Maternal Medicine Flashcards
(211 cards)
1
Q
Respiratory Indications for ECMO
A
ARDS
Pneumonia (infectious/aspiration/interstitial)
Severe asthma
Thoracic trauma causing lung contusion
Alveolar or pulmonary haemorrhage
Severe inhalation injury
Air leak syndromes (bronchopleural fistula)
Acute airway obstruction
Lung transplant
2
Q
Cardiac indications for ECMO
A
Acute MI
Myocarditis
Cardiac arrest
Post heart transplant
Post cardiotomy
Hypothermia with cardiac instability
Postpartum acute cardiomyopathy
Drug intoxication
Septic cardiomyopathy
Arrhythmic storm
Interventional cardiac procedures
3
Q
When to consider ECMO
A
When estimated mortality is in excess of 50-80% despite optimal medical management
4
Q
Complications of ECMO
A
Intracranial haemorrhage
DIC
HIT
Bleeding
5
Q
Hypertrophic cardiomyopathy incidence
A
0.1-0.5% of women
6
Q
Symptoms/signs of hypertrophic cardiomyopathy
A
Syncope
Chest pain
Ejection systolic murmur
Pan-systolic murmur
Heart failure
Arrhythmias
7
Q
Treatment of hypertrophic cardiomyopathy in pregnancy
A
B-blockers
8
Q
Incidence of sarcoidosis in pregnancy
A
1 in 2000
9
Q
Sarcoidosis site involvement
A
Lungs (1st)
Skin (commonest extra-pulmonary)
Heart (50%)
Brain
Eyes
Joints
Liver (20% hepatomegaly)
10
Q
Pulmonary sarcoidosis presents as
A
Interstitial lung disease with fibrosis 20%
Pulmonary hypertension
11
Q
Skin manifestations of sarcoidosis
A
Granuloma (lupus pernio)
Erythema nodosum
Erythema multiforme
Nummular eczema
12
Q
Rate of myocardial infiltration with sarcoidosis
A
2-7%
13
Q
Rate of CNS involvement with sarcoidosis and commonest site
A
5-13%
Cranial nerves
14
Q
Pathogenesis of sarcoidosis
A
Th1 cell mediated
TNF-a
Interferon-y
Influx of CD14 macrophages
15
Q
Investigations for sarcoidosis
A
CXR/CT
broncheolar lavage
Transbronchial biopsy
Cardiac MRI
ECG/echo
MRI head
EMG for myopathy
16
Q
When is pregnancy is contraindicated in insterstitial lung disease?
A
When FVC<1-1.5L
17
Q
Course of sarcoidosis in pregnancy
A
Majority have no change or improvement
Some worsen
Postnatal flare
18
Q
Effects of sarcoidosis on pregnancy
A
PET
VTE
FGR
C/S
PPH
19
Q
Baseline tests for sarcoidosis
A
FBC
U+E
LFT
Calcium
ACE
ECG
Echo if cardiac sarcoidosis is known
24hr tape if palpitations
20
Q
Mycophenelate mofetil risks in pregnancy
A
Microtia (no ear cartilage)
Facial clefts
Micrognathia
Miscarriage
FGR
21
Q
Washout period for mycophenelate
A
6 weeks
22
Q
Washout period for MTXA
A
4 weeks
Give high dose folic acid
23
Q
Leflunomide washout period
A
11 days with cholestyramine
24
Q
When to discontinue adalimumab
A
28 weeks
25
When to discontinue infliximab
20 weeks
26
AN management of sarcoidosis
Aspirin
VTE
Growth scans
Enhanced BP monitoring
Investigate tachycardia and palpitations
27
Haemophilia A
Factor VIII deficiency
28
Haemophilia B
Factor IX deficiency
29
Impact of pregnancy on factor VIII
Increases x 3
30
Impact of pregnancy on factor IX
No effect
31
Normal range for factor VIII and IX outside of pregnancy
0.5-2.0 iu/ml
32
There is no family history in _____ of haemophilia patients
50%
33
Obligate haemophilia carrier status
Affected father
OR
Affected son and relative in maternal line
34
Risk of haemophilia in a male baby after a spontaneous affected sibling
45%
35
Classification of haemophilia A
Severe - <0.01 iu/ml
Moderate - 0.01 - 0.05 iu/ml
Mild - 0.06 - 0.4 iu/ml
36
Risk of resistance to clotting factor treatment
40%
37
Prenatal diagnosis of severe haemophilia
PGD
cell free fetal DNA for fetal sex
CVS for male fetus 11-14 weeks
Amniocentesis 3rd trimester to inform delivery options
38
