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Reproduction > Medical Problems During Pregnancy > Flashcards

Medical Problems During Pregnancy Flashcards

1
Q

what are the most common causes of maternal mortality

A

direct: cardiac disease, neurological, sepsis

indirect- VTE, psychiatric, haemorrhage

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2
Q

who is at higher risk of blood clots during early pregnancy

A

overweight/ obese women

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3
Q

what ethnicities have higher chance of dying during pregnancy

A

black 5x

asian 2x

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4
Q

what are MIs in pregnancy commonly misdiagnosed as

A

panic attacks

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5
Q

what should all women (pregnant or not) with chest pain get

A

ECG (+CT)

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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

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7
Q

what is peri partum cardiomyopathy associated with

A

orthopnoea

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8
Q

what cardiac event in increased risk in pregnancy

A

MI

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9
Q

what cardiac events are common and often benign in pregnancy

A

Palpitations, extra-systoles and systolic murmurs

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10
Q

what cardio pulmonary problems are often fatal in pregnancy

A

Pulmonary HT and fixed pulmonary vascular resistance

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11
Q

what is essential in women with heart disease considering conception

A

pre pregnancy councelling

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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
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13
Q

when do physiological palpitations happen in pregnancy

A

at rest/ lying down

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14
Q

what relives ectopic beats

A

exercise

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15
Q

what Ix for ectopic beats

A

ECG

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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

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17
Q

what Ix for SVT in pregnancy

A

ECG, 24 hr ECG, TFT, echo

usually predates pregnancy

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18
Q

what Ix for hyperthyroidism in pregnancy

A

ECG, TFT, inc. FT4

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19
Q

how might hyperthyroidism present in pregnancy

A

ST, SVT or AF

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20
Q

how might a phaeochromocytoma present and what Ixs

A

(rare)
headache, sweating, HPTx
24hr catecholamines, US

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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)
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22
Q

what improves/ worsens breathlessness in pregnancy

A

more common in 3rd trim
worse at rest/ talking
improves with exertion

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23
Q

how many women are breathless in pregnancy

A

up to 75%

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24
Q

when is breathlessness in pregnancy a red flag

A

when limits normal activities

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25
Q

how many women with asthma will have an acute exacerbation in pregnancy

A

~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

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26
Q

if on steroids throughout pregnancy, what do you need to give during birth

A

IV steroids as body will have become used to that amount of steroids

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27
Q

does well controlled asthma adversely affects pregnancy outcomes

A

no

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28
Q

how might poorly controlled asthma affect pregnancy

A

associated with maternal mortality

might adversely affect fetal development (LBW, premature rupture of membranes, prematurity, HTPx disorders)

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29
Q

what is the stepwise management for asthma in adults

A 
SABA
\+ inhaled steroid
\+ LABA
increase steroids 
\+ LRTA/ theophylline/ oral B2 agonist 
oral steroids
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30
Q

what is the management plan for asthma in pregnancy

A

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

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31
Q

where is DVT in pregnancy more common

A

left leg

70% are ileo femoral

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32
Q

when is risk of DVT highest

A

puerperium (6 weeks after birth)

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33
Q

what medication for VTE risk

A

LWMH - dose weight dependent

34
Q

what scan for leg pain in pregnancy

A

led dopppler )whole leg as can be in groin)

35
Q

what are you worries about for VTE in pregnancy

A

PE

36
Q

why are you more likely to get VTEs in pregnancy

A

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
Q

what do people with intermediate or high risk of VTE need

A

prophylaxis with LWMH

if 4+ RF start 2st trim
3 RF start from 28 weeks

38
Q

what do women with lower risk of VTE need

A

mobilisation and hydration

39
Q

do LMWH or unfractionated heparin cross the placenta

A

no

40
Q

what is the agent of choice for antenatal thromboprophylaxis

A

LMWH- fragmin

41
Q

what are the signs and symptoms of a DVT in pregnancy

A 
Swelling
Oedema
Leg pain or discomfort, may be unable to weight bear 
Tenderness
Increased leg temperature
Lower abdominal pain
Elevated white cell count
42
Q

what Ix for DVT

A

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
Q

what are the signs and symptoms of a PTE

A 
Dyspnoea
Chest pain
Faintness
Collapse
Haemoptysis
Raised JVP
Focal signs in the chest
Symptoms and signs associated with DVT
44
Q

what Ix for PTE

A

ECG and CXR

V/Q (as less risk of breast cancer than CTPA)

