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ORAL EXAM > Medical conditions in pregnancy > Flashcards

Medical conditions in pregnancy Flashcards

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1
Q

prepregnancy assessment and counselling CF

A

MDT -Phys, obs, diet, DM team, CF nurse, PT, anaeathetis, MW, respiratory physicians
testing for diabetes
monitor nutritional status and weight gain
monitor lung function and tx exacerbations
individualised plan for delivery

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2
Q

Effects of pregnancy on CF

A

generally does not shorten survival, but may in severe disease
inadequate weight gain
deteriorating lung function

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3
Q

Effects of CF on pregnancy

A 
GDM
PTB
HTN
IUGR
fetal anomalies
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4
Q

Crohns risks to pregnancy

A

PTB
IUGR
miscarriage
SB

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5
Q

pregnancy effect on crohns

A

most will not have a flare

most at risk of flare if have active disease at conception or new dx crohns in pregnancy

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6
Q

Risks with obstetric cholestasis

A 
SB
PTB
GDM
PET
intractable itch
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7
Q

when to screen for haemoglobinopathy

A

low MCV
low MCH
Normal iron levels
Ethnicity

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8
Q

Maternal haemoglobinopathy - test to screen in father

A

CBC (MCV, MCH)
Ferritin level
Haemoglobinopathy screen

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9
Q

both parents haemoglobinopathy carriers - what to do

A

arrange genetic counselling and molecular testing

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10
Q

beta thalassaemia management in pregnancy

A 
screen for antibodies
baseline CBC and blood film
ECHO - can have cardiomyopathy
Liver USS - can have cirrhosis or cholelithiasis related to iron overload
HbA1c - risk DM
TFTs - risk hypothyroidism
Vitamin D levels
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11
Q

Epilepsy management at booking

A 
MDT approach
Aim monotherapy
Explain increased risk NTD
HD folic acid
Refer to neurologist
advise medication may need to be increased
advise re monitoring levels
possibility of increased seizure frequency during pregnancy
Advise vit k to bubs to prevent HDN
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12
Q

Cervical cancer in pregnancy management

A

MDT input
Colposcopy - exclude invasive disease, biopsy if suspicious of invasive disease
Staging procedure or MRI, CT if think lung mets
CXR
Consider laparoscopic lymphadenectomy for accurate staging, enabling further fetal maturation
If positive nodes, consider TOP; if continuing CT after first trimester
Treatment of 1A2 and beyond - gold standard is radical hysterectomy and BS; can do just trachelectomy during pregnancy with cerclage - high risk PTB, steroid baby @ 24 weeks
If adenocarcinoma - take ovaries too
Timing of delivery - C/S; prelabour, aim 34-36 weeks, earlier depending on well-being of mother; vaginal delivery not advised due to risk of bleeding, and recurrence at epis site
BF contraindicated with CT
Psychological support

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13
Q

Chemotherapy in pregnancy

A

Avoid in first trimester
Monthly growth scans
Monthly MSUs
Avoid CT 3-4 weeks prior to delivery

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14
Q

Myasthenia Gravis and pregnancy

A

rule of thirds for symptoms
delay pregnancy at least 2 years from outset of disease
risk miscarriage and PTB
can develop transient neonatal MG
C/S only for obstetric indication, may require instrumental delivery
Advise epidural
Ok to continue neostigamine
corticosteroids - increased risk oral clefts
Avoid medications that exacerbate symptoms eg magnesium sulfate
NO mycophenylate

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15
Q

Sickle cell risks in pregnancy

A

acute pain crisis/sickle crisis
infection
IUGR
PTB

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16
Q

Prepreg care sickle disease

A 
UTD immunisations (pneumococcal, Hep B)
Antenatal serology
penicillin propylaxis if splenectomy
High dose folic acid
stop hydroxyurea 3/12 before pregnancy
iron chelators to be stopped 
keep warm and well hydrated to reduce risk of sickle crisis
ECG, ECHO
Retinal screening
renal function (BP and urine checks)
Identify partner status - autosomal recessive
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17
Q

Management sickle in pregnancy

A

Monthly MSUs
VTE prophylaxis from 28 weeks, earlier if other risk factors
CBC, LDH, LFTs checked every two weeks
serial USS
High risk sickle crisis and VTE PP
Consider blood transfusion if anaemic and HCT <0.26
Ferritin check each trimester