Risk of intracranial and extra cranial haemorrhage with haemophilia
RR 56% for ICH
RR 92% for ECH
39
Antepartum management of haemophilia
No ECV in severe haemophilia
TXA
Levels 0.5 iu/ml to cover surgical procedures and miscarriage
DDAVP with 1L fluid restriction in 24 hours to increase factor VIII
Recombinant factor VIII if DDAVP ineffective
Recombinant factor IX if <0.5 iu/ml (measure before and after, then 4-6h after rx)
40
Mode and timing of delivery with haemophilia
C/S for affected male babies/status unknown/severe haemophilia
No ventouse/midcavity NBFD
No FSE in severe or moderate haemophilia
41
Intracranial haemorrhage risk with ELLSCS vs forceps in haemophilia
OR 0.69 vs 2.8
(4x less)
42
Optimal level of factor VIII after DDAVP treatment
1.0 iu/ml
43
When to give DDAVP and TXA intrapartum for haemophilia
As close to delivery as possible
44
Postpartum management of haemophilia
Maintain factor VIII/IX above 0.5 for 3 days after SVD, 5 days after operative delivery
TXA until lochia is minimal
No VTE if level <0.6
45
Investigation of the neonate in haemophilia carrier mothers
Cord blood testing in males
Re-test 3-6 months
Follow up with haematology
Cranial USS screening prior to discharge if moderate/severe haemophilia
MRI head if symptoms/signs of ICH
46
Treatment in neonate with haemophilia
Short term prophylaxis if moderate/severe or preterm or trauma at delivery
47
Types of vWD
Type 1 - partial quantitative
Type 2 - qualitative
Type 3 - severe quantitative
48
Commonest bleeding disorder
vWD
49
Level of care for vWD according to type
Normal unit with haem input for mild/moderate type 1
Specialist input for type 2/3 or severe type 1
50
Target level for factor VIII and vWF:RCo
0.5 to cover for spontaneous miscarriage and surgical procedures
51
Prevalence of VWD
1 in 1000
52
Mode of inheritance for vWD
Type 1 - variable penetrance with multiple mutations
Type 2B - dominant
Type 2N - recessive
Type 3 - recessive
53
Prevalence of type 3 vWD
1 in 1 million
Higher in consanguineous communities
54
Antenatal Treatment of vWD
DDAVP
Restrict fluid 1 litre in 24 hours
55
Contraindication to DDAVP
PET
Arterial disease
Uncontrolled hypertension
56
Side effects of DDAVP in VWD
Type 2B can develop thrombocytopenia
57
Intrapartum management of type 2/3 vWD
Avoid FBS, FSE, ECV, ventouse and mid cavity forceps
58
Postpartum care in vWD
TXA for 14 days
Keep factor VIII above 0.5 for 3 days after SVD or 5 days after operative delivery
59
Neonatal management with VWD
Oral vit K
Cord blood testing in type 2/3
Retest at 3-6 months for type 2/3
Cranial US +/- MRI head for type 2/3
Inform parent of signs for ICH
60
Dose of DDAVP
0.3 micrograms/kg of pregnancy body weight
61
Treatment for acute haemorrhage in vWD
DDAVP
Viral inactivated concentrate with VWF and factor VIII (hep A and parvo resistant to inactivation)
62
Factor XI deficiency inheritance
Autosomal dominant
Autosomal recessive
63
Factor XI prevalence
1 in 1 million general population
8% Ashkenazi Jews heterozygous
0.2 - 0.5% Ashkenazi Jews homozygous
64
Factor XI maintenance levels
0.5 iu/ml
65
Effects of pregnancy on Factor XI levels
No effect
66
Antepartum monitoring of factor XI
Booking
3rd tri
Prior to invasive procedures
67
Bleeding risk with factor XI deficiency
Type O
High risk phenotype
68
Testing in neonate for factor XI deficiency
No testing unless mum is homozygous or compound heterozygosity
69
Management of factor XI deficiency
Exclude compounding vWF/thrombocytopenia
Can give TXA OR factor XI concentrate (both together increase risk of VTE) or FFP
70
What are the rare bleeding disorders?
