Medical Issues in Pregnancy Flashcards
(172 cards)
1
Q
Doxycycline is contraindicated in pregnancy T/F
A
True
2
Q
Rx of Listeria in pregnancy
A
ampicillin + Gent
3
Q
DDx for vesicular rash in pregnancy
A
HSV
VZV
4
Q
DDx non vesicular, non pruritic rash in pregnancy
A
rubella, measles, parvo
5
Q
What proportion of women with fever >38 post partum have infection?
A
1/3
6
Q
Define sepsis
A
Severe end organ dysfunction as a result of dysregulated host response to infection
7
Q
Most common organisms causing maternal sepsis
A
GAS
E. coli
8
Q
Define septic shock
A
- Hypotension requiring vasopressors post IV fluid resus
- Lactate >2 post IVF resus
9
Q
Considerations for managing sepsis in pregnant patient
A
- Resus
- Consider steroids if likely to have PTB
- CTG
- Avoid spinal -> GA better
10
Q
Risk factors for early onsent Neonatal sepsis
A
- GBS
- PROM >18-24 hours
- PPROM
- Intrapartum fever 38+
- Maternal chorio
11
Q
Incidence of chorio in all live births vs in setting of PPROM
A
1% all live births
30% in those with PPROM
12
Q
Risk factors for Chorio
A
PPROM and prolonged ROM
Prolonged labour
Multiple VE post ROM
Nulip
GBS colonisation + BV
Etoh and smoking
MSL
EDB
Internal monitoring
13
Q
Signs of chorioamnionitis
A
maternal fever
Maternal tachycardia
Uterine tenderness
Offensive vaginal discharge
Foetal tachycardia
14
Q
Obstetric implications of syphilis
A
miscarriage
Stillbirth
FGR
Non immune hydrops (hepatomegaly and acites)
Congenital syphilis
15
Q
Obstetric implications of HSV
A
FGR
Neonatal herpes -> mucocutaneous, encephalitis/meningitis (6% mortality) or disseminated (30% mortality)
16
Q
Obstetric implication of chlamydia
A
neonatal infection -> conjunctivitis/opthalmia, pneumonia
Associated with PTB, low birth weight, perinatal mortality
?PPROM
17
Q
obstetric implications for gonorrhoea
A
Neonatal gonno -> opthalmia, sepsis
PTB
PPROM
18
Q
Obstetric implication of HIV
A
vertical transmission
Exposure precautions required for staff
19
Q
impact of congenital syphilis
A
early -> rhinitis, desquamative rash, splenomegaly, thrombocytopenia and jaundice.
bones - periostitis and osteochondritis “moth eaten bones”
Eyes - cataracts
Teeth
SN hearing loss
Neurological deficient
Mid face abnormalities
20
Q
Which syphilis blood test helps us monitor treatment response ie titres
A
RPR or VDRL (non treponaemal immuno assays)
21
Q
What is the initial screening test ordered antenatally for syphilis
A
treponemal test -> EIA (enzyme immuno assays)-> life long pos, false neg in very early infection
22
Q
What is the risk of transmission to baby if genital lesion present at time of delivery in the setting of recurrent HSV 1 or 2?
A
2%
23
Q
What is the risk of transmission to baby if first episode HSV with no seroconversion at time of delivery (ie recent primary infection)
A
25-50%
24
Q
Does CS totally eliminate the risk of HSV transmission?
A
No, though reduces risk.
25
Risk reduction strategies for HSV transmission to neonates
Identify primary vs recurrent infection (different risk profile)
Aciclovir PO from 36 weeks
Spec examination in labour
Avoid FSL/FSE/Instrumentals
CS delivery recommended if active lesions or primary infection and not yet seroconverted
Expedite delivery to reduce exposure to shedding (ie augment PROM)
26
Mode of transmisson of HSV to neonate
direct contact with lesions
Asymptomatic viral shedding
27
Risk of developing chlamydial infection in neonate with infected mother at time of delivery?
