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High risk pregnancy ( counselling about pre-existing diseases )

- GP, Specialist physician and specialist obstetrician

- **Criteria to be eligible for pregnancy
o DM: HbA1c <7 for last 3 months
o SLE: no active disease for the last 6 months
o Epilepsy: free of fit for 2 years
o DVT/PE: thrombophilia screen negative

1. Lithium for pregnancy

You are at your GP, when 28 year old Laura presents to you. She is having bipolar disorder since the past 2 years and is
taking Lithium. She is planning to start a family and would like your advice regarding that.
TASKS
1. Take a further relevant history, 2. Counsel the patient accordingly

Quick fact summary

Good decision. – can have healthy pregnancy & normal baby.
Risks- On mother- child birth increases relapse- 37% of women pts, > 60% if no Tx. 23% if with preventive Tx.
( risk highest in 1st month after delivery. Pre-pregnant d/s severity and other factors like sleep deprivation can effect risk too
). hospital admission prn e.g safety concern.
On baby- defects, although not very often; heart defects, Ebstein’s anomaly ( defect in location of one heart valve ) and
other heart defects. ? nerve tube defects.

If lithium is used near delivery, reports of reversible thyroid and kidney toxicity, decreased muscle tone (hypotonia), difficulty
breathing and feeding in the newborn. With careful treatment, the baby should fully recover within 10 days.

Mx- Pregnancy - informed decision, and well planned.

GP, treating psychiatrist & obstetritian. Partner* in Mx plan.
Regular sleep time during pregnancy & post partum ( sleep deprivation – major risk for relapse )
Healthy lifestyle (eg healthy diet, plenty of water to prevent Lithium toxicity, smoking cessation, avoiding illicit drugs).
Prior to your pregnancy, baseline blood tests like serum Lithium level, TFT, RFT and routine antenatal tests.
Folic acid - 5mg/day 3 months before till first 3 months of your pregnancy if on Lamotrigine, otherwise, take the usual dose.
Once pregnant, high-risk pregnancy clinic, by a multidisciplinary team ( obstetrician, psychiatrist and GP ).

Lithium -Depending on the severity of the bipolar episodes, and other factors like support available, specialist 
1. continue taking lithium throughout the whole pregnancy ( complete prophylaxis ),
2. stop it in early months of pregnancy ( partial prophylaxis ) or
3. Stop it completely before and during pregnancy & post-partum( medication-free pregnancy ).

e.g 1, if asymptomatic, specialist may suggest medication-free pregnancy & post-partum period. ( usually for patients with
1.few episodes of the disorder, 2.(at least one year) long periods of mood stability, 3.low risk of self-harm, 4.good support
network, and 5.being able to identify early warning signs, 6.along with a strategy to seek early help. )
How- slow withdrawal of medication under supervision (over two to six weeks) prior to conception. ( 1.at a time of minimal
stress and 2.time of year when relapse is unlikely, 3. prior to conception )

close review and monitoring for any symptom, early warning signs.

e.g 2. If on lithium during pregnancy, regular reviews, serum lithium levels ( lowest effective dose, ** therapeutic level of 0.6–
0.8 mmol/L ), and side-effects like regular TFT, kidney function tests. It is best to take the lowest dose in divided times.

alternatives with less risk - Olanzapine, Quetiapine / Lamotrigine. If not control well, may restart Lithium after 1st trimester.
Quetiapine / Olanzapine ( generally safe in pregnancy; risk for gestational diabetes and large babies )

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Make sure the awareness, informed decision and consent, monitoring and a clear plan if defect happens.

Tests - Screening ( baby- ultrasound at 1st trimester for nuchal translucency, and 18 wks level 2 USD and fetal
echocardiogram at 21-22 wk  may follow up tests depending on the findings.

Routine tests during your pregnancy s/a Down $ screening, Sweet Drink test at 28 weeks ( high chance of Diabetes with
Olanzapine and Quetiapine), repeat ultrasound at 32 weeks, and a bug test at 36 weeks.
more frequent antenatal checks, and as the pregnancy progresses, with CTG monitoring of the baby.

-may reduce Lithium dose at 38 weeks to reduce the risk of high serum lithium levels in baby, but will full dose immediately
after delivery.

Can have normal vaginal delivery, in tertiary hospital under the guidance of specialist.
if not BF, back to full Lithium dose. if BF +, Olanzapine etc, but restart Lithium after weaning. ( not breastfeed if on lithium ).
Other psychosocial Tx like Talk therapy and behavioural strategies are also helpful. tailor to pt.

Roleplay

APPROACH : Ensure confidentiality, reassurance, multidisciplinary Mx and informed decision.

Hx

1. 1-Bipolar disorder – How long / when Dx? Last episode? (if no episode in last 1 year, can stop Lithium). What
symptoms did you have at that time? Any idea of harm to self or others?
Frequency of episodes? Tx if episode?
Current status- Sleep disturbance? mood? Energy level? ( sleep deprivation – major risk for relapse )

2. Tx – last seen by psychiatrist? Last bld tests? Results? Which Tx, dose, how long, compliance? SE like change in
weather preference, appetite, Weight ( Hypothyroid ), tremor, dizziness etc? kidney problem? Lithium level – how
often? When was the last check?
3. psychosocial- support at home? Partner supportive? Any concern at home, finance, baby care etc?
4. pregnancy- 1st pregnancy? When plan? How is yr period? Normal? On any contraception? Any plan for breastfeeding?
5. last pap smear- when? Normal? Any STI?
6. General health? Any other diseases? Any other medication? SADMA?

Counselling

It is a very good decision that you came to me today.

With careful planning & Mx, many women with bipolar disorder ( aka manic-depression) and on Lithium / such medications
can have a healthy pregnancy and a normal healthy baby.

Let me explain you

-risks if you get pregnant, on you and the baby,
-how we will plan and manage to minimize the risks including monitoring & different Tx strategies from now until after
delivery, and
-how to manage if relapse happens or risks to the baby etc.
If any question, pls feel free to interrupt me at any time.

1-Risks if pregnant
On mother- child birth can increase risk of relapse- 37% in women with bipolar disorder, higher than 60% if without Tx and
become lower 23% if with preventive Tx.
Relapse risk is highest in 1st month after delivery. Severity of disease before pregnancy and other factors like sleep
deprivation can effect risk of relapse as well.
If safety concern, may even need hospital admission.

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On baby- Lithium and medications used for bipolar d/o can cause defects in baby, although not very often like heart defects,
what we called Ebstein’s anormaly ( defect in place of one heart valve ) and other heart defects. ? nerve tube defects.

If lithium is used near delivery, there have been some reports of reversible thyroid and kidney toxicity, decreased muscle
tone (hypotonia), difficulty breathing and feeding in the newborn. With careful treatment, the baby should fully recover within
10 days.

Be sure to talk to your Dr about all your choices for breastfeeding.

Mx
We aim to maintain your wellbeing, ensure your baby's safety, and also to plan for the post-partum period.
Pregnancy should be informed decision and should be well planned ahead.

