Maternal medicine

Question 1

Thyrotoxicosis in preg

Answer 1

Increase fetal loss, maternal HFx, prematurity

Graves

Mx:
Use PTU - 1st tri
Carbimazole 2nd

Dont use block and replace

Question 2

Hypothyroidism

Answer 2

Thyroxine safe
Breastfeeding safe on thyroxine

MEasure TSH every triester then 6-8 wks post-partum

Question 3

DB in preg - RFs

Answer 3

prev GDM
prev macrosomia 
Obesity BMI>30
!st degree relative
High risk origin 

If prev GDM –> OGTT as soon as possible then 24-28 weeks.
any other RF –> 24-28wks

Question 4

DB in preg diagnosis

Answer 4

Fasting 5.6

2hr - 7.8

Question 5

GDM Mx

Answer 5

new diagnosis - joint endo ANC

Fasting BGL <7 –> Diet and Ex –> Fx of targets @ 2/52 –> +metformin

FBGL>7 –> Insulin

FBG 6-6.9 + Hydraminos/macrosomia –> insulin

glibencamide only if fx with metformin and refuase insulin

Question 6

Pre-existing DB

Answer 6

WL if BMI>27

Stop all oral hypoglycaemics –> insulin + metformin

Folic acid 5mg (conception –> 12 weeks)\

Aspirin 75mg (12 wks –> birth)

detailed anomaly scan @ 20 weeks

Question 7

BGL targets

Answer 7

fasting - 5.3

1hr - 7.8

2hr - 6.4

Question 8

BP normal physiology

Answer 8

Falls during 1st trimester –> 20-24 wks

Returns to normal term

Question 9

pre-existing HTN - pregnancy

Answer 9

up to 20 weeks gestation

> 140/90

no proteinuria/oedema

Question 10

PIH

Answer 10

> 20wks

140/90

Proteinuria/oedema

Question 11

Pre-eclampsia

Answer 11

PIH + Proteinuria (0.3g/24hr)

Question 12

HTN in preg definition

Answer 12

> 140/90

Or increase of >30/15 between booking readings

Question 13

High risk of HTN - pregnancy

Answer 13

HTN - prev pregnancy
CKD
AI - SLE/antiphospholipid
DB1 & 2

Question 14

Antiphospholipid syndrome in pregnancy

Answer 14

Thrombosis

Presence of Lupus anticoagulant or anti-cardiolipin ab ( vs Cardiolipin component of cell wall)

Diagnosis:
- 2 tests (12weeks apart)
&

1 of:

• Thrombosus
• => 3 miscarriages
• pre-eclampsia +/or FGR < 34 weeks
• Fetal loss >10 wks
• Placental abruption

Complications:

• Recurrent miscarriage
• IUGR
• Still Birth
• VTE
• Premature
• Pre-eclampsia

MX:

• ASPIRIN as soon as confirmed preg
• once fetal heart confirmed - LMWH

Question 15

Post-partum thyroiditis

Answer 15

A.I.

assoc w/ thyroid anti-perocidase Ab

Histology:

• Focal diffuse
• lymphocytic infiltratio
• follicular destruction
• hyperplasia

3 Stages:

1) thyrotoxicosis - 1-3/12
2) Hypothyroid 3-8/12
3) Normal thyroid fn - 1yr post partum

LT surveillance as increase risk permanent hyothyroid

Question 16

HTN in pregnancy Mx

Answer 16

High risk groups:

• Prev HTN w/preg
• CKD
• A.I.
• DB1+2

Aspirin 75mg (12wks to birth)

Labetolol/methldopa/nifedipine

Question 17

Pre-eclampsia - complications

Answer 17

predisposes:

• eclampsia
• fetal risk - premature/IUGR
• haemorrhage - Placental abruption/intrauterine/intracerberal
• cardiac fx
• multi-organ fx

Question 18

pre-eclampsia - risk factors

Answer 18

High risk:

• prev htn - w/preg
• CKD
• Antiphospholipid/SLE
• DB1 & 2

Low Risk:

• 1st preg >40yrs
• Gap between preganncy - 10yrs
• BMI >35
• FHx
• multiple preg

Question 19

Sev pre-eclampsia

Answer 19

BP >170/110 + proteinuria 
Proteinuria ++/+++
Headache
visual change/papilloedema 
Epigastric pain 
hyperreflexia 
low platelets <100

Question 20

Pre -eclampsia mx

Answer 20

Labetolo - 1st line

Nifedipine/hydralazine second

Question 21

pre-eclampsia indications for delivery

Answer 21

refractory severe HTN
LFx/RFx
Low platelets 
neuro 
Fetal CTG/fetal compromise

Question 22

pre-eclampsia - Maternal complications

Answer 22

Low platelets
hypovol
DIC
Renal impairment + uric acid 
AST/ALT

Question 23

Intrahepatic cholestasis

Answer 23

most common cause of jaundice

seen in 3rd trimester

Ft

• pruritus
• high bili
• no rash

Mx:

• UDA
• Wkly LFTs
• Deliver @37wks

Question 24

Acute fatty liver

Answer 24

Rare

• Increaseed ALT >500

Ft

• Abdo pain
• N/V
• Headache
• Jaundice
• sev –> preclampsia

Assoc. w. HELLP:
- heamolysis, educated liver enzymes, low platelets

Question 25

Eclampsia

Answer 25

Convulsions occuring w/ pre-eclampsia in absence Mx: - MgSO4- - used to prevetnt or x - 4g IV --> infusion 1g/hr ``` Montor: UO Reflexes RR O2 sats ``` MgSO4 --> RR Depression --> CA GLUCONATE Fluid restrict

Question 26

Pregnancy DVT/PE

Answer 26

PReg hypercoaguable state --> Esp 3rd trimester Aetiology: - increased F7/8/10 - reduced protein S - Venous stasis Mx - Warfarin CI --> LMWH

Question 27

Thrombophillia in Preg

Answer 27

Main disease: - homocystinuria - Antithrmbin deficiency - Protein C/S deficiency - Antiphospholiid syndrome - prothrombin gene variant - factor V leiden

Question 28

RF og thrombophilia - THROMBOSIS

Answer 28

``` trauma HRT/hypercoaguable Recreational drugs Obesity/Obstetric Malignancy Birth control - OCP Old age Surgery immobile serious ill/sepsis ```

Question 29

Investigation of VTE in preg

Answer 29

US Doppler CXR ABG ECG V/Q - 1st line for PE unlesss lung pathoogy --> CTPA

Question 30

Air travel in preg

Answer 30

Long haul flight - >4hr - Stockings if have a RF --> LMWH on day off and days after

Question 31

Post-partum thromboprophylaxis

Answer 31

Encourage early mobilisation => 2 RF - LMWH - 1/52 =>3 RF --> LMWH + Stockings BMI>40 + Vag deliver --> 1/52 LMWH BMI >40 + Csec --> 6/52 LMWH If antenatal LMWH --> cont for 6/52 post-partum