Complicated Pregnancy

Question 1

What happens to a woman’s insulin requirement during pregnancy?

Answer 1

• Peaks at 9 weeks, nadirs at 16 weeks and increases steadily

Question 2

What glucose levels should be aimed for in pregnancy?

Answer 2

• Fasting 5.3, 2 hours post-meal 6.7
• HbA1c < 6.5% in early pregnancy

Question 3

List some complications of gestational diabetes?

Answer 3

• Foetal - congenital malformations, prematurity, macrosomia, growth restriction
• Neonatal - hypoglycaemia, erythrocytosis, hyperbilirubinaemia, hypocalcaemia, RDS, cardiomyopathy (fat deposition due to insulin), perinatal mortality
• Maternal - pre-eclampsia, polyhydramnios, preterm delivery, higher CS rate, worsening of microvascular disease

Question 4

What changes might you expect to see on a TFT during pregnancy?

Answer 4

• Increase in thyroid binding globulin due to oestrogen
  
  • T3/T4 production must increase to provide enough free hormone (peaks at 20 weeks)
• Stimulation of TSH receptor by HCG
  
  • Decrease in TSH
• ​Generally subclinical

Question 5

Outline (generally) the treatment of hyperthyroidism in pregnancy

Answer 5

• Clinical review if mild or transient (HCG-induced), otherwise beta-blockers (symptoms) or T1 propylthioiracil, T2 methimazole

Question 6

Outline how you might manage a woman with mild hypertension 140-150/90 during pregnancy

Answer 6

• Consider admission if unusual reading (?developing currently), but not necessary
• Check BP twice weekly
• Do not treat blood pressure
• Consider blood tests/growth scan

Question 7

If a woman presented during pregnancy with a blood pressure >160/110, what would you do? What other features would you seek?

Answer 7

• CNS/lung/hepatic/renal damage
• Admit with continuous CTG
• Bloods - FBE, UECs, LFTs, uric acid
• Stabilisation of blood pressure
• Steroids (risk of delivery)
• MgSO4
• Anaesthetic - don’t fluid load before spinal/epidural
• Deliver when possible

Question 8

Pregnancy is likely to worsen renal disease. What antenatal management considerations might you have for a woman with renal disease?

Answer 8

• More frequent prenatal visits (2-4 weekly)
• MSU screening for asymptomatic bacteriuria
• Serial monitoring of renal function
• Monitoring for pre-eclampsia
• Foetal monitoring
• Treatment of hypertension

Question 9

How long does the dilutional anaemia of pregnancy generally take to resolve?

Answer 9

• 6 weeks

Question 10

What effect does beta-thalassaemia trait have on the FBE results of women during pregnancy?

Answer 10

• Stronger physiological anaemia effect