16 - Medical Disorders of Pregnancy Flashcards
1
Q
What is the definition of anaemia in pregnancy and when is it screened for?
A
First trimester Hb <110
Second/Third trimester Hb <105
Postpartum Hb<100
It is screened for in booking appointment and then at 28 weeks
2
Q
Why is anaemia common in pregnancy and what are the presenting symptoms of this?
A
Plasma volume increases due to water retention so dilutes blood
3
Q
What are the different causes of anaemia in pregnancy and how can you differentiate between them?
A
- Low MCV: iron deficiency
- Normal MCV: physiological anaemia
- Raised MCV: B12 or folate deficiency
Women offered haemoglobinopathy screening at the booking clinic for thalassaemia (all women) and sickle cell disease (women at higher risk) as these cause anaemia
4
Q
How is anaemia in pregnancy managed?t
A
Determine cause with blood tests
Iron: Ferrous Sulphate 200mg daily
B12: Test for Intrinsic Factor antibodies for pernicious anaemia then give either IM hydroxycobalamin or PO cynacobalamin
Folate: Up dose from 400mcg to 5mg folic acid
Sickle Cell/Thalassemia: 5mg folic acid, refer to haematologist for transfusions and monitoring
5
Q
What are some risk factors for developing anaemia in pregnancy?
A
- Haemoglobinpathies e.g Thalassaemia and Sickle cell
- Increasing maternal age
- Low socioeconomic status
- Poor diet
- Anaemia during previous pregnancy
6
Q
What are the key bloods you should look at for anaemia in pregnancy?
A
Hb
MCV
7
Q
What are some issues that antiphospholipid syndrome can cause in pregnancy?
A
- Inhibition of trophoblastic (precursor to the placenta) function and differentiation
- Activation of complement pathways at the maternal–fetal interface
- Thrombosis of the uteroplacental vasculature causing miscarriage
8
Q
What are some autoimmune conditions that are associated with antiphospholipid syndrome?
A
- SLE
- RA
- Systemic Sclerosis
9
Q
What are the clinical features of antiphospholipid syndrome in pregnancy?
A
Recurrent Pregnancy Loss and Thrombosis
- DVT/PE
- Stroke
- Livedo reticularis
- Valvular heart disease AR and MR
- CKD due to ischaemia in kidneys
- Thrombocytopaenia
10
Q
What is catastrophic antiphospholipid syndrome?
A
11
Q
What blood tests are used to diagnose antiphospholipid syndrome and which pregnant women should you perform this blood test on?
A
Any women with 3 or more miscarriages, anyone with atypical DVT or recurrent thromboses
- Anticardiolipin
- Lupus anticoagulant: measures the clotting ability of the blood, longer clotting time if antiphospholipid antibodies
- Anti-B2-glycoprotein I
12
Q
What is the diagnostic criteria for antiphospholipid syndrome?
A
Need one laboratory and one clinical criteria
13
Q
How is antiphospholipid syndrome managed once diagnosed?
A
14
Q
Why are pregnant women at increased risk of VTE in pregnancy and when is the risk highest?
A
Increased coagulability of blood (increased fibrinogen, decreased protein S) and Venous Stasis due to pelvic mass
Postpartum period
PE is big cause of obstetric death
15
Q
What are some risk factors for VTE in pregnancy and when should you start VTE prophylaxis?
A
- Smoking
- Parity ≥ 3
- Age > 35 years
- BMI > 30
- Reduced mobility
- Multiple pregnancy
- Pre-eclampsia
- Gross varicose veins
- Immobility
- Family history of VTE
- Thrombophilia
- IVF pregnancy
If 3 risk factors start at 28 weeks, If 4 or more start in first trimester
16
Q
When is VTE prophylaxis needed in pregnancy despite no risk factors?
A
- Covid
- Hospital admission
- Surgical procedures
- Previous VTE
- Medical conditions such as cancer or arthritis
- High-risk thrombophilias
- Ovarian hyperstimulation syndrome
17
Q
What is given for VTE prophylaxis in pregnancy?
A
LMWH e.g dalteparin, enoxaparin
Started at 28 weeks if risk or as soon as possible if high risk.
