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Year 5 Haematology > 3: Obstetric Haematology > Flashcards

3: Obstetric Haematology Flashcards

1
Q

Anaemia in pregnancy definition (dependant on trimester)

A
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2
Q

Blood Count Changes in pregnancy

A

Mild anaemia

  • Red cell mass rises (120-130%) Net Dilution
  • Plasma volume rises (150%)

Macrocytosis

  • Normal
  • Folate or B12 deficiency

Neutrophilia

Thrombocytopenia (increased platelet size from increase in turnover of platelets)

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3
Q

Iron and folate requirement during pregnancy

A

Iron requirement 300mg (foetus); 500mg (maternal RBC mass)

  • RDA 30mg
  • Increase in daily iron absorption 1-2mg to 6mg
  • Iron deficiency → IUGR, prematurity, PPH

Folate requirement increase +200mcg/day

  • Growth and cell division
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4
Q

Iron and folate supplements in pregnancy

A

60mg iron AND 400ug folic acid daily during pregnancy WHO Recommendations

  • However, some Cochrane reviews have found iron or folate supplements had no effect on measures of maternal or foetal outcome → maternal Hb higher, Fe reserves higher, foetal ferritin higher

400ug folic acid (and no iron) daily during pregnancy RCOG Guidelines

  • Supplement before conception and for more than 12-weeks’ gestation
  • High-dose folic acid = 5mg / 5000ug folic acid
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5
Q

Thrombocytopaenia ranges in pregnancy

A
  • Platelet Count Falls in Pregnancy [non-pregnant = 225-249 x 109/L; pregnant = 175-199 x 109/L]
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6
Q

Causes of thrombocytopenia

A

(1) Physiological (gestational or incidental thrombocytopenia)
(2) Pre-eclampsia (HELLP – Haemolysis, Elevated Liver enzymes, Low Platelets)
(3) Immune thrombocytopenia (ITP) – BM creates lots of platelets but there is peripheral destruction
(4) MAHA syndromes

All other causes – BM failure, hypersplenism, DIC, leukaemia

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7
Q

Gestational thrombocytopenia (a physiological decrease in platelets – affects ~10%)

A
  • >50x109/L enough for delivery (>70 required for epidural)
  • Mechanism is poorly defined (dilution and increased consumption potentially)
  • Baby is not affected

Platelet count rises 2-5 days post-delivery

Most likely cause…

>70 x 109/L = gestational thrombocytopenia <70 x 109/L = ITP or pre-eclampsia

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8
Q

Pre-eclampsia

A
  • 50% get thrombocytopenia (proportionate to severity)
  • Association with increased activation and consumption (incipient DIC (normal PT, APTT))
  • Platelet count remits following delivery
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9
Q

Immune thrombocytopenia – ITP

5% of these patients get thrombocytopenia in pregnancy (TP may precede pregnancy; early onset)

A

Treatment options – for bleeding or delivery:

  • IVIG + steroids
  • Anti-D (in RhD +ve mothers with spleen) – the anti-D coats the RBCs and is preferentially removed by the reticuloendothelial system in preference to the AB-covered platelets, thus conserving platelet levels

Baby may be affected

  • 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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10
Q

Microangiopathic syndromes [Microangiopathic Haemolytic Anaemia – MAHA]

A

MAHA syndromes – demonstrates different ways MAHA can present:

  • I.E. TTP, HUS, AFLP, SLE, APLS, etc.
  • TTP (pentad S/S: MAHA, fever, renal impairment, neurological impairment, thrombocytopenia)

Tx TTP dependant on plts number and current bleeding

  • Deposition of platelets in small blood vessels (inc. in the placenta)
  • Cardinal signs = fragmentation (schistocytes) and destruction of RBC within vasculature
    • Increased BR
    • Thrombocytopenia, schistocytes
    • Organ damage – kidney, CNS, placenta

Delivery does not alter course of TTP or HUS

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11
Q

HUS pathophysiology

A
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12
Q

HUS pathophysiology

A
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13
Q

Iron cycle andrequirements

A
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14
Q

VTE during pregnancy

A

VTE during pregnancy → is more common in women with a high BMI (95% of clots in pregnant women are in the left leg)

PE is the leading direct cause of maternal death in the UK (1.56 per 100,000 maternal mortalities)

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15
Q

Coagulation changes during pregnancy

A
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16
Q

Coagulation changes during pregnancy

A
17
Q

highest risk time for PE, largest predictor of incidence of PE, what can you give

A
  • Deaths from PE (largest maternal killer):
    • Highest risk time = post-partum and 1st trimester
    • High BMI (>25) is the largest predictor of incidence of PE
    • Need to be on heparin from the first trimester
18
Q

VTE/PE Ix’s during pregnancy

A
  • Doppler and VQ are safe to perform in pregnancy
  • D-dimer is elevated in pregnancy (not useful for exclusion of thrombosis [is usually used for exclusion])
19
Q

Factors increasing risk of thrombosis in pregnancy

A
20
Q

Prevention and treatment of thromboembolic disease in pregnancy

A
21
Q

Thrombosis → impaired placental circulation → ?