50-70% colonised, 20-50% develop conjunctivitis, 10-20% pneumonia
28
Who should be screened for chlamydia/gonno in pregnancy?
<30yo, high risk sexual contact, drug use, ASTI
29
First line Rx of chlamydia in pregnant population
1g Azithro stat PO
Alt Rx - amox 500mg PO TDS 7 days or erythromycin 500mg QID 7 days
30
Rationale for TOC at 3-4 weeks for chlamydia (+ 3 months post Rx)
ensure Rx efficacy
Risk of reinfection (15% in pregnant women)
31
Clinical presentation of gonorrhoea
asymptomatic
Dysuria
Purulent discharge
Disseminated Gonno I -> fever, skin lesions, joint pain/arthritis.
32
Rx for gonnorrhoea
Ceftriaxone 500mg IM/IV 1% lignocaine + Azithro 1g PO
TOC 2-4 weeks from Rx
33
Gonorrhoea risk of perinatal transmission
30-40%
34
Strategies to reduce vertical transmission of HIV
-cART -> lower viral load, lower risk of transmission
-appropriate delivery mx (MOD and intrapartum zidovudine depending on viral load)
-Avoid breastfeeding
- infant PEP
(Risk <1%)
35
When is elCS indicated for HIV positive women?
on cART with viral load >50
Zidovudine monotherapy
Aim 38-39 weeks
36
Define AIDS
HIV + CD4 count <200 or infection with opportunistic infection
37
Prevalence of HIV in AUS
1:1000
37
When should pregnant women commence cART for hiv?
by 24 weeks + commence on high dose folate
38
Can you perform and ECV or invasive sampling antenatally in HIV positive mother?
yes if viral load <50
38
Mx of PROM with HIV
-Term -> augment with aim to deliver within 24 hr
-PPROM 34+ -> augment, aim delivery within 24hr
-PPROM <34 weeks individualise with MDT input
39
Indications for Zidovudine in labour
1. Unknown viral load
2. viral load >50
3. Women not on ART/non adherence
40
Obstetric implications of rubella?
FGR
Congential rubella syndrome -> cardiac defects -> PVstenosis + VSD, echogenic bowel
Neonate -> Deafness
DM
Thyroid disease
Vascular effects
Encephalitis
growth hormone deficiency
Max risk to pregnancy if rubella in first 16 weeks of pregnancy, if 16-20 hearing loss dominant. Pre conception and >20 week infection no major implications.
41
Obstetric implications of parvo B19?
foetal anaemia -> non immune hydrops 2->17 weeks from infection
Miscarriage
FDIU (in the setting of hydrops) -> excess loss 10%
42
Obstetric implications of measles?
miscarriage, PTB, stillbirth
HING (human normal immunoglobulin) to neonate if born 6 days either side of measles rash appearing on mum
43
Obstetric implications of CMV?
miscarriage, FDIU, congenital CMV
44
Obstetric implications of VZV?
Fetal varicella syndrome,
Maternal morbidity
45
Obstetric implications of influenza?
PTB, low BW, Maternal morbidity/mortality.
46
Obstetric implications of Zika virus?
congenital microcephaly
47
Surveillance post confirmed maternal parvo infection <20 weeks
US 1-2 weekly for 12 weeks -> MCA PSV
48
Congenital CMV incidence
0.3% live births in Aus
49
obstetric implications of CMV
miscarriage
Congenital cmv
- neurodevelopmental delay
- sn hearing loss
-fgr
- jaundice
- microcephaly
-hepatospenomegaly
- thrombocytopenic purpura
50
Risk reduction for CMV
Avoid sharing food/drink/utensils with <3 y olds
Avoid contact with saliva of kids (kissing, dummies)
Hand hygiene when in contact with kids bodily fluids
Clean surfaces in contact with pt bodily fluids
51
Higher chance of transmission of CMV is in which trimester?
