Pre-existing maternal disease Flashcards
Define Chronic hypertension
Chronic hypertension is high blood pressure that exists before 20 weeks gestation and is longstanding.
How common is chronic hypertension? In who is it more common?
5% of pregnancies.
More common in older and obese women
Positive FHx or hx of increased BP when taking COCP
What are the causes of hypertension?
- Primary HTN = most common cause
- Secondary = associated with obesity, M or renal disease e.g. PCKD, RAS or chronic pyelonephritis
- Rarer causes = phaeochromocytoma, Cushing’s, cardiac disease and aortic coarctation
What are the clinical features of chronic hypertension?
- HTN increase in late pregnancy
- May identify fundal changes, renal bruits and radio-femoral delay
- Proteinuria in patients with renal disease is usually noticed at booking
What are the complications of chronic hypertension?
- Worsening HTN
- Increased risk of pre-eclampsia toxicaemia
What are the ix for chronic hypertension?
- Identify if secondary HTN
- 24h urinary catecholamines
- Look for coexistent disease – renal ultrasound and renal function
- Identify PET → URATE and quantify proteinuria
How do we split the management of chronic hypertension?
- Pre-conception
- Antenatal
- Intrapartum
- Postnatal
What should we advise women of chronic hypertension in the pre-conception period?
NICE Guidelines:
- Offer women with chronic hypertension referral to a specialist in hypertensive disorders of pregnancy to discuss the risks and benefits of treatment
- Stop antihypertensive treatment in women taking ACE inhibitors, ARBs, thiazide or thiazide-like diuretics if they become pregnant (preferably within 2 working days of notification of pregnancy) and offer alternatives.
- these increase the risk of congenital abnormalities
- Instead 1st line: Labetolol , 2nd line: Nifedipine
What should we advise women of chronic hypertension in the ante-natal period?
NICE Guidelines:
-
Conservative
- Offer advise on weight management, exercise, healthy eating and lowering the amount of salt in their diet.
-
Medications
- Continue with existing antihypertensive treatment if safe in pregnancy, or switch to an alternative treatment, unless:
- sustained systolic blood pressure is less than 110 mmHg or
- sustained diastolic blood pressure is less than 70 mmHg or
- the woman has symptomatic hypotension.
- Offer antihypertensive treatment to pregnant women who have chronic hypertension and who are not already on treatment if they have:
- sustained systolic blood pressure of 140 mmHg or higher or
- sustained diastolic blood pressure of 90 mmHg or higher.
- TARGET = 135/85 mmHg
- 1st line - Labetalol, 2nd line - Nifedipine, 3rd line - Methyl-dopa
- Offer low-dose aspirin 75-150 mg OD from 12 weeks gestation till birth
- Offer placental growth factor (PlGF)-based testing to help rule out pre-eclampsia between 20 weeks and up to 35 weeks of pregnancy, if women with chronic hypertension are suspected of developing pre-eclampsia.
- Continue with existing antihypertensive treatment if safe in pregnancy, or switch to an alternative treatment, unless:
- Appointments - depends on each pregnancy
- weekly appointments if hypertension is poorly controlled
- appointments every 2 to 4 weeks if hypertension is well-controlled.
What should we advise women of chronic hypertension in the intrapartum period?
- Do not offer planned early birth before 37 weeks to women with chronic hypertension whose blood pressure is lower than 160/110 mmHg
- For women with chronic hypertension whose blood pressure is lower than 160/110 mmHg after 37 weeks, with or without antihypertensive treatment, timing of birth and maternal and fetal indications for birth should be agreed between the woman and the senior obstetrician
- If planned early birth is necessary, offer a course of antenatal corticosteroids and magnesium sulfate if indicated
What should we advise women of chronic hypertension in the postpartum period?
- In women with chronic hypertension who have given birth, measure blood pressure:
- daily for the first 2 days after birth
- at least once between day 3 and day 5 after birth
- as clinically indicated if antihypertensive treatment is changed after birth.
