Obs - Medical disorders in pregnancy

Question 1

why do fetus’ of mothers with diabetes become microsomic?

Answer 1

high fetal blood sugars

fetal islet cell hyperplasia -> hyperinsulinaemia

increased fat deposition

Question 2

defien gestational diabetes

Answer 2

carbohydrate intolerance which
is diagnosed in pregnancy and may or may not resolve
after pregnancy’

Question 3

what are the thresholds for gestational diabetes diagnosis ?

Answer 3

fasting glucose level ≥ 5.6 mmol/L

or >7.8 mmol 2 hours after a 75 g glucose load (glucose tolerance test:GTT)

Question 4

which pregnant women are most likely to suffer from complications as a result of diabetes?

Answer 4

Complications are related to preeconception glucose levels, therefore Gestational DM are less effected

Question 5

list some fetal complications of DM?

Answer 5

Subclassify into trimester!!

Congenital abnormalities eg cardiac defects

Increased birthweight

10% preterm labour

Polyhydramnios due to increased urine output

Shoulder dystocia

Fetal compromise, fetal distress in labour and sudden fetal death - poor 3rd trimester control

Neonatal hypoglycaemia!

Question 6

list some maternal complications of DM?

Answer 6

1st trimester:
Miscarriage

2nd trimester:
 Pre eclampsia more common
 Hypoglycaemic episodes

Generally:
UTI, wound and endometrial infection more common
Diabetic complications accelerate and detriorate:
 Diabetic nephropathy
 Diabetic retinopathy

Intrapartum:
 CS or instrumental delivery more likely

Question 7

what is the overview of management of DM?

Answer 7

Pre-conceptual care:
- optimise health and sugars for pregnancy

Monitoring & Treating DM:
- Consultant led ANC care

Monitoring Fetus:

Monitoring complications of DM:
Renal function and retinae checked
75mg aspirin daily from 12 weeks

Timing/Mode of Delivery:
- delivery on labour ward with neonatal facilities

Neonate and Puerperium:
- Deliver 37-39 wks
- montor carefully as risk neonatal hypoglycaemia due
to hyperinsulinaemic state in utero

Question 8

what is the target hba1c in glucose control for diabetics?

Answer 8

HbA1c level 48mmol/mol (6.5%) or below

Question 9

what consideratoin would a diabetic mother need in labour?

Answer 9

Sliding scale of insulin and dextrose infusion during labour - if required insulin during pregnancy

Monitor capillary glucose every hour during labour and birth and ensure that it is maintained between 4-7 mmol/L

Question 10

what additional monitoring might a fetus of a diabetic mum reequire?

Answer 10

Echo

Umbilical doppler if PET or IUGR

US - growth and liqour

Question 11

what are the components of pre-conceptual care for diabetics?

Answer 11

 Assess renal function, BP and retina
 Optimise glucose control

 Folic acid 5mg/day
 Labetalol or methyldopa as anti-HTN

Question 12

what is the screening schedule for gestatoinal diabetees?

Answer 12

Previous GDM screened at 18 weeks

28 week GTT screening test

Also check if polyhydramnios or persistent glycosuria

Question 13

when is insulin indicated?

Answer 13

Advise diet and exercise then:

If fasting glucose > 7 at diagnosis

If after 2 weeks of Metformin , fasting levels >5.3 before meals,
or >7.8 1 h after meals, go to Step 4 (insulin)

Question 14

what drugs for DM ar eallowed in pregnancy?

Answer 14

metformin and insulin

Question 15

what can you say about these drugs;

Warfarin and ACEi

Answer 15

are teratogenic in pregnancy

Question 16

which types of heart defects are a problem in pregnancy?

Answer 16

Pulmonary hypertension - absolute contraindication

Mitral valve stenosis/regurg - fix before pregnancy

Aortic stenosis - fix before pregnancy

Question 17

managemnt of epilepsy in pregnancy?

Answer 17

Preconception care:
seizure control with as few drugs as possible
5mg folate a day

Carbamazepine and Lamotrigine are safe

10mg vit K given from 36 weeks onwards

Question 18

risks of epilepsy in pregnancy?

Answer 18

seizure control worse = more seizures

neural tube defect risk with drugs

3% risk of baby getting epilepsy

Question 19

most common cause of hypothyroid in pregnancy?

Answer 19

Hashimoto’s thyroiditis or thyroid surgery

Question 20

risk of hypothyroid in pregnancy?

Answer 20

miscarriage, pre-term delivery and intellectual impairment in childhood

PET if antithyroid antibody

Question 21

management of hypothyroid and hyperthyroid in pregnacy?

Answer 21

Hypothyroid:
thyroxine  6 weekly monitoring

Hyperthyroid:
propylthiouracil (low dose - can still cross placenta)

Question 22

risk of graves disease in pregnancy?

Answer 22

Antithyroid antibodies cross placenta -> neonatal thyrotoxicosis and goitre

Question 23

how does postpartum thyroditis present and risk in pregnancy?