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18
Q

Beta thalassaemia pre pregnancy counselling

A

Tests to order: ECHO, LFTs and liver USS, HbA1c, TFTS, infection screen
Stop bisphosphonates
Ensure Vit D and calcium
Test partner - could test cffdna or cordocentesis during pregnancy
Vaccination status (pneumococcal)

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19
Q

beta thal during preg

A

stop chelation therapy
follow as per pre preg counselling
?prophylactic antibiotics (if splenectomy)
Review vaccination status
Early diabetes screen
ECHO third trimester is previous one normal
VTE prophylaxis for 6/52 PP; not given antenatally unless personal history
iron chelation therapy ok in BF

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20
Q

alpha thal

A

fetus would be severely anaemic with risk of hydrops and SB

usually also complicated by pre-eclampsia

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21
Q

HbA1c pre diabetes

A

41-49

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22
Q

Pre-existing diabetes pre preg counselling investigations

A 
HbA1c
PET screen
TFTs with antibodies
booking bloods
coeliac screen for Type 1
smear/swabs
MSU/urine PCR
electrolytes
lipids
last eye review
ECG if DM>10yrs
Dietary advice/exercise
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23
Q

glucose targets in pregnancy

A

fasting <5

post prandial <7

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24
Q

Fetal complications with GDM

A 
macrosomia
IUGR
SB
misc
PTL
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25
Maternal complications with Diabetes
Birth trauma UTI C/S PET/GTN HTN
26
primary adrenal insufficiency in pregnancy
``` nausea vomiting weight loss skin darkening hypoglycaemia hyponatraemia hyperkalaemia ```
27
management acute adrenal crisis in pregnancy
``` IV line Hydrocortisione cover in labour test ACTH, cortisol, glucose and serum electrolytes Identify cause tapering steroid once PP fetal assessment and monitoring ```
28
Differentiating features of Cushings compared to pregnancy
``` proximal myopathy easy bruising osteopenia/# hirsuitism early onset HTN ```
29
Work up of Cushings
urinary cortisol
30
Risks of Cushings in pregnancy
``` SB IUGR PTL misc GDM PET/GTN HTN wound infection CCF psychiatric disorders neonatal adrenal insufficiency Infertility Post op wound dehiscence ```
31
Treatment Cushings
adrenalectomy (unilateral) for adrenal cause Transphenoidal surgery for pituitary cause perform in second trimester or metyrapone or cabergoline
32
Screening for VWD
VWD screen | Factor VIII
33
Management of VWD
Risk of major APH and PPH Labour in hospital Refer/involve haematology and anaesthesia Obtain/review Factor VIII/vWF levels, aim 50/IU/dL close to delivery. Have a plan drawn up for antenatal/intrapartum and postpartum care May need TXA, DDAVP, vWF concentrates recombinant ,vWF + FVIII if severe bleeding Refer to haematologist, anaesthetist and care ideally through multidisciplinary highrisk pregnancy clinic
34
Thrombocytopaenia screen
``` FBC reticulocyte count Peripheral blood film coag screen U/Es LFTs TFTs Direct Coombs test APL antibodies ANA Hep B, Hep C, HIV Immunoglobulins Vitamin B12/folate H. Pylori ```
35
Risks with thrombocytopaenia
Haemorrhage | Neonatal thrombocytopaenia
36
DDx thrombocytopaenia
``` ITP Gestational Pregnancy induced - HELLP syndrome Other - haemotological malignancy AFLP HUS ```
37
Management of thrombocytopaenia antepartum
``` iron/diet monitor platelets monthly IOL by term MDT approach further investigations if platelets <70 Treatment if platelets <50 Consider trial of steroids for response +/- immunoglobulin birth in hospital ```
38
intrapartum management of thrombocytopaenia
``` Anticipate PPH FBC, G&H, platelets Anaesthetics Neuraxial issues <70 Avoid instrumental/FBS/clip Platelets >50 (>20 likely safe) Stress steroids IV hydrocortisone 50 mg Q6H from established labour to 6 hours after birth For CS, give 100 mg IV hydrocortisone at time of anaesthesia, then 6 hours post birth Neonatal platelets and repeat Possible platelet transfusion Active management of third stage ```
39
Risks of hypothyroidism in pregnancy
``` miscarriage PIH/PET Anaemia PPH Abruption Preterm birth Cognitive impairment Developmental delay Low birthweight Increased risk of perinatal mortality ```
