Pre-existing medical conditions and pregnancy

Question 1

. Pre-existing medical conditions

Name the group of diseases

Answer 1

Renal diseases
Diabetes mellitus
Thyroid diseases
Obesity
Thrombophilia
Epilepsy
Cardiac diseases
Respiratory disorders

Autoimmune : SLE
Hemoglobinopathies
- Sickle cell anaemia

Question 2

Renal diseases

Implications

Answer 2

Question 3

Renal diseases

Management

Answer 3

a. Pre-pregnancy counseling for making informed decisions.

b. Pregnant women with renal disease

Question 4

Renal disease

Management

Pre-pregnancy counseling for making informed decisions.

Answer 4

Pre-pregnancy counseling for making informed decisions.

i. Polycystic kidney disease requires this consult for the risk of inheritance to baby.

ii. Renal transplanted women have no contra indication for pregnancy, but only
after a period where they are stabilized.

iii. Chronic renal disease may deteriorate to kidney failure with dialysis
requirements

Question 5

Renal disease

Management

Pregnant women with renal disease

Answer 5

Pregnant women with renal disease

i. Provide obstetrician and renal specialist care.
ii. Assessment of blood pressure, proteinuria, GFR and UTIs.

iii. Prophylactic heparin for women with proteinuria to decrease DVT risk.

iv. Prophylactic antibiotics for women who has more than one UTI during the
pregnancy.

v. Renal calculi treated with conservative management (fluid loading and
alkalization of urine)

vi. Aspirin (75mg) from week 12 to reduce pre-eclampsia risk.

vii. Re-evaluate medications that are taken

viii. Fetal growth assessments scans from 3rd trimester.

Question 6

Diabetes mellitus

Implications

Answer 6

Question 7

Diabetes mellitus

Management

Answer 7

a. Pre-pregnancy counseling.

b. HbA1c < 6.1% levels are needed prior to conception to reduce complications of
pregnancy.

c. Medications:
i. Metformin continued.
ii. ACE inhibitors stopped.
iii. Increase folic acid intake to prevent neural tube defects.
iv. Low dose aspirin for pre-eclampsia.

d. Maternal assessments

i. Maintain normal range glucose levels during pregnancy.

ii. Due to this strict control with insulin, hypoglycemia episodes can develop so IM
glucagon should available.

iii. Close monitoring of capillary blood glucose

iv. Ophthalmic assessment each semester for diabetic retinopathy

e. Fetal assessment
i. Chromosomal problems (1st trimester) and routine anatomy check (week 20).

ii. Additional cardiac anatomy scan.

f. Give birth in hospital with neonatal facilities

Question 8

Thyroid diseases
Features and types

Answer 8

yroid diseases

1. Features:
   a. Estrogen increases TBP (thyroid binding proteins) that reduce levels of T4 and T3 in the
   blood → resulting in increased production by the thyroid to maintain normal levels.
   b. Iodine levels fall due to increased renal loss leading to enlarged thyroid.
   c. TSH levels drop due to hCG.

Types:
- Hyper
- Hypo

Question 9

Hyperthyroidism

Answer 9

a. Causes:
i. Grave’s disease (laboratory shows high T4 and T3 with low TSH)

b. Implications:
i. Pregnancy over disease – increases thyroxine demand so it has less significance
in pregnancy, unless there is untreated thyrotoxicosis.

ii. Disease over pregnancy: pre-eclampsia, fetal growth restriction, still birth, fetal
thyrotoxicosis

c. Management:
i. Thyroid function tests
ii. Anti-thyroid therapy (methimazole and propylthiouracil)
iii. Assessment of fetal growth and heart rate

Question 10

Hypothyroidism

Answer 10

a. Causes:

i. Autoimmune (autoantibodies, Hashimoto disease).
ii. Iatrogenic (thyroidectomy, anti-thyroid drugs)

b. Implications:
i. Pregnancy over disease – few effects.
ii. Disease over pregnancy – spontaneous abortion, pre-eclampsia, low birth
weight, reduced IQ, congenital iodine deficiency syndrome (cretinism)

c. Management:
i. Thyroid function test (T4) and TSH levels every trimester.
ii. Iodine supplementation or dietary

Question 11

Obesity
- Definition, features, implication

Answer 11

1. Definition: BMI > 25 (weight / (height^2)
2. Features:
   a. Co-morbidities of HTN, sleep apnea, cardiovascular disease
3. Implications:
   a. Pregnancy over disease – increased weight gain
   b. Disease over pregnancy
   i. Increased miscarriage and congenital abnormalities (1st trimester)
   ii. Pre-eclampsia and gestational diabetes (2nd trimester)
   iii. Fetal macrosomia
   iv. Childhood obesity and juvenile diabetes.
   v. Induction of labor and C-section.

