Medical Problems During Pregnancy Flashcards
(80 cards)
1
Q
what are the most common causes of maternal mortality
A
direct: cardiac disease, neurological, sepsis
indirect- VTE, psychiatric, haemorrhage
2
Q
who is at higher risk of blood clots during early pregnancy
A
overweight/ obese women
3
Q
what ethnicities have higher chance of dying during pregnancy
A
black 5x
asian 2x
4
Q
what are MIs in pregnancy commonly misdiagnosed as
A
panic attacks
5
Q
what should all women (pregnant or not) with chest pain get
A
ECG (+CT)
6
Q
having what puts a lot more strain on the heart during pregnancy
A
heart conditions:
Pulmonary hypertension (incl. Eisenmenger’s)
Congenital heart disease
Acquired heart disease
Cardiomyopathy (incl. peri-partum cardiomyopathy)
Artificial heart valves
Ischaemic heart disease
Arrhythmias
7
Q
what is peri partum cardiomyopathy associated with
A
orthopnoea
8
Q
what cardiac event in increased risk in pregnancy
A
MI
9
Q
what cardiac events are common and often benign in pregnancy
A
Palpitations, extra-systoles and systolic murmurs
10
Q
what cardio pulmonary problems are often fatal in pregnancy
A
Pulmonary HT and fixed pulmonary vascular resistance
11
Q
what is essential in women with heart disease considering conception
A
pre pregnancy councelling
12
Q
what predicts poor adverse outcomes in cardiac conditions in pregnancy
A
Pulmonary hypertension NYHA functional classification Presence of cyanosis TIA / arrhythmia Heart failure Left heart obstruction Aortic root >45mm Myocardial dysfunction (EF < 40%) Who classification for cardiac problems in pregnancy
13
Q
when do physiological palpitations happen in pregnancy
A
at rest/ lying down
14
Q
what relives ectopic beats
A
exercise
15
Q
what Ix for ectopic beats
A
ECG
16
Q
what Ix for sinus tachy cardia in pregnancy, is it normal?
A
yes normal but do ECG, FBC (anaemia), TFT, echo to exluce pathology
17
Q
what Ix for SVT in pregnancy
A
ECG, 24 hr ECG, TFT, echo
usually predates pregnancy
18
Q
what Ix for hyperthyroidism in pregnancy
A
ECG, TFT, inc. FT4
19
Q
how might hyperthyroidism present in pregnancy
A
ST, SVT or AF
20
Q
how might a phaeochromocytoma present and what Ixs
A
(rare)
headache, sweating, HPTx
24hr catecholamines, US
21
Q
what happens to lung function in pregnancy
A
increased:
- O2 consumption
- BMR
- resting minute ventilation
- tidal volume
- PaO2
- arterial Ph
decreased:
- functional residual capacity
- PaCO2 (maternal hyperventilation)
22
Q
what improves/ worsens breathlessness in pregnancy
A
more common in 3rd trim
worse at rest/ talking
improves with exertion
23
Q
how many women are breathless in pregnancy
A
up to 75%
24
Q
when is breathlessness in pregnancy a red flag
A
when limits normal activities
25
how many women with asthma will have an acute exacerbation in pregnancy
~10%
during pregnancy asthma may improve, deteriorate or remain
Deterioration often due to decreased / cessation of therapy due to safety concerns
unchanged
Deterioration more likely in t2 and t3
26
if on steroids throughout pregnancy, what do you need to give during birth
IV steroids as body will have become used to that amount of steroids
27
does well controlled asthma adversely affects pregnancy outcomes
no
28
how might poorly controlled asthma affect pregnancy
associated with maternal mortality
| might adversely affect fetal development (LBW, premature rupture of membranes, prematurity, HTPx disorders)
29
what is the stepwise management for asthma in adults
```
SABA
+ inhaled steroid
+ LABA
increase steroids
+ LRTA/ theophylline/ oral B2 agonist
oral steroids
```
30
what is the management plan for asthma in pregnancy
achieve good contorl
do not discontinue inhalers during pregnancy (Inhaled ß2-agonists do not impair uterine activity or delay the onset of labour)
IV Hydrocortisone during labour if oral steroids >2/52
Immunocompromise in pregnancy, encourage vaccinations for flu and whooping cough
aim for vaginal birth
31
where is DVT in pregnancy more common
left leg
| 70% are ileo femoral
32
when is risk of DVT highest
puerperium (6 weeks after birth)
