1 / 25

Medical Complications of Pregnancy

Medical Complications of Pregnancy. AIMGP UHN and MSH - May 2003 Katina Tzanetos, MD FRCP(C). Important Topics to Be Covered Today. Venous Thromboembolism Hyperthyroidism. Other Important Topics Related to Pregnancy. Liver Disease Diabetes Renal Disease Asthma. VTE: References.

loyal
Download Presentation

Medical Complications of Pregnancy

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Medical Complications of Pregnancy AIMGP UHN and MSH - May 2003 Katina Tzanetos, MD FRCP(C)

  2. Important Topics to Be Covered Today • Venous Thromboembolism • Hyperthyroidism

  3. Other Important Topics Related to Pregnancy... • Liver Disease • Diabetes • Renal Disease • Asthma

  4. VTE: References • Dizon-Townson D. Pregnancy-Related Venous Thromboembolism. Clin Obst Gyn. 2002; 45: 363. • Greer I. Thrombosis in pregnancy: maternal and fetal issues. Lancet. 1999; 353:1258. • Toglia MR, Weg JG. Venous thromboembolism during pregnancy. N Engl J Med. 1996; 335:108.

  5. VTE: Epidemiology • Rare - 1-2/1000 pregnancies • Leading cause of death in pregnant women in western world • Excluded in 75% of those who present with subsequent testing

  6. VTE: Risk Factors • PREGNANCY!!! • Virchow’s triad: all factors exaggerated in pregnancy • Hypercoagulability: Estrogen stimulates hepatic production of Factors V, VII, VIII, IX, X, XII and a decrease in activity of fibrinolytic system

  7. Hemostatic Changes in Pregnancy • Venous stasis: mechanical compression on venous system by gravid uterus • Vascular damage: ensues with separation of placenta and with C-sxn

  8. VTE: Diagnosis - Clinical • Iliofemoral area >> calf area • Predilection for left leg (90%) • Usual symptoms may be confusing due to similarity with symptoms of pregnancy • May have lower abdominal pain due to periovarian collateral circulation

  9. Diagnosis - Algorithm • As in non-pregnant states, decide if DVT or PE is main presenting concern --> algorithms • Note: Suspected DVT + negative initial doppler: Most diagnosticians would not stop there, but rather go to serial doppler or even venography

  10. DVT: Diagnosis - Objective Testing doppler u/s negative positive stop serial doppler venography treat negative positive treat no treat

  11. PE: Diagnosis - Objective Testing doppler U/S treat positive negative V/Q high indeterminate normal low suspicion suspicion low low high high pulmonary angiogram treat no treat

  12. VTE: Estimated Fetal Radiation

  13. VTE: Treatment - LMWH • LMWH: safe as does not cross placenta • Duration: 6 weeks - 3 months post-partum • Hypercoagulable w/u indicated

  14. Treatment • Keep in mind: • dose may need adjusting with weight changes (anti-Xa levels helpful) • d/c during labour • no epidural if taken within 12-24 hours • anesthesia consult prudent • long-term use associated with osteopenia

  15. VTE: Treatment - Warfarin • Contraindicated in pregnancy • 1st trimester: nasal hypoplasia, stippling of bone, optic atrophy, mental retardation, cleft lip, cleft palate, cataracts, microopthalmia, ventral midline dysplasia • beyond 1st trimester: CNS abnormalities • Peri-partum: bleeds (mom and baby) • Acceptable with breastfeeding

  16. Thyroid Disease in Pregnancy • American College of Obstetricians and Gynecologists. ACOG Practice Bulletin. 2002; 37:387. • Lazarus JM, Othman S. Thyroid disease in relation to pregnancy. Clinical Endocrinology. 1991: 34: 91.

  17. Effect of Pregnancy on Thyroid Function • TBG  2ndary to reduced hepatic clearance and estrogenic stimulation of synthesis • TT4, TT3 increase • FT3, FT4: transient  in 1st trimester then fall to normal and continue to fall in 3rd trimester; still w/in normal range

  18. Effect of Pregnancy on Thyroid Function • TSH - no change • Plasma iodide levels  b/c of fetal use and  maternal clearance -->  thyroid gland size

  19. Hyperthyroidism in Pregnancy • 0.2% pregnancies • Graves’ accounts for 95% of cases • Pre-existing Graves’ may see spontaneous remission

  20. Differential Diagnosis of Elevated TSH • Toxic multinodular goitre • Toxic nodule • Trophoblastic tumour • Hyperemesis gravidarum

  21. Consequences of Uncontrolled Hyperthroidism • Mother • HTN, preeclampsia, CHF, storm, miscarriage, abortion • Fetus • hyperthyroidism, IUGR, SGA, prematurity, stillbirth

  22. Treatment - Hyperthyroidism in Pregnancy • Usually Graves’ disease • Aim for medical mgmt • PTU • traditionally used • ? Less likely to cross placenta • Methimazole • ? Associated with fetal aplasia cutis, a congenital skin defect of scalp

  23. Treatment - Hyperthyroidism in Pregnancy • Goal: FT4 in high normal range using lowest possible dosage • Consider stopping drugs in 2nd trimester and monitoring for remission • +/- Propranolol for symptoms

  24. Treatment - Hyperthyroidism in Pregnancy • Monitor fetus for heart rate, growth, goitre • PTU and methimazole considered safe in breastfeeding • Radioactive iodine contraindicated in pregnancy and breastfeeding • If surgery needed, aim for T2 • Thyroid storm: as in non-pregnant

  25. THE END • ??? QUESTIONS???

More Related