Medical Problems in Pregnancy and Labour

Question 1

most common causes of maternal mortality in order?

Answer 1

cardiac disease
thrombosis/thromboembolism
other indirect cause
neurological

Question 2

what medical problems are common in pregnancy?

Answer 2

diabetes and hypertension mainly
cardiac disease
resp disease - asthma
venous thromboembolism
connective tissue disease
epilepsy
obesity

Question 3

what cardiac changes are seen in pregnancy?

Answer 3

blood volume increases by 30%
plasma volume increases 45%
CO increases 30-50%
stroke volume increases 25%
HR increases 15-25%
peripheral vascular resistance decreases 15-20%
CVP unchaged

Question 4

what cardiac factors can predict ability to tolerate pregnancy and any adverse outcomes?

Answer 4

pulmonary hypertension
NYHA heart failure classification
presence of cyanosis
TIA
arhythmia
heart failure
left heart obstruction (MV <2cm, AV <1.5cm or >30mm)
aortic root >45mm
myocardial dysfunction (EF <40%)

Question 5

what benign cardio symptoms are common in pregnancy?

Answer 5

palpitations
extra-systoles
systolic murmurs

Question 6

what cardiac symptoms are more likely to be fatal in pregnancy?

Answer 6

pulmonary hypertension
fixed pulmonary vascular resistance
implications of anti-coagulation in women with valvular heart disease should be considered

Question 7

what can cause palpitations in pregnancy?

Answer 7

physiological (common, occur at rest)
ectopic beats (common, thumping relieved by exercise)
sinus tachycardia (normal but should investigate to rule out pathology)
SVT (paroxysmal, usually predates pregnancy)
hyperthyroidism
phaeochromocytoma (rae, associated with headache, sweating and hypertension)

Question 8

how are palpitations investigated in pregnancy?

Answer 8

ECG
ECHO
FBC
TFT
24 hr ECG if SVT suspected
free T4 if thyroid suspected
24hr catecholamines and US if phaeochromocytoma suspected

Question 9

what lung functions increase in pregnancy?

Answer 9

O2 consumption (higher demand)
metabolic rate
resting minute ventilation
tidal volume
PaO2
arterial pH

Question 10

what lung functions decrease in pregnancy?

Answer 10

functional residual capacity

PaCO2

Question 11

what lung functions stay the same in pregnancy?

Answer 11

resp rate
vital capacity
FEV1 and PEFR

Question 12

what ABG result is common to see in pregnancy?

Answer 12

compensated resp alkalosis

Question 13

how does breathlessness commonly present in pregnancy?

Answer 13

seen in up to 75%
increased awareness of physiological hyperventilation
more common in 3rd trimester
often at rest or while talking
improves with exertion
shouldnt limit normal activities but can lead to indigiestion

Question 14

commonest chronic medical disorder to complicate pregnancy?

Answer 14

asthma

Question 15

how does pregnancy affect asthma?

Answer 15

may improve deteriorate or remain unchanged
clinical features same as non-pregnant
can deteriorate due to reduction or cessation of therapy due to safety concerns
those who improve may experience deterioration during puerperium
course of asthma similar in successive pregnancies

Question 16

does asthma cause a risk in pregnancy?

Answer 16

well controlled asthma has no effect on pregnancy outcome
- can cause problems if severe or poorly controlled, poorly controlled is a bigger risk than the medications used to treat it

Question 17

step up asthma treatment?

Answer 17

1. SABA
2. SABA + steroid
3. add LABA
4. increase steroid
5. add 4th drug (LTRA, theophylline
6. oral steroid

Question 18

intra-partum care in asthma?

Answer 18

aim for vaginal birth
asthma attack during labour is rare due to endogenous steroids but should not stop inhalers anyway
IV hydrocortisone if oral steroids >2 weeks

Question 19

VTE risk in pregnancy?

Answer 19

increased risk during pregnancy and in puerperium

Question 20

what blood factors can cause hypercoagulability?

