Friday, April 8, 2011

Drugs in Pregnancy

Safe Drugs in Pregnancy and Safe drugs in Lactation

Antipyretic, fever medications safe in pregnancy
  • Paracetamol (acetaminophen) 1000mg QDS

Runny nose, itch, flu medication safe in pregnancy
  • Chlorpheniramine (piriton) 4mg QDS

Cough Medication safe in pregnancy
  • Dextromorphan (DMP) 15mg tds
  • Diphenhydramine 10mls tds
  • Bromhexine (Bisolvon) 8mg tds

Sore Throat medication safe in pregnancy
  • Lozenges

Anti vomiting medication safe in pregnancy
  • Pyridoxine 50mg OM (for hyperemesis gravidarum)
  • Metoclopramide (Maxolon) 10mg tds

Anti- Diarrhoea medication safe in pregnancy
  • Charcoal 1 tablet tds

Antibiotics safe in pregnancy
  • Amoxycillin 500mg tds
  • Erythromycin 500mg tds
  • Cephalexin 500mg tds
  • Augmentin (Amoxycillin-clavulanate acid) 625mg bd to tds

Sunday, April 3, 2011

Epilepsy in Pregnancy

About 1 in 200 women have epilepsy. During pregnancy, seizure control can become worse and there is a risk of congenital defect of the fetus, especially neural tube defects. This is cause mostly by drugs and monotherapy is generally preferred to multi-drug therapy.
The fetus also have a higher chance of developing epilepsy (4%)

All epileptic women who are planning for pregnancy should be started on folic acid and this should be continued throughout pregnancy.
Vitamin K orally should be given in the last 4 weeks of pregnancy. reduce chance of coagulopathy in neonates.

Monday, March 28, 2011

Gestational Diabetes in pregnancy

Pregnancy causes increase in glucose intolerance. For some women, this can lead to gestational diabetes. In general, insulin requirement of a women increases during pregnancy. Approximately 8.6% of all pregnancy are complicated by gestational diabetes.

Definition of gestational diabetes (GDM)
  • The diagnosis of gestational diabetes is based on an oral glucose tolerance test (OGTT) in which a 75g load of glucose is given to the patient.
  • GDM is diagnosed if (ADA guidelines 2011)
  • - Fasting ≥92 mg/dl (5.1 mmol/l)

  • - 1 h ≥180 mg/dl (10.0 mmol/l)

  • - 2 h ≥153 mg/dl (8.5 mmol/l)

When and how to screen for Gestational Diabetes
There has been no consensus on this issue. The ADA and RCOG (Jan 2011) recommends the following:

  • Screen for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, using standard diagnostic criteria.

  • In pregnant women not known to have diabetes, screen for GDM at 24–28 weeks of gestation, using a 75-g 2-h OGTT

  • Screen women with GDM for persistent diabetes 6 weeks postpartum.

  • Women with a history of GDM should have lifelong screening for the development of diabetes or prediabetes at least every 3 years.

In Singapore, the MOH reccommends OGTT only for high risk patients early in the pregnancy and at 26-28 weeks
In all other patients urine should be tested for glucose. If glucosuria 1+ or more, plasma glucose levels will be done. OGTT is done if glucose >6.6 more tahn 2 hrs after meal or >7.0 within 2 hrs after meal.

Risk Factors for Gestational Diabetes
  • Obesity
  • Family history of diabetes
  • Medical history of gestational diabetes
  • History of large baby more than 4kg
  • Previous unexplained stillbirth
  • PCOS
  • Polyhydramnious
  • Twin
Fetal Complications for diabetic women
  • Related to glucose levels
  • Congenital abnormalities
  • Pre-term labour
  • Polyhydramnios
  • Decrease fetal lung maturity
  • Large baby
  • Fetal distress and sudden fetal death more common.
  • Neonatal Hypoglycemia
Maternal Complications of Diabetes in pregnancy
  • Ketoacidosis (rare)
  • Hypoglycemia (too strict control)
  • UTI
  • Infection: Wound or endometrial
  • Hypertension and pre-eclampsia more common,
  • Diabetic retinopathy
Management of patients with gestational diabetes
  • Close surveillance
  • Dietary Control: Maintain fasting glucose at <5.5 mmol/L and 2hr post prandial glucose at <6.7 mml/L
  • Metformin and Glibenclamide has been used is oral agents
  • Insulin still the safest choice.
  • Mothers should monitor fetal movement in last 12 weeks of pregnancy
  • Ultrasound for congenital abnormalities at 18-22 weeks
  • Fetal growth ultrasound 29-33 weeks
  • Non stress cardiotocography with umbilical doppler flow may be considered.
  • Screen for hypertension.
  • Infants fed early and baby screen for hypoglycemia
  • Contraception: OCP in complicated diabetes or infection with IUCD.

