Medical Disorders in Pregnancy

Medical disorders in pregnancy Diabetes Mellitus Pregnancy is diabetogenic (cortisol etc from placenta à increase glucose), if insulin cannot rise à DM Gestational DM & type II both worsen in 3rd trimester (GTT at 28 weeks for screening) Risk to mother Much tighter diabetic control is required as insulin requirements will change (increase). Good control à Increased risk of proliferative retinopathy. à Lose hypo warning, hypos more common – teach partner Poor control à glycosuria à increased incidence UTI à increase miscarriage risk General à Increased PET risk (esp if pre-existing renal disease/HT) à IUGR à Risk of CAD/MI/Angina due to vascular disease + thrombophilic effects of preg à worsening of proteinuria if nephropathy (makes PET difficult to diagnose) Risk to Baby High glucose in first trimester (eg Type I/II) à 3x higher incidence of cardiac, NTD & renal abnormalities High glucose for fetus à more fetal insulin produced à promotes fetal growth à macrosomia (asymmetric – abdo grows more than head) with organomegaly shoulder dystocia à risk of erbs palsy (C5-7 mainly), 10% don’t resolve increased erythropoiesis & polycythaemia à neonatal jaundice Increased incidence of intrauterine death (? Due to hypoxia & lactic acidaemia) Risk of neonatal hypoglycaemia, low MG & Ca, polycythaemia & respiratory distress syndrome Fetal polyuria à polyhydramnios which can à malpresentation, cord prolapse & premature labour Prematurity/C-sect delivery increase risk of surfactant deficiency (RDS) NB: gestational DM NOT have increased anomaly risk or maternal complications. IS still risk of macrosomia, PET, IUFD & birth trauma Screening – GTT (at 28 weeks) OR if Symptomatic Glycosuria ++ on 2 occasions FH of type II DM (NOT type I) Prev gestational DM (do early as high recurrence rate) High BMI Prev macrosomia/unexplained stillbirth Non Caucasian Fasting à 75g oral glucose load Diabetes = fasting > 7.8mmol/l or 2 hr > 11.2 mmol/l Impaired glucose tolerance = fasting < 7.8mmol/l but 2 hr between 11.2 & 8 mmol/l Repeat 6 weeks PN. If still abnormal then previously undiagnosed type II Management Initially with diet unless severe (increase high fibre carbs). Tablet control not appropriate so onto insulin 7 point profiles (4-5/week) – aim for <6(5) pre meal, <9(8) post prandial (ideals) Adjust insulin regime to short act b4 each meal + long acting @ breakfast & before bed (+snack at bedtime). Monthly HbA1C for pre-existing diabetics (higher result = higher risk for congenital anomaly) Offer detailed fetal scan at 20 weeks (to pre-existing DM) Regular scans from 28 weeks to assess birth weight Regular CTG from 36 weeks (due to risk of IUFD) NB: Downs serum screening becomes less reliable so offer NT scan with serum AFP Give steroids to avoid lung disease if premature (in hospital as worsens maternal control) Delivery C-sect if very macrosomic (>4kg) Induce at 38-9 weeks for vaginal delivery (because increase risk fetal death) Aim for tight intrapartum control (insulin hourly sliding scale & glucose IV) Constant intrapartum fetal monitoring & team prepared incase shoulder dystocia Screen at PN 6 week follow up as 1/3 of gestation DM à full DM within 25 yrs Cardiac disease Most important where pulmonary blood flow cannot be increased (eg. Eisenmengers syn) SOB, syncope, atrial ectopic beats & ejection systolic murmurs common & often normal in preg Investigate if murmer is > 2/6, thrills or other suspicious features Monitor closely esp if condition à suboptimal PO2 Venous Thromboembolic Disease Pregnancy = thrombophilic state (increased fibrinogen, prothrombin etc, slight increase in fibrinolysis) Uterus à venous stasis in legs Risk factors – obesity, >35yrs, FH, PMH, high parity, immobility, pre-eclampsia, varicose veins, thrombophilia, infection, c-section. Investigate – as normal as risk to mother > risk to fetus Rx – clexane s.c. SLE Flare-ups are common in pregnancy, esp postnatal. SLE nephritis is assoc with increased risk ok PET SLE is linked with increased miscarriage & prem labour. Risk of fetal heart block due to anti-Ro and anti-La Ab (+ haemolytic anaemia, leucopenia, thrombocytopenia = neonatal lupus) Low dose aspirin advisable for history of TED, closely monitor renal function. Epilepsy NB: a seizure in pregnancy is eclampsia until proven otherwise. Increased plasma vol à increased dose of anti-epileptic medication required Lamotragine is safest anti-epileptic (re teratogenicity) Hepatic disorders Obstetric cholestasis – itching of limbs & trunk after 30 weeks Acute fatty liver of pregnancy – rare but can à hepatic failure Thrombocytopenia Mild form in 8% women Autoimmune ITP with antiplatelet Ab most common in early preg. If Ab cross placenta à fetal (alloimmune) thrombocytopenia Thyroid disorders Hypothyroid – untreated à 2x risk miscarriage / stillbirth + fetal neurological impairment Hyperthroid – untreated à high fetal mortality & maternal thyroid crisis @ birth