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Kat's Pathology > Obstetric Haematology > Flashcards

Obstetric Haematology Flashcards

(62 cards)

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1
Q

FBC abnormalities in pregnancy

A

Mild anaemia
Macrocytosis
Neutrophilia
Thrombocytopenia

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2
Q

Cause of macrocytosis in pregnancy

A

Normal (physiological)

Folate or B12 deficiency

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3
Q

Why does mild anaemia occur in pregnancy

A

Red cell mass rises (120-130%)

Plasma volume rises (150%)

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4
Q

What are the increased iron requirements in pregnancy

A

300mg for the foetus
500mg for the maternal increased red cell mass

RDA: 30mg
Increase in adily iron absorption: 1-2mg to 6mg

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5
Q

What requirements increase in pregnancy

A

Iron

Folate

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6
Q

Why are folate requirements increased in pregnancy

A

Growth and cell division

Approximately additional 200mcg/day required

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7
Q

What can iron deficiency cause in pregnancy

A

IUGR
Prematurity
Postpartum haemorrhage

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8
Q

What are the iron and folate supplements recommended by WHO for pregnancy

A

WHO recommended 60mg iron + 400mcg folic acid daily during pregnancy

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9
Q

What is routinely supplemented in pregnancy

A

Folic acid

Iron is not routinely supplemented in the UK

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10
Q

Why is folic acid supplements recommended in pregnancy

A

Advice reduces risk of neural tube defects
Supplement before conception and for >12 weeks gestation
Dose of 400ug/day

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11
Q

What happens to the platelet count in pregnancy

A

Platelet count falls in pregnancy

Non-pregnancy: 225-249
Pregnancy 175-199

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12
Q

Causes of thrombocytopenia in pregnancy

A

Physiological - gestational/incidental thrombocytopenia
Pre-eclampsia
Immune thrombocytopenia (ITP)
Microangiopathic syndromes
All other causes: BM failure, leukaemia, hypersplenism, DIC, etc…

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13
Q

Most common cause of thrombocytopenia with platelets <150 in pregnancy

A

Gestational

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14
Q

Most common cause of thrombocytopenia with platelets <100 in pregnancy

A

Gestational

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15
Q

Most common cause of thrombocytopenia with platelets <70 in pregnancy

A

ITP and pre-eclampsia

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16
Q

What is gestational thrombocytopenia

A

Physiological decrease in platelet count ~ 10%
>50x109/l sufficient for delivery (>70 for epidural)
Mechanism poorly defined: Dilution + increased consumption
Baby not affected
Platelet count rises day 2 – 5 post delivery

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17
Q

Why does pre-eclampsia cause thrombocytopeina in pregnancy

A

50% get thrombocytopenia - proportionate to severity
Probably due to increased activation and consumption
Association with coagulation activation
Usually remits following delivery

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18
Q

Features of immune thromboycytopenia in pregnancy

A

5% of thrombocytopenia in pregnancy - may precede pregnancy, early onset
Baby may be affected

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19
Q

Treatment options for ITP in pregnancy

A

IVIG
Steroids, etc…
Anti-D where RhD +ve

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20
Q

Features of ITP effects on baby

A 
Unpredictable (platelets <20 in 5%)
Check cord blood and then daily 
May fall for 5 days after delivery 
Bleeding in 25% of severely affected (IVIG if low) 
Usually normal delivery
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21
Q

What are the features of microangiopathic haemolytic anaemia (MAHA)

A

Deposition of platelets in small blood vessels
Thrombocytopenia
Fragmentation and destruction of rbc within vasculature
Organ damage (kidney, CNS, placenta)

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22
Q

What are some MAHA syndromes

A

Pre-eclampsia
HELLP
TTP
HUS

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23
Q

What are the coagulation changes in pregnancy

A 
Factor VIII and vWF increase 3-5 fold 
Fibrinogen increases 2 fold 
Factor VII increases 0.5 fold 
Protein S falls to half basal 
PAI-1 increases 5 fold 
PAI-2 produced by placenta increase 5 fold

A hypercoagulale and hypofibrinolytic state

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24
Q

Why is haemorrhage at pregnancy a risk

A

Pregnancy causes a hypercoagulable and hypofibrinolytic state

Rapid control of bleeding from placenta site essential at time of delivery (700ml/min blood loss)

