Intrapartum Care for women with medical conditions or obstetric complications & their babies NICE 2019

Question 1

Described NYHA
Class 1
Class 2
Class 3
Class 4

Answer 1

Class 1 No Sx
Class 2 Sx at ordinary activity
Class 3 Sx at less than ordinary activity
Class 4 Sx at rest

Question 2

Women with mechanical heart value who are taking warfarin in 3rd trimester, when to switch to LMWH

Answer 2

Switch by 36 weeks or 2 weeks before planned birth
Start LMWH after 24hrs, BD dosing

Question 3

When to check anti-Xa levels? What should be the aim?

Answer 3

3-4 hours after LMWH
Aim 1.0-1.2

Check trough dose (before LMWH) >0.6

Question 4

Once anti-Xa level is in target how often should it be checked?

Answer 4

1 x weekly

Question 5

If mechanical heart valve when to stop therapeutic LMWH?

Answer 5

24 hours before planned CS, perform CS as close to 24 hours as possible, no later than 30 hours

Or switch to IV unfractioned heparin (stop 4-6 hours before CS)

Question 6

If IOL and mechanical heart value, a senior obstetrician should be involved with:

Answer 6

• Decide when to stop IV unfractioned heparin to LMWH
• Reviewing progress of labour - 12 hours from LMWH, 4-6 hrs IV uheparin

Question 7

If mechanical heart value on warfarin and present in labour>

Answer 7

Check INR, discuss with haemorrhage
Senior review (Obs, haem, anaesthetics)
Consider reversal

Question 8

Post partim review for women with mechanical heart value

Answer 8

Assess within 3-4 hrs after birth by senior obs and anaesthetics

Aim restart LMWH/uheparin within 4-6 hours

Question 9

When to restart warfarin in women with mechanical heart value postnatally?

Answer 9

At least 7 days after birth with specialist follow up

Question 10

Offer planned CS to which women with cardiac conditions

Answer 10

High risk disease of aorta
PAH
NYHA class 3-4

Offer IOL or CS to mechanical heart value

Question 11

For which women is fluid balance critical to heart function?

Answer 11

• severe left-sided stenotic lesions (for example, aortic stenosis and mitral stenosis)
• hypertrophic cardiomyopathy
• cardiomyopathy with systolic ventricular dysfunction
• pulmonary arterial hypertension
• Fontan circulation and other univentricular circulations
• NYHA class IV heart disease.

Question 12

For women who fluid balance is critical what monitoring should be done?

Answer 12

Hourly fluid input/output
Cont ECG
Cont intra-arterial BP monitoring
Cardiac output monitoring with non-invasive techniques

Question 13

What Sx may indicate heart failure if no other cause?

Answer 13

SOB lying flat/at rest
Unexplained cough, espieaclly lying flat/frothy pink
PND
Palpiatations

Question 14

Consider heart failure in intraprtum period if:

Answer 14

pale, sweaty, agitated, cool peripheries
HR >110
RR >20
Low BP
O2 sats <95% RA
Elevated JVP
Added murmur or HS
reduced air entry, basal crackles/wheeze

Question 15

What Ix if suspect heart failure?

Answer 15

IV cannula
Bloods FBC, U+E
ABG
ECG
CXR

If cannot be ruled out - ECHO and BNP

Question 16

What considerations should be taken for regional anaesthesia WHO class 3-4

Answer 16

Involve anaesthetic
Consider regional
Preserve CV stability - sequential Combine spinal-epidural technique
Cont invasive intra-arterial pressure monitoring

Question 17

For patients with significant aortopathy, what uterotonics can you give, what us contraindicated?

Answer 17

1st: Oxytocin
2: Miso and Carboprost

Avoid Ergo (hypertension induced aortic dissection or rupture)

Question 18

For patients with low cardiac output , what uterotonics can you give, what us contraindicated?

EF < 30%, severe valvular stenosis, HCOM, fontan, cyanotic heart disease

Answer 18

1. Slow infusion oxytocin (avoid haemodynamic change)
2. Miso and carboprost

Avoid Long acting oxytocin analogues and erometrine

Question 19

For patients with pulmonary arterial hypertension , what uterotonics can you give, what us contraindicated?

Answer 19

1. Oxytocin
2. Miso

Avoid: Ergo, carboprost and long acting oxytocin analogues

Question 20

For patients with coronary artery disease , what uterotonics can you give, what us contraindicated?

