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RANZCOG 2024 - maternal medical conditions > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Discuss asthma in pregnancy
-Incidence
-Effect of pregnancy on asthma (5)
-Effect of asthma on pregnancy (5)

A
  1. Incidence
    -Asthma impacts 7% of pregnancies
  2. Effect of pregnancy on asthma
    -33% have deterioration, 33% no change 33% improved
    -Effect of pregnancy on asthma depends on severity
    -Deterioration often due to cessation of treatment due to safety risks
    -Severe episodes from 24-36 weeks
    -90% labour without asthma sx. occurring
  3. Effect of asthma on pregnancy
    -Mostly if well controlled asthma doesn’t impact pregnancy
    -If poorly controlled: HTN, PET, reduced glucose tolerance,
    -PPROM, PTB, LBW (Inhaled corticosteriods protective against this)
    -TTN/NICU/Hypoglycemia
    -Atopic disease in neonate (10% if mother affected 33% if both parents affected)
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2
Q

Discuss asthma treatment in pregnancy
-Types of medications (4)
-Safety
-Association with malformations

A
  1. B2 agonists - ventolin - safe in pregnancy
  2. Inhaled corticosteroids - Flixotide
    -Minimal absorption by fetus
    -May improve birthweight
    -No poor fetal outcomes
    -Safe in pregnancy
  3. Systemic steroids
    -Do not impact fetal hypothalamic, pituitary, adrenal axis
    -High doses in first trimester linked to cleft palate but has been refuted
    -No evidence of increased MC, SB, NND
    -Safe to use in pregnancy
  4. Leukotriene receptor antagonists - Montelukast
    -Minimal evidence on safety
    -Don’t start in pregnancy
    -If asthma well controlled on motelukast then continue in pregnancy
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3
Q

Discuss antenatal management of asthma in pregnancy (7)

A
  1. MDT input
  2. Advise poorly controlled asthma has worse outcomes than well controlled asthma.
  3. Advise to stop smoking and avoid triggers
  4. Caution with aspirin for PET prophylaxis
  5. Counsel regarding risk of atopic disease in child (10% only mother 30% both parents)
  6. Optimise treatment as would for non-pregnant women
  7. Monitor BP and glucose levels if on PO steroids
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4
Q

Discuss management of asthma in pregnancy
-Intrapartum
-Postpartum

A
  1. Intrapartum care
    -Continue medications in labour
    -Aim vaginal delivery
    -If been on PO steroids >7.5mg prednisolone for >2 weeks then cover with hydrocortisone
    -OK for miso/prostaglandin/synto induction
    -Caution with carboprost and ergometrine
    -Caution with morphine
  2. Postpartum
    -Encourage breastfeeding - reduces risk of atopy
    -Continue asthma meds
    -Caution with NSAIDS
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5
Q

Discuss cystic fibrosis in pregnancy
-Incidence (2)
-Pathophysiology (6)
-Likelihood of fetus being affected (3)

A
  1. Incidence
    -1:2000 live births
    -1:25 are carriers
  2. Pathophysiology
    -Autosomal recessive condition with 1700 mutations identified to the CFTR gene on chromosome 7
    -CFTR important for sodium and water transport. Results in thick mucous secretions
    -In lungs results in mucous build up and increased resp infections
    -In pancreas results in stagnant secretions in ducts and malabsorption
    -In billary tract results in bile stasis and cirrhosis
    -In women fertility not impacted but in men congenital absence of Vas
  3. Likelihood of fetus being affected
    -Mother will be homozygous
    -If father is a carrier then risk to fetus is 50%
    -If father is not a carrier of common mutations then risk is 1:250
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6
Q

Discuss cystic fibrosis in pregnancy
-Effect of pregnancy on cystic fibrosis (5)
-Effect of cystic fibrosis on pregnancy (4)
-What are the predictors of poor outcome in pregnancy (4)

