maternal medical problems Flashcards

Question

Cocaine

Answer 1

Fetal effects Potent vasoconstriction (fetal vascular disruption) Transplacental passage greatest T1 and T3 and it limits gas and nutrient exchange Placental abruption Meconium liquor PPROM Fetal hypoxia IUGR Preterm birth Stillbirth Intestinal atresia, limb reduction defects, aplasia cutis Restricts head circumference Prune-belly syndrome, hydronephrosis, hypospadias, heart defects, gastroschisis Neonatal withdrawal syndrome (peak at 3 days of life and may persist for 3 weeks, increased risk of mild ICH in babies with LBW) Long term effects on children: reduced HC, developmental delay, reduced verbal and visual reasoning, more likely to live with relatives or in foster homes, more likely to be aggressive Mx- recommend cessation, give support

Answer 2

Commonest illicit drug used in pregnancy Increased chance of gastroschisis No evidence of abnormal developmental outcome at 1 month However negative effect on performance present at 3 years

Answer 3

``` Maternal risks Increased risk HTN and PET   Fetal risks Cleft palate and gastroschisis Vasoconstriction leads to: Fetal hypoxia IUGR Stillbirth Placental abruption Preterm birth Neonatal withdrawal Effect on children: 80% brought up in stable foster homes Impaired long-term growth Poor school performance with significant deficits in maths and languages ``` ``` Mx MDT care Encourage stopping drug use Frequent BP and urine checks Monitor fetal growth CEFM in labour Inform paeds of impending delivery ```

Answer 4

``` Effect of depression on pregnancy Maternal risks: Substance abuse Postpartum depression PET Fetal risks: Low birthweight Pre-term birth Effect of pregnancy on depression N/A ``` Risk factors for depression in pregnancy Previous depression (5x risk) Family history of mood disorder Marital conflict Younger age Limited social support with greater numbers of children Tobacco or alcohol use Unemployed Lower educational attainment   Management MDT with maternal mental health Depends on severity and woman's preference First line is CBT Antidepressants if this fails, or severe symptoms, or functional impairment SSRI or SNRI Ideally avoid paroxetine in the first trimester (minor congenital heart disease) and not in pregnancy if possible (neonatal toxicity- lethargy, hypotonia, anticholinergic Sx and withdrawal Sx) Discuss the risk of relapse of 75% if antidepressant is discontinued in pregnancy Postnatally observe for postnatal depression

Answer 5

Effect of pregnancy on Cushings None Effect of Cushings on pregnancy ``` Fetal Miscarriage IUR Prematurity Mortality High maternal cortisol may suppress fetal corticosteroid secreation and cause neonatal adrenal insufficiency Maternal Mortality CHF due to HTN PET GDM Wound breakdown Infections Emotional lability Pscyhosis ``` ``` Management Pre-pregnancy Well controlled women do well Advise complete treatment pre-pregnancy Optimise HTN and DM ``` Pregnancy MDT care with MFM and obs med etc First line treatment for adrenal tumours is surgery and this should be timed in the second trimester (safe in pregnancy and reduces risk of fetal loss, prematurity and maternal morbidity) Second line treatment is medical and there is no evidence for safety Routine care UA dopplers at 22-24 weeks Regular growth USS Vaginal delivery preferred due to poor wound healing Monitor mother and baby for cortisol withdrawal