Answer 20

1. Oxytocin
2. Miso

Avoid ergo

Question 21

What uterotonic to avoid in parties with asthma?

Answer 21

Carboprost - prostaglandin F2 alpha, risk of bronchospasm

Question 22

What amount of steroids is considered long term to cause adrenal insufficiency?

Answer 22

5mg preg OD for > 3 weeks

Question 23

If on long term steroids, what should be done in labour?

Answer 23

Continue regular steroids and when established in labour IM hydrocortisone - minimum 50mg every 6 hours and 6 hours after baby born

Question 24

If on long term steroids, what should be done for CS?

Answer 24

Continue regular +
IV hydrocortisone 50mg if had hydrocortisone in labour
IV 100mg if not had

Further dose 6 hours after delivery

Question 25

Plan from 36 weeks in woman with ITP

Answer 25

Weekly bloods from 36 weeks Deliver on LW If <50 - discuss intrapartum plan with obs and haem, consider steroids and IVIG Consider baby will be at risk of bleeding

Question 26

Under what count is regional anaesthesia contraindicated, based on platelet counr

Answer 26

Contraindicated < 50 Consider 50-80, clinical Hx, woamsn preference, anaesthetic expertise

Question 27

What plan should be in place for baby of mother with ITP?

Answer 27

Inform neonates No FBS/ventose/mid-cavity or rotational forceps, Measure platelet count in the umbilical cord @ birth

Question 28

Is baby at risk in gestational thrombocytopenia?

Answer 28

No

Question 29

What should be considered for women with bleeding disorders in 3rd stage

Answer 29

Do not give utertonics IM Carefully monitor blood loss No NSAIDs

Question 30

How to classify women as low or high risk who have Hx intracranial bleeding or AV malformation?

Answer 30

Low risk: Fully treated CV malformation, intracranial bleeding of unknown cause >2 years ago High risk: untreated or partially treated CV malfoamrtion that has bleed previously, aneurysm 7mm +, complex AV malformation, cavernous with high risk features, intracranial bleeding within the last 2 years

Question 31

If low risk of bleeding

Answer 31

Mode of birth woman's preference and obstetrics

Question 32

If high risks of cerebral haemorrhage who prefer to aim for vaginal delivery or in the second stage of labour

Answer 32

Consider CS Offer regional anaesthesia Explained risk of assisted 2nd stage vs active pushing alone

Question 33

Cor CKD 4-5 what should be the management in labour?

Answer 33

MDT - Obs, anaesthetis, MW, renal physician HR hourly At least 4 hourly: BP/RR/fluid output/O2 Sats Individualised fluid plan to avoid AKI/pulmonary odeama Assess renal function every 24 hrs

Question 34

How to manage AKI

Answer 34

Identify and correct cause HR hourly At least 4 hourly: BP/RR/fluid output/O2 Sats 250mls fluid bolis and review fluid status Monitor fluid balance and renal function Avoid nephrotoxics

Question 35

Consider planned delivery by 40 weeks for which renal disorders?

Answer 35

CKD stage 1, urine PCR >300 CKD 2-4 with stable renal function

Question 36

When should women with CKD stage 5 or 3b/stage 4 that are deteriorating?

Answer 36

Before 34 weeks Consider dialysis Do not deliver after 38 weeks

Question 37

when should critical care specialist be involved for a women with sepsis in labour

Answer 37

Altered consciousness Hypotension Reduced UO 40% oxygen to maintain sat>92% temp <36

Question 38

If someone who is unbooked in labour, what questions should you as, to investigate safeguarding?

Answer 38

- young maternal age - maternal mental health - maternal learning disability - maternal substance misuse - domestic or sexual abuse - homelessness - human trafficking - undocumented migrant status - female genital mutilation - the woman or family members being known to children's services or social services.

Question 39

what Ix to do for unbooked pregnancy

Answer 39

Obstetric and general examination USS Booking bloods, random blood glucose, HIV/Hep B/syphilis Escalate to safeguarding Communicated with GP

Question 40

CKD deficiency Stage 1 Steg 2 Stage 3 Stage 4 Stage 5

Answer 40

St 1: Normal >90 St 2: Mild 60-90 St 3a: Mild - mod 45-59 St 3b Mod-severe 30-44 Stager 4 severe 15-29 Stage 5 <15