Maternal Medical Conditions Flashcards

Question

Bleeding Disorders in Pregnancy (RCOG 2017) vWD Preconception (2)

Answer 1

- Genetic counselling about risk of transmission - Subtype of vWD and response to desmopressin

Answer 2

- Multidisciplinary approach - Avoid aspirin/NSAIDs - Check vWF antigen + activity levels and factor VIII levels at booking and in third trimester - Desmopressin with fluid restriction - FFP or cryoprecipitate

Answer 3

- Treatment as close to delivery - Pre- and post-treatment vWF activity/factor VIII levels as well as post-birth - TXA - Platelets (type 2B) - Avoid ECV, FBS, FSE, ventouse or midcavity forceps if fetus may be affected by type 2 or 3 Neuraxial anaesthesia: - Ok for type 1 with normal vWF levels - Avoid in type 2 unless activity and factor VIII >0.5iu/mL - Avoid in type 3 - Consider additional treatment prior to removal of epidural catheter

Answer 4

- IM injections/NSAIDs ok if vWF activity/factor VIII >0.5iu/mL - Maintain levels >0.5iu/mL for 3 days post NVD or 5 days post instrumental/CS - TXA 1g TDS - QID for 7-14 days postnatally - Clexane ok if levels >0.5iu/mL - Risk of delayed bleeding - May need factor concentrate 2-3 weeks following birth for type 3

Answer 5

- Diagnostic tersting - Type 2/3: cord bloods for vWF levels/activity - Oral vitamin K - Consider cranial imaging and prophylaxis for type 3

Answer 6

1. Lesions - Small or mild PS, PDA, mitral valve prolapse - Repaired simple lesions (ASD, VSD, PDA, anomalous pulmonary venous drainage) - Atrial or ventricular ectopic beats 2. Risk - No detectable increased maternal mortality - No/mild increased risk on morbidity 3. Maternal cardiac event - 2.5-5% 4. Once or twice in pregnancy 5. Local hospital

Answer 7

1. Lesions - Unoperated ASD/VSD - Repaired ToF - Most arrhythmias - Turner syndrome without aortic dilatation 2. Risk - Small increased risk of maternal mortality - Moderate increase in morbidity 3. Maternal cardiac event rate - 5.7-10.5% 4. Once per trimester 5. Local hospital

Answer 8

1. Lesions - Mild LV impairment EF >45% - Hypertrophic cardiomyopathy - Native or tissue valve disease not I or IV (mild MS, moderate AS) - Marfan or other hereditary thoracic aortic disease syndromes without aortic dilation - Aorta <45mm with bicuspid AV - Repaired coarctation - Atrioventricular septal defect 2. Risk - Intermediate increased risk of maternal mortality - Moderate-severe increase in morbidity 3. Cardiac event rate - 10-19% 4. See every two months 5. Tertiary hospital

Answer 9

1. Lesions - Moderate LV impairment EF 30-45% - Previous peripartum cardiomyopathy without any residual LV impairment - Mechanical valve - Systemic RV with good or mildly decreased ventricular function - Fontan circulation if otherwise well - Unrepaired cyanotic heart disease - Other complex heart disease - Moderate MS - Severe asymptomatic AS - Moderate aortic dilatation (40-45mm in Marfan or other HTAD, 45-50mm in bicuspid aortic valve, Turner syndrome aortic size index 20-25mm, ToF <50mm) - VT 2. Risk - Significantly increased risk of maternal mortality - Severe morbidity 3. Maternal cardiac event rate - 19-27% 4. See monthly 5. Tertiary centre with specialist obstetric cardiac input

Answer 10

1. Lesions - Pulmonary arterial hypertension - Severe ventricular dysfunction EF <30%, NYHA III-IV - Previous peripartum cardiomyopathy with residual LV impairment - Severe MS - Severe symptomatic AS - Systemic RV with moderate or severely decreased ventricular function - Severe aortic dilatation (>45mm Marfan or other HTAD, >50mm in bicuspid aortic valve, Turner aortic size index >25mm, ToF >50mm) - Vascular EDS - Severe (re) coarctation - Fontan with any complication 2. Risk - Pregnancy contraindicated - Extremely high risk of maternal mortality - Severe morbidity 3. Maternal cardiac event rate - 40-100% 4. See monthly 5. Tertiary centre with specialist obstetric cardiac input

