chronic medical problems in pregnancy.ppt
TRANSCRIPT
Chronic Medical Conditions Chronic Medical Conditions in Pregnancyin Pregnancy
Dr Jessica Servey, FAAFPDr Jessica Servey, FAAFP
15 March 200715 March 2007
Travis Family Medicine Travis Family Medicine ResidencyResidency
ObjectivesObjectives
Review thyroid Review thyroid disorderdisorderReview Review isoimmunizationisoimmunizationReview preeclampsiaReview preeclampsiaReview Review thrombocytopeniathrombocytopeniaReview asthmaReview asthmaReview anemiaReview anemiaReview pyelo/renal Review pyelo/renal stonesstones
Review chronic Review chronic hypertensionhypertensionReview liver disordersReview liver disordersReview migraine Review migraine treatmenttreatmentReview Review thromboembolic thromboembolic disordersdisordersReview seizure Review seizure disordersdisorders
Real ObjectivesReal Objectives
Review asthma in pregnancyReview asthma in pregnancy– TreatmentTreatment– SurveillanceSurveillance
Review thyroid disorders in pregnancyReview thyroid disorders in pregnancy– TreatmentTreatment– SurveillanceSurveillance
Basic Intuition in Family MedicineBasic Intuition in Family Medicine
All pregnancies do better if the chronic All pregnancies do better if the chronic medical problems are controlledmedical problems are controlled
Most babies do better inside the mommyMost babies do better inside the mommy
We as Family Physicians are uniquely We as Family Physicians are uniquely gifted to take care of these coupletsgifted to take care of these couplets
Asthma
Why asthma?Why asthma?
The percentage in women having asthma The percentage in women having asthma has more than quadrupled since 1990has more than quadrupled since 1990– 3.1 per 1000 to 15.6 per 10003.1 per 1000 to 15.6 per 1000
Can be managedCan be managed
People still die from this!People still die from this!
Pregnancy complicationsPregnancy complications
Pre-eclampsiaPre-eclampsia
PIHPIH
Hyperemesis gravidarumHyperemesis gravidarum
Maternal hemorrhageMaternal hemorrhage
GDMGDM
PTL and preterm deliveryPTL and preterm delivery
Effects on InfantEffects on Infant
Increased risk IUGRIncreased risk IUGR
Increase neonatal hypoxiaIncrease neonatal hypoxia
Increase low birth weightIncrease low birth weight
Increase neonatal mortalityIncrease neonatal mortality
Pregnancy physiologyPregnancy physiology
Dyspnea occurs in 60-70 % all pregnant womenDyspnea occurs in 60-70 % all pregnant women
Rule of thirdsRule of thirds– Worsen 24-36 weeksWorsen 24-36 weeks
Subsequent pregnancies are the sameSubsequent pregnancies are the same
Possible reasons to worsen: Increased GER, Possible reasons to worsen: Increased GER, mucosal edema and URI, stress, decreased mucosal edema and URI, stress, decreased FRCFRC
FEV1 unchanged, but respiratory alkalosis is FEV1 unchanged, but respiratory alkalosis is normalnormal
Chronic Asthma TreatmentChronic Asthma Treatment
Categorized and maximize medicationCategorized and maximize medicationPEFRPEFR– Twice daily, no change with pregnancyTwice daily, no change with pregnancy
Flu vaccineFlu vaccineTreat GERD and SARTreat GERD and SARGive Action PlanGive Action PlanLook for triggers (pets/mites/PAR)Look for triggers (pets/mites/PAR)ImmunotherapyImmunotherapy– Safe to continue if at maintenanceSafe to continue if at maintenance
Chronic TreatmentChronic TreatmentPart of routine OB visit!!!Part of routine OB visit!!!
Objective lung measure at every visitObjective lung measure at every visit
Formal PFT?????Formal PFT?????
Ultrasound to assess growthUltrasound to assess growth– No trials to give guidanceNo trials to give guidance
APFT – can consider if not well controlledAPFT – can consider if not well controlled– No formal trialsNo formal trials
Pulmonary consult/Anesthesia if neededPulmonary consult/Anesthesia if needed
Asthma ExacerbationAsthma Exacerbation
Treat the same as if not pregnantTreat the same as if not pregnant
Look closely at blood gasesLook closely at blood gases
Frequent follow up Frequent follow up
MedicationsMedications
Most asthma medications are Cat B and Most asthma medications are Cat B and Cat CCat C
Swedish epidemiologic data has increased Swedish epidemiologic data has increased some inhaled steroids to Bsome inhaled steroids to B
Oral Steroids Cat COral Steroids Cat C– Carries risk PTL, low birth weight, PROM, Carries risk PTL, low birth weight, PROM,
cleft lip?cleft lip?
Risks of uncontrolled asthma is higher!Risks of uncontrolled asthma is higher!