Stopped during labour then restarted after delivery for 6 further weeks
If CI then use mechanical prophylaxis like IPC and AES
18
Q
How do DVTs and PEs present?
A
DVT
- Unilateral calf or leg swelling (>3cm difference)
- Dilated superficial veins
- Tenderness to the calf
- Oedema
- Colour changes to the leg
PE
- Shortness of breath
- Cough with or without blood
- Pleuritic chest pain
- Hypoxia
- Tachycardia
- Raised respiratory rate
- Low-grade fever
- Haemodynamic instability causing hypotension
19
Q
How are DVTs diagnosed in pregnant women?
A
Doppler US
If negative repeat on day 3 and 5
Well’s cannot be used and neither can D-dimers as raised in pregnancy anyway
20
Q
How are PEs diagnosed in pregnant women?
A
Initial investigations:
- ECG
- CXR
Definitive Diagnosis
- CTPA
- V/Q Scan
- If DVT on Doppler US and signs of PE does not need further imaging to diagnose to save radiation
21
Q
How do you decided whether to do a CTPA or VQ scan on a pregnant woman with a suspected PE?
A
CTPA is gold standard if abnormal CXR
- CTPA: higher risk of breast cancer for mother
- VQ scan higher risk of childhood cancer for fetus
22
Q
How is a confirmed VTE treated in a pregnant woman?
A
Start LMWH (e.g dalteparin, enoxaparin) as soon as possible based on weight of woman at booking clinic
Need to continue LMWH until delivery then 6 weeks after
Can switch to oral DOAC after delivery
23
Q
How is a massive PE with haemodynamic compromise managed in a pregnant woman?
A
- Unfractionated heparin
- Thrombolysis
- Surgical embolectomy
24
Q
What is pre-eclampsia and the complications of leaving this untreated?
A
New high blood pressure in pregnancy with proteinuria with or without oedema
Triad: HTN, Proteinuria, Oedema
Complications: Seizures, End organ damage, IUGR,
25
What is the definition of the following:
* Chronic hypertension
* Gestational hypertension
* Pre-eclampsia
* Eclampsia
**Chronic hypertension:** exists before 20 weeks gestation and is longstanding
**Gestational hypertension:** ***\>140/90*** occurring after 20 weeks gestation, without proteinuria.
**Pre-eclampsia:** pregnancy-induced hypertension associated with organ damage, notably ***proteinuria***
**Eclampsia:** ***seizures*** occur as a result of pre-eclampsia
26
What is the pathophysiology of pre-eclampsia?
**Trophoblast invasion** of endometrium sends signals to **spiral arteries** to **reduce their vascular resistance**, making them more fragile. Blood flow to these arteries increases and they break down, leaving **lacunae** where maternal blood flows. Happens around **20 weeks gestation**
If lacunae are inadequate, can develop pre-eclampsia. **High vascular resistance in the spiral arteries** and **poor perfusion of the placenta.** This causes **oxidative stress** in the placenta, and the **release of inflammatory chemicals** into the systemic circulation, leading to **systemic inflammation** and impaired endothelial function in the blood vessels.
27
What are the different risk factors for pre-eclampsia?
**_High Risk if one of the following:_**
* **History of hypertensive disease during a previous pregnancy**
* **CKD**
* **Autoimmune disease** (e.g. SLE or antiphospholipid syndrome)
* **Type 1 or type 2 diabetes**
* **Chronic hypertension**
**_High Risk if two of the following moderate risk factors:_**
* **First pregnancy**
* **Aged 40 years or older**
* **Pregnancy interval of more than 10 years**
* **BMI of 35 kg/m2 or greater at the first visit**
* **Family history of pre-eclampsia**
* **Multiple pregnancy**
28
If a woman is at high risk of pre-eclampsia due to one high risk factor or two moderate risk factors, what should we do to prevent them developing pre-eclampsia?
75-100mg Aspirin prophylaxis from 12 weeks to birth
Advise good diet, exercise and diabetes control
29
What are some signs and symptoms of pre-eclampsia?
