Chronic Medical Conditions Chronic Medical Conditions in Pregnancyin Pregnancy

Dr Jessica Servey, FAAFPDr Jessica Servey, FAAFP

15 March 200715 March 2007

Travis Family Medicine Travis Family Medicine ResidencyResidency

ObjectivesObjectives

Review thyroid Review thyroid disorderdisorderReview Review isoimmunizationisoimmunizationReview preeclampsiaReview preeclampsiaReview Review thrombocytopeniathrombocytopeniaReview asthmaReview asthmaReview anemiaReview anemiaReview pyelo/renal Review pyelo/renal stonesstones

Review chronic Review chronic hypertensionhypertensionReview liver disordersReview liver disordersReview migraine Review migraine treatmenttreatmentReview Review thromboembolic thromboembolic disordersdisordersReview seizure Review seizure disordersdisorders

Real ObjectivesReal Objectives

Review asthma in pregnancyReview asthma in pregnancy– TreatmentTreatment– SurveillanceSurveillance

Review thyroid disorders in pregnancyReview thyroid disorders in pregnancy– TreatmentTreatment– SurveillanceSurveillance

Basic Intuition in Family MedicineBasic Intuition in Family Medicine

All pregnancies do better if the chronic All pregnancies do better if the chronic medical problems are controlledmedical problems are controlled

Most babies do better inside the mommyMost babies do better inside the mommy

We as Family Physicians are uniquely We as Family Physicians are uniquely gifted to take care of these coupletsgifted to take care of these couplets

Asthma

Why asthma?Why asthma?

The percentage in women having asthma The percentage in women having asthma has more than quadrupled since 1990has more than quadrupled since 1990– 3.1 per 1000 to 15.6 per 10003.1 per 1000 to 15.6 per 1000

Can be managedCan be managed

People still die from this!People still die from this!

Pregnancy complicationsPregnancy complications

Pre-eclampsiaPre-eclampsia

PIHPIH

Hyperemesis gravidarumHyperemesis gravidarum

Maternal hemorrhageMaternal hemorrhage

GDMGDM

PTL and preterm deliveryPTL and preterm delivery

Effects on InfantEffects on Infant

Increased risk IUGRIncreased risk IUGR

Increase neonatal hypoxiaIncrease neonatal hypoxia

Increase low birth weightIncrease low birth weight

Increase neonatal mortalityIncrease neonatal mortality

Pregnancy physiologyPregnancy physiology

Dyspnea occurs in 60-70 % all pregnant womenDyspnea occurs in 60-70 % all pregnant women

Rule of thirdsRule of thirds– Worsen 24-36 weeksWorsen 24-36 weeks

Subsequent pregnancies are the sameSubsequent pregnancies are the same

Possible reasons to worsen: Increased GER, Possible reasons to worsen: Increased GER, mucosal edema and URI, stress, decreased mucosal edema and URI, stress, decreased FRCFRC

FEV1 unchanged, but respiratory alkalosis is FEV1 unchanged, but respiratory alkalosis is normalnormal

Chronic Asthma TreatmentChronic Asthma Treatment

Categorized and maximize medicationCategorized and maximize medicationPEFRPEFR– Twice daily, no change with pregnancyTwice daily, no change with pregnancy

Flu vaccineFlu vaccineTreat GERD and SARTreat GERD and SARGive Action PlanGive Action PlanLook for triggers (pets/mites/PAR)Look for triggers (pets/mites/PAR)ImmunotherapyImmunotherapy– Safe to continue if at maintenanceSafe to continue if at maintenance

Chronic TreatmentChronic TreatmentPart of routine OB visit!!!Part of routine OB visit!!!

Objective lung measure at every visitObjective lung measure at every visit

Formal PFT?????Formal PFT?????

Ultrasound to assess growthUltrasound to assess growth– No trials to give guidanceNo trials to give guidance

APFT – can consider if not well controlledAPFT – can consider if not well controlled– No formal trialsNo formal trials

Pulmonary consult/Anesthesia if neededPulmonary consult/Anesthesia if needed

Asthma ExacerbationAsthma Exacerbation

Treat the same as if not pregnantTreat the same as if not pregnant

Look closely at blood gasesLook closely at blood gases

Frequent follow up Frequent follow up

MedicationsMedications

Most asthma medications are Cat B and Most asthma medications are Cat B and Cat CCat C

Swedish epidemiologic data has increased Swedish epidemiologic data has increased some inhaled steroids to Bsome inhaled steroids to B

Oral Steroids Cat COral Steroids Cat C– Carries risk PTL, low birth weight, PROM, Carries risk PTL, low birth weight, PROM,

cleft lip?cleft lip?

Risks of uncontrolled asthma is higher!Risks of uncontrolled asthma is higher!