Answer 23

Usually subclinical hyperthyroidism (3m post partum) followed by 4m of hypothyroidism

this hypothyroidism can be permanent in 20%

can cause post natal depression

Question 24

how does obstetric cholestasis present?

Answer 24

itching WITHOUT skin rash WITH abnormal LFTs

and/or raised serum bile acid

Both resovle post delivery

(itching - soles of feet and palms of hand typical)

Question 25

what are the complications of obstetric cholestasis?

Answer 25

``` Fetal fetal arrhythmia - > stillbirth Premature birth Meconium passage IUGR ``` Maternal: Intense itching affects sleep and overall well-being Maternal PP haemorrhage (uncharacterised)

Question 26

rx of obstetric cholestasis?

Answer 26

1. Bile acids <40 symptomatic Monitor lfts weekly form diagnosis till delivery ``` Medical: Topical emollients for itch e.g. Diprobase Antihistamines • Cholestyramine + Vit K • Ursodeoxycholic Acid ``` 2. Bile acids >40 micromol/L (severe cholestasis) and gestational age <37 weeks § Medical • Ursodeoxycholic Acid or phenobarbital (sedative side-effects) • Dexamethasone (DM excluded) for symptom relief and prepare foetal lung development for potential preterm delivery - dont give unless in an RCT! • VitAMIN K daily from 36 wks - if PT prolonged Intrapartum: o Offer induction of labour (IOL) at 37 weeks MONITORING: LFTS, doppler+ctg

Question 27

pregnant woman presents with Malaise, vomiting, jaundice and vague epigastric pain and thirst. what is the dfx?

Answer 27

Acute fatty liver of pregnancy

Question 28

what is the rx of acute fatty liver of pregnancy?

Answer 28

Critical care support o IV fluids o 10% dextrose IV o Coagulopathy screen every 4-6 hours to asses for DIC o Continuous foetal monitoring o Dexamethasone if <37 weeks gestation o Magnesium sulphate if <32 weeks gestation • Delivery as soon as possible

Question 29

presence of lupus anticoagulant and/or anticardiolipin antibodies indicates?

Answer 29

Antiphospholipid Syndrome

Question 30

list some complications of Antiphospholipid Syndrome and why

Answer 30

Placental thrombosis  recurrent miscarriage, IUGR and early preeclampsia high fetal loss

Question 31

how is Antiphospholipid Syndrome managed?

Answer 31

Aspirin and LMWH - only if high antibody level - low levels normal high risk pregnancy - consultant led care postnatal LMWH

Question 32

what are the diagnostic criteria for APLS?

Answer 32

1 or more of Clinical criteria: o Vascular thrombosis o 1+ death of fetus >10 weeks o PET or IUGR requiring delivery <34 weeks o 3+ fetal loss <10 weeks, otherwise unexplained + laboratory criteria measured twice >3 months apart o Lupus anticoagulant o High anticardiolipin antibodies o Anti-B2 Glp I ab

Question 33

what are the common sites of thromboses in pregnancy?

Answer 33

Thromboses | are normally ileofemoral and more common in the left than the right.

Question 34

how would you ivx and mx a patient with suspected dvt?

Answer 34

basic ivx on everyone -> cxr, ecg, bloods, start lmwh clinical sx and signs of dvt : Yes - compression duplex ultrasound leg No: CXR abnormal - CTPA CXR normal - V/Q scan if nothing found but still high suspicion DVT -continue LMWH whilst lookinig for alternate diagnosis

Question 35

how is obesity ivx/ managed in pregnancy?

Answer 35

Preconception: diet and exercisie advise for weight reduction 5mg folate viitamin d Pregnancy: do not lose weight pregnancy - malnutrition high riisk bmi >35

Question 36

how should BPAD be managed in pregnancy ?

Answer 36

 Lithium frequently used and associated with increased rate of cardiac abnormalities  Discontinuation risks relapse – only stopped in those well or low risk  Monthly monitoring of lithium levels during pregnancy as increased excretion during pregnancy

Question 37

which antidepressant is contraindicated in pregnancy ?

Answer 37

paroxetine - cardiiac defects

Question 38

which treatments can you NOT use in schizophrenia?

Answer 38

clozapine and olanzapine

Question 39

how would you help some1 with opiate dependency?

Answer 39

opiate replacement: Methadone maintenance

Question 40

what is the risk of benzo use in pregnancy?

Answer 40

cleft lip neonatal hypotonia and withdrawal sx

Question 41

A woman comes in to ANC, their bloods show that they are anaemic list the causes of a anemia in pregnancy?

Answer 41

o Inadequate intake o Poor absorption - coeliac etc o Haemolysis e.g. sickle cell o Excessive demands e.g. twins o Vaginal loss or pre-existing haemorrhage

Question 42

how is anaemia managed?

Answer 42

Considier folate and B12 deficiency (prescribe if so) Antenatal o 100-200 mg oral iron (ferrous sulphate) - iV iron in severe cases § Re-check Hb in 2-3 weeks • Intrapartum may require o Active management of 3rd stage o Active management of PPH o Consider prophylactic syntocinon infusion

Question 43

