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Medical Conditions in Pregnancy - Coggle Diagram
Medical Conditions in Pregnancy
General Principles
Teratology and prescribing
Prophylaxis : folic acid / Aspirin / LMHW prophylaxis
Risk assessment - maternal / foetal / need for additional screening
Address organisation of care - likely to need specialist care
Ideally - Pre-pregnancy consultation / Planning
Tertogenicity
Avoid
Warfarin
ACE i
Isotretinone
Consider alternative meds / regimens
Prophylactic measures
Education
Clinics / Services
Consultant led
Integrated medical / endocrine clinics
Specialist clinics / consultants
Referral pathwasy for investigations
Advanced nurse/ midwife practitioners
Delivery of care
Scheduled and unscheduled visits
Detailed MDT care plan
Peripartum planning
HDU / ICU / CCU
Discharge plan /contraception
Pre-pregnancy planning / counselling
Epilepsy
Epidemiology
1 in 200/350 in IRE
Complications related to non-compliance
Epileptic woman over represented in maternal deaths
Risk of status epilepticus iis >1%
Seizure Frequency - Effect of Pregnancy on Epilespy
Unpredictable effect - rule of thirds
1/3 better
1/3 same
1/3 worse
Not always correlated with AED levels
Unrelated to control in previous pregnancy
Teratogenicity iwith Anticonvulsants
Risk on Anticonvulsants
Increased risk with number of anticonvulsants
4-6%
Complications / Defects
Neural tube defects
Craniofacial
Congenital heart disease
Digit malformations
Polypharmacy
Avoid!
Sodium valproate
Topiramate
Commonly used Anticonvulsants in Pregnacy
Cabamazepine
Lamotrigine
Levetiracetam
Seizure effect on foetus
Foetal hypoxia -
Neurodevelopmental effects
Management
Pre-Pregnancy
Folic acid 5mg PO OD
Optimise pharmacological management
Least number of drugs with lowest effective dose
Aim for monotherapy
Compliance
Pre-pregnancy councelling
Antenatal Care
Specialist care
Neurologist
Obstetrician
Advanced nurse practitioner (ANP)
Screening
Anatomy scans
Facial clefts
Cardiac abnormalities
Foetal Echo 22-24Wk
Labour
Analgesia
Avoid Pethidine analgesia - lowers seizure threshold
Morphine preferred
Postnatal
Neontal Vit K IM
Reduces risk of haemorrhagic disease of neonate
Breastfeeding
Crosses to breasmilk but not c/i
Sleep deprivation may lower seizure threshold
Contraception
COCP / POP may be affected by Enzyme inducing AED
Copper IUD/Mirena preferred
Common Disorders
Hypertension
Kidney disease
Diabetes / Thyroid
Epilepsy
Asthma
Cardiac disease
Inflammatory bowel disease
8.Autoimmune disease
Skin disorders
10 .VTE / haemotology / sickle cell disease
Hypothyroidism
Epidemiology
Most common endocrine disorder
3-5 %
Risks / Complications
Miscarriage / subfertility
GDM
Preterm
Neurodevelopmental deficits
PET
Management
Pre-pregnancy
Optimise TSH <2.5
Antenatal
Optimise TSH 1.0-2.0
Monitoring 4-6 weekly
Free T4
TSH
Increase Levothyroxine by 24-30%
Labour
Normal
Postpartum
Breastfeed as normal
Prepregnancy dose of levothyroxine
Neonatal TFTs
Postnatnal TFTs
Subclinical HT / Autoantibodies
Cardiac Disease
Common CVD
Hypertension
MI / IHD
Aortic dissection
Peripartum cardiomyopathy
Valve disease
Adult congenital cardiac disease
Red Flag symptoms
Orthopnoea (SOB lying flat)
Syncope
Management
Pre-pregnancy
Counselling - maternal and foetal risks
Medication review
Stop ACEi / ARBs
HNT: Labetalol or nifedipine
Thromboprophylaxis
Full therapuetic Anti-coagulation in valve replacemence
