Maternal medicine Flashcards

Question

What is the medical treatment for chronic hypertension in pregnancy? Why is traditional antihypertensives not used?

Answer 1

Induction of labour/C-section: decision made by senior staff after the convulsions have been controlled taking into consideration the parity, maturity, presentation, engagement and the size of the fetus and pelvis. Labor should be closely monitored with adequate analgesia and 2nd stage shortened by instrumental delivery. Syntocinon infusion instead of syntometrine should be used to prevent primary post partum hemorrhage. Steroids: betamethasone is steroid of choice to promote fetal lung maturity if gestation age <34 weeks. Accounts for 65% reduction of respiratory distress syndrome. Dexamethasone is associated with lower incidence of neonatal intracranial hemorrhage but is associated with higher NICU admission rate Anticonvulsants * MgSo4: IV infusion continued for 24 hours after the last convulsion or 24 hours after delivery in the case of prophylaxis. If convulsions recur more than 20 mins after initial IV infusion than 2gm of MgSO4 slow IV injection over 5-10 mins should be given --> or other anticonvulsants such as diazepam or thiopentone * Method of admin: infusion pump --> loading dose of 4gm of MgSO4 solution in 100ml NS given over 20 min IV * Toxicity includes areflexia, respiratory depression, altered cardiac conduction and cardiac arrest * Knee reflex, RR and urine output must be checked q1h and MgSO4 should be withheld when 1 of the following is present: absence of knee reflex, respiratory rate <16/min, urine output <30ml/hour Antihypertensives * Indicated in patients with BP >160/100mHg or mean arterial pressure >125mmHg * Medications given to maintain diastolic pressure <100mmHg * IV labetolol or **hydralazine** are choices

Answer 2

**Early OGTT** done between booking visit and 16 weeks. Indicated in patients with classical and locally identified risk factors for GDM * Advanced maternal age (AMA) >35 years old * Maternal obesity * Maternal glycosuria * Family history of DM * Previous big babies (macroosmia) * Previous unexplained stillbirth or abnormal babies **Routine OGTT** done between 28-32 weeks * All low risk antenatal patients booked before 32 weeks should be screened between 28-32 weeks of gestation * Patients booked after 32 weeks should have a routine OGTT arranged as early as possible unless delivery is imminent * Patients with negative result for early OGTT should still have a repeat OGTT performed between 28-32 weeks of gestation * Patient presented or diagnosed with fetal structural anomalies not related to known chromosomal abnormaliteis should have GDM excluded by OGTT if not yet performed 75g OGTT DM: fasting (>7mmol/L), 2 hours glucose level (>11.1) GDM: fasting (5.1-6.9mmol/L, 1hr glucose level (10mmol/L), 2 hour glucose level (8.5-11mmol/L) Glycated haemoglobin: HbA1c correlates with blood glucose concentration over the prior 2-3 months Fructosamine: correlates with blood glucose concentration over the prior 2-3 w3eeks. Reflects glycemic control over a shorter period of time compared with HbA1c

Answer 3

## Footnote Oral hypoglycemic agents: metformin and glyburide (glibenclamide)

Answer 4

* RA * Systemic sclerosis: coexistence of Raynaud phenomenon and GERD are typically observed in systemic sclerosis. Expresses anti-Scl-70 * Sjogrens syndrome: presents with objective signs of keratoconjunctivitis sicca and xerostemia. Expresses anti-Ro/SSA and Anti-La/SSB * Bechets disease: oral aphthae are present in almost all patients with Bechets syndrome. Other overlapping features include inflammatory eye disease, neurological disease, vascular disease and arthritis * Dermatomyositis and polymyositis: have more overt proximal muscle weakness. Patients with dermatomyositis have characteristic skin findings including Gottrons papules, heliotrope eruptinon and photodistributed poikiloderma * Mixed connective tissue disease (MTCD): overlapping feaetures of SLE, systemic sclerosis and polymyositis. Expresses anti U1 ribonucleic acid (anti-U1 RNP) * Overlap syndrome: distinct entity where patient is diagnosed to have 2 well defined rheumatological syndrome most commonly RA and SLE * Undifferentiated connective tissue disease (UCTD)

Answer 5

4 out of 17 criteria including at least 1 clinical criterion and 1 immunological criterion or Biopsy proven lupus nephritis with +ve ANA or anti-dsDNA Clinical criteria * Acute cutaneous lupus: malar rash, photosensitive lupus rash, maculopapular lupus rash. Subacute cutaneous lupus: non indurated psoriaform, annular polycyclic lesion (more common): resolve without scarring * Chronic cutaneous lupus: discoic rash (localized above neck, generalized), hypertrophic (verrucous) lupus, lupus panniculitis, lupus erythematomsus tumidus * Non scarring alopecia: diffuse thinning or hair fragility with visible broken hairs * Oral or nasal ulcers * Joint disease: tenderness in >2 joints and >30 mins of morning stiffness * Serositis: typical pleurisy >1 day, pleural effusion. Pericardial effusion, pericardial rub, pericariditis by ECG (in absence of other causes such as infection, uremia and Dressler syndrome) * Renal: urine protein to creatinine ratio or 24 hour urine protien representing 500mg protein/24 hours, RBC casts * Neurologic: seizure, psychosis, myelitis, peripheral or cranial neuropathy, mononeuritis multiplex * Haemolytic anemia * Leukopenia or lymphopenia * Thrombocytopenia Immunologic criteria * ANA * Anti-ds DNA * Anti-Sm * Antiphospholipid (lupus anticoagulant, anti B2 glycoprotein I, anticardiolipin antibody) * Low complement: low C3, C4, CH50 * Direct Coombs test: posible in the absence of haemolytic anemia