Labor and DeliveryLabor and Delivery

Monitoring InfantMonitoring Infant– Continuous fetal monitoringContinuous fetal monitoring

AsthmaAsthma– Peak flow during laborPeak flow during labor– Continue regular medicationsContinue regular medications– Allow for albuterol prnAllow for albuterol prn– IV hydrocortisone if received systemic IV hydrocortisone if received systemic

corticosteroids during pregnancy ( 3 doses)corticosteroids during pregnancy ( 3 doses)

Labor and DeliveryLabor and Delivery

Pain managementPain management– Bronchospasm increases with increased painBronchospasm increases with increased pain– Morphine and demerol are histamine Morphine and demerol are histamine

releasersreleasers– Epidural is the preferred methodEpidural is the preferred method– Propofol for general anesthesiaPropofol for general anesthesia

HemorrhageHemorrhage– No hemabateNo hemabate– May use prostaglandins for inductionMay use prostaglandins for induction

Thyroid diseases

Normal Thyroid FunctionNormal Thyroid Function

Thyroid binding globulin increases Thyroid binding globulin increases

TSH and FT4 no changeTSH and FT4 no change

Iodide levels decreaseIodide levels decrease

Increase thyroid size, normal TFTIncrease thyroid size, normal TFT

Transient increase T4 and decrease TSH Transient increase T4 and decrease TSH first trimester, related to elevated hcG first trimester, related to elevated hcG levelslevels

Fetal DevelopmentFetal Development

Concentrates iodine at 10-12 weeksConcentrates iodine at 10-12 weeks

Levels of TSH and TBG, FT4 and T3 Levels of TSH and TBG, FT4 and T3 increase throughoutincrease throughout

TSH does NOT cross placentaTSH does NOT cross placenta

T4 and T3 cross the placentaT4 and T3 cross the placenta

Immunoglobulins and thioamides cross the Immunoglobulins and thioamides cross the placentaplacenta

HyperthyroidismHyperthyroidism

0.2% pregnancies0.2% pregnancies

Other causes than Graves: gestational Other causes than Graves: gestational trophoblastic neoplasia, adenoma trophoblastic neoplasia, adenoma hyperfunctioning, toxic multinodular goiter, hyperfunctioning, toxic multinodular goiter, thyroiditis, extrathyroid sourcethyroiditis, extrathyroid source

Risks of hyperthyroidismRisks of hyperthyroidism

Preterm deliveryPreterm delivery

Severe preeclampsiaSevere preeclampsia

Heart failureHeart failure

MiscarriageMiscarriage

Low birth weight/IUGRLow birth weight/IUGR

Fetal lossFetal loss

Poor maternal weight gainPoor maternal weight gain

TreatmentTreatment

Thioamides- usually Propylthiouracil (PTU) Thioamides- usually Propylthiouracil (PTU) but can use methimazolebut can use methimazole

Goal of treatment is FT4 in highest Goal of treatment is FT4 in highest possible normal areapossible normal area

May need to monitor every 2-4 weeksMay need to monitor every 2-4 weeks

Breastfeeding is fineBreastfeeding is fine

Consider beta blockers for symptomsConsider beta blockers for symptoms

Iodine 131Iodine 131

ContraindicatedContraindicated

Avoid pregnancy for 4 monthsAvoid pregnancy for 4 months

Avoid breastfeeding for 4 monthsAvoid breastfeeding for 4 months

If exposed- check gestational ageIf exposed- check gestational age– <10 weeks should be fine<10 weeks should be fine– > 10 weeks, discuss options> 10 weeks, discuss options

Thyroid stormThyroid storm

1% of hyperthyroid mothers1% of hyperthyroid mothers

High risk of maternal heart failureHigh risk of maternal heart failure

Clinical picture can be fever, tachycardia, Clinical picture can be fever, tachycardia, altered mental status, vomiting, diarrhea, altered mental status, vomiting, diarrhea, cardiac arrhythmiascardiac arrhythmias

Do not wait for lab results to treatDo not wait for lab results to treat

? Up to 25% mortality? Up to 25% mortality

Treatment-thyroid stormTreatment-thyroid storm

PTUPTUPotassium iodide solutionPotassium iodide solutionDexamethasoneDexamethasonePropanololPropanololPhenobarbitalPhenobarbitalSupportive careSupportive careSearch for and fix the causeSearch for and fix the causeDo not deliver unless fetal indicationDo not deliver unless fetal indication

HypothyroidismHypothyroidism

Hashimoto’s most common in USHashimoto’s most common in US

Iodine deficiency most common worldwideIodine deficiency most common worldwide

Drugs:Lithium, Dilantin, Rifampin, FeSO4,Drugs:Lithium, Dilantin, Rifampin, FeSO4,

sucralfate, amiodaronesucralfate, amiodarone

5-8% incidence if Type I DM5-8% incidence if Type I DM

25% risk pp thyroid dysfunction in Type I 25% risk pp thyroid dysfunction in Type I DMDM

