need to be optimum at conception to reduce risk of fatal complications.
HbA1c <6.5% and pregnancy not advised if >10%. Fasting glucose should be 4-7mmol/K if achievable without hypoglycaemia. Metformin and insulin are appropriate, but others must be stopped
5mg folic acid
Statins stopped and anti-hypertensives (labetalol/methyldopa) given instead
Renal function (creatinine <120umol/L), BP and retinae are assessed
What is the aim for glucose levels in pregnancy?
Fasting <5.6mmol/L
1hr <7.8mmol/L
What other measures need to be taken during pregnancy to Monitor for diabetes?
Renal function checked and retinae screened for retinopathy - if abnormal, this needs to be repeated every trimester
Aspirin (75mg) daily from 12 weeks advised to reduce risk of pre-eclampsia
Foetal monitoring: fetal echo, USS to monitor growth and liquor volume at 32 and 35 weeks
At what week gestation is delivery advised for diabetic women?
37-39 weeks as birth trauma more likely
C-section where estimated foetal weight is >4kg.
During labour, glucose levels are maintained with sliding scale of insulin and dextrose infusion
Why does the neonate commonly develop hypoglycaemia?
What is the management of this?
become accustomed to hyperglycaemia and therefore has high insulin levels
Levels should be checked within 4 hours - breastfeeding Is strongly advised
What are the factors indicating screening for gestational diabetes?
Previous large baby (>4.5kg) Unexplained stillbirth 1st degree relative with diabetes BMI >30kg/m2 Minority ethnic family origin Previous gestational diabetes Large for dates fetus
Women with pregnancy factors - e.g. polyhydramnios or persistent glycosuria
What is the screening for gestational diabetes?
24-28 weeks:
An OGTT
The patient drinks a 75g glucose drink at the start of the test. The blood sugar level is measured before the sugar drink (fasting) and then at 2 hours.
Hba1c levels to identify pre-existing diabetes.
Target levels are the same in pre-existing diabetes
What is the management of gestational diabetes?
Initially managed with diet and exercise advice.
Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin
Fasting glucose above 7 mmol/l: start insulin ± metformin
Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin
What % increase of CO is there in pregnancy? Why does this occur?
40%
Due to increase in stroke volume and heart rate and a 40% increase in blood volume
50% decrease in systemic vascular resistance, so BP often drops in 2nd trimester but has returned to normal by term
What % women have a flow murmur during pregnancy?
90%
What ECG changes are seen in pregnant women?
left axis shift and inverted T waves
What % of women are affected by cardiac disease?
0.3%
why does cardiac disease occur in pregnancy?
Increased Co –> exercise test (heart may be unable to cope)
decompensation in association with blood loss and fluid overload >28 weeks or soon after labour
Fluid overload can also occur in early puerperium as the uterine involution squeezes a large fluid load into the circulation
How are patients assessed pre-pregnancy for cardiac disease?
echo
contraindication of some drugs - ACEi and warfarin
hypertension often managed by beta-blockers ad thromboprophylaxis by LMWH
Fluid balance important = elective epidural analgesia reduces after load - elective forceps helps avoid the additional stress of pushing in severe cases
What are the types of cardiac disease that can onset in pregnancy?
Mild abnormalities - e.g. mitral valve prolapse, PDA, uncomplicated VSD/ASD
Pulmonary HTN - e.g. eisenmenger’s because of high maternal mortality, pregnancy = contraindicated
Cyanotic heart disease without pulmonary HTN - usually corrected but there is a particular risk of paradoxical embolism. anti-coagulation is advised
Aortic stenosis - severe disease causes an inability to increase CO when required and should be corrected before pregnancy. Beta-blockage
epidural analgesia is contraindicated in the most severe cases
Mitral valve disease - should be treated before pregnancy.
MI
Peripartum cardiomyopathy
How is mitral stenosis treated in late pregnancy?
Beta-blockade used
artificial metal valves are prone to thrombosis, so anti-coagulation is indicated
When does permpartum cardiomyopathy tend to develop?
Last month or first 6 months after pregnancy
Frequently diagnosed late.
Cause of maternal death and more than 50% leads to permanent LV dysfunction.
What is the management of peripartum cardiomyopathy?