40
Treatment of hyperthyroidism in pregnancy
prophylthiouracil
41
Risks to fetus in mum on tx hyperthyrodism
fetus can be hypothyroid due to mum's drug crossing placenta | if TRABs, then risk of fetal hyperthyroidism
42
Management of maternal hyperthyroidism
treat with meds Monitor TSH and T4 and TRABs monthly Fetal USS for signs hyperthyroidism
43
antibodies associated with hypothyroidism
TPO | Thyroglobulin
44
fetal thyrotoxicosis
``` Clinical Presentation: fetal sinus-tachycardia (around 180-200 bpm) holosystolic tricuspid insufficiency IUGR Goiter Oligo- or Polyhydramnios microcephaly hydrops fetalis premature delivery intrauterine fetal demise Diagnosis: patient history biochemical examination (fT4, TSH, TSHR-Ab) targeted ultrasound examination ```
45
BPAD risks on pregnancy
IUGR PTB poor bonding Psychosis
46
Risk with lithium
NTD Epstein's anomaly other cardiac anomalies GDM
47
Management of lithium use in pregnancy
Monthly lithium levels (weekly from 36 weeks), TFTs, U/Es HD folic acid - ideally preconception iodine, vit d early anatomy scan and fetal echo GDM ?child welfare agency serial growth scans active management of the 3rd stage withhold lithium in labour (high placental transfer) check lithium level 12 hours post delivery before restarting Not to be used in BFing
48
Postpartum psychosis
``` Psych liason risk of infanticide - ensure baby is safe/remove Ensure safe from self/risk of self harm transfer to acute mental health unit ongoing lithium use sedation if required ```
49
Spinal cord injury considerations
injury t4 or above - ventilation assessment in pregnancy injury T6 or above - risk of autonomic dyreflexia - rise in BP 20-40mmHg is indicative above T10-altered perception of fetal movements, unable to feel labour pains, risk late preterm labour and UTI above T12 - malpresentation above L2-L4 - scar tissue in epidural space can make epidural analgesia difficult
50
Effect of pregnancy on spinal cord injury
worsening mobility worsening breathing possible change of bladder care ?IDC towards end of pregnancy C/S only if indicated by injury at young age or pelvic trauma
51
pre preg assessment spinal cord injury
``` support groups pelvimetry if indicated Respiratory function assessment if injury T4 or above; chest physiotherapy avoid constipation (risk AD) maintain good bladder cares (risk AD) Baseline CXR Consider imaging of head and spine ```
52
Autonomic dysreflexia
uncontrolled sympathetic outflow rise in BP 20-40mmHg medical emergency remove noxious stimuli (even constipation, bladder cares) complication=ICH, death, fetal bradycardia due to paroxysmal HTN episodes treat with nifedipine sublingual, GTN, or IV labetalol or hydralazine
53
Intrapartum management SCI
good bladder care - place IDC monitor observations - rises from baseline should be flagged prophylactic epidural continuous CTG If AD in second stage - instrumental - if don't have pain relief, then they must be given some!!!
54
tx of spasticity in pregnancy
baclofen (intrathecal) otherwise oxybutinin for bladder spasms diazepam
55
Covid in pregnancy risks
``` Pneumonia, ARDS, resp failure AKI, VTE, myocarditis strokes, vasculitis PTL IUGR SB ```
56
Covid vaccine explanation
higher risk in pregnancy due to reduced lung function, , increased oxygen consumpton, and reduced immune function mRNA vaccine does not contain live virus may offer passive immunity to baby vaccination best way to prevent these risks and can be given in any trimester does not effect miscarriage or fertility rates does not increase VTE
57
Risks uncontrolled hyperthyroidism in pregnancy
``` PET thyroid storm thyrotoxic heart failure FGR prematurity stillbirth fetal thyrotoxicosis fetal hypothyroidism ```
58
Management thyrotoxicosis
PTU - ok in first trimester and BFing, risk maternal liver function damage carbimazole - risk aplasia cutis, ok in 2nd and 3rd trimester No radioactive iodine surgery rarely required - if need to do, aim second trimester
59
Rates of depression and anxiety
approx 12-15%
60
Risk of postpartum psychosis with BPAD
20-30%
61
Neonatal Adaption syndrome
irritability, sleep disturbance, hypoglycaemia self-limiting, supportive cares neonate at risk if SSRI use or benzos
62
CF investigations
ECHO | baseline lung function tests

ORAL EXAM (20 decks)

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