16 \200 Risk factors \200 Age >35 years old \200 Early pregnancy BMI >30 \200 Smoker \200 P arity \211 3 \200 Multiple pregnancy \200 Assisted reproduction \200 Gross varicose veins \200 Paraplegia \200 Sickle cell disease/SLE \200 Nephrotic syndrome \200 Som e cardiac causes \200 Past thromboembolism1 \200 Thrombophilia \200 Myeloproliferativ e dis. \200 In \202 ammatory bowel dis. \200 Hyperemesis/dehydration \200 Pre-eclamp sia \200 Immobility for \211 3 days eg symphysis pubis dysfunc- tion s c i r t e t s b O Ovarian hyperstimulation \200 Major infection (eg pyelo- nephritis, wound infection) so hospital admission Labor lasting >24h \200 Mid-cavity forceps \200 Elective cesarean \200 Blood loss >1L /transfused \200 Surgery in puerperium eg evacuation of retained products of conception \200 Postpartum sterilization \200 Lon g travel time ( \211 4h) (HR) Previous VTE unprovoked/idiopathic or estrogen (or pregnancy)-relat- ed; or VTE + (1st degree relative with VTE or thrombophilia); or VTE + docu- mented thrombophilia: give LMWH antenatally and 6 weeks postpartum. (IR) If a single previous VTE provoked by major risk factor no longer present and no other risk factors give LMWH for 6wks postpartum (PP). Women with asymptomatic thrombophilia: See p33. 1 Non-estrogen related provoked thromboembolism eg previous major surgery is not a risk fac tor. 17 Minor symptoms of pregnancy \200\207Before prescribing any drug, think \200\224Is it neces sary? Is it safe? Consult Data-sheets a national teratology information service (tel 019 1 232 1525uk). Symptoms and signs in the \201 rst 10 weeks: Early symptoms are amenor- rh oea, nausea, vomiting, and bladder irritability. Breasts engorge, nipples enlarge (darken a t 12 weeks), Montgomery \200\231s tubercles (sebaceous glands on nipples) become prominent. Vulval vascularity increases and the cervix sof- tens and looks bluish (4 weeks). At 6 \200\22310 weeks the uterine body is more globu- lar. Temperature rises (<37.8 C). Headach es, palpitations, and fainting are all commoner in pregnancy. Dilated peripheral circulatio n \200\200sweating and feeling hot. Management: In- crease \202 uid intake: take showers . If feels faint from postural hypotension, stand slowly. Urinary frequency is due to press ure of the fetal head on the bladder in later pregnancy. Exclude UTI. Abdominal pain: See p 38. Breathlessness is common. See p6. Constipation tends to occur as gut motility decreases . Adequate oral \202 uids and a high- \201 bre diet help combat it. Avoid stimulant laxa tives \200\224they increase uterine activity in some women. Increased venous distensibility and pelvic congestion predispose to hemorrhoids (if they prolapse, rest the mother head do wn, apply ice packs and replace them) and varicose veins. Resting with feet up and properly worn elastic stockings help. Re \202 ux oesophagitis and heartburn occur as pyloric sphin cter relaxation al- lows irritant bile to re \202 ux into the stomach. Cigarettes and spic es should be avoided, small meals taken, and antacids may be used. Use more pillows, and a semi-recumbent position. Third trimester backache: Due to pelvic ligament and muscle relaxa tion, pain tends to be worse at night. A \201 rm mattress, \202 at shoes, standing with back straight, and pelvic support from physiotherapy all help. Carpal tunnel syndrome (p71 4) in pregnancy is due to \202 uid retention. Advise wrist splints until delivery cures t he problem. Itch/itchy rashes are common (up to 25%) and may be due to the usual caus- es ( OHCM p64, check LFT \200\224see p26) or to pruritic eruption of pregnancy (PEP = prurigo of pregnancy) \200\224an intensely itchy papular/plaque rash on the abdo- men and limbs. PEP is most common in \201 rst pregnancies beyond 35 weeks \200\231 gestation. Emollients and weak topical steroids ease it. Delivery cures it. If vesicles are present, think of pemphi goid gestationis (PG): a rare (1 : 50,000) condition which may cause fatal heat loss and ca rdiac failure; the baby may be brie \202 y aff ected; refer early (prednisolone may be nee ded). PG may recur in later pregnancies. Ankle oedema: This is a very common, almost normal , manifestation of preg- nancy. Measure BP and check urine for protein (pre-eclampsia, p48) . Check legs for DVT. It often responds to rest and leg elevation. Reassure that it is harm less (unless pre-eclampsia). Leg cramps 33% get cramp, the latter half of pregnancy, severe in 5%, often worse at night. Raising the foot of the bed by 20cm will help. Chloasma: This is a patch of darker pigmentation, eg on the face: p586. Nausea aff ects 80%. Vomiting oc curs in 