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CP2 OBS > Other Medical Disorders in Pregnancy > Flashcards

Other Medical Disorders in Pregnancy Flashcards

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1
Q

Why does glucose tolerance decrease in pregnancy?

A

Due to altered carbohydrate metabolism and the antagonistic effects of human placental lactogen, progesterone and cortisol

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2
Q

What do we mean when we say pregnancy is ‘diabetogenic’?

A

women without diabetes, but with impaired or potentially impaired glucose tolerance often deteriorate enough to be classified as diabetic in pregnancy

Even slightly increased glucose levels have adverse pregnancy effects - they are reduced by treatment

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3
Q

at what threshold do the kidneys of non-pregnant women start to excrete glucose?

How does this change in pregnancy?

A

11mmol/L

Varies more, but often decreases, so glycosuria may occur at physiological blood glucose concentrations

urinalysis for glycosuria is not a useful diagnostic test

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4
Q

What is the result of raised foetal blood glucose levels?

A

Foetal hyperinsulinaemia

causing foetal fat deposition and excessive growth - macrosomia

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5
Q

What % of pregnant women are affected by pre-existing diabetes?

A

1%

In those on insulin, increasing amounts will be required in these pregnancies to maintain normoglycaemia

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6
Q

What is gestational diabetes?

A

Gestational diabetes refers to diabetes triggered by pregnancy. It is caused by reduced insulin sensitivity during pregnancy, and resolves after birth.

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7
Q

What is the NICE threshold for gestational diabetes?

A

normal:
Fasting: < 5.6 mmol/l
At 2 hours: < 7.8 mmol/l
Results higher than these values are used to diagnose gestational diabetes.

It is really easy to remember the cutoff for gestational diabetes as simply 5 – 6 – 7 – 8.

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8
Q

What are the foetal complications of gestational diabetes?

A

Congenital abnormalities - NTD (2-4 Ames more common in women with established diabetes and are related to periconceptual glucose control)

Preterm labour (natural or induced) occurs in >10% women with established diabetes

Fetal lung maturity - less than with non-diabetic pregnancies

Birthweight - increased

Dystocia - and birth trauma: baby larger. related particularly to poor 3rd trimester glucose control

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9
Q

Why does gestational diabetes result in large babies?

A

foetal pancreatic islet cell hyperplasia leads to hyperinsulinaemia and fat deposition - this leads to increased urine polyhydramnios

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10
Q

What are the maternal complications of gestational diabetes?

A

Insulin requirements - increase by up to 300% by the end of pregnancy
Ketoacidosis - rate but hypoglycaemia may result
UTI
Wound or endometrial infection
Hypertension and pre-eclampsia
Pre-existing ischaemic heart disease
C-section or instrumental delivery
Diabetic nephropathy (5-10%)
can lead to massive proteinuria and deterioration of maternal renal function
Diabetic retinopathy - often deteriorates in pregnancy - may need to be treated

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11
Q

What is the preconceptual care of diabetes?

A

Glucose levels need to be optimum at conception to reduce risk of fatal complications.

HbA1c <6.5% and pregnancy not advised if >10%. Fasting glucose should be 4-7mmol/K if achievable without hypoglycaemia. Metformin and insulin are appropriate, but others must be stopped

5mg folic acid

Statins stopped and anti-hypertensives (labetalol/methyldopa) given instead

Renal function (creatinine <120umol/L), BP and retinae are assessed

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12
Q

What is the aim for glucose levels in pregnancy?

A

Fasting <5.6mmol/L

1hr <7.8mmol/L

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13
Q

What other measures need to be taken during pregnancy to Monitor for diabetes?

A

Renal function checked and retinae screened for retinopathy - if abnormal, this needs to be repeated every trimester

Aspirin (75mg) daily from 12 weeks advised to reduce risk of pre-eclampsia

Foetal monitoring: fetal echo, USS to monitor growth and liquor volume at 32 and 35 weeks

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14
Q

At what week gestation is delivery advised for diabetic women?

A

37-39 weeks as birth trauma more likely

C-section where estimated foetal weight is >4kg.

During labour, glucose levels are maintained with sliding scale of insulin and dextrose infusion

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15
Q

Why does the neonate commonly develop hypoglycaemia?

