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Y4 Obstetrics and Gynaecology > 15 - Medications and Infections in Pregnancy > Flashcards

15 - Medications and Infections in Pregnancy Flashcards

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1
Q

What happens to hypothyroidism in pregnancy?

A

Levothyroxine dose needs to be increased by around 25-50mcg, titrated based on TSH levels aiming for low to normal

Levothyroxine can cross placenta to get to baby

Undertreated hypothyroidism: anaemia, miscarriage, SGA, pre-eclampsia

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2
Q

How should you manage a hypertensive woman who is on medication and then becomes pregnant?

A

STOP

  • ACEis e.g ramipril
  • ARB e.g Losartan
  • Thiazides e.g Indapamide

They can cause congenital abnormalities

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3
Q

If a woman with epilepsy becomes pregnant, how does her epilepsy management change?

A

Before conception: 5mg folic acid daily, switch to single AED

AED: Lamotrigine, Carbamazepine, Levetiracetam

When pregnant seizure control is worse due to added stress, lack of sleep and changes to medication. Seizures do not harm baby bar physical injury

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4
Q

How may the treatment regime in a woman with RA be altered if she becomes pregnant?

A

Ideally should have good symptom control for 3/12 before getting pregnant

Symptoms of RA will get better during pregnancy and may flare after delivery

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5
Q

What are the issues with using the following drugs during pregnancy:

  • NSAIDs
  • B-Blockers
  • ACEi/ARB
A

NSAIDs

  • Need to be avoided as they inhibit prostaglandins
  • Only used in RA
  • Can cause premature closure of ductus arteriosus and can delay labour

B-Blockers

  • Only use labetalol
  • Can cause FGR, hypoglycaemia in the neonate, bradycardia in the neonate

ACEi/ARB

  • Affects fetal kidneys so oligohydramnios
  • Hypocalvaria
  • Miscarriage
  • Renal failure in the neonate
  • Hypotension in the neonate
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6
Q

What are the issues with using the following drugs during pregnancy:

  • Opiates
  • Warfarin
  • Sodium Valproate
A

Opiates

  • Neonatal Abstinence Syndrome: withdrawal 3-72 hours after delivery, baby has irritability/poor feeding, tachypnea, high temp

Warfarin

  • Crosses placenta and is teratogenic
  • Can cause fetal loss, craniofacial abnormalities, PPH, fetal haemorraghe, intrapartum bleeding

Sodium Valproate

  • Neural tube defects and developmental delay
  • Should be on pregnancy prevention programme if on this
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7
Q

What are the issues with using the following drugs during pregnancy:

  • Lithium
  • SSRIs
  • Isotretinoin (Roaccutane)
A

Lithium

  • Avoided especially in first trimester as congenital cardiac abnormalities e.g Ebstein’s anomaly
  • If need to take it should monitor every 4 weeks then every week from 36 weeks
  • Can get in breast milk and is toxic so avoid breastfeeding

SSRIs

  • Risks vs Benefits
  • If used in first trimester risk of congenital cardiac abnormalities, especially Paroxetine
  • If used in third trimester risk of persistent pulmonary hypertension in neonate
  • Neonate can have withdrawals but usually mild

Isotretinoin

  • Highly teratogenic can cause miscarriage and congenital abnormalities
  • Reliable contraception before, during and for one month after use
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8
Q

What is congenital rubella syndrome and how can it be avoided?

A

When a pregnant woman becomes infected with Rubella before 20 weeks gestation. Worse if before 10 weeks

German Measles

If planning to become pregnant check MMR vaccines, if doubt do antibody tests then if negative vaccinate with two doses three months apart

DO NOT VACCINATE DURING PREGNANCY AS LIVE VACCINE!! Get after birth

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9
Q

What are the features of congenital rubella syndrome?