50%. It may start by 4 weeks and decline over the following weeks. At 20 weeks 20% may still vomit. Most re- spond to frequent small meals, reassurance, and a stress-free en vironment. It is associated with good outcome (fewer fetal losses). Hyperemesis: p18. s c i r t e t s b O Hyperemesis gravidarum 18 \200 This is de \201 ned as persisting vomiting in pregnancy which causes weight loss (>5% of p re-pregnancy weight) and ketosis. It aff ects 1% of pregnant women. Risk is increased in yo uth, non-smokers, primips, working outside home, pre- existing diabetes, hyperthyroidism, p sychiatric illness, family history, those with previous eating disorders and multiple or mo lar pregnancy (hence the idea that excessively high HCG levels may be the cause \200\224whe reas steeply rising oestrogens may cause the very common feature of morning sickness). Rare ly, hyperemesis has been fatal. Recurrence rate 15% (10% if changed paternity). 53 Presenta tion Inability to keep food or \202 uids down; weight \200\201 (2 \200\2235kg) nutri- tional de \201 ciency, dehydration, hypovolaemia, tachycardia, postural hypoten- sion, el ectrolyte disturbance with hypokalaemia and hyponatraemic shock, polyneuritis (B vitamins \200\201), behavior disorders, liver and renal failure. There may be ptyalism (inability to swallow saliva) and spitting. Tests Do PCV and U&E to help guide IV \202 uid regimen. 50 % have abnormal LFTs (usually raised aminotransferase and bilirubin). TFTs are abnormal in 60% of those with hyperemesis. This is biochemical hyperthyroidism with raised free thyroxi ne and suppressed TSH. In women with hyperemesis thyroxine is con- verted to reverse tri-io dothyronine in the tissues which is physiologically in- active so stimulating metabolic rat e less and conserving energy stores. The severity of hyperemesis correlates with the degree of biochemical hyperthy- roidism, and those with abnormal TFTs require longer hospitalizat ion to pre- vent readmission. The biochemical hyperthyroidism settles as vomiting settles s o does not require treatment in its own right. Chart losses, weigh, record pulse and standi ng and lying blood pressure. Exclude UTI. Do ultrasound scan to exclude twins or hydatidifo rm mole. Treatment Admit to hospital. Give thromboprophylaxis (eg enoxaparin 40mg/24h SC) a nd anti-embolic stockings. Spend time optimizing psychological wellbeing. Is she worried ab out how her other children are being cared for? s c i r t e t s b O Most settle with due care and attention. If not too severe it may settle with rest, ginger, pyridoxine, dry bland food, and carbonated drinks. Rou- tine thiamine supplementation is w ise for all women admitted (eg thiamine 25 \200\22350mg/8h PO) or if IV required 100mg dilu ted in 100mL normal saline given over 60min, repeated at weekly intervals. This is to preve nt development of Wernicke \200\231s encephalopathy (see OHCM p707) \200\224which is then a ssociated with 40% fetal loss. Correct dehydration with IV infusion (eg with normal saline infusion with potassium added to each bag as guided by U&E). Beware rapid reversal of hypon atraemia which can cause fatal central pontine myelinosis. 54 If condition does not improve after rehydration anti-emetics may be needed eg cyclizine 50mg/8h PO/IM or IV. Other recog nized anti-emetics used: meto- clopramide, prochloperazine, chlorpromazine, domperidone, on dansetron. 55 Phenothiazines can cause drowsiness, extrapyramidal side eff ects, and ocu- l ogyric crisis. Those resistant to conventional treatments may respond to steroid treatment, eg hydrocortisone 100mg twice daily followed by 40mg prednisolone/24h tapering down. Predn isolone can then usually be reduced to 2.5 \200\22310mg/24h by 20 weeks gestation. If it i s needed long-term screen for UTI and gestational diabetes. Prednisolone is metabolized by the placenta, fetal blood levels are low and adverse fetal eff ects have not been reported. Parenteral nutrition may, very rarely, be needed \200\224OHCM p574. If nutritional support is required both nasojejunal tube feeding and percutaneous endoscopic gastrostomy have been successfully used. 56 Parenteral nutrition has been found to be associated with serious co mplications (eg line sepsis). \200\207Get a dietician \200\231s help. Sickle-cell disease in pregnancy57 Sickle-cell disease (SCD) is caused by a group of hemogl obin disorders (single gene recessive) which predispose to \200\230sickling \200\231 of re d cells in low oxygen con- ditions causing vaso-occlusion in small vessels, and cells prone to increased haemolytic breakdown. Disease complications include painful crises, stroke, p