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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.

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Medical Complications of Pregnancy

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  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???

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