what is the aetiology of sickle cell?

Answer 43

Inherit 2 abnormal copies of B globin gene on chromosome 11. Abnormal beta chain formation (S chain) -> Abnormal Hb molecule: 2 alpha and 2 S

Question 44

what is the screening for sickle cell and thalssaemia?

Answer 44

all pregant women get elctrophoresis if are heterozygote - get prenatal diagnosis i.e. amniocentesis or CVS to see if baby has it.

Question 45

what is the prognosis and rx of alpha thalssaemia?

Answer 45

Four gene deletions -> death in utero Heterozygous  one or two deletions -> anaemic and require folate + iron

Question 46

what is the prognosis and rx of beta thalssaemia?

Answer 46

Homozygous: affected by iron overload and pregnancy unusual, give folate, NO iron Heterozygous: chronic anaemia, worsens during pregnancy

Question 47

what are the types of FGM?

Answer 47

• Type 1: Clitoridectomy: partial or total removal of the clitoris, or of the prepuce. • Type 2: Excision: partial or total removal of the clitoris and the labia minora, ± the labia majora. • Type 3: Infibulation: narrowing of the vaginal opening by cutting and repositioning the labia, with or without removal of the clitoris. • Type 4: Other: all other non-medical procedures to the female genitalia for non-medical purposes.

Question 48

When is LMWH given in pregnancy based on VTE score?

Answer 48

Vte of 4 = lmwh from start of pregnancy Vte of 3 = lmwh from 28 weeks Vte < 3 = mobilisation and hydration Lmwh used is clexane Postpartum - reassess Vte 2+ = lmwh for 10days High risk eg previous vte = lwmh for 6 weeks

Question 49

Which kind of monitoring is needed in the following: 1. 1st plot below 10th centile 2. Static fundal height 3. Fundal height slowly decreasing 4. Steep rise in fundal height centile

Answer 49

1-3 growth scan 4 - obstetric ANC referral Obviously all your basic things eg : CTG

Question 50

Lady comes in and is pregnant, she has hx of severe depression, is not currently on any meds. How would you approach?

Answer 50

Take hx - screen current mood - Current risk assessment - whooley questions: any thoughts to harm yourself NICE - (May need to:) start psychological intervention - assess need for for meds Refer to prenatal mental health team Refer to obstetrician for appointments

Question 51

how do you screen for and manage mental health in pregnant women?

Answer 51

At booking, ask: ``` Whooley questions (depression) GAD-2 (anxiety) ``` If yes to any of above questions do PHQ9, Edinburgh PNDS. Then refer to GP or mental health personnel

Question 52

What are the crucial questoins to ask if suspecting mental health (or to incorporate into any hx)

Answer 52

1. Hx and fox mental health 2. Physical health problems 3. Alcohol and drug use 4. Atttude and experience of pregnancy 5. Relationship with baby 6. Current or past rx for mental health

Question 53

A woman books for pregnancy at 13 weeks. she is currently on lithium and has been for some months. how would you counciil her?

Answer 53

Confirm pregnancy May be able to continue drug, often not - seek psychiatry input. Explain: stopping or changing drug may not remove risk of malformation Offer screening for fetal anomalies Offer councelling about continuing pregnancy

Question 54

what counts as severe cholestasis?

Answer 54

Bile acids >40micromol/L

Question 55

what are the risks in severe cholestasis?

Answer 55

all the risks associated with IHCP are increased so risk of preterm birth etc.

Question 56

what is the prognosis of Obstetriic cholestasis? how can it be predicted?

Answer 56

poor outcome cannot be predicted by the biochemical results. Fetal monitoring isnt particularly predictive of its outcome either. continuous ctg recommended. all the treatments given are for symptomatic relief, rather than to solve the issue. there is no evidence that theese therapies help prevent fetal stillbirth eetc

Question 57

how do you different a diagnosis of GDM from pre-existing diabetes? why do we need to do this?

Answer 57

Measure HbA1c at the time of diagnosis in newly diagnosed GDM to identify those with pre-existing undiagnosed T2DM Women with preexisting DM likely to fair less well. Intrapartum: o Advise women with T1DM or T2DM to have elective birth by induction of labour or elective C-section between 37-39 weeks o Consider birth < 37 weeks if there are complications o Advise women with GDM to give birth no later than 40+6 weeks

Question 58

complications of vq scan vs ctpa?

Answer 58

CTPA - increased risk of breast cancer VQ scan - increased risk of childhood cancer

Question 59

what is Ebsteins anomaly?

Answer 59

Ebstein anomaly is a rare heart defect in which the tricuspid valve — As a result, blood leaks back through the valve and into the right atrium. symptoms; cyanosis, breathlessness child adviised to avoid sports but mainly well.