Maternal Medicine Flashcards

1
Q

Respiratory Indications for ECMO

A

ARDS
Pneumonia (infectious/aspiration/interstitial)
Severe asthma
Thoracic trauma causing lung contusion
Alveolar or pulmonary haemorrhage
Severe inhalation injury
Air leak syndromes (bronchopleural fistula)
Acute airway obstruction
Lung transplant

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2
Q

Cardiac indications for ECMO

A

Acute MI
Myocarditis
Cardiac arrest
Post heart transplant
Post cardiotomy
Hypothermia with cardiac instability
Postpartum acute cardiomyopathy
Drug intoxication
Septic cardiomyopathy
Arrhythmic storm
Interventional cardiac procedures

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3
Q

When to consider ECMO

A

When estimated mortality is in excess of 50-80% despite optimal medical management

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4
Q

Complications of ECMO

A

Intracranial haemorrhage
DIC
HIT
Bleeding

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5
Q

Hypertrophic cardiomyopathy incidence

A

0.1-0.5% of women

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6
Q

Symptoms/signs of hypertrophic cardiomyopathy

A

Syncope
Chest pain
Ejection systolic murmur
Pan-systolic murmur
Heart failure
Arrhythmias

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7
Q

Treatment of hypertrophic cardiomyopathy in pregnancy

A

B-blockers

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8
Q

Incidence of sarcoidosis in pregnancy

A

1 in 2000

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9
Q

Sarcoidosis site involvement

A

Lungs (1st)
Skin (commonest extra-pulmonary)
Heart (50%)
Brain
Eyes
Joints
Liver (20% hepatomegaly)

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10
Q

Pulmonary sarcoidosis presents as

A

Interstitial lung disease with fibrosis 20%
Pulmonary hypertension

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11
Q

Skin manifestations of sarcoidosis

A

Granuloma (lupus pernio)
Erythema nodosum
Erythema multiforme
Nummular eczema

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12
Q

Rate of myocardial infiltration with sarcoidosis

A

2-7%

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13
Q

Rate of CNS involvement with sarcoidosis and commonest site

A

5-13%
Cranial nerves

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14
Q

Pathogenesis of sarcoidosis

A

Th1 cell mediated
TNF-a
Interferon-y
Influx of CD14 macrophages

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15
Q

Investigations for sarcoidosis

A

CXR/CT
broncheolar lavage
Transbronchial biopsy
Cardiac MRI
ECG/echo
MRI head
EMG for myopathy

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16
Q

When is pregnancy is contraindicated in insterstitial lung disease?

A

When FVC<1-1.5L

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17
Q

Course of sarcoidosis in pregnancy

A

Majority have no change or improvement
Some worsen
Postnatal flare

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18
Q

Effects of sarcoidosis on pregnancy

A

PET
VTE
FGR
C/S
PPH

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19
Q

Baseline tests for sarcoidosis

A

FBC
U+E
LFT
Calcium
ACE
ECG
Echo if cardiac sarcoidosis is known
24hr tape if palpitations

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20
Q

Mycophenelate mofetil risks in pregnancy

A

Microtia (no ear cartilage)
Facial clefts
Micrognathia
Miscarriage
FGR

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21
Q

Washout period for mycophenelate

A

6 weeks

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22
Q

Washout period for MTXA

A

4 weeks
Give high dose folic acid

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23
Q

Leflunomide washout period

A

11 days with cholestyramine

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24
Q

When to discontinue adalimumab

A

28 weeks

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25
Q

When to discontinue infliximab

A

20 weeks

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26
Q

AN management of sarcoidosis

A

Aspirin
VTE
Growth scans
Enhanced BP monitoring
Investigate tachycardia and palpitations

