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Maternal Disorders in Pregnancy Flashcards

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1
Q

What is the fall in BP during pregnancy?

A

30/15 mmHg during the second trimester

Returns to pre-pregnant levels by term

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2
Q

What causes hypertension in pregnancy?

A

Pregnancy-induced - BP rises above 140/90 after 20 weeks

  • pre-eclampsia
  • transient hypertension

Pre-existing - BP above 140/90 before 20 weeks

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3
Q

What is pre-eclampsia?

A

Hypertension
Proteinuria

Blood vessel endothelial damage + exaggerated immune response -> vasospasm, increased permeability and clotting dysfunction

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4
Q

What are risk factors for pre-eclampsia?

A 
Nulliparity
Previous history
Family history
Older age
Chronic HTN
Diabetes
Twin pregnancy
Autoimmune disease
Renal disease
Obesity
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5
Q

What are the classifications for pre-eclampsia?

A

Mild

  • proteinuria
  • mild/moderate HTN

Moderate

  • proteinuria
  • severe HTN with no complications

Severe

  • proteinuria
  • HTN before 34 weeks or with complications
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6
Q

How does pre-eclampsia occur?

A

Incomplete trophoblastic invasion of spiral arterioles so decreased uteroplacental blood flow

Ischaemic placenta + exaggerated maternal inflammatory response causes

  • widespread endothelial cell damage
  • vasoconstriction
  • increased vascular permeability
  • Clotting dysfunction
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7
Q

How does pre-eclampsia present?

A 
Asymptomatic
Headache
Drowsiness
Visual disturbances
Nausea/vomiting
Epigastric pain - complications impending
HTN
Oedema
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8
Q

What are maternal complications of pre-eclampsia?

A

Early onset more severe, any of these is indication to deliver

Eclampsia - grand mal seizure from cerebrovascular vasospasm -> hypoxia
Tx: magnesium sulphate

Cerebrovascular haemorrhage

Liver and coagulation problems - haemolysis (dark urine), elevated liver enzymes, low platelet count, DIC -> epigastric pain
Tx: magnesium sulphate

Renal failure

Pulmonary oedema -> adult respiratory distress syndrome
Tx: oxygen and frusemide

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9
Q

What are fetal complications of pre-eclampsia?

A

IUGR
Preterm delivery
Placental abruption
Morbidity and mortality

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10
Q

What investigations are done for pre-eclampsia?

A

Dipstick urine - if positive, rule out infection with culture

Protein:creatinine ratio (PCR) >30

Blood: high uric acid and Hb

  • rapid fall in platelets
  • rise in LFTs

USS - assess fetal growth
Umbilical artery Doppler and CTG

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11
Q

What is given to reduce risk of pre-eclampsia?

A

75mg aspirin

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12
Q

How is the severity of pre-eclampsia assessed?

A

Woman with new onset HTN is assessed in day unit

If symptomatic, proteineuria 2+, BP >160/110 or suspected fetal compromise then admitted

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13
Q

What medication is used in pre-eclampsia?

A

Antihypertensives if BP >150/10

  • oral nifedipine
  • IV labetalol

Magnesium sulphate

  • prevents eclampsia
  • increases cerebral perfusion
  • indicates delivery should be done
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14
Q

When should babies be delivered with pre-eclampsia?

A

One or more complications are likely within 2 weeks of onset of proteinuria

Mild - deliver by 37 weeks
Moderate - 34-36 weeks
Severe - whatever the gestation by c-section

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15
Q

What medications can be used during labour with pre-eclampsia?

A

Induction with prostaglandin
Epidural
Antihypertensives
Oxytocin rather than ergometrine for 3rd stage

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16
Q

What postnatal care is done for pre-eclampsia?

A

Blood - LFT, platelets and renal monitored
Fluid balance
BP - beta-blocker, nifedipine, ACE inhibitor

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17
Q

What are risk factors for HTN before 20 weeks?

A

Older women
Obesity
FH
HTN with COCP

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18
Q

What blood pressure medication is contraindicated in pregnancy?

A

ACE inhibitors - give labetalol, methyldopa or nifedpine instead

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19
Q

What is red blood cell isoimmunisation?

A

Mother mounts immune response against antigens on fetal RBC

Antibodies cross placenta and cause fetal RBC destruction

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20
Q

What makes up the rhesus system?

A

Three linked gene pairs
Cc Dd Ee
DD or Dd is Rhesus positive
dd is Rhesus negative

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21
Q

What sensitizing events can occur in Rhesus disease?

