Maternal Medicine Flashcards
(47 cards)
1
Q
Why is maternal medicine important?
A
- pre-existing maternal disease can have an adverse effect on pregnancy
- pregnancy can have an adverse effect on pre-existing maternal disease
- there is increased maternal / fetal mortality
2
Q
What is the major indirect cause of maternal mortality and why?
A
cardiovascular disease
- more women with cardiac anomalies are surviving into adulthood
- there is a higher incidence of older women becoming pregnant
- higher incidence of obesity
the overall incidence of maternal deaths is 8-10 per 100,000
3
Q
Why is it important to consider health inequalities in maternal mortality?
A
ethnic group:
- the proportion of black women giving birth and those who died do not correlate
socioeconomic status:
- due to language barriers, social barriers (e.g. children at home), higher incidence of HTN & diabetes
4
Q
How is maternal death defined?
A
- death during pregnancy or within 6 weeks of the end of pregnancy
- this includes giving birth, ectopic pregnancy, miscarriage or termination
death can occur up to 1 year following pregnancy, but it most commonly occurs within the 6 weeks after birth
5
Q
What is meant by direct maternal mortality?
A
- results from obstetric complications of the pregnant state
- this can be due to interventions, omissions, incorrect treatment or a chain of events
the death is directly related to the pregnancy
6
Q
What is meant by indirect maternal mortality?
A
- death results from pre-existing disease or a disease that developed during pregnancy
- it is NOT due to obstetric causes
- but it is aggravated by the physiological effects of being pregnant
7
Q
What is meant by a late maternal death?
A
- maternal death occurring between 6 weeks and 1 year after the end of pregnancy
- this could be due to direct or indirect maternal causes
8
Q
What is meant by a coincidental / fortuitous maternal death?
A
- from unrelated causes which happen to occur in pregnancy or puerperium
- e.g. car accident
9
Q
What is the most common direct cause of maternal mortality?
A
venous thromboembolism (VTE)
10
Q
What are the maternal and foetal risks associated with maternal diabetes?
A
maternal risks:
- hypo-/hyperglycaemia
- DKA in T1DM (rare)
- hypertension, eclampsia & pre-eclampsia
foetal risks:
- congenital abnormalities
- stillbirth
- shoulder dystocia
- neonatal hypoglycaemia
- babies are usually bigger in diabetics due to increased glucose intake
- this increases the risk of shoulder dystocia / difficult delivery
- after birth, the baby may not be able to effectively manage their own blood sugars due to lack of insulin
11
Q
How are patients with maternal diabetes managed differently?
A
- high risk groups are offered screening
- a high dose of 5mg folic acid daily is given to prevent NTDs
- planned early delivery
high risk groups - diabetic in previous pregnancy, FHx of diabetes, certain ethnic groups, large baby in past
12
Q
How is diabetes in pregnancy managed?
A
- some women with gestational diabetes may not require medication
- only insulin and metformin are used in pregnancy
- they can be used alone or in combination
13
Q
What is important to give all pregnant women with epilepsy?
A
folic acid 5mg daily
- this reduces the risk of NTDs
- ideally, it should be given prior to conception
14
Q
How can pregnancy affect seizure activity?
What effect does this have on the fetus?
A
- pregnancy can worsen / change seizure activity due to:
- additional stress
- lack of sleep
- altered medication regimes
- seizures are not harmful in pregnancy, except for risk of physical injury
15
Q
How is epilepsy ideally managed prior to conception?
A
- ideally, medication regime should be changed prior to conception
- a single anti-epileptic drug should be used for control
16
Q
What are the safest anti-epileptics to use in pregnancy?
A
- lamotrigine
- carbamazepine
- levetiracetam
17
Q
What anti-epileptics should be avoided during pregnancy?
A
sodium valproate:
- can cause NTDs and developmental delay
phenytoin:
- causes cleft lip / palate
18
Q
What are the NICE guidelines surrounding use of sodium valproate?
A
- it must be avoided in girls / women unless there are no suitable alternatives
- strict criteria must be met to ensure they do not get pregnant
it is highly teratogenic
19
Q
How might dose of anti-epileptic drugs need to change in pregnancy?
What needs to be given in addition?
A
- the doses may need to be increased
- drug clearance is faster in pregnancy
- oral vitamin K is given in the last 4 weeks
20
Q
How is VTE diagnosed in pregnancy?
A
- through risk assessment + symptoms/signs
- Well’s score is NOT used in pregnancy (they are already high risk)
- D-dimer is NOT used (it is raised in pregnancy)
21
Q
What are the risk factors for DVT in pregnancy?
A
- smoking
- parity 3+
- age > 35
- BMI > 30
- reduced mobility
- multiple pregnancy
- pre-eclampsia
- gross varicose veins
- family history of VTE
- thrombophilia
- IVF pregnancy
the risk is already increased due to hypercoaguability
22
Q
When should VTE prophylaxis be started in pregnancy?
A
- prophylaxis started from 28 weeks if there are 3 risk factors
- prophylaxis started from the first trimester if there are 4+ risk factors
23
Q
When might VTE prophylaxis be considered in pregnancy in the absence of other RFs?
