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Self-assessment questions: Pre-existing medical diseases
Current
Obstetrics
& Gynaecology
(I 999)
9, I 13-l
16
0 1999 Harcourt Publishers Ltd
Self-assessment
Self-assessment questions: Pre-existing medical diseases
H. E. Hopkinson
b) A hypothyroid mother will require large increases in thyroxine replacement during a pregnancy c) Pregnancy avoidance is recommended for 12 months after treatment with radio-iodine d) The fetus may be rendered hypothyroid by maternal treatment with anti-thyroid drugs e) Maternal thyroid autoantibodies do not cross the placenta.
Question 1
Answer True or False. For women with diabetes mellitus: a) Diabetic control should be optimized before conception b) Large increases in insulin dosage may be required during pregnancy c) There is an increased risk of fetal malformation d) Maternal ketoacidosis is non-threatening to the fetus because of the presence of fetal insulin e) Diabetic retinopathy often improves in pregnancy.
Question 4
Answer True or False. Steroid administration pregnant woman:
to a
a) Is contraindicated b) In the form of prednisolone will suppress fetal adrenal function c) In the form of prednisolone will produce a serum concentration in the fetus approximately onetenth that in the mother d) In the first trimester is teratogenic e) May be used for the same indications as in the non-pregnant state.
Question 2
Answer True or False. In women with essential hypertension: a) The aim of treatment in pregnancy is to prevent pre-eclampsia b) Methyldopa is a relatively safe drug to use in pregnancy c) Beta-blocker treatment in pregnancy can be associated with fetal growth restriction d) Angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists are contraindicated in pregnancy e) Treatment may often be safely stopped preconception.
Question 5
Answer True or False. With regard to other maternal endocrine disease: a) Mothers with Addison’s disease usually only require an increase in their steroid replacement to cover intercurrent illnesses, and stresses such as labour b) Pituitary tumours secreting prolactin can undergo clinically-significant enlargement during pregnancy c) A woman with a prolactinoma should be actively discouraged from breast feeding d) Bromocriptine is relatively safe in pregnancy
Question 3
Answer True or False. In maternal thyroid disease: a) Propylthiouracil (PTU) is the treatment of choice for thyrotoxicosis in pregnancy Dr Helen E. Hopkinson, Division of Therapeutics, Department of Medicine, Queen’s Medical Centre, Nottingham NG7 2UH
113
114
Current Obstetrics & Gvnaecolonv
e) Hyperprolactinaemia pregnancy.
may resolve after a .
Question 6 You are consulted about a 24-year-old nulliparous patient who is hoping to conceive. She suffers from grand ma1 epilepsy usually controlled with phenytoin: a) Should an attempt be made to wean her off the phenytoin? b) Is there an’increased risk of fetal malformation? c) Is the dose of phenytoin important in assessing risk? d) Is it better to use a small dose of an additional anticonvulsant to improve seizure control rather than increasing the dose of single agent therapy? e) Are there any other precautions that can be taken against fetal malformation in a woman taking anticonvulsants? Question 7 You are consulted by a GP about a woman who is planning pregnancy and suffers from debilitating migraine headaches, often 1 per week: a) What can you advise about the most likely prognosis for migraine in pregnancy? b) Are there any complications of migraine which may be more likely to occur in pregnancy? c) What treatment can you recommend for acute migraine? d) If there is a need for migraine prophylaxis, what therapy would you recommend? Question 8 Heartburn and nausea, common symptoms in normal pregnancy, are occasionally associated with serious pathology in the gastrointestinal tract:
Answer 1 a) True b) True c) True d) False e) False Diabetic and obstetric care is ideally provided in a joint clinic including a dietitian and diabetes specialist nurse, to which the patient should be referred before stopping contraception. Insulin requirements can start to rise early in the first trimester and may be double the pre-pregnant dose by the third trimester. Teratogenesis is thought to be the effect of maternal hyperglycaemia causing fetal hyperinsulinaemia, thus risk can be reduced towards the background level by tight maternal glucose control before conception.
a) What additional symptoms should alert you to the need for further investigation? b) What is the usual course of pre-existing peptic ulcer disease in pregnancy? c) What is the likely clinical course of gallstones in pregnancy? d) What remedies can you recommend for dyspepsia in pregnancy? Question 9 A woman infected with HIV becomes pregnant: a) At which stage of pregnancy is the fetus most at risk of vertical spread? b) Can anti-viral agents affect the rate of vertical spread? c) If the mother has AIDS and is taking combination therapy what changes should be made in her treatment? d) Is breast feeding safe? Question 10 A woman with a history of deep vein thrombosis and pulmonary embolism in a previous pregnancy, who is no longer taking anticoagulants, consults you for prepregnancy counselling: a) Are there any screening tests you would perform? b) What other risk factors for thromboembolic disease should you establish? c) You and the patient agree to commence prophylactic heparin at 28 weeks’ gestation: what are the maternal risks of long-term heparin therapy? d) What are the advantages of new low-molecularweight heparins?