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27
Q

Haemophilia A

A

Factor VIII deficiency

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28
Q

Haemophilia B

A

Factor IX deficiency

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29
Q

Impact of pregnancy on factor VIII

A

Increases x 3

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30
Q

Impact of pregnancy on factor IX

A

No effect

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31
Q

Normal range for factor VIII and IX outside of pregnancy

A

0.5-2.0 iu/ml

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32
Q

There is no family history in _____ of haemophilia patients

A

50%

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33
Q

Obligate haemophilia carrier status

A

Affected father

OR

Affected son and relative in maternal line

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34
Q

Risk of haemophilia in a male baby after a spontaneous affected sibling

A

45%

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35
Q

Classification of haemophilia A

A

Severe - <0.01 iu/ml

Moderate - 0.01 - 0.05 iu/ml

Mild - 0.06 - 0.4 iu/ml

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36
Q

Risk of resistance to clotting factor treatment

A

40%

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37
Q

Prenatal diagnosis of severe haemophilia

A

PGD
cell free fetal DNA for fetal sex
CVS for male fetus 11-14 weeks
Amniocentesis 3rd trimester to inform delivery options

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38
Q

Risk of intracranial and extra cranial haemorrhage with haemophilia

A

RR 56% for ICH

RR 92% for ECH

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39
Q

Antepartum management of haemophilia

A

No ECV in severe haemophilia
TXA
Levels 0.5 iu/ml to cover surgical procedures and miscarriage
DDAVP with 1L fluid restriction in 24 hours to increase factor VIII
Recombinant factor VIII if DDAVP ineffective
Recombinant factor IX if <0.5 iu/ml (measure before and after, then 4-6h after rx)

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40
Q

Mode and timing of delivery with haemophilia

A

C/S for affected male babies/status unknown/severe haemophilia
No ventouse/midcavity NBFD
No FSE in severe or moderate haemophilia

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41
Q

Intracranial haemorrhage risk with ELLSCS vs forceps in haemophilia

A

OR 0.69 vs 2.8

(4x less)

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42
Q

Optimal level of factor VIII after DDAVP treatment

A

1.0 iu/ml

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43
Q

When to give DDAVP and TXA intrapartum for haemophilia

A

As close to delivery as possible

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44
Q

Postpartum management of haemophilia

A

Maintain factor VIII/IX above 0.5 for 3 days after SVD, 5 days after operative delivery
TXA until lochia is minimal
No VTE if level <0.6

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45
Q

Investigation of the neonate in haemophilia carrier mothers

A

Cord blood testing in males
Re-test 3-6 months
Follow up with haematology
Cranial USS screening prior to discharge if moderate/severe haemophilia
MRI head if symptoms/signs of ICH

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46
Q

Treatment in neonate with haemophilia

A

Short term prophylaxis if moderate/severe or preterm or trauma at delivery

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47
Q

Types of vWD

A

Type 1 - partial quantitative

Type 2 - qualitative

Type 3 - severe quantitative

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48
Q

Commonest bleeding disorder

A

vWD

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49
Q

Level of care for vWD according to type

A

Normal unit with haem input for mild/moderate type 1

Specialist input for type 2/3 or severe type 1

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50
Q

Target level for factor VIII and vWF:RCo

A

0.5 to cover for spontaneous miscarriage and surgical procedures

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51
Q

Prevalence of VWD

A

1 in 1000

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52
Q

Mode of inheritance for vWD

A

Type 1 - variable penetrance with multiple mutations

Type 2B - dominant

Type 2N - recessive

Type 3 - recessive

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53
Q

Prevalence of type 3 vWD

A

1 in 1 million

Higher in consanguineous communities

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54
Q

Antenatal Treatment of vWD

A

DDAVP
Restrict fluid 1 litre in 24 hours

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55
Q

Contraindication to DDAVP

A

PET
Arterial disease
Uncontrolled hypertension

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56
Q

Side effects of DDAVP in VWD

A

Type 2B can develop thrombocytopenia

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57
Q

Intrapartum management of type 2/3 vWD

A

Avoid FBS, FSE, ECV, ventouse and mid cavity forceps

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58
Q

Postpartum care in vWD

A

TXA for 14 days
Keep factor VIII above 0.5 for 3 days after SVD or 5 days after operative delivery

