Medical Complications in Pregnancy and Post-Partum Flashcards
(81 cards)
1
Q
Disorders that can affect pregnancy?
A
There are many
Common conditions include: • Hypertension, PIH, PET • Diabetes • Epilepsy • Crohn's / UC
2
Q
How to manage any medical disorder in pregnancy?
A
- The usual antenatal care (ANC)
- Consider effect of pregnancy on the medical condition
- Effect of the medical condition on pregnancy (baby and mother)
- Medications and safe prescribing
- Planning of delivery (timing and mode)
- Post-partum follow-up
3
Q
What does the usual ANC involve?
A
Confirmation of pregnancy
Booking visit where: • General pregnancy advice is given • Woman is identified as being either low / high risk • Info on choices for place of birth • Discuss screening
Check:
• Height and weight (BMI)
• BP
Arrange:
• Dating USS, at 12 weeks
• Arrange booking bloods
4
Q
What parameters are checked on the booking bloods?
A
FBC, blood group and Abs
Haemoglobinopathies
Infection screen - hep B, HIV, Rubella, VDRL
Random Blood Glucose
5
Q
Schedule of antenatal visits with the midwife?
A
- Booking visit @ 8-12 weeks
- Dating USS @ 11-12 weeks (hospital)
- Anomaly Scan at 20 weeks
- Monthly visits till 28 weeks
- Anti D - 28 weeks & 34 weeks
- Fortnightly visits 28-36 weeks
- Weekly visits 37 weeks till delivery
6
Q
What happens at each antenatal visit?
A
BP
Urinalysis
SFH (FSH)
Foetal heart and movements
NOTE - if any problems are detected, referral to consultant unit
7
Q
Occurrence of hypertensive disorders in pregnancy?
A
Hypertension is the most common medical problem in pregnancy
Other issues include PET, severe PET and eclampsia (these are less common)
NOTE - the incidence of eclampsia and its complications have decrease in the UK
8
Q
Types of hypertensive disorders in pregnancy?
A
Chronic (essential) hypertension - present at booking or <20 weeks
Gestational hypertension - new hypertension >20 weeks, without significant proteinuria
Pre-eclampsia - new hypertension >20 weeks + significant proteinuria
9
Q
Physiology of pregnancy-specific hypertension?
A
There is potentially a placental cause that leads to maternal endothelial dysfunction and maternal hypertension
There is decreased blood flow to organs in pregnancy, due to:
• VASOCONSTRICTION
• Intravascular thrombosis
• Pro-coagulation
10
Q
Signs of renal disease?
A
Decreased GFR
Protein uria
Increased serum uric acid (also placental ischaemic) and increased creatinine / potassium / urea
Oliguria / anuria
11
Q
Causes of acute renal failure?
A
Acute tubular necrosis
Renal cortical necrosis
12
Q
Signs of liver disease?
A
Epigastric or RUQ pain
Abnormal liver enzymes
Hepatic capsule rupture
HELLP syndrome:
• Haemolysis
• Elevated liver enzymes
• Low platelets
13
Q
What is HELLP syndrome?
A
Life-threatening pregnancy complication usually considered to be a variant or complication of preeclampsia
It is an abbreviation of HELLP syndrome:
• Haemolysis
• Elevated Liver enzymes
• Low Platelet count
14
Q
Types of placental disease that can occur due to hypertension?
A
IUGR
Placental abruption
Intrauterine death
15
Q
Ix for conditions assoc. with hypertension?
A
U&Es, serum urate
LFTs
FBC
Coagulation screen
CTG
USS (biometry, AFI, Doppler)
16
Q
Mx of hypertension at booking and antenatally?
A
Assess risk factors for preeclampsia; if present, ASPIRIN
These patient require surveillance:
• Scans - dating, anomaly, growth scans and umbilical artery doppler
• BP monitoring
• Urine testing
17
Q
Principles of managing hypertension during pregnancy?
A
Booking:
• Assess risk at booking
• If hypertension is <20 weeks, look for a secondary cause
• Antenatal screening (BP, urine)
Antenatal:
• Treat hypertension
During labour: • Maternal and foetal surveillance • Timing of delivery • Stabilise and treat hypertenion, prevent convulsions • Deliver
18
Q
Medications used to treat hypertension in pregnancy?
A
- Labetalol
- Methyldopa
- Nifedipine (usually if monotherapy fails, i.e: it is used as a top-up)
STOP ACEIs and ARBs
19
Q
Medications used to treat severe hypertension (165/110)?
A
Labetalol (oral or IV)
Hydralazine (IV)
Nifedipine (oral)
20
Q
Target BP control?
A
Aim for BP <150 / 80-100 mmHg
If there is end-organ damage, e.g: renal damage causing proteinuria or retinal damage, aim for BP <140/90 mmHg
If BP <140/90, consider reducing drug dose; if <130/90, reduce the dose
21
Q
Delivery if patient has hypertension?
