Pre-existing Medical Disorders

Question 1

Types of pre-existing diabetes

Answer 1

-Type 1 diabetes – insulin dependent, usually juvenile onset
-Type 2 diabetes – non-insulin dependent, usually onset in adulthood
-Monogenic diabetes

Question 2

Effects of pregnancy on diabetes

Answer 2

-Increased doses of insulin as pregnancy progresses
-2x increased risk of progression of retinopathy
=Related to degree of pre-peri-conception diabetic control
-Nephropathy may deteriorate
-Autonomic neuropathy and gastroparesis may worse
-Hypoglycaemia for every 1% fall in HbA1C,there is a 33% increased risk of hypo
-DKA: Especially with hyperemesis, infection, corticosteroids

Question 3

Effects of diabetes on pregnancy: the woman

Answer 3

-Increases insulin req
-Hypoglycaemia
-Infection
-DKA
-Proteinuria and oedema
-Increased risk of pre-eclampsia
-Birth trauma / Caesarean section

Question 4

Effects of diabetes on pregnancy: the foetus

Answer 4

-Miscarriage
-Anomaly
-Macrosomia
-Still birth
-Pre-term birth (iatrogenic)
-Neonatal morbidity and mortality
=Hypoglycaemia
=Polycythaemia
=Jaundice
=RDS

Question 5

Management of diabetes preconception

Answer 5

-Joint pre-conception planning appt
-HbA1C as low as safely achievable
-Assess any existing complications-Review medications
-Folic acid 5mg

Question 6

Management of diabetes in 1st trimester

Answer 6

-Joint clinic
-Viability scan
-Management of hyperemesis
-Aspirin 150mgod
-Retinopathy screening
-Booking scan

Question 7

Management of diabetes 2nd trimester

Answer 7

-Home BP monitor
-Foetal anomaly scan
-Foetal cardiac scan
-Retinopathy screening

Question 8

Management of diabetes 3rd trimester

Answer 8

-Growth scans
-Plan for birth –mode and timing
-Plan for contraception
-Plan for diabetes during and after birth
-Intrapartum care

Question 9

Management of diabetes post birth

Answer 9

-Breastfeeding plan
-Contraception

Question 10

Use of technology in diabetes management

Answer 10

-Flash / continuous glucose monitors(CGM)
-Hybrid closed loop /artificial pancreas system

Question 11

What is hypertension?

Answer 11

-Threshold values of ≥140 mmHg systolic or 90 mmHg diastolic blood pressure define hypertension in pregnancy, with blood pressure ≥160 mmHg systolic or ≥110 mmHg diastolic described as severe hypertension

Question 12

Definition of chronic hypertension

Answer 12

-The presence of hypertension before 20 weeks’ gestation (in the absence of a hydatidiform mole) or
-Persistent hypertension beyond 6 weeks post-partum

Question 13

Classification of chronic hypertension

Answer 13

1. Chronic hypertension (without proteinuria)
2. Chronic renal disease (proteinuria with or without hypertension)
3. Chronic hypertension with superimposed pre-eclampsia (new-onset proteinuria)

Question 14

Epidemiology of hypertension in pregnancy

Answer 14

-Hypertension is the most common medical problem encountered in pregnancy, complicating 10% to 15% of pregnancies.
-Pre-existing or chronic hypertension is one of the most common conditions in women of childbearing age and is becoming more prevalent due to increasing maternal age and increased prevalence of obesity.
-Chronic hypertension is estimated to affect 1% to 5% of pregnant women and is frequently diagnosed for the first time during antenatal care

Question 15

Describe chronic hypertension

Answer 15

-Secondary hypertension is identified in less than 5% of the general population but has been shown to be present in 14% of women of childbearing age.
-Renal disease is the most common cause of secondary hypertension in pregnancy.
-Chronic kidney disease affects up to 3% of women aged 20 to 39 years and pregnancy may be the first time it is identified.

Question 16

History and examination in chronic hypertension

Answer 16

-Asymptomatic.
-End organ damage/ potential underlying aetiology should be taken.
=Late enuresis and recurrent urinary tract infections in childhood; reflux nephropathy
=Detailed family history: genetic basis for primary hypertension or identify familial renal disease.
=Paroxysmal or severe hypertension associated with headache and sweating or palpitations may be indicative of a Phaeochromocytoma, which can be fatal in pregnancy if missed.