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59
Q

Neonatal management with VWD

A

Oral vit K
Cord blood testing in type 2/3
Retest at 3-6 months for type 2/3
Cranial US +/- MRI head for type 2/3
Inform parent of signs for ICH

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60
Q

Dose of DDAVP

A

0.3 micrograms/kg of pregnancy body weight

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61
Q

Treatment for acute haemorrhage in vWD

A

DDAVP

Viral inactivated concentrate with VWF and factor VIII (hep A and parvo resistant to inactivation)

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62
Q

Factor XI deficiency inheritance

A

Autosomal dominant
Autosomal recessive

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63
Q

Factor XI prevalence

A

1 in 1 million general population
8% Ashkenazi Jews heterozygous
0.2 - 0.5% Ashkenazi Jews homozygous

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64
Q

Factor XI maintenance levels

A

0.5 iu/ml

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65
Q

Effects of pregnancy on Factor XI levels

A

No effect

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66
Q

Antepartum monitoring of factor XI

A

Booking
3rd tri
Prior to invasive procedures

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67
Q

Bleeding risk with factor XI deficiency

A

Type O
High risk phenotype

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68
Q

Testing in neonate for factor XI deficiency

A

No testing unless mum is homozygous or compound heterozygosity

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69
Q

Management of factor XI deficiency

A

Exclude compounding vWF/thrombocytopenia

Can give TXA OR factor XI concentrate (both together increase risk of VTE) or FFP

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70
Q

What are the rare bleeding disorders?

A

Deficiencies of fibrinogen
Factor II, V, VII, X and XIII
Combined factor V and VIII deficiencies
Congenital deficiency of vit K dependent factors

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71
Q

Maintenance level for the rare bleeding disorders

A

Aim >0.2 iu/ml

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72
Q

Management of rare bleeding disorders

A

TXA 15-20 mg/kg or 1g QDS for minor bleeds
+/- factor replacement

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73
Q

Factor II deficiency is AKA

A

Prothrombin deficiency

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74
Q

Management of prothrombin (factor II) deficiency

A

If bleeding/labour or for c/s and <0.2/ml give prothrombin complex concentrate 10-20 iu/kg at 48 hour intervals

Maintain level >0.2 for 3 days minimum

If already receiving prophylactic prothrombin complex then continue through pregnancy

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75
Q

Management of factor V deficiency

A

If activity <0.2/bleeding/delivery then give 15-25ml/kg FFP

Further FFP at 10ml/kg 12 hourly to maintain activity 0.2-0.4 for 3 days

Consider platelets for severe bleeding or c/s

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76
Q

Factor VII deficiency management

A

Recombinant factor VIIa 15-30 micrograms/kg every 4-6 hours to maintain level >0.2
3-5 days after c/s
Only in response to severe bleeding for other women

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77
Q

Severe factor X deficiency management

A

Antenatal prophylaxis 2-3x/week for recurrent bleeding or adverse pregnancy outcome with prothrombin complex concentrate

Give 20-40iu/kg prothrombin complex concentrate for bleeding or c/s to maintain activity >0.4
10-20 iu/kg daily for 3 days maintenance

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78
Q

Severe factor XIII deficiency management

A

Factor XIII plasma concentrate prophylaxis every 14-21 days
Maintain activity >0.2
Consider additional 10-40 iu/kg in established labour/ prior to c/s

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79
Q

Factor V and factor VIII deficiency management

A

Consider FFP 15-25 ml/kg in established labour or before c/s. Maintain level 0.2-0.4 iu/ml

Consider factor VIII if less than 0.5 iu/kg in third trimester

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80
Q

Fibrinogen disorders and their inheritance

A

Afibrogenaemia - recessive (bleeding)

Hypfribrinogenaemia with or without qualitative defects (dysfribrinogenaemia) - dominant (variable bleeding/thrombosis risk)

