OB CASE DISCUSSION

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OB CASE DISCUSSION
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Case Review Discussion Points
Gestational Diabetes Hypertension In
Pregnancy Hypothyroidism in Pregnancy Obesity in
Pregnancy Preterm Labour
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Gestational Diabetes (GDM)?

• Defined as glucose intolerance with onset or
  first recognition during pregnancy
• Prevalence
• 3.5-3.8 non-Aboriginal population
• 8.0-18.0 Aboriginal population

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QUESTION?

• What factors influence your clinical decision
  making around the ordering of a GTT?

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Risk Factors For Gestational Diabetes(GDM) as
listed in CPG 2008

• Previous diagnosis of GDM
• Previous delivery of macrosomic infant (gt9 lbs)
• Etnicity (Aboriginal,Hispanic,SouthAsian,Asian,Afr
  ican
• Age (gt 35 yrs)?
• Obesity (BMIgt 30 kg/m)?
• Polycystic ovary syndrome and/or hirsutism
• Acanthosis nigricans
• Chronic corticosteriod use

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QUESTIONS?

• If you order a GTT, what do you order and at what
  stage of gestation? How do you counsel the
  patient around this issue?
• How do you interpret the test results and how
  would the results potentially change your
  management of this pregnancy?

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Screening Controversy

• Selective Screening
• Society of Obstetricians and Gynecologists of
  Canada
• Lack of RCT showing clear benefit for
  screening/treatment for GDM
• USPSTF May 2008 Discuss and screen case by case
  only
• Universal Screening
• Canadian Diabetes Association 2008 Guidelines
  recommend universal screening of all women 24-28
  weeks gestational age
• Higher risk women should be screened in the first
  trimester and if negative, rescreened at 24 weeks

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Screening For and Diagnosis of GDMper CPG 2008

• All pregnant women between 24 and 28 weeks
  gestation
• If multiple risk factorsscreen during first
  trimester of pregnancy and reassess in second and
  third trimesters.
• 1 hr PG following a 50 gram glucose load given at
  anytime of the day
• If 1hr PG is gt10.3 mmol/L, then confirm
  gestational diabetes (GDM).
• If 1 hr PG is between 7.8-10.2 mmol/L, repeat
  with a 75 gram glucose load and measure FBG, 1 hr
  PG and 2hr PG levels.
• FPG gt5.3 mmol/L
• 1 hr PG gt10.6mmol/L
• 2 hr PG gt8.9 mmol/L
• If 2 out of the 3 following targets are exceeded
  with a 75 g OGTT then confirm GDM.
• If 1 target exceeded then IGT of pregnancy.

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QUESTION?

• Are pregnancies complicated by gestational
  diabetes (vs impaired glucose tolerance) at any
  increase risk, both for the mother and infant?

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Importance of Managing Glycemic Control During
Pregnancy

• To reduce complications for baby such as
• Macrosomia
• Neonatal hypoglycemia
• Neonatal hypocalcemia and hyperbilirubinemia
• Respiratory Distress Syndrome
• Potential long term effects
• To reduce complications for mother
• Trauma during birth with macrosomia
• Long term risks- increased risk of Type 2 Diabetes

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Management

• Nutritional consultation
• Home glucose monitoring
• Goals FBS 3.8-5.2, 2 hr PC 5.0-6.6
• If unable to achieve control after 2
  weeks-initiate insulin ( can consider glyburide
  or metformin-off label)

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Hypertensive Disorders of Pregnancy (HDP)

• SOGC March 2008
• Volume 30 3
• Supplement 1

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QUESTIONS?- PART 1

• Do you need any other information or
  investigations in order to manage this patient
  today?
• Does her clinical presentation today change your
  management of her pregnancy? If so , how?
• What is her risk for developing pre-eclampsia and
  can this be prevented?
• How will you counsel her?

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Measurements and Diagnosis

• Measurement- Sitting, arm at level of heart
• Diagnosis. Based on office or in-hospital
  diastolic BP of gt 90 mmHg, using same arm and
  based on at least two measurements.
• If systolic BP gt 140 mmHg, follow closely for
  development of diastolic hypertension
• Severe hypertension systolic BP of gt 160 mmHg or
  diastolic BP of gt 110 mmHg. Repeat in 15
  minutes for confirmation.
• For non-severe hypertension, serial BP
  measurements before a diagnosis of hypertension
  is made.
• Gestational Hypertension lt 34 weeks-35 of women
  develop pre-eclampsia which tends to be more
  severe.