Labor and DeliveryLabor and Delivery
Monitoring InfantMonitoring Infant– Continuous fetal monitoringContinuous fetal monitoring
AsthmaAsthma– Peak flow during laborPeak flow during labor– Continue regular medicationsContinue regular medications– Allow for albuterol prnAllow for albuterol prn– IV hydrocortisone if received systemic IV hydrocortisone if received systemic
corticosteroids during pregnancy ( 3 doses)corticosteroids during pregnancy ( 3 doses)
Labor and DeliveryLabor and Delivery
Pain managementPain management– Bronchospasm increases with increased painBronchospasm increases with increased pain– Morphine and demerol are histamine Morphine and demerol are histamine
releasersreleasers– Epidural is the preferred methodEpidural is the preferred method– Propofol for general anesthesiaPropofol for general anesthesia
HemorrhageHemorrhage– No hemabateNo hemabate– May use prostaglandins for inductionMay use prostaglandins for induction
Thyroid diseases
Normal Thyroid FunctionNormal Thyroid Function
Thyroid binding globulin increases Thyroid binding globulin increases
TSH and FT4 no changeTSH and FT4 no change
Iodide levels decreaseIodide levels decrease
Increase thyroid size, normal TFTIncrease thyroid size, normal TFT
Transient increase T4 and decrease TSH Transient increase T4 and decrease TSH first trimester, related to elevated hcG first trimester, related to elevated hcG levelslevels
Fetal DevelopmentFetal Development
Concentrates iodine at 10-12 weeksConcentrates iodine at 10-12 weeks
Levels of TSH and TBG, FT4 and T3 Levels of TSH and TBG, FT4 and T3 increase throughoutincrease throughout
TSH does NOT cross placentaTSH does NOT cross placenta
T4 and T3 cross the placentaT4 and T3 cross the placenta
Immunoglobulins and thioamides cross the Immunoglobulins and thioamides cross the placentaplacenta
HyperthyroidismHyperthyroidism
0.2% pregnancies0.2% pregnancies
Other causes than Graves: gestational Other causes than Graves: gestational trophoblastic neoplasia, adenoma trophoblastic neoplasia, adenoma hyperfunctioning, toxic multinodular goiter, hyperfunctioning, toxic multinodular goiter, thyroiditis, extrathyroid sourcethyroiditis, extrathyroid source
Risks of hyperthyroidismRisks of hyperthyroidism
Preterm deliveryPreterm delivery
Severe preeclampsiaSevere preeclampsia
Heart failureHeart failure
MiscarriageMiscarriage
Low birth weight/IUGRLow birth weight/IUGR
Fetal lossFetal loss
Poor maternal weight gainPoor maternal weight gain
TreatmentTreatment
Thioamides- usually Propylthiouracil (PTU) Thioamides- usually Propylthiouracil (PTU) but can use methimazolebut can use methimazole
Goal of treatment is FT4 in highest Goal of treatment is FT4 in highest possible normal areapossible normal area
May need to monitor every 2-4 weeksMay need to monitor every 2-4 weeks
Breastfeeding is fineBreastfeeding is fine
Consider beta blockers for symptomsConsider beta blockers for symptoms
Iodine 131Iodine 131
ContraindicatedContraindicated
Avoid pregnancy for 4 monthsAvoid pregnancy for 4 months
Avoid breastfeeding for 4 monthsAvoid breastfeeding for 4 months
If exposed- check gestational ageIf exposed- check gestational age– <10 weeks should be fine<10 weeks should be fine– > 10 weeks, discuss options> 10 weeks, discuss options
Thyroid stormThyroid storm
1% of hyperthyroid mothers1% of hyperthyroid mothers
High risk of maternal heart failureHigh risk of maternal heart failure
Clinical picture can be fever, tachycardia, Clinical picture can be fever, tachycardia, altered mental status, vomiting, diarrhea, altered mental status, vomiting, diarrhea, cardiac arrhythmiascardiac arrhythmias
Do not wait for lab results to treatDo not wait for lab results to treat
? Up to 25% mortality? Up to 25% mortality
Treatment-thyroid stormTreatment-thyroid storm
PTUPTUPotassium iodide solutionPotassium iodide solutionDexamethasoneDexamethasonePropanololPropanololPhenobarbitalPhenobarbitalSupportive careSupportive careSearch for and fix the causeSearch for and fix the causeDo not deliver unless fetal indicationDo not deliver unless fetal indication
HypothyroidismHypothyroidism
Hashimoto’s most common in USHashimoto’s most common in US
Iodine deficiency most common worldwideIodine deficiency most common worldwide
Drugs:Lithium, Dilantin, Rifampin, FeSO4,Drugs:Lithium, Dilantin, Rifampin, FeSO4,
sucralfate, amiodaronesucralfate, amiodarone
5-8% incidence if Type I DM5-8% incidence if Type I DM
