Chronic Medical Conditions in Pregnancy

1. Chronic Medical Conditions in Pregnancy Dr Jessica Servey, FAAFP 15 March 2007 Travis Family Medicine Residency

2. 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 Objectives

3. Real Objectives • Review asthma in pregnancy • Treatment • Surveillance • Review thyroid disorders in pregnancy • Treatment • Surveillance

4. 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

5. Asthma

6. 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!

7. Pregnancy complications • Pre-eclampsia • PIH • Hyperemesis gravidarum • Maternal hemorrhage • GDM • PTL and preterm delivery

8. Effects on Infant • Increased risk IUGR • Increase neonatal hypoxia • Increase low birth weight • Increase neonatal mortality

9. 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

10. 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

11. 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

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

13. 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!

14. 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)

15. 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

16. Thyroid diseases

17. 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

18. 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

19. Hyperthyroidism • 0.2% pregnancies • Other causes than Graves: gestational trophoblastic neoplasia, adenoma hyperfunctioning, toxic multinodular goiter, thyroiditis, extrathyroid source

20. Risks of hyperthyroidism • Preterm delivery • Severe preeclampsia • Heart failure • Miscarriage • Low birth weight/IUGR • Fetal loss • Poor maternal weight gain

21. 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

22. Iodine 131 • Contraindicated • Avoid pregnancy for 4 months • Avoid breastfeeding for 4 months • If exposed- check gestational age • <10 weeks should be fine • > 10 weeks, discuss options

23. 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

24. Treatment-thyroid storm • PTU • Potassium iodide solution • Dexamethasone • Propanolol • Phenobarbital • Supportive care • Search for and fix the cause • Do not deliver unless fetal indication

25. Hypothyroidism • Hashimoto’s most common in US • Iodine deficiency most common worldwide • Drugs:Lithium, Dilantin, Rifampin, FeSO4, sucralfate, amiodarone • 5-8% incidence if Type I DM • 25% risk pp thyroid dysfunction in Type I DM

26. 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 Risks of hypothyroidism

27. 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

28. 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

29. 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

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

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

32. Thyroid Cancer • Pregnancy itself doesn’t 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

33. 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

34. 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)

35. Questions???