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Measurement of Proteinuria

• All pregnant women should be assessed for
  proteinuria.
• Urine dipstick is acceptable for screening when
  suspicion of pre-eclampsia is low
• Do more definitive testing (quantitative random
  urine, urinary proteincreatinine ratio or 24
  hour urine collection) when suspicion of
  preeclampsia,
• Includes women who are hypertensive with rising
  BP or in normotensive women with symptoms or
  signs suggestive of preeclampsia.
• Proteinuria should be strongly suspected when
  urinary dipstick proteinuria is gt2.
• Proteinuria -gt 0.3g/d in a 24 hour collection,
  or gt30 mg/mmol creatinine in a random sample

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Classification of HDP

• Pre-existing prior to 20 weeks
• Gestational hypertension- after 20 weeks
• Either can be /- comorbid conditions ( DM, renal
  or heart disease etc.) OR with pre-eclampsia.
• Pre-eclampsia-In women with pre-existing
  hypertension
• 1.resistant/worsening hypertension,
• 2.new or worsening proteinuria, or
• 3. one or more of the other adverse conditions
  (symptoms,end organ dysfunction, AbN labs, abN
  fetal surveillance)
• Pre-eclampsia-in women with gestational
  hypertension
• as new-onset proteinuria or
• one or more of the other adverse conditions.

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Our Case

• Other information needed?-what does she do for a
  living? ?lab
• Change in management-monitor more closely
• Risk-higher if she develops GH 30
• Counseling-physically demanding work ? risk but
  evidence for reduced stress??
• Best rest?-conflicting data
• Nutrition-calcium in women who are deficient,
  but trials were in 1st trimester ( 1gm/day)

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QUESTIONS?

• What are your concerns at this point?
• How would you reassure yourself with regard to
  maternal and fetal health?
• How would you subsequently manage her pregnancy?
• How would you make a decision about referral?

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Investigations

• Pre-existing hypertension
• Creatinine, K, urinalysis
• Baseline LFTs, cbc-plts
• Suspect pre-eclampsia-assess maternal fetal
• Cbc/plts, creatinine, uric acid, lfts,
• Fibrinogen,PTT, INR
• Uterine artery doppler
• NST, BPP, umbilical artery doppler
• How often? Based on stability

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Management

• Umbilical doppler velocimetry decreases perinatal
  mortality ( OR .71, 95 CI .5-1.01) How
  often?-weekly suggested
• . Anti-hypertensive medication does NOT prevent
  preeclampsia (RR 0.99 95 CI 0.84-1.18) BUT DOES
  prevent severe hypertension in women with mild
  hypertension (RR 0.52 95 CI 0.41-0.64)
• Goals-135-155/80-105 unless co-morbid conditions
  Some evidence of harm ( fetal growth)
• Methyldopya, labetolol, nifedipine acceptable
• Consider steroids for lung maturity in women with
  pre-eclampsia prior to 34 weeks.
• Best rest?-Reduced stress?-may be prudent to
  reduce workload-evidence conflicting

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Our case.. Part 2

• Dx gestational hypertension
• Assessment of maternal and fetal health-lab work,
  US with umbilical dopper
• Management-see biweekly, weekly assessment of
  fetal well being if stable
• Drug treatment?-
• Off work?
• Referral?-depends on the community/resources
• Absolutely if pre-eclampsia develops

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Hypothyroidism and Pregnancy
CPG Management of Thyroid Dysfunction during
Pregnancy and Postpartum An Endocrine Society
Clinical Practice Guideline The Journal of
Clinical Endocrinology Metabolism 92(8)
(Supplement) S1-S4
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Prevalence

• In women of child bearing age- 1.
• During pregnancy-estimated to be 0.3-0.5 for
  overt hypothyroidism and 2-3 for subclinical
  hypothyroidism.
• Thyroid autoantibodies occur in 5-15 of women in
  childbearing age
• Chronic autoimmune thyroiditis is the main cause
  of hypothyroidism during pregnancy.
• World wide- the most important cause remains
  iodine deficiency known to affect over 1.2
  Billion individuals.

