Other Medical Disorders in Pregnancy Flashcards
why is pregnancy diabetogenic
decreased glucose tolerance due to the antagonistic effects of lactogen, progesterone and cortisol
what are the foetal complications of gestational diabetes
Foetal hyperinsulinaemia due to islet cell hyperplasia which leads to increased fat deposition, leading to a large baby (macrosomia)
Congenital abnormalities (especially neural tube defects)
Preterm labour
Reduced Foetal lung maturity
Increased birthweight
Dystocia and birth trauma
how is foetal macrosomia best detected
An increase in abdominal width on antenatal scanning
what are the maternal complications of gestational diabetes
Increased insulin requirements
Ketoacidosis
UTI
Wound/endometrial infection
Hypertension and pre-eclampsia
Worsening of pre-existing heart disease
C-section or instrumental delivery more likely due to foetal size
Diabetic nephropathy (5-10%)
Diabetic retinopathy
why is glucosuria not a reliable physiological sign for gestational diabetes
because it is normal in pregnancy
How do you diagnose gestational diabetes
fasting glucose >5.6mmol/L
OGTT >7.8mmol/L 2 hours after 75g of glucose
what is the incidence of gestational diabetes
16%
how should you manage pre-existing diabetes in pregnant women
Precise glucose control and foetal monitoring
Dietary advice, Metformin and insulin are the only appropriate agents for monitoring in pregnancy
Preconceptual care
Glucose levels should be at normal physiological levels at conception, and pregnancy is not advised beyond 10% HbA1c
5mg folic acid
Statins stopped and antihypertensives given instead
Labetolol/methyldopa most commonly used
Renal function, eyes and blood pressure are measured
During pregnancy the aims are <5.3mmol/L fasting and <7.8mmol/L 1 hour post 75g glucose load
Aspirin 75mg is advised >12 weeks to avoid the risk of pre-eclampsia
Foetal monitoring
Foetal echocardiography is indicated
Extra scans at 32 and 36 weeks are indicated for growth/liquor volume
Neonate commonly develops hypoglycaemia initially due to it being used to higher glucose levels, therefore levels should be checked within 4 hours – breast feeding is strongly advised
what factors put women at risk of developing gestational diabetes
Previously large baby
Unexplained stillbirth
1st degree relative with diabetes
BMI >30
Minority ethnic origin
Previous gestational diabetes
Persistent glycosuria
Polyhydramnios
what % of women develop T2DM after an episode of gestational diabetes
50%
what is the care after birth for a woman whos had gestational diabetes
oral glucose tolerance test 6 weeks post birth
what are the physiological changes to the cardiovascular system in pregnancy
Cardiac output increases in pregnancy, due to increased blood volume (40%), increased heart rate and increased stroke volume
There is a 50% decrease in systemic vascular resistance, so BP often drops in 2nd trimester but returns to normal by term
90% of women have an ejection systolic murmur and an abnormal ECG (left axis deviation, inverted T waves)
How is pre-existing valve disease managed in pregnancy
Beta-blockers
valve replacement if serious
what are the physiological changes to the respiratory system in pregnancy
Tidal volume is increased by 40% in pregnancy
There is no corresponding change in respiratory rate
what respiratory condition is common in pregnancy
asthma
what is required for a woman on long term steroids during labour
increased dose of steroids due to chronic adrenal suppression
if the mother has epilepsy what is the chance the baby develops it
3%
what are the physiological changes to the thyroid system in pregnancy
Thyroid status does not change in pregnancy but foetal thyroxine does not get produced until 12 weeks so maternal TSH is increased to cover this deficiency
what are the implications of maternal hypothyroidism in pregnancy
severe perinatal mortality miscarriage preterm delivery increased risk of intellectual impairment increased risk of pre-eclampsia
why is an untreated thyroid disorder in pregnancy rare
hypo/hyper causes anovulation
what is the foetal risk of maternal hyperthyroidism
foetal thyrotoxicosis and goitre
what is the treatment for maternal hyperthyroidisim
