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Laura MRCOG Part 2 > 9) Maternal Medicine - Rheumatology/Ortho > Flashcards

9) Maternal Medicine - Rheumatology/Ortho Flashcards

(68 cards)

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1
Q

Incidence of rheumatoid arthritis in pregnancy

A

1 in 1000-2000

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2
Q

What percentage of people with RA have secondary Sjogrens?

A

15%

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3
Q

What antibodies might be seen in RA?

A

80-90% Rheumatoid Factor
ANA 30% (Sjogren’s particularly associated with anti-Ro and anti-La)
Anti-CCP (predicts severity)
5-10% have antiphospholipid antibodies

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4
Q

Course of RA in pregnancy

A

50% improve (20% complete remission)
- Predicted based on previous remission and absence of rheumatoid factor or anti-CCP
25% significant disability

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5
Q

Course of RA post-natally

A

90% flare in 4 months after (not associated with anti-CCP or rheumatoid factor)

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6
Q

Pregnancy risks associated with RA

A

PTB
Growth restriction
Anti-Ro antibodies - risk of neonatal lupus
Hip abduction rarely impedes vaginal delivery.
Atlanto-axial subluxation after GA.

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7
Q

Risks of NSAIDs in pregnancy

A
  • Can impair fertility by “leutinised unruptured follicle syndrome” or blastocyst implantation failure.
  • Increased risk neonatal haemorrhage
  • Oligohydramnios (reversible)
  • Premature closure of DA (reversible)
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8
Q

If NSAIDs used in pregnancy when should they be discontinued?

A

32-34 weeks

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9
Q

Preferred 1st and 2nd line treatments for RA in pregnancy

A

Paracetamol and then steroids

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10
Q

When are parenteral steroids required in labour?

A

> 5mg/day for >3 weeks (some sources >7.5mg >2weeks)

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11
Q

Azathioprine in pregnancy?

A

Safe and can breast feed.

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12
Q

Hydroxychloroquine in pregnancy?

A

Safe and can breast feed.

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13
Q

Mycophenolate in pregnancy?

A

Teratogenic (cleft lip + palate, microbial with atresia external auditory canal, micrognathia, hypertelorism)

Need to switch 3/12 pre-conception

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14
Q

Penicillamine in pregnancy?

A

Stop if used for RA due to risk of congenital connective tissue abnormalities (needed to continue with Wilsons disease).

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15
Q

Sulfasalazine in pregnancy?

A

Safe to continue but DHFR inhibitor therefore need 5mg folic acid.

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16
Q

Cyclophosphamide in pregnancy?

A

Teratogenic. Stop 3/12 prior. 15% risk congenital abnormalities.

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17
Q

Methotrexate in pregnancy?

A

Teratogenic. Stop 3/12 prior. 15% risk congenital abnormalities.

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18
Q

Chlorambucil in pregnancy?

A

Teratogenic. Stop 3/12 prior. 15% risk congenital abnormalities.

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19
Q

Leflunomide in pregnancy?

A

Avoid pregnancy for 2 years afterwards.

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20
Q

Safe RA drugs in pregnancy

A 
Paracetamol
Steroids
(In certain situations NSAIDs)
Azathioprine, sulfasalazine, hydroxychloroquine.
Biologics.
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21
Q

