Systemic Disease in Pregnancy Flashcards
In pregnancy, there is an increase/decrease in the levels of thyroxine-binding globulin (TBG).
increase
In pregnancy, there is an increase in the levels of thyroxine-binding globulin (TBG). This causes
an increase in the levels of total thyroxine but does not affect the free thyroxine level.
Untreated thyrotoxicosis increases the risk of
fetal loss, maternal heart failure and premature labour
most common cause of thyrotoxicosis in pregnancy
Graves’ disease
activation of the TSH receptor by
HCG may also occur - often termed transient gestational hyperthyroidism.
HCG levels will fall in
second and third trimester
Thyrotoxicosis mx
‘Propylthiouracil is used in the first trimester of pregnancy in place of carbimazole, as the latter drug may be associated with an increased risk of congenital abnormalities. At the beginning of the second trimester, the woman should be switched back to carbimazole
propylthiouracil is associated with an increased risk of
severe hepatic injury
maternal free thyroxine levels should be kept in the which part of the normal reference range to avoid fetal hypothyroidism
upper third
thyrotrophin receptor stimulating antibodies should be checked at what gestation
30-36 weeks gestation
thyrotrophin receptor stimulating antibodies should be checked why?
helps to determine the risk of neonatal thyroid problems
block-and-replace regimes should not be used in pregnancy
true
radioiodine therapy is contraindicated in pregnancy
true
thyroxine is safe during pregnancy & breastfeeding
true
serum thyroid-stimulating hormone measured when in hypothyroidsm?
each trimester and 6-8 weeks post-partum
women require an increased/decrease dose of thyroxine during pregnancy
increase
by up to 50% as early as 4-6 weeks of pregnancy
most common liver disease of pregnancy.
Intrahepatic cholestasis of pregnancy
Intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis) occurs in around ?% of pregnancies and is generally seen in the ?trimester
Intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis) occurs in around 1% of pregnancies and is generally seen in the third trimester
Intrahepatic cholestasis of pregnancy sx
pruritus, often in the palms and soles no rash (although skin changes may be seen due to scratching)
Intrahepatic cholestasis of pregnancy ix
raised bilirubin
Intrahepatic cholestasis of pregnancy mx
ursodeoxycholic acid is used for symptomatic relief
weekly liver function tests
women are typically induced at 37 weeks
Intrahepatic cholestasis of pregnancy complications?
Complications include an increased rate of stillbirth. It is not generally associated with increased maternal morbidity
Acute fatty liver of pregnancy is rare complication which may occur when?
in the third trimester or the period immediately following delivery.
Acute fatty liver of pregnancy sx
abdominal pain nausea & vomiting headache jaundice hypoglycaemia
Acute fatty liver of pregnancy severe disease may result in?
pre-eclampsia
Acute fatty liver of pregnancy ix
ALT is typically elevated e.g. 500 u/l
Acute fatty liver of pregnancy mx
support care
once stabilised delivery is the definitive management
Gilbert’s, Dubin-Johnson syndrome, may be exacerbated during pregnancy
true
Rx smoking
Increased risk of miscarriage (increased risk of around 47%)
Increased risk of pre-term labour
Increased risk of stillbirth
IUGR
Increased risk of sudden unexpected death in infancy
Rx alcohol
Fetal alcohol syndrome (FAS)
learning difficulties
characteristic facies: smooth philtrum, thin vermilion, small palpebral fissures, epicanthic folds, microcephaly
IUGR & postnatal restricted growth
Binge drinking is a major risk factor for FAS
Rx cannabis
Similar to smoking risks due to tobacco content
Rx cocaine
Maternal risks
hypertension in pregnancy including pre-eclampsia
placental abruption
Fetal risk
prematurity
neonatal abstinence syndrome
Rx Heroin
Risk of neonatal abstinence syndrome
pregnancy is a hypercoagulable state
true
Pregnancy: DVT/PE majority occur ?
last trimester
Pregnancy: DVT/PE pathophysiology
increase in factors VII, VIII, X and fibrinogen
decrease in protein S
uterus presses on IVC causing venous stasis in legs
Pregnancy: DVT/PE mx
warfarin contraindicated
S/C low-molecular weight heparin preferred to IV heparin (less bleeding and thrombocytopenia)
Diabetes mellitus may be a pre-existing problem or develop during pregnancy, gestational diabetes.
true
Diabetes in pregnancy brealdown by type?