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25
What are the features of the procoagulant state in pregnancy
Increased thrombin generation Increased fibrin cleavage Reduced fibrinolysis Interact with other maternal factors
26
What can occur due to the pro-coagulation state in pregnancy
Increased rate of thrombosis: PE, DVT
27
When in pregnancy is the greatest risk of death from PE
1st and 2nd trimesters, but risk continues into the post-partum period (6 weeks post-delivery)
28
What are the risk factors for PE in pregnancy
``` BMI >25 Personal/family history for VTE Air travel Hyperemesis gravidarum Ovarian hyperstimulaton syndrome Unrelated surgery ```
29
What are the investigations carried out for suspected PE in pregnancy
Doppler and VQ are safe to perform in pregnancy | D-dimer often elevated in pregnancy - not useful for exclusion of thrombosis
30
What factors increase the risk of thrombosis in pregnancy
``` Changes in blood coagulation Reduced venous return - approximately 85% are left DVT Vessel wall changes Hyperemesis/dehydration Bed rest Obesity - BMI>29 x 3 risk of PE Operative delivery Previous thrombosis/thrombophilia Age Parity Multiple pregnancy Other medical problems: HbSS, nephrotic syndrome IVF: ovarian hyperstimulation ```
31
What are some symptoms of PE to be vigilant of in early pregnancy
Chest pain Shortness of breath Leg pain
32
What diagnostic tests can be done for PE in pregnancy
VQ CXR Venogram CTPA
33
What is the treatment for suspected PE in pregnancy
Thromboprophylaxis in at risk groups | Therapy should be given pending the results of further testing
34
How can thromboembolic disease be prevented in pregnancy
Women with risk factors should receive prophylactic heparin + TED stockings: either throughout pregnancy, or in peri post partum period, highest risk get adjusted dose of LMWH Mobilise early Maintain hydration
35
How are high risk of PE pregnant women managed
Required antenatal prophylaxis with LMWH | Continue at least 6 weeks postnatal prophylaxis
36
How are intermediate risk of PE pregnant women managed
Consider antenatal prophylaxis with LMWH | Continue at least 10 days postnatal prophylaxis
37
How is a PE in a pregnant women with three risk factors managed
Prophylaxis with LMWH from 28 weeks
38
When giving treatment for PE/prophylaxis, what is the management plan
LMWH as for non-pregnant women - does not cross the placenta. Give 1 or 2/day DO NOT GIVE WARFARIN (crosses placenta) After 1st trimester monitor anti-Xa (4 hour post 0.5-1.0u/ml) Stop treatment for labour of planned delivery, especially for epidural...Epidural: wait 24 hours after treatment dose, 12hours after prophylactic dose
39
Why is thrombophilia in pregnancy associated with pregnancy complications
An increasde tendency to thrombosis is associated with impaired placental circulation
40
What are the complications of thrombophilia in pregnancy
``` IUGR Recurrent miscarriage Late foetal loss Abruptio placentae Severe PET ```
41
What is antiphospholipid syndrome
Thrombophilia associated with pregnancy complications. | Recurrent miscarriage + persistent lupus anticoagulant (LA)/ anticardiolipin antibodies (ACL)
42
What increases the likelihood of antiphospholipid syndrome
Adverse pregnancy outcome: three or more consecutive miscarriages before 10 weeks of gestation One or more morphologically normal fetal losses after the 10th week of gestation One or more preterm births before the 34th week of gestation owing to placental disease.
43
Beyond antiphospholipid syndrome, what other thrombophilias may be associated with pregnancy complications
AT, PC, PS deficiency Factor V leiden Hyperhomocysteinemia
44
What are the causes of post-partum haemorrhage
Placenta praevia | Placenta accreta
45
What is the principle reason for hysterectomy
Post partum haemorrhage
46
Define post-partum haemorrhage
>500ml blood loss 5% of pregnancies have blood loss >1L at delivery
47
Major risk factors for post-partum haemorrhage
Uterine atony Trauma Haematological factors are usually minor, except: dilutional coagulopathy after resuscitation, DIC in abruption, amniotic fluid embolism
48
DIC in pregnancy
Coagulation changes in pregnancy predispose to DIC
49
What can precipitate DIC in pregnancy
``` Amniotic fluid embolism Abruptio placentae Retained dead foetus Pre-eclampsia (if severe) Sepsis ```
50
Features of amniotic fluid embolism
1 in 20000-30000 births Sudden onset shivers, vomiting, shock. DIC 86% mortality Presumed due to Tissue Factor in amniotic fluid Almost all >25 years old Usually third trimester No association with parity
51
Symptoms of amniotic fluid embolism
Sudden onset shivers, vomiting, shock. DIC
52
Aims of haemoglobinopathy screening in pregnancy
To avoid birth of children with: Alpha-thalassaemia (death in utero, hydrops fetalis) Beta-thalassaemia (transfusion dependent) HbSS - life expectancy 43 years Other compound HbS syndromes - symptomatic, stroke, etc... Some compound thalassaemias - transfusion dependent, iron overload
53
NHS sickle cell and thalassaemia screening programme features
In high prevalence areas Family origin questionnaire FBC: MCH HPLC
54
Ethnicities important in alpha-thalassaemia trait
Far east SE Asia Greece Turkey
55
Haemoglobinopathy counselling for thalassaemias
Important disorders are all recessive Therefore if mother is heterozygous partner should be tested. Combinations as important as homozygous states
56
What are the options following screening for haemoglobinopathies
``` Proceed Prenatal diagnosis@ CVS sampling (10-12 weeks) Amniocentesis (15-17 weeks), fetal blood sampling Ultrasound screening for hydrops ```
57
Features of sickle cell disease in pregnancy
Hb SS (sickle cell anaemia), HbS/clinically abnormal Hb e.g. HbC; βthal ~100 pregnancies/year in SCD females in UK Vaso-occlusive crises become more frequent Anaemia and existing chronic diseases exaggerated
58
Complications of sickle cell disease in pregnancy
Foetal growth restriction Miscarriage, preterm labour, pre-eclampsia Venous thrombosis
59
Management of sickle cell disease in pregnancy
Red cell transfusion (top up or exchange) Prophylactic transfusion: reduced number of vaso-occlusive episodes, not clear whether affects foetal or maternal outcome Alloimmunisation - extended phenotype RhD, E, Kell
60
``` Normal or low Hb Low MCH (proportionate to Hb) Low MCHC Raised RDW Low or normal RBC Hb electrophoresis normal ```
Iron deficiency
61
``` Normal (rarely low) Hb Low MCH Relatively preserved MCHC Normal RDW Increased RBC Hb electrophoresis HbA2 raised in beta-thalassaemia, normal in alpha-thalassaemia trait ```
Thalassaemia trait
62
What is neonatal alloimmune thrombocytopenia and haemolytic disease of the newborn
Maternal immune response against foetal antigens requiring monitoring and intervention during pregnancy

Kat's Pathology (105 decks)

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