Answer 6

``` Maternal consequences Most asymptomatic Rarely have features of increased calcium   Fetal consequences High perinatal complication rate Fetal loss and neonatal tetany ``` Mx Maternal parathyroidectomy   Prolactinomas Effect of pregnancy on prolactinomas Microprolactinomas <1cm: less than 3% have symptomatic growth in pregnancy Macroprolactinomas >1cm: 30% have symptomatic growth, highest in T3 Effect of prolactinomas on pregnancy No adverse effects ``` Mx Pre-pregnancy MDT Avoid pregnancy until treated MRI Pituitary function Folic acid Bromocriptine/cabergoline Surgery for macroprolactinomas Radiotherapy   Pregnancy Obs led care with MDT input Routine pregnancy care Microprolactinoma: monitor Sx each trimester and stop meds Macroprolactinoma: give cabergoline and review monthly If symptoms check visual fields and get MRI If tumour enlarged: Elective delivery if fetus mature Medical treatment with cabergoline if premature Surgery if failed medical treatment ``` Delay radiation until after surgery Mode of birth as per usual obstetric indications Cabergoline may suppress lactation MRI to monitor size

Answer 7

Effect of acromegaly on pregnancy ``` No adverse effect as growth hormone does not cross the placenta   Effect of pregnancy on acromegaly Tumour growth may cause visual field defects Pregnancy does not alter the course   Management Prepregnancy MDT input MRI to evaluate size of tumour Pituitary function tests Screen for DM, HTN and cardiomyopathy Surgery +/- radiotherapy +/- cabergoline/bromocriptine Folic acid ``` Pregnancy MDT team Treatment can usually be delayed until after pregnancy unless significant tumour growth Observe for signs of tumour growth Routine care Mode of birth as per usual obstetric indications Breastfeeding fine (lactation may be suppressed by cabergoline)

Answer 8

Objective testing and treatment without delay when suspected Management Involve haematology Check: FBC, UEC, thrombophilia screen, coags and LFTS Consider fetal risks (but minimal as heparin does not cross the placenta) Start LMWH 1mg/kg BD (preferred in pregnancy) Monitor platelets 7-10 days after starting Arrange antenatal anaesthetics review Plan for labour When in labour, withhold LMWH, restart post-partum (6 hours post vaginal birth, 12 hours post LSCS) For an IOL administer a prophylactic dose on the day prior and continue this until labour has established To avoid epidural haematoma, no LMWH for 12 hours after prophylactic dose and 24 hours after treatment dose Do not give LMWH for 4 hours after epidural catheter inserted/removed For LSCS Thromboprophylactic dose on day prior to delivery and omit on morning of delivery Thromboprophylactic dose 3-4 hours after delivery and treatment dose that evening Consider UF heparin in high risk of bleeding Start warfarin postnatally Day 2-3 Check INR daily and target INR 2.0-3.0

Answer 9

``` Effect of pregnancy on ITP Nil Detected in the first trimester  Effect of ITP in pregnancy Mother Relates to platelet count Baby Antiplatelet antibodies cross the placenta causing thrombocytopenia in 20-30% of cases Risk of bleeding is low (ICH risk 2%) Blood sampling not needed   Management Pre-pregnancy MDT care- haem and obstetricians Advise women with severe refractory ITP to avoid pregnancy ``` Consider splenectomy and give women penicillin V 250mg BD and pneumococcus and meningococcal, H. Influenzae vaccines Pregnancy Platelets every 2-4 weeks Aim for platelets >80 for delivery Treat: prednisone, IvIG, splenectomy, azathioprine, platelet transfusion Review by anaesthetics to discuss plan for analgesia Inform anaesthetics/paeds regarding delivery If platelets <80 avoid regional If platelets <50 have platelets available Avoid FSE, FBS, ventouse, difficult forceps Repair perineal trauma promptly Observe wound sites Avoid NSAIDS, can give Clexane if platelets >50 Cord blood for neonatal platelet count and monitor

Answer 10

``` Effect on pregnancy Haemodilution, increased platelet activation and clearance Maternal risks relate to platelet count No adverse fetal effects   Management No adverse consequences Monthly platelet counts Ensure ITP excluded ```

Answer 11

Haemophilia A (factor 8): severity constant in a family Haemophilia B (factor 9): more mild vWD type 1: mild vWF and Factor VIII deficiency vWD type 2: qualitative defect, type 2b associated with thrombocytopenia vWD type 3: severe   Effect of pregnancy on haemophilia and vWD FVIII and vWF increase with increasing gestation so there is an improvement in both Both rapidly fall after delivery No increase in F IX levels in pregnancy (haemophilia B) 2b vWD thrombocytopenia worsens in pregnancy 3 vWD no increase in vWF with gestation   Effect of haemophilia and vWD on pregnancy Risk of excessive bleeding with early pregnancy miscarriage, ectopic, CVS Increased risk PPH (20% in vWD, mainly secondary) Spontaneous bleeding in affected fetus is rare Traumatic delivery may cause ICH and cephalohaematoma   Severity of disease: Bleeding disorder correlates with factor level: factor level >/= 40 is safe tor vaginal birth If <40 then need Rx at the onset of labour Management Pre-pregnancy MDT care, management with haematologists, haemophilia team Genetic counselling For haemophilia: confirm history and carrier status, consider PIGD For vWD: assess subtype, avoid aspirin and NSAIDs in type 2b, offer hep A and B vaccine, assess the effect of DDAVP   Pregnancy Test factor XIII and vWF levels in early pregnancy, 2nd and 3rd trimesters, and prior to delivery as may not need treatment if factor levels rise in pregnancy Anaesthetic review to discuss regional analgesia In labour- FBC and G&H, factor XIII and vWF If levels <50 then start treatment at the onset of labour DDAVP Recombinant factor 8 TXA If levels <40 then avoid IM injection Avoid regional if factor levels not in normal range When risk of affected baby: Atraumatic unassisted vaginal delivery Avoid FSE and FBS Avoid ventouse and difficult forceps delivery Low cavity forceps by an experienced operator is preferable to a difficult LSCS Repair perineal trauma promptly Monitor for bleeding from wound sites and for primary/secondary PPH Maintain factor levels >40 for 3-4 days after vaginal delivery and 4-5 days after LSCS Contraceptive advice Cord bloods from baby for factor assay and avoid IM injections until haemophilila/vWD status known

Answer 12

