Chronic Medical Problems in Pregnancy.ppt

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  • Secondary to estrogen stimulation and dec hepatic clearance Occ first trimester change Fetal use and maternal renal clearance
  • Graves 95%
  • PTU also reduces peripheral conversion of t4 to t3 and suppresses quicker Methimazole used to be assoc with fetal aplasia cutis – recent studies say no
  • 1% of hyperthyroid pts- inciting event
  • Iron decreases intestinal absorption
  • Age 10 checked out for IQ
  • 115 women No definite rec about fetal echo/level 2 u/s
  • Thioamides balance stimulatory antibodies Antibodies cleared less rapidly than thioamides so late Graves for baby
  • Chronic Medical Problems in Pregnancy.ppt

    1. 1. Chronic Medical Conditions in Pregnancy Dr Jessica Servey, FAAFP 15 March 2007 Travis Family Medicine Residency
    2. 2. Objectives <ul><li>Review thyroid disorder </li></ul><ul><li>Review isoimmunization </li></ul><ul><li>Review preeclampsia </li></ul><ul><li>Review thrombocytopenia </li></ul><ul><li>Review asthma </li></ul><ul><li>Review anemia </li></ul><ul><li>Review pyelo/renal stones </li></ul><ul><li>Review chronic hypertension </li></ul><ul><li>Review liver disorders </li></ul><ul><li>Review migraine treatment </li></ul><ul><li>Review thromboembolic disorders </li></ul><ul><li>Review seizure disorders </li></ul>
    3. 3. Real Objectives <ul><li>Review asthma in pregnancy </li></ul><ul><ul><li>Treatment </li></ul></ul><ul><ul><li>Surveillance </li></ul></ul><ul><li>Review thyroid disorders in pregnancy </li></ul><ul><ul><li>Treatment </li></ul></ul><ul><ul><li>Surveillance </li></ul></ul>
    4. 4. Basic Intuition in Family Medicine <ul><li>All pregnancies do better if the chronic medical problems are controlled </li></ul><ul><li>Most babies do better inside the mommy </li></ul><ul><li>We as Family Physicians are uniquely gifted to take care of these couplets </li></ul>
    5. 5. Asthma
    6. 6. Why asthma? <ul><li>The percentage in women having asthma has more than quadrupled since 1990 </li></ul><ul><ul><li>3.1 per 1000 to 15.6 per 1000 </li></ul></ul><ul><li>Can be managed </li></ul><ul><li>People still die from this! </li></ul>
    7. 7. Pregnancy complications <ul><li>Pre-eclampsia </li></ul><ul><li>PIH </li></ul><ul><li>Hyperemesis gravidarum </li></ul><ul><li>Maternal hemorrhage </li></ul><ul><li>GDM </li></ul><ul><li>PTL and preterm delivery </li></ul>
    8. 8. Effects on Infant <ul><li>Increased risk IUGR </li></ul><ul><li>Increase neonatal hypoxia </li></ul><ul><li>Increase low birth weight </li></ul><ul><li>Increase neonatal mortality </li></ul>
    9. 9. Pregnancy physiology <ul><li>Dyspnea occurs in 60-70 % all pregnant women </li></ul><ul><li>Rule of thirds </li></ul><ul><ul><li>Worsen 24-36 weeks </li></ul></ul><ul><li>Subsequent pregnancies are the same </li></ul><ul><li>Possible reasons to worsen: Increased GER, mucosal edema and URI, stress, decreased FRC </li></ul><ul><li>FEV1 unchanged, but respiratory alkalosis is normal </li></ul>
    10. 10. Chronic Asthma Treatment <ul><li>Categorized and maximize medication </li></ul><ul><li>PEFR </li></ul><ul><ul><li>Twice daily, no change with pregnancy </li></ul></ul><ul><li>Flu vaccine </li></ul><ul><li>Treat GERD and SAR </li></ul><ul><li>Give Action Plan </li></ul><ul><li>Look for triggers (pets/mites/PAR) </li></ul><ul><li>Immunotherapy </li></ul><ul><ul><li>Safe to continue if at maintenance </li></ul></ul>
    11. 11. Chronic Treatment <ul><li>Part of routine OB visit!!! </li></ul><ul><li>Objective lung measure at every visit </li></ul><ul><li>Formal PFT????? </li></ul><ul><li>Ultrasound to assess growth </li></ul><ul><ul><li>No trials to give guidance </li></ul></ul><ul><li>APFT – can consider if not well controlled </li></ul><ul><ul><li>No formal trials </li></ul></ul><ul><li>Pulmonary consult/Anesthesia if needed </li></ul>