What is the management of this?

A

become accustomed to hyperglycaemia and therefore has high insulin levels

Levels should be checked within 4 hours - breastfeeding Is strongly advised

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16
Q

What are the factors indicating screening for gestational diabetes?

A 
Previous large baby (>4.5kg) 
Unexplained stillbirth 
1st degree relative with diabetes 
BMI >30kg/m2 
Minority ethnic family origin 
Previous gestational diabetes
Large for dates fetus

Women with pregnancy factors - e.g. polyhydramnios or persistent glycosuria

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17
Q

What is the screening for gestational diabetes?

A

24-28 weeks:
An OGTT
The patient drinks a 75g glucose drink at the start of the test. The blood sugar level is measured before the sugar drink (fasting) and then at 2 hours.

Hba1c levels to identify pre-existing diabetes.
Target levels are the same in pre-existing diabetes

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18
Q

What is the management of gestational diabetes?

A

Initially managed with diet and exercise advice.

Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin

Fasting glucose above 7 mmol/l: start insulin ± metformin

Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin

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19
Q

What % increase of CO is there in pregnancy? Why does this occur?

A

40%

Due to increase in stroke volume and heart rate and a 40% increase in blood volume

50% decrease in systemic vascular resistance, so BP often drops in 2nd trimester but has returned to normal by term

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20
Q

What % women have a flow murmur during pregnancy?

A

90%

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21
Q

What ECG changes are seen in pregnant women?

A

left axis shift and inverted T waves

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22
Q

What % of women are affected by cardiac disease?

A

0.3%

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23
Q

why does cardiac disease occur in pregnancy?

A

Increased Co –> exercise test (heart may be unable to cope)

decompensation in association with blood loss and fluid overload >28 weeks or soon after labour

Fluid overload can also occur in early puerperium as the uterine involution squeezes a large fluid load into the circulation

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24
Q

How are patients assessed pre-pregnancy for cardiac disease?

A

echo
contraindication of some drugs - ACEi and warfarin

hypertension often managed by beta-blockers ad thromboprophylaxis by LMWH

Fluid balance important = elective epidural analgesia reduces after load - elective forceps helps avoid the additional stress of pushing in severe cases