propyluracil - not carbamazepine
what happens to graves disease post partum
gets worse
what are features of post-partum thyroiditis
Common (5-10%)
May lead to post-natal depression
Risk factors are antithyroid antibodies and T1DM
There is usually a 3 month transient, subclinical hyperthyroidism followed by a 4 month period of hypothyroidism – in 20% this is permanent
what is acute fatty liver + what are some of its features
rare obstetric complication causing acute hepatorenal failure, DIC and hypoglycaemia
malaise vomiting jaundice vague epigastric pain preceding thirst weeks earlier
how do you treat acute fatty liver of pregnancy
early identification key
correction of clotting defects and hypoglycaemia first
supportive treatment: dextrose blood products careful fluid balance occasional dialysis recurrence rates low
what is obstetric cholesatasis and what are some common features
obstetric intrahepatic cholestasis of unexplained origin
Unexplained pruitis
Abnormal LFTs
Raised bile acids
Resolution post-delivery
if a patient has had obstetric cholestasis previously what is the chance of recurrence
50%
what are the complications of obstetric cholestasis
Stillbirth (bile acid toxicosis)
Early meconium passage
Postpartum haemorrhage
what is the treatment for obstetric cholestasis
No main treatment
Ursodeoxycholic acid (UDCA) may relieve itching
Vit K given after 36 weeks due to risk of post-partum haemorrhage - 10mg/day
Induction is offered
38 weeks if bile acids are high
40 weeks otherwise
6 week follow up mandatory to check liver function returns to normal
what physiological changes occur in pregnancy due to the renal system
GFR increases by 40% in pregnancy causing creatinine and urea to drop
what is the threshold for CKD in pregnancy
creatinine >200mmol/L
what are some foetal complications of CKD in pregnancy
Preterm delivery
Pre-eclampsia
IUGR
Polyhydramnios
whats the management for CKD in pregnancy
USS for foetal growth
Renal monitoring
Hypertension control
If necessary – dialysis
what are the complications of a UTI in pregnancy
Preterm labour
Anaemia
Increased perinatal morbidity and mortality
what are complications of antiphospholipid syndromes in pregnancy
Placental thrombosis
IGUR
Pre-eclampsia
Recurrent miscarriage
how should you manage a woman with antiphospholipid syndrome in pregnancy
Serial USS
Induction at term
Aspirin + LMWH
Postnatal anticoagulation
what are prothrombotic conditions that must be screened for in pregnancy
Antiphospholipid syndrome
Prothrombin gene mutation
Factor V leiden heterozygosity
Protein S or C defiency
Antithrombin deficiency
what is hyperhomocysteinemia associated within pregnancy and how do you treat
increased pregnancy losses
increased risk of preeclampsia
high dose folic acid
how is SLE managed in pregnancy
if there is no lupus anticoagulation/anticardiolipid antibodies, the main risk comes with the organ associated damage from active disease
what physiological change occurs to the hematological system in pregnancy
pregnancy is a pro-thrombotic condition
clotting factors are increased, fibrinolytic activity is decreased, blood flow is altered by obstruction
what is the leading cause of obstetric related maternal death in the UK
pulmonary embolism
how does a central venous thrombosis present in pregnancy
headache/stroke
whats the treatment for a central venous thrombosis in pregnancy
LMWH (depending on thrombophilia screen and anti-factor Xa level)
More needed in pregnancy as clearance is increased
If possible, treatment should be stopped around labour
Warfarin is teratogenic and may cause foetal bleeding so seldom used antenatally
Warfarin and LMWH are safe for breastfeeding women
More general measures
Mobilisation
Hydration
Compression stockings (especially if LMWH contraindicated)
what are the risks of obesity in pregnancy
Thromboembolism Pre-eclampsia Diabetes C-section Wound infection Postpartum haemorrhage Difficult surgery Death Higher rates of congenital abnormalities Death due to complications of diabetes and pre-eclampsia
what extra management is required for obesity in pregnancy
high dose folic acid (5mg)
Vitamin D
close monitoring of blood pressure