Supportive - diuretics and ACE-i
Significant recurrence rate if subsequent pregnancies
By what volume is tidal volume increased by in pregnancy
40% - no change in respiratory rate
What common respiratory condition is common in pregnancy?
asthma
Why do women on long-term steroids require an increased dose in labour?
chronically suppressed adrenal cortex is unable to produce adequate steroids for the stress of labour
What % of women does epilepsy affect?
0.5% - seizure control can deteriorate in pregnancy (particularly in labour)
How are epileptic women managed in pregnancy?
Epilepsy = significant cause of maternal death
Anti-epileptic treatment should be continued, however, the risk of congenital abnormalities (NTD) is increased due to drug therapy. risk = dose dependent, higher with multiple drug usage and certain drugs
Seizure control with as few drugs as possible + folic acid (5mg/day)
Valproate avoided
Vit-K for enzyme inducing anti-epileptics
What is the risk of the new born developing epilepsy if the mother is epileptic?
3%
What drugs are safest for epilepsy in pregnancy?
Levetiracetam, lamotrigine and carbamazepine are the safer anti-epileptic medication in pregnancy
Sodium valproate is avoided as it causes neural tube defects and developmental delay
Phenytoin is avoided as it causes cleft lip and palate
When does foetal thyroxine production begin?
12 weeks
Before foetuses start producing thyroxine, where do they get their thyroxine from?
other - maternal TSH is increased in early pregnancy
What are the causes of hypothyroidism in pregnant women?
Hashimoto’s thyroiditis or thyroid surgery
What are the associated risks of hypothyroidism in pregnancy?
untreated - high perinatal mortality
subclinical - miscarriage, preterm delivery and intellectual impairment in childhood.
Increased risk of pre-eclampsia , particularly if antithyrozine antibodies are present
What is the cause of hyperthyroidism in pregnant women?
Grave’s disease
What is the result of untreated hyperthyroidism?
perinatal mortality
anti-thyroid antibodies can cross the placenta and cause neonatal thyrotoxicosis and goitre.
For the mother, thyrotoxicosis may improve in late pregnancy, but poorly controlled disease can lead to a ‘thyroid storm’
What is hyperthyroidism treated with?
Propylthiouracil (PTU) in the 1st trimester rather than carbimazole, but it can cross the placenta and cause neonatal hypothyroidism
What is postpartum thyroiditis?
Common condition causing post-natal depression
Usually a transient and subclinical hyperthyroidism at about 3 months postpartum followed by about 4 months by hypothyroidism - permanent in 20%
What are the risk factors for portpartum thyroiditis?
anti-thyroid antibodies and T1DM
What is the incidence of acute fatty liver in pregnancy?
Very rare (1 in 9000) - serious condition that is part of the spectrum of pre-eclampsia
What are the early features of acute fatty liver?
malaise, vomiting, jaundice and vague epigastric pain
thirst may occur weeks earlier
What is the management of acute fatty liver in pregnancy?
early diagnosis and prompt delivery - correction of clotting defects and hypoglycaemia are needed first
Treatment = then supportive; further dextrose, blood products, careful fluid balance and occasionally dialysis
What are the clinical features of intrahepatic cholestasis of pregnancy?
Unexplained pruritus
Abnormal LFT
Raised bile acids
What is the cause of obstetric cholestasis?
Obstetric cholestasis is characterised by the reduced outflow of bile acids from the liver.
thought to be the result of increased oestrogen and progesterone levels.
Occurs in 0.7% women
familial
tends to reoccur (50%)
What are the associated risks of obstetric cholestasis
Increased risk of stilbirth?
Meconium passage
PPH - stillburth is thought to be due to the toxic effects of bile salts
What is the management of obstetric cholestasis?
Resolves with delivery
UDCA (ursodeoxycholic acid) helps relieve itching - reducing bile acid leves
Emollients + antihistamines
High risk of maternal and foetal haemorrhage - vitamin K 10mg/day given from 36 weeks
Induction of labour offered
six week follow up after labour to endure liver function returns to normal
By how much does GFR increase by in pregnancy?
What are the effects o this?
40%
Urea and creatinine levels decrease
What is the threshold risk for pregnancy being v high risk in ckd?
> 200mmol/L
What are the foetal complications of CKD in pregnancy?
Preterm delivery
Pre-eclampsia
IUGR
Polyhydramnios
What is the management of CKD in pregnancy?
USS for foetal growth
measurement of renal function
screening for urinary infection
control of HTN - in severe cases, dialysis is necczsssay
What are urinary infections associated with in pregnancy?