87.5% have gestational diabetes
7.5% have type 1 diabetes
5% have type 2 diabetes
Risk factors for gestational diabetes
BMI of > 30 kg/m²
previous macrosomic baby weighing 4.5 kg or above
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
Screening for gestational diabetes
women who’ve previously had gestational diabetes:
(OGTT) asap after booking and at 24-28 weeks if the first test is normal.
women with any of the other risk factors should be offered an OGTT at 24-28 weeks
NICE also recommend that early self-monitoring of blood glucose is an alternative to the OGTTs
Diagnostic thresholds for gestational diabetes
these have recently been updated by NICE, gestational diabetes is diagnosed if either:
fasting glucose is >= 5.6 mmol/l
2-hour glucose is >= 7.8 mmol/l
Management of gestational diabetes
if the fasting plasma glucose level is < 7 mmol//l a trial of diet and exercise should be offered
if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started
if glucose targets are still not met insulin should be added to diet/exercise/metformin
if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started
if the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered
glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment
Monitoring of gestational diabetes
newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week
women should be taught about selfmonitoring of blood glucose
advice about diet (including eating foods with a low glycaemic index) and exercise should be given
Management of pre-existing diabetes
weight loss for women with BMI of > 27 kg/m^2
stop oral hypoglycaemic agents, apart from metformin, and commence insulin
folic acid 5 mg/day from pre-conception to 12 weeks gestation
aspirin 75mg/day from 12 weeks until the birth of the baby, to reduce the risk of pre-eclampsia
tight glycaemic control reduces complication rates
true
Diabetic retinopathy can improve in pregnancy
false
can worsen
Diabetic women detailed anomaly scan at 20 weeks including
four-chamber view of the heart and outflow tracts
Targets for self monitoring of pregnant women (pre-existing and gestational diabetes)
Time
Fasting 5.3 mmol/l
1 hour after meals 7.8 mmol/l, or:
2 hour after meals 6.4 mmol/l
For patients with a suspected deep vein thrombosis (DVT) ix
Compression duplex ultrasound should be undertaken where there is clinical suspicion of DVT
For patients with a suspected pulmonary embolism (PE) ix
ECG and chest x-ray should be performed in all patients
In women who also have symptoms and signs of DVT, compression duplex ultrasound should be performed. If compression ultrasonography confirms the presence of DVT, no further investigation is necessary and treatment for VTE should continue
the decision to perform a V/Q or CTPA should be taken at a local level after discussion with the patient and radiologist
CTPA slightly increases the lifetime risk of maternal
lifetime risk of maternal breast cancer (increased by up to 13.6%, background risk of 1/200 for study population). Pregnancy makes breast tissue particularly sensitive to the effects of radiation
V/Q scanning carries a slightly increased risk of
childhood cancer compared with CTPA (1/50,000 versus less than 1/1,000,000)
D-dimer is of limited use in the investigation of thromboembolism as it often raised in pregnancy.
true
Pregnant women are screened for anaemia at:
the booking visit (often done at 8-10 weeks), and at
28 weeks
NICE use the following cut-offs to determine whether a woman should receive oral iron therapy:
Booking visit < 11 g/dl
28 weeks < 10.5 g/dl
The risks of uncontrolled epilepsy during pregnancy generally outweigh the risks of medication to the fetus.
true
All epileptic women thinking about becoming pregnant should be advised to take
folic acid 5mg per day well before pregnancy to minimise the risk of neural tube defects
Around ?% of newborns born to non-epileptic mothers have congenital defects. This rises to ?% if the mother takes antiepileptic medication.