Risks of hypothyroidismRisks of hypothyroidism

Preeclampsia and PIH Preeclampsia and PIH (unknown reason)(unknown reason)Miscarriage (twice the Miscarriage (twice the normal risk)normal risk)20% perinatal mortality 20% perinatal mortality (stillbirths)(stillbirths)10-20% congenital 10-20% congenital anomaliesanomaliesPlacental abruptionPlacental abruptionAnemiaAnemia

? Intellectual ? Intellectual developmentdevelopmentPostpartum Postpartum hemorrhagehemorrhagePreterm deliveryPreterm delivery**Old studies, few **Old studies, few women, poor women, poor controlcontrol

Miscarriage riskMiscarriage risk

1990 study of 552 women – thyroid 1990 study of 552 women – thyroid diseasedisease- 17 % miscarried with positive antibodies- 17 % miscarried with positive antibodies

- 8.4% miscarried without antibodies- 8.4% miscarried without antibodies? Related to antibody or just immune ? Related to antibody or just immune

functionfunction1999 study- 15 women1999 study- 15 women– Antibody levels decreased in women without Antibody levels decreased in women without

miscarriagemiscarriage

Fetal anomaliesFetal anomalies

Study done published 2001Study done published 2001

Retrospective chart reviewRetrospective chart review

Meant to look at population dataMeant to look at population data

23.5 % anomalies hypothyroid women23.5 % anomalies hypothyroid women

21.8 % anomalies hyperthyroid women21.8 % anomalies hyperthyroid women

Cardiac anomalies significantly elevated in Cardiac anomalies significantly elevated in hypothyroidhypothyroid

HypothyroidismHypothyroidism

Large European study, 2.5% women with Large European study, 2.5% women with subclinical hypothyroidismsubclinical hypothyroidism

Screening?Screening?– High risk patients should be considered: prior history High risk patients should be considered: prior history

thyroid disease, history of autoimmune or endocrine thyroid disease, history of autoimmune or endocrine disorder, family history thyroid disease, neck disorder, family history thyroid disease, neck radiation, goiter on exam, medications that alter radiation, goiter on exam, medications that alter thyroxine, hyperlipidemiathyroxine, hyperlipidemia

– Recent study in Maine in 2006- up to 48% with thyroid Recent study in Maine in 2006- up to 48% with thyroid disordersdisorders

TreatmentTreatment

Thyroid replacement to normalize TSHThyroid replacement to normalize TSH

Increased thyroid hormone requirementsIncreased thyroid hormone requirements

At least every 4-6 weeks needs TFT At least every 4-6 weeks needs TFT checkedchecked

Postpartum readjustmentPostpartum readjustment

APFTs? Serial ultrasound? APFTs? Serial ultrasound?

AntibodiesAntibodies

Anti-microsomal, Anti-thyroglobulin, Anti-microsomal, Anti-thyroglobulin, stimulating/inhibitory antibodies, stimulating/inhibitory antibodies, peroxidaseperoxidase

Perinatal vs endocrine opinionPerinatal vs endocrine opinion

Thyroid CancerThyroid Cancer

Pregnancy itself doesn’t alter the coursePregnancy itself doesn’t alter the course

Thyroid symptoms less in pregnancyThyroid symptoms less in pregnancy

Surgery preferred second trimesterSurgery preferred second trimester

Iodine 131 avoidedIodine 131 avoided

Discuss breastfeedingDiscuss breastfeeding

No other infant concernsNo other infant concerns

Suppressive doses of thyroid hormoneSuppressive doses of thyroid hormone

Baby risks- hyperthyroid momBaby risks- hyperthyroid mom

Fetal thyrotoxicosisFetal thyrotoxicosis– Even is the mom has been treated because Even is the mom has been treated because

antibodies still cross the placentaantibodies still cross the placenta– 1-5% of infants whose mom has Graves will 1-5% of infants whose mom has Graves will

have hyperthyroidismhave hyperthyroidism– Lower incidence if not ablated yetLower incidence if not ablated yet

Fetal goiter from thioamidesFetal goiter from thioamides

Transient hypothyroidism from medsTransient hypothyroidism from meds

Baby risks- hypothyroid momBaby risks- hypothyroid mom

Low Birth Weight (in hypothyroidism Low Birth Weight (in hypothyroidism related to risk of preterm delivery)related to risk of preterm delivery)

Cretinism (growth failure, mental retarded, Cretinism (growth failure, mental retarded, neuro deficits)neuro deficits)

Developmental delays (although not Developmental delays (although not proven currently)proven currently)

Questions???Questions???