GP, treating psychiatrist & obstetritian. The psychiatrist will review you and medications.
Partner – should involve in Mx plan, while we will ensure the partner’s well being

Regular sleep time during pregnancy & post partum ( sleep deprivation – major risk for relapse )
Healthy lifestyle (eg healthy diet, plenty of water to prevent Lithium toxicity, smoking cessation, avoiding illicit drugs).

 Prior to your pregnancy, we will do baseline blood tests like serum Lithium level, TFT, RFT and routine antenatal tests
as well.

Folic acid - 5mg/day 3 months before and for the first 3 months of your pregnancy if you will be taking Lamotrigine,
otherwise, take the usual dose.

Once you become pregnant, you will be monitored in the high-risk pregnancy clinic, and will be seen by a multidisciplinary
team composed of the obstetrician and the psychiatrist.

Lithium -Depending on the severity of the bipolar episodes, and other factors like support available, specialist will usually
recommend you, that you 1. continue taking lithium throughout the whole pregnancy ( complete prophylaxis ), 2. stop it at
some times like early months of pregnancy ( partial prophylaxis ) or 3. Stop it completely before and during pregnancy &
post-partum( medication-free pregnancy ).

For example, specialist may suggest medication-free pregnancy & post-partum period if asymptomatic. Such option is
usually for patients with 1.few episodes of the disorder, 2.(at least one year) long periods of mood stability, 3.low risk of self-
harm, 4.good support network, and 5.being able to identify early warning signs, 6.along with a strategy to seek early help.

How- Supervised withdrawal of medication slowly (over two to six weeks) prior to conception. ( prn only 1.at a time of
minimal stress and 2.time of year when relapse is unlikely, 3. prior to conception )

We will closely review and monitor you for any symptom, early warning signs.

If you are on lithium during pregnancy, regular reviews of medication dose, serum lithium levels (aiming for the lowest
effective dose, ** therapeutic level of 0.6–0.8 mmol/L ), and side-effects like regular TFT, kidney function tests. It is best to
take the lowest dose that works for you and spread the dose out over the course of the day.

The specialist may consider the alternative medications with less risk like Olanzapine, Quetiapine or Lamotrigine. If cannot
control well, Specialist may restart Lithium after the 1st trimester.
Quetiapine / Olanzapine ( generally safe in pregnancy; risk for gestational diabetes and large babies )

We will make sure that your awareness, informed decision and consent, monitoring and a clear plan if defect happens.

Screening ( The baby will be monitored by ultrasound at 1st trimester, and 18 wks and fetal echocardiogram at 21-22 wk )/
1.1st trimester USD to measure a pocket of fluid normally found behind the baby’s neck, used to screen for heart defect, 2. If
used during pregnancy, level 2 USD around 18 wk to check baby’s growth & development and 3. fetal echocardiography
around 21-22 wks, are recommended.

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Specialists- recommend follow up tests depending on the findings.

Routine tests during your pregnancy s/a Down syndrome screening, Sweet Drink test at 28 weeks ( high chance of Diabetes
with Olanzapine and Quetiapine), repeat ultrasound at 32 weeks, and a bug test at 36 weeks will be done.

more frequent antenatal checks, and as the pregnancy progresses, with CTG monitoring of the baby.

Specialist may reduce Lithium dose at 38 weeks to reduce the risk of high serum lithium levels in baby, but will restore to a
full dose immediately after delivery.

Can have normal vaginal delivery, plan in tertiary hospital under the guidance of a specialist.

 What is your plan for breast feeding? Make sure to talk to your Dr about your choice for breastfeeding.

After delivery, if you will not be breastfeeding, you will be put back on the full therapeutic dose of Lithium. However, if you
intend to breastfeed, then Olanzapine will be given to you instead.
Breast Feeding - not breastfeed if on lithium (with careful monitoring). Alternative - Olanzapine etc, but should restart Lithium
after weaning.

Other psychosocial Tx like Talk therapy and behavioural strategies are also helpful. We will tailor to you.

Reading materials, website links etc, Review, Referral, Reassurance.

Bipolar disorder & pregnancy

2016 https://www.racgp.org.au/afp/2016/december/management-of-bipolar-disorder-over-the-perinatal-period/

Childbirth - relapse in 37% women, 66% if without Tx, 23% if on prophylactic Tx.
Relapse – more if more severe bipolar disorder, recent illness. less likely if long euthymia and good social supports.
Prophylactic mood stabilisers - much reduce the risk of relapse, but risks to baby & mother.
Relapse - highest risk in 1st month postpartum.
Sleep deprivation –major risk factor for relapse. Maintain regular sleep time.
identify early warning signs of relapse and written plan, discuss with partner and Tx team.
Prn Referral perinatal outreach services.
If safety concern in relapse, involuntary admission prn, in a mother and baby unit

Mx
Once Dx, counsel to accept the Dx & need for long term medication.
Ideally, pregnancy should be well planned. to make an informed decision.
Mx by perinatal psychiatrist team, GP & obstetric team.
If unplanned preg, urgent clinical & medication review ( Do not stop Tx adruptly  relapse )

Mx
1-confirm Dx.
2-assess severity of bipolar ( episodes: frequency, number, symptoms ); Tx & SEs; social factors (eg housing, finances,
lifestyle); support; and capacity to care for her baby.
3-Mx options over the perinatal period, use and risks of medications.

Mood stabilisers during pregnancy -can be teratogenic.

Lithium- most effective mood stabiliser. considered in severe bipolar disorder.

Defects of heart called Ebstein’s anomaly and other heart defects -> USD at 1st trimester, level 2 USD at 18 wks, & fetal
ECHO at 21-22 wk.
Breast Feeding - not breastfeed if on lithium (with careful monitoring). Alternative - Olanzapine etc or sodium valproate ( if
with adequate contraception), but should restart Lithium after weaning.

Alternatives -2nd generation antipsychotics, like quetiapine or olanzapine ( generally safe in pregnancy; risk for gestational
diabetes and large babies.

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Lamotrigine- lower risk during pregnancy. can give to breastfeeding mothers, 2.7% - congenital abnormalities but less
efficacy in preventing mania.

Mx
to maintain maternal wellbeing, ensure fetal safety and prepare for the postpartum period.

Specialist clinic. GP, obstetric team and treating psychiatrist. Plan well.
Partner – should involve in Mx plan, partner’s well being

Regular sleep time during pregnancy & post partum ( sleep deprivation – major risk for relapse )
Healthy lifestyle (eg healthy diet, smoking cessation, avoiding illicit drugs).

3 Tx options depending on the disease severity and pt’s circumstances.

1st- medication-free pregnancy and postpartum period, if asymptomatic.
Reserved for patients with 1.few episodes of the disorder, 2.(at least one year) long periods of mood stability, 3.low risk of
self-harm, 4.good support network, and 5.being able to identify early warning signs, 6.along with a strategy to seek early
help.
How- stop medication slowly (over two to six weeks), 1.at a time of minimal stress and 2.time of year when relapse is
unlikely, 3.prior to conception.

2nd-partial prophylaxis ( stop Tx prior to conception  a medication-free 1st trimester reintroduce, generally lithium, after
organogenesis is complete & no cardiac defect found in USD )
If patient prefers to be medication-free throughout the pregnancy, can start lithium after delivery, at pre-pregnancy dose.

3rd- full prophylaxis. throughout pregnancy.