A
Vaginal delivery
If preeclampsia, deliver at 37 weeks
22
Q
Effects of pregnancy on diabetes?
A
Pregnancy is a diabetogenic state so: • Poorer control • Deterioration of renal function • Deterioration of ophthalmic disease • Gestational DM
23
Q
Effects of diabetes on pregnancy?
A
Miscarriage
Foetal malformations (cardiac, neural tube defects, caudal regression syndrome)
IUGR or macrosomia
Unexplained IUD
PET
24
Q
Mx of diabetes in pregnancy?
A
- Diet
- Metformin
- Insulin
25
Delivery if patient has diabetes?
Vaginal delivery; induce labour at 37-38 weeks
26
Types of diabetes in pregnancy?
Pre-existing T1DM
Pre-existing T2DM
Gestational diabetes
27
Effects of diabetes on the foetus?
Hyperglycaemia leads to foetal hyperinsulinaemia
This causes the following:
• Foetal macrosomia - risk of birth injury / shoulder dystocia
• Polyuria, polyhydramnios - risk of preterm labour / malpresentation / cord prolapse
• Increased O2 demands, polycythaemia - risk of unexplained term stillbirth
• Neonatal hypoglycaemia - risk of CP
28
Risk factors for GDM?
• Previous GDM
• FH:
– One first degree relative
– Two second degree relatives
* Poor obstetric history, esp. death of previous macrosomic baby
* Significant glycosuria
* Polyhydramnios
* Macrosomic infant in this pregnancy
* Polycystic ovary syndrome
* Weight >100kg or BMI >30
* South Asian, Middle Eastern or African origin
29
Ix and monitoring of diabetic pregnant women?
Screening
Detailed USS, inc. extended cardiac views
Diabetic control - aim for a BM of 4-6 and keep the HbA1c <6.0%
• Diabetic support
• Diet, metformin, insulin
• Retinal screening every trimester
30
Mx for diabetes during pregnancy?
Regular antenatal care is required, with serial growth scans at 28, 32 and 36 weeks
Must be monitored for PET
Elective delivery via IOL:
• If pre-existing DM, this should occur at 37-38 weeks
• If GDM on insulin, may be 38 wees
• If GDM on diet with a normal BM and foetal growth, may wait until 41 weeks
31
Mx for the neonate born to mother with diabetes?
Neonatal surveillance at delivery; monitor the BM to ensure that there is no neonatal hypoglycaemia
32
Mx of diabetes post-natally?
If pre-existing DM, return to pre-pregnancy insulin / oral hypoglycaemic agent regime
If GDM, stop treatment and monitor BM for 48 hours, to ensure return to normal and no persistence of IGT
33
Foetal effects of diabetes?
Macrosomia - increased risks of birth injury and shoulder dystocia; it is a major cause of obstetric litigation
Polyhydramnios:
• Foetal malpresentations
• Increased risk of preterm labour
Hyperinsulinaemia - leads to severe neonatal hypoglycaemia (risk of CP)
Polycythaemia:
• Thrombotic effects
• Jaundice
Hypocalcaemia
Hypertrophic cardiomyopathy (HOCM)
34
When is an LSCS recommended for macrosomia?
Macrosomia and EFW >4000g
35
Occurrence of VTE in pregnancy?
Rare but remains the MAIN CAUSE OF MATERNAL DEATH
Diagnosis is difficult during pregnancy, due to swollen calves and ankles, etc
36
Effects of pregnancy on VTE risk?
Increased risk of VTE / PE, as pregnancy is a pro-thrombotic state
This is compounded by the effects of Virchow's triad:
• Stasis secondary to venous compression by the pregnant uterus
• Hypercoagulability
• Vascular damage (leads to varicose veins)
37
Medications used for VTE in pregnancy?
LMWH
38
Coagulation changes in pregnancy?
Increased levels of factor VII, VIII, X and fibrinogen
There are effects on both the intrinsic and extrinsic pathways
39
Risk factors for VTE?
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Pre-existing risk factors:
• Previous VTE (biggest risk factor)
• Known high risk thrombophilia
• Medical comorbidities
• FH of unprovoked or oestrogen-related VTE in 1st degree relative
• Known low risk thrombophilia (no VTE)
• Age >35 years
• Obesity
• Parity ≥3
• Smoker
• Gross varicose veins
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Obstetric risk factors:
• Preeclampsia in current pregnancy
• ART / IVF (antenatal only)
• Caesarian section in labour
• Elective caesarian section
• Mid-cavity or rotational operative delivery
• Prolonged labour (>24 hours)
• PPH (>1L or transfusion)
• Preterm birth <37 weeks in current pregnancy
• Stillbirth in current pregnancy
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Transient risk factors:
• Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum, e.g: appendicectomy, postpartum sterilisation
• OHSS (1st trimester only)
• Current systemic infection
• Immobility, dehydration
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There is a risk assessment available; scores can be given to each risk factor
40
Mx of high risk patients for VTE?