-Examination: fundoscopy to identify hypertensive retinopathy and assessment for radio-femoral delay (coarctation of the aorta).
=Enlarged kidneys (polycystic kidneys)
=Renal bruit (renal artery stenosis)
=Clinical features of endocrine disease (e.g., hyperthyroidism, tachycardia, goitre, proptosis). Some of these conditions may have genetic or endocrine implications for the fetus

Question 17

Investigations in chronic hypertension

Answer 17

-Any woman of childbearing age identified to have chronic hypertension should have confirmation with 24-hour ambulatory monitoring and should be investigated for end organ damage, including an echocardiogram to assess for left ventricular hypertrophy and assessment of renal function and proteinuria.
-Referral for investigation for secondary causes should be made to an appropriate specialist depending on local expertise and interest (e.g., nephrology, clinical pharmacology, cardiology and endocrinology).
=Renal disease is the most common cause of secondary hypertension in pregnancy. Chronic kidney disease affects up to 3% of women aged 20 to 39 years and pregnancy may be the first time it is identified.

Question 18

Causes of chronic hypertension in pregnancy

Answer 18

-Chronic Kidney Disease
=Reflux nephropathy
=Lupus nephritis
=Immunoglobulin A nephropathy
=Autosomal-dominant polycystic kidney disease (ADPKD)
=Hypertensive nephropathy and obesity-related focal segmental glomerulosclerosis are becoming increasingly common.
=Women with reflux nephropathy and ADPKD may have affected family members but both conditions can also occur spontaneously.

-Endocrine
=Hyperthyroidism in women of childbearing age. A careful clinical history and examination may identify features of other conditions, including primary hyperparathyroidism, phaeochromocytoma, carcinoid and acromegaly.

Question 19

Pre-pregnancy counselling for chronic hypertension in pregnancy

Answer 19

-Optimise their hypertensive control, to plan switching from teratogenic medication to alternative agents and inform women about potential complications in the pregnancy. =Women should be advised that statin and fibrate treatment should be stopped before or at conception.
-Lifestyle adaptation, such as weight loss, reduced alcohol intake, a low-salt diet and exercise. Smoking cessation should be recommended for all smokers.
-Regarding treatment for chronic hypertension, some drugs that are commonly used in the non-pregnant (such as angiotensin-converting enzyme inhibitors) are best avoided as they have adverse fetal effects. The agents commonly used, labetalol and methyldopa. The dose of a single agent should be maximised before introduction of a second agent.
-All women with essential hypertension should be advised to take 100 to 150 mg aspirin from 12 weeks until delivery in order to reduce the risk of pre-eclampsia.

Question 20

Maternal complications of chronic hypertension

Answer 20

-The incidence of superimposed pre-eclampsia in women with chronic hypertension is approximately 20% but can be higher in women with secondary hypertension.
-Women with chronic hypertension may have undetectable renal damage that is only revealed by pregnancy.
-Therefore, a quantitative assessment of proteinuria should be performed at booking for comparison in later pregnancy.

Question 21

Timing of delivery in chronic hypertension

Answer 21

-Pre-term delivery, often iatrogenic, is more common in women with chronic hypertension compared with the general population.
-Timing of delivery should be guided by the severity of hypertension and the presence of proteinuria and fetal compromise, and balanced against the risks of prematurity at lower gestations.
-UK guidelines suggest that delivery for women with chronic hypertension should be managed as for women with gestational hypertension or, if proteinuria is present, then as for pre-eclampsia.

Question 22

Neonatal complications in chronic hypertension

Answer 22

-Neonatal complications are also more commonly reported for women with chronic hypertension than normotensive women, including higher rates of perinatal mortality, fetal growth restriction and admission to neonatal special care units

Question 23

Postpartum management in chronic hypertension

Answer 23

-Peak postpartum blood pressure usually occurs at 3 to 5 days.
-It is recommended that women with chronic hypertension should continue to have their blood pressure measured postpartum, and treatment titrated to keep blood pressure lower than 140/90 mmHg.
-Women with previously diagnosed chronic hypertension can be discharged when their blood pressure is stable and <140/90 mmHg or <150/100 mmHg with treatment.
-All women with chronic hypertension should be offered a medical review 6 to 8 weeks after delivery for future pre-pregnancy counselling.
-It is recommended that estrogen-containing contraceptives be avoided in women with hypertension due to their potential to exacerbate sodium retention and hypertension

Question 24

Risks of hypothyroidism

Answer 24

-If untreated, there is an increase in the rate of spontaneous miscarriages and stillbirths compared with the euthyroid population, as well as a risk of
=fetal neurological impairment.
-There is no fetal risk if the mother is treated and is euthyroid.