Thursday, March 24, 2011

Triple test screening for down syndome

This test measures 3 hormones:
  • AFP (alpha fetal protein)
  • HCG
  • Estriol
This helps to screen for down syndrome and AFP helps to screen for neural tube defects.
The mother undergoes a blood test between 14 weeks to 20 weeks. The blood test results generally takes a few days to be available.
The detection rate for down syndrome is about 65%

Cobine Screening: Nuchal transluncency and first trimester screening

Nuchal Transluncy test as described in the previous post, can be combined with doing a blood test.
The blood test measures 2 items:
  • Free beta HCG
  • PMPPA (pregnanct associated plasma protein A)
Like the Nuchal translucency test, this is done between 11 week 3 days to 13 weeks 6 days. The blood test results barely takes a few hours for the results to be available.
The detection rate of down syndrome is improved with this test at up to 90%

Nuchal Translucency Test Screening

The Nuchal transluncency test is an ultrasound test. It measures a fluid filled area at the back of the neck of the fetus called nuchal. The test is done between 11 week 3 days to 13 weeks 6 days of pregnancy

Detection rate of Chromosomal disorder via NT test alone is about 80%

Monday, March 21, 2011

Signs of of Pre-eclampsia in pregnancy

  • Pre-eclampsia is a multi system disorder characterised by hypertension and proteinuria. It is difficult to define clinically due to it's heterogeneous nature.
  • It is defined as blood pressure of more than 140/90 and more than 300mg/24hr of protein in the urine.
  • In women who are hypertensive, a rise of systolic of more than 30mmHg or diastolic of more than 15mmHg is taken.
  • Affects 5% to 10% of pregnancies
  • Believed to be placenta in origin
  • Increase vascular resistance : hypertension
  • Increase vascular permeability: proteinuria, edema
  • Decrease placenta blood flow: Intra-uterine growth restriction
  • Decrease cerebral perfusion: Eclampsia
  • Edothelial cell damage: Clotting abnormality and liver damage
Classification of pre-eclampsia
  • Mild - BP <170/110
  • Moderate - BP >170/110
  • Severe - Pre-eclampsia <32>
Risk factors for pre-eclampsia
  • Nulliparous
  • Previous pre-eclampsia
  • Family history of pre-eclampsia
  • Extremes of maternal age
  • Large placeneta : eg twin
  • Microvascular disease : DM, renal disease, autoimmune disease
  • Existing hypertension
  • Obesity
Symptoms of Pre-eclampsia
  • Central nervous system: Headache, drowsy, visual problems
  • Gastro-intenstinal: Nausea, vomting, epogastric pain
Signs of Pre-eclampsia
  • Hypertension
  • Edema
  • Clonus
  • Epigastric tenderness
Complications of pre-eclampsia and treatment of problems
  • Eclampsia : grand mal seizure - treat with IV magnesium sulphate
  • Cerebral hemorrhage: Preventing BP of more than 170/110 (belived to prevent loss of autoregulation)
  • HELLP: Hemolysis, Elevated Liver enzymes, Low Platelets. - supportive
  • DIVC (disseminated intra-vascular coagulation)
  • Renal failure: May need dialysis
  • Pulmonary edema: Frusemide, ventilation
  • Fetal: IUGR, Placental abruption, fetal hypoxia
Prevention of pre-eclampsia
  • Patients with previous severe or early onset pre-eclampsia should be offered low dose aspirin.
Admission criteria for pre-eclampsia
  • BP> 160/110
  • Any complications
  • Once proteinuria 1+ (admit for 24hr UTP)or >300mg/24hr
Management of Pre-eclampsia
  • Monitor for complications: Fetal and blood and clinical monitoring
  • Control BP: Oral nifedipine and methyldopa (s.e depression, loss of patellar reflex)
  • Steroids if gestation <34>
  • Delivery (Eclampsia can still happen up to 24hrs post delivery)