Deficiencies of fibrinogen
Factor II, V, VII, X and XIII
Combined factor V and VIII deficiencies
Congenital deficiency of vit K dependent factors
71
Maintenance level for the rare bleeding disorders
Aim >0.2 iu/ml
72
Management of rare bleeding disorders
TXA 15-20 mg/kg or 1g QDS for minor bleeds
+/- factor replacement
73
Factor II deficiency is AKA
Prothrombin deficiency
74
Management of prothrombin (factor II) deficiency
If bleeding/labour or for c/s and <0.2/ml give prothrombin complex concentrate 10-20 iu/kg at 48 hour intervals
Maintain level >0.2 for 3 days minimum
If already receiving prophylactic prothrombin complex then continue through pregnancy
75
Management of factor V deficiency
If activity <0.2/bleeding/delivery then give 15-25ml/kg FFP
Further FFP at 10ml/kg 12 hourly to maintain activity 0.2-0.4 for 3 days
Consider platelets for severe bleeding or c/s
76
Factor VII deficiency management
Recombinant factor VIIa 15-30 micrograms/kg every 4-6 hours to maintain level >0.2
3-5 days after c/s
Only in response to severe bleeding for other women
77
Severe factor X deficiency management
Antenatal prophylaxis 2-3x/week for recurrent bleeding or adverse pregnancy outcome with prothrombin complex concentrate
Give 20-40iu/kg prothrombin complex concentrate for bleeding or c/s to maintain activity >0.4
10-20 iu/kg daily for 3 days maintenance
78
Severe factor XIII deficiency management
Factor XIII plasma concentrate prophylaxis every 14-21 days
Maintain activity >0.2
Consider additional 10-40 iu/kg in established labour/ prior to c/s
79
Factor V and factor VIII deficiency management
Consider FFP 15-25 ml/kg in established labour or before c/s. Maintain level 0.2-0.4 iu/ml
Consider factor VIII if less than 0.5 iu/kg in third trimester
80
Fibrinogen disorders and their inheritance
Afibrogenaemia - recessive (bleeding)
Hypfribrinogenaemia with or without qualitative defects (dysfribrinogenaemia) - dominant (variable bleeding/thrombosis risk)
81
Pregnancy outcomes with fibrinogen disorders
APH
PPH
VTE
pregnancy loss
ICH
Umbilical bleeding
82
Management of fibrinogen deficiency
Maintain levels 0.5-1 g/litre antepartum and 3 days post partum
TXA for minor bleeding
Fibrinogen concentrate 50-100mg/kg through pregnancy 2x/week - consider LMWH if low risk for bleeding
83
What is Bernard Soulier syndrome? (BSS)
Deficiency of membrane GP Ib-IX-V complex
Causes abnormal adhesion of platelets
84
Inheritance of BSS
Autosomal recessive
85
Management of BSS
TXA at outset of labour until lochia is minimal
Platelets prophylactically before delivery
No central neuraxial analgesia
Platelets should be HLA matched
Consider DDAVP (variable response)
86
Maternal risks of BSS
PPH
Wound haematoma
87
What is Glanzmann’s thrombasthenia? (GT)
Non-functioning GP IIb/IIIa caused by missense mutation in ITGA2B and ITGB3
Platelet-platelet aggregation is impaired
88
Inheritance of GT
Autosomal recessive
89
Maternal and fetal risks of GT
APH
PPH
Fetal thrombocytopenia
Fetal ICH/bleeding
90
Management of GT
HLA matched platelet transfusion and/or recombinant factor VIIa prophylactically at delivery
TXA in established labour until lochia is minimal
No central neuraxial anaesthesia
91
Management of platelet fetal allo-immunisation in GT
Check antibodies at 28 and 34 weeks
FMU referral
IV IgG +/- steroids
Cord platelets
Oral vit K until platelet level is back
Check again day 3-5
Give platelets if <30 x 10(9)/litre
92