33
what medication for VTE risk
LWMH - dose weight dependent
34
what scan for leg pain in pregnancy
led dopppler )whole leg as can be in groin)
35
what are you worries about for VTE in pregnancy
PE
36
why are you more likely to get VTEs in pregnancy
virchows triad:
- hypercoagulability
- venous stasis
- vascular damage
```
Increased von Williebrand factor
Increased factors VII, IX, X, XII
Increased fibrinogen
Reduced protein S
Acquired aPC resistance
Impaired fibrinolytic activity
slowed blood flow (vasodilation to cope with increased CO)
```
37
what do people with intermediate or high risk of VTE need
prophylaxis with LWMH
if 4+ RF start 2st trim
3 RF start from 28 weeks
38
what do women with lower risk of VTE need
mobilisation and hydration
39
do LMWH or unfractionated heparin cross the placenta
no
40
what is the agent of choice for antenatal thromboprophylaxis
LMWH- fragmin
41
what are the signs and symptoms of a DVT in pregnancy
```
Swelling
Oedema
Leg pain or discomfort, may be unable to weight bear
Tenderness
Increased leg temperature
Lower abdominal pain
Elevated white cell count
```
42
what Ix for DVT
compression duplex USS
if normal repeat in one week, treat as DVT
if iliac VTE suspected (whole leg swollen + back pain) consider MRI venography
43
what are the signs and symptoms of a PTE
```
Dyspnoea
Chest pain
Faintness
Collapse
Haemoptysis
Raised JVP
Focal signs in the chest
Symptoms and signs associated with DVT
```
44
what Ix for PTE
ECG and CXR
| V/Q (as less risk of breast cancer than CTPA)
45
does warfarin cross the placenta
yes and is teratogenic
46
what can warfarin cause in babies
Warfarin embryopathy
- midface hypoplasia
- stippled chondral calcification
- short proximal limbs
- short phalanges
- scoliosis
risk dose dependent
47
when should you have converted warfarin to LMWH in pregnancy
by 6 weeks
48
can you give warfarin when breastfeeding
yes
49
what can you give for post natal anticoagulation
either heparin or warfarin as neither CI in breastfeeding
start warfarin % days post natal (risk of PPH)
continue for 6 weeks- 3 months
50
what are the possible complications of connective tissue disease in pregnancy
```
Miscarriage
PET
Abruption
FGR
Stillbirth
Preterm birth
Labour / delivery
Post-natal
Lupus Flare
Renal
Haematological
APS
Thrombosis arterial/venous
Rheumatoid
Scleroderma
Renal
Pulmonary HT
```
```
treatment:
Teratogenic
Fetotoxic
Sepsis
Diabetes (steroids)
Osteoporosis (long term steroids)
```
51
what tends to happens with CTDs in pregnancy
autoimmune conditions tend to improve in pregnancy
52
what CTD drugs are safe in pregnancy
```
Steroids
Azathioprine
Sulfasalazine
Hydroxychloroquine
Aspirin
(Etanercept / Infliximab / Adalimumab)
(Rituximab)
```
53
what CTD drugs are NOT safe in pregnancy
```
NSAIDs (>32 weeks)
Cyclophosphamide
Methotrexate
Chlorambucil
Gold
Penicillamine
MMF
Leflunamide
```
54
what type of disease is APS
acquired thrombophilia
55
what causes the symptoms in APS
Antiphospholipid antibodies (aPL) - autoantibodies that react with the phospholipid component of the cell membrane
56
what antibody markers in APS
```
anticardiolipin antibodies (aCL)
lupus anticoagulant (LA)
antiphospholipid antibodies (aPL)
```
57
what are the clinical features of APS
Arterial / venous thrombosis
Recurrent early pregnancy loss
Late pregnancy loss - usually preceded by FGR
Placental abruption
Severe early onset pre-eclampsia (PET)
Severe early onset Fetal Growth Restriction (FGR)
58
how do you clinically diagnose APS
Vascular Thrombosis
-Venous / Arterial / Small Vessel
Pregnancy Morbidity
- ≥ 3 miscarriages <10 weeks
- ≥ 1 fetal loss >10 weeks (morphologically normal fetus)
- ≥1 preterm birth (<34 weeks) due to PET or utero-placental insufficiency
59
how do you diagnose APS via tests
IgM / IgG aCL (medium / high titre)
LA
x2 >6 weeks apart
Cautions:
Acute infections = transient +ve results
Chronic infections (HIV, Hep C, Malaria, Syphilis) = persistent +ve results
60
what are common pregnancy outcomes in APS
early pregnancy loss
T2/T3 IUD