Answer 11

- Pre-pregnancy risk assessment/counselling for all known or suspected patients with heart disease - Risk assessment before and after conception using mWHO classification - Genetic counselling for congenital heart disease/arrhythmias, cardiomyopathies, aortic disease or genetic malformations associated with cardiovascular disease

Answer 12

- High-risk patients managed in tertiary unit with MDT approach - Steroids recommended if mother is for cardiac surgery 24 - <37/40 - Fetal echo if elevated risk of fetal abnormalities - Coronary bypass surgery or valve surgery may be considered when conservative/medical therapy has failed in life-threatening conditions not amenable to PCI Imaging: - CXR when investigating dyspnoea - Echo is recommended for pregnant patients with unexplained or new cardiovascular signs in pregnancy - Consider MRI (without gadolinium) if echo insufficient - CT and electrophysiological studies in select patients - Cardiac catheterisation can be considered with strict indications

Answer 13

- Antibiotic prophylaxis to prevent endocarditis during delivery not recommended - Vaginal delivery recommended for most - Consider delivery before surgery if >26/40 - IOL should be considered at 40/40 for all women with cardiovascular disease - If hypertensive, recommend epidural and consider elective instrumental Caesarean should be considered for: - Standard obstetric indications - Dilated ascending aorta >45mm - Severe AS - Pre-term labour on anticoagulation - Eisenmenger's syndrome - Severe heart failure

Answer 14

- Preconception counselling about aortic dissection risk if known aortic disease - Imaging of entire aorta (CT/MRI) prior to pregnancy with genetically proven aortic syndrome/known aortic disease - Imaging of ascending aorta recommended if bicuspid AV Pregnancy not recommended: - Patients with/history of aortic dissection - Vascular EDS - HTAD with aortic root >45mm - Biscuspid AV with aortic root >50mm (or >27mm/mm2 BSA) - Turner syndrome with aortic size index >25mm/mm2 BSA

Answer 15

- Strict BP management with known aortic dilatation, history of dissection or genetic predisposition - Echo monitoring every 4-12 weeks during pregnancy/6 months postnatal if ascending aortic dilation - Imaging with MRI if known dilatation of distal ascending aorta, aortic arch or descending aorta - Prophylactic surgery should be considered if aorta diameter >45mm and increasing rapidly - ß-blockers should be considered in women with Marfan syndrome/other HTAD - Vascular EDS patients should have celiprolol

Answer 16

- Deliver in a tertiary centre where cardiothoracics is available - If fetus is viable, deliver prior to surgery - Vaginal delivery recommended if diameter <40mm - Epidural anaesthesia - Expedited second stage - Consider caesarean section if aorta diameter 40-45mm - Recommend caesarean section with ascending aorta >45mm or history of aortic dissection - Avoid ergometrine where possible

Answer 17

Pre-pregnancy evaluation including echo and counselling

Answer 18

- Restricted activities and ß-blockers recommended if symptomatic or pulmonary hypertension - Diuretics recommended when CHF sx persist despite ß-blockers - Intervention recommended pre-pregnancy with MS and valve area <1.0cm2 and considered <1.5cm2 - Anticoagulation is recommended for AF, LA thrombosis or prior embolism - Percutaneous intervention should be considered with severe symptoms or systolic pulmonary pressure >50mmHg despite medical therapy

Answer 19

Intervention recommended before pregnancy with severe AS if: - Symptomatic - LVEF <50% - Symptoms from exercise testing Intervention should be considered if asymptomatic with severe AS when a fall in BP below baseline during exercise testing occurs Balloon valvuloplasty should be considered with severe AS and severe sx

Answer 20

Surgical treatment recommended before pregnancy in patients with severe AR or MR with symptoms of impaired function or ventricular dilatation Medical therapy is recommended in pregnancy when symptoms occur