Spinal epidural anaesthesia should never be given to patients with _____
Type 3 vWD
93
Clotting factors that increase in pregnancy
VIII
IX
X
Fibrinogen (50%)
94
DVT vs PE proportions
75% DVT
25% PE
95
VTE incidence in pregnancy
1-2/1000
96
RR of VTE in pregnancy
4-6 x
97
Sites of DVT in pregnancy
85% left sided
72% iliofemoral
98
Inherited Thrombophilias
Anti-thrombin III (highest risk)
Protein C deficiency
Protein S deficiency
Activated protein C resistance
Prothrombin gene mutation
Factor V Leiden
Hyperhomocystinaemia
99
Acquired thrombophilia
Antiphospholipid
Lupus anticoagulant
High anti-cardiolipin antibody
B glycoproteins 1 antibodies
100
Pulmonary hypertension risk after PE
3-4%
101
Recurrent DVT risk outside of pregnancy
3.7%
102
Recurrent DVT risk outside pregnancy
10.9%
103
Most common acquired thrombophilia
APLS
104
Risks associated with APLS
Pregnancy loss
PET
PTB
FHR
VTE
105
Anti-coagulation regimen for APLS
If on long term anti-coagulation = intermediate/therapeutic dose LMWH
If no long term anti-coagulation = intermediate/high dose prophylaxis LMWH
106
LMWH for previous VTE and inherited thrombophilia
Antithrombin deficiency - high dose LMWH (50% or 75% or treatment dose)
Give standard prophylaxis for other thrombophilias
107
Low risk inheritable thrombophilias
Heterozygous factor V Leiden
Heterozygous prothrombin mutation
108
Investigation of DVT
Compression duplex USS - repeat day 3 + 7 if negative but still suspected
Pelvic US colour Doppler (pelvic vessels)
MRV or contrast venography (iliac vein)
109
PE is diagnosed in _____% of women with symptoms
5
110
ECG changes in PE
Sinus tachycardia
RBBB
Peaked P waves lead III
S1, T3, Q3 (rare)
111
Breastfeeding advice after V/Q scan
Discard milk for 48 hours
112
Increased risk of breast Cancer after CTPA
>13%
113
Investigations for PE
V/Q scan if CXR normal
CTPA if CXR abnormal
114
Use unfractionated heparin for
Massive PE
Rapid reversal needed
115
Heparin monitoring
Measure APTT 4-6 hours after loading dose
6 hours after dose change
Twice daily once in therapeutic range
116
Life threatening PE treatment
Thrombolysis in combination with unfractionated heparin (omit loading dose)
117
Treatment of VTE
LMWH
UFH
Thrombolysis
Pulmonary embolectomy
IVC filter for iliac thrombosis
118
Length of treatment time after VTE
Minimum 6/52 postpartum
At least 3 months to prevent post thrombotic syndrome
119
LMWH and labour management
Stop 24 hours before planned delivery or when labour starts
Wear stockings until LMWH can be resumed
Staples or interrupted skin sutures for c/s
120
Risk of wound haematoma after c/s on LMWH/UFH
2%
121
Side effects of LMWH
Thrombocytopenia
Allergy
Osteoporosis 1 in 500
Bruising
122
Side effects UFH
Vertebral fractures 2%
Allergy
HIT
123
Indications for high dose LMWH
Antithrombin deficiency
Previous VTE whilst anti-coagulated
APLS + previous VTE
124
Timing of Regional analgesia when on LMWH
>12 hours after last dose of prophylactic
>24 hours if therapeutic LMWH
125
Epidural catheter and LMWH management
Perform 12h after last dose of prophylactic, 24h if therapeutic
Next dose LMWH 4 hours after removal
126
Flying VTE risk
3x increase
Additional 18% for every 2 hours
127
Reducing VTE risk when flying
Aisle seat
Mobilise in seat and in the aisle
Fluid intake
Minimise caffeine
TEDS if >4hr flight
LMWH if other risk factors
128
Commonest inherited thrombophilia
Factor V Leiden
129
Prevalence of factor V Leiden
3-5% U.K.