45
Q

does warfarin cross the placenta

A

yes and is teratogenic

46
Q

what can warfarin cause in babies

A

Warfarin embryopathy

  • midface hypoplasia
  • stippled chondral calcification
  • short proximal limbs
  • short phalanges
  • scoliosis

risk dose dependent

47
Q

when should you have converted warfarin to LMWH in pregnancy

A

by 6 weeks

48
Q

can you give warfarin when breastfeeding

A

yes

49
Q

what can you give for post natal anticoagulation

A

either heparin or warfarin as neither CI in breastfeeding

start warfarin % days post natal (risk of PPH)

continue for 6 weeks- 3 months

50
Q

what are the possible complications of connective tissue disease in pregnancy

A 
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
Q

what tends to happens with CTDs in pregnancy

A

autoimmune conditions tend to improve in pregnancy

52
Q

what CTD drugs are safe in pregnancy

A 
Steroids
Azathioprine
Sulfasalazine
Hydroxychloroquine
Aspirin
(Etanercept / Infliximab / Adalimumab)
(Rituximab)
53
Q

what CTD drugs are NOT safe in pregnancy

A 
NSAIDs (>32 weeks)
Cyclophosphamide
Methotrexate
Chlorambucil
Gold
Penicillamine
MMF
Leflunamide
54
Q

what type of disease is APS

A

acquired thrombophilia

55
Q

what causes the symptoms in APS

A

Antiphospholipid antibodies (aPL) - autoantibodies that react with the phospholipid component of the cell membrane

56
Q

what antibody markers in APS

A 
anticardiolipin antibodies (aCL)
lupus anticoagulant (LA)
antiphospholipid antibodies (aPL)
57
Q

what are the clinical features of APS

A

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
Q

how do you clinically diagnose APS

A

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
Q

how do you diagnose APS via tests

A

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
Q

what are common pregnancy outcomes in APS

A

early pregnancy loss
T2/T3 IUD
preterm birth (<34weeks)
FGR

61
Q

what is the management for ASP in pregnancy

A

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
Q

what usually happens to seizure frequency in epilepsy during pregnancy

A

improved/ unchanged

>50% will have no seizures

63
Q

what are the possible complications of epilsepy in pregnancy

A 
spontaneous miscarriage 
ante partum haemorrhage 
HPTx/ PET
induction of labour 
C section 
preterm brth 
FGR
PPH
64
Q

what are the fetal risk from a maternal GTC seizure

A

maternal abdo trauma - fetal maternal haemorrhage
pre term rupture of membranes
preterm birth
hypoxia/ acidosis

65
Q

what are the fetal risk in epilepsy

A 
Major congenital malformations
Minor malformations
Adverse perinatal outcomes
Long-term developmental effects
Haemorrhagic disease of the newborn
Risk of childhood epilepsy
66
Q

what should be offered to women on anti epileptic drugs

A

detailed ultrasound scan assessment of fetal anatomy at 18-20 weeks

67
Q

what is the risk of teratogenicity in anti epileptic drugs

A

2-3x background risk (2-3%) risk for single AED

16% risk in polytherapy

68
Q

what AEDs have the lowest risk of teratogenicity

A

lamotrigine, levitiracetam and carbamazepine monotherapy at lower doses

69
Q

what are the most common congential malformations with AEDs

A

neural tube defects, congenital heart disorders, urinary tract and skeletal abnormalities and cleft palate

70
Q

what is sodium valporate associated with in babies

A

NT defects
facial cleft
hypodpadias

71
Q

who should not get valproate

A

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
Q

when might women be advised to continue sodium valporate/ AED polytherapy in pregnancy

how do they reduce their risks

A

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
Q

what needs to be considered in women with epilepsy during birth

A

(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
Q

should AED intake be continued in labour

A

yes

75
Q

what is the management for intra partum seizures

A 
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
Q

how do you ensure baby safety whos parent has epilepsy

A

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
Q

what are the maternal risks of obesity

A 
Miscarriage
GDM
HPTx/PET
VTE
CS
PPH
wound infection 
UTI
endometriosis
breast feeding problems
increased perinatal mortality
78
Q

are congenital abnormalites are more common in obesity

A

yes

79
Q

what perinatal outcomes are increased in obesity

A 
Congenital Anomaly
Macrosomia
Shoulder Dystocia
SCBU Admission
still birth 
neonate death
80
Q

what extra management is needed in obesity in pregnancy

A 
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 &amp; birth
P/N Review

Reproduction (51 decks)

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