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25
What are the types of cardiac disease that can onset in pregnancy?
Mild abnormalities - e.g. mitral valve prolapse, PDA, uncomplicated VSD/ASD Pulmonary HTN - e.g. eisenmenger's because of high maternal mortality, pregnancy = contraindicated Cyanotic heart disease without pulmonary HTN - usually corrected but there is a particular risk of paradoxical embolism. anti-coagulation is advised Aortic stenosis - severe disease causes an inability to increase CO when required and should be corrected before pregnancy. Beta-blockage epidural analgesia is contraindicated in the most severe cases Mitral valve disease - should be treated before pregnancy. MI Peripartum cardiomyopathy
26
How is mitral stenosis treated in late pregnancy?
Beta-blockade used | artificial metal valves are prone to thrombosis, so anti-coagulation is indicated
27
When does permpartum cardiomyopathy tend to develop?
Last month or first 6 months after pregnancy Frequently diagnosed late. Cause of maternal death and more than 50% leads to permanent LV dysfunction.
28
What is the management of peripartum cardiomyopathy?
Supportive - diuretics and ACE-i | Significant recurrence rate if subsequent pregnancies
29
By what volume is tidal volume increased by in pregnancy
40% - no change in respiratory rate
30
What common respiratory condition is common in pregnancy?
asthma
31
Why do women on long-term steroids require an increased dose in labour?
chronically suppressed adrenal cortex is unable to produce adequate steroids for the stress of labour
32
What % of women does epilepsy affect?
0.5% - seizure control can deteriorate in pregnancy (particularly in labour)
33
How are epileptic women managed in pregnancy?
Epilepsy = significant cause of maternal death Anti-epileptic treatment should be continued, however, the risk of congenital abnormalities (NTD) is increased due to drug therapy. risk = dose dependent, higher with multiple drug usage and certain drugs Seizure control with as few drugs as possible + folic acid (5mg/day) Valproate avoided Vit-K for enzyme inducing anti-epileptics
34
What is the risk of the new born developing epilepsy if the mother is epileptic?
3%
35
What drugs are safest for epilepsy in pregnancy?
Levetiracetam, lamotrigine and carbamazepine are the safer anti-epileptic medication in pregnancy Sodium valproate is avoided as it causes neural tube defects and developmental delay Phenytoin is avoided as it causes cleft lip and palate
36
When does foetal thyroxine production begin?
12 weeks
37
Before foetuses start producing thyroxine, where do they get their thyroxine from?
other - maternal TSH is increased in early pregnancy
38
What are the causes of hypothyroidism in pregnant women?
Hashimoto's thyroiditis or thyroid surgery
39
What are the associated risks of hypothyroidism in pregnancy?
untreated - high perinatal mortality subclinical - miscarriage, preterm delivery and intellectual impairment in childhood. Increased risk of pre-eclampsia , particularly if antithyrozine antibodies are present
40
What is the cause of hyperthyroidism in pregnant women?
Grave's disease
41
What is the result of untreated hyperthyroidism?
perinatal mortality anti-thyroid antibodies can cross the placenta and cause neonatal thyrotoxicosis and goitre. For the mother, thyrotoxicosis may improve in late pregnancy, but poorly controlled disease can lead to a 'thyroid storm'
42
What is hyperthyroidism treated with?
Propylthiouracil (PTU) in the 1st trimester rather than carbimazole, but it can cross the placenta and cause neonatal hypothyroidism
43
What is postpartum thyroiditis?
Common condition causing post-natal depression Usually a transient and subclinical hyperthyroidism at about 3 months postpartum followed by about 4 months by hypothyroidism - permanent in 20%
44
What are the risk factors for portpartum thyroiditis?
anti-thyroid antibodies and T1DM
45
What is the incidence of acute fatty liver in pregnancy?
Very rare (1 in 9000) - serious condition that is part of the spectrum of pre-eclampsia
46
What are the early features of acute fatty liver?
malaise, vomiting, jaundice and vague epigastric pain thirst may occur weeks earlier
47
What is the management of acute fatty liver in pregnancy?
early diagnosis and prompt delivery - correction of clotting defects and hypoglycaemia are needed first Treatment = then supportive; further dextrose, blood products, careful fluid balance and occasionally dialysis
48
What are the clinical features of intrahepatic cholestasis of pregnancy?
Unexplained pruritus Abnormal LFT Raised bile acids
49
What is the cause of obstetric cholestasis?
Obstetric cholestasis is characterised by the reduced outflow of bile acids from the liver. thought to be the result of increased oestrogen and progesterone levels. Occurs in 0.7% women familial tends to reoccur (50%)
50
What are the associated risks of obstetric cholestasis
Increased risk of stilbirth? Meconium passage PPH - stillburth is thought to be due to the toxic effects of bile salts