Fetal demise can occur as a result of an apparently mild degree of maternal ketoacidosis. Mothers should test urine for ketones if unwell, and be treated aggressively with fluids and insulin. Women without retinopathy at conception rarely develop it during pregnancy, but pre-existing retinal ischaemic changes can often progress, paradoxically, as diabetic control is improved.
Answer 2 a) False b) True c) True d) True e) True
Self-assessment auestions: Pre-existing medical disease Although a woman with essential hypertension may have an increased risk of developing pre-eclampsia, rendering her normotensive has no effect on the subsequent development of pre-eclampsia or eclampsia. If a beta-blocker is started before 28 weeks’ gestation there may be a reduction in gestationally adjusted birth weight. Angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists have been teratogenie in animal studies, and use in late pregnancy can lead to fetal renal impairment. Treatment of moderately elevated blood pressure in non-pregnant women is aimed at long-term vascular risk reduction, therefore, a brief interruption in therapy for a pregnancy will have little bearing long term. In addition, the reduction in blood pressure which occurs in normal pregnancy will obviate the need for treatment in all but the most severe cases (in which a secondary cause for the hypertension should be actively sought). Answer 3
a) b) c) d) e)
True False True True False
There is a theoretical risk of aplasia cutis of the fetus with carbimazole. Thyroxine requirements are usually unchanged in pregnancy if they have been stable beforehand. Monitoring thyroid function once each trimester is recommended, with appropriate dosage alterations based on biochemical results rather than clinical symptoms. It is need recommended that pregnancy is avoided for 12 months following radio-rodine treatment. This is the standard recommendation of the Royal College of Physicians. It is possible that a fetus may become hypothyroid in reaction to maternal anti-thyroid drugs. For this reason anyithyroid drug dosage should be kept to the minimum required to maintain a biochemical euthyroid state in the mother. Cases of both neonatal thyrotoxicosis and (more rarely) hypothyroidism have occurred owing to transplacental passage of maternal antibodies.
115
amounts in the fetal circulation, although this is less so for dexamethasone and betamethasone. There is no evidence of increased congenital abnormalities in the offspring of women who have taken steroids in the first trimester. Where steroid treatment is required to control systemic disease in a pregnant woman, it should not be withheld, but the potential for serious maternal side effects must be appreciated, as in the non-pregnant state. Answer 5
a) True b) True c) False d) True e) True Prolactin-secreting tumours may enlarge during a pregnancy and cause clinical symptoms owing to pressure such as headache and visual disturbance. Hyperprolactinaemia causing infertility can be successfully treated with bromocriptine, and no increased risk of congenital malformation has been reported. The drug is also used to prevent tumour enlargement in pregnancy in cases thought to be at risk (usually macro-prolactinomas). Post-partum resolution hyperprolactinaemia has been reported in up to 40% of cases. Answer 6
a) In general, women are advised that the risk to themselves and their baby from a fit in pregnancy is greater than the risk of an anticonvulsant causing fetal malformation. If she has been completely tit-free for 3 years, a case could be made for withdrawing anticonvulsant therapy, although the implications for driving must also be taken into account. b) Congenital abnormality is about three times more common in the offspring of women with epilepsy. c) The teratogenic effect of an anticonvulsant drug is dose dependent, so the smallest dose which provides seizure control should be prescribed. d) The teratogenic risk of different anticonvulsants is additive, so seizure control should be achieved with the minimum number of drugs possible. e) Folic acid 5 mg daily should be given before conception and continued throughout pregnancy.
Answer 4
a) b) c) d) e)
False False True False True
Corticosteroids are metabolized by the placenta to inactive 1 1-ketosteroids, and appear in reduced
Answer 7
a) Migraine improves in pregnancy in around 80% of cases. b) Migraine in pregnancy can become hemiplegic in nature. c) Paracetamol and metoclopramide have been used extensively with good safety profiles in pregnancy.