Antenatal
MDT input
Anaesthesia
Neonatology
Labour
Mode of delivery
NSVD preferred -
CS and Spinal analgsia affects stroke output and cardiac contractility
Cautious use of oxytocin - avoid bolus (affects conduction pathways and may cause arrhythmias)
Analgesia
Early controlled epidural
Postnatal
Postnatal decompensation
Manage in HDU for 24hr
Inflammatory Bowel DIsease
Management
Pre-pregnancy
Optimise condition
Medication review
Safe:
Sulphasalazine
Steroid
Stop
methotrexate
3 months before conception
Start
Folic acid
Multivitimins
Avoid Iron PO - Irritates bowel
Antenatal
MDT
Gastroenterologist
Obstetrician
Colorectal Surgeon
Medications - per gastroenterology
Stop Anti-TNF in 2nd trimester - risk of neonatal immunosuppression
Labour / Delivery
Vaginal unless c/i
Indications for CS
Active perianal disease
Anticipate complex surgery if previous gastro surgery +/- stoma
Postnatal
Breastfeed as usual
Medications can be continued
Postnatal flare in IBD - review with gastro
No live vaccine x6months since exposure to Anti-TNF
Epidemiology
Affect of pregnancy on IBD - rule of thirds
1/3 improve
1/3 the same
1/3 worsen
Systemic Lupus Erythmatosus
Risks
High risk of PET
Renal impairment
Miscarriage
IUGR
Perinatal mortality
Congenital heart block 2%
Epidemiology
20% have
Ro / La antibodies
Cross placenta
Affect foetal cardiac condution pathways- congenital heart block + pacemaker
Management
Individual basis
Antenatal
Aspirin prophylaxis for PET
Corticosteroids lowest maintainence dose
Close maternal foetal monitoring
+/- nephrology
Labour / Delivery
Delivery by 37 weeks or less
Often required ealier
Postnatal
Postnatal flare
Often need corticosteroids
Skin Conditions
PUPPP
Pruritic urticarial papules and plaques of pregnancy
Presentation
Severe itch along striae gravidarum
Can continue for 4-6 weeks
Managment
Antihistamine
Topical cooling
Topical steroids
Common Conditions
Eczema
Psoriasis
Acne
PUPP
Pemphigoid gestationis
Intrahepatic cholestatsis (no rash)
Epidemiology
PUPP polymorphic eruption 1/150
Pemphigoid gestationis fetal risk 1/100,000
See specialist
Intrahepatic cholestasis fetal risks 1/100
Management
Topical emollient
Topic Steroids
C/i
Tetracyclines (for rosacea) - irreversible staining of teeth
Isotretinoin (roaccutane) - fetal abnormalities
Venous Thromboembolism
Epidemiology
Most common cause of materal mortality
Pregnancy is a pro-coagulant state
80% DVTs left sided
70% DVTs in ilio-femoral - PE more likely if higher up
Pathophysiology
Gravid uterus causes mechanical venous obstruction
Presentation
Tender red calf
Swelling of calf
Breathlessness
Chest pain
Investigations
D-dimer not helpful in pregnancy
Bloods
ABG
Hypoxemia
Hypocapnia
Resp alkalosis
Bedsides
ECG
Tachycardia
RBBB
T wave inversions
Imaging
CXR
R/o pneumonia
V/Q scan
CTPA (CT pulmonary angiogram) - transfer to radiology SJH
Compression Duplex Dopplers - Leg DVT
Risk Factors
Maternal age > 35
2.Obesity (BMI>30)
Parity ≥ 3
Gross varicose veins
Multiple pregnancy
Infection
PET
Major illness
Immobility
CS / complex surgery
Fhx DVT / PE / Thrombophilia
Management
Prophylaxis
LMWH
Indicated for women with risk fctors
Therapeutic
LMWH
Indicated in DVT / PE diagnosis
Thrombophilias
Inherited
Antithrombin deficiency
Protein C deficiency
Protein S deficiency
Factor V Leiden mutation
Prothrombin gene variant
Aquired
APAS - antiphospholipid antibody syndrome
Lupus antigcoagulant / Anti-cardiolipin ab