Usually asymptomatic and picked up on routine urine dips/BPs. If any symptoms, present urgently to hospital
**_Symptoms_**
* **Headache**
* **Visual disturbance**
* **Oedema** (facial, peripheral)
* **Abdominal/Epigastric pain** (liver)
* **Vomiting**
**_Signs_**
* **Altered mental status**
* **Dyspnea**
* **Clonus**
* **Oedema**
* **Brisk reflexes**
30
What investigations should you do if you suspect pre-eclampsia?
**_Bedside_**
* Blood pressure
* Vital signs
* Urine dipstick and culture for proteinuria
* Albumin:creatinine ratio
**_Blood tests_**
* **FBC**: falling platelet counts may show HELLP syndrome.
* **U+Es:** serum creatinine should be monitored for signs of AKI
* **LFT**: derangement of transaminases is common, also become elevated in HELLP syndrome.
* **Clotting screen**
* **Platelet Growth Factor:** low if preeclampsia
**_Imaging_**
* **USS**: assessment of foetal development.
* **CT/MRI:** rarely
31
What are the NICE guidelines for a diagnosis of pre-eclampsia?
* Systolic BP above 140 mmHg
* Diastolic BP above 90 mmHg
**PLUS** any of:
* ***Proteinuria*** (1+ or more on urine dipstick)
* ***Organ dysfunction*** (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
* ***Placental dysfunction*** (e.g. fetal growth restriction or abnormal Doppler studies)
32
How are women routinely screened for pre-eclampsia at antenatal appointments?
* Blood pressure
* Urine dipstick for proteinuria
* Ask about symptoms
33
How are women with chronic hypertension treated in pregnancy?
(important card)
**Stop ACEi/ARBs and Thiazides**
**Use labetalol,** if CI use **nifedipine**, if both CI use **methyldopa**
**Offer aspirin from 12 weeks to birth** as high risk of pre-eclampsia
**Offer placental growth factor (PlGF) testing** to rule out pre-eclampsia between 20-35 weeks
34
How should you managed a woman with chronic hypertension once she has given birth?
* Measure BP daily for first 2 days then once between day 3 and 5
* If on methyldopa stop within 2 days and switch to another
* Offer antihypertensive review within 2 weeks with GP
35
At what blood pressure should you admit a pregnant woman to hospital?
\>160/110
36
Once diagnosed, how is pre-eclampsia monitored?
* **Scoring systems** to decide whether to admit based on risk of maternal outcomes (***fullPIERS*** or ***PREP‑S*** up to 34 weeks)
* **BP measurement every 48 hours** using labetalol, nifedipine or methyldopa to keep below 140/90
* **US of the fetus, amniotic fluid and dopplers every 2 weeks**
* **Consider need for early birth**
37
What are some drugs used for pre-eclampsia?
* **Labetolol:** First line
* **Nifedipine:** Second line
* **Methyldopa:** Third line, needs to stop 2 days after birth
* **Intravenous hydralazine:** in critical care in severe pre-eclampsia or eclampsia
* **IV magnesium sulphate:** given during labour and in the 24 hours afterwards to prevent seizures
* **Fluid restriction:** during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload
38
When would you consider early delivery with pre-eclampsia?
* Inability to control BP despite using 3 or more classes of antihypertensives
* Maternal pulse oximetry less than 90%
* Progressive deterioration in LFTs, renal function, haemolysis, or platelet count
* Ongoing neurological features, such as severe intractable headache, repeated visual scotomata, or eclampsia
* Placental abruption
* Reversed end-diastolic flow in the umbilical artery doppler velocimetry, a non-reassuring cardiotocograph, or stillbirth
39
What is eclampsia and how is it treated?
Seizures in pregnancy from high blood pressure
**Initial Mx:** Oxygen, Secure Airway, Place in left lateral position, Consider intubation
**1st Line:** IV Magnesium Sulfate
**Definitive:** Delivery!!!!! If premature give IM corticosteroids to mature fetal lungs
40
What are some complications associated with pre-eclampsia? (maternal and fetal)
* **Eclampsia**
* **HELLP Syndrome:** Haemolysis Elevated Liver enzymes Low Platelets syndrome
* **DIC:** Life-threatening coagulopathy where wide-spread activation of the clotting system leads to micro-thrombi formation and consumption of clotting factors leading to haemorrhage and multi-organ failure.
