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Year 3 Clinical > Medical Complications in Pregnancy and Post-Partum > Flashcards

Medical Complications in Pregnancy and Post-Partum Flashcards

1
Q

Disorders that can affect pregnancy?

A

There are many

Common conditions include:
• Hypertension, PIH, PET 
• Diabetes
• Epilepsy
• Crohn's / UC
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2
Q

How to manage any medical disorder in pregnancy?

A
  1. The usual antenatal care (ANC)
  2. Consider effect of pregnancy on the medical condition
  3. Effect of the medical condition on pregnancy (baby and mother)
  4. Medications and safe prescribing
  5. Planning of delivery (timing and mode)
  6. Post-partum follow-up
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3
Q

What does the usual ANC involve?

A

Confirmation of pregnancy

Booking visit where:
• General pregnancy advice is given
• Woman is identified as being either low / high risk
• Info on choices for place of birth
• Discuss screening

Check:
• Height and weight (BMI)
• BP

Arrange:
• Dating USS, at 12 weeks
• Arrange booking bloods

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4
Q

What parameters are checked on the booking bloods?

A

FBC, blood group and Abs

Haemoglobinopathies

Infection screen - hep B, HIV, Rubella, VDRL

Random Blood Glucose

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5
Q

Schedule of antenatal visits with the midwife?

A
  • Booking visit @ 8-12 weeks
  • Dating USS @ 11-12 weeks (hospital)
  • Anomaly Scan at 20 weeks
  • Monthly visits till 28 weeks
  • Anti D - 28 weeks & 34 weeks
  • Fortnightly visits 28-36 weeks
  • Weekly visits 37 weeks till delivery
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6
Q

What happens at each antenatal visit?

A

BP

Urinalysis

SFH (FSH)

Foetal heart and movements

NOTE - if any problems are detected, referral to consultant unit

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7
Q

Occurrence of hypertensive disorders in pregnancy?

A

Hypertension is the most common medical problem in pregnancy

Other issues include PET, severe PET and eclampsia (these are less common)

NOTE - the incidence of eclampsia and its complications have decrease in the UK

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8
Q

Types of hypertensive disorders in pregnancy?

A

Chronic (essential) hypertension - present at booking or <20 weeks

Gestational hypertension - new hypertension >20 weeks, without significant proteinuria

Pre-eclampsia - new hypertension >20 weeks + significant proteinuria

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9
Q

Physiology of pregnancy-specific hypertension?

A

There is potentially a placental cause that leads to maternal endothelial dysfunction and maternal hypertension

There is decreased blood flow to organs in pregnancy, due to:
• VASOCONSTRICTION
• Intravascular thrombosis
• Pro-coagulation

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10
Q

Signs of renal disease?

A

Decreased GFR

Protein uria

Increased serum uric acid (also placental ischaemic) and increased creatinine / potassium / urea

Oliguria / anuria

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11
Q

Causes of acute renal failure?

A

Acute tubular necrosis

Renal cortical necrosis

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12
Q

Signs of liver disease?

A

Epigastric or RUQ pain

Abnormal liver enzymes

Hepatic capsule rupture

HELLP syndrome:
• Haemolysis
• Elevated liver enzymes
• Low platelets

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13
Q

What is HELLP syndrome?

A

Life-threatening pregnancy complication usually considered to be a variant or complication of preeclampsia

It is an abbreviation of HELLP syndrome:
• Haemolysis
• Elevated Liver enzymes
• Low Platelet count

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14
Q

Types of placental disease that can occur due to hypertension?

A

IUGR

Placental abruption

Intrauterine death

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15
Q

Ix for conditions assoc. with hypertension?

A

U&Es, serum urate

LFTs

FBC

Coagulation screen

CTG

USS (biometry, AFI, Doppler)

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16
Q

Mx of hypertension at booking and antenatally?

A

Assess risk factors for preeclampsia; if present, ASPIRIN

These patient require surveillance:
• Scans - dating, anomaly, growth scans and umbilical artery doppler
• BP monitoring
• Urine testing

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17
Q

Principles of managing hypertension during pregnancy?