Answer 20

increased von willebrand factor
increased factors 7, 9, 10 and 12
increased fibrinogen
reduced protein S
acquired aPC resistance
impaired fibrinolytic activity

Question 21

when is VTE prophylaxis given in pregnancy?

Answer 21

4+ risk factors = prophylaxis from 1st trimester
3 risk factors = prophylaxis from 28 weeks
major risk factor = antenatal prophylaxis with LMWH
high risk (previous VTE) = must give LMWH and refer to thrombosis in pregnancy team

Question 22

agent of choice for antenatal thromboprophylaxis?

Answer 22

LMWH

• safe in pregnancy
• once daily dosing
• enoxaparin
• dalteparin
• tinzaparin

Question 23

symptoms and signs of DVT?

Answer 23

swelling
oedema
leg pain/discomfort
tenderness
increased leg temp
lower abdo pain
elevated WCC

Question 24

objective testing for DVT?

Answer 24

compression duplex US scan
if normal but clinical suspicion is high then repeat test after 1 week to exclude extending calf vein thrombosis
if iliac vein thrombosis is suspected (whole leg swollen + back pain) then consider MRI venography

Question 25

symptoms and signs of PE?

Answer 25

``` dyspnoea chest pain faintness collapse haemoptysis raised JVP focal signs in the chest symptoms and signs associated with DVT ```

Question 26

how is PE diagnosed?

Answer 26

CTPA = gold standard | V/Q scan also used

Question 27

why is warfarin not used in pregnancy, what is used instead?

Answer 27

``` crosses the placenta and is teratogenic causes face and limb abnormalities (warfrin embryopathy) - midface hypoplasia - stippled chondral calcification - short proximal limbs - short phalanges - scoliosis ``` use LMWH instead (convert by 6 weeks)

Question 28

what anticoagulation is used in post-natal period?

Answer 28

heparin and warfarin are both safe in breastfeeding commence warfarin on 5th day post-natal continue until at least 6 weeks post natal and until 3 months post partum

Question 29

pregnancy related complications of connective tissue disease (CTD)?

Answer 29

``` miscarriage PET abruption Fetal growth restriction stillbirth preterm birth labour/delivery post-natal ```

Question 30

treatment related complications of CTD?

Answer 30

``` teratogenic fetotoxic sepsis diabetes osteoporosis ```

Question 31

disease related complications of CTD?

Answer 31

lupus flare = renal and haematological problems APS = thrombosis rheumatoid flare scleroderma = renal issues, pulmonary hypertension

Question 32

what CTD drugs are safe in pregnancy?

Answer 32

``` steroids azathioprine sulfasalazine hydroxychloroquine aspirin etanercept/infliximab/adalimumab) rituximab ```

Question 33

what CTD drugs are not safe in pregnancy?

Answer 33

``` NSAIDs (>32 weeks) cyclophosphamide methotrexate chlorambucil gold penicillamine MMF leflunamide ```

Question 34

what is APS?

Answer 34

``` antiphospholipid syndrome acquired thrombophillia with variable presentation and severity antiphospholipid antibodies (anticardiolipin and lupus anticoagulant) react with the phospholipid component of the cell membrane ```

Question 35

clinical features of APS?

Answer 35

arterial/venous thrombosis recurrent early pregnancy loss late pregnancy loss (usually preceeded by late FGR) placental abruption severe early onset pre-eclampsia severe early onset fetal growth restriction

Question 36

how is APS diagnosed?

Answer 36

clinical - vascular thrombosis - pregnancy morbidity (3+ miscarriages at < weeks or 1+ fetal losses >10 weeks when fetus is morphologically normal or 1+ preterm birth due to pre-eclampsia or utero placental insufficiency) lab diagnosis - IgM/IgG aCL (anti cardiolipin) - LA (lupus anticoagulant) - both must be present on 2 occasions >6 weeks apart

Question 37

what pregnancy problems can APS cause?

Answer 37

early pregnancy loss IUD in 2nd or 3rd trimester preterm birth fetal growth restriction

Question 38

how is APS managed?

Answer 38

no thrombosis or pregnancy problem = LDA, surveillance previous thrombosis = stop warfarin, start LDA + LMWH (treatment dose) recurrent early pregnancy loss = LDA + LMWH (prophylaxis dose) late fetal loss/severe pre-eclampsia/FGR = LDA + LMWH (prophylaxis dose)

Question 39

how does epilepsy change in pregnancy?

Answer 39

seizure frequency is improved or unchanged in most >50% have no seizures during pregnancy up to 92% will remain seizure free in pregnancy if there were no seizures in 9 months leading up to pregnancy

Question 40

does epilepsy cause adverse pregnancy outcomes?

Answer 40

potentially has been associated with spontaneous miscarriage, haemorrhage, hypertension/PET, early labour, C section and fetal growth restriction

Question 41

risks to fetus of a maternal seizure?

Answer 41