- AIM: lower than 140/90 mmHg + continue antihypertensive treatment, if required
- offer a review of antihypertensive treatment 2 weeks after the birth, with their GP or specialist
- If a woman has taken methyldopa to treat chronic hypertension during pregnancy, stop within 2 days after the birth and change to an alternative antihypertensive treatment
- Offer women with chronic hypertension a medical review 6–8 weeks after the birth with their GP or specialist as appropriate.
What fetal complications are associated with maternal diabetes?
- Congenital abnormalities are 3-4x more likely in established diabetics
- Related to periconceptual glucose control
- Neural tube and cardiac defects
- Fetal lungs are less developed at any given gestation
- Increased birthweight
- 10% preterm labour
- Polyhydramnios due to macrosomia
- Shoulder dystocia and birth trauma
- Fetal compromise, fetal distress and sudden fetal death are more common and related to poor control in the third trimester
What maternal complications are associated with maternal diabetes?
UTI, wound and endometrial infection more common
Pre-existing hypertension found in 25% of overt diabetics
PET more common
IHD worsens
CS or instrumental delivery more likely due to fetal compromise and → fetal size
Diabetic nephropathy associated with poor fetal outcomes
Diabetic retinopathy often deteriorates
How do we think of managing pre-existing diabetes during pregnancy?
- Preconception
- Antenatal
- Intrapartum
- Postnatal
What should we do in the preconception period of women with diabetes?
Advise women with diabetes who are planning to become pregnant:
- that the risks associated with diabetes in pregnancy will increase the longer they have had diabetes
- to use contraception until they have good blood glucose control
- that blood glucose targets, glucose monitoring, medicines for treating diabetes (including insulin regimens) and medicines for complications of diabetes will need to be reviewed before and during pregnancy → agree to some targets
- T1DM: Waking 5 to 7 mmol/L and pre-meal 4-7 mmol/L
- HbA1c level below 48 mmol/mol (6.5%) - strongly advice women whose HbA1c level is above 86 mmol/mol (10%) not to get pregnant until their HbA1c level is lower
- who have a body mass index (BMI) above 27 kg/m2, offer advice on how to lose weight
- to take folic acid (5 mg/day) until 12 weeks of gestation to reduce the risk of having a baby with a neural tube defect.
- Offer up to monthly measurement of HbA1c levels for women with diabetes who are planning a pregnancy.
- Offer blood glucose meters for self-monitoring to women with diabetes who are planning a pregnancy.
- Offer blood ketone testing strips and a meter to women with type 1 diabetes who are planning a pregnancy, and advise them to test for ketonaemia if they become hyperglycaemic or unwell
- Adjust medications
- Advise to stop all glucose-lowering agents except metformin and insulin
- As early as possible, offer a structured education programme to women with diabetes who are planning a pregnancy
- For women with diabetes who are seeking preconception care, offer a retinal assessment at their first appointment
- Offer women with diabetes a renal assessment
What should we do for women with diabetes antenatally?
o Arrange contact with joint diabetes and antenatal clinic every 1-2 weeks
o Conservative
Ensure mother is up to date with retinal and renal screening
o Monitoring
T1DM or T2DM or gestational diabetes who are on a multiple daily insulin injection regimen - Capillary blood glucose monitoring should be performed by the patient a min. of 7x/day (upon waking, before each meal, 1hr after each meal + bedtime blood glucose levels)
T2DM or gestational diabetes - fasting and 1-hour post-meal blood glucose levels daily if they are:
- managing their diabetes with diet and exercise changes alone or
- taking oral therapy (with or without diet and exercise changes) or single-dose intermediate-acting or long-acting insulin.