116
Current Obstetrics & Gynaecology
The new 5HT receptor agonists are not rec’ommended for use in pregnancy since there is insufficient experience of their use in this situation. d) Beta-blockers are both safe and effective for migraine prophylaxis in pregnancy, and they are of particular value in cases of hemiplegic migraine. Low-dose amitriptyline is also effective. Answer 8 a) Severe epiga&ic pain, particularly if radiating to the back, and haematemesis. b) Peptic ulcers often remit during pregnancy, thought to be due to a protective effect of oestrogens on gastric mucosa. Symptoms tend to recur post-partum with a relapse of ulceration, particularly of previous duodenal ulcers. c) Gall bladder contractility is reduced in pregnancy, so attacks of biliary colic are very rare. However, bile is more lithogenic in pregnancy so sludge and stones may cause symptoms in the puerperium. d) Postural advice, and small frequent meals are often effective. If these measures fail, alginate antacid combinations are valuable, and reduce the dose of antacid required. This is because the preparation behaves as a layer which floats on the surface of the gastric fluid so that any reflux into the oesophagus is neutral, and there is no need to neutralize the whole stomach content. Ranitidine appears to be safe, but is reserved for resistant cases. Answer 9 a) The risk to the fetus of vertical transmission of HIV infection is greatest from exposure to maternal blood during vaginal delivery, although trans.-placental infection also occurs.
b) The fetus can be protected from vertical spread by maternal treatment with zidovudine. This drug can be given in labour and to the neonate for postexposure prophylaxis even if there is no direct maternal indication. c) Maternal need prevails over that of the fetus, therefore, combination therapy for maternal AIDS is continued during pregnancy. Some clinicians temporarily stop treatment during the lirst trimester if pregnancy is diagnosed. d) Breast feeding by mothers infected with HIV is not recommended. Answer 10 a) A thrombophilia screen should be performed as well as an assay for lupus anticoagulant and anticardiolipin antibodies, at a time distant from any anticoagulant therapy. b) Maternal age, parity, family history of thromboembolic disease, smoking, and maternal obesity are additional risk factors which may influence your treatment of a future pregnancy. c) Maternal osteopenia and thrombocytopenia. Both are unpredictable risks and not confined to pregnancy, but the risk to bone is increased in pregnancy whereas the risk of heparin induced thrombocytopenia is rare in pregnancy. d) Once daily administration, less painful injections, reduced requirement for monitoring in terms of coagulation tests.
Obstetrics
& Gynaecology
(I 999)
9, I 13-l
16
0 1999 Harcourt Publishers Ltd
Self-assessment
Self-assessment questions: Pre-existing medical diseases
H. E. Hopkinson
b) A hypothyroid mother will require large increases in thyroxine replacement during a pregnancy c) Pregnancy avoidance is recommended for 12 months after treatment with radio-iodine d) The fetus may be rendered hypothyroid by maternal treatment with anti-thyroid drugs e) Maternal thyroid autoantibodies do not cross the placenta.
Question 1
Answer True or False. For women with diabetes mellitus: a) Diabetic control should be optimized before conception b) Large increases in insulin dosage may be required during pregnancy c) There is an increased risk of fetal malformation d) Maternal ketoacidosis is non-threatening to the fetus because of the presence of fetal insulin e) Diabetic retinopathy often improves in pregnancy.
Question 4
Answer True or False. Steroid administration pregnant woman:
to a
a) Is contraindicated b) In the form of prednisolone will suppress fetal adrenal function c) In the form of prednisolone will produce a serum concentration in the fetus approximately onetenth that in the mother d) In the first trimester is teratogenic e) May be used for the same indications as in the non-pregnant state.
Question 2
Answer True or False. In women with essential hypertension: a) The aim of treatment in pregnancy is to prevent pre-eclampsia b) Methyldopa is a relatively safe drug to use in pregnancy c) Beta-blocker treatment in pregnancy can be associated with fetal growth restriction d) Angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists are contraindicated in pregnancy e) Treatment may often be safely stopped preconception.
Question 5
Answer True or False. With regard to other maternal endocrine disease: a) Mothers with Addison’s disease usually only require an increase in their steroid replacement to cover intercurrent illnesses, and stresses such as labour b) Pituitary tumours secreting prolactin can undergo clinically-significant enlargement during pregnancy c) A woman with a prolactinoma should be actively discouraged from breast feeding d) Bromocriptine is relatively safe in pregnancy
Question 3
Answer True or False. In maternal thyroid disease: a) Propylthiouracil (PTU) is the treatment of choice for thyrotoxicosis in pregnancy Dr Helen E. Hopkinson, Division of Therapeutics, Department of Medicine, Queen’s Medical Centre, Nottingham NG7 2UH
113
114
Current Obstetrics & Gvnaecolonv
e) Hyperprolactinaemia pregnancy.
may resolve after a .