First (30-40%)
52
Dx of primary maternal CMV
new CMV IgG if prev seronegative, or CMV IgM with low IgG avidity
53
When would you perform amnio PCR to dx foetal CMV infection
Serology suggestive of primary mat CMV (IgG pos in prev seroneg pt, IgM pos + IgG pos with low avidity) approx 8 weeks post suspected infection and >21 weeks (less risk of FN)
54
Emerging Rx for CMV
- booking screening for CMV and at 14/16 weeks
- Oral valacyclovir 8g daily in cases of primary infection until amnio PCR result
- consider continuing antiviral rx if amnio pos
55
In utero Ix for CMV
serial G+W US
Foetal MRI in 3T ( if all normal, prognosis good)
56
Increased eGFR and decreased Cr are due to what physiological change in pregnancy?
R>L dilatation of urinary collecting system -> relaxation of smooth muscle
57
Renal related phsyiological changes in pregnancy
1. Increased circulating blood volume (30-50%) -> E/P impact RAAS -> increased salt and water retention
2. Increased eGFR and decreased Cr
3. Degree of hydronephrosis due to smooth muscle dilatation and obstruction by gravid uterus
58
Most common causative organisms for UTI during pregnancy
E Coli (70-80%)
GBS (10%)
59
Incidence of asymptomatic bacteruria in pregnancy
2-10%
60
Additional pregnancy RF for renal stones?
Increased urinary Ca secretion, urinary stasis due to ureteral dilatation, decreased urinary pH
61
Obstetric risks of renal disease - maternal
-HTN
- PET
- Worsening renal function -> transition to dialysis
-Nephrotic syndrome
- Worsened anaemia
-Acceleration of disease progression
-Disease flare
62
Foetal risk for renal disease
FGR
Uteroplacetental dysfunction
PTB
FDIU
63
Pre-conception counselling for lupus nephritis
- Aim 6 month stable remission
- Transition to drugs safe in pregnancy
- Baseline Cr and proteinuria
64
Immunosuppresive drugs safe in pregnancy
-azithioprine
-Steroids (low dose pred, pulse methylpred PRN for flares)
- Hydroxychloroquinne
tacrolimus - (retractory disease/second line)
65
Effect of mycophenalate on pregnancy
increased risk of miscarriage
Craniofacial, cardiac malformations, oesophagael atresia
Avoid in BF
Substitute with AZA
66
Risk of cylophosphamide on pregnancy
avoid in 1st T
Crainofacial, limb and digit abnormalities. Miscarriage
Also fertility impact
67
Effect of ACE-I in pregnancy
contraindicated
Tetatogenic
Oligohydramnios in 2-3rd T
68
Poor prognostic factors for pregnant patients with renal transplant
chronic rejection
Cr >125
Poor BP control
If stable, well controlled BP -> 97% chance of good pregnancy outcome
69
Why treat asymptomatic bacteruria in pregnancy?
risk of progression to UTI (40%) or pyelo (30%)
Risk due to inflammation of PPROM, PTB and LBW
70
Rate of pregnancy on pt on Haemodyanlysis
1:200 per year
71
Amox/clav avoided in pregnancy due to risk of what?
NEC (demonstrated in PPROM prophylaxis trials)
72
What investigations can you perform to distinguish PET from Lupus flare?
Anti-dsDNA (rising in a flare)
Falling complement
Leukopenia
Haematuria/casts in urine
Low urate
Cf baseline Cr and protein function
73
MOA Infliximab, Etanercept and Adalimumab
TNF alpha inhibitor - okay in pregnancy and BF
74
MOA mesalazine
aminosalicylate - okay in pregnancy, risk of jaundice with BF
75
Name two calcinurin inhibitors
tacrolimus
Cyclosporine
(Both safe in pregnancy)
76
Cyclophosphamide MOA
alkylating agent -> teratogenic, avoid in pregnancy and BF
77
MOA mycophenylate mofetil?
anti proliferative immunosuppresant -> teratogenic, avoid preg + BF
78
MTX MOA
folic acid antagonist - teratogenic
79
Is hydroxychloroquine (plaquenil) safe in pregnancy?
yes + BF
80
Which AI conditional are associated with congenital heart block
those with Anti SSA/Ro and Anti SSB/La Abs
SLE
Sjogrens
CHB 2% incidence
81
NSAID effect on developing foetus?