ulmonary hypertension, renal dysfunction, leg ulcers, retinal disease, avascu- lar necrosis (eg of hip). Pregnancy complications include maternal painful cri- ses, prematurity and fe tal growth restriction. Some studies suggest increased maternal infection, thromboembolic e vents and pre-eclampsia. Most preva- lent in those of African descent it is also prevalent in the Caribbean, Middle East, Mediterranean, parts of India, South and Central America. Th ere are 100 \200\223200 pregnancies in women with SCD in the UK annually. Preconception Wom en with SCD should be under annual clinic review to monitor disease. Arrange sickle special ist preconception review. Advice should cover factors aff ecting sickling crises (cold, hyp oxia, dehydration-hence nausea and vomiting of pregnancy, over-exertion, stress). Pregnancy worsens anemia, so \200\200 risk of crises and acute chest syndrome (ACS)-chest pain, cou gh, tachypnoea and new in \201 ltrates on CXR: treat as for pneumonia+blood trans- fusion. Screen for red cell antibodies (if present \200\200risk of haemolytic disease of newborn) . Pregnancy \200\200 risks of infection (especially UTI). Address \200\200 risk of fetal growth restriction (hence \200\200 induction, \200\200cesarean section rates). Address ch ance of fetus being aff ected (partner \200\231s blood to check carrier/hemoglobin- opathy status: genetic counseling if needed). Assess current disease: echocar- diography if not do ne in last year to exclude pulmonary hypertension (tricuspid regurgitant jet velocity >2.5m /s high risk, p20); BP & urinalysis, U&E, LFT; retinal screening (proliferative retinopathy common); screen for iron overload if mul- tiply transfused (if signi \201 cantly overload ed, preconception chelation therapy is advised). SCD is a hyposplenic state; advise daily p enicillin or erythromycin and update vaccines: hepatitis B, single dose haemophilus in \202 uenza B & menin- gococcal C, 5-yearly pneumococcal, and annual H1N1 with seasonal in \202 uenza. Stop ACE/A2A drugs & hydroxycarbamide \211 3 months), preconceptually. Give 5m g folic acid daily (p2) preconceptually (requirement \200\200 as haemolysis). Antenatal ca re Ensure preconception measures addressed. Manage by specialist multidisciplinary team if possible; if not, by \200\230high-risk \200\231 team using protocols. If fetus has haemogl obinopathy risk, off er prenatal testing by 8 \200\22310 weeks. From 12 weeks give 75mg asp irin daily to reduce risk of developing pre- eclampsia. Suggest graduated compression stock ings in pregnancy. If hospi- talized, give heparin thromboprophylaxis. Check BP at all ante natal visits and an MSU monthly. Off er viability scan at 7 \200\2239 weeks, dating scan at 11 \200\22314, anom- aly scan at 20, and growth scan 4-weekly from 24 weeks. Only suppleme nt iron if proven de \201 ciency. Blood transfusion is not routine; if needed for sickling complication use fully compatible rhesus C,D,E and Kell typed CMV-negative blood (if so, t ransfusion regimen may be needed for rest of pregnancy). Top up transfusions may be needed if Hb falls to 6 or by 2g/dL from booking. Crises aff ect 27 \200\22350%. Admit if fever, s evere or atypical pain, chest pain, or breathless. If pain needs IV opiates use morphine/di amorphine (not pethidine, it risks \201 ts); give nasal O2 if oxygen sats <95% (take to I TU if O2 sats not maintained), and adequate \202 uid intake 60mL/kg/h PO/IV unless pre-ec lampsia (then specialist advice). Exchange transfusion is needed for acute chest syndrome o r if stroke. Intrapartum care Aim for delivery at 38 weeks at hospitals able to manage SCD and high-risk pregnancy. Keep warm and hydrated in labor/post-partum. Monitor fetus, and ma ternal O2 sats. Avoid pethidine (above). Give 7d heparin thromboprophylaxis post vaginal de livery, 6 weeks if cesarean. Progestogen- ic contraception is that of choice. 19 s c i r t e t s b O Cardiac disease in pregnancy 20 In pregnancy cardiac output (CO) increases to a maximum of 30 \200\22340% > non- pregnant l evels by \200\200 heart rate and stroke volume. Twins \200\200 CO 30% more. Heart disease aff ects <1% of pregnant women. Examine the heart carefully early in all preg nancies. Ask the opinion of a cardiologist if there is doubt: \200 Past history (eg conge nital heart disease, rheumatic fever). \200 Previous Kawasaki disease (now a more common cause of acquired heart disease than rheumatic fever). \200 Murmurs (other than 5 \200 \2237 in the list below). 