41
IV magnesium sulfate should be given to women with severe pre-eclampsia to prevent seizures. What are some features fo severe preeclampsia and what dose should these women be given?
* **Ongoing or recurring severe headaches**
* **Visual scotomata**
* **Nausea or vomiting**
* **Epigastric pain**
* **Oliguria and severe hypertension**
* **Progressive deterioration in blood tests** (such as rising creatinine or liver transaminases, or falling platelet count)
Loading dose of 4 g IV over 5 to 15 minutes, followed by an infusion of 1 g/hour for 24 hours
42
How are women with severe pre-eclampsia treated?
* Anti-hypertensives
* MgSO4
* Corticosteroids if likely to deliver in next 7 days
* Fluid restriction 80mls/hr
* Transfer to critical care or delivery suite
**Only will resolve once placenta is delivered as placental disease. At risk fo seizures still after delivery, safe by day 5**
43
Why does gestational diabetes occur and what is the issue with this?
Insulin sensitivity that occurs during pregnancy
**Issues:** Macrosomia, Shoulder dystocia, Risk of T2DM in mother long term, Neonatal Hypoglycaemia
44
How is gestational diabetes screened for?
**OGTT at 24-28 weeks gestation** if risk factors:
* Previous gestational diabetes
* Previous macrosomic baby (≥ 4.5kg)
* BMI \> 30
* Ethnic origin (black Caribbean, Middle Eastern and South Asian)
* Family history of diabetes (first-degree relative)
45
How is gestational diabetes diagnosed (actual values)
OGTT
Given 75g glucose after a fast in the morning. Measure blood sugars before drink then 2 hours after
**_Gestational diabetes if:_**
* **Fasting:** \>5.6 mmol/l
* **At 2 hours:** \> 7.8 mmol/l
46
How is gestational diabetes managed once diagnosed?
**CONSULTANT LED**
Offer all women diet and exercise and teach them to measure and regularly check blood sugars.
**Consider early delivery** and have a**dditional growth scans at 28, 32, 36 weeks** for polyhydraminos, accelerated growth
* **Fasting glucose less than 7 mmol/l:** trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin
* **Fasting glucose above 7 mmol/l:** start insulin ± metformin
* **Fasting glucose above 6 mmol/l plus** ***macrosomia*** **(or other complications):** start insulin ± metformin
47
How is pre-existing diabetes managed in pregnancy?
* **Good blood sugar control** before conception
* **Stop any oral drugs and switch to Metformin + Insulin** if Type 2 and Insulin if Type 1
* **Retinopathy screening:** shortly after booking and at 28 weeks gestation as rapid retinopathy can occur
* **Planned delivery** between 37 and 38 + 6 weeks. Use sliding scale during labour if T1DM or poorly controlled T2DM. If gestational can go up to 40 + 6
48
How are woman with diabetes managed after birth?
**Gestational:** Stop any diabetic medications immediately. Have fasting glucose test 6 weeks later, be warned 50% will have T2DM
**Pre-existing:** Lower insulin doses and be wary of hypoglycaemia
49
What are some complications or babies when their mother has diabetes?
* **Neonatal hypoglycaemia**
* Shoulder dystocia
* Polycythaemia (raised haemoglobin)
* Jaundice (raised bilirubin)
* Congenital heart disease
* Cardiomyopathy
* Transient tachypnea
50
How is neonatal hypoglycaemia managed?
Monitor babies with diabetic mothers closely and give frequent feeds
If **asymptomatic** encourage **breast/bottle feed**
If **\<2 BM or symptomatic** then give **IV dextrose** and **NG tube feeding**
51
What can be used in gestational diabetes if metformin is not tolerated due to GI side effects and insulin is declined?
**Glibenclamide** (sulfonylurea)
52
What is obstetric cholestasis?
