9) Maternal Medicine: Respiratory

Question 1

Most common chronic condition in pregnancy

Answer 1

Asthma

Question 2

Incidence of asthma in pregnancy

Answer 2

10%

Question 3

Effect of pregnancy on asthma

Answer 3

1/3 improve, 1/3 worsen, 1/3 unchanged

Severe disease more likely to deteriorate than mild disease - 60%/10%

Question 4

When are asthma exacerbations most common?

Answer 4

24-36 weeks

Question 5

Risks of pregnancy with asthma?

Answer 5

Higher risk of PIH/PET.
If poorly controlled, risk of low birthweight.
May have increased risk of CS.

Most women with well controlled asthma no or minimal risks.

Question 6

Medical management of stable asthma

Answer 6

1: Short acting B2 agonist PRN
2: Inhaled steroid
3: Long acting B2 agonist
4: Increase steroid dose. Add montelukast (leukotriene receptor antagonist), SR theophylline or B2 agonist tablet.
5: Oral steroids.

Question 7

Which asthma drug requires levels monitoring in pregnancy?

Answer 7

Theophylline

Question 8

What percentage of women with asthma experience exacerbations during labour?

Answer 8

<20% (severe/life threatening exacerbations rare)

Question 9

Which drugs associated with labour/delivery should be avoided in women with asthma?

Answer 9

Prostaglandin F2 = haemobate
Labetalol.
NSAIDs.

Ergometrine may cause bronchospasm but can be used during PPH (give syntocinon for routine 3rd stage).

Prostaglandin E2 = prostin is fine to use.

Question 10

Risk of asthma exacerbations postpartum

Answer 10

None

Question 11

Criteria for moderate acute asthma exacerbation

Answer 11

Increasing symptoms
PEFR 50-75%
No severe features

Question 12

Criteria for severe acute asthma exacerbation

Answer 12

PEFR 33-50%
RR >25
HR >110
Inability to complete sentences

Question 13

Criteria for life threatening acute asthma exacerbation

Answer 13

PEFR <33%
SpO2 <92%
PaO2<8
Normal PaCO2 4.6-6
Altered conscious level
Exhaustion
Arrhythmia
Hypotension
Cyanosis
Silent chest 
Poor respiratory effort

Question 14

Criteria for near fatal asthma

Answer 14

Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures

Question 15

Treatment of acute exacerbation of asthma

Answer 15

O2 to maintain sats 94-98%
Steroids (40-50mg)
B-agonists (nebuliser if severe/life-threatening)
Ipratropium (if severe/life threatening or poor response to B agonists)
IV MgSO4 (1.2-2g IV over 20 mins)

ABG if sats<92% or any other life threatening feature
CXR if life threatening or suspect another pathology.

Question 16

Incidence of TB in pregnancy in UK

Answer 16

4.2 per 100,000

Question 17

Proportion of women with TB asymptomatic

Answer 17

1/2 to 2/3

Question 18

Extrapulmonary TB in pregnancy - how common compared to pulmonary TB?

Answer 18

As common

Question 19

What proportion of non-respiratory TB is CNS?

Answer 19

5%

Question 20

What proportion of maternal deaths is CNS TB responsible for?

Answer 20

2/3

Question 21

Most common site of extra pulmonary TB

Answer 21

Lymph nodes

Question 22

Investigation to establish latent TB infection

Answer 22

Mantoux test

Question 23

What can cause false positive Mantoux test?

Answer 23

Other mycobacteria, previous BCG

Question 24

What is the gold standard for diagnosis of TB?

Answer 24

Culture

Question 25

TB on pregnancy

Answer 25

If not treated can cause increased PET, PPH, PTL, IUGR, Perinatal mortality.

Question 26

How does congenital TB present?

Answer 26

2nd or 3rd week Hepatosplenomegaly, respiratory distress, fever, low weight gain, irritability (Very rare)

Question 27

Standard regimen for treatment of TB in pregnancy

Answer 27

Rifampicin + Isoniazid + Ethambutol (+ Pyrazinamide if resistance suspected) + Pyridoxine to protect against isoniazid neuropathy.

