Medical Conditions and Pregnancy part 2

Question 1

What are the teratogenic effects of sodium valproate

Answer 1

Neurocognitive impairment,
Autism spectrum disorders,
Attention deficit disorders,
Neural tube defects - even if not on AED there is still a higher risk of neural tube defects with maternal epilepsy.
Hypospadias,
Heart defects,
Craniofacial anomalies,
Skeletal anomalies,
Developmental delay

Question 2

What are the effects AEDs on fetal vitamin K

Answer 2

AEDs induce fetal hepatic activity which lower vitamin K and then results neonatal bleeding.
It is recomended to give all neonates konakion

Question 3

What are the effects of pregnancy on epilepsy

Answer 3

Often seizure activity isn’t changed but it can deteriorate. Potentially due to reduced absorption (N+V), impaired sleep and reduced drug levels due to the increased vol of distribution and metabolism.

Question 4

What is the management of epilepsy in pregnancy

Answer 4

Counselling - Monotherapy and requires folate supplement.
AED dose - lamotrigine increases.
Detailed ultrasound - neural tube, cardiac and cariofacial abnormalities.
Vitamin K for women on enzyme inducing AEDs.
Seizures - most will be self limiting but if prolonged then give diazepam/loraz.
Postnatal - breastfeeding safe
Contraception - Need higher dose oestrogen or alternative

Question 5

What is the antenatal, intraoartum and postpartum management for epilepsy

Answer 5

Antenatal - Drug monitoring and screen for birth defects at 11-13wk and 20wks.
Intrapartum - IV acess, continue AEDs at normal time, avoid maternal exhaustion, CTG monitoring, Benzos for seizure termination.
Postnatal - May need to modify doses, however most are safe with breastfeeding

Question 6

Describe the considerations around contraception and epilepsy

Answer 6

IUD, LNG-IUS and progesterone injections are not affected by enzyme inducing AEDs so promoted as most reliable

Question 7

What are the potential complications of Varicella Zoster virus in pregnancy?

Answer 7

Maternal chickenpox - pneumonia, hepatitis, encephalitis and mortality.
Fetal varicellar syndrome - Occurs if a non-immune women contracts VZV in the first week of pregnancy

Question 8

What are the features of congenital varicella syndrome?

Answer 8

Low birth weight, limp hypodysplasia, skin scarring, microcephaly, eye defects, learning disabilities

Question 9

What are the precaustions and management of varicella infections in pregnancy

Answer 9

If women has history of chickenpox/shingles or had to doses of vaccine and is not immunocompromised then not at risk.
If no history of VZV and has history of significant contact then test for VZV IgG. If positive then woman is immune. If negative then may need antiviral treatment of VZV immunoglobulin (VZIG)

Question 10

HIV and pregnancy

Answer 10

Highest risk of transmission during birth but can have prenatal transmission.
ART recommended during pregnancy.
If viral load < 50 copies/mL at 36 weeks then a planned vaginal delivery recommended.
If viral load > 50 copes/mL at 36wks then planned caesarian at 38weks.
Neonate started on PEP (zidovudine) within first 4 hrs and given for 4 weeks.
Avoid breastfeeding

Question 11

Neonatal testing for HIV

Answer 11

1. During first 48hrs before discharge.
2. 6 weeks of age
3. 12 weeks of age
4. 18 months

Question 12

Explain rhesus isoimmunisation

Answer 12

Occurs when rhesus negative mother carries a rhesus positive baby. Rh antigens from baby enter maternal circulation in delivery. Mother generates anti-Rh antibodies which with attack a subsequent Rh+ baby - HDN.

Question 13

What are the signs and symptoms of haemolytic disease of the newborn

Answer 13

Antenatally - Polyhydramnios, theickened placentas, hydrops (subcut oedema) and in-utero demise.
Postnatally - Jaundice, hepato-splenomegally, pallor, kernicterus (billirubin encephalopathy) and hypoglycaemia

Question 14

What are the investigations and management of rhesus incompatibility

Answer 14

Ix - check maternal blood groups and fetal blood group amnio
Rx - Anti-D after ectopic pregnancy, molar pregnancy, surgical TOP, medical/surgical miscarrage > 12 wks, severe bleeding < 12weks, after sensitising event >12wks. Also offer prophylaxis at 28 wks. After delivery test infant cord blood (blood group) and maternal blood (dose of Anti-D required)

Question 15

WHat are normal skin changes in pregnancy?

