Obs and gynae Flashcards
Post-partum thyroiditis
Occurs in up to 10% of pregnancies
Occurs as immune surveillance rebounds post-pregnancy
- More common if have TPO antibodies prior to
delivery
- Due to general thyroid inflammation
- May have painless smooth thyroid
enlargement
Triphasic pattern:
- 1-6 months = thyrotoxicosis
- 6-9 months = hypothyroidism
- 9-12 months = euthyroid
Treatment:
- Supportive
- Beta-blockers e.g. propranolol
- Levothyroxine if symptomatic hypothyroidism or TSH > 10
Intrahepatic cholestasis of pregnancy
Pruritis + elevated bile acids in the 2nd/3rd trimesters
Pathophysiology:
- Elevated oestrogen -> biliary stasis with reduced bile excretion
- Fetus is unable to remove excess bile acids from the blood + causes placental vasoconstriction with risk of hypoxia
Risk factors:
- Previous ICP
- Older maternal age
- Multiple gestation
Features:
- Pruritus
- Hands and feet
- Worse at night
- RUQ pain
- Nausea
- Elevated serum bile acids > 10
- May have transaminase derangement too
Management:
- Antihistamines
- Ursodeoxycholic acid as chelation
- Weekly LFT monitoring with preterm delivery dependent on the levels
Complications:
- Intra-uterine fetal abortion
- Preterm delivery
- Meconium-stained amniotic fluid +/- NRDS
Acute fatty liver of pregnancy
Presents with maternal liver dysfunction in the 3rd trimester
- Rare but life-threatening condition
Pathophysiology:
- Abnormal maternal fatty acid metabolism leads to infiltration of hepatocytes with microvesicles of fat
Risk factors:
- Pre-eclampsia or HEELP
- Male fetus
- Low BMI (<20)
Features:
- Nausea/vomiting
- Jaundice
- RUQ or epigastric pain
- Potential acute liver failure
Investigations:
- LFT elevation > 3x normal, raised bilirubin
- Leucocytosis
- Renal dysfunction
- Deranged clotting
- Hypoglycaemia
Management:
- Frequent glucose monitoring and fetal monitoring
- Immediate delivery - can be SVD or C-section
- Consider liver transplant if in fulminant liver failure
Complications:
- Maternal liver failure
- Maternal coagulopathy
- Increased risk of fetal loss
Cervical cancer
Aetiology:
- 70% related to HPV-16 and HPV-18
Polycystic ovarian syndrome
A common cause of anovulatory infertility
- Associated with peripheral insulin resistance
which increases cardiovascular risk
Pathophysiology:
- Peripheral insulin resistance with subsequent hyperinsulinaemia
- Reduced hepatic sex hormone-binding gobulin -> high free androgens -> ovarian suppression + weight gain
Features:
- Hyperangrogenism
- Hirsutism
- Acne
- Oligo/amenorrhoea
- Infertility
- Peripheral insulin resistance
- Weight gain
- HTN
- Diabetes
Investigations:
- Sex hormone levels:
- High testosterone
- High LH
- Low/normal FSH and oestradiol
- US abdomen (if > 18)
- >= 12 follicles in one of both ovaries with size
2-9mm
- Increased ovarian volume
- Rule-out thyroid disease, prolactinoma etc.
Management:
- Lifestyle optimisation
- Management of complications e.g. hirsutism, diabetes
- Medication:
- Co-cyprindiol - effective antiandrogen
- COCP if co-cyprindiol not possible
- Metformin
Hypothyroidism in pregnancy
High maternal TSH (uncontrolled disease) is associated with increased risk of fetal loss, HTN of pregnancy, placental abruption, preterm delivery, and aberrant neurological development
Consider screening for all women who are high risk with TSH and T4 levels
- Want TSH < 2.5 in 1st trimester and < 3.0 in
2nd/3rd trimesters
Haemodynamic changes in pregnancy
From 2nd trimester, increase in cardiac output + circulating blood volume
- Gain up to 1.6L
- Up to 50% increase in CO
- Increased metabolic demand
- Increased SV and HR, reduced peripheral
vascular resistance
- Tachycardia + large-volume pulse + warm
extremities
Reduced peripheral vascular resistance -> lower diastolic pressures
- Fading of aortic regurg murmurs
Can have displacement of the apex beat due to cardiomegaly and elevation of the diaphragm
Diabetes in pregnancy - complications in fetus
Maternal hyperglycaemia leads to fetal hyperglycaemia
- Anabolic effects
- Macrosomia + visceromegaly = increased risk
of obstructed birth, asphyxia, hypoxia etc.
- Macrosomia + visceromegaly = increased risk
- Placental vasculature effects
- Impaired development = IUGR
- Post-birth hypoglycaemia
- Manage with early feeding or IV dextrose
- Other:
- Persistent fetal circulation
- Polycythaemia with risk of jaundice, NEC
- Respiratory distress, TTN
- Congenital heart disease
Hyperthyroidism in pregnancy
In known hyperthyroidism, ensure TFTs are optimised prior to attempting pregnancy
- Monitor thyroid receptor autoantibodies
- Increased risk of neonatal hyperthyroidism
Management:
- Medical management
- 1st line - propylthiouracil
- 2nd line - carbimazole
- Avoid radioiodine, avoid surgery if possible
Transient gestational hyperthyroidism
13% of women have physiological and transient hyperthyroidism in 1st trimester due to the TSH-like effects of bHCG
Have increased free T4 and increased thyroid mass
Settles later in pregnancy
Gestational diabetes
Insulin requirement but also insulin resistance increases during pregnancy
Investigations:
- Fasting glucose > 5.6
- OGTT 1hr > 10
- OGTT 2hr > 7.8
Management:
- No complications and normal fasting glucose
- 1-2 weeks trial of diet + exercise
- Offer metformin if ineffective
- Fasting glucose > 7.0 or 6.0-6.9 with complications:
- Commence insulin