A

Mother is often asymptomatic. If she has symptoms often malaise, headache, maculopapular rash

  • Congenital deafness
  • Congenital cataracts
  • Congenital heart disease (PDA and pulmonary stenosis)
  • Learning disability
  • Microencephaly
  • Blueberry muffin rash
  • Late onset: DM, Thyroiditis, GH abnormalities, behavioural disorders
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10
Q

How is congenital rubella syndrome managed?

A

Luckily very rare due to mass MMR vaccination

Mother: No treatment, Antipyretics, Inform her she is infective from 7 days prior to onset of symptoms to 4 days after

Neonate: see image, if over 20 weeks no issue

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11
Q

What are the issues with chickenpox during pregnancy?

A

VSV can cause in

  • Mother: varicella pneumonitis, hepatitis or encephalitis
  • Baby: Fetal Varicella Syndrome, Severe Neonatal Varicella infection if infected near time of delivery
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12
Q

How do you manage a woman who is pregnant who has had varicella contact?

A
  • Previous chickenpox: no management needed.
  • If no previous chickenpox: Test IgG, if negative, oral aciclovir is now the first choice of PEP
  • For pregnant women at any stage of pregnancy,
    antivirals should be given at day 7 to day 14 after exposure, not immediately.
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13
Q

How do you manage a woman that is pregnant who has chicken pox?

A
  • Aciclovir PO if presents within 24 hours of rash and >20 weeks gestation
  • Counsel about symptoms of pneumonia and haematological rash and tell them to return if have this
  • Refer for serial US scans 5 weeks post infection to look for
  • Consider vaccine AFTER pregnancy
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14
Q

How is Varicella of the Newborn managed?

A

Occurs if infection in last 4 weeks of pregnancy

Transfers via placenta, vagina or contact

Management: VZIG +/- Aciclovir

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15
Q

What are some symptoms of fetal varicella syndrome?

A

Only occurs if infection was before 20 weeks gestation

  • Fetal growth restriction
  • Microcephaly, hydrocephalus and learning disability
  • Skin scarring in dermatomal pattern
  • Limb hypoplasia
  • Eyes: Cataracts, Chorioretinitis, Micropthalmia
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16
Q

What is listeria and why is it dangerous in pregnancy?

A

Gram positive bacteria from unpasteurised dairy e.g blue cheese, and processed meats. Avoid these and practice good food hygeine

Infection in mother may be asymptomatic, cause a flu-like illness, or pneumonia, meningoencephalitis

Listeriosis in pregnant women has a high rate of miscarriage or fetal death. It can also cause severe neonatal infection.

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17
Q

How is CMV transmitted to a pregnant woman?

A

Often through urine or saliva of asymptomatic child

Around 1 in 100 women will get this infection, ⅓ will pass it to the fetus and then 5% of those will have damage from the virus

Risk of damage to fetus highest in first trimester

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18
Q

How is CMV in a pregnant woman investigated and managed?

A

Cytomegalovirus (CMV) in Pregnancy – Basic Summary

Diagnosis: Blood tests for CMV IgG and IgM antibodies, along with IgG avidity testing, determine if the infection is recent.

Fetal Testing: If maternal infection is confirmed, amniocentesis after 21 weeks’ gestation and at least six weeks post-infection can detect CMV DNA in amniotic fluid.

Management: High-dose valaciclovir (8 g/day) initiated during the first 12 weeks of pregnancy may reduce the risk of fetal transmission.

Monitoring: Regular ultrasounds every 2–3 weeks assess fetal growth and detect anomalies. Fetal MRI between 28–32 weeks’ gestation can evaluate brain development.

Newborn Testing: Infants born to mothers with confirmed or suspected CMV infection should be tested within the first 21 days of life using urine or saliva samples.

Treatment: Symptomatic newborns may benefit from antiviral therapy (e.g., valganciclovir) to reduce the risk of hearing loss and improve developmental outcomes.

Prevention: Pregnant women should practice good hygiene, such as regular handwashing, especially after contact with young children’s saliva or urine.

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19
Q

What issues can congenital cytomegalovirus cause?