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81
Q

Pregnancy outcomes with fibrinogen disorders

A

APH
PPH
VTE
pregnancy loss
ICH
Umbilical bleeding

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82
Q

Management of fibrinogen deficiency

A

Maintain levels 0.5-1 g/litre antepartum and 3 days post partum
TXA for minor bleeding
Fibrinogen concentrate 50-100mg/kg through pregnancy 2x/week - consider LMWH if low risk for bleeding

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83
Q

What is Bernard Soulier syndrome? (BSS)

A

Deficiency of membrane GP Ib-IX-V complex
Causes abnormal adhesion of platelets

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84
Q

Inheritance of BSS

A

Autosomal recessive

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85
Q

Management of BSS

A

TXA at outset of labour until lochia is minimal
Platelets prophylactically before delivery
No central neuraxial analgesia
Platelets should be HLA matched
Consider DDAVP (variable response)

86
Q

Maternal risks of BSS

A

PPH
Wound haematoma

87
Q

What is Glanzmann’s thrombasthenia? (GT)

A

Non-functioning GP IIb/IIIa caused by missense mutation in ITGA2B and ITGB3

Platelet-platelet aggregation is impaired

88
Q

Inheritance of GT

A

Autosomal recessive

89
Q

Maternal and fetal risks of GT

A

APH
PPH
Fetal thrombocytopenia
Fetal ICH/bleeding

90
Q

Management of GT

A

HLA matched platelet transfusion and/or recombinant factor VIIa prophylactically at delivery
TXA in established labour until lochia is minimal
No central neuraxial anaesthesia

91
Q

Management of platelet fetal allo-immunisation in GT

A

Check antibodies at 28 and 34 weeks
FMU referral
IV IgG +/- steroids
Cord platelets
Oral vit K until platelet level is back
Check again day 3-5
Give platelets if <30 x 10(9)/litre

92
Q

Spinal epidural anaesthesia should never be given to patients with _____

A

Type 3 vWD

93
Q

Clotting factors that increase in pregnancy

A

VIII
IX
X
Fibrinogen (50%)

94
Q

DVT vs PE proportions

A

75% DVT
25% PE

95
Q

VTE incidence in pregnancy

A

1-2/1000

96
Q

RR of VTE in pregnancy

A

4-6 x

97
Q

Sites of DVT in pregnancy

A

85% left sided
72% iliofemoral

98
Q

Inherited Thrombophilias

A

Anti-thrombin III (highest risk)
Protein C deficiency
Protein S deficiency
Activated protein C resistance
Prothrombin gene mutation
Factor V Leiden
Hyperhomocystinaemia

99
Q

Acquired thrombophilia

A

Antiphospholipid
Lupus anticoagulant
High anti-cardiolipin antibody
B glycoproteins 1 antibodies

100
Q

Pulmonary hypertension risk after PE

A

3-4%

101
Q

Recurrent DVT risk outside of pregnancy

A

3.7%

102
Q

Recurrent DVT risk outside pregnancy

A

10.9%

103
Q

Most common acquired thrombophilia

A

APLS

104
Q

Risks associated with APLS

A

Pregnancy loss
PET
PTB
FHR
VTE

105
Q

Anti-coagulation regimen for APLS

A

If on long term anti-coagulation = intermediate/therapeutic dose LMWH

If no long term anti-coagulation = intermediate/high dose prophylaxis LMWH

106
Q

LMWH for previous VTE and inherited thrombophilia

A

Antithrombin deficiency - high dose LMWH (50% or 75% or treatment dose)

Give standard prophylaxis for other thrombophilias

107
Q

Low risk inheritable thrombophilias

A

Heterozygous factor V Leiden
Heterozygous prothrombin mutation

108
Q

Investigation of DVT

A

Compression duplex USS - repeat day 3 + 7 if negative but still suspected

Pelvic US colour Doppler (pelvic vessels)

MRV or contrast venography (iliac vein)

109
Q

PE is diagnosed in _____% of women with symptoms

A

5

110
Q

ECG changes in PE

A

Sinus tachycardia
RBBB
Peaked P waves lead III
S1, T3, Q3 (rare)