60% of maternal cardiac deaths occur after delivery. Cardiac failure can oc- cur at any sta ge in pregnancy (risk \200\200 in later pregnancy, and highest in the early puerperium). E isenmenger \200\231s syndrome risks maternal mortality (MM) of 30%; pulmonary hypertension (MM= 30 \200\22350%); coarctation of the aorta (surges of BP \200\200 in the proximal segme nt), severe aortic or mitral stenosis, and inoper- able cyanotic heart disease are associat ed with \200\200MM, so advise against preg- nancy \200\224or arrange meticulous specialist care. Seek pre-pregnancy advice for those with Marfan \200\231s or Ehlers \200\223Danlos. Termination may be medically advised. Prosthetic valve anticoagulation: Get expert help. Wa rfarin risks fetal harm (p640); heparin risks valve thrombosis. 58 Some use IV heparin infu sion weeks 6 \200\22312 and 37 \200\223term+7d; warfarin with target level of INR of 3 at o ther times. Antenatal management Regular visits to cardiologist/obstetric combined clinic. Prevent anemia, obesity, and smoking. Ensure suffi cient rest. Treat hypertension. Treat in fections early. Examine carefully to exclude pulmonary oedema and arrhythmias at all visits . Heart failure requires admission. Labor Outcome is worst for mothers unable to \200\200 their cardiac output (rare). Have O2 and drugs to treat cardiac failure to hand. Avoid lith otomy position (dangerous \200\200 venous return after labor \200\224the best position is semi-sitting). Aim for vaginal delivery at term with a short 2nd stage (lift-out forceps or ven- touse). Pain relief should be good. Epidurals are safe if hypotension is avoided. Bew are large volumes of IV \202 uids. Avoid ergometrine (use oxytocin, if neces- sary). Cesa rean section should not be done (except during eclampsia) if in heart failure. Heart failur e is most likely within the \201 rst 24h after delivery, so ensure careful observations a t this time. Cardiac failure If symptoms or signs found, admit for bed rest, and treatment with diuretics digoxin. If acute failure develops, give 100% oxygen, nurse semi-recumben t, and give furosemide 40mg IV slowly (<4mg/min), morphine 10mg IV. Are vasodilators (nitra tes or hydralazine) needed? Seek advice on ACE inhibitors. If there is no improvement, cons ider ventilation. Arrhythmias Atrial \201 brillation: Is there mitral stenosis? \200\224a dmit. \200\224 is as for the non-pregnant and may include digitalization or cardioversion. Narrow complex tachycardia: may precipitate cardiac failure. If Valsalva maneuver and caro tid massage fail, anesthetize and cardiovert. These signs may be normal in pregnancy 1 Oede ma and an increased pulse volume. 2 Vigorously pulsating neck veins (but JVP should not be \200\200). 3 The apex beat is forceful (but <2cm lateral to midclavicular line). 4 The \201 rst heart sound is loud and a third heart sound can be heard in 84%. 5 An ejection sys tolic murmur is heard in 96% of women. 6 Systolic or continuous murmurs over either 2nd int ercostal spaces 2cm from sternal edge, modi \201 ed by pressure may be from mammary vessel s. s c i r t e t s b O 7 Venous hums may be heard in the neck (modi \201 ed by posture). 8 CXR may show slight ca rdiomegaly, \200\200 pulmonary vascular markings, disten- sion of pulmonary veins due to \200\200 cardiac output. 21 Psychopharmacology in pregnancy For puerperal depression, see p408. Try to avoid drugs in pregnancy (eg in depression, cogn itive-behavior therapy is a favored alternative) but sometimes psychotropics are essential, eg if the mother is neglecting herself or her pregnancy. If used, psychotropic drugs must be combined with well-planned psychosocial support from a trusted con \201 dant of the pat ient. In those with history of major depression, relapse is higher if prophylactic drugs ar e discontinued. 59 If used, aim for monotherapy. Depression in pregnancy \200\224Unipolar: For diagnosis, see p336. Try to wait until the 2nd trimester before prescribing. Most exper ience is with tricyclics such as amitriptyline, and these have lowest known risk in pregnan cy, 60 \200\224and are therefore the 1st choice when drugs are essential. They are more dan gerous than SSRIs in overdose. It is wise to discuss decisions with another doctor, or your local drug information service. Problems are unlikely, but the exact risk of teratogenesis is unknown. Withdrawal eff ects have been seen in neonates, eg agitation respiratory de pression with amitriptyline, and colic, spasms, and hyper- or hypotension with imipramine, convulsions with clomipramine. Get a second opinion if ECT may be indicated. SSRIs should o nly be used with caution: \202 uoxetine has lowest known risk in pregnancy. They may caus e per- sistent pulmonary hypertension if used after 20 weeks gestation. \200\207Avoid par oxetine (teratogenic \200\224see p2: neonatal convulsions can be a withdrawal reaction 61 a nd 1st trimester use may be associated with cardiac malforma- tions). 