``` Effect of pregnancy on sickle cell Increased frequency of sickling Increased frequency of painful crises Increased susceptibility to infection (hest, urinary tract)   Effect of sickle cell on pregnancy Fetal risks Miscarriage FGR PTB Fetal distress Perinatal mortality 4x ``` ``` Maternal risks PET Placental abruption Thromboembolism Bone marrow embolism (acute chest syndrome) Increased mortality   Management MDT team Partner screening 5mg folic acid throughout pregnancy Prophylactic penicillin 250mg BD Regular Hb, urinanalysis and BP Regular growth scans Thromboprophylaxis if needed Uterine artery dopplers at 20 weeks then from 24 weeks Urine dip and BP each visit ``` ``` Mode of birth for obstetric indications Continue penicillin Ensure adequate pain relief Continuous CTG Maintain hydration Consider post-partum thromboprophylaxis ```

Answer 13

Effect of pregnancy on beta thal Trait: mild anaemia in pregnancy Major: worsened disease and transfusion requirement   Effect of beta thal on pregnancy Trait: normal outcome Major: if Hb maintained >100, well chelated and no bone abnormalities, then good outcome If maternal anaemia or inadequate transfusion: IUGR, preterm birth, fetal hypoxia Maternal complications of iron overload If short stature with bone abnormality then increased risk of cephalopelvic disproportion and LSCS

Answer 14

``` Effect of pregnancy on alpha thal trait Nil Effect of alpha thal trait on pregnancy If the fetus is unaffected- normal outcome If fetus is affected- alpha thal major Fetal risks 4 gene deletion: incompatible with life Severe anaemia Hydrops fetalis Hepatosplenomegaly Abnormal organogenesis Cardiac failure Polyhydramnios Placentomegaly Stillbirth Maternal risks (secondary to fetal and placental hydrops) HTN PET Placental abruption Obstructed labour APH and PPH DIC ```

Answer 15

Pre-pregnancy Bloods: FBC, reticulocytes, ferritin, folate Hb electrophoresis First AN bloods (check antibody status) Screen for iron overload: ECHO, fibroscan, TFTs glucose, ECG, LFTs Check renal fx Hep A & B vaccines Folic acid 5mg/day Stop iron chelation therapy 3/12 prepregnancy after aggressive chelation (desferrioxamine in T2-T3 is potentially OK but aim to avoid) Don't give iron Screen the partner Alpha thal: fetal risk 25% if partner has alpha thal trait Beta thal: fetal risk 25% if partner has beta thal trait, sickle cell trait or HbE Counsel on maternal/fetal risks Sickling disorders: check for pulmonary HTN, discontinue hydroxyurea, give pneumococcal, meningococcal and h. Influenzae vaccine, prophylactic Abx Consider spinal Xray Antenatal If partner screening positive offer prenatal diagnosis Continue folate 5mg/day through pregnancy In splenectomy: give prophylactic penicillin and consider thromboprophylaxis Regular Hb checks and blood transfusions

Answer 16

``` Ddx gestational hypertensive immune haemolytic causes other - sepssi, lvier disease, drugs infection HIV malaria If less then 50 suspect non gestational FBC HIV Infection screen Screen for B symptoms Review bloods before ``` IITP Avoid invasive procedures 20 antenetally, >50 intrapartum >90 for epidural/spinal Avoid fetal trauma/invasive monitoring Cord platelets and neonatal review – risk of falling over 3-5/7 10-30% affected <1% morbidity Postnatal TEDS – careful consideration of LMWH as per risk of bleed Consider Tx acid No NSAIDs