Preterm labour
Anaemia
Increased perinatal morbidity and mortality
How are urinary infections managed in pregnancy?
Urine cultured at booking visit (12 weeks( and asymptomatic bacteruria treated
What are the clinical features of pyelonephritis?
What is the predominant cause?
Loin pain, rigors, vomiting and fever
E.coli
What is antiphospholipid syndrome (APS)
When the lupus anticoagulant and/or anticardiolipin antibodies occur in association with adverse pregnancy complications or thrombotic events. Fetal loss = high
What are the consequences of APS?
Placental thrombosis
Recurrent miscarriage
IUGR
Early pre-eclampsia
What is the management for APS?
‘high risk’ - serial USS and elective induction of labour at least by term
Treatment with aspirin and LMWH - postnatal ant-coagulation is recommended to prevent venous thromboembolism
What are the other protherombotic disorders that can increase risk of pregnancy complications?
Antithrombin deficiency
Protein S or C deficience
Prothrombin gene mutation
Factor V Leiden heterozygosity
What is hyperhomocysteinaemia associated with?
Increased pregnancy loss and pre-eclampsia
Tx - high dose folic acid
Postnatal anticoagulation
What are the effects of pregnancy being prothrombotic?
Incidence of VTE = sixfold
Blood clotting factors = increased, fibrinolytic activity is reduced and blood is altered by mechanical obstruction and immobility
Describe the effects of PE in pregnancy?
leading ‘direct’ cause of death
Embolism - mortality 3.5%
Causes chest pain, dyspnoea, tachycardia, raised RR and JVP and chest abnormalities
how is PE diagnosed in pregnancy?
Doppler ultrasound is the investigation of choice for patients with suspected deep vein thrombosis.
Women with suspected pulmonary embolism require:
Chest xray
ECG
CTPA
V/Q
The Wells score is not validated for use in pregnant women. D-dimers are not helpful in pregnant patients, as pregnancy is a cause of a raised D-dimer.
Where do DVTs tend to occur in pregnancy?
Iliofemoral and on the left - doppler examination and venogram/pelvic MRI used to diagnose
What is the presentation of cerebral venous thrombosis?
Headache/stroke
How is cerebral venous thrombosis managed?
thrombophilia screen before tx with subcut LMWH
dosing = weight based and adjusted according to anti-Factor Xa level
clearance rapid, so level higher
NOT warfarin antenatally (teratogenic)
LMWH/warfarin safe in breastfeeding
Mobilisation + maintenance of hydration. compression stockings
Who are given antenatal / postpartum prophylaxis of VTE
Antenatal - women @ very high risk e.g. previous VTE
ASAP or from 28 weeks
Postpartum - if used antenatally, then continued or if there is a major or intermediate risk factor or two or more minor risk factors - LMWH is prescribed for at least 10 days and can usually be given 12 hours after delivery
What are the criteria for high risk VTE postpartum?
What is the management?
if LMWH used antenatally
Previous VTE
What are the intermediate risk factors for VTE postpartum?
What is the management
Thrombophilia Caesarean in labour BMI >40 prolonged hospitalisation IV drug abuser medical illness
1 week LMWH if 1+
What are the moderate risk factors for VTE postpartum?
What is the management?
BMI >30 Age >35 or parity >3 Smoker Elective caesarian Varicose veins Current systemic infection Pre-eclampsia Immobility PPH Rotational delivery Labour >24h
I week LMWH if 2+
What are the risks associated with BMI >30 in pregnancy?
Thromboembolism Pre-eclampsia Diabetes C-section Wound infection Difficult surgery PPH maternal death
Higher rate of congenital abnormalities
What is the management of obesity in pregnancy?
High dose folic acid (5mg)
vitamin D
High risk if >35 (screening for diabetes and closer BP surveillance)
Formal anaesthetic risk assessment and antenatal thromboprophylaxis if >40
Elective C-section?
When is the most high risk time for mental illness in pregnant women?
early postnatal
What are the red flag signs for mental illness?
Recent significant change in mental state
Emergence of new symptoms
New thought
Acts of violent self harm
New and persistent expressions of incompetency as mother
Estrangement from the infant
What are the risks of BPAD?
Lifetime risk - 1%
Onset most commonly during child-bearing age
Delivery can precipitate in women with bipolar
What are the treatments for BPAD?