Question 6 You are consulted about a 24-year-old nulliparous patient who is hoping to conceive. She suffers from grand ma1 epilepsy usually controlled with phenytoin: a) Should an attempt be made to wean her off the phenytoin? b) Is there an’increased risk of fetal malformation? c) Is the dose of phenytoin important in assessing risk? d) Is it better to use a small dose of an additional anticonvulsant to improve seizure control rather than increasing the dose of single agent therapy? e) Are there any other precautions that can be taken against fetal malformation in a woman taking anticonvulsants? Question 7 You are consulted by a GP about a woman who is planning pregnancy and suffers from debilitating migraine headaches, often 1 per week: a) What can you advise about the most likely prognosis for migraine in pregnancy? b) Are there any complications of migraine which may be more likely to occur in pregnancy? c) What treatment can you recommend for acute migraine? d) If there is a need for migraine prophylaxis, what therapy would you recommend? Question 8 Heartburn and nausea, common symptoms in normal pregnancy, are occasionally associated with serious pathology in the gastrointestinal tract:
Answer 1 a) True b) True c) True d) False e) False Diabetic and obstetric care is ideally provided in a joint clinic including a dietitian and diabetes specialist nurse, to which the patient should be referred before stopping contraception. Insulin requirements can start to rise early in the first trimester and may be double the pre-pregnant dose by the third trimester. Teratogenesis is thought to be the effect of maternal hyperglycaemia causing fetal hyperinsulinaemia, thus risk can be reduced towards the background level by tight maternal glucose control before conception.
a) What additional symptoms should alert you to the need for further investigation? b) What is the usual course of pre-existing peptic ulcer disease in pregnancy? c) What is the likely clinical course of gallstones in pregnancy? d) What remedies can you recommend for dyspepsia in pregnancy? Question 9 A woman infected with HIV becomes pregnant: a) At which stage of pregnancy is the fetus most at risk of vertical spread? b) Can anti-viral agents affect the rate of vertical spread? c) If the mother has AIDS and is taking combination therapy what changes should be made in her treatment? d) Is breast feeding safe? Question 10 A woman with a history of deep vein thrombosis and pulmonary embolism in a previous pregnancy, who is no longer taking anticoagulants, consults you for prepregnancy counselling: a) Are there any screening tests you would perform? b) What other risk factors for thromboembolic disease should you establish? c) You and the patient agree to commence prophylactic heparin at 28 weeks’ gestation: what are the maternal risks of long-term heparin therapy? d) What are the advantages of new low-molecularweight heparins?
Fetal demise can occur as a result of an apparently mild degree of maternal ketoacidosis. Mothers should test urine for ketones if unwell, and be treated aggressively with fluids and insulin. Women without retinopathy at conception rarely develop it during pregnancy, but pre-existing retinal ischaemic changes can often progress, paradoxically, as diabetic control is improved.
Answer 2 a) False b) True c) True d) True e) True
Self-assessment auestions: Pre-existing medical disease Although a woman with essential hypertension may have an increased risk of developing pre-eclampsia, rendering her normotensive has no effect on the subsequent development of pre-eclampsia or eclampsia. If a beta-blocker is started before 28 weeks’ gestation there may be a reduction in gestationally adjusted birth weight. Angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists have been teratogenie in animal studies, and use in late pregnancy can lead to fetal renal impairment. Treatment of moderately elevated blood pressure in non-pregnant women is aimed at long-term vascular risk reduction, therefore, a brief interruption in therapy for a pregnancy will have little bearing long term. In addition, the reduction in blood pressure which occurs in normal pregnancy will obviate the need for treatment in all but the most severe cases (in which a secondary cause for the hypertension should be actively sought). Answer 3
a) b) c) d) e)
True False True True False
There is a theoretical risk of aplasia cutis of the fetus with carbimazole. Thyroxine requirements are usually unchanged in pregnancy if they have been stable beforehand. Monitoring thyroid function once each trimester is recommended, with appropriate dosage alterations based on biochemical results rather than clinical symptoms. It is need recommended that pregnancy is avoided for 12 months following radio-rodine treatment. This is the standard recommendation of the Royal College of Physicians. It is possible that a fetus may become hypothyroid in reaction to maternal anti-thyroid drugs. For this reason anyithyroid drug dosage should be kept to the minimum required to maintain a biochemical euthyroid state in the mother. Cases of both neonatal thyrotoxicosis and (more rarely) hypothyroidism have occurred owing to transplacental passage of maternal antibodies.