51
What is the management of obstetric cholestasis?
Resolves with delivery UDCA (ursodeoxycholic acid) helps relieve itching - reducing bile acid leves Emollients + antihistamines High risk of maternal and foetal haemorrhage - vitamin K 10mg/day given from 36 weeks Induction of labour offered six week follow up after labour to endure liver function returns to normal
52
By how much does GFR increase by in pregnancy? What are the effects o this?
40% Urea and creatinine levels decrease
53
What is the threshold risk for pregnancy being v high risk in ckd?
>200mmol/L
54
What are the foetal complications of CKD in pregnancy?
Preterm delivery Pre-eclampsia IUGR Polyhydramnios
55
What is the management of CKD in pregnancy?
USS for foetal growth measurement of renal function screening for urinary infection control of HTN - in severe cases, dialysis is necczsssay
56
What are urinary infections associated with in pregnancy?
Preterm labour Anaemia Increased perinatal morbidity and mortality
57
How are urinary infections managed in pregnancy?
Urine cultured at booking visit (12 weeks( and asymptomatic bacteruria treated
58
What are the clinical features of pyelonephritis? What is the predominant cause?
Loin pain, rigors, vomiting and fever E.coli
59
What is antiphospholipid syndrome (APS)
When the lupus anticoagulant and/or anticardiolipin antibodies occur in association with adverse pregnancy complications or thrombotic events. Fetal loss = high
60
What are the consequences of APS?
Placental thrombosis Recurrent miscarriage IUGR Early pre-eclampsia
61
What is the management for APS?
'high risk' - serial USS and elective induction of labour at least by term Treatment with aspirin and LMWH - postnatal ant-coagulation is recommended to prevent venous thromboembolism
62
What are the other protherombotic disorders that can increase risk of pregnancy complications?
Antithrombin deficiency Protein S or C deficience Prothrombin gene mutation Factor V Leiden heterozygosity
63
What is hyperhomocysteinaemia associated with?
Increased pregnancy loss and pre-eclampsia Tx - high dose folic acid Postnatal anticoagulation
64
What are the effects of pregnancy being prothrombotic?
Incidence of VTE = sixfold Blood clotting factors = increased, fibrinolytic activity is reduced and blood is altered by mechanical obstruction and immobility
65
Describe the effects of PE in pregnancy?
leading 'direct' cause of death Embolism - mortality 3.5% Causes chest pain, dyspnoea, tachycardia, raised RR and JVP and chest abnormalities
66
how is PE diagnosed in pregnancy?
Doppler ultrasound is the investigation of choice for patients with suspected deep vein thrombosis. Women with suspected pulmonary embolism require: Chest xray ECG CTPA V/Q The Wells score is not validated for use in pregnant women. D-dimers are not helpful in pregnant patients, as pregnancy is a cause of a raised D-dimer.
67
Where do DVTs tend to occur in pregnancy?
Iliofemoral and on the left - doppler examination and venogram/pelvic MRI used to diagnose
68
What is the presentation of cerebral venous thrombosis?
Headache/stroke
69
How is cerebral venous thrombosis managed?
thrombophilia screen before tx with subcut LMWH dosing = weight based and adjusted according to anti-Factor Xa level clearance rapid, so level higher NOT warfarin antenatally (teratogenic) LMWH/warfarin safe in breastfeeding Mobilisation + maintenance of hydration. compression stockings
70
Who are given antenatal / postpartum prophylaxis of VTE
Antenatal - women @ very high risk e.g. previous VTE ASAP or from 28 weeks Postpartum - if used antenatally, then continued or if there is a major or intermediate risk factor or two or more minor risk factors - LMWH is prescribed for at least 10 days and can usually be given 12 hours after delivery
71
What are the criteria for high risk VTE postpartum? | What is the management?
if LMWH used antenatally | Previous VTE
72
What are the intermediate risk factors for VTE postpartum? | What is the management
``` Thrombophilia Caesarean in labour BMI >40 prolonged hospitalisation IV drug abuser medical illness ``` 1 week LMWH if 1+
73
What are the moderate risk factors for VTE postpartum? | What is the management?
``` BMI >30 Age >35 or parity >3 Smoker Elective caesarian Varicose veins Current systemic infection Pre-eclampsia Immobility PPH Rotational delivery Labour >24h ``` I week LMWH if 2+
74
What are the risks associated with BMI >30 in pregnancy?
``` Thromboembolism Pre-eclampsia Diabetes C-section Wound infection Difficult surgery PPH maternal death ``` Higher rate of congenital abnormalities
75
What is the management of obesity in pregnancy?
High dose folic acid (5mg) vitamin D High risk if >35 (screening for diabetes and closer BP surveillance) Formal anaesthetic risk assessment and antenatal thromboprophylaxis if >40 Elective C-section?
76
When is the most high risk time for mental illness in pregnant women?
early postnatal
77