Reduced outflow of bile acids from the liver due to increased oestrogen and progesterone
**Causes pruritus and elevated bile acids**
More common in South Asian women
53
Why is it important to recognise intrahepatic cholestasis of pregnancy?
**Risk of stillbirth**
Also risk of preterm labour, meconium aspiration, neonatal respiratory distress syndrome
Levels ≥ 100 micromol/L associated with significantly increased risk of stillbirth
54
How does obstetric cholestasis present?
* Itching (usually palms and soles of feet)
* Fatigue
* Dark urine
* Pale, greasy stools
* Jaundice
THERE IS NO RASH, if rash consider polymorphic eruption of pregnancy or pemphigoid gestationis
55
What are some other causes of pruritus and raised LFTs in pregnancy apart from obstetric cholestasis?
* Gallstones
* Acute fatty liver
* Autoimmune hepatitis
* Viral hepatitis
56
How do you investigate a woman with pruritus and what may the investigations show?
Pruritus may precede biochemical abnormalities, so tests should be repeated if suspected
* **Bile Acids:** raised
* **LFTs:** ALT, AST and GGT raised
* **Liver US:** rule out alternative diagnoses
57
How is obstetric cholestasis managed?
***Ursodeoxycholic acid***
* **Symptom control:** Emollients like calamine lotion and Antihistamines like Chlorphenamine
* **Water-soluble vitamin K:** If PT deranged as low bile acids can derange clotting
* **Monitor LFTs weekly and after delivery (after at least ten days):** ensure the condition does not worsen and resolves after birth
* **Planned delivery after 37 weeks** may be considered, particularly when the LFTs and bile acids are severely deranged to reduce risk of still birth
58
What is acute fatty liver of pregnancy and what are the complications with this?
**Rapid accumulation of fat in the liver cells** in the **third trimester** of pregnancy causing **acute hepatitis**
**Liver failure and Mortality risks** in both mother and fetus
59
What is the pathophysiology of acute fatty liver of pregnancy?
Impaired processing of ***fatty acids*** in the ***placenta***
***Long-chain 3-hydroxyacyl-CoA dehydrogenase*** (***LCHAD***) ***deficiency*** in the fetus, which is ***autosomal recessive***
Fetus and placenta are unable to break down fatty acids so they enter the maternal circulation, and accumulate in the liver, causing acute hepatitis
60
How may acute fatty liver of pregnancy present?
Vague symptoms of hepatitis
* General malaise and fatigue
* Nausea and vomiting
* Jaundice
* Abdominal pain
* Anorexia
* ***Ascites***
61
What may blood tests show in acute fatty liver of pregnancy?
* **Raised ALT and AST**
Other bloods may be deranged, with:
* Raised bilirubin
* Raised WBC count
* Deranged clotting
* Low platelets
62
If a pregnant woman has raised LFTs and low platelets, what diagnosis should you think of?
HELLP Syndrome
63
How is acute fatty liver of pregnancy managed?
Obstetric Emergency **need to delivery the baby**
Most resolve after delivery, if not then treatment of ***acute liver failure*** if it occurs, including consideration of ***liver transplant***
64
Why does heart burn occur during pregnancy and what are some management options for this?
**_Causes:_**
* Relaxation of LOS muscles
* Baby pushing up on stomach
**_Management:_**
* Avoid smoking, alcohol
* Eat small meals often
* Antacids and Alginates (do not take iron supplements at the same time)
* **Ranitidine or Omeprazole**
65
What are some symptoms of pelvic girdle dysfunction?
**Pain:**
* Over the pubic bone at the front in the centre
* Across 1 or both sides of lower back
* Perineum
* Spreading to thighs
* Clicking or grinding in pelvic area
66
How is pelvic girdle dysfunction managed?
* Physiotherapy
* TENS
* Pelvic support belts
67
What is the maximum gestation that a woman with gestational diabetes can get to ?
40+6 weeks
If gets to this then elective c section or induction
68
What blood tests need to be done in severe pre-eclampsia, how often and why?
Monitor for HELLP
69
How is a massive PE with haemodynamic compromise managed in a pregnant woman?
* Unfractionated heparin
* Thrombolysis
* Surgical embolectomy