A

Booking:
• Assess risk at booking
• If hypertension is <20 weeks, look for a secondary cause
• Antenatal screening (BP, urine)

Antenatal:
• Treat hypertension

During labour:
• Maternal and foetal surveillance
• Timing of delivery
• Stabilise and treat hypertenion, prevent convulsions
• Deliver
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18
Q

Medications used to treat hypertension in pregnancy?

A
  1. Labetalol
  2. Methyldopa
  3. Nifedipine (usually if monotherapy fails, i.e: it is used as a top-up)

STOP ACEIs and ARBs

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19
Q

Medications used to treat severe hypertension (165/110)?

A

Labetalol (oral or IV)

Hydralazine (IV)

Nifedipine (oral)

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20
Q

Target BP control?

A

Aim for BP <150 / 80-100 mmHg

If there is end-organ damage, e.g: renal damage causing proteinuria or retinal damage, aim for BP <140/90 mmHg

If BP <140/90, consider reducing drug dose; if <130/90, reduce the dose

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21
Q

Delivery if patient has hypertension?

A

Vaginal delivery

If preeclampsia, deliver at 37 weeks

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22
Q

Effects of pregnancy on diabetes?

A 
Pregnancy is a diabetogenic state so:
• Poorer control
• Deterioration of renal function
• Deterioration of ophthalmic disease
• Gestational DM
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23
Q

Effects of diabetes on pregnancy?

A

Miscarriage

Foetal malformations (cardiac, neural tube defects, caudal regression syndrome)

IUGR or macrosomia

Unexplained IUD

PET

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24
Q

Mx of diabetes in pregnancy?

A
  1. Diet
  2. Metformin
  3. Insulin
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25
Q

Delivery if patient has diabetes?

A

Vaginal delivery; induce labour at 37-38 weeks

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26
Q

Types of diabetes in pregnancy?

A

Pre-existing T1DM

Pre-existing T2DM

Gestational diabetes

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27
Q

Effects of diabetes on the foetus?

A

Hyperglycaemia leads to foetal hyperinsulinaemia

This causes the following:
• Foetal macrosomia - risk of birth injury / shoulder dystocia
• Polyuria, polyhydramnios - risk of preterm labour / malpresentation / cord prolapse
• Increased O2 demands, polycythaemia - risk of unexplained term stillbirth
• Neonatal hypoglycaemia - risk of CP

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28
Q

Risk factors for GDM?

A

• Previous GDM

• FH:
– One first degree relative
– Two second degree relatives

  • Poor obstetric history, esp. death of previous macrosomic baby
  • Significant glycosuria
  • Polyhydramnios
  • Macrosomic infant in this pregnancy
  • Polycystic ovary syndrome
  • Weight >100kg or BMI >30
  • South Asian, Middle Eastern or African origin
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29
Q

Ix and monitoring of diabetic pregnant women?

A

Screening

Detailed USS, inc. extended cardiac views

Diabetic control - aim for a BM of 4-6 and keep the HbA1c <6.0%
• Diabetic support
• Diet, metformin, insulin
• Retinal screening every trimester

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30
Q

Mx for diabetes during pregnancy?

A

Regular antenatal care is required, with serial growth scans at 28, 32 and 36 weeks

Must be monitored for PET

Elective delivery via IOL:
• If pre-existing DM, this should occur at 37-38 weeks
• If GDM on insulin, may be 38 wees
• If GDM on diet with a normal BM and foetal growth, may wait until 41 weeks

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31
Q

Mx for the neonate born to mother with diabetes?

A

Neonatal surveillance at delivery; monitor the BM to ensure that there is no neonatal hypoglycaemia

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32
Q

Mx of diabetes post-natally?

A

If pre-existing DM, return to pre-pregnancy insulin / oral hypoglycaemic agent regime

If GDM, stop treatment and monitor BM for 48 hours, to ensure return to normal and no persistence of IGT

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33
Q

Foetal effects of diabetes?