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Diagnosis

• Elevated TSH (gestational age specific) suggests
  primary hypothyroidism
• Serum free T4 further distinguish between SCH (
  sub-clinical) and OH ( overt)
• SCHhigh TSH with N free T4
• Determination of antibody titres (thyroid
  peroxidase and thyroglobulin antibodies) confirms
  the autoimmune origin of the disease.
• There is no clear consensus on the adaptation of
  trimester specific pregnancy ranges, so use T4
  ranges especially with caution.

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Questions?

• Are there any increased risks to the patient
  during this pregnancy as a result of her
  hypothyroidism
• Are there any increased risks to the fetus and
  under what circumstances would they occur?

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Adverse Fetal Effects

• OH associated with premature birth, low birth
  weight
• neonatal respiratory distress.
• Normal fetal brain development requires thyroid
  hormone -evidence for adverse effects on
  neuropsychological developmental indices, IQ
  scores and school learning abilities

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Maternal Adverse Effects

• First trimester abortion
• Anemia
• gestational hypertension
• placental abruption and postpartum hemorrhages.
• Complications are more frequent with overt
  hypothyroidism (OH) than with subclinical
  hypothyroidism(SCH)
• NB-adequate thyroxine treatment greatly decreases
  the risk of a poorer obstetrical outcome

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QUESTION?

• How often do you monitor her thyroid and how?

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How to Manage ( A level recommendations)

• Preconception diagnosis?- TSH level not higher
  than 2.5 microU/ml before pregnancy.
• By 4-6 weeks gestation-may require a 30-50
  increase in dosage.
• Diagnosed during pregnancy?-TFTs should be
  normalized as rapidly as possible.
• Target TSH lt 2.5 micro U/ml in first trimester
  and lt 3 in the second and third trimesters.
• Monitor TFTs within 30-40 days of making a change
  or adding medication.
• Known thyroid antibody-but euthyroid? monitor
  for elevation of TSH above normal range as they
  are at increased risk of becoming hypothyroid.
• Postpartum-, decrease in the T4 dosage usually
  needed

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QUESTION?

• She had her diagnosis made during her first
  pregnancy. Should we be screening all women for
  hypothyroidism during pregnancy?

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Universal screening?

• Targeted case finding is recommended at first
  prenatal visit or when pregnancy diagnosed.
  USPSTF level is B, evidence is fair.
• Universal screening cannot be recommended at this
  time
• Controlled Antenatal Thyroid Study (CATS) is
  currently underway and will be of great
  importance in developing screening guidelines.
• Targeted screening is recommended for women who
  have an increased incidence of thyroid disease
  and in whom treatment would be warranted.
• USE TSH

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Who to screen?

• History of thyroid disorder, antibodies or
  thyroid lobectomy
• Positive family history of thyroid disease.
• Women with a goiter.
• Symptoms or signs suggestive including anemia,
  elevated cholesterol, and hyponatremia.
• History of type 1 Diabetes
• History of other autoimmune disorders
• Women with infertility should have serum TSH as
  part of their infertility workup
• History of prior therapeutic head or neck
  irradiation
• Prior history of miscarriage or preterm delivery
• Women living in iodine deficient areas

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What about subclinical Hypothyroidism?

• Associated with an adverse outcome for both
  mother and child. ( see prev slides)
• T4 treatment has been shown to improve
  obstetrical outcome but has NOT been proven to
  modify long term neurological development in the
  offspring.
• Expert opinion-recommend T4 replacement in women
  with subclinical hypothyroidism

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CASE -OBESITY

• Definition- pre-pregnant weight gt30
• How big a problem is this?
• Canadian study 15 adults 20-64 BMIgt30
• Pregnancy-US studies 36 BMIgt29

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QUESTIONS?

• What are Ms. HVs risk factors in this pregnancy?
• What is she at higher risk for now and as the
  pregnancy progresses?