A

TOP or ERPC after miscarriage
Ectopic pregnancy
Vaginal bleeding

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22
Q

How is Rhesus disease prevented?

A

Exogenous anti-D is given to mother
This mops up any fetal RBC in mother to prevent recognition by mother’s immune system

Given even if “father” is also Rhesus negative
Pointless if maternal anti-D is already present

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23
Q

When is Anti-D given?

A

At 28 weeks
Given within 72hr of sensitising event
Postnatally again if baby is Rhesus postive
Kleihauer test - if large amount of fetal RBC then extra large dose of Anti-D given

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24
Q

How does Rhesus disease manifest?

A

Neonatal jaundice
Neonatal anaemia
In utero anaemia -> cardiac failure, ascites, oedema

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25
How are Rhesus disease women identified?
Screening at booking and 28 weeks gestation | If anti-D less than 10, fetal problem unlikely and levels are checked every 2-4 weeks
26
How is severity of fetal anaemia assesed?
Doppler USS of middle cerebral artery has high sensitivity to significant anaemia Done fortnightly If severe FBS done
27
How is fetal anaemia treated in utero?
If anaemia confirmed during FBS, Rhesus negative, high haemocrit blood is injected into umbilical vein Done in increasing intervals until 36 weeks when baby is delivered
28
What effect does pregnancy have on glucose levels?
Diabetogenic - women with impaired glucose tolerance deteriorate to be classed as diabetic Kidneys start excreting glucose at a lower blood glucose level so glycosuria may occr at physiological concentrations
29
What is gestational diabetes?
Carbohydrate intolerance diagnosed in pregnancy which may or may not resolve after pregnancy Fasting glucose >7mmol
30
What fetal complications are associated with diabetes?
Congenital abnormalities (neural tube and cardiac) - 4x risk Preterm labour - with reduced fetal lung maturity Increased birthweight - fetal pancreatic islet cell hyperplasia -> hyperinsulinaemia and fat deposition Polyhydramnios from increased urine output Macrosomia -> shoulder dystocia and birth trauma Increased fetal compromise, distress and sudden death
31
What maternal complications are associated with diabetes?
Increased insulin requirement UTI and wound/endometrial infection after delivery Pre-eclampsia more common Worsens IHD C-section and instruments more likely Diabetic retinopathy often deteriorates
32
How is pre-existing diabetes managed in pregnancy?
Precise glucose control Fetal monitoring for compromise Appointments every 2 weeks up to 34 weeks and then weekly Usual pregnancy scans + fetal echocardiogram 75mg aspirin from 12 weeks
33
How are babies delivered in maternal diabetes?
By 39 weeks Elective c-section if weight >4kg Neonate commonly develops hypoglycaemia - breast feed
34
What are risk factors for gestational diabetes?
``` Previous history Previous fetus >4,5kg Previous unexplained stillbirth First-degree relative with diabetes BMI >30 South Asian/Black Caribbean/Middle Eastern Polyhydramios Persistant glycosuria ```
35
How is gestational diabetes screened for?
Women with risk factors have GTT at 28 weeks
36
How is gestational diabetes managed?
Diet and exercise Oral metformin Insulin Stop insulin at birth and GTT at 3 months
37
What are the physiological changes of cardiac function in pregnancy?
40% increase in cardiac output - increase in stroke volume and heart rate 40% increase in blood volume
38
How does pregnancy change the ECG?
Ejection systolic murmur Left axis shift and inverted T waves
39
How does pregnancy affect women with pre-existing heart conditions?
Increased cardiac output acts as exercise test | Manifests after 28 weeks or during labour
40
How is cardiac disease managed in pregnancy?
Warfarin -> LMWH ACE inhibitors -> beta-blockers USS at 20 weeks may pick up cardiac anomaly which is more common Check for anaemia
41
How is labour managed in ladies with cardiac disease?
Fluid balance check Elective epidural Elective forceps to reduce stress
42
Which cardiac diseases cause little problem in pregnancy?
PDA VSD ASD
43
Which cardiac diseases complicate pregnancy?
Pulmonary HTN (Eisenmenger's syndrome) - pregnancy contraindicated Aortic stenosis needs correcting before pregnancy - epidural may be contraindicated Mitral valve disease - needs treating before Peripartum cardiomyopathy - develops in last month of pregnancy or following 6 months