A

Macrosomia - increased risks of birth injury and shoulder dystocia; it is a major cause of obstetric litigation

Polyhydramnios:
• Foetal malpresentations
• Increased risk of preterm labour

Hyperinsulinaemia - leads to severe neonatal hypoglycaemia (risk of CP)

Polycythaemia:
• Thrombotic effects
• Jaundice

Hypocalcaemia

Hypertrophic cardiomyopathy (HOCM)

34
Q

When is an LSCS recommended for macrosomia?

A

Macrosomia and EFW >4000g

35
Q

Occurrence of VTE in pregnancy?

A

Rare but remains the MAIN CAUSE OF MATERNAL DEATH

Diagnosis is difficult during pregnancy, due to swollen calves and ankles, etc

36
Q

Effects of pregnancy on VTE risk?

A

Increased risk of VTE / PE, as pregnancy is a pro-thrombotic state

This is compounded by the effects of Virchow’s triad:
• Stasis secondary to venous compression by the pregnant uterus
• Hypercoagulability
• Vascular damage (leads to varicose veins)

37
Q

Medications used for VTE in pregnancy?

A

LMWH

38
Q

Coagulation changes in pregnancy?

A

Increased levels of factor VII, VIII, X and fibrinogen

There are effects on both the intrinsic and extrinsic pathways

39
Q

Risk factors for VTE?

A 
Pre-existing risk factors:
• Previous VTE (biggest risk factor)
• Known high risk thrombophilia
• Medical comorbidities
• FH of unprovoked or oestrogen-related VTE in 1st degree relative
• Known low risk thrombophilia (no VTE)
• Age >35 years
• Obesity
• Parity ≥3
• Smoker
• Gross varicose veins
Obstetric risk factors:
• Preeclampsia in current pregnancy
• ART / IVF (antenatal only)
• Caesarian section in labour
• Elective caesarian section
• Mid-cavity or rotational operative delivery
• Prolonged labour (>24 hours)
• PPH (>1L or transfusion)
• Preterm birth <37 weeks in current pregnancy
• Stillbirth in current pregnancy
Transient risk factors:
• Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum, e.g: appendicectomy, postpartum sterilisation
• OHSS (1st trimester only)
• Current systemic infection
• Immobility, dehydration

There is a risk assessment available; scores can be given to each risk factor

40
Q

Mx of high risk patients for VTE?

A

Any previous VTE requires antenatal prophylaxis with PMRH

41
Q

Mx of intermediate risk patients for VTE?

A

Consider antenatal prophylaxis with LMWH

42
Q

Mx of patients with risk factors for VTE antenatally?

A

High risk requires antenatal prophylaxis with LMWH:
• Any previous VTE

Intermediate risk requires consideration of antenatal prophylaxis with LMWH

If ≥4 risk factors are present, prophylaxis from 1st trimester

If 3 risk factors present, prophylaxis from 28 weeks

If fewer than 3 risk factors, mobilisation and avoidance of dehydration

43
Q

Mx of patient with risk factors for VTE postnatally?

A

High risk requires at least 6 weeks of postnatal prophylactic LMWH

Intermediate risk requires at least 10 days of postnatal prophylactic LMWH

If fewer than 2 risk factors, early mobilisation and avoidance of dehydration

44
Q

What is a DVT?

A

Thrombosis in one of the deep veins of the leg

45
Q

Signs of DVT?

A

1/2 of early DVTs are asymptomatic

Homan’s sign (unreliable) - discomfort behind the knee on forced dorsiflexion of the foot

46
Q

Ix DVT in pregnancy?

A 
Baseline Ix:
• FBC
• Clotting
• U&amp;Es
• LFTs
• D-dimer (cannot be used in pregnancy)
• Anti-Xa levels (not routine)
• Platelet levels (not routine)
• Thrombophilia screen (not routine and controversial as results are affected in pregnancy and there is no influence on immediate Mx)

D-dimer (cannot be used in pregnancy)

Duplex US on lower limb

47
Q

Mx of DVT in pregnancy?

A

THERAPEUTIC LMWH (treat and then Ix) - given OD, as it has a long duration of action:
• Enoxaparin
• Tinzaparin
• Daltaparin

Continue till 3 months after delivery OR 6 months after treatment (whichever longer)

48
Q

Use of thromboembolic deterrent stockings?