62 In general, breast feeding is contraindicated, as metabolites pass to the baby (imipramine, nortriptyline, and sertraline have lowest levels; highest with citalopram and \202 uoxetine). Bipolar: Lith ium (Li+, p354) is linked with teratogenicity (heart defects, includ- ing Ebstein \200\231s anomaly, p2). Off er specialist fetal echocardiography at 16 weeks in those women electing to stay on Li+. Used outside the 1st trimester, lithium can still cause problems with the fetal renal and thyroid function. Monitor drug levels frequently (exactly 12h post-dose 4-w eekly to 36wks, then week- ly, and keep the dose as low as possible, and, in general, aim f or a level of <0.4mmol/L). Do not change brands, as bioavailability varies. Do extra monit- oring during intercurrent illness, D&V, and when poor compliance or toxicity is suspected (tremor, drowsiness, visual disturbance). Deliver in hospital. Moni- tor \202 uid balance and avoid dehydration in labor. If lithium is stopped for a pregnancy or labor, restart it within a few days of birth. High doses are ex- creted in breast milk, so breastfeeding is contraindicated. Phenothiazines for schizophrenia in pregnancy There is con \202 icting da ta on safety \200\224but there is agreement that most pregnancies will be unaff ected. Pre- birth exposure may result in a syndrome of hyperre \202 exia, hypertonia, and tremor, whic h may persist for the \201 rst months of life. NB: rates of fetal abnor- mality are incre ased in schizophrenia, even in those taking no drugs. NICE warn of possible raised prolacti n levels (hence reduced fertility) with amisulpride, sulpiride, and risperidone; gestationa l diabetes from weight gain with olan- zapine; fetal agranulocytosis if breastfeeding mothe r on clozapine; and extrap- yramidal symptoms in neonate if mother on depot antipsychotics. Low-dose typical antipsychotics eg chlorpromazine are favored by NICE. Anxiety in pregnanc y Benzodiazepines may be linked to fetal malformation and should be avoided. Avoid diazepam around the time of delivery, as with- drawal may occur in the baby ( \202 oppy baby syndr ome). Avoid \200 -blockers, as these retard fetal growth. Relaxation techniques (p344) and supportive psy- chotherapy (p380) are far more appropriate. s c i r t e t s b O Anemia in pregnancy 22 \200 \200 \200\207Even a small PPH may become life threatening if the mother is anemic. Anemia predi sposes to infection, makes heart failure worse, and is the main cause of perinatal problems associated with malaria. Above all, anemia is a leading mechanism by which poverty exacts its morbid toll in pregnancy. WHO de \201 nition of anemia of pregnancy Hb <11g/dL. By thi s standard 50% of women not on haematinics become anemic. The fall in Hb is steepest around 20 weeks \200\231 gestation, and is physiological (p6). Who is prone to anemia? Those who start pregnancy anemic, eg from menorrhagia, hookworm, malaria, with haemoglobinopathies; t hose with frequent pregnancies, twin pregnancy, or a poor diet. Antenatal screening include s Hb estimation at booking, at 28 and 36 weeks. In black patients do sickle-cell tests; in others of overseas descent consider Hb electrophoresis for other haemoglobinopathies. From malarious areas con- sider malaria, and thick \201 lms. See p27. Treatment Pregnancy incr eases iron needs by 700 \200\2231400mg (per pregnancy), provided for by a pregnancy-induced 9-fold increase in iron absorption. Iron and folate supplements (and prevention against ho okworm and malaria) are recommended in many developing countries. 63 s c i r t e t s b O Off er oral iron (eg ferrous sulfate 200mg/24h PO; twice-weekly may be suffi - cient if una ble to tolerate this) 64 if likely to be iron de \201 cient (see above) or would refuse tr ansfusion if hemorrhaging (p85). Parenteral iron may be given (to those with iron de \201 ciency anemia not tolerating oral iron) as iron dextran or iron sucrose. Beware anaphylaxis . Use only if cardiopulmonary resuscitation facilities to hand. Hb rises over 6 weeks, so l ate severe anemia (Hb <9g/dL) may need blood transfusion. One unit of blood increases the H b by 0.7g/dL. Thalassaemias (OHCM p336) These globin chain production disorders are found in Mediterranean, Indian, and South-east Asian populations. Although anemic, never give par enteral iron as iron levels are usually high. Seek expert advice as to use of oral iron and folate. \200 -thalassaemia does not aff ect