1.pt needs to be aware of the risks to the fetus, 2.consent, 3.USDs and monitoring and a clear plan if defect happens.

Regular review & monitoring of the patient’s clinical state, medication dose, serum lithium levels (aiming for the lowest
effective dose), and side-effects.

Screening 1.1st trimester USD to measure a pocket of fluid normally found behind the baby’s neck, used to screen for
heart defect, 2. If used during pregnancy, level 2 USD around 18 wk to check baby’s growth & development and 3. fetal
echocardiography around 21-22 wks, are recommended.
Specialists- recommend follow up tests depending on the findings.

Lithium - Regularly monitoring the serum lithium levels ** therapeutic level of 0.6–0.8 mmol/L, , TFTs ( hypothyroidism ),
RFT.

Reduce dose at 38 weeks to reduce the risk of the infant having high serum lithium levels,
Restore to a full dose immediately after delivery.

Breast Feeding - not breastfeed if on lithium (with careful monitoring). Alternative - Olanzapine etc or sodium valproate ( if
with adequate contraception), but should restart Lithium after weaning.

Alternatives -2nd generation antipsychotics, like quetiapine or olanzapine ( generally safe in pregnancy; risk for gestational
diabetes and large babies.
Lamotrigine- lower risk during pregnancy. can give to breastfeeding mothers, 2.7% - congenital abnormalities but less
efficacy in preventing mania.

Relapse ( highest risk in 1st month postpartum )

identify early warning signs of relapse and written plan, discuss with partner and Tx team.
Prn Referral perinatal outreach services.
If safety concern in relapse, involuntary admission prn, in a mother and baby unit.

If suspect any relapse - prompt assessment and treatment.

Tx - depend on the symptom severity and context.
1-Emergent hypomanic symptoms, such as irritability, increased energy and sleep disturbance  short-term sedating 2nd-
generation antipsychotic to restore a stable sleep–wake cycle.
2- mild-to-moderate symptoms  Psychosocial treatments e.g CBT,
3-moderate-to-severe symptoms Pharmacotherapy

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Psychosocial

sleep deprivation - major risk factor for relapse. regular sleep time and evening mealtime in pregnancy & postpartum ( key
feature ).
s/a expressing milk (if breastfeeding) during the day, to allow others eg partner to feed the infant overnight.
CBT is helpful to reduce anxiety and depressive symptoms.
Behavioural strategies- helpful for demands of baby care.

Prn theory.
Lamotrigine- lower risk during pregnancy. can give to breastfeeding mothers, 2.7% - congenital abnormalities but less
efficacy in preventing mania.

Relapse ( highest risk in 1st month postpartum )

identify early warning signs of relapse and written plan, discuss with partner and Tx team.
Prn Referral perinatal outreach services.
If safety concern in relapse, involuntary admission prn, in a mother and baby unit.

If suspect any relapse - prompt assessment and treatment.

Tx - depend on the symptom severity and context.
1-Emergent hypomanic symptoms, such as irritability, increased energy and sleep disturbance  short-term sedating 2nd-
generation antipsychotic to restore a stable sleep–wake cycle.
2- mild-to-moderate symptoms  Psychosocial treatments e.g CBT,
3-moderate-to-severe symptoms Pharmacotherapy

T half 20 hours. Generally, the lithium is cleared from the body over a three to four day period.
Father on Lithium – few studies - reduced quality and movement of sperms & reduced sex drive but more studies required.
Could be C’ of depression. No report about birth defect.

Prn ( 3-Carbamazepine -linked to fetal abnormalities should not use in pregnancy.

4-Sodium valproate; 10–11% of infants - major congenital malformations & risk of significant intellectual impairment Not
the first-line mood stabiliser in women of childbearing age.If on valproate if unplanned pregnancy, - take folate while taper it
over a week, substitute another medication.

GP- contraception, medications with lower risk of harm to a fetus (eg avoiding sodium valproate). long-term Mx. )

2. Pre-pregnancy counseling for Epilepsy

Case: 26-year-old female presented in your GP who’s known to be epileptic and is treated by sodium valproate. Over the
last 2 years, she had not fits and now in your GP clinic, asking for an advice for her chances and preparation to be pregnant.

Task
a. Counsel patient (include risks)

History:
1- Epilepsy- when Dx, by whom? When was the last fit? Type? fit (pre-warning signs-aura, prn -tongue bite, loss of
consciousness, wetting of clothes ), any known triggers ( stress, sleep deprivation, alcohol, drugs?) Any known
C’? Any hospital admission?
2- Tx- last seen by neurologist? **Medications- All current and previous used with control & SE? Any invx done
(CT/EEG etc, drug serum level & monitor tests for SE s/a FBC, LFT etc )
3- psychosocial- support at home? Stable partner? Partner supportive? Any concern at home, finance, baby care
etc?

4- pregnancy- 1st pregnancy? when plan? How is yr period? Normal, any heavy bleeding, bld clots? On any
contraception? any miscarriage before? plan for breastfeeding?
5- last pap smear- when? Normal? Any STI?
6- General health? Any other diseases like HT, DM? Any other medication? SADMA?

Counselling tips:

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- Remember to be positive! Reassurance!

**Criteria to be eligible for pregnancy  Epilepsy: free of fit for 2 years
- Risks on mother & baby.
- Multi-disciplinary Mx s/a Specialist Neurologist, obstetrician, GP
- Are you alone? Would you like someone to be with us?

Counselling
- More than 90% of epileptic women – successful pregnancy. Must be fit-free for 2 years before conception.
- Ensuring effective contraception until seizure control is achieved (higher oestrogen dose of combined pills, Depo
inj every 10 wks rather than 12 wks, levonorgestrel-releasing IUCD. Not suitable - POP, implant –as levels
lowered by eze inducers.
- Risks present on both mother and baby but we have effective Mx to minimize the risks.
- Avoid – Valproate. More with polytherapy than with monotherapy.
- if possible, cease / use the lowest effective dose of a single drug, in divided doses, avoiding high peak levels, and
should not change medication once pregnant.

Mother – more common- pre-eclampsia, bleeding esply in 3rd trimester, placental abruption, prematurity.
– increased risk of seizure in labour and delivery. ( Multifactorial; poor levels of AEDs, compliance, sleep deprivation, anxiety
and hyperventilation during labour. Try to avoid those )
in pregnancy - For most women, seizure frequency and medication unchanged. ( Other factors also found in increased
seizure frequency s/a sleep-deprivation or noncompliant because of concerns of SE on fetus. )

- Baby- prolonged fits - sustained fetal hypoxia, injury to the fetus, abruption or miscarriage due to maternal trauma.
- risk of defects like neural tube defect, cleft lip, premature labour, LBW, lower Apgar scores, a 4-fold increase in the
risk of epilepsy in infants.
- higher risk of congenital malformations, multifactorial, in the first trimester, whereas effects on fetal cognitive
development can occur throughout gestation (gross motor skills, sentence skills, autistic traits) at 18 and 36
months of age ). reduced cognitive abilities in a range of domains at 6 years of age.
- Recent evidence - no greater risk of major congenital malformations with lamotrigine.
- Avoid Valproate - highest rate of malformations, at doses above 1100 mg/day, 9.3%
- Less with phenobarbitone, topiramate, carbamazepine, phenytoin, levetiracetam and lamotrigine.
- VPA - neural tube defects, hypospadias, cardiac defects and oral clefts, higher risks of autism & autism spectrum
disorder. phenobarbitone - cardiac defects and oral clefts; topiramate - cleft lip.

