Pre-existing conditions in preg Flashcards
Discuss importance of asthma management in preg
Preg women greater risk of uncontrolled asthma = risk of foetal hypoxia
review asthma every 4-6 wks
What is used to treat asthma in preg?
SABA
LABA
ICS preventer = beclomethasone, budesonide, fluticasone –> not C/I in preg
Oral corticosteroids = dose for asthma –> no risk of mother or baby
Discuss the importance of treating epilepsy in pregnancy
Preg women = more freq seizures, may remain same, or dec in freq
Uncontrolled = dangerous, potentially life threatening to both mother and foetus
Consider inc failure of anti-convulsant therapy due to dec [serum] and altered pharmacokinetics
Outline of epilepsy management prior to preg
Consider w/drawl if seizure free for at least 2 yrs
stabilise on monotherapy if possible, w/ lowest dose
Folic acid 5mg/day, 1 month before conception
Discuss the treatment of epilepsy in pregnancy
Balance risk of anti-eps vs Mother/baby ADRs
All anti-epileptics are teratogenic (valproate is the worst), no drug of choice
Monotherapy if possible
Vit K supplement = some anti-eps deplete vit K in foetus (inc bleeding risk)
Outline the monitoring of epileptic mothers in preg
Plasma drug levels monitored throughout and 3 months post-partum
Better than 90% chance that baby will be normal
What med hx should be considered in women presenting w/ prei-natal depression?
Past mental health disorders = inc chance of depression occurring and bipolar occurrence in preg
Family hx of psychosis postnatally –> inc risk of mental health disorders
What women are at inc risk of peri-natal depression?
Women who experience multiple preg
Those who conceive through IVF
Those w/ PCOS
What are some potential harms to foetus w/ psychotropic use in preg?
Miscarriage, foetal death in utero, still birth
pre-term birth, congenital abnormality
growth restriction, poor neonatal adaptation
long term neurodevelopmental effects
Outline the psychotropics used in pregnancy for depression
Paroxetine not good, TCAs, SSRI safe w/ lowest dose
TCAs = may cause premature delivery and congenital malformation (seizure, altered muscle) –> AVOID doxepin (neonate resp depress)
SSRIs = may cause immature delivery, persistent pulmonary HTN, withdrawal, no risk of malformations except w/ peroxetine,
Antidepressants post natally = monitor babu feeding, neurological and resp difficulties
What antipsychotics should not be stopped/started in pregnancy?
Do not prescribe sodium valproate in preg
Do not stop antipsychotics
Do not initiate clozapine
Do not start peroxetine
Avoid doxepin
Discuss hypothyroidism in preg
Effect foetal brain development due to inc need for maternal thyroxine
hCG have inversely proportional relationship to TSH
Use levothyroxine therapy (inc dose 30-50%), monitor thyroid function each trimester
reassess maintenance dose 6-8 wks post partum
Discuss hyperthyroidism in preg
Common due to graves’ disease and gestational thyrotoxicosis
PTU preferred before conception + 1st tri
Switch to carbimazole in 2nd tri
Block-replace regimen = C/I
Discuss post-partum thyroid dysfunction
Common, result in hypo/hyperthyroidism = auto-immune conditions at risk
Must be differentiated from new onset/relapsed graves
Initial phase of hyperthyroidism due to thyroiditis followed by temporary hypothyroidism, eventual normal
What is the counselling for diabetes in women of reproductive age?
Need for excellent BG control and how to achieve
Nutrition advice
Folate supplementation to reduce risk of neural tube defect
Not smoking
Potential change in antihypertensive therapy during preg (ACEi can cause foetal damage in tri 2 and 3)
What is the treatment of Type 1 diabetes in preg?
multidose regimen = v/short acting insulin, intermediate insulin at bed time
What is the risk of pre-existing diabetes in pregnancy
Maternal mortality inc if pre-existing CHD
Potential progression to microvascular complications
Inc risk of pre-eclampsia and peri-partum intervention
Malformations rate correlated w/ poor control
What is the treatment of Type 2 diabetes in preg?
Management by diet is not usually sufficient
If diet cannot maintain glycaemic control = insulin therapy should be initiated
No absolute C/I for metformin
What is the monitoring for pre-existing diabetes in pregnancy?