the fetus but in homozygotes regular transfus ions sustain life only until young adulthood. There are \200 chains in fetal HbF, so in \200 -thalassaemias the fetus may be anemic or, if severe, stillborn. Mothers carrying leth ally aff ected hy- dropic fetuses risk severe pre-eclampsia, and delivery complications due to a large fetus and bulky placenta. Prenatal diagnosis is possible by chorionic villus sa mpling (p10) for thalassaemias anticipated by parental blood studies. Sickling disorders ca n aff ect people of African origin, Saudi Arabians, In- dians, Mediterranean, South and Cen tral American populations. Sickle-cell trait is not usually a problem. Sickle-cell disease see page 19. Sickle-cell hae- moglobin c disease is a milder variant of sickle-cell disease . Hb levels are usu- ally near normal so women may be unaware they are aff ected. They are still susceptible to sickling crises in pregnancy and the puerperium, so antenatal diagnosi s is essential. Prenatal sickle-cell diagnosis is possible by chorionic vil- lus sampling. \200\207Aim for diagnosis at birth (cord blood) at the latest so that penicillin pneum- oc occal prophylaxis may be started (OHCM p334). HIV in pregnancy and labor 65 (see also p34) Without interventions 15% babies acquire HIV if the mother is +ve ( \200\200 risk in Africa; but HIV-2 transmitted less). \200\207Verti cal transmission occurs during vaginal delivery (1st twins are twice as often infected as 2 nd). Membrane rupture for >4h doubles risk then \200\200 by 2%/h for 24h. Breast feeding d oubles risk. Maternal anti- retroviral use, elective cesarean delivery, and bottle feeding attains \211 2% risk. 23 \200 Off er HIV tests at booking, if declined, again at 28wks. If HIV status unknown in labor ra pid (20min) tests are available and are recommended. If positive in labor; use drugs to red uce maternal \200\223fetal transmission (below; seek expert advice). If HIV+ve arrange mult idisciplinary care with HIV physician to monitor viral loads, drug regimens and toxicity mo nitoring. Check for hepatitis B & C, vari- cella zoster, measles & toxoplasmosis antibodies . Off er hepatitis B, pneumococ- cal and in \202 uenza vaccines (safe in pregnancy). Scree n for genital infections at booking and at 28wks. Treat infections, even if asymptomatic (t o reduce risk of pre-term birth). Women needing highly active antiretroviral treatment (HAA RT) for their own health (symptomatic HIV/falling or low CD4 lymphocyte count <350 \211 \210 106/L) should continue treatment throughout pregnancy and postpar- tum. If on HAART at booking; screen for gestational diabetes and warn of \200\200risk of premature labor. If on co-trimoxazole for pneumocystis jiroveci prophy- laxis (CD4 <200 \211\210 106/L) add pr e-pregnancy/1st trimester 5mg folic acid/day. Women not needing antiretrovirals for their o wn health should start HAART 20 \200\22328wks, taking until delivered. (If good CD4 levels, viral load <10,000 copies/ mL, and elective cesarean delivery planned zidovudine monothera py orally from 20 \200\22328wks, IV in labor is an alternative.) Plan mode of delivery by 3 6wks. Premature labor If membranes rupture >34wks expedite delivery, what- ever the materna l viral load. If membranes rupture <34wks give steroids (p51), give erythromycin (p50), ens ure mother takes usual HAART regimen, seek HIV specialist advice on how to optimize her reg imen to reduce fetal transmission eg maternal nevirapine crosses placenta with long fetal p lasma concentration, plus zidovudine infusion. Determine delivery balancing risks of premat urity, and infection. Manage preterm labor without membrane rupture as if HIV-ve. Delivery Vaginal delivery: Off er to women with viral loads <50 copies/mL, (<400 copies/mL if on HAA RT). \200 48 Continue HAART in labor. Avoid fetal blood sampling/scalp electrodes. Avoid am niotomy unless delivery imminent. Oxy- tocin can be used for augmentation. Low cavity force ps are preferred over ventouse (less fetal trauma). Avoid mid-cavity or rotational forceps. Cesarean section: Off er elective cesarean section at 38 weeks \200\231 gestation to women if on zidovudine monotherapy (above), if on HAART with viral loads > those above, or if co -infected with hepatitis C. If viral load is <50 copies/mL, and elective section needed, pl an for 39+ weeks (this viral load level is accept- able for vaginal delivery so membrane ru pture is not of consequence). Postpartum Avoid breastfeeding in resource-rich countries (br eastfeeding doubles HIV transmission risk). Cabergoline 1mg PO within 24h of birth is rec- ommended to suppress lactation. Newborns are treated