Answer 15

Hyperpigmentation,
Striae gravidarum,
Hair and nail changes,
Vascular - angiomas and spider naevia,
Greasier skin,
Pruritis

Question 16

What are some common skin diseases in pregnancy?

Answer 16

Atopic eruption of pregnancy,
Polymorphic eruption of pregancy.
Acne vulgaris or rosacea,
Psoriasis - give emmolients/steroids/dithranol/UVB.
Infections - Candida, warts or varicella.
Infestations - scabies.
Autoimmune - SLE or pemphigus gestationis

Question 17

Describe features of actopic eruption of pregnancy

Answer 17

Most common and presents before 3rd trimester.
E- type (eczema) - rough and red patches, typically on face, neck, elbows and knees.
P-Type (Prurigo) - Bumps develop and affect abdomen, arms and legs.
Treatment - Emollients, aqueous creams, topical steroids, antihistamines, UVB and oral steroids if severe.

Question 18

Describe features of polymorphic eruption of pregnancy

Answer 18

Pruritic eruption of lower abdomen and striae with umbilical sparing.
Fetal prognosis is normal.
Treatment - emollients, topical steroids and offer sedating antihistamine if itch causing sleep difficulties

Question 19

Describe features of pemphigus gestationis

Answer 19

Occurs in 2nd or 3rd trimester. Autoimmune disease which can cause urticarial lesions, wheals and bullae in umbilical area.
Risks (rare) - premature delivery FGR, transient blistering on infant, secondary infection.
Treatment - refer to dermatology. Treat with topical steroids, antihistamines and if severe then oral steroids.

Question 20

Rubella and pregnancy

Answer 20

Women planning to get pregnant should get MMR vaccine.
If in doubt then test for rubella immunity. If not immune then give two doses of MMR vaccine, three months apart.
If already pregnant then do not give vaccine as it is live. Instead give after birth

Question 21

What is congenital rubella syndrome and its features

Answer 21

Caused by maternal infection with rubella virus within first 20wks of pregnancy.
Features - congenital deafness, cataracts, congenital heart disease and learning difficulties

Question 22

Describe features of listeria in pregnancy

Answer 22

Listeria = gram +ve bacteria which causes listeriosis. 3x more likely in pregnant women.
Infection can be asymptomatic or cause flu-like illness, pneumonia or meningoencephalitis. it can increase risk of miscarrage or fetal death.

Question 23

Describe features of congenital CMV infection

Answer 23

Occurs when mother is infected with CMV in pregnancy.
Features - FGR, microcephaly, hearing and vision loss, learning difficulties and seizures.

Question 24

Describe features of congenital toxoplasmosis

Answer 24

Occurs when mother is infected with toxoplasma gondii.
Classic triad of congenital toxo: intracranial calcification, hydrocephalus and chorioretinitis (inflammation of choriod and retina)

Question 25

Describe features of parvovirus B19 infection normally

Answer 25

Self limiting viral infection which causes a diffuse bright red rash on both cheeks (Slapped cheek syndrome). It later causes a reticular erythematous rash on trunk.
Supportive treatment. No longer infectious once rash has appeared

Question 26

Describe features of parvovirus B19 in pregnancy

Answer 26

Can lead to several complications eg, miscarriage or fetal death, severe fetal anaemia which then leads to heart failure (hydrops fetalis) which can then lead to maternal pre-eclampsia-like syndrome

Question 27

Describe features of mirror syndrome

Answer 27

Maternal pre-eclampsia-like syndrome which is a rare complication of hydrops fetalis. Involves triad of hydrops fetalis, placental oedema and oedema in mother.
Also HTN and proteinuria.
Ix - IgM and IgG to parvovirus, rubella antibodies.
Treat supportively.

Question 28

Describe features of congenital zika virus

Answer 28

Occurs when women are infected with zika virus (spread by aedes mosquitos).
Features: Microcephaly, FGR and intracranial abnormalities (ventriculomegaly and cerebellar atrophy).
Ix - viral PCR and antibodies to Zika virus. No treatment.

Question 29

What is the managment of chickenpox in pregnancy?

Answer 29

Give oral aciclovir if she is >20wks and presents within 24 hours onset of rash.