Incidence of lupus

A

1 in 1000

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22
Q

Ethnic variation in lupus

A

Non-Caucasian more common

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23
Q

Percentage of women with lupus who have other autoimmune disorders

A

6%

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24
Q

Most common features of lupus

A 
Arthritis (90%)
Skin involvement (80%)
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25
What blood test indicates active lupus?
Fall in C3/C4 levels by >25%
26
Which antibodies are found in lupus?
96% anti-nuclear antibodies: - Most specific and predictive of lupus nephritis: anti-dsDNA and Smith (78%) - Anti-Ro/La (30%) - aPL (40%)
27
Course of lupus in pregnancy
Increased chance of flare (60%) which can occur at any stage of pregnancy but is more likely active disease in 6m before conception.
28
Effect of pregnancy on lupus nephritis
Doesn't jeopardise renal function in long term. | 30% risk of renal flare (significantly higher if active or recent flare nephritis - advise delay pregnancy 6m)
29
Adverse pregnancy outcomes in lupus
``` Miscarriage IUFD IUGR PTB PET ```
30
What factors influence the adverse pregnancy outcomes in lupus?
Presence of renal involvement, hypertension, APLS and disease activity at the time of conception.
31
Risks of PET and IUGR/PET in a lupus patient with renal involvement.
PET 25-30% | 30% risk IUGR/PTB
32
How should lupus flares be managed?
Steroids
33
What to do with hydroxychloroquine in lupus in pregnancy
Continue as stopping may increase risk of flares
34
What proportion of general population have anti-Ro/La antibodies?
<1%
35
Risk of cutaneous neonatal lupus in patient with anti-Ro/La
5%
36
Risk of congenital heart block in patient with anti-Ro/La
2%
37
What increases the risk of developing a neonatal lupus syndrome?
Previous children affected (15% if one child, 50% if two children)
38
How does cutaneous neonatal lupus present?
- First 2 weeks of life - Erythematous lesions across face and scalp which are photosensitive and may appear after sun/phototherapy - Rash disappears over 4-6m
39
How does congenital heart block present?
- Appears in utero | - Detected due to fetal bradycardia and then echo confirms atrioventricular dissociation
40
Mortality associated with congenital heart block
15-20% (in utero or early neonatal)
41
Treatments for congenital heart block
- None which reverse heart block | - Dexamethasone may reverse lesser degrees of heart block and prevent progression to complete HB
42
What proportion of infants with congenital heart block need pacing in infancy?
50-60%
43
What type of drug infliximab?
anti-TNF
44
What type of drug etanercept?
anti-TNF
45
What type of drug adalimumab?
anti-TNF
46
What type of drug golimumab?
anti-TNF
47
What type of drug certolizumab?
anti-TNF
48
What type of drug anakinra?
Anti-IL1
49
What type of drug tociluzumab?
Anti-IL6
50
What type of drug abatacept?
T cell modulator
51
What type of drug rituximab?
B cell depleting agent
52
What type of drug belimumab?
B cell depleting agent
53
What should be screened for before starting anti-TNF agent?
Latent TB | Cervical smear
54
Which vaccines should be avoided when on anti-TNF?
``` Live vaccines: BCG MMR Oral polio Yellow fever Rotavirus ```
55
What to do if someone with latent TB needs anti-TNF?
Prophylaxis isoniazid + rifampicin
56
Risk of immediate hypersensitivity reaction during first anti-TNF infusion?
3-5%
57
Which type of reaction to anti-TNF is common?
Type alpha reactions - fever, headaches, myalgia (cytokine mediated)
58
Risk of anti-TNF on congenital malformations
None!
59
Which anti-TNF agents are actively transported across placenta?
Infliximab Etanercept Adalimumab Golimumab
60
When should infliximab be stopped in pregnancy?
16 weeks
61
When should etanercept be stopped in pregnancy?
28 weeks
62
When should adalimumab be stopped in pregnancy?
28 weeks
63
When should certolizumab be stopped in pregnancy?
Doesn't need to be :)
64
When can you restart anti-TNF agents after pregnancy?
Immediately but allow a few days if CS wound or perineal wound to reduce risk infection.
65
Breastfeeding with anti-TNF
Yes
66
Risk to neonate if receive anti-TNF later than advised in pregnancy
High neonatal levels with risk of infection. In particular risk of disseminated infection after live vaccination therefore live vaccines should be delayed 6 months if neonate exposed after the suggested gestation.
67
Adverse effects of B cell depleting agents
Cause transient cytopenias and neonatal B cell depletion that can persist up to 6 months
68
How long to avoid pregnancy after rituximab?
12 months

Laura MRCOG Part 2 (56 decks)

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