Maternal medical conditions Flashcards
xFprola
General principles
Condition
- diagnosis, sequelae, last flare, treatments, MDT carers
Impact of condition on pregnancy
- risks
- antenatal care
- fetus and neonate
- delivery consideration
- postpartum care
Impact of pregnancy on condition
- risks of flare
- additional investigations
- delivery consideration
- post partum care
Pre-pregnancy counselling
- PMHx - counsel re impacts of condition on pregnancy and impacts of pregancy on condition. Optimise.
- Meds - stop teratogens, counsel re relative safety/benefits of others if appropriate
- FHx - also note congential abnormalities
- Social Hx - smoking cessation, avoid alcohol and other substances. Review occupational hazards. Supports. DV screen.
- Document height, weight, BMI. Address gestational weight gain
- Cervical smear if due
- Antenatal bloods
- Vaccinations - MMR, Varicella, DTaP, COVID-19, HPV, Hep B
- Folic acid (appropriate dose), iodine
- Genetic carrier screening - CF, SMA, Fragile X
- Discuss travel, CMV avoidance if applicable, food safety
- CONTRACEPTION if not ready
Obesity
Risks
Management
Pregnancy care
Risks:
- Maternal - Infertility, GDM, PIH and PET, labour dystocia and CS birth, shoulder dystocia, PPH, perineal trauma, maternal death, VTE, higher procedural complexity, anesthetic complications, postnatal depression, breastfeeding difficulty
- Fetal - miscarriage, fetal anomaly (NTD), preterm birth, growth restriction, macrosomia, stillbirth, NICU admission, childhood obesity
Antenatal:
- MDT = high risk obs, anaesthetics, dieticians, social work
- Limit gestational weight gain 5-9kg
- High dose folate, vitamin D
- Detailed fetal anatomy
- Early OGTT (BSLs if bariatric surgery)
- Growth USS surveillance
- Consider VTE prophylaxis
Intrapartum:
- Tertiary centre with bariatric equipment available
- IOL 39weeks if BMI >50
- IV line (may need USS guidance)
- USS for presentation on arrival
- Consider early epidural and CSE
- CTG (FSE if poor pick up)
- Active 3rd stage (deltoid IM)
- If CS: Senior staff, pannus retraction, Alexis-O, consider suprapannus incision, higher dose cefazolin, PDS for sheath
Postnatal:
- Early mobilisation
- Weight adjusted clexane for VTE prophylaxis
- Breastfeeding support
- Contraception
- PND screen
- Weightloss support - refer for bariatric surgery
Rheumatoid arthritis
Periconceptual
Antenatal
Intrapartum
Postnatal
Risks, management
Periconceptual:
- Counsel risks: >50% improve in pregnancy, 90% flare PP. Atlanto-axial subluxation if GA (rare), PTB, IUGR, impacts of medications, GDM if on steroids, neonatal SLE if anti-Ro/La,
- Review meds: Azathioprine, hydroxycholorquinine, sulfasalazine okay. Biologics okay but avoid in late 3rd trimester (neonatal suppression effect). NSAIDs okay in 2nd trimester. Stop MTX and defer for 3months
- Anti Ro/La screen
Antenatal:
- MDT: High risk obs, rheumatology, obs physcians, anaesthetists
- Review joints
- BSL monitoring if on prednisone
- Monitor Hb and supplement
Intrapartum:
- Aim vaginal birth
- Sress dose monitoring if on prednisone
- Mindful of maternal positioning (hips)
- Alert anaesthetics (risk of axial/atlantosubluxation)
Postpartum:
- Re-establish medications
- Monitor for flare
- Breastfeeding support (meds dependent)
- VTE prophylaxis
- Contraception
How do you manage a pregnancy concieved on MTX?
- Review reason for MTX
- e.g. RA, dose, timing
- Assess disease control
- Counsel: embryotoxic - risk miscarriage, fetal anomly in particular NTD. May also be healthy.