A
  1. Effect of pregnancy on cystic fibrosis
    -Increased maternal mortality compared to non-CF pregnant women. But NOT pregnancy related.
    -Pregnancy well tolerated if CF is well controlled with FEV1 >70% predicted
    -Poor maternal weight gain
    -Deterioration in lung function (reversible)
    -Diabetes or impaired glucose tolerance
  2. Effect of cystic fibrosis on pregnancy
    -No impact on miscarriage or congenital abnormalities
    -PTB
    -IUGR secondary to chronic hypoxia
    -Still birth
  3. Predictors of poor outcome in pregnancy
    -Pulmonary HTN / Cor pulmonale (pregnancy contraindicated)
    -Severe lung disease FEV1 <60% expected (<30-40% of expected. Pregnancy contra-indicated)
    -Poor maternal nutrition (BMI <18)
    -Hypoxemia
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7
Q

Discuss preconception management for women with cystic fibrosis (7)

A
  1. Counsel about risk to fetus, risk of pregnancy to woman
  2. Offer to assess risk to fetus
    -Check partner
    -Offer amnio/CVS
  3. Optimise maternal nutrition
  4. Optimise lung function with PT and antibiotics
  5. Get baseline Lung function testing and echo
  6. 5mg folic acid and vit D supplementation
  7. Check for diabetes with OGTT
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8
Q

Discuss antenatal care for women with cystic fibrosis (7)

A
  1. MTD input with physician, PT, MW, Obs, nuritionist
  2. Support nutrition with increased calorie diet
  3. Screen for diabetes at 16 weeks and if negative at 28 weeks
  4. Aggressively control infection
  5. Avoid periods of hypoxia with admission for bed rest and O2 if necessary
  6. Serial growth scans
  7. Anaesthetic review (Best to avoid GA)
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9
Q

Discuss management of cystic fibrosis in pregnancy
-Intrapartum cares
-Postnatal cares

A
  1. Intrapartum cares
    -Can aim for a spontaneous vaginal delivery at term
    -CS rate higher cf normal population
    -Consider instrumental to reduce length of second stage to avoid risk of pneumothoracies
    -Monitor O2 sats
    -Avoid GA
  2. Postpartum cares
    -Breastfeeding OK but high nutritional requirement and so exclusive breastfeeding might be too hard
    -Monitor respiratory function
    -Screen new born for CF
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10
Q

Discuss tuberculosis in pregnancy
-Effects of pregnancy on TB (4)
-Effects of TB on pregnancy (5)

A
  1. Effects of pregnancy on TB
    -Pregnancy doesn’t alter the course of disease
    -Pregnancy can lead to delayed diagnosis
    -Increased mortality 30-40% when treatment is delayed
    -Increase in incidence of extra-pulmonary TB
  2. Effect of TB on pregnancy
    -PTB
    -IUGR (Esp extra-pulmonary TB)
    -Congenital TB
    -Neonatal TB
    -PET
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11
Q

Discuss management of TB in pregnancy
-Antenatal care (7)
-Postnatal care (5)

A
  1. Antenatal care
    -Treat latent TB with isoniazid
    -Treat active TB with triple/quadruple therapy
    -Monitor LFTs
    -In those treated with isoniazid also give pyridoxine 25-50mg OD)
    -In those treated with isoniazid or rifampicin give Vit K 10mg OD from 36 weeks to decreased PPH and HDN
    -Serial growth scans
    -MDT
  2. Postnatal
    -Screen neonate for TB
    -Give BCG vaccination
    -Consider isoniazid prophylaxis
    -Encourage breastfeeding in sputum smear negative mothers.
    -PO contraception has reduced efficacy with TB meds. Choose alternative
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12
Q

Discuss influenza in pregnancy
-Maternal complications (3)
-Fetal complications (7)

A
  1. Maternal complications
    -Increased risk of severe infection and complications
    -Higher rates of hospitalisation
    -Increased risk of maternal death
  2. Fetal complications
    -Spontaneous miscarriage
    -LBW
    -PTB
    -Still birth
    -If infection during first trimester
    ->Hydrocephaly, cleft lip. NTD, congenital heart defects (Probably fever. Influenza doesn’t cross placenta)
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13
Q

Why do pregnant women have increased risk of influenza susceptibility (4)

A
  1. Change in respiratory physiology in pregnancy
    -Reduced functional residual capacity
    -Progesterone mediated hyperventilation
    -Increased oxygen demand
  2. Shift towards Th2 immunity and away from Th1 immunity which is targeted at intracellular microbes.
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14
Q