111
Q

Breastfeeding advice after V/Q scan

A

Discard milk for 48 hours

112
Q

Increased risk of breast Cancer after CTPA

A

> 13%

113
Q

Investigations for PE

A

V/Q scan if CXR normal
CTPA if CXR abnormal

114
Q

Use unfractionated heparin for

A

Massive PE
Rapid reversal needed

115
Q

Heparin monitoring

A

Measure APTT 4-6 hours after loading dose
6 hours after dose change
Twice daily once in therapeutic range

116
Q

Life threatening PE treatment

A

Thrombolysis in combination with unfractionated heparin (omit loading dose)

117
Q

Treatment of VTE

A

LMWH
UFH
Thrombolysis
Pulmonary embolectomy
IVC filter for iliac thrombosis

118
Q

Length of treatment time after VTE

A

Minimum 6/52 postpartum
At least 3 months to prevent post thrombotic syndrome

119
Q

LMWH and labour management

A

Stop 24 hours before planned delivery or when labour starts
Wear stockings until LMWH can be resumed
Staples or interrupted skin sutures for c/s

120
Q

Risk of wound haematoma after c/s on LMWH/UFH

A

2%

121
Q

Side effects of LMWH

A

Thrombocytopenia
Allergy
Osteoporosis 1 in 500
Bruising

122
Q

Side effects UFH

A

Vertebral fractures 2%
Allergy
HIT

123
Q

Indications for high dose LMWH

A

Antithrombin deficiency
Previous VTE whilst anti-coagulated
APLS + previous VTE

124
Q

Timing of Regional analgesia when on LMWH

A

> 12 hours after last dose of prophylactic
24 hours if therapeutic LMWH

125
Q

Epidural catheter and LMWH management

A

Perform 12h after last dose of prophylactic, 24h if therapeutic

Next dose LMWH 4 hours after removal

126
Q

Flying VTE risk

A

3x increase
Additional 18% for every 2 hours

127
Q

Reducing VTE risk when flying

A

Aisle seat
Mobilise in seat and in the aisle
Fluid intake
Minimise caffeine
TEDS if >4hr flight
LMWH if other risk factors

128
Q

Commonest inherited thrombophilia

A

Factor V Leiden

129
Q

Prevalence of factor V Leiden

A

3-5% U.K.
low in black/asian populations
Sweden - 15%

130
Q

Monitor platelets in women at risk of VTE if ____ every ____

A

On UFH or treatment dose LMWH
Every 14 days

131
Q

Fetal Radiation exposure with CTPA and V/Q

A

0.1 mGy

0.5 mGy

132
Q

Radiation to breast of CTPA

A

10 mGy

133
Q

Reducing risk of post thrombotic syndrome

A

Graduated elastic compression stockings for 2 years

134
Q

Essential HTN pregnancy outcomes

A

PET 25.9%
C/S 41.4%
SGA 16.9%
NNU admission 20.5%
Perinatal death 4%

135
Q

Aspirin reduces early onset PET in ____ women

A

60%

136
Q

Effect of Severe hypertension on NNU admission

A

Increases risk from 23% to 47%

137
Q

Negative predictive value for PlGF or sFlt is for ____

A

2 weeks

138
Q

Chance of complications with PET <37 weeks

A

50%

139
Q

Target HbA1c preconception

A

48

140
Q

Risk of congenital abnormalities in women with pre-existing diabetes is highest if ____

A

HbA1c >86

141
Q

Pre-pregnancy Glycaemic targets with pre-existing diabetes

A

Waking 5-7
Fasting 4-7

142
Q

Risk of stillbirth with pre-existing diabetes is highest at ____ HbA1c

A

> 60

143
Q

BM peak time after steroids

A

6-8 hours

144
Q

DKA risk in T1DM

A

1-2%

145
Q

Risk of stillbirth with DKA

A

160 per 1000 births

146
Q

How long does hyperglycaemic effect of steroids last?

