Transcript Medical Disorders in Pregnancy

Medical Disorders in
Pregnancy
Dr Than Than Yin
Obstetric cholestasis
• Unique to pregnancy
• Severe pruritus affecting limbs and trunk
mainly palm and sole
• Developing in the second half of pregnancy
(usually during the third trimester)
Diagnosis
• A typical history of pruritus without rash
• Abnormal liver function tests
– Moderate < less than three-fold elevation in
transamimases ( ALT is the most sensitive)
– Raised ALP 9> pregnancy values
– Raised Ƴ glutamyl transpeptidase
– Mild elevation of bilirubin
– Increased total serum bile acid
• Exclusion of other causes of itching and
abnormal liver function
Diagnosis
• To exclude other causes of abnormal liver
function
• Liver scan
• Viral serology ( for hepatitis A,B,C and E,EBV
and CMV)
• Liver autoantibodies( for pre-exisisting liver
diseasse, anti-smooth muscle antibodies,
antimitochondrial antibodies
Management
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Counselling
Weekly LFT and bile acids
No evidence of monitoring fetal well-being
To check prothrombin time prior to delivery
Intrapartum management
• Labour may be induced at 37-38 weeks
gestation if persistantly raised bile acid levels
• If bile acid levels < 40 µmol/L, reasonable to
await spontaneous onset of labour
Drug therapy
• Vitamin K mandatoroy for women with prolonged
prothrombin time, commenced at 32 weeks
• Antihistamine
• Ursodeoxycholic acid
• Dexamethasone
• Rifampicin
• Cholestyramine
• S-Adenosylmethionine
• Activated charcol
• Epomediol
Diagnosis
• BP, urinalysis, uric acid, platelet count,
clotting screen, blood film
• Blood glucose, serum calcium, sodium, liver
function tests
• CT or MRI
• EEG
Epilepsy in pregnancy
• Many cases are idiopathic
• 30% have a family history of epilepsy
• Secondary Epilepsy
– Previous surgery
– Intracranial mass or lesions
– Antiphospholipid syndrome
Effect of pregnancy on epilepsy
• A common indirect maternal death
• No effect in majority
• Women who have been seizure free for years are
unlikely to have seizures in pregnancy
• Women with multiple type seizures are more likely to
have increase in seizure frequency
• The risk of seizures is highest in peripartum
• Sudden Unexplained Death in Pregnancy (SUDEP)risk factors
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seizure frequency
Increasing number of antiepileptic drugs
Low IQ
Early onset epilepsy
Effect of epilepsy on pregnancy
• The fetus is relatively resistant to short periods
of hypoxia
• No increased risk of miscarriage or obstetric
complications
• Status epilepticus is dangerous for both mother
and fetus
• The risk of child developing epilepsy is increased
(4-5%) if either parent has epilepsy and, risk is
10-15% if both parents have epilepsy, 10% risk
with previously effected sibling
Teratogenic risk of anti-epileptic
drugs(AED)
• Phenytoin, primidone, phenobarbitone, carbamazepine,
sodium valproate, lamotrigine, topiramate and
levetiracetam all cross the placenta and are teratogenic
• Major malformations caused by AEDs
– Neural tube defects ( especially valproates 1-3.8% and
carbamazepine 0.5-1%)
– Orofacial clefts ( particularly Phenytoin, carbamazepine,
phenobarbitone and valproate)
– Congenital heart defects (particularly Phenytoin,
phenobarbitone and valproate)
• Minor malformations
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Dysmorphic features
Hypertelorism
Hypoplastic nails and distal digits
Hypoplasia of the mid face
Teratogenic risk of anti-epileptic
drugs(AED)
• Metaanalysis of all studies showed that the
risk of any one drug is approximately 6-7%
• Various theories
– Genetic deficiency of the detoxifying enzyme
epoxide hydrolase
– Cytotxic free radicals
– Folic acid deficiency
Management
• Antenatal management
– Folic acid 5mg daily
– No need to change the AED if epilepsy is well controlled
– Pre-natal screening for congenital abnormalities and detailed
ultrasound at 18-20 weeks should be ordered, including fetal
cardiac assessment
– Vitamin A 10-20mg daily should be prescribed in the last four
weeks of pregnancy
• Intrapartum management
– Risk of seizures increase around the time of delivery
– 1-2% will have a seizure during labour and 1-2% will have a
seizure in post partum 24 hours period
– Should continue regular AED
– Effective pain relief and epidural analgesia
• Postnatal management
– The neonate should recieve 1mg Vitamin K Inj IM
– Breast feeding should be encouraged
Cardiac disease in pregnancy
• Leading cause of maternal death as result of
– Myocardial infarction
– Ischemic heart disease
– Dissecting aortic aneurism
• Other heart disease
– Peripartum cardiomyopathy
– Rheumatic heart disease- 25% of pregnant
population who not born in the UK
– Congenital heart disease
Management
• Preconception counselling
• Antepartum
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Risk assessment
Joint clinic attended by obstetrician, cardiologist, anaesthetist
Echocardiogram
Fetal echocardiogram for women with congenital cardiac disease
32-34 weeks gestation –multidisciplinary meeting for birth plan
• Intrapartum
– Early slow incremental epidural analgesia, assisted vaginal delivery
– Caesarean section is only necessary for obstetric indications
• Postpartum
– Anticoagulation
– Long observation in high dependency area
– Prophylaxis against postpartum haemorrhage
• Low dose oxytocin infusion
Thyroid disease in pregnancy
Hyperthyroidism
Hyperthyroidism
• Thyrotoxicosis complicates
in 1 in 500 pregnancies
• 50% of affected women
have a positive family
history of autoimmune
thyroid disease
• 95% are due to Grave’s
disease, an autoimmune
disorder caused by TSH
receptor stimulating
antibodies
• 1% of pregnancies
• Most cases have already
been diagnosed
• Associated with
autoimmune diseases,
pernicious anemia, vitiligo,
type 1 diabetes
• Commonest causes
encountered in pregnancyHashimoto’s thyroiditis,
treated Grave’s disease
Pregnancy –specific normal ranges
TSH(MU/l)
Throxine
(pmol/L)
Triiodothyronine
(pmol/L)
Non-pregnant
0.27-4.2
12-22
3.1-6.8
1st trimester
0-5.5
10-16
3-7
2nd trimester
0.5-3.5
9-15.5
3-5.5
0.5-4
8-14.5
2-5.5
3rdt
trimester