- Offer TOP
- Stop MTX - refer MDT and review other meds as alternatives
- Refer to MFM
- High dose folic acid
- Early anatomy USS
Postpartum: Consider switch back if needing for disease control, avoid breastfeeding, LARC and stop 3months prior to future pregnancy
Differential diagnosis for worsening SOB in pregnancy
- Physiological
- Anaemia
- Anxiety
- Multiple pregnancy
- Polyhydramnios (including TTTS)
- PE
- Pulmonary oedema (with PET)
- Cardiomyopathy
- Aortic dissection
- Arrythmia
- Infective (pneumonia, influenza, COVID-19, varicella)
- Asthma flare
- Pneumothorax
- Thyroid disease
VTE
Risk factors
Pre-existing, antenatal
Pre-existing:
* Previous VTE
* Known thrombophilia - heritable or acquired
* Medical comorbidities - malignancy, heart failure, active SLE, IBD, nephrotic syndrome, T1DM with nephropathy, sickle cell, current IVDU
* Age >35
* BMI >30
* Parity >/=3
* Smoking
* Gross varicose veins
* Paraplegia or other reason for immobilisation
Antenatal:
* OHSS
* Multiple pregnancy
* PET
* Hospitalisation, immobilisation
* Prolonged labour
* PPH >1000mL
* Caesarean birth
* Surgery in pregnancy or peurperium
* Stillbirth
Suspected PE in pregnancy
Investigations and management
Investigation:
* FBC, coags
* Thrombophilia screen: Protein C and S, antithrombin III, prothrombin gene mutation, factor V leiden, APL antibodies (Repeat outside of pregnancy)
* ECG
* CXR
* ABG
* CT-PA if unstable, VQ not available or CXR abnormal
* Otherwise VQ scan
* USS lower limbs only if symptoms
Management:
* ABCs
* Apply oxygen - high flow
* Transfer to appropriate location
* MDT - high risk obs, haematology, ICU, anaesthetics
* Anticoagulation - LMWH vs UFH if unstable
* Consider: thrombolysis or thoracotomy and clot retrieval if massive
PE in pregnancy
Intrapartum, postpartum
Intrapartum:
- Deliver tertiary centre
- Consider IOL to time anticoagulants
- Stop LMWH 24h prior
- Consider switch to UFH if higher risk
- Anaesthesia: avoid regional if <24h after LMWH. Utilise PCA. May need GA.
- IV line, up to date CBC and G&H (2units X-matched), check APTT
- Remain hydrated, utilise TEDS and SCDs
- Active 3rd stage, prepare for PPH
- Surgical considerations: drains, interrupted subcut suturing, staples
- Protamine sulphate on hand
Postpartum:
- Caution re epidural removal
- Re-start anticoagulation at least 6weeks duration (MDT discussion with anaesthetics, haematology)
- Repeat thrombophilia screen if applicable
- Breastfeeding support
- Contraception (avoid COCP)
- Consider future pregnancy
Counsel a patient about risks and benefits of CTPA
Risks:
* Significantly more radiation exposure to breast tissue than VQ scan - lifetime risk of breast cancer increased by 14%
* Theoretical risk neonatal hypothyroidism if given iodine (recent studies suggest maybe not)
Benefits:
* Low radiation dose to fetus
* Quick and readily available
* Utility if abnormal CXR: can diagnose other abnormalities e.g. pneumonia, pulmonary oedema, aortic dissection
* Can breastfeed
Counsel a patient about risks and benefits of VQ scan
Risks:
* Slightly increased risk of childhood cancer
* Unable to breastfeed for 12 hours after scan.
* Less accurate if CXR abnormal
Benefits:
* Substantially less radiation to breast tissue
* Negligable radiation exposure
* Good at diagnosing peripheral PE
* Lower rate of non-diagnosis as less prone to suboptimal image quality/artefacts
A patient is diagnosed with Cushing syndrome from adrenal source and is treated. How do you counsel her in pregnancy?
Risks:
PTB
IUGR
Stillbirth
GDM
HTN and PET
Excessive weight gain
Neonatal adrenal insufficiency
CS infection
Management:
BP surveillance
OGTT
Dietician
Growth USS
Aim VB
Treatment - adrenalectomy > medication
Type 1 DM
Periconceptual
Antenatal
Delivery
Postnatal
Periconceptual
* Counsel risks: higher if poorly controlled - infertility, miscarriage, fetal anomaly (cardiac, NTD, sacral agenesis), PTB, HTN, PET, stillbirth, IUGR, LGA, shoulder dystocia, CS, progression of pre-existing disease, neonatal hypoglycaemia
* Optimise HbA1c - aim <48
* High dose folic acid
* Screen retinopathy, nephropathy - baseline urine ACR, CBC, Renal
* Ascertain if hypo awareness
Antenatal
* MDT - high risk obs, endocrine/diabetes/obs physicians, dietician, anaesthetics
* Aspirin from 12weeks
* Detailed fetal anatomy scan + echo, uterin artery doppler
* PET screen
* Growth surveillance - USS 28, 32, 36weeks
* Monitor BSL and insulin requirements - expect to rise, but risk of hypo in T1. Notify if falling
* Sick day advice
* HbA1c each trimester
* Screen re mental health
Delivery
* Aim VB. CS if LGA >4.5kg
* IOL 38weeks
* Insulin/glucose infusion
* CTG
* Active 3rd stage
Postnatal
* BSL monitor, alter insulin
* Neonatal BSL checks
* Breastfeeding support
* VTE prophylaxis
* Contraception
* Diabetes team follow up
How do you manage DKA in pregnancy?