Question 25

Management of hypothyroidism in pregnancy

Answer 25

-Thyroid function should be regularly monitored, aiming to keep thyroid-stimulating hormone (TSH) and free thyroxine (T 4 ) within the normal range for pregnancy.
-If the woman is already on treatment and euthyroid at booking, the dose need not be increased.
-There is no evidence that treating subclinical hypothyroidism (normal T 4 with elevated TSH) either before or during pregnancy benefits pregnancy outcome.

Question 26

Risks of hyperthyroidism in pregnancy

Answer 26

-Untreated thyrotoxicosis is associated with high fetal mortality and a risk of maternal thyroid crisis when giving birth.
-Well-controlled hyperthyroidism is not associated with an increase in fetal anomalies, but there is a tendency for babies to be small for gestational age.
-Graves disease usually improves during pregnancy.

Question 27

Management of hyperthyroidism in pregnancy

Answer 27

-Carbimazole and propylthiouracil cross the placenta but are safe in pregnancy and potentially cause fetal thyroid suppression only in high doses.
-Radioactive iodine is contraindicated in pregnancy and surgery is indicated only for those with a very large goitre or poor compliance with oral therapy.
-The fetal thyroid gland secretes thyroid hormones from the 12th week and is independent of maternal control.

Question 28

Describe postpartum thyroiditis

Answer 28

-This occurs following 5% to 10% of all pregnancies, usually with initial hyperthyroidism, followed by hypothyroidism, and then recovery.
-Because the hypothyroidism occurs at around 1 to 3 months, the condition may be confused with postnatal depression.
-Symptoms of hyperthyroidism may be treated with propranolol (antithyroid drugs).
-Hypothyroidism should be treated with thyroxine as above, withdrawing around 6 months after childbirth.
-Affected women may require long-term treatment or may develop subsequent hypothyroidism.

Question 29

Risks of epilepsy in pregnancy

Answer 29

-Around a third of pregnant women with epilepsy have an increase in seizure frequency independent of the effects of medication.
-For women with epilepsy on treatment, the fall in antiepileptic drug (AED) levels due to dilution, reduced absorption, and increased drug metabolism may necessitate increased doses during pregnancy.
=This is particularly the case for lamotrigine.
-There is an increased incidence of fetal anomalies in association with the older AEDs (phenytoin 6%, carbamazepine 4% to 5% vs 3% in the general population)
-Single-drug regimens are less teratogenic than multidrug therapy and sodium valproate carries the highest risk of teratogenesis (10%),
=as well as being associated with an increased risk of neurocognitive impairment, autism spectrum disorders, and attention deficit disorder.
-The risk of congenital malformations seems not to be increased with lamotrigine and levetiracetam.

Question 30

Management of epilepsy in pregnancy

Answer 30

-Pre-pregnant counselling
=Monotherapy with AED ideal. Folate supplementation (5 mg/day) should be continued until at least 12 weeks

-AED dosage
=AED doses adjusted on clinical grounds. There are fetal risks from AEDs as well as from not taking the drugs (from increased fit frequency).
=Increased doses recommended for lamotrigine therapy.

-Detailed USS scan at 18-22 weeks
=Neural tube, cardiac, and craniofacial abnormalities, as well as diaphragmatic herniae, are more common

-Seizures
=Most seizures in pregnancy will be self-limiting. If prolonged, however, rectal or IV diazepam or IV lorazepam, with or without ventilation, may be required.

-Postnatal
=The mother may breastfeed safely (drugs pass into the milk, but neonatal levels are low for most AEDs).
=Advice should be given about safe and suitable settings for feeding, bathing, and so forth.
=Carbamazepine, phenytoin, primidone, and phenobarbitone induce liver enzymes, reducing the effectiveness of the standard-dose combined oral contraceptives. Therefore, a higher-dose estrogen preparation or alternative form of contraception is required.