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1

The CLASP Trial
- Journal/Author
- Objective
- Enrolment
- Primary outcome
- Findings

The Lancet 1994
Redman et.al.
Prospecitve, multicentre, double blind placebo control RCT
To reliably characterise the safety of LDA and to determine if Rx produces worthwhile effects in pregnancies considered at high risk of PET or IUGR.
9300 women, ’88-’92.
12-32 weeks
Clinician judged to ‘be at risk of PET’ enough for LDA to be contemplated > randomised to LDA or placebo.
> Prophylactic group (previous PET or IUGR, HTN, kidney dx, other RF)
> Rx group (symptoms or signs of PET or IUGR)

>> 60mg Aspirin or placebo from 12/40 to delivery

Primary:
- Proteinuric PET
- GA
- BW, and BW <20/40

*NON-SIG*
- 12% redn PET with proteinuria
- 1 day longer GA
- BW 32g heavier
- No increased bleeding risk (APH or abruption)
- No effect SB/NND/total mortality

2

Polyhydramnios - Causes

Maternal:
- Diabetes
Foetal:
- Neurological impairment
- GIT obstruction
- Multiple gestation
- Parvo infection
- Other causes of high output heart failure e.g. foetomaternal haemorrhage or alloimmunisation
- Aneuploidy
Idiopathic

3

Heparin Induced Thombocytopaenia

5% of people on Heparin for >5/7
Usually develops within 5/7
Usually resolves after 7/7

4

Risk factors for VTE in Pregnancy and the Puerperium
(> or = 3 consider AN prophylaxis; >= 2 consider 7/7 PN)

- Previous VTE
- Thrombophilia
- Medical dx (heart, kidney, sickle, IVDU)
- >35y
- BMI >30
- Parity >2
- Smoker
- Varicose veins
- Paraplegia
OBS
- Multiple pregnancy
- PET
- CS
- OHSS
- IVF
- Prolonged labour or rotational delivery
- PPH > 1L
OTHER
- Operation
- OHSS
- Hyperemesis
- Admission/immobility
- post part wound infection
- long distance travel

5

RR of VTE
- Non-preg
- LNG
- Gestodene
- Pregnancy

- Non=preg 5/100 000
- LNG RR 3
- Gesteodene RR 5
- Pregnancy RR 12

6

Contraindications for COCP (2 VTE risk)

- Current or previous VTE
- 1st degree relative w VTE < 45y
- Known thrombophilia
- Within the first 3/52 PP
- Immediately following T1/T2 TOP
- Smoking (within 1y) and >35y (20x risk)
Caution...
- BMI > 35
- Superficial thrombophlebitis
- Immobilisation
- SLE
- 1/12 pre-op

7

Foetal risks of PD pregnancy

SB - at 41/40 RR 1.3 (0.1%), and 42/40 RR 2
Birth asphyxia
Macrosomia
IUGR
Birth trauma - CPD, SD, #, BPI
Mec asp
Low apgars
CP
Early epilepsy

8

Maternal risks of PD pregnancy

CS/labour dystocia
3rd/4th degree tears
PPH
Failed VBAC

9

NNT PD IOL perinatal death

410

10

Cochrane PD IOL

- less CS
- fewer perinatal deaths
- less mec asp

11

Hannah et. al. NEJM 1992. IOL c.f. expectant mgt in PD preg.

Canadian multi centre RCT
3400 women
>41/40, well, singleton
IOL vs expectant (3x/wk CTG and AFI, kick counts)
1: PNM (underpowered)
2: MOD
Findings:
- more mech and foetal distress in expectant group
- PNM not SS
- less CS IOL (SS)
- Similar rates of instrumental delivery

12

EDS = >13

PPV 62%

13

Neonates and SSRIs

Risk of ‘poor neonatal adaptation:
- poor sleep, irritability, hypoglycaemia
- 5-85%
- usually mild and self limiting
- resolve within 2/52
- 0.7% chance of seizure

14

Folate for prevention of NTD

RR 0.28

15

Causes of thrombocytopenia - Preg

- HELLP
- PET
- AFLP
- DIC

16

Causes of thrombocytopenia - Not pregnanct

Infection
- malaria
- HIV
HUS
Hypersplenism
Spurious result
Drugs
- Heparin
- Antiinflammatories
- Antidepressants
BM infiltration

17

Neonates affected by ITP

10-15% will have plt < 50
5% plt < 20

18

Rx ITP

Steroids
IVIG

19

RANZCOG 5 Principles of PPH

- Recognition
- Communication
- Resuscitation
- Monitoring and Ix
- Direct Rx

20

Anti D prophylaxis - reduction in alloimmunisation

1% to 0.3%
70% reduction

21

T1 indications for Anti-D

MC
TOP
Ectopic
CVS

22

T2/3 indictations for Anti-D

- ECV
- Abdo trauma
- APH
- Amnio/cordocentesis

23

Puerpeural psychosis - prevalence

0.1%

24

AN anxiety/depression

10%

25

PN anxiety/depression

16%

26

Post birth PTSD

2-3%

27

Breech - risk of DDH

Girl 12%
boy 2%

28

Timing of division of zygote in twins

DCDA 13 days

29

What ar the inherited thrombophilias?

Proteins:
- Antithrombin III
- Protein C
- Protein S
Genes:
- Factor V Leidence (Activated protein C resistance)
- Prothrombin gene mutation
- Homozygote MTHFR``

30

What are the acquired thrombophilias?

Hyperhomocycteinaemia (no good evidence of increase in thrombotic disease)
Antiphospholipid syndrome
Platelet pathology