Use in 1st trimester -> congenital cardiac defects
2nd trimester -> low birth weight
3rd trimester -> oligohydramnios, constriction of ductus arteriosis, NEC, IVH.
82
Is tramadol safe to use on pregnancy
first trimester -> miscarriage, congenital malformations.
Third trimester -> NAS
Small breastmilk concentrations -> okay for short term use
83
Is codeine safe in pregnancy?
yes - not teratogenic or increased risk of MC
NAS
Variance in codeine metabolism
Avoid in BF
84
Are steroids safe in pregnancy?
Yes -> minimal transplacental transfer of cortisol or pred (10% active drug reaches feotus)
Not teratogenic
Some association with FGR and PPROM
Aim <20mg per day
85
management of Anti Ro Abx
Most neonates will need permanent pacemakers at delivery
G+W Us to monitor FHR and evidence of hydrops
- first T use of hydroxychloroquine can prevent congenital heart block
86
Which drugs require additional folate supplementation in pregnancy?
Anti-epileptics
Azathioprine
MTX (should cease 1-3 months pre conception and supps should start then)
Sulfasalazine
87
Post partum implications in using biologic agents for disease control (eg inflixumab)
delay in vaccination schedule for neonate
88
What is the risk of congenital heart block in the presence of Anti Ro/La abx
2%
89
Pregnancy complications of lupus - maternal
Maternal mortality (20 fold increase)
PET
Eclampsia
DVT/PE
CVA
Lupus flare
90
Pregnancy complications of Lupus - Foetal
miscarriage
FGR
PTL
Stillbirth
NND
Neonatal lupus
91
Is the risk of lupus flares increased in pregnancy?
yes -> 2-3x disease activity, with incidence 13->65%
92
clinical manifestations of neonatal lupus
Presentation often 2weeks of life
Cutaneous -> rash face and scalp
Haem -> low plt low neutro
Hepatic -> raised LFTs
Cardiac - heart block, structural abnormalities, cardiomyopathy, CCF
Usualy resolve (except cardiac) -> approx 6 months
93
Pathogenesis of heart block in babies with anti Ro/La
maternal autoantibody crosses placenta, effect on cardiac conduction fibres -> inflammation and then fibrosis of AV node.
94
What proportion of women with SLE have APLA?
30%
95
Criteria of Dx of antiphospholipid syndrome
1 of both clinical and lab criteria met
Clinical
1. Vascular -> any venous, arterial or small vessel thrombus
2. Obstetric
-> 3x consecutive unexplained MC <10 weeks
-> 1 unexplained MC >10 weeks
-> PTB <34 weeks due to PET or FGR
Lab
Presence 12 weeks apart of
Lupus anticoagulant
Anticardiolipin Abs (med or high titres)
Anti B2 glycoprotein 1 Ab
96
RA likely to worsen or improve in pregnancy?
RA more likely to go into remission during pregnancy and flare PP.
97
Conditions associated with secondary APLS
SLE
RA -> 5-10%
98
Principles of mx of Arthridities other than SLE in pregnancy
aim for disease remission pre conception
Transition to pregnancy safe medications
Monitor for medication impacts on pregnancy
Chronic inflammation associated with FGR, PTB
RA and seronegative arthridities usually dont have significant impact on pregnancy per se
99
What features of scleroderma contraindicates pregnancy?
