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Endocrine > Pregnancy > Flashcards

Pregnancy Flashcards

1
Q

What are the three key events in the ovarian cycle?

Briefly describe each.

A
  1. Follicular growth - starts on day 1 of the ovarian cycle (day one of menstruation) - they egg is inside the follicle. This structure matures and grows in size over about 13 days
  2. Ovulation - the egg is released from the follicle
  3. Luteal phase - the lining of the uterus becomes thicker in anticipation of implantation
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2
Q

Which hormones do each of the following produce?

  1. Follicle
  2. Corpus luteum
  3. Implanted zygote
  4. Placenta (3)
  5. Pituitary
A
  1. Follcile secretes oestradiol
  2. Corpus luteum (remnants of the follicle after the oocyte has been released) produces progesterone
  3. If fertilization occurs, then the implanted zygote produces HCG (the hormone which is utilized in pregnancy testing)
  4. The placenta produces
    - Human placental lactogen (hPL)
    - Placental progesterone
    - Placental oestrogens
  5. During pregnancy, the pituitary expands in size and produces prolactin (lactogen), which is required for lactation
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3
Q

When does foetal organogenesis start?

What implications does this have for a mother with diabetes?

A

Foetal organogenesis starts at 5 weeks + and possibly earlier -> this means that organogenesis has started before the mother realises she is pregnant -> consequences for mothers with endocrine problems who require treatment throughout the pregnancy.

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4
Q

What do progesterones and hPL contribute to in a pregnant woman?
What consequence might this have?

A

Progesterones and hPL contribute to insulin resistance in the mother during pregnancy. In a predisposed patient, this can lead to raised blood glucose, and consequent gestational diabetes mellitus.

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5
Q

Give three complications that T1DM and T2DM can cause in pregnancy

A
  1. Congenital Malformation
  2. Prematurity
  3. Intra-uterine growth retardation (IUGR)
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6
Q

Give three complications that gestational diabetes can cause in pregnancy

A
  1. Macrosomia (>90th centile for size) - Delivery !!
  2. Polyhydramnios (lots of fluid)
  3. Intrauterine Death
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7
Q

If a mother is hyperglycaemic in pregnancy, what does this do to the baby during the pregnancy and post natal?

A

If a mother is hyperglycaemic during the pregnancy, then this will be passed onto the baby who will start producing a large amount of insulin to counter act it. Then, when the baby is born, they no longer get this raised supply of glucose, but they still have high insulin levels (note that insulin is a major growth factor in the developing foetus). This leads to a very heavy baby at birth, which then goes hypo after birth.

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8
Q

Give some complications related to each of the following systems, caused by gestational hyperglycaemia

  • CNS
  • MSK
  • GI/GU
A

CNS: Anencephaly, spina bifida
Skeletal: caudal regression syndrome
Genital + GI: ureteric duplication

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9
Q

What should you prescribe in pregnancy for a mother with type I or II diabetes?
What dose?
Why?

A

Folic Acid 5mg (cf 400ug in nonDM pregnancy) – this is especially important in diabetics. Folic acid reduces the risk of CNS defects. In diabetes you need a much bigger dose than normal – 5 mg as opposed too 4000ug.

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10
Q

How should you change a womans diabetes prescription in pregnancy?
What are the only two diabetic drugs safe in pregnancy?
How should you treat hypertension?

A

Consider change from tablets to insulin – a lot of modern drugs are not safe for use in pregnancy.
Metformin and glibenclamide are the only two diabetes drugs which are safe in pregnancy.
Regular eye checks (3 monthly) - accelerated progression of pre-existing retinopathy in pregnant women.
Avoid ACEI, Statin - for BP use Labetalol, Nifedipine, methyldopa.

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11
Q

What do you use to maintain good blood glucose during labour?

A

IV insulin

IV dextrose

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12
Q

Which drug treatments should you use for each of the following in pregnancy?

  • T1
  • T2
  • MODY
  • GDM
A

T1 Diabetes - Insulin
T2 Diabetes – Metformin, will probably need Insulin later
MODY - Glibenclamide
GDM – Lifestyle, Metformin, may need Insulin

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13
Q

How should you follow up GDM post partum?