- Admit to HDU
- MDT
- Screen for cause/trigger and treat
- Insulin infusion +/- dextrose
- Aggressive rehydration
- Correct electrolytes, especially K+
- Hourly BSLs, ketones
- 2 hourly VBGs
- Fluid balance - monitor UO
- Fetal monitoring - CTG (may be abnormal until maternal stabilisation)
- If need to deliver, stabilise maternal status prior
- Follow up - sick day education, BSL and ketone monitoring, MDT
SLE
Periconceptual
Antenatal
Delivery
Postnatal
Periconceptual
* Counsel risks - higher if untreated or flare <6months. Miscarriage, early onset FGR, PTB, HTN, PET, VTE, Stillbirth, neonatal lupus.
* Review medications usually benefit > risk but NOT for methotrexate. Continue hydroxychloroquinine.
* Baseline c3/c4, anti ds DNA, CBC, Renal, LFTs, urine ACR
* Anti Ro/La screen (30% have - if present 5% risk cutaneous lupus and 2% risk CHB)
Antenatal
* MDT - high risk obs, rheum, anaesthetics
* Aspirin (LMWH if APLs or prev VTE)
* Fetal heart auscultation if Anti Ro/La weekly from 16weeks
* FAS + uterine artery doppler
* Growth surveillance from 24weeks
* BP, PET surveillance
* Screen for flares
Delivery
* Aim VB
* IOL 38+
* CTG
* Active 3rd stage
* Hydrocortisone if high dose/long term steroids
Postnatal
* Neonatal review
* Breastfeeding support
* VTE prophylaxis
* Contraception
A patient has had a history of IHD and is in early pregnancy. How do you counsel?
History - timing of event, context, diagnosis, intervention, ongoing management, current exercise tolerance
Counsel re risks - recurrence, progression of CHD in pregnancy, maternal mortality, impact of medications, PTB, IUGR
Review medications
Baseline echo
Modify RFs
Pregnancy - MDT, echo if concerns, growth surveillance, aim VB but if poor exercise tolerance or repeat event late 3rd trimester CS recommended
Postpartum - HDU monitoring, VTE prophylaxis, contracetion, breastfeeding support
How can you differentiate an SLE flare from PET in pregnancy?
Active <6m prior to conception - more likley SLE
Concurrent SLE symptoms - more likely SLE
Timing <20weeks - more likley SLE
Casts on urine microscopy - more likely SLE
Thrombocytopaenia - can happen for both
Urate low - less likely PET
Anti ds DNA rising from baseline - more likely SLE
Falling complement levels from baseline - more likley SLE
Seizure - may happen in both
Renal biopsy is definitive but not done in pregnancy
An alpha thalassaemia trait is diagnosed in a preconceptual work-up. How do you proceed?