Answer 21

- Mechanical heart valve patients should be managed with tertiary obs/cardiac team - Recommend discontinuing warfarin and start on heparin at 36/40 - Consider continuing warfarin in 1st trimester if <5mg/day, otherwise change to 1mg/kg/BD clexane - Weekly anti-Xa for those on heparin, targeting 0.8-1.2U/L for AV or 1.0-1.2 IU/ML for mitral and RV replacements - 1-2 weekly INR on warfarin - Echocardiogram with mechanical vales and dyspnoea or embolic event

Answer 22

- Caesarean recommended if labour starts while on warfarin or <2 weeks after discontinuation - Recommend changing LMWH to UFH >36/40 before planned delivery. UFH continued until 4-6h pre-birth and restarted 4-6h after if no bleeding

Answer 23

- ECG and troponin recommended when a pregnant woman has chest pain - Primary coronary angioplasty is recommended as preferred re-perfusion for STEMI - Consider invasive reperfusion for NSTEMI with high risk criteria - Conservative management for stable NSTEMI with low risk criteria - Breastfeeding not recommended in mothers who take antiplatelets other than aspirin due to lack of evidence

Answer 24

- Counsel women with reduced EF about risk of deterioration during pregnancy and peripartum - Risk of recurrence in subsequent pregnancies of peripartum/dilated cardiomyopathies, even if LV function has recovered - Pregnancy should be avoided in peripartum/DCM if LV hasn't recovered

Answer 25

- Anticoagulation recommended for patients with intracardiac thrombus or systemic embolism or AF - Treat women with heart failure using non-pregnancy guidelines, omitting contraindicated drugs - Continue ß-blockers or commence them if indicated for women with reduced EF - Cardiogenic shock/inotrope requirement should be transferred to a facility where mechanical circulatory support is available - Bromocriptine may be considered to stop lactation and enhance recovery in peripartum cardiomyopathy (with anticoagulation)

Answer 26

- Same risk stratifications as non-pregnant women - ß-blockers should be continued - ß-blockers should be started if develop symptoms of LVOT or arrhythmia - Cardioversion should be considered for persistent AF

Answer 27

- Vagal manoeuvres or adenosine for acute conversion of PSVT - Electrical cardioversion for any tachycardia with haemodynamic instability or AF - ß-1 selective ß-blockers for acute conversion of PSVT - Flecainide for termination of atrial flutterAF in stable patients with normal hearts

Answer 28

- ß1-blockers or Verapamil for prevention of SVT - Flecainide for prevent of SVVT with WPW - ß-blockers recommended for rate control of atrial tachycardia/AF - Flecainide or Sotalol should be considered for prevention of SVT, atrial tachycardia or AF if AV nodal blocking agents fail - Digoxin or Verapamil should be considered for atrial tachycardia or AF if ß-blockers fail - Catheter ablation should be considered if drug-refractory and poorly tolerated SVT

Answer 29

- Immediate electrical cardioversion for sustained unstable and stable VT - Can consider ß-blocker, Sotalol, Flecainide or pacing if stable monomorphic VT

Answer 30

- ICD recommended pre-pregnancy if

Answer 31

- ßhCG similar to TSH, so there may be a transient increase in T4 with suppression of TSH - Increased GFR = increased iodine clearance = increased iodine intake in pregnancy - If pre-existing thyroid disease, cannot respond to physiological demands of pregnancy = increased thyroid replacement required - Fetus is reliant on transplacental maternal thyroid hormone until 12/4- - Fetus and fully breastfed infant is dependent on maternal iodine for thyroid hormone synthesis

Answer 32

Use local pregnancy-specific ranges for TSH and T4 - TSH can be 0.5mU/L than non-pregnancy range for 1st trimester, then the same in 2nd and 3rd trimesters - 4mU/L is the upper limit of normal throughout pregnancy Hypothyroidism is defined as: - Increased TSH and low T4 - Or TSH >10mU/L regardless of T4 level