A
  • Fetal growth restriction
  • Microcephaly
  • Hearing loss
  • Vision loss
  • Learning disability
  • Seizures

20-30% mortality due to DIC, hepatic dysfunction or bacterial superinfection

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20
Q

What is congenital toxoplasmosis caused by?

A

Toxoplasma gondii parasite that is found in cat faeces

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21
Q

How does congenital toxoplasmosis present?

A

Classic Triad:

  • Intracranial calcification
  • Hydrocephalus
  • Chorioretinitis
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22
Q

How is congenital toxoplasmosis diagnosed and managed?

A

Dx: Aminocentesis and test Maternal IgM

Mx: Spiramycin antibiotic

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23
Q

How does parvovirus B-19 present in children and non-pregnant adults?

A

Slapped Cheek Syndrome/Erythema Infectiosum

Starts with non-specific viral symptoms then after 2 – 5 days diffuse bright red rash on both cheeks

A few days later a reticular mildly erythematous rash affecting the trunk and limbs appears, which can be raised and itchy

Infectious 7-10 days before rash appears

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24
Q

What are the issues with Parvovirus B19 infections during pregnancy?

A
  • Miscarriage or fetal death
  • Severe fetal anaemia
  • Hydrops fetalis (fetal heart failure)
  • Maternal pre-eclampsia-like syndrome
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25
What is **maternal pre-eclampsia-like syndrome/Mirror syndrome** and why does it occur?
Complication of hydrops fetalis **Triad of:** hydrops fetalis, placental oedema and oedema in the mother. Also hypertension and proteinuria
26
Why may hydrops fetalis occur during pregnancy after infection with Parvovirus B19?
Parvovirus infection of erythroid progenitor cells in the fetal bone marrow and liver that produce RBCs Faulty RBCs means shorter life span so anaemia. Anaemia leads to heart failure
27
If a pregnant woman is suspected to have been infected/in contact with Parvovirus B19, how is this diagnosed and managed?
**_Dx:_** Check IgM and IgG to PVB19, Rubella antibodies **_Mx_** **Refer to fetal medicine specialist** to monitor for malformations and complications **Serial US** 4 weeks post infection, then repeat every 1-2 weeks until 30 weeks If evidence of fetal hydrops on US, refer to tertiary centre for **intrauterine erythrocyte transfusion**
28
What are some signs of fetal hydrops on ultrasound?
* Ascites * Subcutaneous oedema * Pleural effusion * Pericardial effusion * Scalp oedema * Polyhydramnios
29
What is congenital Zika syndrome?
Spread by Aedes mosquito or sex with infected person * **Microcephaly** * **Fetal growth restriction** * **Other intracranial abnormalities:** e.g ventriculomegaly and cerebellar atrophy
30
What is group B streptococcus infection and what are the issues with this in pregnancy?
Streptococcus agalactiae, usually asymptomatic commensal of the GI and GU system * **Early onset GBS disease of the newborn:** sepsis, pneumonia, meningitis * **Chorioamnioitis or** **endometritis in mother**
31
What are some risk factors for neonatal GBS infection?
* GBS infection in a previous baby * Prematurity \<37 weeks * Rupture of membranes \>24 hours before delivery * Pyrexia during labour * Positive test for GBS in the mother * Mother diagnosed with a UTI found to be GBS during pregnancy
32
What are some clinical features of GBS infection in the newborn?
Pyrexia, cyanosis, difficulty breathing and feeding, and floppiness
33
How is GBS in pregnancy detected?
* **Single swab in vagina and rectum** on enriched culture medium. PCR * **Urine culture** if woman is symptomatic for UTI
34
Is GBS screened for in pregnancy?
Not screened for unless high risk as not all women who screen positive are positive at delivery so unnecessary treatment **_High risk:_** symptoms of UTI or chorioamnionitis in pregnancy, those with STI symptoms previously, previous baby with GBS
35
How is a GBS infection managed to prevent it passing to the newborn?
**High dose IV benzylpenicillin** during labour and delivery Not indicated to give abx if planned C-Section as it is the rupture of membranes that exposes baby to GBS
36