severe organ involvement - renal, pulmonary fibrosis and pulmonary HTN
100
Pregnancy considerations for Ehlers-Danlos
-Risk of poor wound healing
-PTB ( collagen deficiency ?related to cervical incompetence)
-PPH due to atony
-Hypermobile joints- risk of dislocation with positioning
Pelvic girdle pain
Rupture of viscera (bowel, aorta, vessels)
POTS - careful preloading to avoid hypotension
101
considerations for pregnancy mx with marfans
Major risk for morbidity/mortality if aortic root dissection -> minimise by avoiding valsalva (aim shortest possible second stage), tachycardia (Rx with beta blockers)
risk of dissection increased with aortic root diameter >4cm
102
Impact of Fe deficiency in pregnancy
Increased risk of PND, PPH, Sepsis, death (worldwide), low birth weight, PTB, neurodevelopmental impairement
103
Who should take high dose folate?
prev neural tube defects/FHx/Personal Hx in either partner
Anti-epileptic medications
High BMI
DM
SIckle cell/thal
104
what is the inheritance pattern of haemaglobinopathies?
autosomal recessive (Ie 2 carriers have 25% chance of offspring having disease
105
Classic demographic for 1) sickle cell 2) thal
1) african
2) asian/mediterranean
106
What is the globin chain structure for HbA vs HbA2 vs HBF
HBA - Alpha 2 Beta 2
HBA2 - alpha 2 delta 2
HBf - alpha 2 gamma
107
Complications of thalassemia
iron overload (haemolysis and anaemia mx with Tf)
- hypersplenism, endocrinology (DM, hypogonadortophic hypogonadism-> subfertility), hypoparathyroidism, adrenal insufficiency, cardiomyopathy
Hepatitis/fibrosis/cirrhosis
Joint pain
Osteoporosis
108
How many alleles are present in a diploid cell for alpha globin?
4 (2 mat/2 pat)
109
Clinical manifestation of HBH (3 alpha alleles affected)
hb Barts (tetrameric A chains) and Hb H (tetrameric B chains) -> high binding capacity for o2, poor tissue delivery, precipitate out -> anaemia, splenomegaly
110
When do people with Beta Thal major present?
3-6 months (transition for HbF -> adult Hb
111
Blood film sign suggestive of HB H
heinz bodies and target cells
112
Obstetric considerations for women with beta thal major
Transfusion dependent anaemia - avoid iron, risk of RBC antibodies
Cease chelation in pregancy
Folate supp
Cardiology ax - iron deposition in myocardium
Partner EPG
VTE risk
Monitor foetal growth
Splenectomy precautions (vax)
113
Obstetric implications for HBH (Barts HBnopathy)
Chronic haemolytic anaemia - > high dose folate and transfusions
114
Features of Beta thal pt with high risk of VTE in pregnancy?
splenectomy + non transfusion dependent
Plt >600
Should start antenatal clexane + LDA
115
Can you use iron chelation in pregnancy?
safety data for desferrioxamine during ovulation induction and 20+ weeks, avoid 1st trimester
116
Management of Sickle Cell painful occlusive crisis in pregnancy
consider underlying cause (infection, dehydration, acute chest syndrome, severe anaemia, hypersplenism and VTE)
CTG
FBC + HBs percentage, haemolysis screen
CXR
VTE prophylaxis
Analgesia - opiates
117
Acute chest syndrome Mx
HDU setting
Exchange transfusion (reduces proportion of sickle cell)
Abx (concurrent or resultant pneumonia)
CTPA
Bloods inc ABG
Haem input
118
Pathophysiology of Sickle Cell disease
autosomal recessive single gene mutation of HbS gene that alters beta globin structure.
Polymerisation in deoxygenated states causes rigid and sickled RBC - prone to haemolysis and vasoocculsion
119
What is HbAS vs HbSS vs HbSBeta^0 vs HbSC
HbAS = sickle cell trait (ie S hb and A- normal Hb)
Hb SS = Sickle cell disease
HbSBeta0 = sicklel cell + beta thal
HbSC - sickle cell + C Hb
120
Triggers for sickle cell crisis
dehydrations
Pain
Infection
Hypoxia
Cold
Stress
121
Prevalence of different causes of low plt in pregnancy
gestational (75%)
Hypertensive (12-20%)
ITP (3-4%)
Other (1-2% eg SLE, TTP, infective)
122
Prevalence of cholelithiasis in pregnancy
6%
123
What signs of normal preganncy can mimic liver disease?