Any previous VTE requires antenatal prophylaxis with PMRH
41
Mx of intermediate risk patients for VTE?
Consider antenatal prophylaxis with LMWH
42
Mx of patients with risk factors for VTE antenatally?
High risk requires antenatal prophylaxis with LMWH:
• Any previous VTE
Intermediate risk requires consideration of antenatal prophylaxis with LMWH
If ≥4 risk factors are present, prophylaxis from 1st trimester
If 3 risk factors present, prophylaxis from 28 weeks
If fewer than 3 risk factors, mobilisation and avoidance of dehydration
43
Mx of patient with risk factors for VTE postnatally?
High risk requires at least 6 weeks of postnatal prophylactic LMWH
Intermediate risk requires at least 10 days of postnatal prophylactic LMWH
If fewer than 2 risk factors, early mobilisation and avoidance of dehydration
44
What is a DVT?
Thrombosis in one of the deep veins of the leg
45
Signs of DVT?
1/2 of early DVTs are asymptomatic
Homan's sign (unreliable) - discomfort behind the knee on forced dorsiflexion of the foot
46
Ix DVT in pregnancy?
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Baseline Ix:
• FBC
• Clotting
• U&Es
• LFTs
• D-dimer (cannot be used in pregnancy)
• Anti-Xa levels (not routine)
• Platelet levels (not routine)
• Thrombophilia screen (not routine and controversial as results are affected in pregnancy and there is no influence on immediate Mx)
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D-dimer (cannot be used in pregnancy)
Duplex US on lower limb
47
Mx of DVT in pregnancy?
THERAPEUTIC LMWH (treat and then Ix) - given OD, as it has a long duration of action:
• Enoxaparin
• Tinzaparin
• Daltaparin
Continue till 3 months after delivery OR 6 months after treatment (whichever longer)
48
Use of thromboembolic deterrent stockings?
Used in the acute phase, for up to 2 years; there are issues with compliance
They decrease thrombotic syndrome by 50%
49
Advantages of using heparin?
Does not cross the placenta and is safe for the foetus
More effective in DVT
Less haemorrhagic manifestation, mortality, HIT, osteopaenia
50
Side effects of heparin?
Haemorrhage
Hypersensitivity
Allergy at the injection site
Heparin Induced Thrombocytopaenia (HIT)
Osteopaenia (prolonged usage can lead to osteoporosis)
51
Ix for PE?
ABGs, CXR (radiation dose to the foetus is negligible), ECG
Duplex US lower limbs - if -ve, not very helpful
Ventilation / perfusion scans
If any results are abnormal and there is a high clinical suspicion, do a CTPA (gold standard)
NOTE - treatment with heparin should be initiated prior to Ix
52
Use of CXR to look for a PE?
Normal in 1/2 of PE cases
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Signs include:
• Atelectasis
• Effusion
• Focal opacities
• Regional oligaemia
• Pulmonary oedema
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53
Risk of cancer with CTPA?
Risk of childhood cancer (lower than with a V/Q scan)
Increased risk of breast cancer (check for a history of this)
54
Delivery when patient is on heparin?
For a vaginal delivery, stop heparin when patient is in labour
Anaesthesia (epidural):
• Therapeutic - stop 24 hours before planned delivery
• Prophylactic - stop 12 hours before
55
Treatment of VTE or PE risk postnatally?
Within 6 weeks postnatal, treat for at least 3 months
Preferred choice is warfarin but LMWH may be used
56
Why is warfarin avoided during during initial pregnancy?
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Avoided at 6-12 weeks:
• Teratogenic
• Miscarriage risk
• Neuro problems
• Stillbirth
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57
If warfarin is used during pregnancy, when must it be stopped?
Avoid at 6-12 weeks
Stop 6 weeks before labour
58
Breastfeeding risks with warfarin?
Warfarin is fine with breastfeeding
59
Mx of hypothyroidism in pregnancy?
Increase levothyroxine by 25-50 mcg in the 1st trimester; repeat TFTs every trimester
Vaginal delivery
60
Effects of pregnancy on hyperthyroidism?
Worsens due to HCG in the 1st trimester but improves during the 2nd and 3rd trimester
61
Effects of hyperthyroidism on pregnancy?
IUGR, preterm labour
Thyroid storm
62
Mx of hyperthyroidism during pregnancy?
Carbimazole / PTU (TFTs are checked every trimester)
Propranolol (risk of IUGR)
Growth scans
63
Respiratory changes that occur in pregnancy?