44
How is respiratory disease managed in pregnancy and labour?
Long term steroids need upping in labour as chronically suppressed adrenal cortex unable to produce adequate steroids
45
How does epilepsy affect pregnancy?
Seizure control can decrease in pregnancy/labour Sodium valproate - neural tube defect Newborn has 3% risk of developing epilepsy
46
What is optimum management of epilepsy in pregnancy?
Folic acid + carbamazepine or lamotrigine Oral vit K 20 week USS and EKG important to rule out abnormalities
47
What effect does hypothyroidism have on pregnancy?
Miscarriage Preterm delivery Intellectual impairment Pre-eclampsia Monitor TSH, dose may need increasing
48
How does hyperthyroidism affect pregnancy?
Antithyroid antibodies can cross placenta -> neonatal thyrotoxicosis and goitre Maternal thyrotoxicosis may improve in late pregnancy If poorly controlled -> thyroid storm with acute symptoms and heart failure near delivery
49
How is hyperthyroid treated in pregnancy?
PTU as less likely to cross placenta than carbimazole Use lowest dose Safe when breastfeeding
50
What is postpartum thyroiditis?
Can cause postnatal depression | RF: antithyroid antibodies and type I diabetes
51
What are risk factors for Acute Fatty Liver of Pregnancy?
Primips Male babies Twins May be on spectrum of pre-eclampsia
52
How does fatty liver present?
``` Malaise Vomiting Jaundice Vague epigastric pain Thirst ``` Acute hepatorenal failure DIC Hypoglycaemia
53
What is intrahepatic cholestasis of pregnancy?
Itching without skin rash and with abnormal LFTs Abnormal sensitivity to cholestatic effects of oestrogen
54
What is intrahepatic cholestasis of pregnancy associated with?
Sudden stillbirth Preterm delivery Maternal and fetal haemorrhage Reocurrs
55
How is intrahepatic cholestasis of pregnancy managed?
Vit K from 26 weeks UDCA for itching Induction at 38 weeks
56
What is antiphospholipid syndrome (APS)?
Lupus anticoagulant +/- anticardiolipin antibodies occur in association with adverse pregnancy complications Placental thrombosis Recurrent miscarriage IUGR Early pre-eclampsia
57
How is APS managed?
Aspirin and LMWH Serial USS and elective induction at term Postnatal anticoagulation to prevent VTE
58
What is the impact of pregnancy on renal system?
GFR increases by 40% | Urea and creatinine levels decrease
59
How is chronic renal disease managed in pregnancy?
Proteinuria can cause diagnostic confusion with pre-eclampsia Pre-eclampsia IUGR Polyhydramnios Preterm delivery
60
What effect do urinary infection have on pregnancy?
Preterm labour Anaemia Pyelonephritis
61
What effect does pregnancy have on the clotting system?
Pregnancy is prothrombotic - VTE 6x Increased blood clotting factors Decreased fibrinolytic activity Pulmonary embolus and DVT need to be avoided - treat with LMWH
62
What thromboprophylaxis is given in pregnancy?
Compression stockings Antenatal and postnatal LMWH given if: - previous VTE or needed in pregnancy (6 weeks) - increased BMI, smoker, age, elective c-section, labour >24 hours
63
What are complications of obesity in pregnancy?
Maternal - thromboembolism - pre-eclampsia - diabetes - C-section - wound infection - PPH Fetal - congenital abnormalities - increased perinatal mortality
64
How is obesity managed?
Folic acid and vit D Maintain weight in pregnancy
65
Which psychiatric drugs are used in pregnancy?
Prefer to stop lithium, but monthly monitoring if continued SSRIs (preferably fluoxetine) AVOID paroxetine, clozapine and olanzapine
66
What risks are associated with opiate abuse?
``` Preterm delivery IUGR Stillbirth Developmental delay SIDS ```
67
What risks are associated with cocaine abuse?
``` Teratogenic IUGR Placental abruption Preterm delivery Stillbirth SIDS ```
68
What risks are associated with ecstasy abuse?
Cardiac defects | Gastroschisis
69
What risks are associated with benzo abuse?
Facial clefts | Neonatal hypotonia
70
What does smoking increase the risk of?
``` Miscarriage IUGR Preterm birth Placental abruption Stillbirth SIDS ```
71
What is the effect of pregnancy on anaemias?
Increase in blood volume leads to decrease in Hb concentration New normal = 110 Give oral iron and folic acid

Obs & Gynae (20 decks)

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