3: Medical problems in pregnancy

Question 1

Which groups of women are more likely to die during pregnancy?

Answer 1

Women with co-morbidities

Ethnic minority women

Overweight / obese women (cardiovascular disease risk i.e VTE)

Question 2

What cardiovascular diseases are common causes of death in pregnancy?

Answer 2

Hypertension

Cardiac disease i.e MI

VTE i.e DVT, PE, stroke, MI

Diabetes

Question 3

What cardiovascular changes occur in pregnancy?

Answer 3

Increased heart rate, contractility, stroke volume –> CO

Decreased BP and TPR

Question 4

Why is the prevalence of heart disease in pregnancy increasing?

Answer 4

Increased maternal age

More obese women

More women with pre-existing or congenital heart disease

Question 5

What is a major risk factor for ischaemic heart disease in women?

Answer 5

Pregnancy

:/

Question 6

What innocent cardiovascular signs and symptoms are seen in pregnant women?

Answer 6

Innocent murmur

Palpitations

Question 7

Which anticoagulant is teratogenic?

Answer 7

Warfarin

LMWH isn’t, so swap it

Question 8

Which cardiovascular disease is often fatal if carried into pregnancy?

Answer 8

Pulmonary hypertension

Question 9

What is Eisenmenger’s syndrome?

Answer 9

Right-to-left shunt caused by PH secondary to a congenital heart defect e.g VSD

Question 10

Which

a) endocrine
b) genetic disorders are associated with congenital heart disease?

Answer 10

a) Diabetes

b) Marfan’s syndrome (aortic root dilation -> regurg)

+ a million more

Question 11

Palpitations occuring during pregnancy are usually ___.

Answer 11

benign

Question 12

What cardiac investigations should be done for a woman presenting with palpitations?

Answer 12

ECG

If dodgy, do echo

Question 13

Which endocrine diseases may cause palpitations in pregnant women?

Answer 13

Hyperthyroidism

Phaeochromocytoma

Question 14

Which NYHA class of cardiovascular disease is a contraindication for pregnancy?

Answer 14

3+

make sure the woman is using contraception

Question 15

What respiratory changes occur during pregnancy?

Answer 15

Increased oxygen consumption

Increased tidal volume BUT NOT respiratory rate

Decreased functional residual capacity (lungs are compressed by pregnancy)

Question 16

What blood gas changes occur during pregnancy?

Answer 16

% O2 increases

% CO2 decreases

So blood pH increases

Question 17

Palpitations is a common cardio complaint in pregnancy.

What is a common respiratory complaint?

Answer 17

SOB

Question 18

Which chronic respiratory condition is often seen in pregnant women?

Answer 18

Asthma

Question 19

Why do many pregnant women experience a deterioration in their asthma early in pregnancy?

Answer 19

Concerns re: medication effect on baby (steroids, inhalers)

so they stop using them and their asthma gets worse

Question 20

What should women on long-term steroids be given during childbirth?

Answer 20

IV steroids e.g hydrocortisone

bc. they will have adrenal insufficiency

Question 21

Can women continue on their inhalers during childbirth?

Answer 21

Yes

Question 22

What is the most common direct cause of maternal death in pregnancy?

Answer 22

Venous thromboembolism

i.e DVT

Question 23

Where exactly do DVTs tend to occur in pregnant women?

Answer 23

Left leg

Iliac / femoral vein

Question 24

When in the course of pregnancy does DVT tend to occur?

Answer 24

Post-birth

Question 25

**Virchow's triad** for venous thromboembolism includes **epithelial damage, hypercoagulability** and **venous stasis**. How do pregnant women fulfill these factors?

Answer 25

**Epithelial damage** - rapid cardiovascular changes **Venous stasis** - lying down a lot, especially in hospital **Hypercoagulability** - some women have thrombophilia

Question 26

Which type of drug is given as prophylaxis for DVT in pregnant women?

Answer 26

**Anti-coagulant** NOT warfarin - LMWH

Question 27

What congenital disease, causing hypercoagulability, causes DVT in pregnancy?

Answer 27

**Thrombophilia**

Question 28

What **LMWH** is used for pregnant women in Tayside?

Answer 28

**Dalteparin**

Question 29

What influences the dose of **dalteparin** given to pregnant women to prevent **VTE?**

Answer 29

**Maternal weight**

Question 30

What investigation is used to diagnose **DVT** in pregnant women?

Answer 30

**Duplex ultrasound** like a doppler for your leg

Question 31

What biochemical test used for DVT and PE is useless in pregnancy?

Answer 31

**D dimers** always raised

Question 32

Which **investigations** are used to diagnose **PE** in all patients?

Answer 32

**CT pulmonary angiogram** **V/Q scan**

Question 33

**CTPA** and **V/Q scans** are used to diagnose PE. What's the problem with this in pregnant women?

Answer 33

**CTPA** involves a radiation dose to the woman and increases breast cancer risk **V/Q scan** involves a radiation dose and increases risk to baby

Question 34

Which anti-coagulant drug is teratogenic? What should you change it to?

Answer 34

**Warfarin** **LMWH** e.g dalteparin

Question 35

Can mothers **breastfeed** while on warfarin or LMWH?

Answer 35

**Yes**

Question 36

Which **rheu disease** causes recurrent miscarriage and skin changes?

Answer 36

**Anti-phospholipid syndrome (APS)**

Question 37

**APS** causes which blood disorder in women?

Answer 37

**Thrombophilia**

Question 38

Which three autoantibodies are seen in APS?

Answer 38

**Anti Lupus anticoagulant** **Anti cardiolipin** **Anti beta 2 glycoprotein**

Question 39

What are the signs of APS?

Answer 39

**Recurrent miscarriage** **Recurrent early-onset pre-eclampsia**

Question 40

How is **APS** managed?

Answer 40

If found during late pregnancy it's probably not treatable but can be **subsequently treated with aspirin and LMWH** + **regular monitoring (USS)**

Question 41

Which neuro disorder is common in pregnant women?

Answer 41

**Epilepsy**

Question 42

What symptom of epilepsy is responsible for pregnancy complications?

Answer 42

**Seizures** trauma, premature rupture, premature delivery

Question 43

Many of the ___ used to treat epilepsy are teratogenic.

Answer 43

**drugs**

Question 44

Which **anti-epilepsy** **drug** is most likely to cause congenital malformations?

Answer 44

**Sodium valproate** but they're all dodgy

Question 45

The more anti-epilepsy drugs a pregnant woman is on, the more likely they are to develop what?

Answer 45

**Foetal abnormalities**

Question 46

Which drug is used to prevent neural tube defects in pregnant women? In what doses?

Answer 46

**Folic acid** 400 micrograms normal risk 5 milligrams increased risk (e.g on antiepileptic drugs)

Question 47

What disease **other than epilepsy** causes seizures in pregnant women?

Answer 47

**Eclampsia**

Question 48

How are **epileptic seizures** terminated in labour?

Answer 48

**Benzodiazepines** These are majorly teratogenic but the baby's being delivered at that point

Question 49

What state increases your risk of virtually every complication of pregnancy?

Answer 49

**Obesity**

Question 50

What dose of **folic acid** should **obese women** take? Why?

Answer 50

**5 milligrams** Increased risk of neural tube defects