raised ALP
N/V
Spider naevi
Palmer erythema (excess oestrogen)
124
Definition of Obs Chole (Intrahepatic Cholestasis of Pregnancy ICP)
itch
Raised random BA >19
No rash (except evidence of pruritis)
125
Stillbirth risk with mild ICP (BA peak 19-39)
similar to Bg risk
126
Stillbirth risk with severe ICP (BA peak 39-99)
similar to bg until 38-39 weeks
127
Timing of delivery for severe CIP (BA >100)
35-36 weeks (risk of stillbirth 3-4%)
128
DDX for ICP
gestational pruritis (normal BA)
choledocolithiasis
Hepatitis
129
Incidence of ICP
0.7%
130
Risks associated with ICP
Stillbirth (stratefied by BA peak and gestation at onset)
Spont and iatrogenic PTB
MSL
birth asphyxia
131
RX for IPC
Urso - may reduce pruritis , no impact on perinatal outcomes
Topical emollients
Sedating antihistamines
Rifampicin
132
133
Risk factors/associations with AFLP?
LCHAD deficiency of foetus - mitochondial fatty acid oxidation disorder -> excessive production of free fatty acids by the foetus overwhelming maternal liver.
- spectrum of PET
Primip
AMA
Male foetus
Multiple pregnancy
134
Features of Ix suggestive of AFLP
hypoglycaemia
Derranged LFTs
Coagulopathy
High ammonia
High urate
Neutrophilia
(Swansea criteria diagnostic tool)
135
Clinical manifestations of AFLP
generally unwell
Encephalopathy
Hypoglycaemia
Jaundice
Polydipsia/polyuria
Ascites
N/v
Reduced appetite
Abdo pain
136
Mx AFLP
MDT (ICU/hepatology/obs, anaesthetics)
Supportive care - correct coagulpathy + hypoglycaemia
With guidance of hepatology - NAC, plasmaphoresis, transplant
Delivery
137
Which hepatic lesions are most likely to rupture during pregnancy?
haemangiomas >10cm
Adenomas >10cm, close to liver capsule
138
overall outcomes of pregnancy in liver transplant pts
overall favourable (more so than renal transplants)
Pet, fgr, ptb, gdm more common
Graft rejection
Appropriate immunosuppresive drugs
139
What laxative should be avoided in pregnancy and breastfeeding?
senna containing laxatives (docusate okay)
140
Rate of congenital anomalies in preexisting DM
double baseline risk
141
pathophys of GDM
Human placental lactogen, placental growth hormone, cortisol increase peripheral insulin resistance (50% by third trimester)
142
Does maternal insulin cross the placenta?
no, hence NN hypoglycaemia in poorly controlled GDm, as foetus has upregulated its own insulin production.
143
Complications of DM on pregnancy
miscarriage
HTN/PET
CS risk
UTI/infections
Poor wound healing
Perineal trauma
Peridontal disease
144
Foetal/nn complications of DM
FGR/LGA
Stillbirth
PTB
Birth injury/shoulder dystocia
Hypogylcaemia
Congenital abnormalities (cardiac, renal, neural tube, sacral agenesis, microcephaly)
145
Target HBA1c pre conception for DM 1/2
6.5% <
146
Additional considerations for antenatal mx of existing DM
high dose folate, offer FTS
LDA
Foetal echo 20-24 weeks
Serial 3t G+W US 4 weekly
Delivery by 39 weeks
If diabetic nephropathy - VTE prophylaxis antenatally
147
MOA of metformin
biguanide
Delays intestinal glucose absorptions
Reduced hepatic glucose production
Sensitises skeletal muscle to insulin.
148
Effect of warfarin on pregnancy?