A

24 hours

147
Q

Elective birth for T1/T2DM timing

A

37-38+6 if no complications
Before 37 weeks if maternal or fetal complications

148
Q

Refer to nephrologist for diabetic women with _________

A

Creatinine >120 OR

Urinary ACR >30 OR

Total protein excretion >0.5g/day

149
Q

Proteinuria level to consider VTE prophylaxis

A

> 5g/day OR
ACR >220

150
Q

Incidence of solid organ transplants in pregnant women

A

50-60 per year (30-40 kidneys)

151
Q

Most common solid organ transplant

A

Kidney

152
Q

Risk of organ rejection in first year of transplant

A

10-15%

153
Q

Prevalence of pre-pregnancy hypertension in women with renal transplants

A

50%

154
Q

Risk of new HTN in pregnancy after renal transplant

A

16%

155
Q

Increased risk of loss of renal function after pregnancy if _____

A

Pre-pregnancy proteinuria is 1g/day

156
Q

Which immunosuppressive drugs increase risk of GDM

A

Steroids
Tacrolimus
Ciclosporin

157
Q

Risk of GDM is ____ in patients after renal transplant

A

Doubled

158
Q

Risk ratio for PET after renal transplant

A

6x

159
Q

Risk of caesarean delivery after renal transplant

A

64%

160
Q

Risk of PTB after renal transplant

A

52% late PTB
9% early PTB

161
Q

Risk of SGA after renal transplant

A

24% (3x higher)

162
Q

Risk of neonatal unit admission after renal transplant

A

38%

163
Q

Kidney graft rejection rate in pregnancy

A

2-4.2%

164
Q

Effect of pregnancy on tacrolimus and ciclosporin

A

Reduces serum levels

165
Q

Effect of pregnancy on erythropoetin requirement

A

Increases

166
Q

Target MgSO4 level if required for renal transplant patients

A

<3.5 mmol/L
Check 3-6 hours after commencing

167
Q

Risk of trauma to renal graft during c/s

A

1-2%
Consider midline incision

168
Q

Surgical review should be at ____ weeks gestation for women with kidney-pancreas transplants

A

30-34 weeks

169
Q

Incidence of pregnancy after liver transplant

A

12 per year

170
Q

GDM screening for patients with the following solid organ transplants

A

Kidney
Pancreas
Liver
Lung (Cystic fibrosis is indication)

171
Q

Pre-conceptual investigation after cardiac transplant

A

ECG
Echo
Angiography
Endomyocardial biopsy as clinically indicated

172
Q

Highest risk organ transplant for pregnancy is ____

A

Lung - pregnancy loss and graft rejection is highest

173
Q

Detection of lung graft rejection is by

A

Decreased FEV1 or FVC as these are unchanged by pregnancy

174
Q

DKA incidence

A

6.3 per 100 000

175
Q

Incidence of DKA for T1DM

A

85%

176
Q

Incidence of DKA in third trimester

A

71%

177
Q

Commonest causes of DKA

A

Infection
Vomiting
Steroid therapy
Medication errors

178
Q

Perinatal mortality for DKA

A

16%

179
Q

Diagnosis criteria for DKA

A

Blood ketones 3.0 or urine ketones 2+
BM 11.0 or known DM
Bicarbonate <15 or pH <7.3

180
Q

IV fluid management in DKA

A

10-15ml/kg/hr in the first hour
OR
1L for 1 hour, 500ml/hr for 4 hours, 250ml/hr for 8 hours then 150ml/hr maintenance

181
Q

Management of K+ in DKA

A

Give K+ if <3.3 and don’t give insulin
Give K+ with insulin if 3.3-5.5
Give insulin without K+ if >5.5

182
Q

Metabolic targets in DKA treatment

A

Fall in ketones 0.5mmol per hour
Increase bicarbonate by 3mmol/hr
Decrease in BM by 3mmol/l/hr