Answer 6

Antimalarial drugs: hydroxyzhloroquine is indicated in all patients (reduces flare rate, organ damage and mortality. AE: GI disturbance most common, hyperpigmentation, myopathy, corneal deposition, Bulls eye maculopathy NSAIDs: indication for serotiis, arthralgia and myalgia Immunosuppressants * Corticosteroids: oral (prednisolone), IV (methylprednisolone) * Azathioprine indicated in lupus nephritis, diseases refractory to hydroxychloroquine * Mycophenolate mofetil indicated for lupus nephritis (preferred over cyclophosphamide), diseases refractory to HCQ. AE: diarrhea, anemia, leukopenia. * Cyclophosphamide indicated for lupus nephritis, CNS diseases. AE: gonadal toxicity (male: oligospermia, female: infertility). teratogenicity (dont use in pregnancy), hemorrhagic cystitis, bladder cancer. Secondary malignnacy: leukemia, lymphoma. Myelosuppression: neutropenia/ leukopenia/thrombocytopenia. * Cyclosporin A indicated for lupus nephritis. AE: nephrotoxicity, tremor, gum hyperplasia. * Methotrexate indicated for arthritis, skin diseases. AE: interstitial pneumonitis, liver cirrhosis, myelosuppression (pancytopenia) * Belimumab, rituximab indicated in refractory SLE. AE: B cell depletion, reactivation of HBV/ TBV, progressive multifocal leukoencephalopathy

Answer 7

1. Acute nephritic syndrome secondary to lupus nephritis 2. Protein to creatinine ratio by 24 hour urine sample. Creatinine clearance by 24 hour urine sample (show impaired renal function), blood test: anti dsDNA, decreased C3/C4, increased CRP (suggestive of concomitant infection). USG kidneys (confirm kidneys not shrunken before doing biopsy), renal biopsy (normal clotting profile done before) 3. Corticosteroids, cyclophosphamide, azathioprine/mycophenolate mofetil (maintenance therapy following cyclophosphamide) 4. Hypertension, hyperlipidemia, complications of treatment (leukopenia, infection, alopecia (cyclophosphamide), amenorrhea (cyclophosphamide)

Answer 8

1. Relapse of underlying SLE: infection due to immunocompromised state --> SLE itself is immunocompromising 2. Serositis (pleura/pericardium/peritoneum), pulmonary embolism +/-infarciton: can gice rise to pleuritic chest pain 3. Delineate underlying infection: CXR, blood cultures, sputum and urine smears and culture. Delineate possible SLE relapse: ANA, anti dsDNA, serum C3 and C4, Commbs test. Delineate possible renal involvement during relapse: urine microscopy, 24 hour urinary protien and creatinine estimation, renal biopsy 4. Increase dosage of immunosuppressant. Azathioprine substituted to a more potent agent such as cyclosphosphamide, cyclosporin A or mycophenolic acid 5. Bone necrosis of right femoral head due to steroid usage 6. NSAID, steroid dosage adjustment PT, referral to orthopedic surgeon

Answer 9

o Anticardiolipin antibodies (aCL) IgG or IgM ELISA o Anti-β2-glycoprotein-I antibodies IgG or IgM ELISA o Lupus anticoagulant (LA) test

Answer 10

 Also known as abruptio placentae  Refers to partial or complete premature placental detachment after 20 weeks of gestation and prior to delivery of the fetus * Diagnosis is typically reserved for pregnancy over 20 weeks of gestation

Answer 11

P - Pulmonary Hypoplasia O - Oligohydramnios T - Twisted skin (wrinkly skin) T - Twisted face (Potter facies) E - Extremities defect R - Renal a genesis (bilateral)

Answer 12

 Urinary incontinence  Vaginal discharge * Related to infection  Perspiration

Answer 13

 Delivery under antibiotic coverage irrespective of gestation if there is * Antibiotics that cross placenta barrier should be chosen * Dosage should be large enough to maintain a therapeutic level in fetus * Parenteral route should be chosen initially to achieve a therapeutic level quickly

Answer 14

Pituitary gland undergoes global hyperplasia during pregnancy. The increase in size is accompanied by a concomitant increase in size and population of lactotroph cells and a progressive increase in serum prolactin. The placental estrogen surge during pregnancy has been shown to induce the mitotic activity of lactotrophic cells. * Tumor cells in patients with prolactinomas express estrogen receptors --> possible tumor enlargement during pregnancy. * Small macroadenoma stop DA therapy once pregnancy is confirrmed. If symptomatic --> return for FU. Visual perimetry routinely done. * If substantial tumor growth shown in MRI, immediate reinstitution of DA therapy is appropriate * Large macroadenomas must be definitively treated before conception by either aggresive DA therapy or surgical evacuation of the bulk of the tumor. * If tumors are DA sensitive, patients should be maintained on DA therapy throughout pregnancy and informed that these drugs inhibit lactation. Worrying symptom is headache/visual field loss

Answer 15

Actim test to confirm low suspicion of PROM. If small amount of amniotic fluid leakage it can be high water leak that seals off afterwards. Can go home. However requires antibiotic prophylaxis oral erthromycin + IV ampicillin followed by oral amoxicillin to avoid chorioamniotis regardless of GBS result.

Maternal medicine Flashcards

(103 cards)