Mx

- Since before the pregnancy, Multi-disciplinary Mx s/a GP, Specialist Neurologist, obstetrician ( will refer ). high risk
pregnancy clinic in a tertiary hospital.
- informed decision, take time to discuss with partner.
- Obstetrician – will make sure everything is alright, and continue FU.

- The neurologist will review your medication to consider medication with less risk. ?? Lamotrigine
- Sodium Valproate – usu not given in pregnancy.
- Single therapy preferred, in lowest effective dose, in divided doses, avoiding high peak levels, and should not change
medication once pregnant.
- 5mg of folic acid from 1st visit attempting pregnancy (3 months before pregnancy up to 1st trimester).
- Serum drug level, tests for SE s/a FBC, LFT, and all antenatal checkup tests will be done before pregnancy.
- with good control, check serum concentration each trimester till 8th week post partum, more frequent assessment if with
complicated epilepsy. Serum levels– usu lower in pregnancy.
-
- Encourage to register in the Australian Pregnancy Registrar (APR) of AEDs.
- USD at 11–13 weeks. Early referral to Obstetrician If defect suspected ( acrania (the precursor of anencephaly) or
increased nuchal translucency (useful screening test for cardiac and other structural defects. )
- expert morphological USD at 18-20 wks.
- May consider Vitamin K from 26th week onwards to prevent bleeding. ( Controversial. NICE - no longer recommend
vitamin K if on EIAEDs in late pregnancy, but rather phytomenadione to the neonate. )
- Will do routine antenatal care tests, more frequent visits.

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Delivery – Most women – can have normal vaginal delivery. Tertiary Hospital with adequate facilities for maternal and
neonatal resuscitation. An intravenous access. Should continue AED. Attention to avoid hyperventilation and maternal
exhaustion.

Be ready to Mx any seizure; can use IV benzodiazepine (eg. lorazepam or diazepam). continuous CTG tracing if
generalised tonic-clonic seizures.

Postpartum- neurologist to adjust the AED dose as drug level usu falls, esply reduce dose of Lamotrigine and
oxcarbazepine. Continue monitoring of plasma levels ( may fluctuate until 8th wk postpartum)

Breastfeeding - All AEDs are secreted in the mother’s milk; benefits balanced against adverse effects in the baby. If
lamotrigine and levetiracetam – preferably avoid breastfeeding.

Counselling 1. to minimize risks of fits in mother; medication compliance, adequate sleep, review by specialist etc. and

2. to minimize risk of injury to the baby; sit close to or on the floor while feeding, should nurse baby on the floor surrounded
by cushions, minimal carrying of the baby, bath the baby at presence of another person, and using a pram with an automatic
brake..

 Best contraception advice

 RRR etc.

Ref: https://www.racgp.org.au/afp/2014/march/epilepsy-in-pregnancy/

Other theory prn;

- Defects in fetus (multifactorial; direct effect of AEDs, d/t toxic AED metabolites, reduced folate availability, hypoxic
injury from seizures, and genetic predisposition )

Preconception care

Hormonal contraceptive failure with enzyme-inducing AEDs (EIAEDs) s/a phenobarbitone, primidone, phenytoin,
carbamazepine, oxcarbazepine, felbamate and topiramate.

unaffected by non-EIAEDs, s/a valproic acid (VPA), zonisamide, benzodiazepines, gabapentin, levetiracetam, pregabalin,
tiagabine and vigabatrin

higher oestrogen dose COCP (eg. 50 µg ethinyl oestradiol) recommended / Depo inj every 10 weeks rather than 12 weeks /
Hormone IUCD ( Mirena )/ barrier.

EIAEDs lower the blood levels of hormone – POP, levonorgestrel or etonogestrel implants - unsuitable if on EIAEDs.

COCPs increases the metabolism of lamotrigine (through increased glucuronuidation), about 50% - significant worse seizure
control  increased lamotrigine dose if on COCP, reduce if stop.

reports of increased rates of sexual dysfunction, hypothalamic amenorrhoea, hyperprolactinaemia, premature menopause,
increase in anovulatory cycles and polycystic ovarian syndrome (PCOS) in women with epilepsy.

3. Pre-pregnancy counseling of SLE

Case: You are a GP and your next patient is a 24-year-old patient who is a diagnosed case of SLE for 5 years. She wants to
become pregnant and is seeking your advice.

Task
a. Counsel the patient (steroids but no longer taking it because she is symptom-free)

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b. Answer her questions

** SLE & pregnancy:

- mother: SLE 40% - flare-ups, while 10% - remissions, miscarriages, recurrent miscarriage ( antiphospholipid
antibodies ), pre-eclampsia ( 20% )
- Baby:  IUGR, prematurity (50%), IUFD ( SLE is infl. Of small vessels so effecting placenta )
- at delivery (5%)  Lupus-like syndrome in baby = rash and abnormal blood cell counts. It is not SLE. temporary
response due to passage of certain proteins ( antiphospholipid antibodies ) from the mom to the baby. resolves
within the 1st 4 weeks;
- congenital heart blocks: only 2% of pregnancies.

Questions: / to address
- Can I become pregnant like other females? Risks on mother? On baby?
- Effects of pregnancy on SLE?
- Do I need some special medications during pregnancy? ( steroid safe, adjust dose prn, Azathioprin prn, others CI’)

History
1- SLE:
-Dx when? by whom? Last seen by specialist? Last bld tests? Any flare up s/a Fever, Jt pain, rash? symptom free
for**how long? ( must be 6 mths symptom free ), any events / admission? Any C’ organ C’ like kidney problem?
-Current Tx? Good control / any symptom** like skin rash, F’, joint pain? any SE of Tx s/a infection?
-Previous miscarriage? FH of SLE/ miscarriage?
2- Pregnancy plan Q? period Q, any contraception? 1st pregnancy? Any past Hx recurrent miscarriages? Any FHx
of SLE / recurrent miscarriages? Bld tests done?
3- Other Ps’- last pap smear-when? N?
4- General health? Any other medical conditions? Prn SADMA?

Counseling

SLE-autoimmune disease ( our own body defense system wrongly attacks own body tissues, affecting many organs s/a
kidneys, joints, skin )
Exact cause unknown but many trigger factors known s/a certain genes, virus, drugs
very common in women of childbearing age (20-45).
No cure but Controllable / manageable with effective medications to prevent flare-ups & C’.

SLE & pregnancy- majority of women with SLE are able to have kids.
Certain risks; on mother- more flare ups, miscarriage, preeclampsia. Baby- IUGR, IUFD, prematurity.