``` maternal abdominal trauma PPROM (pre term premature rupture of membranes) preterm birth hypoxia/acidosis major/minor congenital malformations adverse perinatal outcomes long term developmental defects haemorrhagic disease of newborn risk of childhood epilepsy ```

Question 42

all women taking anti epileptic medication should be offered a detailed US scan assessment of fetal anatomy at which week?

Answer 42

19-20 weeks

Question 43

most common major congenital malformations associated with anti epileptics?

Answer 43

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

Question 44

valproate should not be prescribed to female children, female adolescents, women of child bearing potential or pregnant women, when might this not be true?

Answer 44

if valproate is the onyl drug which effectively controls their epilepsy in this case treatment decisions should be had about risks

Question 45

how can risk in epilepsy be reduced?

Answer 45

5mg folic acid 3 months before conception and until end of first trimester use lowest effective dose of anti epileptic medication minimise exposure to valproate or polytherapy by changing medication prior to conception ( as recommended by epilepsy specialist after evaluation of risks and benefits)

Question 46

labour and birth in epileptic mothers?

Answer 46

most have normal labour and vaginal birth only 2.6% have a seizure - if general tonic clonic seizure occurs, can cause maternal hypoxia, fetal hypoxia and acidosis stress, pain, sleep deprivation, over-breathing and dehydration can increase risk of seizure

Question 47

how is an intra-partum seizure managed?

Answer 47

``` benzodiazepines are drug of choice left lateral tilt IV lorazepam/diazepam PR diazepam/buccal midazolam IV phenytoin may need C/section give magnesium sulphate if theres no history of epilepsy ```

Question 48

how measures can help protect the baby after birth when mother is epileptic?

Answer 48

``` avoid excessive maternal fatigue safe area for 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 brake additional support for bathing ```

Question 49

risks of obesity at each stage of reproductive life?

Answer 49

pre-pregnancy = mesntrual disorders, subfertility early pregnancy = miscarriage antenatal = fetal anomalies, PET, GD, VTE labour/delivery = IOL, dysfunctional labour, C section needed post-natal = haemorrhage, infection, VTE, breast feeding issues fetal/neonatal = macrosomnia, birth injury, perinatal mortality post menopausal = endometrial hyperplasia, prolapse, incontinence of urine

Question 50

main maternal risks in obesity?

Answer 50

``` miscarriage GDM hypertension PET VTE CS PPH wound infection ```

Question 51

examples of congenital anomalies which obesity pre-disposes to?

Answer 51

neural tube defects CV defects cleft palate/lip

Question 52

potential perinatal outcomes in obesity?

Answer 52

``` congenital anomaly macrosomnia shoulder dystocia SCBU admission still birth neonatal death ```

Question 53

non-medical problems of obesity in pregnancy?

Answer 53

regional anaesthesia (e.g epidural) doesnt work as well

Question 54

general pregnancy management guidance?

Answer 54

``` check maternal BMI and inter-pregnancy weight change PET prophylaxis (aspirin) thromboprophylaxis detailed US OGTT obstetric US to assess growth anaesthetic review at 34 weeks MDT plan for labour and birth ```