Answer 33

Adverse effects (untreated): - Anovulation and miscarriage - PET - Placental abruption - Anaemia - PPH - Prematurity - Perinatal mortality - Neurodevelopmental delay in children Target Testing recommended: - Symptoms of thyroid disease - T1DM - Personal hx thyroid disease Treatment and Monitoring - Pre-existing thyroid disease: 30-50% increase in thyroxine (2x doses per week) - Monitor TSH at least once per trimester - Target TSH lower half of trimster-specific ranges

Answer 34

- Inconsistent data between SCH and adverse pregnancy outcomes - Treatment not recommended, even if TPO-ab positive Recurrent Miscarriage: - No proven benefit in treating euthyroid TPO-positive women to prevent miscarriage - Mixed evidence in treating SCH to reduce miscarriage

Answer 35

No AEDs: 2.8% Carbamazepine: 2% - Neural tube defects: 0.5-15 - Cleft palate - Enzyme-inducing - Least risk <400mg/d Lamotrigine: 3.4% - Least risk <300mg/d Levetiracetam: 0.7% Phenobarbitol: 6.5% - Cardiac malformations - Enzyme-inducing Phenytoin: ~3% - Cardiac malformations - Cleft palate - Enzyme-inducing - Phenytoin syndrome (3-5%: mental retardation, SGA, craniofacial anomalies, limb defects Sodium valproate: 10.7% - NTD: 1-2% - Facial cleft - Hypospadias - Polydactyly - Kidney malformations - Cardiac malformations - Long-term neurodevelopmental issues - Childhood autism - Generally avoid Polytherapy: 16.8% Previous child with major malformation: 16.8%

Answer 36

- Consider stopping AED if seizure free for 2-5 years - Change AED to one safer in pregnancy - Pre-conception counselling about likelihood of fetal anomalies with each drug - High dose folic acid at least 3 months pre-conception until at least the end of the first trimester

Answer 37

- MDT input - 5mg folic acid until end of first trimester - No clear evidence routine monitoring of AED levels improves outcome (case-by-case) - Fetal anomaly scan 18-20+6 - Serial growth scans from 28/40

Answer 38

- Birth in centre with obstetrics/neonates - Mode of birth as per usual obstetric indications - One-to-one midwifery care - Consider IV access - Avoid triggers - Continue AEDs - CEFM if high risk of seizure or following intrapartum seizure Pain relief: - Early epidural to minimise triggers - TENS, entonox, morphine all safe - Avoid pethidine, ketamine, sevoflurane - Consider water birth if seizure-free for significant period of time

Answer 39

- Left lateral tilt - Airway management/oxygenation - Benzodiazepines +/- phenytoin as per local protocols - Consider tocolysis if uterine hypertonis - CTG following stabilisation of mother - If seizure >5 minutes or recurrent, consider expediting delivery

Answer 40

- Higher risk of seizure immediately after delivery compared to antenatal (still low risk) - Minimise triggers (sleep deprivation) - Review AED dose within 10 days to avoid postpartum toxicity - Education around seizure and infant safety - Screening for depressive disorders

Answer 41

- IUD/IUS reliable and not affected by enzyme-inducing AEDs - POP, COCP and jadelle at increased risk of failure on enzyme-inducing AEDs - COCP and lamotrigine is associated with decreased lamotrigine levels = increased seizure risk

Answer 42

- Alert neonatal team due to risk of neonatal withdrawal syndrome from benzodiazepines and AEDs - Vitamin K IM to prevent haemorrhagic disease of the newborn on enzyme-inducing AEDs - Benefits of breastfeeding generally outweigh small risk to infant; monitor for sedation and poor feeding

Answer 43

Hypertension in pregnancy: - sBP ≥140mmHg - dBP ≥90mmHg - 3 consecutive readings at least two minutes apart, repeated again >4h to confirm - Mild: 140-159/90-109mmHg - Severe: ≥160/110mmHg GHTN - Elevated BP ≥140/90mmHg on two readings at least 4h apart - Diagnosed for the first time >20/40 - Absence of any features suggestive of PET PET - Hypertension - Evidence of end-organ dysfunction CHTN - Elevated BP pre-pregnancy or <20/40 - Retrospective diagnosis if GHTN persists >3/12 postnatal Whitecoat HTN - Elevated BP in clinical setting - Normal ambulatory or home BP readings - Progression to persistent HTN/PET: 8% Masked HTN - Normal BP in clinical setting - Raised BP on ambulatory or home monitoring - Outcomes for those presenting >20/40 equate to GHTN

