Medical Problems in Pregnancy Flashcards by Beth Mickel

what is the uk maternal mortality rate

8/100,000
8 women died per every 100,000

ethnicity, age and weight associated with increased risk

overweight women have a higher risk of blood clots

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what are some common medical problems in pregnancy

Diabetes 
Hypertension 
Cardiac disease 
Respiratory disease - asthma 
Venous thromboembolism 
Connective tissue disease - anti-phospholipid syndrome 
Epilepsy 
Obesity

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what to consider if someone has a medical disorder in pregnancy

How does pregnancy affect disorder

How does disorder affect pregnancy

for mother and fetus
drugs
consider impact on each trimester

How can you reduce risk and improve outcomes

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common heart disease in pregnancy

pulmonary hypertension 
congenital heart disease 
acquired heart disease 
cardiomyopathy 
artificial heart valves 
ischaemic heart disease 
arrhythmias

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what signs are negative predictions for the outcome of heart disease in pregnancy

pulmonary hypertension 
NYHA heart failure classification 
Presence of cyanosis 
TIA/arrythmia 
Heart failure 
Left heart obstruction 
Aortic root >45mm
Myocardial dysfunction (EF<40%)

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normal heart disease changes in pregnancy

palpitations
extra-systoles
systolic murmurs

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what heart disease signs are often fatal in pregnancy

pulmonary hypertension

fixed pulmonary vascular resistance

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what types of palpitations do you get in pregnancy

Physiological (common, occur at rest/lying down)

Ectopic beats (common thumping released by exercise)

Sinus tachycardia (part of normal pregnancy but need to exclude pathology)

SVT (super ventricular tachycardia) - usually predates pregnancy

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what happens to lung function during pregnancy

Increased O2 consumption 
Increased metabolic rate 
Increased resting minute ventilation 
Tidal volume 
Respiratory rate stays the same 
Functional residual capacity decreases 
Vital capacity stays the same 
FEV1 and PEFR stays the same 
PaO2 increases 
PaCO2 decreases 
Arterial pH increases

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characteristics of breathlessness in pregnancy

very common - up to 75% of women 
increased awareness of physiological hyperventilation 
more common in third trimester 
rest/talking makes it worse
improves with exertion

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what is the most common chronic medical disorder to complication pregnancy

Asthma
7% of women of child bearing age have it

10% will have an acute exacerbation in pregnancy

associated with maternal mortality

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what is the prognosis of asthma in pregnancy

may improve, may deteriorate or may remain unchanged

deterioration often due to decreased therapy due to safety concerns

those who improve may have deterioration during post partum

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impact of asthma on pregnancy

poorly controlled asthma may adversely affect fetal development

poorly controlled asthma is higher risk that the medication used to prevent it

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asthma management

Step 1 - inhaled SABA
Step 2- inhaled pregnancy
Step 3 - add LABA, if LABA still not controlling, increase steroid, if no response to LABA stop LABA and increase inhaled steroid

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asthma management specific to pregnancy

Aim for vaginal birth
Acute asthma during labour is unlikely due to endogenous steroids

increased risk of cystic fibrosis for women with moderate-severe asthma

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Epidemiology of VTE in pregnancy

4-6x increase in risk of VTE in pregnancy
incidence 1-2 per 1000

85-90% of DVTs occurring during pregnancy arise in the left leg

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what is Virchow’s triad

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hyper coagulability
venous stasis
vascular damage

what are the symptoms of DVT

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swelling 
oedema 
leg pain or discomfort 
tenderness 
increased leg temperature 
lower abdominal pain 
elevated white cell count

how do you test for DVT

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Compression duplex ultrasound

if normal and clinical suspicion is high then repeat to exclude extending calf vein thrombosis

if iliac vein thrombosis is suspected consider MRI venography

Symptoms and signs of a pulmonary embolism

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

what are the 2 investigations for PTE

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CT pulmonary angiogram

V/Q scan

benefits to CTPA

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readily available
may detect other pathology
better sensitivity and specificity
low radiation dose to fetus

benefits of V/Q scan

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high negative predictive value in pregnancy

low radiation dose to maternal breast tissue

how do you treat PTE/DVT in pregnancy

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LMWH

warfarin is teratogenic

what impact does warfarin have on a foetus

Warfarin embryopathy - midphase hypoplasia - stippled chondral calcification - short proximal limbs - short phalanges - scoliosis

what anticoagulation can be used in post-natal

Heparin Warfarin neither are contraindicated in pregnancy start warfarin on 5th post-natal day anticoagulant therapy continued until at least 6 weeks post-natal until at least 3 months post partum