- Ascertain mutation
- Ascertain partner’s status
- Consider PIGD or donor gamete with screening prior
- In pregnancy: NIPT for fetal genotype, amniocentesis to confirm if will change management
- Screen Hb, only supplement Fe if low
Beta thalassaemia
Periconceptual
Antenatal
Delivery
Postnatal
Periconceptual:
* Counsel risks - inheritance, worsening anaemia, IUGR, PTB, CS for CPD
* Test partner, consider PIGD or gamete donation
* Aggressive Fe chelation, stop 3m prior to pregnancy
* Screen re Fe overload - TFT, echo, ECG, cardiac MRI, LFTs, liver USS, DEXA scan, fructossamine,
* RBC antibody and hepatitis screen
* High dose folate
Antenatal:
* MDT - high risk obs, MFM, haematology, anaesthetics, paediatrics, genetics
* High dose folate
* Fe only if low
* Aspirin if splenectomy and plt count >600
* Fetal genotype if at risk - NIPT or CVS/amniocentesis
* Growth surveillance
* Fructossamine or BSL monitoring - HbA1c less reliable if transfusion dependent
* Consider chelation after 20weeks
Delivery:
* Aim VB
* CTG
* Active 3rd stage
* IV desferrioxamine
Postnatal:
* Breastfeeding support
* VTE prophylaxis
* Contraception
Essential HTN
Periconceptual
Antenatal
Delivery
Postnatal
Periconceptual:
* Counsel risks - progression of HTN, renal disease, cardiomyopathy, ACS, stroke, CS delivery, PET, miscarriage, stillbirth, PTB, IUGR
* Review if underlying cause or not
* Baseline urine PCR, renal, LFTs, CBC, HbA1c, lipids
* Adjust meds
Antenatal:
* MDT - obs phys, high risk obs, anaesthetics
* Aspirin/Ca from 12weeks
* UtA doppler with FAS
* Serial BP checks, PET screens
* Treat BP to remain <140/90
* Growth USS 4weekly from 28weeks
Delivery
* Aim VB
* IOL 39weeks
* CTG
* Analgesia - epidural to optimise
* Active 3rd stage - avoid syntometrine
Postnatal
* BP monitoring
* Adjust meds
* Breastfeeding support
* VTE prophylaxis
* Contraception
Myasthenia Gravis
Periconceptual
Antenatal
Delivery
Postnatal
Periconceptual:
* Counsel risks - course unpredictable (40% relapse, 30% improve, 30% no change), early pregnancy changes may reduce medication efficacy, risk fetal arthyrogyroposis, transient neonatal MG
* Optimise pre pregnancy, consider thymectomy
* Review meds, stop teratogens
Antenatal:
* MDT - high risk obs, anaesthetics, neurology, paeds
* Continue pyridostigmine, alter dose frequency
* Clear documentation of medications to avoid incl aminoglycosides, Bblockers, MgSo4 (may cause a crisis!) anaesthetic drugs
* Monitor TFTs
* Detailed USS if reduced FMs, polyhydramnios
Delivery:
* Aim VB
* Early epidural
* May need AVB if exhausted
* Give meds IV, stress dose hydrocortisone if long term steroids
Postnatal:
* Observe neonate for 48hrs
* Breastfeeding support
* Re-adjust meds if needed
* Thymectomy if not had prior
* Monitor for PP relapse
Rheumatic heart disesase with mitral stenosis
Periconceptual
Antenatal
Intrapartum
Postnatal
Periconceptual:
* Counsel risks - cardiac failure, pulmonary oedema, arrythmia, atrial thrombus, maternal mortality up to 3%, IUGR, PTB, IUFD
* Review function, symptoms, treatment, last echo
* Review meds
* Baseline echo, ECG, CXR
* Contraception and defer if valve <1cm2- vavotomy
Antenatal
* MDT - high risk obs, cardiology, anaesthetics
* Consider TOP if severe
* Echo each trimester
* Avoid high HR to enable LA filling - Bblock, restrict exercise, rhthym control
* Balloon valvotomy if severe
* Growth USS
* Optimise Fe
* VTE prophylaxis
Intrapartum:
* Aim VB
* IOL/schedulled timing to allow for MDT
* Optimise analgesia (avoid high HR)
* Passive 2nd stage
* Telemetry
* Fluid balance
* Avoid supine or lithotomy
* Active 3rd stage (caution re syntometrine and carboprost)
Postnatal:
* Care in CCU/HDU
* Strict fluid balance +/- frusemide
* Telemetry
* VTE prophylaxis
* Breastfeeding suport
* Contraception
* MH screen
* Cardiology follow up
You see a patient with increasing SOB in pregnancy and suspect cardiomyopathy. How do you manage?
Assess:
* History
* Examination - obs, weight, JVP, auscultation ?oedema/effusion, murmur, peripheral oedema
* Investigation - CXR, BNP, ECG, echocardiogram
Management:
* MDT - high risk obs, cardiology, anaesthetics
* HDU/ICU
* Serial echo
* Treat HF - Bblockers, rhythm conrol (digoxin), diuretics (frusemide), vasoidlators (hydralazine, GTN)
* BP treatment
* VTE prophylaxis
* Avoid aortocaval compression
* Delivery - elective, mode depends on tolerance. If VB early epidural, shorten 2nd stage
* Ecbolics - slow oxytocin, avoid syntometrine and carboprost
* Postnatal - strict fluid balance as highest time of deterioration, telemetry, may need inotropes, VTE prophylaxis, contraception, breastfeeding support, 33% recurrence risk, debrief