A

Used in the acute phase, for up to 2 years; there are issues with compliance

They decrease thrombotic syndrome by 50%

49
Q

Advantages of using heparin?

A

Does not cross the placenta and is safe for the foetus

More effective in DVT

Less haemorrhagic manifestation, mortality, HIT, osteopaenia

50
Q

Side effects of heparin?

A

Haemorrhage

Hypersensitivity

Allergy at the injection site

Heparin Induced Thrombocytopaenia (HIT)

Osteopaenia (prolonged usage can lead to osteoporosis)

51
Q

Ix for PE?

A

ABGs, CXR (radiation dose to the foetus is negligible), ECG

Duplex US lower limbs - if -ve, not very helpful

Ventilation / perfusion scans

If any results are abnormal and there is a high clinical suspicion, do a CTPA (gold standard)

NOTE - treatment with heparin should be initiated prior to Ix

52
Q

Use of CXR to look for a PE?

A

Normal in 1/2 of PE cases

Signs include:
• Atelectasis
• Effusion
• Focal opacities
• Regional oligaemia  
• Pulmonary oedema
53
Q

Risk of cancer with CTPA?

A

Risk of childhood cancer (lower than with a V/Q scan)

Increased risk of breast cancer (check for a history of this)

54
Q

Delivery when patient is on heparin?

A

For a vaginal delivery, stop heparin when patient is in labour

Anaesthesia (epidural):
• Therapeutic - stop 24 hours before planned delivery
• Prophylactic - stop 12 hours before

55
Q

Treatment of VTE or PE risk postnatally?

A

Within 6 weeks postnatal, treat for at least 3 months

Preferred choice is warfarin but LMWH may be used

56
Q

Why is warfarin avoided during during initial pregnancy?

A 
Avoided at 6-12 weeks:
• Teratogenic
• Miscarriage risk
• Neuro problems
• Stillbirth
57
Q

If warfarin is used during pregnancy, when must it be stopped?

A

Avoid at 6-12 weeks

Stop 6 weeks before labour

58
Q

Breastfeeding risks with warfarin?

A

Warfarin is fine with breastfeeding

59
Q

Mx of hypothyroidism in pregnancy?

A

Increase levothyroxine by 25-50 mcg in the 1st trimester; repeat TFTs every trimester

Vaginal delivery

60
Q

Effects of pregnancy on hyperthyroidism?

A

Worsens due to HCG in the 1st trimester but improves during the 2nd and 3rd trimester

61
Q

Effects of hyperthyroidism on pregnancy?

A

IUGR, preterm labour

Thyroid storm

62
Q

Mx of hyperthyroidism during pregnancy?

A

Carbimazole / PTU (TFTs are checked every trimester)

Propranolol (risk of IUGR)

Growth scans

63
Q

Respiratory changes that occur in pregnancy?

A

Increased RR - causes respiratory alkalosis:
• Increased pH 7.43
• Decreased pCO2
• Decreased HCO3

Changes in PFTs due to mechanical effects of pregnancy on the lungs

O2 demand increases

TIDAL VOLUME increase

Inspiratory capacity increases

Residual volume decreases

Expiratory reserve decreases

Marked reduction in functional residual capacity:
• Diaphragmatic elevation
• Increase in subcostal angle and transverse thoracic diameter

FEV1 and PEFR unchanged

64
Q

Effects of pregnancy on asthma?

A

May improve, deteriorate or remain unchanged; patients who improve during the 3rd trimester may deteriorate during the postnatal period

If mild disease, unlikely to experience issues

If severe disease, there is a greater risk of deterioration, esp. in the 3rd trimester

65
Q

Why might asthmatic patients deteriorate during pregnancy?

A

Often due to a reduction or cessation of medication, due to unfounded safety fears

66
Q

Effects of asthma on pregnancy?