A

NB – you need to make sure that GDM has gone away after the pregnancy, so do a 6 week post natal glucose tolerance test.
If you have GDM, then after 15 years you have a 50% risk of developing T2DM.
Note than in a very small number of patients, GDM may coincidentally be the start of T1DM.

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14
Q

What three things is it important to remember?

A
  1. Maternal thyroxine is important for neonatal development, especially CNS
  2. Increased demand on thyroid during pregnancy
  3. Plasma protein binding increases
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15
Q

What does hCG do in pregnancy related to the thyroid?

A

hCG effect (has a TSH like effect)

  • fT4 increased (14% of pregnancies)
  • Low TSH (0.1-0.4) 9% of pregnancies
  • Hyperemesis gravidarum – hCG HIGH, 50-60% have abnormal TSH/fT4
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16
Q

At what point are hCG levels highest in pregnancy?

How does this related to the thyroid?

A

hCG has a cross activity with TSH – get burst of hCG just after implantation -> helps to stimulate the thyroid -> increased levels of T4.
Through negative feedback, levels of TSH drop.
Remember that sickness and nausea in pregnancy is related to hCG levels – the higher they are, the more likely you are to vomit.

17
Q

What should you prescribe a hypothyroid patient as soon as they find out they are pregnant?

A

Increase thyroxine dose by 25mcg AS SOON AS pregnancy suspected
Check TFTs monthly for first 20 weeks then 2 monthly until term
The average dose increase is by 50% (e.g. from 100mcg to 150mcg) by 20 weeks.
Aim for TSH <3 mU/l

18
Q

Give some complications that hypothyroidism in pregnancy can cause

A

Increased abortion, preeclampsia, abruption, postpartum haemorrhage, preterm labour,
Foetal neuropsychological development

19
Q

Give five complications that hyperthyroidism can cause in pregnancy

A 
Infertility
Spontaneous miscarriage
Stillbirth
Thyroid crisis in labour
Transient Neonatal thyrotoxicosis – makes the baby jittery and fidgety
20
Q

Give three ways that you can tell the difference between hyperemesis from hyperthyroidism in pregnancy.

A
  1. Hyperemesis gravidarum has increased hCG, so TSH will be low
  2. Not TRab antibody positive
  3. Resolves by 20 wks gestation i.e. improves
21
Q

Give four features common to both hyperemesis and hyperthyroidism in pregnancy

A
  1. Nausea and vomiting
  2. Tachycardia
  3. Warm and sweaty
  4. Lack of wt gain
22
Q

How does the treatment of Graves disease differ in pregnancy as opposed to not

A

The treatment of Graves disease out of pregnancy it different to how you would usually manage it – usually you would start at a high dose and then gradually reduce, but in pregnancy you start low and work up.

23
Q

Which drugs should you prescribe for hyperthyroidism at each stage of the pregnancy?
When should you ideally start these drugs?

A

Propylthiouracil 1st trimester
Carbimazole 2/3rd trimester
Wait as late as possible

24
Q

Give four problems that Carbimazole can cause in pregnancy

A
  1. Can cause embryopathy in 1st trimester
  2. Scalp abnormalities
  3. GI abnormalities
  4. Choanal & Oesophageal atresia,
25
Q

Propylthiouracil

  • What can this cause the foetus?
  • When in the pregnancy should you give this?
A

Risk of liver toxicity

Best avoided except possibly in 1st trimester, but then switch to CBZ

26
Q

TrAb antibodies in pregnancy

  • Are these a normal finding?
  • What do they cause?
A

Check TRAb antibodies during pregnancy (ideally third trimester) -> if present alert neonatologist.
TRAb antibodies can cross the placenta and cause neonatal transient hyperthyroidism.

27
Q

What is the classic natural history of post partum thyroiditis?
How common is this?

A

At about 6-8 weeks you get transient hyperthyroidism.
It then crashes and you get hypothyroid at 4-6 months, then gradually increases back to normal
Don’t give drugs at first point, as you’ll make the hypo worse.
5% (3-16%) postpartum women (25% T1DM)

Endocrine (9 decks)

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