Medical Complications Of Pregnancy

15th Jan 2009 Rob Bradley

Medical Complications of Pregnancy

Medical complications in Pregnancy

Medical complications in Pregnancy

• Pregnancy effect on disease • Disease effect on pregnancy

Medical complications in Pregnancy • • • • • • •

Diabetes Thyroid Asthma Epilepsy Renal Cardiac Obstetric cholestasis

Medical complications in Pregnancy

Medical complications in Pregnancy • •

Diagnosis Pregnancy specific issues – Effect of pregnancy on disease – Effect of disease on pregnancy

•

Management – Prevention of complications – Monitoring

•

Post natal issues

Diabetes in pregnancy •

Diabetes

Glycaemic control – insulin – diet

•

Monitor complications – retinopathy – nephropathy

•

Preventative advice for GDM

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15th Jan 2009 Rob Bradley

Medical Complications of Pregnancy

Diabetes in pregnancy

Diabetes in pregnancy • •

• Fetal malformation • Fetal macrosomia • Intrauterine death

• • •

Screening for GDM Glycaemic control – pre-conception – during pregnancy Anomaly screening Fetal growth assessment Delivery planning – gestation – mode

Thyroid in pregnancy

Medical complications in Pregnancy

Hypothyroid •

Pregnancy has little effect on disease – no monitoring if good control prepregnancy

Thyroid •

Severe untreated hypothyroidism – infertility, menstrual disturbance – miscarriage, PET, LBW

•

Thyroid in pregnancy

Thyroid in pregnancy

Hyperthyroid

Hyperthyroid

95% Graves – TSH stimulating antibodies

• •

May improve with pregnancy Severe untreated hyperthyroidism – infertility, menstrual disturbance – miscarriage, IUGR, preterm labour

• •

Poor control may result in thyroid crisis Good outcome with adequate control

•

Treat with PTU or carbimazole – PTU for new cases – lowest effective dose

•

Thyroid stimulating Ab measurement

• •

Beta blockers for severe symptoms Neonatal TFTs

– neonatal observation for up to a week

– cord and at 2 weeks

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15th Jan 2009 Rob Bradley

Medical Complications of Pregnancy

Asthma in pregnancy

Medical complications in Pregnancy

Asthma

• •

Epilepsy in pregnancy • • • • • •

Folic acid 5mg - conception +/- 12 wks Rationalise drug therapy Anomaly scans (NB heart) Drug levels if control worsens Vitamin K (10mg po od) from 36/40 Neonatal vitamin K

Usually no significant change

•

Continue medication – reassure re safety

Epilepsy in pregnancy

Medical complications in Pregnancy

Epilepsy

•

Some worsen, most stable Teratogenesis (background 2-3%) – – – – –

National Teratology Unit 0191 232 1525 6% one drug, 15% two, 50% three NTDs (valproate & carbamazepine) orofacial clefts (phenytoin) heart defects (phenytoin & valproate)

Medical complications in Pregnancy

Renal

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15th Jan 2009 Rob Bradley

Medical Complications of Pregnancy

Renal disease in pregnancy • •

Renal disease in pregnancy

UTI more common Chronic renal disease may get worse

• • • •

– more BP, more proteinuria – pregnancy loss, IUGR, pre-term delivery

•

CRF on dialysis bad outcome

•

Renal transplant

– only 20-30% successful

Pre-conception counselling Joint care Option of ToP Timing of delivery

– little effect on kidney in most cases – generally good outcome if good renal function

Heart disease in pregnancy

Medical complications in Pregnancy

•

– cyanosis – pulmonary hypertension – degree of dyspnoea

Heart disease

• • • • •

Medical complications in Pregnancy

Obstetric cholestasis

Worse outcome with:

Discuss ToP if appropriate Fetal congenital heart defect Joint care including anaesthetist Time and mode of delivery Antibiotic prophylaxis (SBE)

Obstetric cholestasis rcog.org.uk – green top guidelines 2006

• • • • • •

Itching, raised ALT & bile salts SB rate similar to general population SB not related to level of ALT or bile salts No tests predict SB Symptomatic relief for itching Vitamin K orally to reduce PPH

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