Around 1-2% of newborns born to non-epileptic mothers have congenital defects. This rises to 3-4% if the mother takes antiepileptic medication.
sodium valproate: associated with
neural tube defects
phenytoin: associated with
cleft palate
lamotrigine: studies to date suggest the rate of congenital malformations may be low.
true
The dose of lamotrigine may need to be increased/decreased in pregnancy
increased
Aim for monotherapy in epilepsy
true
monitor antiepileptic drug levels
false
no indication
Breast feeding is generally considered safe for mothers taking antiepileptics with the possible exception of
the barbiturates
It is advised that pregnant women taking phenytoin are given
vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn
The update concludes that sodium valproate should not be used during pregnancy and in women of childbearing age unless clearly necessary. Why?
The November 2013 issue of the Drug Safety Update also carried a warning about new evidence showing a significant risk of neurodevelopmental delay in children following maternal use of sodium valproate.
Women of childbearing age should not start treatment without specialist neurological or psychiatric advice.
Gestational diabetes is the second most common medical disorder complicating pregnancy (after hypertension), affecting around 4% of pregnancies.
true
Gestational thrombocytopenia is
elatively common condition of pregnancy that results from a combination of dilution, decreased production and increased destruction of platelets. The latter is thought to be due to the increased work of the maternal spleen leading to mild sequestration.
Immune thrombocytopenia (ITP) is
an autoimmune condition that is usually associated with acute purpuric episodes in children, but a chronic relapsing course may be seen more frequently in women.
Differentiating between ITP and gestational thrombocytopenia is difficult
true
Gestational thrombocytopenia may be considered more likely if the platelet count continues to fall as pregnancy progresses, but this is not a reliable sign.
If the patient becomes dangerously thrombocytopenic mx?
she will usually be treated with steroids and a diagnosis of ITP assumed
Pregnant women found to have low platelets during a booking visit or those with a previous diagnosis of ITP may need to be tested for
serum antiplatelet antibodies for confirmation.
Which type of thrombocytopenia can affect neonate?
Gestational thrombocytopenia does not affect the neonate, but ITP can do if maternal antibodies cross the placenta.
Thromobocytopenia and neonate mx?
Depending on the degree of thrombocytopenia in the newborn, platelet transfusions may be indicated. Serial platelet counts can also be performed to see whether there is an inherited thrombocytopenia.
Rheumatoid arthritis (RA) typically develops in women of a reproductive age.
true
patients with early or poorly controlled RA should be advised to?
defer conception until their disease is more stable
RA symptoms tend to improve in pregnancy & resolve in most
false
RA symptoms tend to improve in pregnancy but only resolve in a small minority. Patients tend to have a flare following delivery
Methotrexate is safe in pregnancy
false
Methotrexate needs to be stopped at least ? before conception
6 months
Which rheumatoid drugs are safe/unsafe in pregnancy
methotrexate, leflunomide is not safe in pregnancy
sulfasalazine and hydroxychloroquine are considered safe in pregnancy
RA mx pregnancy
low-dose corticosteroids may be used in pregnancy to control symptoms
NSAIDs may be used until 32 weeks but after this time should be withdrawn due to the risk of early close of the ductus arteriosus
RA patients should be referred to an obstetric anaesthetist due to the risk of ?
atlanto-axial subluxation
A woman with a previous VTE history is automatically considered high risk and requires
low molecular weight heparin throughout the antenatal period and also input from experts.
A woman at intermediate risk of developing VTE due to ? should be considered for antenatal prophylactic low molecular weight heparin.
hospitalisation, surgery, co-morbidities or thrombophilia
The assessment at booking should include risk factors that increase the womans likelihood of developing VTE. These risk factors include:
Age > 35 Body mass index > 30 Parity > 3 Smoker Gross varicose veins Current pre-eclampsia Immobility Family history of unprovoked VTE Low risk thrombophilia Multiple pregnancy IVF pregnancy
VTE risk factors & mx protocols?
Four or more risk factors warrants immediate treatment with low molecular weight heparin continued until six weeks postnatal.
If a woman has three risk factors low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal.
If diagnosis of DVT is made shortly before delivery - mx?
continue anticoagulation treatment for at least 3 month, as in other patients with provoked DVTs.
VTE drugs safe/unsafe in preg
Low molecular weight heparin is the treatment of choice for VTE prophylaxis in pregnancy. Direct Oral Anticoagulants (DOACs) and warfarin should be avoided in pregnancy.