Miscarriage
Stillbirth
Warfarin embryopathy -> nasal hypoplasia, skeletal abnormalities- particularly 1st T exposure- risk 10-30%
developmental delay
APH/PPH/internal bleeding of foetus
149
When would you continue warfarin in pregnancy?
mothers with mechanical heart valve -> risk benefit of warfarin on foetus vs risk of maternal death due to thrombus (LMWH not as effective anticoag for these women)
150
When would you recommend CS for delivery in cardiac disease
Mitral stenosis severe
pulmonary HTN
Aortic stenosis
(Risk of Acute pulmonary oedema)
Aortic root dilatation >45mm
151
?rising burden of cardiac disease in pregnant population
#increased CV RF - older, HTN, obesity, smoking
#Congenital cardiac disease survival/effective Rx
#immigration- unrecognised RHD/congenital CHD
152
ECG changes in pregnancy (physiologic)
sinus tachy
LAD
Q wave III
flattened T wave III
153
What is the NYHA classification for cardiac disease?
functional classification, prognosticator
Class 1 no exertional syx
Class 2 symptoms with ordinary activities
Class 3 marked syx/limitation of physical activities, no rest syx
Class 4 symptoms at REST
154
What is the CARPREG score?
prognostication scoring system - chance of cardiac complication in pregnancy
Criteria;
Prior cardiac event
NYHA class II or above or cyanosis
Left heart obstruction
Systemic ventricular systolic dysfunction (ie EF<35%)
- >1 point = 75% chance of complication
155
List cardiac conditions mWHO class 1
mild PS
PDA
MV prolapse Mild
Prev repaired ASD/VSD/shunt
156
MWHO class IV conditions - ie pregnancy contra-indicated
PAH
EF<30
Severe MR
Severe symp AS
Severe aortic dilatation
Vascular EDS
Severe coarctation
Fontan’s with any complication
(Also cyanotic heart disease+ mechanical valves HR group)
157
What genetic mutation is associated with Tetralogy of Fallot?
22q11.2 microdeletion (Di George Syndrome) ~15-20%
T21 - 7%
158
What is eisenmenger’s syndrome?
complication of congenital cardiac disease with large L-> R shunts (usually septal defects) causing PAH.
159
When is the risk of CV complications with pre-existing HD highest in pregnancy?
early pregnancy (rapid increased in BV, CO)
Second trimester-> peak preload and CO
Second stage of labour
Immediate post partum
Changes in HD status - eg pph, spinal, position.
160
Intrapartum care for pt with cardiac disease
avoid ergometrine (increased peripheral resistance/risk of APO)
Maintain normal HR (beta blockers, early EDB)
Careful fluid balance (aim dry)
Assisted second stage (minimise valsalva/tachycardia)
161
Do pregnant women with congenital cardiac disease or prosthetic valves need specific infective endocarditis prophylaxis?
no evidence to support.
162
Principles of Mx for cardiac disease in pregnancy
# serial G+W US
#Ideally pre-conception counselling and risk stratification based on specific lesion, NYHA functional status, mWHO c
#MDT -> MFM +
Cardiologist review throughout pregnancy
#care at appropriate tertiary centre
#optimise function and medications appropriate to pregnancy
#consider need for anticoagulation
# MOD and TOB plannings -> VD vs CS individualised
#screening foetus for CHD/foetal echo
163
Maternal mortality with PAH?
up to 30%
164
Maternal mortality Eisenmengers syndrome?
20-50%
165
Foetal survival if O2 sats <85%
12%
166
Aortic root diameter contraindicating pregnancy in a) connective tissue diseases eg Marfans/EDS b) gen pop c) turners syndrome
a) 4.5cm
B) 5cm
C) 2.7cm
167
Baseline risk of CDH vs in mother with CHD?
1%
5-6% (depending on underlying pathology)
168
Most common cause of AMI in pregnant population?
SCAD (spont coronary artery dissection)
Paradoxial embolism into coronary arteries
(Atherosclerosis less likely)
169
RF for AMI in pregnant patients
Age (>35 30% increased risk each year)
HTN
Multiple pregnancy
Multiparity
PPH/transfusion
Cocaine use
170