what is required when a pregnant woman has a BMI >40
Formal anaesthetic assessment required
Antenatal thromboprophylaxis should be used
when is mental illness most affected in pregnancy
in the puerperium
what are some red flags relating to mental illness in the puerperium
Recent significant change in mental health
Emergence of new symptoms
New thought
Acts of violence/self-harm
New and persistent expressions of incompetency as a mother
Estrangement from the infant
what is the guidance surrounding the use of SSRIs in pregnancy/post pregnancy
they are generally safe, some neonates may go through withdrawal so its important to watch out for that
what antipsychotics are safe to use in pregnancy
most 2nd generation however olanzipine/quitiapine are associated with weight gain and arent recommended for high BMI/gestational diabetes
which of the common recreational drugs are definitely teratogenic
cocaine
ecstasy
benzodiazepines
what is the use of recretional opiates associated with in pregnancy
Stillborn
Preterm delivery
Developmental delay
IUGR
SIDS
neonatal withdrawal/convulsion post-delivery
what treatment is required for opiate addiction in pregnancy
methadone maintenance
what is the use of cocaine associated with in pregnancy
IUGR
Stillbirth
SIDS
Preterm delivery
Placental abruption
what teratogenic features is ecstasy associated with
cardiac defects
gastroschiasis
whats associated with benzodiazepine use in pregnancy
foetal clefts
Maternal hypotonia
Withdrawal symptoms
whats associated with alcohol intake in pregnancy
early miscarriage
IUGR
Foetal Alcohol syndrome
whats associated with smoking during pregnancy
Stillbirth
IUGR
Preterm birth
Placental abruption
SIDS
Childhood illnesses - namely increased risk of asthma
why is anaemia common in pregnancy
The 40% increase in blood volume in pregnancy is much more of a serum increase than a red cell increase, therefore there is a dilutional anaemia that occurs in pregnancy
Therefore the normal Hb in pregnancy is as low as 11.0 g/dl
what is a high Hb associated with in pregnancy
IUGR and preterm birth
what is the differences between adult and foetal Hb
adult Hb has 2 alpha and 2 beta chains
Foetal has 2 alpha and 2 gamma chains
foetal Hb has more affinity to oxygen meaning they’re better saturated at the same oxygen pressure
what are the maternal complications of sickle cell disease in pregnancy
Acute painful crises (35%)
Pre-eclampsia
Thrombosis
what are the foetal complications of sickle cell disease
IUGR
Miscarriage
Preterm labour
Death
how do you manae sickle cell disease in pregnancy
Sickle cell specialist
Hydroxycarbamide is teratogenic and stopped
Penicillin V continued
High dose folic acid
Aspirin + LMWH indicated
Monthly urine culture
Iron used to prevent overload
Crises management
Hydration
Analgesia
Antibiotics/anticoagulation
USS every 4 weeks, induce by 38/40
what are maternal complications of thalassaemia in pregnancy
Diabetes
Reduced fertility
Hepatic dysfunction
Cardiac failure
what are foetal complications of thalassaemia in pregnancy
Growth restriction
Foetal death
what should be arranged in preconceptual planning of pregnancy with women with sickle cell disease
Chelation is teratogenic and avoided in 1st trimester
Deferrioxamine may be used
USS is used 4 weekly
what are the 4 types of fmale genital mutilation
Type 1 – clitoridectomy
Type 2 – excision
Partial/total removal of the clitoris and labia minora +/- labia majora
Type 3 - Infibulation
Partial closing of the opening of the vagina via repositioning of the labia
+/- removal of the clitoris
Type 4
Other
what are common regions for female genital mutilation
Africa
Middle east
Malysia
Indonesia
what are some common reasons cited for female gential mutilation
‘fertility’
Hygeine
Adherence to cultural norms
Religion - although not condoned in the bible or koran
what are short term complications of female genital mutilation
Pain
Bleeding
Infection
Urinary retention
Damage to pelvic organs
Death
what are longer-term complications of female genital mutilation
Failure to heal
UTI
Pain during sex
Infertility
Difficulty menstruating
Fistula
Severe perineal trauma during childbirth
Chronic pelvic dysfunction
Vulval pain due to cysts and neuromas