Connective tissue disease complications in pregnancy

``` Miscarriage Pre-eclamptic toxicity Abruption Foetal growth restriction Still birth preterm birth labour/delivery post-natal ``` Disease related - lupus flare, renal haematological - Antiphospholipid syndrome - rheumatoid - scleroderma

what drugs cannot be used to treat CTD in pregnancy

``` NSAIDS Clyclophosphamide Methotrexate Chlorambucil Gold Penicillamine MMF Leflunamife ```

what drugs can be used to treat CTD in pregnancy

``` Steroids Azathioprine Sulfsalazine Hydroxycholoquine Aspirin some biologics ```

what is antiphosphlipid syndrome

An acquired thrombophilia aPL (antiphospholipid antibodies) - reacted with the phospholipid component of the cell membrane anticardiolipin antibodies and lupus anticoagulant APS described the clinical syndrome associated with these antibodies

what are the clinical features of anti-phospholipid syndrome

``` Arterial/venous thrombosis Recurrent early pregnancy loss Late pregnancy loss Placental abruption Severe early onset pre-eclampsie Severe early fetal growth restriction ```

how do you diagnose antiphospholipid syndrome

Vascular thrombosis (venous, arterial, small vessel) Pregnancy morbidity (>3 miscarriages <10 weeks, >1 fetal loss >10 weeks, >1 preterm birth (less than 34 weeks)) LgM/LgG aCL LA

How do you manage antiphospholipid syndrome in pregnancy

No thrombosis/adverse pregnancy outcome - low dose aspirin - maternal/ fetal observance previous thrombosis - stop warfarin - give low dose aspirin and LMWH recurrent early pregnancy loss - LMWH - Low dose aspirin lade fetal loss/severe pre-eclampsia toxicity/ foetal growth restriction - low dose aspirin - LMWH

how does seizure frequency change in pregnancy

improved or unchanged >50% of women have no seizures during pregnancy

fetal risks of epilepsy seizures

Maternal abdominal trauma PPROM (premature pre-rupture of membranes - early waters breaking) Preterm birth hypoxia/acidosis ``` congenital malformations adverse perinatal outcomes long-term developmental effect s haemorrhage disease of the new born risk of childhood epilepsy ```

how do you reduce the risk in women with epilepsy who are pregnancy

5mg daily of folic acid | Minimise exposure to valproate and other poly therapy - aim to change medication prior to conception

how does epilepsy effect labour and birth

most women have normal labour and vaginal birth | 2.6% will have a seizure

what increases the risk of intrapartum seizure

``` stress pain sleep deprivation over-breathing dehydration ```

how do you treat seizures in labour

benzodiazepines- IV lorazepam/diazepam IV phenytoin may need to expedite deliver by CS

how to you reduce the risk to the baby if the mother has epilepsy

``` avoid maternal fatigue get a safe area for the baby if mother feels unwell safe feeding position lowest setting for high chairs dress baby on floor carry baby in padded sling/carrycot handle-release pram break additional support for bathing ```

what does obesity increase the risk of in pregnancy

``` miscarriage gestational diabetes hypertension/precelampsia VTE Cystic fibrosis Post partum haemorrhage wound infection congenital anomalies macrosomnia shoulder dystocia still birth neonatal death ```

management of obesity in pregnancy

``` Weight assessed at booking Pre-eclampsia prophylaxis - aspirin thromboprohpylaxis detailed US oral glucose tolerance test obstetric US to asses fetal growth anaesthetic review MDT plan for labour and birth post natal review ```

Medical Problems in Pregnancy Flashcards

(42 cards)