Answer 44

1. Signs/symptoms of pre-eclampsia 2. BP monitoring - Day unit - Home BP monitoring - Inpatient admission 3. Investigations - CBC +/- ix for haemolysis - UECs - LFTs - uPCR - sFlt-1/PlGF as per local availability - Fetal growth assessment 4. Inpatient admission indicated for: - Severe HTN - Symptoms associated with adverse outcomes: headache, neurological irritability, epigastric/chest pain, dyspnoea, nausea/vomiting

Answer 45

Women should be screened for their risk of PET early in pregnancy Combined first trimester screening to identify women at risk is conditionally recommended based on local availability - Maternal features - Biomarkers - Sonography: UtA-PI High risk: 1 or more risk factors - Previous hypertensive disorder in pregnancy - CKD or renal impairment - Multi-fetal gestation - Pre-existing CHTN - Pre-existing diabetes mellitus - Autoimmune disorders (SLE, APS) Moderate risk: 2 or more risk factors - AMA 40y - BMI ≥35 - Fhx PET - Interpregnancy interval >10y - ART - sBP >130mmHg or dBP >80mmHg at booking

Answer 46

Mechanism: - Non-selective irreversible COX-1 inhibitor - Decreases TXA concentration - Mediation of unbalanced TXA/PGI-2 ratio - Reduces platelet aggregation and inhibits vasoconstriction when there is enhanced uterine blood flow Recommendations - Aspirin recommended in women at high risk of PET <16/40 - 150mg/day strongly recommended - Bedtime aspirin conditionally recommended - Cessation between 34/40 and birth based on clinical judgement and shared decision making - Universal aspirin in low-risk nulliparous population not recommended - Counselling on use of aspirin in pregnancy recommended to improve adherence Benefits: - PET: RR 0.67 - Early onset PET: RR 0.29 - Preterm birth: RR 0.51 - SGA: RR 0.52 - No statistically significant difference in placental abruption, APH, PPH or neonatal intra-cerebral haemorrhage - Small benefit in reducing risk of PTB when commenced >16/40 but nil else

Answer 47

- Recommended in women with low dietary intake of calcium to prevent PET, PTB and GHTN <1g/day - Assess dietary intake prior to recommending oral calcium - Consider assessing serum calcium level in those taking calcium to avoid hypercalcaemia

Answer 48

- Urine dipstick can be used for screening but is inadequate to diagnose proteinuria - Confirmatory testing with uPCR/ACR recommended if clinical suspicion of PET - uPCR >30mg/mmol, uACR ≥8mg/mmol - Cut-off for multiple gestation is unclear - Repeated urinary protein assessment in women with proteinuria from established PET not recommended in the absence of other indications

Answer 49

Clinical and biochemical features of PET overlap with abnormalities from other medical issues (CHTN, CKD, chronic liver disease, SLE) sFlt-1 - Soluble fms-like tyrosine kinase 1 - Anti-angiogenic factor PlGF - Placental growth factor - Pro-angiogenic factor Prediction sFlt-1/PlGF ≤38 rules out PET - Within 1 week: NPV 99.3% - Within 4 weeks: NPV 94.3% - Ratio >38 not helpful in ruling in PET within 4 weeks: PPV >36% Recommendations - Utility of sFlt-1/PlGF ≤38 in ruling out PET within 1-4 weeks of testing in women where there is a clinical suspicion of PET is recommended where available in a timely manner - Not recommended to diagnose PET, determine fetal outcome, severity of disease, timing of birth or for routine screening in asymptomatic women - Use as an adjunct to clinical assessment - PlGF use alone has not been clinically validated

Maternal Medical Conditions Flashcards

(74 cards)