Chronic Medical Conditions in Pregnancy

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Chronic Medical Conditions in Pregnancy

• Dr Jessica Servey, FAAFP
• 15 March 2007
• Travis Family Medicine Residency

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Objectives

• Review thyroid disorder
• Review isoimmunization
• Review preeclampsia
• Review thrombocytopenia
• Review asthma
• Review anemia
• Review pyelo/renal stones

• Review chronic hypertension
• Review liver disorders
• Review migraine treatment
• Review thromboembolic disorders
• Review seizure disorders

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Real Objectives

• Review asthma in pregnancy
• Treatment
• Surveillance
• Review thyroid disorders in pregnancy
• Treatment
• Surveillance

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Basic Intuition in Family Medicine

• All pregnancies do better if the chronic medical
  problems are controlled
• Most babies do better inside the mommy
• We as Family Physicians are uniquely gifted to
  take care of these couplets

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Asthma
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Why asthma?

• The percentage in women having asthma has more
  than quadrupled since 1990
• 3.1 per 1000 to 15.6 per 1000
• Can be managed
• People still die from this!

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Pregnancy complications

• Pre-eclampsia
• PIH
• Hyperemesis gravidarum
• Maternal hemorrhage
• GDM
• PTL and preterm delivery

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Effects on Infant

• Increased risk IUGR
• Increase neonatal hypoxia
• Increase low birth weight
• Increase neonatal mortality

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Pregnancy physiology

• Dyspnea occurs in 60-70 all pregnant women
• Rule of thirds
• Worsen 24-36 weeks
• Subsequent pregnancies are the same
• Possible reasons to worsen Increased GER,
  mucosal edema and URI, stress, decreased FRC
• FEV1 unchanged, but respiratory alkalosis is
  normal

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Chronic Asthma Treatment

• Categorized and maximize medication
• PEFR
• Twice daily, no change with pregnancy
• Flu vaccine
• Treat GERD and SAR
• Give Action Plan
• Look for triggers (pets/mites/PAR)
• Immunotherapy
• Safe to continue if at maintenance

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Chronic Treatment

• Part of routine OB visit!!!
• Objective lung measure at every visit
• Formal PFT?????
• Ultrasound to assess growth
• No trials to give guidance
• APFT can consider if not well controlled
• No formal trials
• Pulmonary consult/Anesthesia if needed

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Asthma Exacerbation

• Treat the same as if not pregnant
• Look closely at blood gases
• Frequent follow up

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Medications

• Most asthma medications are Cat B and Cat C
• Swedish epidemiologic data has increased some
  inhaled steroids to B
• Oral Steroids Cat C
• Carries risk PTL, low birth weight, PROM, cleft
  lip?
• Risks of uncontrolled asthma is higher!

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Labor and Delivery

• Monitoring Infant
• Continuous fetal monitoring
• Asthma
• Peak flow during labor
• Continue regular medications
• Allow for albuterol prn
• IV hydrocortisone if received systemic
  corticosteroids during pregnancy ( 3 doses)

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Labor and Delivery

• Pain management
• Bronchospasm increases with increased pain
• Morphine and demerol are histamine releasers
• Epidural is the preferred method
• Propofol for general anesthesia
• Hemorrhage
• No hemabate
• May use prostaglandins for induction

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Thyroid diseases
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Normal Thyroid Function

• Thyroid binding globulin increases
• TSH and FT4 no change
• Iodide levels decrease
• Increase thyroid size, normal TFT
• Transient increase T4 and decrease TSH first
  trimester, related to elevated hcG levels

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Fetal Development

• Concentrates iodine at 10-12 weeks
• Levels of TSH and TBG, FT4 and T3 increase
  throughout
• TSH does NOT cross placenta
• T4 and T3 cross the placenta
• Immunoglobulins and thioamides cross the placenta

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Hyperthyroidism

• 0.2 pregnancies
• Other causes than Graves gestational
  trophoblastic neoplasia, adenoma
  hyperfunctioning, toxic multinodular goiter,
  thyroiditis, extrathyroid source

