Obs 2 Flashcards
Define epilepsy in pregnancy
A continuing tendancy to have seizures
What are the RFs for epilepsy?
- Family history
- Previous intracranial surgery
- Head injury
- Cerebrovascular disease
- CNS infections
What are the S/S of epilepsy in pregnancy?
Known personal history of epilepsy
What are the causes of seizures in pregnancy?
- Epilepsy
- Eclampsia
- Encephalitis or meningitis
- SOL
- CVA
- Cerebral malaria or toxoplasmosis
- TTP
- Drug/alcohol withdrawal
- Toxic overdose
- Metabolic abnormalities (e.g. hypoglycaemia)
What are the investigations for epilepsy in pregnancy?
- Bloods: (Effects of anticonvulsants) FBC (increase MCV), serum folate, serum anticonvulsants levels, LFTs
- Fetus: Detailed foetal anomaly scan +/- foetal echo
What is the management of epilepsy in pregnancy?
Pre-conceptual:
- Maximise control on least teratogenic monotherapy if possible
- Folic acid 5mg od
- Stress importance of compliance with medication
- Explain risk of congenital malformation
- Explain risk from recurrent seizures
Medication:
- Remains the same (benefits outweigh risks of changing) if well controlled with phenytoin, carbamazepine, lamotrigine, valproate, phenobaritone or levetiracetam
- Seizures should be controlled with the minimum possible dose of the optimal anticonvulsant drug
- May require increased doses / may need to monitor drug levels
- If diagnosed in pregnancy, lamotrigine and carbamazepine are drugs of choice
- Vitamin K from 36/40 if enzyme- inducing drugs taken
- Seizures (1st presentation) in 2nd half of pregnancy, which can’t be attributed to epilepsy - immediate treatment for eclampsia until definitive diagnosis made by full neuro assessment
Delivery:
- Delivery MODE and TIMING unaffected unless seizures are increasing in frequency
- Continue medications
- May require diazepam/lorazepam if seizures during labour
- Epidural recommended to reduce stressors that can illicit seizures
Post-natal:
- IM neonatal vitamin K
- Gradually reduce doses of any medications increased in pregnancy to baseline
- Encourage breastfeeding (this is safe)
What are the complications of anti-epileptic medication on pregnancy?
Increased risk of congenital abnormality (2-3x increase)
- Neural tube defects
- Facial clefts
- Cardiac defects
- Developmental delay
- Nail hypoplasia
- IUGR
- Midface abnormalities
These complications can often be detected in anomaly scans
What are the best AEDs to use in pregnancy?
NO Sodium valproate > neural tube defects
NO Phenytoin > cleft palate
YES Lamotrigine > lowest rate of congenital malformations (and levetiracetam)
YES Carbamazepine > least teratogenic of the old antiepileptics
What is gestational trophoblastic disease (GTD)?
Molar pregnancy
A group of rare diseases in which abnormal trophoblast cells grow inside the uterus after conception.
What is the aetiology of GTD?
Caused by a chromosomal abnormality of trophoblastic tissue
What are the 2 classifications of GTD?
Non-invasive:
- Hydatidiform mole
Invasive:
- Malignancy
What is a Hydatidiform mole?
A benign tumour of the trophoblastic tissue
What are the types of Hydatidiform mole?
Complete:
- Empty egg fertilised by 2 sperm or 1 which duplicates DNA
- Diploid - 46 XY or 46 XX
- Paternal origin
- 15% > GTN
Partial:
- Normal egg fertilised by 2 sperm or 1 which duplicates DNA
- Triploid - 69 XXX or 69 XXY
- 1x maternal and 2x paternal origin
- 0.5% > GTN
What are the RFs for GTD?
- Extremes of reproductive age
- Asian ethnicity
- Previous GTD
What are the S/S of a Hydatidiform mole?
- Painless PV bleeding (i.e. miscarriage) in 1st or early 2nd trimester
- Exaggerated symptoms of pregnancy e.g. hyperemesis
- Uterus large for dates
- Very high serum levels of hCG
- Hypertension / pre-eclampsia
- Hyperthyroidism (high bHCG mimicking TSH)
- Often seen on USS before symptoms
What does pre-eclampsia occurring early on in pregnancy suggest?
Molar pregnancy?
What are the investigations for a Hydatidiform mole?
Bloods:
- βHCG grossly elevated
- (b-hCG similar to TSH > low TSH, high T4)
Pelvic USS:
- Complete mole = snowstorm (solid collection of echoes with numerous small anechoic spaces) / ‘cluster of grapes’ (swollen chorionic villi), no foetal parts
- Incomplete mole = abnormal foetal parts
What is the management for a Hydatidiform mole?
Urgent referral to specialist centre…
1st = Surgical:
- ERPC / surgical curettage
- Products sent for histopathology and genetic testing
Then… monitoring:
- Weekly βHCG monitoring until it’s no longer detectable
- If bhCG continues to rise / plateaus / till positive at 6m > refer to gynae oncologist for likely chemo > choriocarcinoma?
- Methotrexate if rising or stagnant levels?
Advice:
- Avoid pregnancy until 6 months of normal levels
- Do not conceive until follow-up is complete (barrier and COCP)
- Avoid IUDs until hCG normalised
What is malignant GTD?
A form of GTD associated with local invasion or metastasis
- Rapidly metastasising (lung, vagina, brain, liver, kidney)
What are the types of malignant GTD?
Invasive mole:
- Hydatidiform mole with local invasion in the uterus (myometrium, necrosis and haemorrhage)
Choriocarcinoma:
- Rare, fast growing trophoblastic malignancy
- Rapidly metastasise (commonly lung)
Placental site trophoblastic tumour:
- From intermediate trophoblasts (very rare – less than 1% of GTD is PSTTs)
What are the aetiologies of malignant GTD?
- Invasive moles always follow hydatidiform mole
Choriocarcinoma arises from…
- Molar pregnancy (50%)
- Viable pregnancy (22%)
- Miscarriage (25%)
- Ectopic pregnancy (3%)
What are the S/S of malignant GTD?
- Persistent PV bleeding, hyperemesis gravidarum, lower abdominal pain
- Lung metastasis – haemoptysis, dyspnoea, pleuritic pain
- Bladder/bowel – haematuria, PR bleeding
- O/E → excessive uterine size for gestation