    12. 12. Asthma Exacerbation <ul><li>Treat the same as if not pregnant </li></ul><ul><li>Look closely at blood gases </li></ul><ul><li>Frequent follow up </li></ul>
    13. 13. Medications <ul><li>Most asthma medications are Cat B and Cat C </li></ul><ul><li>Swedish epidemiologic data has increased some inhaled steroids to B </li></ul><ul><li>Oral Steroids Cat C </li></ul><ul><ul><li>Carries risk PTL, low birth weight, PROM, cleft lip? </li></ul></ul><ul><li>Risks of uncontrolled asthma is higher! </li></ul>
    14. 14. Labor and Delivery <ul><li>Monitoring Infant </li></ul><ul><ul><li>Continuous fetal monitoring </li></ul></ul><ul><li>Asthma </li></ul><ul><ul><li>Peak flow during labor </li></ul></ul><ul><ul><li>Continue regular medications </li></ul></ul><ul><ul><li>Allow for albuterol prn </li></ul></ul><ul><ul><li>IV hydrocortisone if received systemic corticosteroids during pregnancy ( 3 doses) </li></ul></ul>
    15. 15. Labor and Delivery <ul><li>Pain management </li></ul><ul><ul><li>Bronchospasm increases with increased pain </li></ul></ul><ul><ul><li>Morphine and demerol are histamine releasers </li></ul></ul><ul><ul><li>Epidural is the preferred method </li></ul></ul><ul><ul><li>Propofol for general anesthesia </li></ul></ul><ul><li>Hemorrhage </li></ul><ul><ul><li>No hemabate </li></ul></ul><ul><ul><li>May use prostaglandins for induction </li></ul></ul>
    16. 16. Thyroid diseases
    17. 17. Normal Thyroid Function <ul><li>Thyroid binding globulin increases </li></ul><ul><li>TSH and FT4 no change </li></ul><ul><li>Iodide levels decrease </li></ul><ul><li>Increase thyroid size, normal TFT </li></ul><ul><li>Transient increase T4 and decrease TSH first trimester, related to elevated hcG levels </li></ul>
    18. 18. Fetal Development <ul><li>Concentrates iodine at 10-12 weeks </li></ul><ul><li>Levels of TSH and TBG, FT4 and T3 increase throughout </li></ul><ul><li>TSH does NOT cross placenta </li></ul><ul><li>T4 and T3 cross the placenta </li></ul><ul><li>Immunoglobulins and thioamides cross the placenta </li></ul>
    19. 19. Hyperthyroidism <ul><li>0.2% pregnancies </li></ul><ul><li>Other causes than Graves: gestational trophoblastic neoplasia, adenoma hyperfunctioning, toxic multinodular goiter, thyroiditis, extrathyroid source </li></ul>
    20. 20. Risks of hyperthyroidism <ul><li>Preterm delivery </li></ul><ul><li>Severe preeclampsia </li></ul><ul><li>Heart failure </li></ul><ul><li>Miscarriage </li></ul><ul><li>Low birth weight/IUGR </li></ul><ul><li>Fetal loss </li></ul><ul><li>Poor maternal weight gain </li></ul>
    21. 21. Treatment <ul><li>Thioamides- usually Propylthiouracil (PTU) but can use methimazole </li></ul><ul><li>Goal of treatment is FT4 in highest possible normal area </li></ul><ul><li>May need to monitor every 2-4 weeks </li></ul><ul><li>Breastfeeding is fine </li></ul><ul><li>Consider beta blockers for symptoms </li></ul>
    22. 22. Iodine 131 <ul><li>Contraindicated </li></ul><ul><li>Avoid pregnancy for 4 months </li></ul><ul><li>Avoid breastfeeding for 4 months </li></ul><ul><li>If exposed- check gestational age </li></ul><ul><ul><li><10 weeks should be fine </li></ul></ul><ul><ul><li>> 10 weeks, discuss options </li></ul></ul>
    23. 23. Thyroid storm <ul><li>1% of hyperthyroid mothers </li></ul><ul><li>High risk of maternal heart failure </li></ul><ul><li>Clinical picture can be fever, tachycardia, altered mental status, vomiting, diarrhea, cardiac arrhythmias </li></ul><ul><li>Do not wait for lab results to treat </li></ul><ul><li>? Up to 25% mortality </li></ul>
    24. 24. Treatment-thyroid storm <ul><li>PTU </li></ul><ul><li>Potassium iodide solution </li></ul><ul><li>Dexamethasone </li></ul><ul><li>Propanolol </li></ul><ul><li>Phenobarbital </li></ul><ul><li>Supportive care </li></ul><ul><li>Search for and fix the cause </li></ul><ul><li>Do not deliver unless fetal indication </li></ul>