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Risks of hyperthyroidism

• Preterm delivery
• Severe preeclampsia
• Heart failure
• Miscarriage
• Low birth weight/IUGR
• Fetal loss
• Poor maternal weight gain

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Treatment

• Thioamides- usually Propylthiouracil (PTU) but
  can use methimazole
• Goal of treatment is FT4 in highest possible
  normal area
• May need to monitor every 2-4 weeks
• Breastfeeding is fine
• Consider beta blockers for symptoms

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Iodine 131

• Contraindicated
• Avoid pregnancy for 4 months
• Avoid breastfeeding for 4 months
• If exposed- check gestational age
• lt10 weeks should be fine
• gt 10 weeks, discuss options

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Thyroid storm

• 1 of hyperthyroid mothers
• High risk of maternal heart failure
• Clinical picture can be fever, tachycardia,
  altered mental status, vomiting, diarrhea,
  cardiac arrhythmias
• Do not wait for lab results to treat
• ? Up to 25 mortality

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Treatment-thyroid storm

• PTU
• Potassium iodide solution
• Dexamethasone
• Propanolol
• Phenobarbital
• Supportive care
• Search for and fix the cause
• Do not deliver unless fetal indication

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Hypothyroidism

• Hashimotos most common in US
• Iodine deficiency most common worldwide
• DrugsLithium, Dilantin, Rifampin, FeSO4,
• sucralfate, amiodarone
• 5-8 incidence if Type I DM
• 25 risk pp thyroid dysfunction in Type I DM

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Risks of hypothyroidism

• Preeclampsia and PIH (unknown reason)
• Miscarriage (twice the normal risk)
• 20 perinatal mortality (stillbirths)
• 10-20 congenital anomalies
• Placental abruption
• Anemia

• ? Intellectual development
• Postpartum hemorrhage
• Preterm delivery
• Old studies, few women, poor control

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Miscarriage risk

• 1990 study of 552 women thyroid disease
• - 17 miscarried with positive antibodies
• - 8.4 miscarried without antibodies
• ? Related to antibody or just immune function
• 1999 study- 15 women
• Antibody levels decreased in women without
  miscarriage

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Fetal anomalies

• Study done published 2001
• Retrospective chart review
• Meant to look at population data
• 23.5 anomalies hypothyroid women
• 21.8 anomalies hyperthyroid women
• Cardiac anomalies significantly elevated in
  hypothyroid

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Hypothyroidism

• Large European study, 2.5 women with subclinical
  hypothyroidism
• Screening?
• 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
• Recent study in Maine in 2006- up to 48 with
  thyroid disorders

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Treatment

• Thyroid replacement to normalize TSH
• Increased thyroid hormone requirements
• At least every 4-6 weeks needs TFT checked
• Postpartum readjustment
• APFTs? Serial ultrasound?

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Antibodies

• Anti-microsomal, Anti-thyroglobulin,
  stimulating/inhibitory antibodies, peroxidase
• Perinatal vs endocrine opinion

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Thyroid Cancer

• Pregnancy itself doesnt alter the course
• Thyroid symptoms less in pregnancy
• Surgery preferred second trimester
• Iodine 131 avoided
• Discuss breastfeeding
• No other infant concerns
• Suppressive doses of thyroid hormone

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Baby risks- hyperthyroid mom

• Fetal thyrotoxicosis
• Even is the mom has been treated because
  antibodies still cross the placenta
• 1-5 of infants whose mom has Graves will have
  hyperthyroidism
• Lower incidence if not ablated yet
• Fetal goiter from thioamides
• Transient hypothyroidism from meds

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Baby risks- hypothyroid mom

• Low Birth Weight (in hypothyroidism related to
  risk of preterm delivery)
• Cretinism (growth failure, mental retarded, neuro
  deficits)
• Developmental delays (although not proven
  currently)

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Questions???