Reassure- have effective measures to prevent C’, counselling & Mx by Specialist physician, Obstetrician and GP even
before conception. 6 months symptom free before conception.
- high-risk pregnancy.
- I will do some blood tests ( complete thrombophilia screen s/a protein C, protein S, Factor V Leiden, antithrombin
3, anticardiolipin antibody, Antiphospholipid antiboby & USD,and other routine bld tests FBE, UEC, Blood group,
rubella antibody status even before pregnancy.
- continue close monitoring throughout your pregnancy in addition to routine AN care tests s/a USD, Bug test etc.
- SLE Mx by specialist- steroids – safe usually, may adjust the dose. Azathioprine prn. All other cytotoxic drugs –CI’
- Specialist may consider to give Aspirin or inj Heparin to prevent the risk of clotting problems or thrombophilia,
continue after delivery (especially if anticardiolipin is positive).
- Specialists will decide mode and timing of delivery depending on the baby’s condition. Will be at the tertiary
hospital. If concerned with baby’s growth, may intervene earlier.
- Reading material, SLE association of Australia.

4. Pre-pegnancy DVT Counseling ( HB pls )

Case: Your next patient is a 28-year-old woman. Her last pregnancy was 18 months ago which was complicated by DVT
and postpartum pulmonary embolism. She has come to see you for pre-pregnancy counseling. She has stopped warfarin 12
months ago. There are no abnormalities on PE. She is not overweight.

Task

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a. Take relevant history (NSVD, episiotomy scar and baby was normal; did not breastfeed; DVT happened
postpartum and treated with warfarin x 6 mos)
b. Management

History
- How was the previous pregnancy? When did the DVT happen and how was it treated? Have you had any clotting
episodes other than that? Do you have any calf pains? Shortness of breath? Recent long immobilization? Any
other bleeding problems (in the family)?
- Contraception? Periods? Are they longer? Do you bleed heavily during your periods? Blood group?
- Rubella status (vaccinate and avoid pregnancy for 3 mos)?
- FHx of bleeding disorders?
- SADMA?

Management
- Since you had a previous history of clotting during your first pregnancy, you have a high risk of having another
one. Pregnancy itself is a hypercoagulable state because of the physiological and hormonal changes. Your
pregnancy will be monitored by a physican and obstetrician and GP.
- Before you get pregnant I would like to do some tests to exclude a group of disorders that can predispose to
clotting. This is known as thrombophilia screening. There are 7 things in this screening: Protein C & S, factor V
Leiden, antithrombin III, anticardiolipin, antiphospholipid antibodies and anti-lupus anticoagulant
- Rubella vaccination if not yet immunized
- Start taking folic acid 0.5mg OD 3 months before pregnancy and up to first trimester of pregnancy
- During pregnancy, you would be managed by a team.
-
We will start you on LMWH on the 14th week of gestation as a prophylactic measure until 6 weeks post delivery.
- It’s advised to wear elastic compression stockings during the day and avoid immobilization
- Labor will be in a controlled manner at 38-39 weeks. On the planned date, we will withhold the morning dose of
heparin. After labor, warfarin would be given for 6 weeks (safe in breastfeeding) and we will monitor INR everyday
to begin with (INR 2-3).
- If thrombophilia screen is positive: lifelong warfarin

Critical issues: failure to do thrombophilia screen; failure to advise LMWH during pregnancy; and failure to advise about
warfarin use in pregnancy

5. Pre-Pregnancy Counseling of Obese Women

Case: You are a GP and a 30-year-old female came in because she has been trying to conceive for the last 12 months. She
wants your advice on that matter. Height 1.5m, BMI 40, BP Normal, BSL Normal

Task
a. History not more than 3 minutes (periods irregular, 5-6 weeks pain, stable partners, pap smear 1 year ago, junk
food, no exercise)
b. Counsel & Advise Accordingly

Infertility
- >12 mos: investigation
- >24 months: infertile

Hx
1. Complaint- Difficult to conceive? Any special concern? Any sign of pregnancy like missed period, sickness, breast
tenderness?
2. pregnancy- ever pregnant before even with any previous partner? How is yr period? Normal, *any pain? any heavy
bleeding, bld clots? On any contraception? any miscarriage before? Any PCOS irregular periods, acne, abnormal hair
growth, Diabetes, USD many cysts in ovaries etc?
3. Partner – stable relationship, sexual frequency? Any STI in both? Aware of optimal time for sex to conceive?
4. last pap smear- when? Normal?
5. Obesity – recent Wt gain? Or since when? Ever checked BSL, BP, lipid, USD, TFT? Any impact on your life like joint
problem, emotional, social impacts?
6. General health? Any medical conditions DM, thyroid problems like recent change in appetite, weather preference? any
Sx esply in your genital tract or lower tummy? Any other medication s/a ( steroid, anti-psychotic, pills )? SADMA?

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7. FHx: overweight? infertility? Gyne problems? miscarriages? Any problems in pregnancy & labour s/a ( difficult delivery,
CPD )?

Counseling

BMI normal 18-24. > 24- 29 - overweight, 30- 35 – obesity. > 35 Morbid obesity  obesity-related problems (heart disease,
DM, hypertension, stroke, joint problems, sleep apnoea, stress or depression). menstrual irregularities, problem with
ovulation & fertility

During pregnancy, GDM, PIH, sleep apnoea, IUGR

During labor, difficult labour, shoulder dystocia, Non-progress of labor, Obstructive labor, higher chance of CS & its C’, more
fat  difficult to give pain relief, difficult to monitor fetal HR and activity (fat obstructs signals), difficult to give epidural
anesthesia to predict effects of medication.
After labor, wound infection, Clotting problems, Postnatal depression (more common)

Mx
 very important for you to start losing weight now. Please bring your partner next time to discuss.
 Set a goal: to lose 5-10% of BW in 6-12 mos
 Make dietary changes – refer to dietitian
 diary of your diet and weight
 Increase energy loss by regular exercise. some written material. Healthy active life style.
 regular follow up

 more frequent AN visits, regular USD to monitor baby’s growth. BSL check at 26 wks and each visit.
 Referral to specialist at 28-34 weeks, for assessment due to higher rate of CS.
 A normal VD is encouraged, planned delivery in a controlled environment under close monitoring by the specialist
obstetrician, facility for CS is ready. Elective CS is preferred as it is hard to do emergency CS since it is difficult to move
patient. more difficult to give epidural anesthesia to predict effects of medication.
 After labour, some meds to prevent clotting.
 Breast feeding – encouraged, helps you to lose weight in addition to benefits of BF.
 Review after delivery and will check wound.
 Reading material, Review

6. Pre-pregnancy counseling of preexisting Diabetes ( HB. Pg 102, cond. 14 )

Case: You are a GP and your next patient is a 24-year-old patient who is a diagnosed case of Diabetes. She wants to
become pregnant and is seeking your advice.
Task a. counsel her about the complications of diabetes on mother and baby.
b.Answer her questions.

Case: You are a GP and your next patient is a 24-year-old patient who is a diagnosed case of Diabetes. She wants to
become pregnant and is seeking your advice.
Task
c. Counsel the patient
d. Answer her questions.

Questions: / to address
- Can I become pregnant like other females? Risks on mother? On baby?
- Effects of pregnancy on Diabetes?
- Do I need some special medications during pregnancy?

History
1. Diabetes - Dx when? Type? by whom? Last seen by specialist? Last bld tests? any events like v high or v low sugar
level? any admission? Any C’ organ C’ like kidney problem, vision, leg, infection? Any inf from down below or
waterworks?
2. Tx- Current Tx? Insulin – type, dose? Good control, monitoring – frequency, results? SE of Tx s/a v low sugar level?
compliance?