    25. 25. Hypothyroidism <ul><li>Hashimoto’s most common in US </li></ul><ul><li>Iodine deficiency most common worldwide </li></ul><ul><li>Drugs:Lithium, Dilantin, Rifampin, FeSO4, </li></ul><ul><li>sucralfate, amiodarone </li></ul><ul><li>5-8% incidence if Type I DM </li></ul><ul><li>25% risk pp thyroid dysfunction in Type I DM </li></ul>
    26. 26. Risks of hypothyroidism <ul><li>Preeclampsia and PIH (unknown reason) </li></ul><ul><li>Miscarriage (twice the normal risk) </li></ul><ul><li>20% perinatal mortality (stillbirths) </li></ul><ul><li>10-20% congenital anomalies </li></ul><ul><li>Placental abruption </li></ul><ul><li>Anemia </li></ul><ul><li>? Intellectual development </li></ul><ul><li>Postpartum hemorrhage </li></ul><ul><li>Preterm delivery </li></ul><ul><li>**Old studies, few women, poor control </li></ul>
    27. 27. Miscarriage risk <ul><li>1990 study of 552 women – thyroid disease </li></ul><ul><li>- 17 % miscarried with positive antibodies </li></ul><ul><li>- 8.4% miscarried without antibodies </li></ul><ul><li>? Related to antibody or just immune function </li></ul><ul><li>1999 study- 15 women </li></ul><ul><ul><li>Antibody levels decreased in women without miscarriage </li></ul></ul>
    28. 28. Fetal anomalies <ul><li>Study done published 2001 </li></ul><ul><li>Retrospective chart review </li></ul><ul><li>Meant to look at population data </li></ul><ul><li>23.5 % anomalies hypothyroid women </li></ul><ul><li>21.8 % anomalies hyperthyroid women </li></ul><ul><li>Cardiac anomalies significantly elevated in hypothyroid </li></ul>
    29. 29. Hypothyroidism <ul><li>Large European study, 2.5% women with subclinical hypothyroidism </li></ul><ul><li>Screening? </li></ul><ul><ul><li>High risk patients should be considered: prior history thyroid disease, history of autoimmune or endocrine disorder, family history thyroid disease, neck radiation, goiter on exam, medications that alter thyroxine, hyperlipidemia </li></ul></ul><ul><ul><li>Recent study in Maine in 2006- up to 48% with thyroid disorders </li></ul></ul>
    30. 30. Treatment <ul><li>Thyroid replacement to normalize TSH </li></ul><ul><li>Increased thyroid hormone requirements </li></ul><ul><li>At least every 4-6 weeks needs TFT checked </li></ul><ul><li>Postpartum readjustment </li></ul><ul><li>APFTs? Serial ultrasound? </li></ul>
    31. 31. Antibodies <ul><li>Anti-microsomal, Anti-thyroglobulin, stimulating/inhibitory antibodies, peroxidase </li></ul><ul><li>Perinatal vs endocrine opinion </li></ul>
    32. 32. Thyroid Cancer <ul><li>Pregnancy itself doesn’t alter the course </li></ul><ul><li>Thyroid symptoms less in pregnancy </li></ul><ul><li>Surgery preferred second trimester </li></ul><ul><li>Iodine 131 avoided </li></ul><ul><li>Discuss breastfeeding </li></ul><ul><li>No other infant concerns </li></ul><ul><li>Suppressive doses of thyroid hormone </li></ul>
    33. 33. Baby risks- hyperthyroid mom <ul><li>Fetal thyrotoxicosis </li></ul><ul><ul><li>Even is the mom has been treated because antibodies still cross the placenta </li></ul></ul><ul><ul><li>1-5% of infants whose mom has Graves will have hyperthyroidism </li></ul></ul><ul><ul><li>Lower incidence if not ablated yet </li></ul></ul><ul><li>Fetal goiter from thioamides </li></ul><ul><li>Transient hypothyroidism from meds </li></ul>
    34. 34. Baby risks- hypothyroid mom <ul><li>Low Birth Weight (in hypothyroidism related to risk of preterm delivery) </li></ul><ul><li>Cretinism (growth failure, mental retarded, neuro deficits) </li></ul><ul><li>Developmental delays (although not proven currently) </li></ul>
    35. 35. Questions???

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