Discuss management of influenza in pregnancy (3)

A
  1. Oseltamivir - start within 48hrs of symptoms
    -Cat B1 medication
    -Give to pregnant women and up to 2/52 PP
    -Increase ICU admission and maternal death rate given after 48hrs
  2. Give steroids if concern for need to delivery / TPTL before 34+/40. Doesn’t cause maternal worsening of symptoms.
  3. Severe disease
    -MDT supportive care
    -Consider secondary bacterial sepsis
    -Thromboprophylaxis
    -Consider delivery if gravid uterus impacting ventilation
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15
Q

Discuss influenza vaccination RANZCOG guidelines (3)

A
  1. Recommended pre-pregnancy or during any trimester
  2. Recommended in each pregnancy
  3. Safe to receive during breastfeeding
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16
Q

Discuss the influenza vaccine in pregnancy
1. When to give (1)
2. Impact to fetus (3)
3. Contraindications (1)
4. Impact to mother (1)
5. Other recommendations (1)

A
  1. When to give
    -Can be given in any trimester
    -Safe in pregnancy and breastfeeding
  2. Impact to fetus
    -No evidence of vaccine teratogenicity, carinogenicity, growth or neurological effects
    -Maternal antibodies cross the placenta and protect neonate until 6months of life with 60% reduction in influenza
  3. Contraindications
    -Contra-indicated if previous anaphylaxis
  4. Impact to mother
    -Vaccine reduces lab dx of influenza by 50% in mothers
  5. Other recommendations
    -Obstetric staff should be vaccinated
17
Q

Discuss COVID and pregnancy
-Risk to mother (3)
-Risk to fetus (5)

A
  1. Risk to mother
    -Pregnancy doesn’t effect risk of infection
    -Increased risk of severe illness esp. in the third trimester
    -Risk of maternal death very low (Strain dependant)
  2. Fetal risks
    -No increase in congenital abnormalities
    -Vertical transmission is uncommon
    -Risk of stillbirth doubled
    -Risk of SGA
    -PTB (90% is iatrogenic)
18
Q

Discuss COVID vaccination in pregnancy (7 points)

A
  1. Vaccination is strongly recommended
  2. No evidence vaccination effects fertility
  3. Those with 3 x vaccines are 88% less likely to be admitted to hospital with omicron variant
  4. Booster is recommended
  5. Vaccination can be given at anytime during pregnancy or PN period
  6. Pfizer and Moderna vaccines are preferred in pregnancy
  7. Thrombosis associated with the vaccine is not higher in pregnant women than non-pregnant women
19
Q

Discuss thromboprophylaxis in pregnant women infected with COVID (2 points)

A
  1. All women admitted to hospital with confirmed or suspected COVID should be offered prophylactic LMWH
  2. All women who have been hospitalised with confirmed COVID should have 10/7 thromboprophylaxis following discharge
20
Q

Discuss antenatal management of COVID (9 points)

A
  1. Delay routine antenatal cares until out of quarantine
  2. Encourage influenza vaccination
  3. Growth scan 14 days post recovery
  4. If concern for PTD give betamethasone
  5. If oxygen requirement consider dexamethasone for mother
  6. Maintain O2 sats above 94%
  7. Monitor for signs of deterioration and involve other services.
  8. Fluid balance and aim for neutral fluid balance
  9. Consider remdesivir if moderate to severe illness or no improvement.
21
Q

Discuss management of labour for women with COVID (7 points)

A
  1. Recommend continuous fetal monitoring
  2. Avoid water birth if severely unwell
  3. Birth in hospital
  4. Avoid entonox
  5. No contra-indications to FSE or FBS
  6. Delayed cord clamping OK
  7. Beware that COVID delays transfer to OT and manage labour accordingly
22
Q

Discuss postnatal care for women with COVID (3 points)

A
  1. Mother and baby should remain together
  2. Breast feeding should be continued and is recommended
  3. Wash hands, breast pump and bottles to reduce viral spread. Wear a face mask while breastfeeding

RANZCOG 2024 - maternal medical conditions (14 decks)

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