115
amounts in the fetal circulation, although this is less so for dexamethasone and betamethasone. There is no evidence of increased congenital abnormalities in the offspring of women who have taken steroids in the first trimester. Where steroid treatment is required to control systemic disease in a pregnant woman, it should not be withheld, but the potential for serious maternal side effects must be appreciated, as in the non-pregnant state. Answer 5
a) True b) True c) False d) True e) True Prolactin-secreting tumours may enlarge during a pregnancy and cause clinical symptoms owing to pressure such as headache and visual disturbance. Hyperprolactinaemia causing infertility can be successfully treated with bromocriptine, and no increased risk of congenital malformation has been reported. The drug is also used to prevent tumour enlargement in pregnancy in cases thought to be at risk (usually macro-prolactinomas). Post-partum resolution hyperprolactinaemia has been reported in up to 40% of cases. Answer 6
a) In general, women are advised that the risk to themselves and their baby from a fit in pregnancy is greater than the risk of an anticonvulsant causing fetal malformation. If she has been completely tit-free for 3 years, a case could be made for withdrawing anticonvulsant therapy, although the implications for driving must also be taken into account. b) Congenital abnormality is about three times more common in the offspring of women with epilepsy. c) The teratogenic effect of an anticonvulsant drug is dose dependent, so the smallest dose which provides seizure control should be prescribed. d) The teratogenic risk of different anticonvulsants is additive, so seizure control should be achieved with the minimum number of drugs possible. e) Folic acid 5 mg daily should be given before conception and continued throughout pregnancy.
Answer 4
a) b) c) d) e)
False False True False True
Corticosteroids are metabolized by the placenta to inactive 1 1-ketosteroids, and appear in reduced
Answer 7
a) Migraine improves in pregnancy in around 80% of cases. b) Migraine in pregnancy can become hemiplegic in nature. c) Paracetamol and metoclopramide have been used extensively with good safety profiles in pregnancy.
116
Current Obstetrics & Gynaecology
The new 5HT receptor agonists are not rec’ommended for use in pregnancy since there is insufficient experience of their use in this situation. d) Beta-blockers are both safe and effective for migraine prophylaxis in pregnancy, and they are of particular value in cases of hemiplegic migraine. Low-dose amitriptyline is also effective. Answer 8 a) Severe epiga&ic pain, particularly if radiating to the back, and haematemesis. b) Peptic ulcers often remit during pregnancy, thought to be due to a protective effect of oestrogens on gastric mucosa. Symptoms tend to recur post-partum with a relapse of ulceration, particularly of previous duodenal ulcers. c) Gall bladder contractility is reduced in pregnancy, so attacks of biliary colic are very rare. However, bile is more lithogenic in pregnancy so sludge and stones may cause symptoms in the puerperium. d) Postural advice, and small frequent meals are often effective. If these measures fail, alginate antacid combinations are valuable, and reduce the dose of antacid required. This is because the preparation behaves as a layer which floats on the surface of the gastric fluid so that any reflux into the oesophagus is neutral, and there is no need to neutralize the whole stomach content. Ranitidine appears to be safe, but is reserved for resistant cases. Answer 9 a) The risk to the fetus of vertical transmission of HIV infection is greatest from exposure to maternal blood during vaginal delivery, although trans.-placental infection also occurs.
b) The fetus can be protected from vertical spread by maternal treatment with zidovudine. This drug can be given in labour and to the neonate for postexposure prophylaxis even if there is no direct maternal indication. c) Maternal need prevails over that of the fetus, therefore, combination therapy for maternal AIDS is continued during pregnancy. Some clinicians temporarily stop treatment during the lirst trimester if pregnancy is diagnosed. d) Breast feeding by mothers infected with HIV is not recommended. Answer 10 a) A thrombophilia screen should be performed as well as an assay for lupus anticoagulant and anticardiolipin antibodies, at a time distant from any anticoagulant therapy. b) Maternal age, parity, family history of thromboembolic disease, smoking, and maternal obesity are additional risk factors which may influence your treatment of a future pregnancy. c) Maternal osteopenia and thrombocytopenia. Both are unpredictable risks and not confined to pregnancy, but the risk to bone is increased in pregnancy whereas the risk of heparin induced thrombocytopenia is rare in pregnancy. d) Once daily administration, less painful injections, reduced requirement for monitoring in terms of coagulation tests.