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3. Pregnancy plan Q? period Q, any contraception? 1st pregnancy? Any miscarriages? Any FHx of DM, miscarriages?
Bld tests done?
4. Other Ps’- last pap smear-when? N? Partner – supportive?
5. General health? Any other medical conditions? Prn SADMA?

Counseling

 **DM & pregnancy- able to have kids.

 ** prepregnancy counselling about risks & Mx. **Informed decision.

 Assessment of DM. ** Must have very good sugar control even before conception ( HbA1C & bld glucose monitoring )
 ( bld sugar levels within 5-7 mmol/L in 1st trimester to minimize abnormal defects in baby & keep optimum throughout
pregnancy, to minimize C’ like big baby & unexplained fetal death, respiratory distress after birth and maternal C’ like
preeclampsia & polyhydramnios. Despite good control, risks still present. )

 DM Physician – assessment of general state & target organ damage – peripheral neuropathy, kidney ( RFTs & 24 hour
urine protein ),Fundi check by Ophthalmologist.

 DM: HbA1c <7 for last 3 months before conception.

 If all of these are normal, **Folic acid 0.5-1mg from attempt to pregnant until at least mid-gestation.
 **Even before pregnancy, do routine antenatal tests s/a bld group, indirect Coomb’s test, FBE, hepatitis screening,
VDRL, Rubella serology, MSU etc & if abnormal, Tx before conception. Pap smear if not done.

 Pregnancy - Joint care by Obstetrician & DM physician, Dietitian etc,

 Insulin – need higher dose in pregnancy, will return to pre-pregnant dose within 24 hrs after delivery.
 To keep bld suger levels betn 5-7 mmol/L to minimize C’ like fetal defect & big baby.
 USD – 12, 18 wks to check defect, 32 wks to detect big baby ( macrosomia ).
 Iron & folic acid throughout pregnancy.
 Delivery – well planned delivery, at 37-38 wks, earlier if problems.
 Reading materials, review, referral, etc.

Critical errors
Failure to advise pre-pregnant counselling that even before pregnancy, good sugar control to minimize malformations, To do
tests & to give folic acid even before pregnancy.

DISORDERS in PREGNANCY

Gestational Diabetes ( HB cond 97, pg 526 )

Case: Your next patient in GP practice is a 34-year-old woman who is 28-weeks pregnant. She returns to you for the results
of the OGTT with 75 grams of oral glucose load done 2 days ago. The fasting BSL – 7.5 mmol/L ( N < 5.5 mmol/L ), and
BSL 9.5mmol/L (N<8mmol/L) after 2 hour. Pregnancy so far normal.

Task
a. Further history (FHx of DM, regular PNCU, no symptoms of DM)
b. Explain the results
c. Examination (FH, FHT +, cephalic)
d. Diagnosis and outline management
( OGTT / sweet drink test. How to do - After fasting for 6 -8 hours, oral glucose load and then measure the blood sugar
levels at 1 and 2 hours. )

Hx
1. Pregnancy - How is your pregnancy so far? 1st pregnancy? regular AN visits? Any abnormal in tests? 18 wk USD
result? Blood group? Baby- kicking well? Pregnancy progress? Do you think your tummy is more distended than
expected? Any previous miscarriages? any headache, frothy urine, or blurred vision?
2. Diabetes – any Dx of diabetes before? Polyuria, polyphagia? Recurrent inf, thrush/candidiasis? Inf of Waterworks or
down below? Any FHx of diabetes?
3. General health? Any other health problems? Surgery? SADMA?
4. Periods- normal? Last pap smear –N? partner- supportive, stable relation? Support at home?

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PEFE
1. General appearance: BMI, oedema
2. Vital signs – T’.
3. If chest and heart are normal, I will proceed to obstetric exam – FH, SFH, fetal lie & presentation, floating / engaged,
FHS.
4. Pelvic examination: discharge, thrush, spotting/blood.
5. Urine dipstick - proteinuria, BSL.

Mx

 Results are Confirmative of Gestational Diabetes.

 Other invx - HbA1c, USD, CTG, FBE, urine MCS, etc.

 From the results of OGTT, I suspect you have a condition called gestational diabetes = very high bld sugar level in
pregnancy.
 Cause – certain chemicals released in pregnancy ( prn. placenta – produces Human placental lactogen (HPL)
progesterone and beta-hCG, and cortisol ). All these chemicals have anti-insulin effects, increasing the bld sugar level.

 Risks on mother and baby.

 Reassure. Effective Mx and monitoring can minimize risks.
 MDT ( diabetic physician, obstetrician, dietitian and diabetic educator, GP, others prn )
 Ophthalmologist to check fundi and kidney specialist for kidney function ( RFT, 24hr urine protein (microalbuminuria).
 Our main aim is to maintain the BSL at less than 7mmol/L by dietary modifications.
 Monitoring -measure BSL 3 -4 times a day, esply 2 hours after meals. Diary of BSL.
 Special diet. If diet cannot control, insulin.

 Major risks & Mx are;

 Risks to mother – preeclampsia – regular monitoring.
 Baby – big baby ( macrosomia as high sugar levels cross the placenta to the fetus while insulin cannot cross ).
Jaundice, more risk of IUGR, unexplained fetal death, premature delivery, prematurity and respiratory distress $. risk
of low sugar level in newborn due to increased insulin.

 Baby -1.Macrosomia - USD – 32 – 34 wks to detect. If macrosomic, may deliver by CS.

 2.IUFD – from 32 -34 wks, CTG to monitor the baby. Twice a week if on insulin, macrosomic or polyhydramnios.
 3.Respiratory distress $ / Hyaline memebrane disease – try to delay induction until after 37 wks. ( steroid worsen sugar
control. )

 Delivery – planned delivery at term (38 weeks) at latest. Earlier if C’.

 Continuous CTG during labour.
 Control good sugar level with intermittent insulin injections during labor.
 CS if macrosomic, breech presentation, or fetal distress.

 Will I remain diabetic? The diabetes will resolve after delivery. However, increased chance of recurrence in succeeding
pregnancies and 30% risk of developing DM later in life  follow up OGTT 6-8 weeks after delivery and to be checked
2 yearly (every 5 years in clinical book). Control weight gain.
 Red flags: uterine contractions, leaking of water, BPV, baby not kicking well, inf etc.
 Reading materials, review, partner.

Pregnancy induced hypertension, Preeclampsia, Eclampsia

Pregnancy-Induced Hypertension/Pre-eclampsia

Key points – BP Dxtically high  PIH + features of preeclampsia +  PE + fits  Eclampsia

Tx : if fits  tx as fits –lateral position, airway, suction, Bz IV / PR, MgSO4, antiHT, deliver asap
Anti HT  if BP > 170  IV Hydralazine / Sodium Nitroprusside / Labetolol
If PIH with BP not much high - MethylDopa, Nifedipine

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Remember to read HB, and RANCOG Def and Tx guidelines. ( HB – cond , pg 522 ) SOMANZ-Hypertension-Pregnancy-
Guideline-April-2014.pdf

Case: GP,

Case: You are a GP and a 30-weeks-pregnant primigravida comes to your clinic. She is complaining of headache. Her BP
today is 170/110mmHg. It was the same on a previous occasion.