Increased RR - causes respiratory alkalosis:
• Increased pH 7.43
• Decreased pCO2
• Decreased HCO3
Changes in PFTs due to mechanical effects of pregnancy on the lungs
O2 demand increases
TIDAL VOLUME increase
Inspiratory capacity increases
Residual volume decreases
Expiratory reserve decreases
Marked reduction in functional residual capacity:
• Diaphragmatic elevation
• Increase in subcostal angle and transverse thoracic diameter
FEV1 and PEFR unchanged
64
Effects of pregnancy on asthma?
May improve, deteriorate or remain unchanged; patients who improve during the 3rd trimester may deteriorate during the postnatal period
If mild disease, unlikely to experience issues
If severe disease, there is a greater risk of deterioration, esp. in the 3rd trimester
65
Why might asthmatic patients deteriorate during pregnancy?
Often due to a reduction or cessation of medication, due to unfounded safety fears
66
Effects of asthma on pregnancy?
For the majority of women, there is no adverse effect on pregnancy outcome
If asthma is severe and poorly controlled, the assoc. hypoxaemia may adversely affect the foetus
NOTE - adverse effect on pregnancy are rare and mainly assoc. with poor control:
• PIH / PET
• Preterm labour
• Low birth weight
• IUGR
• Neonatal morbidity, e.g: TTN, hypoglycaemia, seizures, etc
67
Mx of asthma in pregnancy?
Emphasise prevention
Treatment is the same as for non-pregnant women:
• Optimise control prior to pregnancy
• Achieve control ASAP in a new diagnosis
• Mainstay is β2-agonist +/- ICS
68
Occurrence of epilepsy?
Most are known prior to pregnancy
69
Risks assoc. with epilepsy during pregnancy?
All seizure types can be affected by pregnancy
Assoc. with risk of maternal death, due to aspiration
70
Effects of pregnancy on epilepsy?
Many patients experience no change and others have an increased seizure frequency
Poorly controlled epilepsy (>1 seizure per month) is likely to deteriorate
If the patient is seizure-free, prior to pregnancy, they are unlikely to have relapse, unless medication is stopped
71
When is the risk of seizures highest during an epileptic pregnancy?
In the peripartum period
72
Reasons for deterioration of asthma control?
Poor compliance (fears of teratogenesis)
Decreased drug levels due to N&V
Decreased drug levels due to increased Vd and increased drug clearance
Lack of sleep towards term and during labour
Lack of absorption of drugs during labour
Hyperventilation during labour
73
Effects of epilepsy on pregnancy?
Foetus is relatively resistant to short-term hypoxia (during seizures) and there is no evidence of adverse effects
No increased risk of miscarriage or obstetric complications
Status epilepticus (<1% of pregnancies) is dangerous for mother and baby, so treat vigorously
74
What is the major risk of epilepsy during pregnancy?
Teratogenecity of the drugs; even women on no drugs have an increased risk of malformations
This risk increases with the no. of drugs (polypharmacy)
NOTE - benzodiazepines are not teratogenic
75
Risk of the child developing epilepsy?
Higher if there is a FH
76
Teratogenic risks of anti-convulsants?
They are all teratogenic (newer drugs are thought to be safe but there are risks assoc.)
Major malformations:
• NTDs
• Orofacial clefts (esp. phenytoin)
• Cardiac defects (esp. phenytoin and valproate)
Minor malformations (foetal anti-convulsant syndrome):
• Dysmorphic features
• Hypertelorism - abnormally increased distance between 2 organs or bodily parts, usually referring to an increased distance between the orbits
• Hypoplastic nails and distal digits
77
Mx of epilepsy pre-conceptually?
Pre-pregnancy counselling
5mg folic acid (pre-conceptually for 12 weeks and throughout pregnancy)
78
Mx of epilepsy during pregnancy?
Continue folic acid throughout
Continue current drugs if well-controlled, except:
• Phenobarbitone - wean off / change, due to risks of neonatal withdrawal convulsions
Vitamin K, 10-20mg orally, from 34-36 weeks, if on hepatic enzyme inducers (due to risks of foetal vit K deficiency and Haemorrhagic Disease of the Newborn)
If giving steroids, increase the dose if enzyme-inducing drugs, e.g: phenoytoin, phenobarbitone, carbamazapine
79
Advice given to the epileptic patient and her relatives during pregnancy?
Advice shallow baths and showers (risk of drowning with seizure)
Relatives advised regarding the recovery position
80
Delivery of a baby from an epileptic woman?
Most have normal deliveries; LSCS is only used if recurrent generalised seizures in late pregnancy / labour
Continue anti-epileptic drugs in labour
Offer an early epidural to reduce pain / anxiety
81
Post-partum Mx for an epileptic woman?
Neonate given 1mg IM vitamin K
Encourage breastfeeding
Advise regarding shallow baths / showers with an unlocked door
Risks of SUDEP increase in pregnancy and during the postnatal period
