Medical Disorders in Pregnancy

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Medical Disorders in Pregnancy

• Dr Than Than Yin

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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)

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Diagnosis

• A typical history of pruritus without rash
• Abnormal liver function tests
• Moderate lt less than three-fold elevation in
  transamimases ( ALT is the most sensitive)
• Raised ALP 9gt pregnancy values
• Raised ? glutamyl transpeptidase
• Mild elevation of bilirubin
• Increased total serum bile acid
• Exclusion of other causes of itching and abnormal
  liver function

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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

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Management

• Counselling
• Weekly LFT and bile acids
• No evidence of monitoring fetal well-being
• To check prothrombin time prior to delivery

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Intrapartum management

• Labour may be induced at 37-38 weeks gestation if
  persistantly raised bile acid levels
• If bile acid levels lt 40 µmol/L, reasonable to
  await spontaneous onset of labour

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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

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Diagnosis

• BP, urinalysis, uric acid, platelet count,
  clotting screen, blood film
• Blood glucose, serum calcium, sodium, liver
  function tests
• CT or MRI
• EEG

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Epilepsy in pregnancy

• Many cases are idiopathic
• 30 have a family history of epilepsy
• Secondary Epilepsy
• Previous surgery
• Intracranial mass or lesions
• Antiphospholipid syndrome

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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
• seizure frequency
• Increasing number of antiepileptic drugs
• Low IQ
• Early onset epilepsy

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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

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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
• Dysmorphic features
• Hypertelorism
• Hypoplastic nails and distal digits
• Hypoplasia of the mid face

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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

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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

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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

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Management

• Preconception counselling
• Antepartum
• 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

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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 Graves 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 pregnancy-
  Hashimotos thyroiditis, treated Graves disease

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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
3rdt trimester 0.5-4 8-14.5 2-5.5
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