preterm birth (<34weeks)
FGR
61
what is the management for ASP in pregnancy
No thrombosis / adverse pregnancy outcome
LDA, Maternal + Fetal Surveillance
Previous thrombosis
On warfarin = Stop warfarin
LDA + LMWH (treatment dose)
Recurrent early pregnancy loss
LDA + LMWH (prophylaxis dose)
Late fetal loss / Severe PET / FGR
LDA + LMWH (prophylaxis dose)
Consider earlier delivery
62
what usually happens to seizure frequency in epilepsy during pregnancy
improved/ unchanged
| >50% will have no seizures
63
what are the possible complications of epilsepy in pregnancy
```
spontaneous miscarriage
ante partum haemorrhage
HPTx/ PET
induction of labour
C section
preterm brth
FGR
PPH
```
64
what are the fetal risk from a maternal GTC seizure
maternal abdo trauma - fetal maternal haemorrhage
pre term rupture of membranes
preterm birth
hypoxia/ acidosis
65
what are the fetal risk in epilepsy
```
Major congenital malformations
Minor malformations
Adverse perinatal outcomes
Long-term developmental effects
Haemorrhagic disease of the newborn
Risk of childhood epilepsy
```
66
what should be offered to women on anti epileptic drugs
detailed ultrasound scan assessment of fetal anatomy at 18-20 weeks
67
what is the risk of teratogenicity in anti epileptic drugs
2-3x background risk (2-3%) risk for single AED
| 16% risk in polytherapy
68
what AEDs have the lowest risk of teratogenicity
lamotrigine, levitiracetam and carbamazepine monotherapy at lower doses
69
what are the most common congential malformations with AEDs
neural tube defects, congenital heart disorders, urinary tract and skeletal abnormalities and cleft palate
70
what is sodium valporate associated with in babies
NT defects
facial cleft
hypodpadias
71
who should not get valproate
girls, women of child bearing age, pregnant
if have to take in pregnancy counsel about risks as also need to consider risks of seizures in pregnancy
72
when might women be advised to continue sodium valporate/ AED polytherapy in pregnancy
how do they reduce their risks
if the risk of maternal seizure deterioration from changing the AED is deemed to be high
folic acid 5mg/ day prior to conception till at least the end of first trimester
lowest doses possible
73
what needs to be considered in women with epilepsy during birth
(most will have normal labour and SVD, 2.6% will have seizure)
Stress, pain, sleep deprivation, over-breathing and dehydration increase the risk of intra-partum seizures
If generalised tonic-clonic seizures occur, maternal hypoxia, fetal hypoxia and acidosis may result
74
should AED intake be continued in labour
yes
75
what is the management for intra partum seizures
```
terminate seizure asap to avoid hypoxia and fetal acidosis
benzodiazepines drug of choice
Left lateral tilt (to take pressure of uterus of great vessels)
IV lorazepam / diazepam
PR diazepam / buccal midazolam
IV Phenytoin
May need to expedite delivery by CS
If no history of epilepsy - MgSO4
```
76
how do you ensure baby safety whos parent has epilepsy
avoid excess fatigue- encourage family support
Safe area for baby if mother feels unwell
Safe feeding position
Lowest setting for high chairs
Dress baby on the floor
Carry baby in padded sling / carrycot
Handle-release pram brake
Additional support for bathing- try to just have showers
77
what are the maternal risks of obesity
```
Miscarriage
GDM
HPTx/PET
VTE
CS
PPH
wound infection
UTI
endometriosis
breast feeding problems
increased perinatal mortality
```
78
are congenital abnormalites are more common in obesity
yes
79
what perinatal outcomes are increased in obesity
```
Congenital Anomaly
Macrosomia
Shoulder Dystocia
SCBU Admission
still birth
neonate death
```
80
what extra management is needed in obesity in pregnancy
```
Maternal BMI and inter-pregnancy weight change should be assessed at booking
PET prophylaxis - Aspirin
Thromboprophylaxis
Detailed US (including MUAD)
OGTT
Obstetric US to assess fetal growth
Anaesthetic Review @ 34 weeks (harder to do venopuncture, regional anaesthesia- asses for GA)
MDT plan for labour & birth
P/N Review
```