low in black/asian populations
Sweden - 15%
130
Monitor platelets in women at risk of VTE if ____ every ____
On UFH or treatment dose LMWH
Every 14 days
131
Fetal Radiation exposure with CTPA and V/Q
0.1 mGy
0.5 mGy
132
Radiation to breast of CTPA
10 mGy
133
Reducing risk of post thrombotic syndrome
Graduated elastic compression stockings for 2 years
134
Essential HTN pregnancy outcomes
PET 25.9%
C/S 41.4%
SGA 16.9%
NNU admission 20.5%
Perinatal death 4%
135
Aspirin reduces early onset PET in ____ women
60%
136
Effect of Severe hypertension on NNU admission
Increases risk from 23% to 47%
137
Negative predictive value for PlGF or sFlt is for ____
2 weeks
138
Chance of complications with PET <37 weeks
50%
139
Target HbA1c preconception
48
140
Risk of congenital abnormalities in women with pre-existing diabetes is highest if ____
HbA1c >86
141
Pre-pregnancy Glycaemic targets with pre-existing diabetes
Waking 5-7
Fasting 4-7
142
Risk of stillbirth with pre-existing diabetes is highest at ____ HbA1c
>60
143
BM peak time after steroids
6-8 hours
144
DKA risk in T1DM
1-2%
145
Risk of stillbirth with DKA
160 per 1000 births
146
How long does hyperglycaemic effect of steroids last?
24 hours
147
Elective birth for T1/T2DM timing
37-38+6 if no complications
Before 37 weeks if maternal or fetal complications
148
Refer to nephrologist for diabetic women with _________
Creatinine >120 OR
Urinary ACR >30 OR
Total protein excretion >0.5g/day
149
Proteinuria level to consider VTE prophylaxis
>5g/day OR
ACR >220
150
Incidence of solid organ transplants in pregnant women
50-60 per year (30-40 kidneys)
151
Most common solid organ transplant
Kidney
152
Risk of organ rejection in first year of transplant
10-15%
153
Prevalence of pre-pregnancy hypertension in women with renal transplants
50%
154
Risk of new HTN in pregnancy after renal transplant
16%
155
Increased risk of loss of renal function after pregnancy if _____
Pre-pregnancy proteinuria is 1g/day
156
Which immunosuppressive drugs increase risk of GDM
Steroids
Tacrolimus
Ciclosporin
157
Risk of GDM is ____ in patients after renal transplant
Doubled
158
Risk ratio for PET after renal transplant
6x
159
Risk of caesarean delivery after renal transplant
64%
160
Risk of PTB after renal transplant
52% late PTB
9% early PTB
161
Risk of SGA after renal transplant
24% (3x higher)
162
Risk of neonatal unit admission after renal transplant
38%
163
Kidney graft rejection rate in pregnancy
2-4.2%
164
Effect of pregnancy on tacrolimus and ciclosporin
Reduces serum levels
165
Effect of pregnancy on erythropoetin requirement
Increases
166
Target MgSO4 level if required for renal transplant patients
<3.5 mmol/L
Check 3-6 hours after commencing
167
Risk of trauma to renal graft during c/s
1-2%
Consider midline incision
168
Surgical review should be at ____ weeks gestation for women with kidney-pancreas transplants
30-34 weeks
169
Incidence of pregnancy after liver transplant
12 per year
170
GDM screening for patients with the following solid organ transplants
Kidney
Pancreas
Liver
Lung (Cystic fibrosis is indication)
171
Pre-conceptual investigation after cardiac transplant
ECG
Echo
Angiography
Endomyocardial biopsy as clinically indicated
172
Highest risk organ transplant for pregnancy is ____
Lung - pregnancy loss and graft rejection is highest
173
Detection of lung graft rejection is by
Decreased FEV1 or FVC as these are unchanged by pregnancy
174
DKA incidence
6.3 per 100 000
175
Incidence of DKA for T1DM
85%
176
Incidence of DKA in third trimester
71%
177
Commonest causes of DKA
Infection
Vomiting
Steroid therapy