within 4h of birth eg zidovudine twice daily for 4 weeks; HAART if high risk eg untreated mothers; mother with viral loads >50cop ies/mL despite being on HAART. Co-trimoxazole (PCP) prophylaxis is given to babies at high risk of transmission. Babies are tested at day 1, 6wks and 12wks for HIV with con \201 rma tory test at 18 months. Aff ected women should have annual smears. Condoms, intrauterine sy stems (eg Mirena ) and depot progesterone injections are all suitable for women on HAART. Some antiretrovirals are enzyme inducers so may eff ect effi ciency of progesterone only, a nd combined (so use high dose) pills. Check if maternal MMR vaccine (if CD4 count >200/mL, contraindicated if lower), and varicella zos- ter vaccine (only if CD4 count >400/mL) requi red. s c i r t e t s b O Diabetes mellitus (DM) in pregnancy* 24 \200 \200\207Meticulous control around conception decreases malformation rates. Preconception A void unplanned pregnancy. Adjust insulin to optimize con- trol preconception (values as ant enatally, below). Aim for HbA1c of \211 6.1% (avoid pregnancy if HbA1c >10%). Give 5mg fol ic acid daily preconception (p2). Ar- range dietetic review. Stop oral hypoglycaemics (exce pt metformin), statins, ACE and A2A inhibitors (use other antihypertensive p31, if needed). Treat retin- opathy pre-pregnancy. Retinopathy screen; \211 20% develop proliferative re tin- opathy. Nephropathy may worsen; if severe, avoid pregnancy. DM may develop in pregnanc y (GDM, p8). Glycosuria unrelated to DM is common (GFR \200\200 and tubu- lar glucose reab sorption \200\201). Non-diabetic blood glucose levels in pregnancy are constant (3.5 \200 \2234.5mmol/L) except after meals. Fetal glycaemia follows mater- nal. Compensatory fetal h yperinsulinaemia promotes fetal growth. Complications Maternal: Hypoglycaemia unawareness ( esp 1st trimester) so warn about it. Hydramnios (?fetal polyuria), preterm labor, stillbirt h. Fetal: Malformation rates \200\200 \211\2103 (sacral agenesis, almost exclusive to dia betic off spring, is rare; CNS & CVS malformations much commoner). Babies may be macrosomic (too large) or growth restricted. Neonatal risks: Hypoglycaemia, Ca2+ \200\201, Mg2+ \200 \201, and RDS (p118), polycythaemia \200\224so more neonatal jaundice. Antenatal care Use c are plan & review in joint clinic (p3). Con \201 rm gestation with early ultrasound. Detai led abnormality scan at 19 \200\22320 weeks. Fetal echo at 18 \200\22320 weeks. Educate abo ut bene \201 ts of normoglycaemia. Aim for home moni- tored glucose 1h after every meal (p ostprandial) and before bed. Insulin needs increase by 50 \200\223100% as pregnancy progres ses so review regularly. Aim for fasting level 3.5 \200\2235.9mmol/L; 1h post-prandial leve l <7.8mmol/L. Give Glucogel and glucagon kit (ensure partner knows how to use). Exclude k etoacidosis if unwell. Assess renal function; refer to nephrologist if creatinine >120 mol /L, protein excretion >2g/24h (use thromboprophylaxis if >5g/24h). Admit if adequate contro l unachievable at home. Metformin can be used in pregnancy. Monitor fetal growth & wellbein g by ultrasound and cardiotocography (p3). Delivery Deliver the baby where there are good n eonatal facilities. NICE recom- mends elective delivery at 38 weeks. \200 66 In labor: Avo id acidosis and monitor the fetus (p44). Avoid maternal hyperglycaemia (causes fetal hypogl ycaemia). Monitor glucose; prevent hyperglycaemia with extra insulin (may need 5U/h) if glu cocorticoids are used in preterm labor. Aim for vaginal delivery with labor of <12h. Beware shoulder dystocia with macrosomic babies. With elec- tive delivery, give normal insulin th e evening before induction. During labor give 1L of 5 \200\22310% glucose/8h IVI with 1 \200\2232U insulin/h via a pump. Aim for a blood glucose of 4.5 \200\2235.5mmol/L (check ho urly). Insulin needs fall as labor progress- es and immediately postpartum. Stop infusions at delivery. Return to pre-preg- nancy regimen. Do a cesarean section if labor is prolonged . Clamp cord early (polycythaemia risk). Postnatal \200 Encourage breastfeeding (metformi n and glibenclamide are com- patible with breastfeeding). \200 Encourage pre-pregnancy co unseling before next pregnancy (p2) to transfer to insulin if needed. \200 If preprolifer ative retin- opathy review ophthalmologically for 6 months. \200 Discuss contraception. G estational diabetes (OGTT glucose \211 7.8mmol/L, OHCM p198) Incidence: 3%. 67 For screeni ng and who to screen see p8. Monitor glucose if diagnosed. If levels not controlled by diet and exercise over 1 \200\2232 weeks consider oral hypoglycae- mics (metformin, glibenclami de \200\223note NICE and product characteristic sheets con \202 icting advice) or insulin. 