A
  • IUGR (Intra-uterine Growth Restriction) Recurrent miscarriage
  • Late foetal loss Placental abruption
  • Severe PET (pre-eclampsia)

Thrombophilia → APLS (anti-phospholipid syndrome)

22
Q

APLS (criteria) and treatment

A
  • Miscarriages (≥3) + lupus anticoagulant or anticardiolipin antibodies T
    • Adverse pregnancy outcomes – 3+ consecutive miscarriages before 10 weeks of gestation
    • 1 or more morphologically normal foetal losses after 10w of gestation
    • 1 or more preterm birth before 34-weeks of gestation
      • Treat with (unfractionated) heparin** and **aspirin → dramatically improved outcomes
23
Q

PPH causes

A

PPH (large cause of mortality in high income countries – remained very stable over the years)

  • Placenta praevia (placenta attached at vaginal opening)
  • Placenta accrete (wall-invading placenta)
  • Principal reason for hysterectomy

Post-partum Haemorrhage (PPH) = >500ml blood loss (SVD)

  • 5% pregnancies have blood loss more than 1L
  • Requiring transfusion post-partum = 1% after vaginal delivery, 1-7% after C-section

 

PPH – Mechanisms:

  • Major factors – uterine atony and trauma (the 4 T’s = tone, tissue, trauma, thrombin)
    • Haematological factors minor except:
      • Dilutional coagulopathy after resus
      • DIC in abruption, amniotic fluid embolism
24
Q

Decompensation is precipitated by…

A

Amniotic fluid embolism

Preeclampsia (severe/HELLP)

Abruptio placentae

Sepsis

Retained dead foetus

25
Q

Amniotic fluid embolism

A
  • Most catastrophic event in modern obstetrics (86% mortality; 1 in 20,000-30,000 births)
  • Symptoms – sudden onset shivers, vomiting, shock, DIC
  • Presumed due to tissue factor in amniotic fluid entering maternal bloodstream
  • Almost all 25yo+; usually in the 3rd trimester
  • Drugs used to induce labour – misoprostol increase risk
26
Q

Haemoglobinopathy screening aims

A

Screening aims – avoid birth of children with…

  • Alpha 0 thalassaemia / Hb Barts (4 gamma chains) → death in utero, hydrops fetalis
  • Beta 0 thalassemia (transfusion dependent)
  • HbSS / SCD (life expectancy 43yo)
  • Other compound HbS syndromes – symptomatic, stroke
  • Some compound thalassaemia’s – transfusion dependent, iron overload
27
Q

Haemoglobinopathy counselling

A
  • All disorders are recessive
  • If mother is heterozygous, partner tested
  • Combinations important as homozygous states
  • Options:
    • Proceed
    • Prenatal dx at:
      • CVS sampling (10-12 weeks)
      • Amniocentesis (15-17 weeks)
      • cffDNA testing (NEW)
      • US screening for hydrops
28
Q

sickle cell disease in pregnancy

A
29
Q

IDA vs thalassaemia trait

A
30
Q

Which of the following statements is correct?

  • In gestational thrombocytopenia, the baby’s platelet count is usually affected
  • Thrombocytopenia is rarely found in association with pre-eclampsia
  • Thrombotic thrombocytopenic purpura remits spontaneously following delivery
  • Platelet count may fall following delivery in babies born to mothers with ITP
A
  • In gestational thrombocytopenia, the baby’s platelet count is usually affected
  • Thrombocytopenia is rarely found in association with pre-eclampsia
  • Thrombotic thrombocytopenic purpura remits spontaneously following delivery
  • Platelet count may fall following delivery in babies born to mothers with ITP
31
Q

A reduction in pregnancy-associated thrombosis mortality rate can be attributed to…

  • lower obesity rates
  • improved targeted thromboprophylaxis
  • rising maternal age
  • increase in prevalence of gestational thrombocytopaenia
A
  • Lower obesity rates
  • Improved targeted thromboprophylaxis
  • Rising maternal age
  • Increase in prevalence of gestational thrombocytopenia

Year 5 Haematology (7 decks)

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