Answer 17

Pre pregnancy Ongoing discussions around pregnancy intentions Contraception if not desired COCP ok Risks Maternal Complications of Iron overload Fetal Miscarriage (especially thalassaemia + diabetes) IUGR inheritance of disease IUFD ``` Plan: High dose folic acid and Vit D Screen hep B/c/HIV Partner Genetic screening and referral Immunisations pneumococcal and H influenza ``` Optimise iron stores Compliance with chelation – aggressive pre pregnancy chelation can reduce and optimise body iron burden and reduce end organ damage Optimising iron burden pre pregnancy is critical as ongoing iron accumulation from transfusion exposes her to disease progression Screen for end organ damage Hypothyroid is associated with maternal morbidity and perinatal morbidity and mortality Screen for hypothyroid Liver Iron load assessed with Ferriscan or liver T2 Should be <7 mg/g If over 15mg/g the risk of myocardial load increases so chelation is indicated from 20 weeks If high iron burden then should have aggressive chelation pre pregnancy If iron load very high then cardiac load will be present, and therefore may need chelation in pregnancy 20-28 weeks USS liver and gall bladder for cholelithiasis and liver cirrhosis or transfusion related viral hepatitis Risk of cholecystitis in pregnancy Liver cirrhosis and hep C make increase pregnancy risk and should have lvier team involved Heart ECHO and ECG T2 cardiac MRI to assess for iron overload Aim is no cardiac iron but this can take years to achieve – so maybe aim for minimal iron Level of iron on T2 weighted MRI dictates chelation High iron related to increased risk of cardiac failure Iron causes myocyte apoptosis and fibrosis Reduced EF is a relative contraindication to pregnancy MDT input Bone density scanning Pre existing OP should be documented Pathology complex – maybe chelation of calcium, hypogonadism, Vit D deficiency and thalassaemia itself Serum Vit D optimised with supplements as needed Deficiency common Red cell antibodies ABO and full group genotype and antibody titres should be measures Alloimmunity occurs in 16.5% of woman with thalassaemia Limit blood for transfusion Medication review Iron chelators should be reviewed Deferasirox and deferiprone ideally discontinued 3 months before conception Desferrioxamine has a short half life and can be used during ovulation induction but then avoided in T1 Safe at low dose after 20 weeks Bisphosphonates are contraindicated in pregnancyand should be discontinued 3 months pre preg Ovarian stimulation may be needed MDT counselling pre pregnancy ``` Genetic screening Partner testing Genetic counselling Options for testing IVF / ICSI with PGD should be considered in the presence of haemoglobinopathies ``` Egg and sperm donors considering IVF should be screened for haemoglobinopathies Immunisation Hep B vaccination if not already If prev splenectomy should have vaccination for pneumococcus (every 5 years) and haemophilus influenza and meningococcal Annual influenza ``` Infections If previous splenectomy then should have penicillin prophylaxis (erythromycin if allergic) Hep C status should be assessed Supplements 5 mg folic acid High demand for folic acid ``` Antenatal MDT Close monitoring with increase High risk obstetrician, haematologist, high risk MW, other specialties as indicated Individualised Specific to thalassaemia Receive blood transfusions on a regular basis aiming for pretransfusion Hb of 100 For intermedia Clinical decision when to start transfusions If worsening anaemia, FGR then consider regular transfusions Same target – pretransfusion 100 Initially a 2-3 unit then top up the next week – until Hb 120 Hb checked in 2 weeks Hb of 80 is about the threshold for transfusion but this is a clinical multifactorial decision Reviewed monthly until 28 weeks and fortnightly thereafter If diabetic – monthly fructosamine concentrations 28 week cardiac assessment(thalassaemia major) Monitoring iron load Myocardial iron load should have close cardio follow up with careful monitoring of EF – cardiac decompensation is a primary indication for chelation Severe hepatic iron loading should be reviewed and consideration given to chelation VTE prophylaxis Splenectomy or platelets over 600 – aspirin Splenectomy and platelets over 600 – aspirin and heparin At least if admitted ``` Monitor TFTs Fetal monitoring Early dating scan Routine T1 scan 11-14 weeks Anatomy 18-20 Serial biometry 4 weeks from 24 weeks ``` Intrapartum MDT If there are antibodies, cross match blood If Hb below 100 – then cross match 2 untis Peripartum chelation If transfusion dependant and not being chelated then will have a toxic iron species called non transferrin bound iron. This causes free radical damage and cardiac dysrhythmia when the woman is in the active stress of labour If major – IV desferrioxamine 2 g over 24 hours should be administered for the duration of the labour CEFM Increased risk fetal hypoxia and possible operative delivery Active management of third stage to minimise blood loss No specific evidence for timing or MOD Postpartum High risk for VTE LMWH while in hospital 6 weeks post lscs 7 days post NVD Breast feeding is safe and should be encouraged If breastfeeding can start desferrioxamine – not harmful to baby If not breastfeeding – IV or sc desferrioxamine is continued until discharge and resumption of previous chelation

maternal medical problems Flashcards

(41 cards)