• Pre-prandial target = <5.3 mmol/l, 1hr post-prandial target = <7.8 mmol/l Specialist foetal cardiac scan at 19-20 weeks
Serial growth scans + amniotic fluid every 4 weeks from 28-36 weeks
Repeat maternal retinal and renal screening (if abnormal at booking repeat at 16-20 weeks, if normal at booking repeat at 28 weeks)
o Medical
Continue high-dose folic acid 5mg OD until 12 weeks gestation
Low-dose aspirin 75mg OD from 12 weeks gestation
Since insulin resistance increases throughout pregnancy, advise patients to increase their dose of metformin or insulin during the 2nd half of pregnancy
What should we do in the intrapartum period of women with diabetes?
o Organise elective birth between 37+0 – 38+6 weeks (IOL or CS) - if no complications
o Consider delivery before this in the presence of foetal/maternal complications
If antenatal corticosteroids are needed, additional insulin therapy must be given concurrently (to maintain normoglycaemic)
Monitor capillary plasma glucose every hour during labour and birth for women with diabetes, and maintain it between 4 mmol/litre and 7 mmol/litre.
o For women on insulin, commence a sliding scale during labour (aim blood glucose levels between 4-7 mmol/l)
What is the neonatal care in a baby born from a pregnant mother?
o Monitoring
Check neonatal blood glucose within 4 hours of birth (to exclude neonatal hypoglycaemia)
Admit babies of women with diabetes to the neonatal unit if they have:
- hypoglycaemia associated with abnormal clinical signs
- respiratory distress
- signs of cardiac decompensation from congenital heart disease or cardiomyopathy
- signs of neonatal encephalopathy
- signs of polycythaemia, and are likely to need partial exchange transfusion
- need for intravenous fluids
- need for tube feeding (unless adequate support is available on the postnatal ward)
- jaundice requiring intense phototherapy and frequent monitoring of bilirubinaemia
- been born before 34 weeks (or between 34 and 36 weeks, if the initial assessment of the baby and their feeding suggests this is clinically appropriate)
Women with diabetes should feed their babies:
- as soon as possible after birth (within 30 minutes) and then
- at frequent intervals (every 2 to 3 hours) until feeding maintains their pre-feed capillary plasma glucose levels at a minimum of 2.0 mmol/litre.
What should we do in the postpartum period of women with diabetes?
Refer women back to their routine diabetes care arrangements
o Medical
Adjust insulin and metformin doses back to those of pre-pregnancy immediately after birth
What physiological changes occur to pregnancy to the thyroid?
- Enlargement of the thyroid
- increase in T4 and T3
- Increase in TSH in early pregnancy
- Iodine clearance is increased during pregnancy
- Fetal thyroxine starts at week 12 (dependent on mother before)
How common is hypothyroidism in pregnancy?
Hypothyroidism (including subclinical hypothyroidism) occurs in 2.5% of pregnant women.
What are the causes of hypothyroidism?
- Autoimmune thyroiditis - eg, Hashimoto’s thyroiditis (also known as Hashimoto’s disease).
- Radiotherapy or surgery.
- Congenital.
- Drugs - eg, lithium, amiodarone.
- Iodine deficiency.
- Infiltrative diseases.
- Pituitary or hypothalamic disease.
What is the presentation of hypothyroidism in pregnancy?
Often subtle and difficult to distinguish from the symptoms of normal pregnancy.
- Dry skin with yellowing especially around the eyes.
- Weakness, tiredness, hoarseness, hair loss, intolerance to cold, constipation, sleep disturbance.
- Goitre, delayed relaxation of deep tendon reflexes.
- Anaemia, low T4, raised TSH.
- In the subclinical form TSH is raised but free T4 and T3 are normal.
How is hypothyroidism managed during pregnancy?
- Antenatal
- Monitoring
- TFTs should be checked every 2-4 wks (TSH<4mmol/L)
- Medical
- Thyroid replacement therapy
- Adjust dose throughout pregnancy according to TFTs
- Higher doses often required in 1st trimester
- Monitoring
What is the post natal management of hypothyroidism?
- Monitor
- TFTs monitoring at 6-8 weeks postnatal
- Postpartum thyroiditis management
- Thyrotoxic phase: propanolol (anti-thyroid drugs are avoided)
- Hypothyroid phase: thyroxine
What are the complications associated with hypothyroidism during pregnancy?
Untreated or under-treated hypothyroidism in pregnancy can lead to several adverse pregnancy outcomes, including miscarriage, anaemia, small for gestational age and pre-eclampsia.
What should we do in the intrapartum period for cardiac disease?
What types of seizures do we see in WWE during pregnancy? What effect does it have on the mother and baby?