Mood stabiliser
anti-psychotics
anti-convulsants
Lithium
Tx decisions = cost/benefit to foetus
What is the presentation of postpartum psychosis?
Psychiatric emergency - presents suddenly in the early postnatal period with psychotic and severe mood sx
Acute risk of suicide, self-harm or neglect, neglect of the baby, intentional self-harm to the baby = rare
What % of pregnant/postnatal women are affected by depression?
10-15%
highest in post-natal period
What is the management of depression in pregnancy?
CBT - first line in mild to moderate depression
Anti-depressants = effective in severe depression
Sertraline preferred
Paroxetine - congenital malformations and avoided
NB withdrawal and short-term side effects of anti-depressants have been seen in neonate
What are the types of anxiety disorders than can affect pregnant women?
GAD Panic disorder Phobias OCD - may increase in perinatal period PTSD - traumatic experience during delivery
Tokophobia - fear of childbirth
What is the management of anxiety in pregnancy?
Psychological therapies first line
medications reserved for severe cases (anti-depressants)
BDZ not recommended in pregnancy - dependency, neonatal withdrawal and oversedation
What % of women are affected by schizophrenia?
1% women over the course of a lifetime
most common during childbearing age
What is the management of schizophrenia in pregnancy?
What are the effects of these?
Long-term treatment with antipsychotics
Not shown to be teratogenic
However, olanzapine and quetiapine = weight gain and therefore gestational diabetes
Treatment usually continued due to high risks of relapse if medication stopped permanently
What recreational drugs are used in pregnancy and what are the effects of these?
OPIATEs COCAINE ECSTASY BDZ Cannabis
What are the effects of opiate use in pregnancy?
not teratogenic BUT preterm delivery, IUGR, stillbirth, developmental delay, sudden infant death syndrome
methadone advised - some neonates experience severe withdrawal and convulsions
What are the effects of cocaine use?
probably teratogenic, can cause childhood intellectual impairment, IUGR, placental abruption, preterm delivery, stillbirth and SIDS
What are the effects of ecstasy use?
teratogenic, increased risk of cardiac defects and probably gastroschisis
pregnancy complications are similar to cocaine
What are the effects of cannabis use?
Abuse of other drugs makes attribution of risk difficult - may cause IUGR and affect later childhood development
What are the effects of alcohol use in pregnancy?
<3 units a week - no consistent evidence of harm
May cause miscarriage in first 12 weeks - at higher levels, the incidence of IUGR and birth defects increases
Alcohol abuse in pregnancy - fetal alcohol syndrome. Facial abnormalities, growth restriction, small/abnormal brain and developmental delay (>18 units/day)
Alcohol spectrum disorder - lesser variants of the syndrome
USS may not detect syndrome but is used to monitor fetal growth
What are the risks of smoking in pregnancy?
Miscarriage IUGR preterm brith Placental abruption Stillbirth SIDS Childhood illness
Pre-eclampsia less common -
encouraged to stop/cut down - nicotine replacement
What is the % increase of blood volume in pregnancy?
What is the effect of this?
40%
Relatively greater than the increase in red cell mass - result = net fall in Hb concentration, such that the lower limit of normal = 11g/dL
What is the effect of a high HB level in pregnancy?
increased risk of pregnancy complications (preterm and IUGR) - possibly because it reflects low blood volume, as fond in pre-exlampsia and because of its association with smoking
What % of women are affected with iron deficiency anaemia?
> 10%
80% of women not receiving iron have depleted stores by term
What is the treatment of IDA?
Oral iron - increase of up to 0.8g/dL/week but can cause GI upset
in severe cases, IV iron is quicker and may prevent the need for blood transfusion
What other anaemias are pertinent in pregnancy?
Folic acid (more common than) B12
MCV usually increased, so red cell folic acid and vitamin B12 levels are low
What is the treatment of b12/folic acid deficieny
Oral folic acid and vitamin B12
What prophylaxis are given against anaemia and why?
Routine iron supplements
further foetal and neonatal anaemia have adverse outcomes although their relationship to maternal iron stores = unknown
Dietary advice and Hb checked at booking, 28 and 34 weeks
Iron + folic acid if Hb <11 and <10.5 in 2nd trimester
Who receives a higher dose of folic acid (5mg)
epilepsy, diabetes, obesity or previous history of NTD
normal dose is 0.4mg
Why is influenza dangerous in pregnancy?