Medication errors
178
Perinatal mortality for DKA
16%
179
Diagnosis criteria for DKA
Blood ketones 3.0 or urine ketones 2+
BM 11.0 or known DM
Bicarbonate <15 or pH <7.3
180
IV fluid management in DKA
10-15ml/kg/hr in the first hour
OR
1L for 1 hour, 500ml/hr for 4 hours, 250ml/hr for 8 hours then 150ml/hr maintenance
181
Management of K+ in DKA
Give K+ if <3.3 and don’t give insulin
Give K+ with insulin if 3.3-5.5
Give insulin without K+ if >5.5
182
Metabolic targets in DKA treatment
Fall in ketones 0.5mmol per hour
Increase bicarbonate by 3mmol/hr
Decrease in BM by 3mmol/l/hr
183
Insulin regime in DKA
0.1 unit/kg/hr
Do not exceed 15 units/hr
184
When to stop insulin
When eating and drinking
Five rapid insulin and take down FRII after 30-60 minutes
185
Phosphate replacement in DKA is recommended when ___
Levels <0.32
Cardiac impairment
Resp depression
186
Monitoring response to treatment of DKA
First 6 hours:
Hourly blood ketones
2 hourly VBG
187
Time taken for FHR to normalise after DKA treatment
4-8 hours
188
PPCM ejection fraction
<45%
189
Incidence of PPCM
1 in 1000 - 4000 pregnancies
190
PET prevalence in PPCM
22% (4x higher risk)
191
When do women with PPCM present?
78% 4 months post delivery
9% final month of pregnancy
13% before final month and after 4 months
192
Complications of PPCM
Ventricular arrhythmias 20%
Intracardiac thrombus
Cardiogenic shock
VTE 6.8%
193
Investigations for PPCM
ECG
FBC, Trop T, BNP/NT-proBNP, CRP
Echo
CXR
cardiac MRI (thrombus)
Endomyocardial biopsy
194
Management of PPCM when haemodynamically stable and pregnancy
Salt restriction
Loop diuretics
B-1 antagonists
Hydralazine
LMWH
195
Management of PPCM (postpartum and breastfeeding)
ACEI or ARB
Aldosterone antagonists
196
Management of PPCM postpartum not breast feeding
DOAC
SGLT2 inhibitors
Angiotensin receptor nephrilysin inhibitors (ARNI)
197
PPCM management haemodynamically unstable
Delivery
Optimise preload (diuretics)
O2
Inotropes/vasopressors
Bromocriptine
ECMO or cardiac transplant
Cardioversion and defribilation (ICD for 3-6 month)
198
Mode of delivery for PPCM
Aim vaginal if NYHA class I-II
C/S if class III-IV
199
Intrapartum care for PPCM
Continuous ECG and pulse oximetry
Intra-arterial BP monitoring
30 degree left lateral tilt
Regional analgesia NYHA class III-IV
Limit 2nd stage
Avoid ergometrine
200
Prognosis for PPCM
10% mortality risk
50-80% recover 6 months from diagnosis
Worse recovery if LVEF <30% at diagnosis or black women
201
Advice for future pregnancies
50% chance of deterioration with 20% mortality risk if LV dysfunction persists (advice against further pregnancy)
20% chance of recurrence after full recovery
No further pregnancy advised if LVEF <25% at diagnosis
202
Pregnancy management after PPCM
Preconceptual counselling
BNP levels
Echo
Serial scans 24/40
LMWH
Deliver 37/40
203
Echo schedule for previous PPCM
Preconceptual
1st trimester
2nd trimester
One month before delivery
Immediately after delivery (before discharge)
1 month after delivery
204
Bromocriptine dose in PPCM
2.5mg OD for 7/7 if uncomplicated
2.5mg BD for 2/52 then OD for 6/52 if LVEF <25%
205
Bromocriptine increases risk of?
VTE
206
Rates of ACS
0.6 to 10 per 100 000 pregnancies
207
Mortality risk after ACS
5-11%
208
Which trimester is ACS most likely to occur?
3rd
209
Proportion of NSTEMI in pregnancy?
75%
210
Causes of ACS in pregnancy
PASCAD (27%)
Atherosclerosis (39%)
Thrombosis (10-20%)
Coronary artery spasm 2%
211
Causes of raised Trop
ACS
PET
HTN
cardiomyopathy
PE
Takotsubo
Myocarditis
Renal failure
Autoimmune disease with cardiac involvement