A

For the majority of women, there is no adverse effect on pregnancy outcome

If asthma is severe and poorly controlled, the assoc. hypoxaemia may adversely affect the foetus

NOTE - adverse effect on pregnancy are rare and mainly assoc. with poor control:
• PIH / PET
• Preterm labour
• Low birth weight
• IUGR
• Neonatal morbidity, e.g: TTN, hypoglycaemia, seizures, etc

67
Q

Mx of asthma in pregnancy?

A

Emphasise prevention

Treatment is the same as for non-pregnant women:
• Optimise control prior to pregnancy
• Achieve control ASAP in a new diagnosis
• Mainstay is β2-agonist +/- ICS

68
Q

Occurrence of epilepsy?

A

Most are known prior to pregnancy

69
Q

Risks assoc. with epilepsy during pregnancy?

A

All seizure types can be affected by pregnancy

Assoc. with risk of maternal death, due to aspiration

70
Q

Effects of pregnancy on epilepsy?

A

Many patients experience no change and others have an increased seizure frequency

Poorly controlled epilepsy (>1 seizure per month) is likely to deteriorate

If the patient is seizure-free, prior to pregnancy, they are unlikely to have relapse, unless medication is stopped

71
Q

When is the risk of seizures highest during an epileptic pregnancy?

A

In the peripartum period

72
Q

Reasons for deterioration of asthma control?

A

Poor compliance (fears of teratogenesis)

Decreased drug levels due to N&V

Decreased drug levels due to increased Vd and increased drug clearance

Lack of sleep towards term and during labour

Lack of absorption of drugs during labour

Hyperventilation during labour

73
Q

Effects of epilepsy on pregnancy?

A

Foetus is relatively resistant to short-term hypoxia (during seizures) and there is no evidence of adverse effects

No increased risk of miscarriage or obstetric complications

Status epilepticus (<1% of pregnancies) is dangerous for mother and baby, so treat vigorously

74
Q

What is the major risk of epilepsy during pregnancy?

A

Teratogenecity of the drugs; even women on no drugs have an increased risk of malformations

This risk increases with the no. of drugs (polypharmacy)

NOTE - benzodiazepines are not teratogenic

75
Q

Risk of the child developing epilepsy?

A

Higher if there is a FH

76
Q

Teratogenic risks of anti-convulsants?

A

They are all teratogenic (newer drugs are thought to be safe but there are risks assoc.)

Major malformations:
• NTDs
• Orofacial clefts (esp. phenytoin)
• Cardiac defects (esp. phenytoin and valproate)

Minor malformations (foetal anti-convulsant syndrome):
• Dysmorphic features
• Hypertelorism - abnormally increased distance between 2 organs or bodily parts, usually referring to an increased distance between the orbits
• Hypoplastic nails and distal digits

77
Q

Mx of epilepsy pre-conceptually?

A

Pre-pregnancy counselling

5mg folic acid (pre-conceptually for 12 weeks and throughout pregnancy)

78
Q

Mx of epilepsy during pregnancy?

A

Continue folic acid throughout

Continue current drugs if well-controlled, except:
• Phenobarbitone - wean off / change, due to risks of neonatal withdrawal convulsions

Vitamin K, 10-20mg orally, from 34-36 weeks, if on hepatic enzyme inducers (due to risks of foetal vit K deficiency and Haemorrhagic Disease of the Newborn)

If giving steroids, increase the dose if enzyme-inducing drugs, e.g: phenoytoin, phenobarbitone, carbamazapine

79
Q

Advice given to the epileptic patient and her relatives during pregnancy?

A

Advice shallow baths and showers (risk of drowning with seizure)

Relatives advised regarding the recovery position

80
Q

Delivery of a baby from an epileptic woman?

A

Most have normal deliveries; LSCS is only used if recurrent generalised seizures in late pregnancy / labour

Continue anti-epileptic drugs in labour

Offer an early epidural to reduce pain / anxiety

81
Q

Post-partum Mx for an epileptic woman?

A

Neonate given 1mg IM vitamin K

Encourage breastfeeding

Advise regarding shallow baths / showers with an unlocked door

Risks of SUDEP increase in pregnancy and during the postnatal period

Year 3 Clinical (100 decks)

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