Accounted for 10% of all maternal deaths in the UK and US in 2009-10
Pregnancy particularly with co-morbidity increases susceptibility to severe disease
What medications are recommended for treatment of influenza in pregnancy?
Relenza (zanamirr)
More severe - tamiflu (oseltamivir)
ICU and extracorporeal membrane oxygenation
What is the best management of influenza in pregnancy?
Prevention - vaccination of pregnant women at any stage of pregnancy is strongly advised during winter months - vaccine has not known adverse foetal effects and will reduce both maternal and foetal mortality
What is the adult Hb molecule made up of? How does HbF change to become HbA?
Two alpha chains and two beta chains bound together to form a tetramer
Foetal Hb molecule is normally replaced with HbA after birth and is made of two alpha chains and two gamma chains
What is the cause of sickle cell disease?
Recessive disorder - Abnormal beta chain formation (S chain) - resulting in an abnormal Hb molecule made of two alpha chins bound to two S chains
found in people with Afro-Caribbean ancestry
What is the effect of heterozygous HBS?
35% HbS and usually have no problems
What is the effect of homozygous HbS?
‘crises’ of bone pain and pulmonary symptoms - pulmonary hypertension and proliferative retinopathy may occur.
They will have chronic haemolytic anaemia for life.
What are maternal complications of sickle cell anaemia in pregnancy?
Acute painful crises (35%)
Pre-eclampsia
Thrombosis
What are foetal complications of sickle cell anaemia in pregnancy?
Miscarriage
IUGR
Preterm labour
Death
What is the management of sickle cell anaemia in pregnancy?
In conjunction with a haemoglobinopathy specialist - advice on avoiding dehydration and seeking help early is important:
Hydroxycarbamide is probably teratogenic and so stopped Penicillin V is continued High dose folic acid Aspirin and LMWH indicated Monthly bring culture Iron avoided - prevent overload
How are crises managed in pregnancy?
hydration
analgesia
often antibiotics and anti-coagulation
USS every 4 weeks and delivery normally indicated by 38 weeks
What is the cause of alpha thalassaemias?
impaired synthesis of the alpha chain in the Hb molecule
Occurs in largely South-East Asian origin
4 genes are responsible for a chain synthesis.
What is the effect of all 4 deletions?
3?
1 or 2?
Individuals with all 4 deletions die in utero, those with 3 gene deletions have lifelong requirement for transfusions and those with 1 or two deletions are carriers and usually well with mild anaemia
What is the cause of beta thalassaemia?
impaired synthesis of the beta chain in the Hb molecule
recessive disorder and the heterozygous state on a defective chain causes little illness, although a chronic anaemia which can worsen during pregnancy
What is the effect of beta thalassaemia?
Chronic haemolytic anaemia = present and multiple transfusions cause iron overload
therefore, hepatic and cardiac dysfunction, endocrine disease (thyroid and parathyroid) and diabetes
What are the maternal complications of beta thalassaemia
Fertility reduced, liver disease, cardiac failure and diabetes = common
What are the foetal complications of beta thalassamias?
growth restriction and foetal demise = more common
prenatal diagnosis is offered if the partner is heterozygous for either the beta or alpha form
Why is preconceptual planing crucial in beta thalassaemia?
Chelation therapy is probably teratogenic and avoided in 1st trimester - Desferiozamine can be used after this time - USSis used 4 weekly
What is FGM?
Partial or total removal of the external female genitalia or injury to the female genital organs for non-medical reasons
Describe the classification 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 labia minora and labia majora
Type 3 - infibulation - narrowing of the vaginal opening by cutting and repositioning the labia without removal of the clitoris
Type 4 - all other non-medical procedures to the female genitalia for non-medical purposes
Which countries practice FGM?
Africa
Middle East
Malaysia
Indonesia
What is the cause of FGM?
Ideas of preservation of virginity
Promoting hygiene
Adherence to cultural norms
Religion - not condoned in Bibal or Koran
What are the complications of FGM?
Pain Bleeding Infeciton Urinary retention Damage to pelvic organs Death
What are the longer term complications of FGM?
Failure to heal UTI Difficulty urinating or menstruating Chronic pelvic infection Vulval pain due to cysts or neuromas Pain during sex Infertility Fistula Severe perineal trauma during childbirth