Question 12

Risks of obesity in pregnancy

Answer 12

Question 13

Management Obesity

Answer 13

a. Pre-counseling
b. Diet support.
c. Folic acid (until week 12 due to increased neural defects)
d. Assessment for co-morbidities.
e. Low dose aspirin for pre-eclampsia and thromboprophylaxis.
f. OGTT throughout pregnancy.
g. Fetal screening – poor ultrasound visualization because of mother

Question 14

Thrombophilia
- Features
- Implications

Answer 14

1. Features – pregnancy is a prothrombotic state.
2. Implications:
   a. Disease over pregnancy:
   i. Thromboembolism
   ii. Factor V Leiden mutation leads to fetal loss
   iii. Pre-eclampsia
   iv. Placental abruption
   v. Growth restriction
   vi. Miscarriage
   vii. Premature birth

Question 15

Thrombophilia
- Management

Answer 15

a. Screening for thrombophilia (family history, recurrent miscarriage, early onset of preeclampsia)

b. Obstetrician and hematologist assessments
c. Prophylactic LMWH (safer in pregnancy) – around time of birth to avoid bleeding

d. Compression stockings
e. Hydration

f. Antiphospholipid syndrome
i. Recurrent pregnancy loss before week 10 and the presence of lupus
anticoagulant and/or anticardiolipin antibodies.

ii. Therapy with aspirin combined with heparin reduces pregnancy loss

Question 16

Epilepsy
- Definition
- Implication

Answer 16

1. Definition: neurological disorder in which brain activity is abnormal, causing seizures or periods
   of unusual behavior and sometimes loss of awareness
2. Implications:
   a. Pregnancy over disease – variable. Seizures frequency can increase, decrease or stay the
   same.

b. Disease over pregnancy:
i. Congenital abnormalities (due to anti-epileptic drugs)

ii. Tonic-clonic seizures (muscle contractions and relaxations) associated with fetal
loss.

iii. Increased chance for child with epilepsy

Question 17

Epilepsy

Management

Answer 17

a. Pre-counseling to discuss risk and review of taken medications.
b. Risk of uncontrolled epilepsy is greater than risk of taken medications.
c. Aim is to avoid seizures during pregnancy

Question 18

Cardiac diseases

• Features
• Causes

Answer 18

1. Features:
   a. Most common cause for indirect maternal death.
   b. Mostly Acquired
2. Causes:
   a. Valvular lesions
   b. Congenital heart disease
   c. Cardiomyopathies
   d. Arrhythmias
   e. Ischemic heart disease.

Question 19

Cardiac diseases

Implications

Answer 19

a. Pregnancy over disease:

i. Deterioration of conditions (aortic stenosis, regurgitations etc.) due to increased
cardiac demand in pregnancy.

ii. Mimic of normal pregnancy symptoms such as dizziness, syncope, palpitations

iii. Risk for: CHF, hypoxia, bacterial endocarditis, VTE, aortic dissection, angina and
ischemia

4. Disease over pregnancy:

a. Depends in the cardiac problem.
b. Increased risk in general: pre-eclampsia, intrauterine growth, preterm birth

Question 20

Cardiac diseases

Management

Answer 20

a. Pre-counseling as sometimes pregnancy may not be advisable.

i. Eisenmenger’s syndrome - left-to-right cardiac shunt caused by a congenital
heart defect (ventricular septal defect, atrial septal defect or patent ductus
arteriosus) causes pulmonary hypertension

b. Medications (may be required)
i. Anticoagulants

c. Fetal assessments
i. Growth scans
ii. Cardiac abnormalities

d. Special attention to postpartum period as it is most risky due the hemodynamic changes

Question 21

Respiratory disorders

Answer 21

Asthma
CF

Question 22

Asthma

Answer 22

a. Implications:
i. Pregnancy over disease – variable.
ii. Disease of pregnancy – if well controlled no adverse effects, else, premature
birth, pre-eclampsia and growth restrictions.

b. Management:
i. Medications (safe for pregnancies)
ii. Avoid triggering agents.
iii. In acute case the treatment is the same as in non-pregnant.

Question 23

CF

Answer 23

a. Implications:

i. Pregnancy over disease – pregnancy can be tolerated well but risk relate to
degree of pulmonary dysfunction which can deteriorate.

ii. Disease of pregnancy – fetal inheritance, gestational diabetes, preterm birth

b. Management:
i. Genetic counseling
ii. Treatment of GI and lung dysfunctions.

iii. Pulmonary function tests at prior and during pregnancy.

iv. High dose folate (5mg/day)
v. Nutritional support

vi. Treat chest infections immediately.
vii. OGTT

Question 24

SLE

Answer 24

a. Diagnosis:

i. At least 4/11 clinical criteria + serology (positive ANA)

b. Implications:
i. Pregnancy over disease: increased relapses and deterioration of kidney
function.

ii. Disease over pregnancy:

1. Miscarriage
2. Stillbirth
3. Pre-eclampsia
4. Preterm birth
5. If co-existence with APS → increased VTE risk
6. Increased neonatal lupus and congenital heart block

c. Management:
i. Avoid pregnancy at least 6 months after flare.
ii. Medications:
1. Low dose aspirin for pre-eclampsia
2. LMWH for APS co-existence
3. Steroids in severe lupus cases (but only non-teratogenic)

iii. Induced labor at weeks 37-38 to avoid thrombotic events.

Question 25

Hemoglobinopathies

Answer 25

1. Sickle cells anemia:

a. Definition: autosomal recessive disorder of a gene mutation of glutamic acid to valine
on the beta-globin subunit. Polymerization of hemoglobin ensues resulting in sickling of
erythrocytes.

2. Implications:

a. Pregnancy over disease – variable according to severity of disease (heterozygous or
homozygous).

i. Sickle cell crisis - acute conditions leading most commonly to vaso-occlusive
crisis and splenic crisis with splenomegaly presenting with severe pain and limb
swelling.

b. Disease over pregnancy:
i. Anemia and infections
ii. Preterm birth
iii. Miscarriage,
iv. VTE
v. Growth restrictions

c. Management:
i. Prenatal diagnosis (of both partners)
ii. High dose folate due to increased hemolysis

iii. Low dose aspirin for pre-eclampsia.
iv. Prophylactic antibiotics
v. Fetal assessments (growth scans)
vi. Blood transfusions if necessary
vii. VTE prophylaxis