What is the issues with UTI in pregnancy?
If a UTI is not treated during pregnancy, it can lead to serious health issues for both the mother and the baby: **Kidney Infection (Pyelonephritis):** This severe infection can cause high fever, chills, back pain, and vomiting, and may require hospitalization. **Preterm Labour:** UTIs can irritate the uterus, potentially leading to early contractions and premature birth. **Low Birth Weight:** Infections can affect fetal growth, resulting in babies being born with low birth weight. **Preeclampsia:** There's an increased risk of developing this condition, characterized by high blood pressure and potential damage to other organ systems. **Sepsis**: A severe, life-threatening response to infection that can spread throughout the body.
37
People with no urinary symptoms do not usually have a urine dipstick. Why do women who are pregnant have a dipstick even when they have no symptoms?
Screen for **asymptomatic bacturia** and treat it High risk of developing lower UTI and pyelonephritis so need to treat as risk of **preterm birth**
38
How do lower UTIs and pyelonephritis present?
39
How are UTIs in pregnant women treated?
**7 days** of antibiotics either: * **Nitrofurantoin** (avoid in third trimester) * **Cefalexin** * **Amoxicillin** (only when sensitivities known)
40
Why do Nitrofurantoin and Trimethoprim need to be avoided in pregnancy?
**_Nitrofurantoin:_** Avoid in third trimester as risk of ***neonatal haemolysis*** **_Trimethoprim:_** Avoid in first trimester as can cause ***neural tube defects like spina bifida*** as folate antagonist
41
What are some causes of antepartum haemorraghe?
Bleeding from 24 weeks to birth * Placental abruption * Placenta praevia * Vasa praevia * Malignancy or trauma of the genital tract * Infection of the genital tract * Uterine rupture * Inherited bleeding disorder * Gestational trophoblastic disease * Cervical ectropion
42
How is an antepartum haemorraghe managed? (NB)
**Initial Assessment:** Evaluate maternal vital signs and assess fetal well-being. **History Taking:** Gather information on gestational age, bleeding characteristics, pain, and any trauma. **Physical Examination:** Perform an abdominal examination. _Avoid digital vaginal examination_ until placenta previa is excluded via ultrasound. **Investigations:** Order blood tests: full blood count, blood group and save, coagulation profile. For Rhesus-negative women, perform a Kleihauer test to assess fetomaternal hemorrhage. **Imaging**: Conduct an ultrasound to determine placental location and assess for placental abruption. **Classify and Manage:** Minor (<50 ml): Monitor maternal and fetal status; consider outpatient care if stable. Major (50–1000 ml, no shock): Admit for observation; establish IV access; monitor closely. Massive (>1000 ml or any volume with shock): Initiate resuscitation; activate major obstetric haemorrhage protocol; prepare for possible emergency delivery. **Ongoing Care:** Continuously assess maternal vitals and fetal heart rate; repeat investigations as necessary. Plan delivery timing and mode based on maternal and fetal conditions, gestational age, and underlying cause of bleeding. Postpartum: Monitor for further bleeding; administer anti-D immunoglobulin to Rhesus-negative women if indicated; provide psychological support as needed.
43
What are some contraindications to a vaginal exam during pregnancy?
* Preterm rupture of membranes as infection risk * Unexplained PV bleeding as could be placenta praevia so risk of provoking haemorraghe
44
What is Naegele's rule?
Estimate of EDD Add 1 year and 7 days to LMP then subtract 3 months
45
What women need postnatal thromboprophylaxis and for how long?
Four or more risk factors Need for 6 weeks Perform individual risk assessment form
46
What is chorioamnionitis and how does it present?
Infection of the membranes in the uterus * Fever * Abdo pain * Offensive vaginal discharge * Evidence of ROM * Fetal tachycardia * Uterine tenderness
47
How is chorioamnionitis managed?
Treated as maternal sepsis - ADMISSION AND DELIVERY Give **Cefuroxime + Metronidazole IV and continue for 5 days**
48