25% risk pp thyroid dysfunction in Type I 25% risk pp thyroid dysfunction in Type I DMDM
Risks of hypothyroidismRisks of hypothyroidism
Preeclampsia and PIH Preeclampsia and PIH (unknown reason)(unknown reason)Miscarriage (twice the Miscarriage (twice the normal risk)normal risk)20% perinatal mortality 20% perinatal mortality (stillbirths)(stillbirths)10-20% congenital 10-20% congenital anomaliesanomaliesPlacental abruptionPlacental abruptionAnemiaAnemia
? Intellectual ? Intellectual developmentdevelopmentPostpartum Postpartum hemorrhagehemorrhagePreterm deliveryPreterm delivery**Old studies, few **Old studies, few women, poor women, poor controlcontrol
Miscarriage riskMiscarriage risk
1990 study of 552 women – thyroid 1990 study of 552 women – thyroid diseasedisease- 17 % miscarried with positive antibodies- 17 % miscarried with positive antibodies
- 8.4% miscarried without antibodies- 8.4% miscarried without antibodies? Related to antibody or just immune ? Related to antibody or just immune
functionfunction1999 study- 15 women1999 study- 15 women– Antibody levels decreased in women without Antibody levels decreased in women without
miscarriagemiscarriage
Fetal anomaliesFetal anomalies
Study done published 2001Study done published 2001
Retrospective chart reviewRetrospective chart review
Meant to look at population dataMeant to look at population data
23.5 % anomalies hypothyroid women23.5 % anomalies hypothyroid women
21.8 % anomalies hyperthyroid women21.8 % anomalies hyperthyroid women
Cardiac anomalies significantly elevated in Cardiac anomalies significantly elevated in hypothyroidhypothyroid
HypothyroidismHypothyroidism
Large European study, 2.5% women with Large European study, 2.5% women with subclinical hypothyroidismsubclinical hypothyroidism
Screening?Screening?– High risk patients should be considered: prior history High risk patients should be considered: prior history
thyroid disease, history of autoimmune or endocrine thyroid disease, history of autoimmune or endocrine disorder, family history thyroid disease, neck disorder, family history thyroid disease, neck radiation, goiter on exam, medications that alter radiation, goiter on exam, medications that alter thyroxine, hyperlipidemiathyroxine, hyperlipidemia
– Recent study in Maine in 2006- up to 48% with thyroid Recent study in Maine in 2006- up to 48% with thyroid disordersdisorders
TreatmentTreatment
Thyroid replacement to normalize TSHThyroid replacement to normalize TSH
Increased thyroid hormone requirementsIncreased thyroid hormone requirements
At least every 4-6 weeks needs TFT At least every 4-6 weeks needs TFT checkedchecked
Postpartum readjustmentPostpartum readjustment
APFTs? Serial ultrasound? APFTs? Serial ultrasound?
AntibodiesAntibodies
Anti-microsomal, Anti-thyroglobulin, Anti-microsomal, Anti-thyroglobulin, stimulating/inhibitory antibodies, stimulating/inhibitory antibodies, peroxidaseperoxidase
Perinatal vs endocrine opinionPerinatal vs endocrine opinion
Thyroid CancerThyroid Cancer
Pregnancy itself doesn’t alter the coursePregnancy itself doesn’t alter the course
Thyroid symptoms less in pregnancyThyroid symptoms less in pregnancy
Surgery preferred second trimesterSurgery preferred second trimester
Iodine 131 avoidedIodine 131 avoided
Discuss breastfeedingDiscuss breastfeeding
No other infant concernsNo other infant concerns
Suppressive doses of thyroid hormoneSuppressive doses of thyroid hormone
Baby risks- hyperthyroid momBaby risks- hyperthyroid mom
Fetal thyrotoxicosisFetal thyrotoxicosis– Even is the mom has been treated because Even is the mom has been treated because
antibodies still cross the placentaantibodies still cross the placenta– 1-5% of infants whose mom has Graves will 1-5% of infants whose mom has Graves will
have hyperthyroidismhave hyperthyroidism– Lower incidence if not ablated yetLower incidence if not ablated yet
Fetal goiter from thioamidesFetal goiter from thioamides
Transient hypothyroidism from medsTransient hypothyroidism from meds
Baby risks- hypothyroid momBaby risks- hypothyroid mom
Low Birth Weight (in hypothyroidism Low Birth Weight (in hypothyroidism related to risk of preterm delivery)related to risk of preterm delivery)
Cretinism (growth failure, mental retarded, Cretinism (growth failure, mental retarded, neuro deficits)neuro deficits)
Developmental delays (although not Developmental delays (although not proven currently)proven currently)
Questions???Questions???