Some Medical Conditions in Pregnancy Max Brinsmead PhD FRANZCOG August 2012

Anaemia The most common pregnancy complication worldwide Affects 1:2 women in developing countries  Risk of maternal and fetal mortality Also has substantial morbidity and economic sequelae

Haematocrit and Perinatal Mortality

A Definition of Anaemia: WHO definition is Hb <110 g/L but… Hb <100 g/L is more realistic Needs correction for altitude… Add 2.5 g/L for every 1000m up to 4000m Severe when Hb is 40 – 70 g/L Very severe when Hb is <40 g/L

Causes of Anaemia: Nutritional deficiency of Iron and Folate Malaria HIV (+/- TB) Sickle cell Disease or Thalassaemia Hookworm infestation Chronic renal or Hepatic disease Often multifactorial

Losses and gains: Non pregnant iron requirement is 2 mg/day But this reaches 5 mg/day in 3 rd trimester Will be influenced by age, parity, pregnancy spacing and fetal number Hookworm >1000 ova/g faeces will cause a loss of 2 mg iron/day Folate deficiency is aggravated by malaria B12 deficiency is rare

Investigations for Anaemia: Blood film – look for micro or macrocytosis, reticulocytes, segmentation neutrophils, Neutrophil & Lymphocyte count But combined deficiencies can be difficult Malarial parasites may be intermittent or parasitised RBC’s may have been removed from circulation Bone marrow can be useful

Malaria and Anaemia: The picture will depend on whether the woman is immune or non immune to malaria Splenomegaly = Hyperactive Big Spleen Syndrome Due to an abnormal immune response to chronic malaria Requires malarial Rx esp. Proguanil 200 mg/day for life And Folic acid 5 mg/day

Profound Anaemia or Pre eclampsia? Oedema can occur with hyperdynamic heart failure Proteinuria can occur with renal hypoxia There can be hypovolaemia with both Profound anaemia may even present with coma But… Diastolic BP will be low with anaemia and high with pre eclampsia

Management of Profound Anaemia: Admit to hospital if Ht is <0.20 Try to be as specific as possible with Rx Iron dextran infusion can be useful Calculate dose required Adrenaline & hydrocortisone on standby Follow up Indiscriminate Fe by IM injection is not good Parenteral folate rarely required but concomitant oral iron always required

Indications for Transfusion: Heart failure or incipient heart failure Ht <0.14 Miscarrying or in labour and Ht <0.18 Operation required and Ht <0.24 Other disease is present e.g. renal

Maternal Mortality and Transfusion

Transfusion Precautions: Use packed cells and pre transfusion Lasix May require anti malarial drugs May require lower limb torniquets NB The Ht will initially fall

The anaemic patient in labour: Do everything possible to minimise blood loss Because they may have compensated up to that point but blood loss of even 100 – 200 ml may be fatal Monitor for signs of fetal hypoxia Maternal oxygen can be useful

The anaemic patient who fails to respond to treatment: Maybe noncompliant Has underlying renal or hepatic disease Has chronic infection such as HIV, TB or UTI Has concomitant malignancy Has an advanced abdominal pregnancy Has idiopathic hypoplastic anaemia

Thrombocytopenia and Pregnancy Platelet count in pregnancy is normally >150,000 Thrombocytopenia may be due to: – Malaria e.g. hyperactive spleen disease – HIV And transiently with other viral infections – Part of severe anaemia e.g. folate deficiency – Many drugs including alcohol – Fetal death in utero – Late sign in severe pre eclampsia (HELLP) – Idiopathic thrombocytopenia

IdiopathicThrombocytopenia (or ITP) Is actually an autoimmune condition due to anti- platelet antibodies Maternal risk of bleeding does not occur until the platelet count is <20,0000 However, there is a risk of passive transfer of antibody and fetal thrombocytopenia – That may result in intra cranial haemorrhage This can be averted by keeping maternal count >50,000 This is done by the administration of steroids

Steroids for ITP Inhibit anti platelet antibodies But also coat and protect the platelets from destruction in the spleen Check neonatal platelet levels However, the risk of fetal bleeding is not as great as that which occurs with alloimmune ITP – When the maternal platelet count is usually normal

Thyroid Disorder Pregnancy is a state of mild hyperthyroidism Thyroid hormones cross the placenta poorly But The developing fetal brain may be dependent on some maternal thyroxin And Antithyroid drugs cross the placenta readily

Management of Thyroid Disorders in Pregnancy Hypothyroid patients require an increase in their thyroxin replacement therapy Best option is to  dose by 33% ASAP Hyperthroid patients are best treated by PTU but “run them hot” I 131 therapy is contraindicated Thyroid surgery is okay after toxic control

This is the hand of a 14-year primigravida whom you are seeing for the first time…

F inger Clubbing here is most likely due to… Cyanotic congenital heart disease Tetralogy of Fallot Eisenmenger’s Syndrome And you should be worried because there is a very poor prognosis For the mother For the fetus Other High Risk Cardiac Conditions Pulmonary hypertension Severe aortic & mitral stenosis A metal mitral valve replacement (on Warfarin) Marfan’s syndrome with severe aortic incompetence Peripartum cardiomyopathy

Management of Cardiac Disease in Pregnancy Cardiac output increases throughout pregnancy and reaches a peak in labour Close monitoring with multidisciplinary care is required Low threshold for hospitalisation Vigorous treatment of CCF Aim for vaginal delivery Pre term delivery may be required for severe disease Remember thromboprophylaxis

Management of Cardiac Disease in Labour Best done as “intensive care” Low dose epidural good But requires an expert anaesthetist Assist the delivery by ventouse or forceps in a semi sitting position Avoid all oxytocics in the third stage And use mechanical means to control PPH LMW heparin prophylaxis against thromboembolism Progesterone only or T/L best afterwards

Diabetes in Pregnancy Screening for gestational diabetes has become accepted best practice Meticulous control of blood sugar before and during pregnancy for the best outcomes Pre term Caesarean no longer required But Caesarean may be the best option when fetal macrosomia is suspected