183
Q

Insulin regime in DKA

A

0.1 unit/kg/hr
Do not exceed 15 units/hr

184
Q

When to stop insulin

A

When eating and drinking
Five rapid insulin and take down FRII after 30-60 minutes

185
Q

Phosphate replacement in DKA is recommended when ___

A

Levels <0.32
Cardiac impairment
Resp depression

186
Q

Monitoring response to treatment of DKA

A

First 6 hours:
Hourly blood ketones
2 hourly VBG

187
Q

Time taken for FHR to normalise after DKA treatment

A

4-8 hours

188
Q

PPCM ejection fraction

A

<45%

189
Q

Incidence of PPCM

A

1 in 1000 - 4000 pregnancies

190
Q

PET prevalence in PPCM

A

22% (4x higher risk)

191
Q

When do women with PPCM present?

A

78% 4 months post delivery
9% final month of pregnancy
13% before final month and after 4 months

192
Q

Complications of PPCM

A

Ventricular arrhythmias 20%
Intracardiac thrombus
Cardiogenic shock
VTE 6.8%

193
Q

Investigations for PPCM

A

ECG
FBC, Trop T, BNP/NT-proBNP, CRP
Echo
CXR
cardiac MRI (thrombus)
Endomyocardial biopsy

194
Q

Management of PPCM when haemodynamically stable and pregnancy

A

Salt restriction
Loop diuretics
B-1 antagonists
Hydralazine
LMWH

195
Q

Management of PPCM (postpartum and breastfeeding)

A

ACEI or ARB
Aldosterone antagonists

196
Q

Management of PPCM postpartum not breast feeding

A

DOAC
SGLT2 inhibitors
Angiotensin receptor nephrilysin inhibitors (ARNI)

197
Q

PPCM management haemodynamically unstable

A

Delivery
Optimise preload (diuretics)
O2
Inotropes/vasopressors
Bromocriptine
ECMO or cardiac transplant
Cardioversion and defribilation (ICD for 3-6 month)

198
Q

Mode of delivery for PPCM

A

Aim vaginal if NYHA class I-II
C/S if class III-IV

199
Q

Intrapartum care for PPCM

A

Continuous ECG and pulse oximetry
Intra-arterial BP monitoring
30 degree left lateral tilt
Regional analgesia NYHA class III-IV
Limit 2nd stage
Avoid ergometrine

200
Q

Prognosis for PPCM

A

10% mortality risk
50-80% recover 6 months from diagnosis
Worse recovery if LVEF <30% at diagnosis or black women

201
Q

Advice for future pregnancies

A

50% chance of deterioration with 20% mortality risk if LV dysfunction persists (advice against further pregnancy)

20% chance of recurrence after full recovery

No further pregnancy advised if LVEF <25% at diagnosis

202
Q

Pregnancy management after PPCM

A

Preconceptual counselling
BNP levels
Echo
Serial scans 24/40
LMWH
Deliver 37/40

203
Q

Echo schedule for previous PPCM

A

Preconceptual
1st trimester
2nd trimester
One month before delivery
Immediately after delivery (before discharge)
1 month after delivery

204
Q

Bromocriptine dose in PPCM

A

2.5mg OD for 7/7 if uncomplicated
2.5mg BD for 2/52 then OD for 6/52 if LVEF <25%

205
Q

Bromocriptine increases risk of?

A

VTE

206
Q

Rates of ACS

A

0.6 to 10 per 100 000 pregnancies

207
Q

Mortality risk after ACS

A

5-11%

208
Q

Which trimester is ACS most likely to occur?

A

3rd

209
Q

Proportion of NSTEMI in pregnancy?

A

75%

210
Q

Causes of ACS in pregnancy

A

PASCAD (27%)
Atherosclerosis (39%)
Thrombosis (10-20%)
Coronary artery spasm 2%

211
Q

Causes of raised Trop

A

ACS
PET
HTN
cardiomyopathy
PE
Takotsubo
Myocarditis
Renal failure
Autoimmune disease with cardiac involvement