What is haemolytic disease of the newborn and why is it an issue?
When a rhesus -ve mother becomes sensitised to her rhesus +ve child and produces antibodies that can cross the placenta This could be due to childbirth, obstetric procedure, bleeding Can lead to **Hydrops Fetalis** and **Kernicterus**
49
What are some of the pre and post delivery features of haemolytic disease of the newborn?
**_Pre-delivery_** * **Hydrops foetalis:** foetal oedema in at least two compartments (e.g pericardial effusion, pleural effusion, ascites) * **Yellow coloured amniotic fluid** **_Post-delivery_** * **Jaundice and kernicterus** * **Foetal anaemia** causing skin pallor * **Hepatomegaly or splenomegaly** * **Severe oedema** if hydrops foetalis was present in utero
50
What is foetal blood sampling and when should you/shouldn't you do it?
* Done during labour when there is a suspicious CTG to confirm if fetal hypoxia * Make small incision on fetal scalp transvaginally then collect blood and look for acidaemia * DO NOT do during or immediately after a prolonger deceleration
51
What is a TORCH screen and when is it performed?
Screen for infections when there is **IUGR, Intrauterine Death and Suspected congenital infection** May be taken from mother or from baby after birth
52
How is influenza in pregnant women treated?
All pregnant women should have the flu vaccine If pregnant or up to 2 weeks postpartum and catch the flu give them **Oseltamivir**
53
What is the issue with catching influenza during pregnancy?
* Complications like bronchitis and pneumonia * Premature delivery * Low birthweight * Stillbirth
54
What are two important jabs to have during pregnancy?
* Influenza * Whooping cough (16 weeks)
55
What issues can syphilis cause in pregnancy?
* Spontaneous abortion * Stillbirth * Hydrops * Intrauterine growth restriction * Liveborn infected children
56
When is syphilis screened for during pregnancy and how is it treated?
At booking appointment before 10 weeks HIV, Hep B and Syphillis is tested for Given course of Penicillin Need to test partner to see if they need treating to stop reinfection May need to treat baby at birth
57
If a pregnant woman screens positive for Hep B on her booking bloods, what action needs to be taken?
* Test partner and other children for infection and give them vaccines * Baby will need immediate vaccine and 5 follow up vaccines after birth. This is to stop them getting chronic liver disease
58
If a woman is HIV positive and planning to have a baby what advice should she be given?
Sperm washing may not be best option if male viral load is low
59
If a woman is HIV positive, what measures can be taken to reduce the risk of vertical transmission to the baby?
* **ART** to keep viral load low * **C-Section** * **Avoid breast feeding** * **Give baby Z****idovudine** within 4 hours of birth for first 4-6 weeks of life. Test baby 2 days after birth, 6 weeks, 12 weeks, 18 months Reduces chances of transmission from 1 in 4 to 1 in 100
60
What are the issues with COVID during pregnancy?
* Can be passed to baby once born * May cause more serious illness No evidence to suggest it causes miscarriage or affects baby's development. Encourage all pregnant women to take the vaccine
61
What documentation need to be made at the beginning of a CTG?
* Time * Date * Mothers Name and DOB * Indication for CTG * Mother's HR
62
If a woman is having variable decelerations on her CTG, what measures can be done to try and correct these?
* Lie her on her side * Give fluids
63
If there is a prolonged fetal bradycardia over 3 minutes what needs to be done?
CAT 1 C SECTION DELIVER BABY WITHIN NEXT 9 MINUTES (12 MINUTES TOTAL)
64
Why is methyl dopa not used first line for gestation hypertension?
Takes around 1 week to lower BP Need to stop immediately after delivery as high risk of PP depression
65
Which groups of pregnant women cannot use Labetalol for gestational hypertension?
* Severe asthmatics * Diabetic as hypos
66
Why do you need to take caution when giving diabetic mothers 2 x IM steroid injections for fetal lung maturation?
Can cause their BMs to become erratic

Y4 Obstetrics and Gynaecology (23 decks)

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