Task
a. Relevant History
b. Manage the case

History
- Is my patient hemodynamically stable? all the vital signs?
- I would like to give the patient methyldopa now.
- If she develops fits while talking rectal diazepam 5-10 mg
- I would like to ask some history from the patient. Please tell me if you’re having symptoms like headache, BOV,
tummy pain, or bleeding from down below? Any abnormal feelings that you have (derealization)? Do you feel the
baby kicking? Have you noticed any leaking from down below? Any swelling of your ankles? Have you had all
regular antenatal checkups? USD? Blood tests? Sweet test? Are you generally healthy? Any medical or surgical
condition? Before this pregnancy, have you ever been diagnosed with high blood pressure, kidney problems, DM
or any other conditions? FHx of similar condition? SADMA? Blood group!

Physical Examination
- General appearance
- Vital signs
- Evidence of pedal edema (pitting or non-pitting)
- Funduscopy for bulging of the disc
- Chest and heart
- Abdomen (FH, lie/presentation, FHT, tenderness)
- Reflexes
- Urine dipstick and BSL

Management
- left lateral position, call for help.
- Check the airway. if secretions, suction / wipe with clean cloth.
- Put guedal airway. oxygen by mask if possible.
- IV access. IV Magnesium Loading dose 4gms over 15 minutes diluted with NSS and continue with 1 gram in
divided doses over 24 hours.
- IV hydralazine (5-10mg bolus given over 5-10 minutes then infusion of 5mg/hr.
- Aim BP between 140/90 and 160/100; add beta-blocker if with tachycardia) after the patient has been seen by the
specialist.
- At GP clinic  methyldopa or nifedipine spray to lower BP
- I would inform the obstetric team to organize for immediate delivery.
- monitoring: vital signs, urine output, reflexes, continuous ECG,
- invx: FBE, U&E, LFTs, coagulation profile, thrombophilia screening, blood grouping and cross matching, USD,
CTG,
- Aim of treatment: prevent development of fits
- Aim of treatment if with fits: deliver the baby
- If < 34 weeks, steroids Betamethasone (Celestone) 11.4mg IM 2 dose 12 hours apart.
- stabilize patient, and monitor all symptoms. The patient remains at the hospital for observation. If symptoms
worsen, we deliver by CS.
- If pregnancy is more than 34 completed weeks, deliver by induction or cesarean section.
- If low platelets  give FFP
- If pulmonary edema  high-flow oxygen and diuretics.
- Complications: ARF, cardiac failure, cerebral hemorrhages, DIC, IUD, HELLP syndrome,

Counseling of mom
- What your daughter has had just now is a fit as a consequence of a very high blood pressure. This condition is
known as PIH. This can happen because of certain chemicals that are released by the placenta that cause

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constriction of blood vessels and formation of clots because of reduced supply to the brain resulting to the fit. It is
very important to control the symptoms to prevent complications like liver failure, heart failure, and kidney failure.
That is why we are sending her to the hospital right away. She will be seen by a specialist OB. They will lower her
BP with medications, but the cure is to deliver the baby.

MEDICAL CONDITIONS IN PREGNANCY

Pregnancy plus Cardiac Murmur

Case: You are a GP and a 32-year-old 10- week (or 20-week) pregnant lady came in due to shortness of breathing. She is a
primigravida.

Task

a. History (1st pregnancy; noted SOB x 1 month ago with occasional palpitations, no chest pain, especially with
walking, + history of RF 6-7 years old,
b. Physical examination (vital is normal, no thyroid enlargement, no carotid bruits, no rashes or jaundice, chest
normal, apex is normal, tapping, auscultation low-pitch, rumbling diastolic murmur best heard with bell on the left
lateral position; soft, nontender, no hepatosplenomegaly; ankle edema)
c. Diagnosis and management

History
1. short of breath. 1st time? Any doctor / specialist consultation for that? Result? Any tests done? Any Tx before?
Since when? Started suddenly or gradually? Any trigger event before start like cold, change in medication, etc?
progress – remains the same / become worse / better ? how severe now – at rest / sleep / during activities? How
far can you walk ( blocks )? Any Hx of medical d/s like heart problem, asthma, bld d/s?
Other symptoms: fever, cough, noisy breathing, chest pain or tightness? heart - racing or beating irregularly?
2. Heart failure – Can you sleep flat? How many pillows? ever woken up at night SOB? Any swelling of your ankles?
feeling tired? Any tummy discomfort? waterworks?
3. ( psychosocial- support at home? Stable partner? Partner supportive? Any concern at home, finance, baby care
etc? )

4. pregnancy- 1st pregnancy? Planned pregnancy? AN care? Test results? ( How is yr period? Normal, any heavy
bleeding, bld clots? On any contraception? any miscarriage before? Any unusual vaginal discharge or bleeding? )
History of travel?
5. last pap smear- when? Normal? Any STI?
6. General health? Any previous Hx/ FH of HT, DM, heart or lung disease? Any other medication? SADMA?

Physical Examination
7. General appearance – SOB, central / peripheral cyanosis, pallor, J
8. Vital signs: T, Pulse rate & rhythm, BP, RR, SaO2
9. CVS: JVP raised or not?, any visible pulsation, apex beat – displaced, tapping, heaving? Parasternal heave,
palpable P2, thrills, murmur & its features
10. Lungs: basal crepts, any s/ of pl effusion.
11. Abdomen: tenderness, hepatomegaly, spleen, ascites
12. Legs: oedema ankles or presacral.

Dx & Mx

1. According to your history and PE, I suspect narrowing of a heart valve what we called mitral valve stenosis. Mitral
valve is between the upper and lower chamber of the left side of the heart. ( diagram )
Valve Narrow – cannot open fully – disturbing with blood flow.
Many causes – commonly C’ of rheumatic fever. Any Hx of Rheumatic F before like Fever with skin rash & jt pain?

2. Cardiologist for further assessment.

3. ECG and echo to confirm Dx and assess the severity and heart function. Other tests s/a FBC, UEC, BSL, Lipid,
Urine, etc

4. Pregnancy - significant changes in circulation (increased blood volume) so your heart will need to work harder 
may worsen your condition like getting heart failure.

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Heart disease will not be transferred to baby.

5. Reassure. high-risk pregnancy clinic. Obstetrician, cardiologist, and GP. ? midwives

6. more frequent follow-ups and the cardiologist will make a decision on Mx a/t the severity.
7. NYHA classification for Heart Failure ( New York Heart Association )
 I – no symptoms but with signs of cardiac damage
 II – symptoms with physical exertion; dyspnea, SOB, palpitations, tiredness; usually treatment not required in
pregnancy; monitor for deterioration
 III – asymptomatic at rest, symptomatic with minimal physical exertion; treatment required
 IV – symptomatic at rest; admission to hospital for treatment
 If heart failure, can use same drugs (beta-blocker, digoxin, diuretics) as non-pregnant women except ACEI.