Intensive BG monitoring = pre-req
BG lvls should be routine preprandially and bed time, periodic check between 2am and 4am for unchecked hypoglycaemia
HbA1c dec due to haemodilution of preg
Outline the insulin requirements throughout pregnancy
1st tri = insulin sensitivity inc, dec in insulin dose (nausea common, reduce carbs), altered symptoms
wks 22-32 = insulin req rise, fall slightly after 36 wks gestation
Postpartum = insulin req reduce by 20%, hypos anticipated/avoided, carbs should be close by, resume oral insulin once BF is stopped
T2DM = should continue on diet or insulin therapy while BF
What are predisposing factors to gestational diabetes?
Aboriginal, Torres Strait Islander women
Maternal age >30 yrs
Fam Hx DM
Obesity BMI >30kg/m2
Inc incidence 2nd and 3rd tri
Discuss (generally) gestational diabetes
Glucose intolerance in preg, management returns to normal PP
Inc risk of future T2DM
Check BG 4x/day (fasting and postprandial), if lvls exceed 10% –> insulin therapy
Council about likelihood of developing T2DM later in life after GD
When is GD screened for in pregnancy?
26 weeks gestation via per oral glucose tolerance test (POGTT)
Again, 6-12 wks PP glucose tolerance test
What is the treatment for gestational diabetes melilites?
Insulin = for those who don’t obtain optimal BGL w/ lifestyle mods
Metformin (XR or SR) is an option of treatment, no teratogenic problems but may need supplemental insulin
Is VTE prophylaxis required in all pregnancies?
Only those w/ risk factors require prophylaxis = hx VTE and identified thrombophilia
Other risk = obesity, active cancer, delivery by emergency caesarean
What are some signs and symptoms of pulmonary embolism?
Dyspnoea
Palpitations
Chest pain
Haemoptysis
Hypoxia/cyanosis
Tachycardia/Tachypnoea
Hypotension, collapse
What are some signs and symptoms of DVT?
DVT in preg is prox, may not present w/ usual features
Unilateral leg pain, swelling in extremity
Inc in calf/thigh circumference
Inc temp
Prominent superficial vein, pitting oedema
How are VTEs prevented/treated in pregnancy?
Treatments
- Graduated compression stockings
- Low molecular weight heparins (enoxaparin)
Treatment throughout preg and 6wks PP
LMWH should be discontinued at earliest onset of labour, minimise bleeding complications
What are varicose veins?
(treatments, aetiology)
Pooling of blood in surface veins due to insufficient valves (calves, inside legs, vulva)
Usually appear in 1st tri, influenced by:
- fam hx
- elevated BP
- hormones
Symptom relief by elevating feet, avoid long periods of standing
Describe the symptoms of vaginal thrush
Thick, white discharge
Non-offensive odour, vulval itch or soreness
Superficial dyspareunia, external dysuria
How is vaginal thrush treated in pregnancy?
Topical vaginal antifungals = pessary preferred, applicator used w/ care (not rec)
Oral fluconazole = inc risk of miscarriage
What skin rashes occur in preg? Why?
Melasma or chloasma faciei = due to high circulating oestrogen
Physiological changes to skin
- inc pigmentation, hair growth
- vascular instability and striae (stretch marks)
What is striae gravidarum? When occur?
During last trimester, 60-90% women (abdomen, breast, thigh, hips, lower back, buttock)
Initially erythematous = fade and become skin coloured or hypopigmented atrophic
Discuss pruritus in pregnancy (treatments, what it is, when to refer)
Mild itching due to skin stretch
Topical treatment (emollients)
- wet dressing, tepid shower to cool skin
- calamine lotion: avoid on dry skin, dries skin more
- menthol/camphor lotion chilling sensation
Refer = itching is severe —> obstetric cholestasis or intrahepatic cholestasis of preg
Discuss intrahepatic cholestasis in preg (what is, treatment, associations)
Causes unexplained pruritus during the 2nd 3rd = raised blood lvl of bile acids and/or liver enz
Intrahepatic cholestasis associated w/:
- inc risk of preterm delivery
- stillbirth
- risk of later hepatobiliary cancer, thyorid disease, diabetes, psoriasis, crohn disease, CVD
Treatment = ursodeoxycholic acid + aqueous cream w/ menthol