Question 28

Duration of treatment of TB

Answer 28

Standard treatment 6 months Extrapulmonary TB 12 months Drug resistant TB 2 years

Question 29

What to do if TB diagnosed in the 2 weeks following delivery?

Answer 29

Infant needs prophylactic isoniazid (+vit B6) and tuberculin test 6-12w BCG if tuberculin negative.

Question 30

What is the risk of streptomycin in pregnancy?

Answer 30

Fetal ototoxicity

Question 31

Most common bacterial pneumonia

Answer 31

Strep. pneumonia

Question 32

When to suspect influenza?

Answer 32

Fever + two or more other symptoms (myalgia, arthralgia, cough, headache, sore throat, blocked or runny nose, vomiting or watery diarrhoea)

Question 33

Fetal risks associated with influenza

Answer 33

Preterm birth | Perinatal mortality

Question 34

Risk factors for admission with flu

Answer 34

Obesity Asthma Multiple pregnancy Other medical problems

Question 35

Benefit of tamiflu

Answer 35

If started within 2 days reduces risk of critical care admission

Question 36

Incidence of aspiration syndrome after CS and after VD

Answer 36

CS: 1 in 1500 CS: 1 in 6000

Question 37

How does aspiration syndrome present?

Answer 37

Severe inflammation over 8-24 hours. CXR can show complete "white out". Clinical improvement 2-3d.

Question 38

When does bacterial aspiration pneumonia occur?

Answer 38

Symptoms 2-3 days after aspiration

Question 39

How does the CXR finding in bacterial aspiration pneumonia differ from aspiration syndrome?

Answer 39

More localised

Question 40

Organism involved in bacterial aspiration pneumonia

Answer 40

Mixed anerobes

Question 41

Where is the mutation in CF?

Answer 41

CFTR (Chloride channel) gene on chromosome 7

Question 42

What is the incidence of CF carriers?

Answer 42

1 in 25

Question 43

Clinical features of CF

Answer 43

Pancreatic insufficiency - diabetes, malabsorption Respiratory - recurrent infections with pseudomonas, staph aureus, burkholderia Subfertility in men (not women)

Question 44

Median survival with CF

Answer 44

31 years

Question 45

What to do in pregnancy if one partner is a carrier or affected?

Answer 45

Offer partner testing

Question 46

What is the chance of being a carrier if test is negative?

Answer 46

1 in 250

Question 47

What to do if both partners carriers/affected?

Answer 47

Offer counselling and PGD

Question 48

How many women per year with CF embark on pregnancy?

Answer 48

30-40

Question 49

Live birth rate for mothers with CF

Answer 49

70-90%

Question 50

Effect of CF on rate of miscarriage

Answer 50

No change

Question 51

Effect of CF on rate of congenital anomalies

Answer 51

No change

Question 52

Risk of PTB with CF

Answer 52

25%

Question 53

What FEV1 is associated with the lowest risk of complications in CF patients?

Answer 53

>70%

Question 54

Effect of pregnancy on maternal survival

Answer 54

None

Question 55

What percentage of mothers with CF are not still alive for their child's 10th birthday?

Answer 55

20%

Question 56

Management of pregnancy in a mother with CF

Answer 56

``` Folic acid Growth scans Nutritional input + physio input **GTT (first trimester and 24-26)** Monitoring of respiratory function ```

Question 57

Mode of delivery in CF

Answer 57

Dependent on maternal condition. | Epidural recommended in labour to facilitate passive time in 2nd stage and avoid GA if CS.

Question 58

How long after heart/lung transplant should CF patients wait before conceiving?

Answer 58

2-3 years

Question 59

What is the risk of rejection/graft loss with heart/lung transplants compared to other solid organ transplants?

Answer 59

Higher

Question 60

Breast feeding with CF

Answer 60

Breast milk is of normal composition so should be encouraged. May struggle to keep up calorie requirements.

Question 61

Contraception in CF

Answer 61

Avoid deep due to BMD.