Medical Conditions and Pregnancy part 3

Question 1

When are women screening for anaemia in pregnancy and why does it occur?

Answer 1

Booking clinic and at 28 weks.
Anaemia occurs due to the increase in plasma volume. This dilutes Hb concentration

Question 2

What are the investigations and treatment for anaemia in pregnancy

Answer 2

Ix - Hb, MCV (as this is not affected by pregnancy). Can also do ferritin, B12 and folate.
Management - If anaemic then start replacement iron. If not anaemic but have low iron then give iron supplements. Replace B12 if low as requirements increase in pregnancy.

Question 3

Asymptomatic bacteruria and pregnancy

Answer 3

All women are tested for asymptomatic bacteriuria at booking and through pregnancy as they are at higher risk of developing UTIs, pyelonephritis and preterm birth.
Therefore asymptomatic bacteriuria is treated with antibiotics. Test of cure is also done.

Question 4

What is the management of UTIs in pregnancy

Answer 4

7 days of:
1st line - Nitrofurantoin (avoid in near term- 3rd trimester).
2nd line - Amoxicillin or cefalexin
* Trimethoprim is folate antagonist so avoided as it causes neural tube defects.

Question 5

Explain VTE prophylaxis in pregnancy

Answer 5

All women have risk assessment at booking. Start prophylaxis in first trimester if 4+ risk factors or at 28 weeks if 3+ risk factors.
Start women on LMWH eg, dalteparin or enoxiparin. It is continued throughout pregnancy at 6 weeks postnatally (temp stoped during labour)
Other prophylaxis if LMWH is CI - stockings or intermittent pneumatic compression

Question 6

Investigations and treatment for DVT and PE in pregnancy?

Answer 6

DVT - doppler US and repeat on days 3 and 7.
PE - CXR and ECG. Definitive tests are CTPA or VQ scan. CTPA is best if patient has abnormal CXR.
CTPA increases risk of maternal breast CA. VQ scan increases risk of childhood cancer.
If both DVT and PE suspected - Doppler US initially. If DVT found then no need to investigate PE as treatment is same.
Wells score and D-dimers are not helpful in pregnancy.
Managed with LMWH unless massive then thrombolysis/embolectomy/unfractionated heparin

Question 7

Describe clinical features of antiphospholipid syndrome in pregnancy

Answer 7

Recurrent miscarriag,
IGUR,
Pre-eclampsia,
Placental abruption,
Pre-term delivery,
VTE.

Question 8

What is the treatment of antiphospholipid syndrome in pregnant?

Answer 8

Low dose aspirin once pregnancy is confirmed.
LMWH started once fetal heart is seen on US and discontinued at 34wks.

Question 9

What are the maternal complications of obesity in pregnancy?

Answer 9

Spontaneous abortion,
Gestational diabetes,
Hypertensive disorders,
NAFLD,
OSA,
More likely to need induced.
C-sections more difficult.
PPH,
VTE
Even prepregnancy obesity is a strong indication for adverse outcomes.

Question 10

What are the fetal complications of maternal obesity in pregnancy

Answer 10

Congenital anomalies,
Stillbirth,
Macrosomia,
Post-term delivery

Question 11

Asthma and pregnancy

Answer 11

Rule of 3rd - one no change, one worsens and one third improves. However hormonal changes can lead to more susceptibility to infections which can increase risk of exacerbations.
Undertreatment pf asthma can result in asthma exacerbations, preeclampsia, preterm delivery, low maternal birth weight and increased perinatal mortality.
SAFE to continue treatment during pregnancy and breastfeeding

Question 12

What are the fetal complications of asthma

Answer 12

If undertreated it can increase risk of miscarriage, antepartum haemorrhage, PPH, anaemia, depression and need for caesarean

Question 13

What are the effects of SLE on pregnancy?

Answer 13

Aim to be flare-free for 6 months prior to pregnancy.

Maternal - Increases risk of stillbirth, fetal loss, fetal heart block, preterm labour, PPH, VTE, and preclampsia

Fetal outcomes - IUGR, perinatal death, neonatal lupus syndrome
Drugs safe = hydroxychloroquine, oral steroids, azathioprine, taacrolimus.

Question 14

Describe features of neonatal lupus syndrome

Answer 14

Occurs when mother has lupus.
Features - congenital heart block, cardiomyopathy, cutaneous lesions, thrombocytopenia and hepatobiliary disease

Question 15

IBD and pregnancy

Answer 15

Avoid conception is disease is active. Can result in preterm labour and FGR.
C-section if perineal distulas or scarring.
Mesalamine (mesalazine) is most commonly used drug to treat IBD in pregnancy - non teratogenic. Azathioprine and mercaptopurine have potential teratogenic effects but generally safe in pregnancy.
Nutritional concerns

Question 16

RA and pregnancy

Answer 16

Pregnancy improves RA symptoms in many women however may flare up after delivery.
Management - Methotrexate and leflunomide should be avoided. Women should disconctinue methotrexate 3 months before conception.
First line is hydroxychloroquine. Sulfasalazine can also be used. Steroids may be used in flares.

Question 17

Describe features of headaches in pregnancy

Answer 17

Common symptom which mostly bengign but can indicate pre-eclampsia, SAH, ICH or tumours.
Most common is tension headaches - managed with paracetamol, hydration and heat packs.

Question 18

Migraines and headaches

Answer 18

Always take blood pressure and urinalysis.
1st line - paracetamol.
2nd line - Ibuprofen (1st and 2nd trimester only) or sumatriptin.
Avoid NSAIDs in 3rd trimester as can cause premature closure of ductus arteriosus
Do NOT prescribe aspirin or opioids and do NOT intiate preventative treatment in pregnancy or breastfeeding

Question 19

Differential diagnosis of headaches in pregnancy

Answer 19

Pre-eclampsia,
SAH,
Cerebral venous sinus thrombosis,
Meningitis,
Intracranial bleed,
Mass,
Benign causes

Question 20

Shortness of breath in pregnancy

Answer 20

Common symptoms foe many reasons - uterus causing compression which reduced ung expansion, progesterone can increase respiratory rate.

Question 21

What are the causes of cardiac arrest in pregnancy?

Answer 21

4 Ts: Thrombosis (amniotic fluid embolus or VTE), tension pneumo, toxins and tamponade.
4 H’s: Hypoxia, hypovolaemia, hypothermia, hyperkalaemia, hypoglycaemia
Obstetric causes: Eclampsia, intracranial haemorrhage, obstetric haemorrhage, PE, sepsis.

Question 22

What are the three major causes of cardiac arrest in pregnancy?

Answer 22

Obstetric haemorrhage, PE or septic shock.

Question 23

What are the main causes of massive obstetric haemorrhage?

Answer 23

Ectopic pregnancy, placental abruption, placental praevia, placental accreta and uterine rupture

Question 24

What is aortocaval compression

Answer 24

After 20 weeks, a womans uterus compresses the IVC and aorta when she lies supine. This reduced venous return which reduces cardiac output, leading to hypotension. Can cause cardiac arress.
Solution is to place woman in the left lateral position.

Question 25

What are some specific considerations for CRP in pregnancy

Answer 25

A 15 degree tilt to left side for CRP to relieve aortocaval compression.
Early intubation
Early supplementary oxygen,
Aggressive fluid resus,
Delivery baby after 4 mins an within 5 mins of starting CPR