Medical problems in pregnancy

Question 1

What are the 3 types of liver disease in pregnancy? (3)

Answer 1

Intrahepatic cholestasis
Acute fatty liver of pregnancy (severe fulminating illness)
Haemolysis (in pre-eclamptic toxaemia)

Question 2

What physiological change in pregnancy puts increased risk on women with pre-existing heart disease? (1)

Answer 2

40% increase in blood volume in pregnancy, women with heart disease are unable to adequately increase cardiac output.
This increases risk of uterine hypo perfusion and pulmonary oedema.

Question 3

What is chronic hypertension in pregnancy? (2)

Answer 3

Hypertension that is either present before conception or detected before 20/40.

Question 4

Name 3 drugs that are acceptable for treatment of hypertension during pregnancy. (3)

Answer 4

Methyldopa, nifedipine, labetalol

NB ACEi are teratogenic

Question 5

Define eclampsia. (1)

Name 2 symptoms of impending eclampsia. (2)

Answer 5

Tonic-Clonic seizures on a background of pre-eclampsia.

Severe headaches, vomiting, pain just below the ribs, visual disturbance, sudden swelling of face, hands or feet.

Question 6

What is the management for a mother presenting with eclampsia? (3)

Answer 6

A/B: oxygen, maintain patency, ventilate if necessary
C: Left tilt, large-bore IV access, evaluate pulse and bp
Meds: IV magnesium sulphate 4g
Post-seizure: control BP, strict fluid management, may require CVP monitoring, deliver baby once stabilised, consider ITU

Question 7

What is HELLP syndrome? (1)

Answer 7

HELLP syndrome is haemolysis, elevated liver enzymes and low platelet count.

Question 8

What is gestational hypertension? (1)

Answer 8

Gestational hypertension is new hypertension presenting after 20 weeks without significant proteinuria.

Question 9

What is pre-eclampsia? (1)

Answer 9

Pre-eclampsia is new hypertension presenting after 20 weeks with significant proteinuria.

Question 10

What is severe pre-eclampsia? (1)

Answer 10

Severe pre-eclampsia is pre-eclampsia with severe hypertension and/or with symptoms, and/or biochemical and/or haematological impairment.

Question 11

Define mild, moderate and severe hypertension. (3)

Answer 11

Mild hypertension 140-149 / 90–99 mmHg

Moderate hypertension 150-159 / 100-109

Severe hypertension 160+ / 110+ mmHg

Question 12

Name any 2 of the features that would put a woman at high risk of developing pre-eclampsia. (2)
How should she be managed? (1)

Answer 12

CKD, chronic hypertension, previous gestational hypertension in previous pregnancy, Type 1 or 2 DM, SLE or phospholipid syndrome.
If any of high risk factors give aspirin 75mg after 12 weeks gestation until birth.

Question 13

Name any 2 moderate risk factors for developing pre-eclampsia. (2)

When should these women be treated? (2)

Answer 13

First pregnancy
Age >40
More than 10 years since previous pregnancy
Multiple pregnancy
BMI >35 at booking
FH of pre-eclampsia

If more than 1 moderate risk factor give aspirin 75mg daily from 12 weeks until birth.

Question 14

What should the target blood pressure be for hypertension in an uncomplicated chronic hypertensive lady? (1)
What should the target blood pressure be for hypertension in chronic hypertensive lady with evidence of end-organ damage? (1)

Answer 14

Keep lower than 150/100

Keep lower than 140/90

Question 15

What gestation should birth be offered to women with chronic or gestational hypertension with bp less than 160/110? (1)

Answer 15

After 37 weeks

Question 16

What is significant proteinuria? (2)

Answer 16

Diagnose significant proteinuria if the

• urinary protein:creatinine ratio is greater than 30 mg/mmol or
• a validated 24-hour urine collection result shows greater than 300 mg protein.

Question 17

What is the first line treatment for gestational hypertension? (1)

Answer 17

Once 150/110 treat with labetalol daily.

Aim for < 150/100

Question 18

What fetal monitoring should occur in a chronically hypertensive mother? (2)

Answer 18

1. US assessment of fetal growth and amniotic fluid
2. Umbilical artery doppler velocimetry

At 28-30 weeks and at 32-34 weeks.
CTG only if fetal activity abnormal.

Question 19

If a mother has been diagnosed with severe gestational hypertension, or has pre-eclampsia, what fetal monitoring should be undertaken? (2)

Answer 19

At diagnosis: CTG, US assessment of fetal growth and amniotic fluid, Doppler of umbilical artery.

If normal repeat CTG no more than weekly and the US and doppler no more than fortnightly.

Question 20

Name 2 indications for repeating CTG? (2)

Answer 20

Reported change in fetal movements
Vaginal bleeding
Abdominal pain
Deterioration in maternal condition

Question 21

Give 2 factors that would place a woman at high risk of developing pre-eclampsia. (2)

Answer 21

Previous severe pre-eclampsia
Previous pre-eclampsia resulting in birth at <10th centile
Previous Intrauterine death
Previous placental abruption

Question 22

How should a women who has been assessed as at high risk of developing pre-eclampsia be managed? (2)

Answer 22

US assessment of fetal growth and amniotic fluid assessment and umbilical artery doppler velocimetry from 28 weeks and repeated 4 weekly.

Question 23

When should external cephalic version be offered? (1)

Answer 23

If uncomplicated singleton breech presentation at 36 weeks.

Question 24

What gestation should women be routinely offered induction of labour? (1)

Answer 24

41 weeks

Question 25

When should symphysis-fundal height be measured? (1)

Answer 25

From 24 weeks.

Question 26

name 2 risk factors for development of gestational diabetes mellitus. (2)

Answer 26

BMI>30
Previous macrocosmic baby >4.5 kg
Previous GDM
Family history of DM in first degree relative
South Asian or black caribbean or middle eastern

Question 27

Sarah has type 2 diabetes mellitus, and wishes to conceive a child.
What HbA1c should she be aiming for? (1)
Why? (2)

Answer 27

48mmol/mol

Good control of diabetes reduces the risk of miscarriage, congenital malformations, stillbirths and neonatal death.

Question 28

When is testing done for gestational diabetes mellitus in at risk patients? (2)

Answer 28

If previous GDM at booking and at 24-28 weeks if negative

Other risk factors at 24-28 weeks, OGTT.

Question 29

What is the pathophysiology of GDM? (2)

Answer 29

Pregnancy increases peripheral insulin resistance.

increased secretion of insulin antagonists including hPL, cortisol, glucagon

Question 30

What are the management options for gestational diabetes mellitus? (2)

Answer 30

Diet and exercise (30mins walk after eating)
Medical: metformin, then insulin
(glibenclamide can be used if metformin unsuitable)

Question 31

How can the risk of hypoglycaemia be reduced in women on insulin or glibenclamide? (1)

Answer 31

Aim for blood sugars over 4.0

Question 32

Name 2 consequences of subclinical hypothyroidism in pregnancy? (2)

Answer 32

Miscarriage
Preterm delivery
Intellectual impairment in childhood

Question 33

Name 2 drugs that can be used to treat cholestasis in pregnancy. (2)

Answer 33

Ursodeoxycholic acid

Cholestyramine

Question 34

In diabete mellitus in pregnancy, when should delivery be performed? (1)

Answer 34

38 weeks

Question 35

When is the highest risk of VTE in pregnancy? (1)

Answer 35

Post-natal period