A
- hospital admission
- previous VTE
- surgical procedures
- medical conditions - cancer / arthritis
- high risk thrombophilia
- ovarian hyperstimulation syndrome
24
Q
When is VTE risk assessment performed?
A
- initial VTE risk assessment at booking
- should be performed again after birth
- additional ones may be performed e.g. if admitted to hospital
25
What is involved in VTE prophylaxis?
**low molecular weight heparin (LMWH)**
* enoxaparin
* dalteparin
* tinzaparin
## Footnote
unless this is contraindicated
26
How long is LMWH continued for in pregnancy?
When is it started?
* prophylaxis is started **ASAP** in **very high risk** patients (4+ RFs)
* it is started at **28 weeks** in **high risk** patients (3 RFs)
* it is continued throughout pregnancy and for **6 weeks postnatally**
27
Should LMWH prophylaxis be stopped at any time?
* LMWH should be stopped when the woman **goes into labour**
* it can be started **immediately** after delivery
UNLESS
* there is **postpartum haemorrhage** or presence of a **spinal / epidural**
28
What may be considered in women with contraindications to LMWH?
**mechanical prophylaxis**
* intermittent pneumatic compression
* anti-embolism stockings
29
How do you examine for DVT?
* measure the **circumference** of the calf **10cm below the tibial tuberosity**
* more than **3cm difference** between the calves is significant
30
What is the investigation of choice in suspected DVT?
**Doppler USS**
* this should be repeated on day 3 and day 7 if negative but high suspicion of DVT
31
What investigations are initially offered in suspected PE?
* CXR
* ECG
32
What are the 2 options for establishing a definitive diagnosis of PE?
| Which is preferred?
* V/Q scan
* CTPA
* CTPA is the test of choice if an **abnormality is detected on CXR**
## Footnote
CTPA carries a small increased risk of breast cancer and childhood cancer in the fetus
33
What is the investigation if both DVT and PE are suspected?
* **Doppler USS** is performed initially
* if DVT is present, a V/Q scan or CTPA is ***NOT required***
* the **management** for DVT and PE are the **same**
34
What is the management for VTE in pregnancy?
**LMWH**
* dose is based on **weight at booking clinic**
* should be started **IMMEDIATELY before diagnosis** is confirmed if there is a delay in getting a scan
* can be stopped if VTE is excluded
35
How long is LMWH continued for in VTE in pregnancy?
* continued throughout pregnancy and then for **6 weeks postnatally** or **3 months** (whichever is longer)
* can **switch to warfarin or DOAC** after delivery
36
What are the risks associated with pre-established essential HTN?
increased risk of:
* pre-eclampsia / eclampsia
* placental abruption
* haemorrhagic stroke
* foetal growth restriction +/- preterm delivery
37
What hypertensive medications must be stopped in pregnancy?
* **ACE inhibitors** (e.g. ramipril)
* **ARBs** (e.g. losartan)
* **thiazide / thiazide-like diuretics** (e.g. indapamide)
## Footnote
these may cause congenital abnormalities
38
What medications are safe to use to treat hypertension in pregnancy?
* **labetalol** (other beta-blockers may be harmful)
* **nifedipine** (and other CCBs)
* **methyldopa**
* alpha-blockers (e.g. doxazosin)
39
How is management for a hypertensive pregnant woman different?
* they have more frequent **urine & BP checks** to ensure they do not develop **pre-eclampsia**
* regular USS for **foetal growth**
40
What other medication may be given to a woman with pre-existing HTN?
**aspirin**
* given in early pregnancy to anyone **at risk of pre-eclampsia**
* improves the **quality of the placenta** formed by preventing microclots from forming
41
What is puerperal psychosis?
new onset severe mental health illness in the early postpartum period
## Footnote
* risk is massively increased if there is a family Hx of psychosis, personal Hx or both
42
What red flag features require urgent referral to a specialist perinatal mental health team?
* new thoughts of **violent self harm**
* **sudden onset** / **rapidly worsening** mental symptoms
* persistent feelings of **estrangement** from their baby
43
What are the adverse pregnancy outcomes associated with untreated / under-treated hypothyroidism?
* miscarriage
* anaemia
* small for gestational age
* pre-eclampsia
44
What is the management for hypothyroidism in pregnancy?
**levothyroxine**
* this can cross the placenta
* the **dose needs to be increased** in pregnancy
* increase by at least **25-50mcg** (30-50%)
* titrate treatment based on **TSH-level** (aim for low-normal)
45
If someone has rheumatoid arthritis, what should they ensure prior to pregnancy?
* symptoms should be **well controlled** for **at least 3 months** prior to becoming pregnant
* **symptoms may improve** during pregnancy
* symptoms may flare up after delivery
46
What RA drugs are contraindicated in pregnancy?
**methotrexate**
* associated with miscarriage and congenital abnormalities
47
What drugs are considered safe in pregnancy for treating RA?
* **hydroxychloroquine** is first-line
* **sulfasalazine** is also considered sage
* corticosteroids can be used during flare-ups