What are the red flag signs for mental illness?
Recent significant change in mental state Emergence of new symptoms New thought Acts of violent self harm New and persistent expressions of incompetency as mother Estrangement from the infant
78
What are the risks of BPAD?
Lifetime risk - 1% Onset most commonly during child-bearing age Delivery can precipitate in women with bipolar
79
What are the treatments for BPAD?
Mood stabiliser anti-psychotics anti-convulsants Lithium Tx decisions = cost/benefit to foetus
80
What is the presentation of postpartum psychosis?
Psychiatric emergency - presents suddenly in the early postnatal period with psychotic and severe mood sx Acute risk of suicide, self-harm or neglect, neglect of the baby, intentional self-harm to the baby = rare
81
What % of pregnant/postnatal women are affected by depression?
10-15% highest in post-natal period
82
What is the management of depression in pregnancy?
CBT - first line in mild to moderate depression Anti-depressants = effective in severe depression Sertraline preferred Paroxetine - congenital malformations and avoided NB withdrawal and short-term side effects of anti-depressants have been seen in neonate
83
What are the types of anxiety disorders than can affect pregnant women?
``` GAD Panic disorder Phobias OCD - may increase in perinatal period PTSD - traumatic experience during delivery ``` Tokophobia - fear of childbirth
84
What is the management of anxiety in pregnancy?
Psychological therapies first line medications reserved for severe cases (anti-depressants) BDZ not recommended in pregnancy - dependency, neonatal withdrawal and oversedation
85
What % of women are affected by schizophrenia?
1% women over the course of a lifetime most common during childbearing age
86
What is the management of schizophrenia in pregnancy? What are the effects of these?
Long-term treatment with antipsychotics Not shown to be teratogenic However, olanzapine and quetiapine = weight gain and therefore gestational diabetes Treatment usually continued due to high risks of relapse if medication stopped permanently
87
What recreational drugs are used in pregnancy and what are the effects of these?
``` OPIATEs COCAINE ECSTASY BDZ Cannabis ```
88
What are the effects of opiate use in pregnancy?
not teratogenic BUT preterm delivery, IUGR, stillbirth, developmental delay, sudden infant death syndrome methadone advised - some neonates experience severe withdrawal and convulsions
89
What are the effects of cocaine use?
probably teratogenic, can cause childhood intellectual impairment, IUGR, placental abruption, preterm delivery, stillbirth and SIDS
90
What are the effects of ecstasy use?
teratogenic, increased risk of cardiac defects and probably gastroschisis pregnancy complications are similar to cocaine
91
What are the effects of cannabis use?
Abuse of other drugs makes attribution of risk difficult - may cause IUGR and affect later childhood development
92
What are the effects of alcohol use in pregnancy?
<3 units a week - no consistent evidence of harm May cause miscarriage in first 12 weeks - at higher levels, the incidence of IUGR and birth defects increases Alcohol abuse in pregnancy - fetal alcohol syndrome. Facial abnormalities, growth restriction, small/abnormal brain and developmental delay (>18 units/day) Alcohol spectrum disorder - lesser variants of the syndrome USS may not detect syndrome but is used to monitor fetal growth
93
What are the risks of smoking in pregnancy?
``` Miscarriage IUGR preterm brith Placental abruption Stillbirth SIDS Childhood illness ``` Pre-eclampsia less common - encouraged to stop/cut down - nicotine replacement
94
What is the % increase of blood volume in pregnancy? What is the effect of this?
40% Relatively greater than the increase in red cell mass - result = net fall in Hb concentration, such that the lower limit of normal = 11g/dL
95
What is the effect of a high HB level in pregnancy?
increased risk of pregnancy complications (preterm and IUGR) - possibly because it reflects low blood volume, as fond in pre-exlampsia and because of its association with smoking
96
What % of women are affected with iron deficiency anaemia?
>10% | 80% of women not receiving iron have depleted stores by term
97
What is the treatment of IDA?
Oral iron - increase of up to 0.8g/dL/week but can cause GI upset in severe cases, IV iron is quicker and may prevent the need for blood transfusion
98
What other anaemias are pertinent in pregnancy?
``` Folic acid (more common than) B12 ``` MCV usually increased, so red cell folic acid and vitamin B12 levels are low
99
What is the treatment of b12/folic acid deficieny
Oral folic acid and vitamin B12
100
What prophylaxis are given against anaemia and why?
Routine iron supplements further foetal and neonatal anaemia have adverse outcomes although their relationship to maternal iron stores = unknown Dietary advice and Hb checked at booking, 28 and 34 weeks Iron + folic acid if Hb <11 and <10.5 in 2nd trimester
101