50% get full DM, so give lifelong dietary advice and follow-up. 68 Check fasting glucose 6 weeks postpartum. \200\207Exercise, a good diet, and no smoking all help lower this risk. s c i r t e t s b O See diabetic care plan p3. 25 25 Thyroid disease in pregnancy (see also p15) \200\207Whenever a mother isn \200\231t quite right postpartum, check her TSH & free T4 \200\224 but note that any apparent hypothyroidis m may be transitory. Biochemical changes in normal pregnancy NB: normal pregnancy mimics hy perthyroidism (pulse \200\200, warm moist skin, slight goiter, anxiety). \200 Thyroid bi nding globulin & T4 output rise to maintain free T4 levels, p15. \200 High levels of HCG mimic thyroid stimulating hormone (TSH). \200 There is reduced availability of iodine (in iodine-limited localities). \200 TSH may fall below normal in the \201 rst trimester ( suppressed by HCG). \200 The best thyroid tests in pregnancy are free T4, free T3 , and T SH. Pre-pregnancy hyperthyroidism Treatment options include antithyroid drugs (but 60% rela pse on stopping treatment), radioactive iodine (contra- indicated in pregnancy or breastfee ding: avoid pregnancy for 4 months after use), or surgery. Fertility is reduced by hyperthy roidism. Hyperthyroidism in pregnancy (Usually Graves \200\231 disease.) There is \200\200 risk of prematurity, fetal loss, and, maybe, malformations. Severity of hyperthyroid- ism often falls in pregnancy. Transient exacerbations may occur (1st trimester & postpartum). P ropylthiouracil is the best treatment. 69 Keep dose as low as possible. Monitor \211 mont hly. Some advocate stopping antithyroid drugs in the last month of pregnancy. Propylthioura cil is preferred postpartum (less con- centrated in breast milk). If hyperthyroidism cannot be controlled by drugs, partial thyroidectomy can be done in the 2nd trimester. TRAb (TSH- receptor stimulating antibodies): \200\200levels can cause fetal hyperthyroidism after 24w ks causing premature delivery; craniosynostosis so intellectual impairment; goi- tre so pol yhydramnios; extended neck in labor. Note labor, delivery, surgery, and anesthesia can prec ipitate thyroid storm (fever, tachycardia, changed mental state \200\224agitation, psychosi s, coma) requiring urgent treatment. Hypothyroidism Associated with relative infertility, u ntreated hypothyroidism risks \200\200 rates of miscarriage, stillbirth, premature labor, and abnormality. Optimize T4 preconception (p2). Increase levothyroxine by 30% as soon as k nows pregnant. 70 Monitor replacement by T4 and TSH measurement 6-weekly. Aim for TSH \211 2.5mU/L. Use pre-pregnancy levothyroxine doses postpartum. Postpartum thyroiditis Prevalen ce: 5%. Hyperthyroidism is followed by hypo- thyroidism ( 4 months postpartum). The hyperth yroid phase does not usually need treatment as it is self-limiting. If treatment is require d \200 -blockers are usually suffi cient. Antithyroid drugs are ineff ective as thyrotoxic osis is from thyroid destruction releasing thyroxine, rather than increased synthesis. Moni - tor the hypothyroid phase for >6 months, and treat if symptomatic. Withdraw treatment aft er 6 \200\22312 months for 4 weeks to see if long-term therapy is re- quired. 90% have thyr oid antiperoxidase antibodies; 5% of antibody positive women become permanently hypothyroid each year so monitor annually. Hypothyroidism may be associated with postpartum depression , so check thy- roid status of women with postpartum depression. Neonatal thyrotoxicosis Se en in 1% of babies of women with past Graves \200\231 disease, as TRAb crosses the placenta . Signs: fetal tachycardia (>160/min) in late pregnancy intrauterine growth restriction. If mother has been on antithyroid drugs signs may not be manifest until the baby has metab olized the drug (7 \200\22310 days postpartum). Test thyroid function in aff ected babies f re- quently. Antithyroid drugs may be needed. It resolves spontaneously at 2 \200\2233 mont hs, but perceptual motor diffi culties, and hyperactivity can occur later in childhood. Thy roid antibodies Presence of these increase rates of miscarriage and pre- term delivery; ran domized studies suggest thyroxine treatment may reduce miscarriage in euthyroid women with antibodies. 71 s c i r t e t s b O Jaundice in pregnancy 26 \200 \200 \200\207Get expert help promptly. Jaundice in pregnancy may be lethal. Know exact- ly what drugs were taken and when (prescribed or over-the-counter). Where has she traveled to? Wha t lifestyle or occupational risks are there?