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MEDICAL DISORDERS IN PREGNANCY (DM (foetal hyperinsluinaemia result in…
MEDICAL DISORDERS IN PREGNANCY
DM
placenta produces additional cortisol and human placental lactogen, progesterone, hcg = inc maternal glucose level = inc rate of congen abnorm
foetal hyperinsluinaemia result in macrosomia and organomegaly, inc erythropoiesis and neonatal polycythaemia, higher risk of intrauterine fetal death
chronic hypoxia and acidaemia
shoulder dystocia
neonates may have hypoglycaemia, hypocalcaemia, hypomagnesaemia, polycythaemia
inc incidence of hyaline membrane disease
polyhydramnios = results from fetal polyuria -> unstable lie, malpresentation and pre-term labour
screening for gestational diabetes
75g GTT @ 24-28wks for those with risk factors: obese,
if had prev GDM then first have 16-18 wk check then if fine check again at 24-28 wks
normal fasting glucose <5.5mmol/L
GDM - fasting glucose >/= 5.1 and or 2hr level >8.5
overt diabetes - fasting glucose >7
HbA1c >6.5%
random plasma glucose >11.1
management of gestational diabetes
DIET - METFORMIN - INSULIN
insulin treatment aim keep preprandial glucose <5.5 and postprandial <7.5/8
antenatal management of established diabetes
diet, smoking, folate supplements
blood glucose measured several times a day at home, aiming for tight control - aim 3.5-5.9 preprandial and 1hr post being <7.8
maternal kidney function and optic fundi - examined in early preg anda detailed anomaly scan at 18-22wks
deliver at 38wks recommended but no indication for elective C-Section on basis of diabetes alone
if preterm labour occurs - steroids may be given for non-diabetic pt but will lead to deterioration in diabetic control unless insulin doses are increased appropriately or a sliding scale employed
postpartum insulin requrements rapidly decrease back to pre preg levels
VENOUS THROMBOEMBOLIC DISEASE
ANTENATAL
inc levels of fibrinogen, prothrombin, other clotting factors and reduced levels of endogenous anticoagulants
gravid uterus cause mechanical obstruction to venous system
less common in asian/african as white get factor V leiden mutation and prothrombin gene variants
DVT left sided usually- mostly ileofemoral= higher than calf so more likely to get PE
duplex dopler US useful to identify femoral vein thrombosis - x-ray venography more specific but disadv of radiation
venography or magnetic resonance venography is appropriate if doppler studies give equivocal results or neg results despite strong clinical suspicion
CTPA - radiation to breasts
TREAT DVT or PE - sc LMWH - if massive then give IV unfractioanted heparin
after delivery - continue sc lmwh or commence warfarin for 6-12 weeks
IF PREVIOUS VTE single episode = screen for thrombophilia - if neg and event ocurred outside of preg and not severe - antenatal thrombylaxis may not be required. Postnatal thrombylaxis with LMWH recomended for 6wks
if pos screen or other RF or pos fam hx antenatal and postnatal prophylaxis given LMWH (enoxoparin)
HERITABLE THROMBOPHILIAS
protein s deficiency
factor V leiden mutation
protein c deficiency
prothrombin gene variant
antithrombin deficiency
ACQUIRED - lupus anticoagulant and anticardiolipin antibodies
CARDIAC DISEASE
Maternal mortality when pulm blood cant be inc to compensate for inc demand during pregnancy - eg eisenmenger syndrome
normal to feel breathless, have ectopic beats, may have audible ejection systolic murmur
consider terminating if eisenmenger syndrome, any cause of pulm hypertension, or pulm veno-occlusive disease
if have AF then need anticoag to prevent clots
for third stage of labour - syntocinon given slowly rather than syntometrine because ergometrine can cause HTN and bolus syntocinon can cause vasodilation
need particular care in immediate postpartum as inc circulating volume following uterine retraction may lead to fluid overload and congestive failure
CONNECTIVE TISSUE DISEASE
SLE
inc chance of an exacerbation (flare up) in preg = women discouraged to become preg when disease is active
active SLE nephritis during preg assoc miscarriage and preterm delivery, pre eclampsia - difficult to differentiate from a disease flare as both assoc w/ HTN and proteinuria
risk of fetal congenital heart block assoc w/ presence of anti-Ro and anti-La antibodies
if lupus anticoagulant or anticardiolipin antibodies (anti-phospholipid antibodies) are present, low dose aspirin should be given
in women with a previous hx of thromboembolic disease or adverse pregnancy outcome- LMWH indicated
monitor renal function
manage flare ups with prednisolone and regular US fetal biometry due to inc risk of growth restriction
EPILEPSY
first seizure in the second half of pregnancy should be assumed to be elampsia until proven otherwise
for most AEDs the free drug levels fall in pregnancy eg lamotrigine
inc incidence for fetal anomalies