Who receives a higher dose of folic acid (5mg)
epilepsy, diabetes, obesity or previous history of NTD normal dose is 0.4mg
102
Why is influenza dangerous in pregnancy?
Accounted for 10% of all maternal deaths in the UK and US in 2009-10 Pregnancy particularly with co-morbidity increases susceptibility to severe disease
103
What medications are recommended for treatment of influenza in pregnancy?
Relenza (zanamirr) More severe - tamiflu (oseltamivir) ICU and extracorporeal membrane oxygenation
104
What is the best management of influenza in pregnancy?
Prevention - vaccination of pregnant women at any stage of pregnancy is strongly advised during winter months - vaccine has not known adverse foetal effects and will reduce both maternal and foetal mortality
105
What is the adult Hb molecule made up of? How does HbF change to become HbA?
Two alpha chains and two beta chains bound together to form a tetramer Foetal Hb molecule is normally replaced with HbA after birth and is made of two alpha chains and two gamma chains
106
What is the cause of sickle cell disease?
Recessive disorder - Abnormal beta chain formation (S chain) - resulting in an abnormal Hb molecule made of two alpha chins bound to two S chains found in people with Afro-Caribbean ancestry
107
What is the effect of heterozygous HBS?
35% HbS and usually have no problems
108
What is the effect of homozygous HbS?
'crises' of bone pain and pulmonary symptoms - pulmonary hypertension and proliferative retinopathy may occur. They will have chronic haemolytic anaemia for life.
109
What are maternal complications of sickle cell anaemia in pregnancy?
Acute painful crises (35%) Pre-eclampsia Thrombosis
110
What are foetal complications of sickle cell anaemia in pregnancy?
Miscarriage IUGR Preterm labour Death
111
What is the management of sickle cell anaemia in pregnancy?
In conjunction with a haemoglobinopathy specialist - advice on avoiding dehydration and seeking help early is important: ``` Hydroxycarbamide is probably teratogenic and so stopped Penicillin V is continued High dose folic acid Aspirin and LMWH indicated Monthly bring culture Iron avoided - prevent overload ```
112
How are crises managed in pregnancy?
hydration analgesia often antibiotics and anti-coagulation USS every 4 weeks and delivery normally indicated by 38 weeks
113
What is the cause of alpha thalassaemias?
impaired synthesis of the alpha chain in the Hb molecule Occurs in largely South-East Asian origin 4 genes are responsible for a chain synthesis.
114
What is the effect of all 4 deletions? 3? 1 or 2?
Individuals with all 4 deletions die in utero, those with 3 gene deletions have lifelong requirement for transfusions and those with 1 or two deletions are carriers and usually well with mild anaemia
115
What is the cause of beta thalassaemia?
impaired synthesis of the beta chain in the Hb molecule recessive disorder and the heterozygous state on a defective chain causes little illness, although a chronic anaemia which can worsen during pregnancy
116
What is the effect of beta thalassaemia?
Chronic haemolytic anaemia = present and multiple transfusions cause iron overload therefore, hepatic and cardiac dysfunction, endocrine disease (thyroid and parathyroid) and diabetes
117
What are the maternal complications of beta thalassaemia
Fertility reduced, liver disease, cardiac failure and diabetes = common
118
What are the foetal complications of beta thalassamias?
growth restriction and foetal demise = more common prenatal diagnosis is offered if the partner is heterozygous for either the beta or alpha form
119
Why is preconceptual planing crucial in beta thalassaemia?
Chelation therapy is probably teratogenic and avoided in 1st trimester - Desferiozamine can be used after this time - USSis used 4 weekly
120
What is FGM?
Partial or total removal of the external female genitalia or injury to the female genital organs for non-medical reasons
121
Describe the classification of FGM
Type 1 - clitoridectomy - partial or total removal of the clitoris or of the prepuce Type 2 - excision - partial or total removal of the clitoris and labia minora and labia majora Type 3 - infibulation - narrowing of the vaginal opening by cutting and repositioning the labia without removal of the clitoris Type 4 - all other non-medical procedures to the female genitalia for non-medical purposes
122
Which countries practice FGM?
Africa Middle East Malaysia Indonesia
123
What is the cause of FGM?
Ideas of preservation of virginity Promoting hygiene Adherence to cultural norms Religion - not condoned in Bibal or Koran
124
What are the complications of FGM?
``` Pain Bleeding Infeciton Urinary retention Damage to pelvic organs Death ```
125
What are the longer term complications of FGM?
``` Failure to heal UTI Difficulty urinating or menstruating Chronic pelvic infection Vulval pain due to cysts or neuromas Pain during sex Infertility Fistula Severe perineal trauma during childbirth ```

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