8. Most women - easy spontaneous labor vaginally. no indication to induce labor.

9. During labor, on your side or well-propped up to avoid compression of the major vessels (aorta), marked fall in BP.
If delay in 2nd stage, will assist with instruments (forceps/vacuum).
10. If required to stimulate womb contraction, oxytocin is the preferable one.
11. Close monitoring during the delivery and after.
12. Do you have any questions? RRR…

Anemia in Pregnancy

Case: You are a GP and a 28-year-old G4P3 20 weeks’ pregnant lady has come to see you to know the results of the recent
blood tests. The blood tests hemoglobin is low, MCV is low, transferrin is high, ferritin is low.

Task
a. History ( various scenarios – multiple preg with inadequate gaps / vegan etc )
b. Physical examination
c. Diagnosis and Management

History
- Anemia: Hgb <110g/L in 1st trimester, <100g/L in late second or third trimester.
- Iron requirements increased to ( 1300mg/day. )
- Anaemia is Reduced level of blood pigment to deliver oxygen so the tissues get less oxygen.
- In your case, due to deficiency of iron which is main raw material for blood pigment. Called iron deficiency
anemia. Many causes. Let me ask u few Qs?

1- Anaemia – effects – tired, malaise, dizzy, heart-racing, SOB? Baby- kicking well? Pregnancy progress?
2- Pregnancy - How is your pregnancy so far? regular AN visits? Any abnormal in tests and USD? Blood group?
3- Anaemia Causes - Previous pregnancies? Intervals between? Ages of the children? When was your last pregnancy?
any blood loss?
4- Your usual diet? any special diet e.g vegan? Any other health problems?
5- Periods – frequency, heavy, any clots? abnormal bleeding from anywhere else e.g piles? Any blood d/s or blood
thinning medications? Any FH?
6- Last pap smear –N? partner- supportive, stable relation?

PEFE
1- General examination: pallor, jaundice, skin bruising
2- Vital signs: postural drop
3- Lungs – basal crepts
4- Cardiac: murmur (systolic flow M2 d/t hyperdynamic circulation in anaemia )
5- Abdomen: FH (check for IUGR), abdomen soft or tense, FHS
6- With pt’s consent, Pelvic examination: bleeding, discharge & PR- any piles
7- Urine dipstick for RBC, inf and blood sugar

Dx

 Anaemia is reduced level of blood pigment to deliver oxygen so the tissues get less oxygen.
 In your case, due to deficiency of iron which is main raw material for blood pigment. Called IDA.
 IDA - most common cause of anemia in pregnancy. often no symptom and detected on screening as in your case.
 Normal - higher demand of iron during pregnancy & blood loss in labour.

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 Imbalance betn iron demand and intake  IDA. Many causes s/a inadequate intake, bld loss, inadequate gap between
pregnancies like in your case, most likely. Gap should be adequate to recover body iron store and to meet higher
demand due to pregnancy & blood loss in labour..

 Effects on you and baby as less supply of oxygen to tissues.

 Mother - More risks of infections, heart failure.
 Baby - IUGR, fetal distress and in severe cases, stillbirth.

Mx
 iron supplements. 200 mg 2x daily. Some SE like nausea, tummy discomfort, black stool, and constipation. Will
continue medications 3 months after your blood pigment levels become normal.
 Will monitor Hb = blood pigment level – should rise by 1gm/L per week.
 Parenteral iron indications: if close to delivery and if cannot tolerate oral iron and Hgb <7g/L
 Eating a lot of vitamin C rich foods to increase absorption of iron;
 eat more iron-rich foods such as liver, green leafy vegetables, iron-fortified food like cereals, milo, ovaltine, nuts etc.
 Red flags – SOB, palpitation, fetal not kicking well, etc.
 Review after 2 weeks. Refer if not Hb increasing. Reading material.

Asthma in Pregnancy

Case: A 26-year-old female who is 20 weeks pregnant comes to your GP clinic complaining of SOB.

Task
a. History (had mild asthma and use ventolin PRN; sudden, fever; with wet cough; greenish or yellow; ex-smoker and
partner is a smoker)
b. Physical examination (in distress; audible wheeze, BP 120/80; T:38, RR26, O2 93, HR 100; RR increased;
increased work of breathing, retractions, increase vocal fremitus in right lung base; dullness on right lung base and
decreased air entry on right lung base and diffuse wheezing; FH 20cm, FHT 140, uterus soft and non-tender)
c. Diagnosis and management

Differential Diagnosis
- Pulmonary embolism
- Asthma exacerbation
- Spontaneous Pneumothorax
- Heart failure

History
1. short of breath. 1st time? Any doctor / specialist consultation for that? Result? Any tests done? Any Tx before? 
Asthma.
2. Asthma – since when? Last seen by specialist? Attacks – how often, Tx? Any admission, ICU, intubation? any
precipitating factors (smoking, cold air, exercise, dust, pollen, chest infection)? Tx- what, dose, control, SE?
3. Other symptoms: History of travel? fever, shivering? cough, phlegm, color? blood in phlegm? noisy breathing /
wheezy chest? chest pain or tightness, any change with breathing in? Calf pain or swelling? heart - racing or
beating irregularly?
( Any N/ V? tummy pain? Can you sleep flat? ever woken up at night SOB? Any swelling of your ankles? )

4. General health? Any diseases like heart disease, HT, DM? FH of asthma? Any other medication? Smoking / air
pollution, dust, pollens at home, ADMA?
5. pregnancy- 1st pregnancy? Planned pregnancy? AN care? Test results & USD?
6. ( How is yr period? Normal? previous contraception? any miscarriage before? ) Any unusual vaginal discharge or
bleeding?
7. ( last pap smear- when? Normal? Any STI?
8. psychosocial- support at home? Stable partner? Partner supportive? Any concern at home, finance, baby care
etc? )

PE
- General appearance – can speak, cyanosis; respiratory distress s/a accessory m/s working, attached to O2
- Vital signs – T, PR, BP, RR, SaO2
- If ENT –normal, I will proceed.
- Chest: distress, effort of respiration, s/ of infn, pleurisy

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o RR, use of accessory muscle; chest expansion reduced?,

o Change in vocal fremitus, percussion notes, air entry equal? vocal resonance
o VBS / any BBS, rhonchi – expiratory +/- inspiratory, crepts –course ( which change with cough )
o Peak-flow meter, sputum pot
- Heart – any s/ of heart failure.
- Abdomen: FH, uterus – soft, non tender, FHS.
- BSL, ECG, urine dipstick

Mx
- According to your history and PE, most likely an acute asthma attack secondary to chest infection/pneumonia.
- Admission, invx s/a CXR, FBC, ESR, CRP, UEC, bld culture, sputum MCS, urine MCS, BSL etc.
- Tx s/a nebulizer with ventolin, ipratropium to dilate yr narrow airways,
- IV steroids to reduce infln of airways.
- IV broad spectrum antiobiotics to manage infections. s/a ? Benzypenicillin or amoxicillin or erythromycin if with
allergy
- If required, Oxygen, IV fluid hydration.
- Continue monitoring with peak flow meter and clinical response.
- Stay for a few days until we can control your asthma and pneumonia.
- If fever–free for 48 hours, free of asthma symptoms, discharge & Tx as an outpatient.
- Review at GP soon after discharge.
- Will continue antenatal care. RRR.

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