1. Medical Disorders in Pregnancy
Dr Than Than Yin

2. Obstetric cholestasis
Unique to pregnancy
Severe pruritus affecting limbs and trunk mainly palm and sole
Developing in the second half of pregnancy (usually during the third trimester)

3. Diagnosis A typical history of pruritus without rash
Abnormal liver function tests
Moderate < less than three-fold elevation in transamimases ( ALT is the most sensitive)
Raised ALP 9> pregnancy values
Raised Ƴ glutamyl transpeptidase
Mild elevation of bilirubin
Increased total serum bile acid
Exclusion of other causes of itching and abnormal liver function

4. Diagnosis To exclude other causes of abnormal liver function
Liver scan
Viral serology ( for hepatitis A,B,C and E,EBV and CMV)
Liver autoantibodies( for pre-exisisting liver diseasse, anti-smooth muscle antibodies, antimitochondrial antibodies

5. Management Counselling Weekly LFT and bile acids
No evidence of monitoring fetal well-being
To check prothrombin time prior to delivery

6. Intrapartum management
Labour may be induced at weeks gestation if persistantly raised bile acid levels
If bile acid levels < 40 µmol/L, reasonable to await spontaneous onset of labour

7. Drug therapy
Vitamin K mandatoroy for women with prolonged prothrombin time, commenced at 32 weeks
Antihistamine
Ursodeoxycholic acid
Dexamethasone
Rifampicin
Cholestyramine
S-Adenosylmethionine
Activated charcol
Epomediol

8. Diagnosis
BP, urinalysis, uric acid, platelet count, clotting screen, blood film
Blood glucose, serum calcium, sodium, liver function tests
CT or MRI
EEG

9. Epilepsy in pregnancy Many cases are idiopathic
30% have a family history of epilepsy
Secondary Epilepsy
Previous surgery
Intracranial mass or lesions
Antiphospholipid syndrome

10. Effect of pregnancy on epilepsy
A common indirect maternal death
No effect in majority
Women who have been seizure free for years are unlikely to have seizures in pregnancy
Women with multiple type seizures are more likely to have increase in seizure frequency
The risk of seizures is highest in peripartum
Sudden Unexplained Death in Pregnancy (SUDEP)- risk factors
seizure frequency
Increasing number of antiepileptic drugs
Low IQ
Early onset epilepsy

11. Effect of epilepsy on pregnancy
The fetus is relatively resistant to short periods of hypoxia
No increased risk of miscarriage or obstetric complications
Status epilepticus is dangerous for both mother and fetus
The risk of child developing epilepsy is increased (4-5%) if either parent has epilepsy and, risk is 10-15% if both parents have epilepsy, 10% risk with previously effected sibling

12. Teratogenic risk of anti-epileptic drugs(AED)
Phenytoin, primidone, phenobarbitone, carbamazepine, sodium valproate, lamotrigine, topiramate and levetiracetam all cross the placenta and are teratogenic
Major malformations caused by AEDs
Neural tube defects ( especially valproates 1-3.8% and carbamazepine 0.5-1%)
Orofacial clefts ( particularly Phenytoin, carbamazepine, phenobarbitone and valproate)
Congenital heart defects (particularly Phenytoin, phenobarbitone and valproate)
Minor malformations
Dysmorphic features
Hypertelorism
Hypoplastic nails and distal digits
Hypoplasia of the mid face

13. Teratogenic risk of anti-epileptic drugs(AED)
Metaanalysis of all studies showed that the risk of any one drug is approximately 6-7%
Various theories
Genetic deficiency of the detoxifying enzyme epoxide hydrolase
Cytotxic free radicals
Folic acid deficiency

14. Management Antenatal management Intrapartum management
Folic acid 5mg daily
No need to change the AED if epilepsy is well controlled
Pre-natal screening for congenital abnormalities and detailed ultrasound at weeks should be ordered, including fetal cardiac assessment
Vitamin A 10-20mg daily should be prescribed in the last four weeks of pregnancy
Intrapartum management
Risk of seizures increase around the time of delivery
1-2% will have a seizure during labour and 1-2% will have a seizure in post partum 24 hours period
Should continue regular AED
Effective pain relief and epidural analgesia
Postnatal management
The neonate should recieve 1mg Vitamin K Inj IM
Breast feeding should be encouraged

15. Cardiac disease in pregnancy
Leading cause of maternal death as result of
Myocardial infarction
Ischemic heart disease
Dissecting aortic aneurism
Other heart disease
Peripartum cardiomyopathy
Rheumatic heart disease- 25% of pregnant population who not born in the UK
Congenital heart disease

16. Management Preconception counselling Antepartum Intrapartum Postpartum
Risk assessment
Joint clinic attended by obstetrician, cardiologist, anaesthetist
Echocardiogram
Fetal echocardiogram for women with congenital cardiac disease
32-34 weeks gestation –multidisciplinary meeting for birth plan
Intrapartum
Early slow incremental epidural analgesia, assisted vaginal delivery
Caesarean section is only necessary for obstetric indications
Postpartum
Anticoagulation
Long observation in high dependency area
Prophylaxis against postpartum haemorrhage
Low dose oxytocin infusion

17. Thyroid disease in pregnancy
Hyperthyroidism
Hyperthyroidism
Thyrotoxicosis complicates in 1 in 500 pregnancies
50% of affected women have a positive family history of autoimmune thyroid disease
95% are due to Grave’s disease, an autoimmune disorder caused by TSH receptor stimulating antibodies
1% of pregnancies
Most cases have already been diagnosed
Associated with autoimmune diseases, pernicious anemia, vitiligo, type 1 diabetes
Commonest causes encountered in pregnancy- Hashimoto’s thyroiditis, treated Grave’s disease

18. Triiodothyronine (pmol/L)
Pregnancy –specific normal ranges
TSH(MU/l)
Throxine (pmol/L)
Triiodothyronine (pmol/L)
Non-pregnant
12-22
1st trimester
0-5.5
10-16
3-7
2nd trimester
9-15.5
3-5.5
3rdt trimester
0.5-4
8-14.5
2-5.5