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Obesity

• Antepartum complications
• Miscarriage-contradictory may be ? OR 1.2
• GDM-most studies retrospective
• Increases with increasing obesity ( OR 1.6-3.6)
• Higher with first nations populations
• Prospective study wt gain gt3 kg between
  pregnancies increased GDM OR 1.47

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Obesity

• Hypertensive disease
• OR 2-8, studies prospective
• Preeclampsia-4x higher
• 2x higher if women gain gt3 kg between pregnancies
• Thromboembolism
• Increased primarily above 120 kg

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Obesity

• Infection
• UTI, vaginitis
• chorioamnionitis
• Preterm labour-contradictory evidence

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Obesity

• Intrapartum complications
• Conflicting evidence around labour progress
• Increased need for induction and failed induction
• Increase in failed TOR after C/S ( 15 N weight
  women 30 obese)
• Increase in C/S rate CPD and uteroplacental
  insufficiency
• More difficulty with anaesthesia ( intubation
  and epidural catheter)

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Obesity

• Postpartum complications
• Postpartum hemorrhage
• Thromboembolism
• Wound infection
• Failure of lactation/difficulty with breastfeeding

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Fetal Effects

• Increased risk of stillbirth
• Large for gestational age ( controlling for GDM)
• NICU admissions ( multiple etiologies)
• Congenital malformations-NTD ( 2-3x) and cardiac
  ( septal defects)

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QUESTION?

• Would you manage her pregnancy any differently?
  Why or why not?
• What recommendations will you make about
• Nutrition
• Screening during pregnancy
• Counseling regarding her risks, place of birth
  and birth attendant.

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Obesity-Logistic issues

• Do you have a scale which will weigh these women?
• SFH-almost impossible to follow accurately
• US-may be difficulty to appreciate fetal anatomy

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Obesity Pregnancy Management

• Consider high dose folic acid ( 5 mg)
• Encourage integrated PN screening
• Careful US examination for NTD and cardiac
  malformations
• Outcomes appear to be better with lower weight
  gain ( about 6-7 kg)-dietician
• Consider early screening for GDM and repeat at 28
  weeks if negative

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Obesity- Pregnancy Management

• Will need to use regular US screening for growth
• ? More frequent visits in the third trimester to
  monitor bp
• VBAC-counsel re success rate.
• Anaesthetic consult

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Obesity-Intrapartum/Postpartum

• Home birth?
• May need to use internal clip if external
  difficult
• Be prepared for PPH
• Early amubulation after birth
• Breastfeeding support in hospital and early PP

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Case-Pre-term Birth-Question?

• What are her risks in this pregnancy?

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Case- Pre-term Labour

• 7-10 of pregnancies
• PPROM 2-3.5
• Risks
• Prior pre-term birth
• Antepartum hemorrhage
• Incompetent cervix, uterine anomaly
• Overdistended uterus ( poly, twins)
• Infection-UTI, chorio, BV
• Drugs,smoking
• Low maternal weight, age ( lt18,gt25)

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QUESTION?

• How might you manage her pregnancy differently?
• Advice regarding work and activity
• Screening
• Prophylactic manoevers

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Risk Reduction

• No evidence for bed rest
• No evidence for stopping work
• Population based studies from Europe suggest that
  early work leave may reduce PTB
• Early presentation with sx can reduce neonatal
  morbidity
• Contractions
• Vaginal fluid loss
• Vaginal bleeding
• Change in pelvic/vaginal pressure/discharge/back
  ache

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Preterm Risk Reduction

• Screen and treat for asymptomatic bactiuria
• Screen for BV? ( or other genital tract
  infections?) -conflicting evidence I from AHRQ
  ( USPTF)
• No good evidence for routine screening
• May reduce LBW and PPROM in women with prior ptb

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Screening

• Cervical length- 25mm at 24 weeks RR 6.2 for
  PTBlt 34 wks
• In women with prior PTB
• PPV 12.5 25mm, 35 20mm
• May identify women who might benefit for
  corticosteroids
• For women who present with SSX of PTL-fetal
  fibronectin has a NPV of 97.4

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Pre-term Risk Reduction

• Interventions with unclear benefits
• Progesterone-appears to reduce the risk of PTB
  lt34 weeks in women with N cervical length (
  Meta-analysis of 11 rcts)

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Neonatal Risk Reduction

• Antenatal corticosteroids between 24-34 weeks
• Antibiotics ( erythromycin) for 7 days with PPROM
  PLUS steroids
• Tocolysis to allow steroids