Medical Complications of Pregnancy 15th Jan 2009

Rob Bradley

Medical complications in Medical complications in

Pregnancy Pregnancy

• Pregnancy effect on disease

• Disease effect on pregnancy

Medical complications in Medical complications in

Pregnancy Pregnancy

• Diabetes • Diagnosis
• Pregnancy specific issues
• Thyroid
– Effect of pregnancy on disease
• Asthma – Effect of disease on pregnancy
• Epilepsy • Management
• Renal – Prevention of complications
– Monitoring
• Cardiac
• Post natal issues
• Obstetric cholestasis

Medical complications in Diabetes in pregnancy

Pregnancy
• Glycaemic control
– insulin
– diet
Diabetes • Monitor complications
– retinopathy
– nephropathy
• Preventative advice for GDM

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Medical Complications of Pregnancy 15th Jan 2009
Rob Bradley

Diabetes in pregnancy Diabetes in pregnancy

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

Medical complications in Thyroid in pregnancy

Pregnancy Hypothyroid

• Pregnancy has little effect on disease

– no monitoring if good control pre-
Thyroid pregnancy
• Severe untreated hypothyroidism
– infertility, menstrual disturbance
– miscarriage, PET, LBW

Thyroid in pregnancy Thyroid in pregnancy

Hyperthyroid Hyperthyroid
• 95% Graves
• Treat with PTU or carbimazole
– TSH stimulating antibodies
– PTU for new cases
• May improve with pregnancy – lowest effective dose
• Severe untreated hyperthyroidism • Thyroid stimulating Ab measurement
– infertility, menstrual disturbance – neonatal observation for up to a week
– miscarriage, IUGR, preterm labour
• Beta blockers for severe symptoms
• Poor control may result in thyroid crisis
• Neonatal TFTs
• Good outcome with adequate control – cord and at 2 weeks

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Medical Complications of Pregnancy 15th Jan 2009
Rob Bradley

Medical complications in Asthma in pregnancy

Pregnancy

• Usually no significant change

Asthma • Continue medication

– reassure re safety

Medical complications in Epilepsy in pregnancy

Pregnancy
• Some worsen, most stable
• Teratogenesis (background 2-3%)
– National Teratology Unit 0191 232 1525
Epilepsy – 6% one drug, 15% two, 50% three
– NTDs (valproate & carbamazepine)
– orofacial clefts (phenytoin)
– heart defects (phenytoin & valproate)

Epilepsy in pregnancy Medical complications in

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

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Medical Complications of 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
– only 20-30% successful
• Renal transplant
– little effect on kidney in most cases
– generally good outcome if good renal
function
Medical complications in
Pregnancy
Heart disease
Medical complications in
Pregnancy
Obstetric cholestasis
15th Jan 2009
Rob Bradley
Renal disease in pregnancy
• Pre-conception counselling
• Joint care
• Option of ToP
• Timing of delivery
Heart disease in pregnancy
• Worse outcome with:
– cyanosis
– pulmonary hypertension
– degree of dyspnoea
• 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