RPA pregnancy

Question 1

epigastric pain in pre eclampsia

Answer 1

night>day
very severe
not relieved by movement and antacids
spontaneously resolve

Question 2

creatinine in pregnancy

Answer 2

normal range up to 60
usually lower in pregnancy
>70 is suspicious

Question 3

Low platelets in pregnancy

Answer 3

accept >100 in pregnancy

but increased incidence in pre-eclampsia

Question 4

pre-existing hypertension in pregnancy

Answer 4

noted before 20 weeks gestation

Question 5

pre-eclampsia vs chronic hypertension

Answer 5

need to see if it resolves post pregnancy

Question 6

trends of BP during pregnancy

Answer 6

high at the start then falls and rises agian

U shape

Question 7

pathogenesis of pre-eclapsmi

Answer 7

combination of: genetic factorsm abnormal trophoblastm oxidative stress, angiotensin 1 autoantibodies

the normal spiral arteries that should penetrate into the uterine wall to supply blood and oxygen does not undergo the appropriate changes to do that to the placenta.

the placenta then becomes hypoxic and releases things into the circulation - incluing oxidative stress, proinflammatory cytokines, increased AT autoantibodies and syncytiotrophoblast microparticles and nanoparticles

that causes increased antiangiogenesis (decreased VEGF and PIGF) and affects various organs

Question 8

antiangiogenic factors in preeclampsia

Answer 8

SFLT1 and PIGF endoglin (soluble antiangiogenic factors) are elevated in preeclampsia and prior onset

-> endothelial dysfunction

used to predict and diagnose preeclampsia

Question 9

prevention of pre-eclampsia

Answer 9

aspirin of risk >1:100

Question 10

kidneys preclampsia

Answer 10

renal biopsy - glomerloendotheliosis

proteinuria
tubular dysfunction

rising creatining later (>90)

Question 11

haematological preclampsia

Answer 11

DIC
thrombocytopenia
Incr APTT and PI
haemolysis

Question 12

liver pre-eclampsia

Answer 12

ischaemia
haemorrhages
abrnoaml LFTs (but ALP increased in all pregnant women)
epigastric/RUQ pain

Question 13

CNS pre-eclampsia

Answer 13

ischaemia, haemorrhages
haedaches
visual disturbance
retinal vasospasm
hyperreflexia/conus
eclampsia (not all women progress to eclampsia, depends on which vascular bed is affected)
stroke

Question 14

who is prone to eclampsia

Answer 14

young
african

white women less so

Question 15

seizure prophylaxis in pre-eclampsia

Answer 15

lower the BP
sz secondary to hypertensive encephalopathy, ischaemia and oedema

magnesium sulphate works as a cerebral dilator

• can be used as prevention and treatment of eclamptic seizures
• reduce seizures by 50%
• NNT for caucasian population is high

Question 16

fetus pre-eclampsia

Answer 16

IUGR

see slides

Question 17

severe pre-eclampsia

Answer 17

BP >160/100
symptoms
renal dysfunction
ELLP
hyperreflexia, clonus

Question 18

reflexes in pregnant women

Answer 18

increased physiologically

Question 19

management of pre-eclampsia

Answer 19

admit

1. control BP
   - alpha methyldopa/clonidine
   - labetalol
   - nifedipine
   - hydralazine
   - prazosin

rapid escalation
HTN often refractory
cautious w tiny baby with bad CTG due to ?perfusion abnormality

avoid diuretics (plasmavolume depletion) and ACEI (fetotoxic)

2. stabilise fluid status
   - women are usually odematous but intraveously dry
3. treat coagulopathy, thormbocytopenia

Question 20

prevention of pre-eclampsia

Answer 20

low dose aspirin
calcium
only treat thrombophillia in antiphospholipid
see slides

Question 21

recurrence of pre-clampsia

Answer 21

30-60%

Question 22

what does pre-eclampsia increase the risk of

Answer 22

ESRD x4
chronic hypertension x3.7
IHD 2.1

stroke, PVD, DVT, T2DM, TSH high

Question 23

hyperemesis gravidarum def

Answer 23

1st trimester

weight loss and impaired nutrition

Question 24

intrahepatic cholestasis LFTs

Answer 24

transamintis

Question 25

Intrahepatic cholestasis treatment

Answer 25

ODCA but recent PITCHES trial showed no reduction in itch or neonatal outcomes

Question 26

hyperemesis gravidarum thyroid funciton tests

Answer 26

transient hyperthyroxinaemia and suppressed TSH related to cross-reactivity with HCG

Question 27

acute fatty liver of pregnancy

Answer 27

very catastrophic usually t3 microvesciular fatty infiltration (unlike NASH which is macrovescicular) ``` presents w malaise, A, N, V jaundice impaired level of consciousness features of preeclampsia treatment of delivery of fetus regardless of gestation HYPOGLYCAEMIA ``` diagnosis clinically w SWANSEA criteria fetal mortality > maternal mortality

Question 28

LCHAD in acute fatty liver of pregnancy

Answer 28

LCHAD deficiency in fetus

Question 29

intrahepatic cholestasis of pregnancy clinical features

Answer 29

pruritis soles and palms assos w preterm labour, meconium stained amniuotic fluid bile acid >100 assos w stillbirth

Question 30

what rheumatological conditions may deteriorate during pregnancy

Answer 30

everything except RA

Question 31

what antibodies cross the placenta to cause congenital heart block

Answer 31

SSA/SSB

Question 32

what antibodies cross the placenta to cause graves

Answer 32

thyroid receptor antibody may cause fetal/neonatal thyrotoxicosis but rare

Question 33

what haematological autoimmune condition can have antibodies that cross the placenta to affect the fetus

Answer 33

thrombocytopenia (also rare)

Question 34

what neurological autoimmune condition can have antibodies that cross the placenta to affect the fetus

Answer 34

myasthenia gravis (20-30% fetus affected)

Question 35

how does APLS affect pregnancy

Answer 35

thorugh both thormbotic and non-thrombotic effects

Question 36

how many women have a normal pregnancy in APLS

Answer 36

50% normal pregnancy very few have thrombotic events most risk on the fetal side

Question 37

treatment of APLS in pregnancy

Answer 37

probably some benefit of heparin in conjucntion w aspirin cf aspirin alone APL but no thrombosis or fetal loss - aspirin or nothing ALP w previous thrombosis - LMWH and aspirin Recurrent miscarriages - aspirin Fetal loss/severe PET - prophylactic LMWH + aspirin ?hydroxychloroquine

Question 38

Altered pharmacokinetics in pregnancy

Answer 38

Absorption, protein bindingm hepatic metabolism, renal excretion protein bound or renally excreted meds need dose increase (e.g. antiepileptics)

Question 39

why do most conditions flare in post partum period

Answer 39

switch from Th2 dominant to Th1 dominant immune balance

Question 40

radiation from VQ/CTPA in maternal patient

Answer 40

same radiation to fetus (very low and insignificant) CTPA has greater radiation to breasts but CTPA can diagnose more non PE pathologies VQ in postpartum women requires them to discard breastmilk