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Laura MRCOG Part 2 > 9) Maternal Medicine - Rheumatology/Ortho > Flashcards

9) Maternal Medicine - Rheumatology/Ortho Flashcards

1
Q

Incidence of rheumatoid arthritis in pregnancy

A

1 in 1000-2000

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2
Q

What percentage of people with RA have secondary Sjogrens?

A

15%

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3
Q

What antibodies might be seen in RA?

A

80-90% Rheumatoid Factor
ANA 30% (Sjogren’s particularly associated with anti-Ro and anti-La)
Anti-CCP (predicts severity)
5-10% have antiphospholipid antibodies

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4
Q

Course of RA in pregnancy

A

50% improve (20% complete remission)
- Predicted based on previous remission and absence of rheumatoid factor or anti-CCP
25% significant disability

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5
Q

Course of RA post-natally

A

90% flare in 4 months after (not associated with anti-CCP or rheumatoid factor)

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6
Q

Pregnancy risks associated with RA

A

PTB
Growth restriction
Anti-Ro antibodies - risk of neonatal lupus
Hip abduction rarely impedes vaginal delivery.
Atlanto-axial subluxation after GA.

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7
Q

Risks of NSAIDs in pregnancy

A
  • Can impair fertility by “leutinised unruptured follicle syndrome” or blastocyst implantation failure.
  • Increased risk neonatal haemorrhage
  • Oligohydramnios (reversible)
  • Premature closure of DA (reversible)
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8
Q

If NSAIDs used in pregnancy when should they be discontinued?

A

32-34 weeks

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9
Q

Preferred 1st and 2nd line treatments for RA in pregnancy

A

Paracetamol and then steroids

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10
Q

When are parenteral steroids required in labour?

A

> 5mg/day for >3 weeks (some sources >7.5mg >2weeks)

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11
Q

Azathioprine in pregnancy?

A

Safe and can breast feed.

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12
Q

Hydroxychloroquine in pregnancy?

A

Safe and can breast feed.

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13
Q

Mycophenolate in pregnancy?

A

Teratogenic (cleft lip + palate, microbial with atresia external auditory canal, micrognathia, hypertelorism)

Need to switch 3/12 pre-conception

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14
Q

Penicillamine in pregnancy?

A

Stop if used for RA due to risk of congenital connective tissue abnormalities (needed to continue with Wilsons disease).

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15
Q

Sulfasalazine in pregnancy?

A

Safe to continue but DHFR inhibitor therefore need 5mg folic acid.

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16
Q

Cyclophosphamide in pregnancy?

A

Teratogenic. Stop 3/12 prior. 15% risk congenital abnormalities.

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17
Q

Methotrexate in pregnancy?

A

Teratogenic. Stop 3/12 prior. 15% risk congenital abnormalities.

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18
Q

Chlorambucil in pregnancy?

A

Teratogenic. Stop 3/12 prior. 15% risk congenital abnormalities.

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19
Q

Leflunomide in pregnancy?

A

Avoid pregnancy for 2 years afterwards.

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20
Q

Safe RA drugs in pregnancy

A 
Paracetamol
Steroids
(In certain situations NSAIDs)
Azathioprine, sulfasalazine, hydroxychloroquine.
Biologics.
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21
Q

Incidence of lupus

A

1 in 1000

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22
Q

Ethnic variation in lupus

A

Non-Caucasian more common

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23
Q

Percentage of women with lupus who have other autoimmune disorders

A

6%

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24
Q

Most common features of lupus

A 
Arthritis (90%)
Skin involvement (80%)
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25
Q

What blood test indicates active lupus?

A

Fall in C3/C4 levels by >25%

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26
Q

Which antibodies are found in lupus?

A

96% anti-nuclear antibodies:

  • Most specific and predictive of lupus nephritis: anti-dsDNA and Smith (78%)
  • Anti-Ro/La (30%)
  • aPL (40%)
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27
Q

Course of lupus in pregnancy

A

Increased chance of flare (60%) which can occur at any stage of pregnancy but is more likely active disease in 6m before conception.

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28
Q

Effect of pregnancy on lupus nephritis

A

Doesn’t jeopardise renal function in long term.

30% risk of renal flare (significantly higher if active or recent flare nephritis - advise delay pregnancy 6m)

29
Q

Adverse pregnancy outcomes in lupus

A 
Miscarriage
IUFD
IUGR
PTB
PET
30
Q

What factors influence the adverse pregnancy outcomes in lupus?

A

Presence of renal involvement, hypertension, APLS and disease activity at the time of conception.

31
Q

Risks of PET and IUGR/PET in a lupus patient with renal involvement.

A

PET 25-30%

30% risk IUGR/PTB

32
Q

How should lupus flares be managed?

A

Steroids

33
Q

What to do with hydroxychloroquine in lupus in pregnancy

A

Continue as stopping may increase risk of flares

34
Q

What proportion of general population have anti-Ro/La antibodies?

A

<1%

35
Q

Risk of cutaneous neonatal lupus in patient with anti-Ro/La

A

5%

36
Q

Risk of congenital heart block in patient with anti-Ro/La

A

2%

37
Q

What increases the risk of developing a neonatal lupus syndrome?

A

Previous children affected (15% if one child, 50% if two children)

38
Q

How does cutaneous neonatal lupus present?

A
  • First 2 weeks of life
  • Erythematous lesions across face and scalp which are photosensitive and may appear after sun/phototherapy
  • Rash disappears over 4-6m
39
Q

How does congenital heart block present?

A
  • Appears in utero

- Detected due to fetal bradycardia and then echo confirms atrioventricular dissociation

40
Q

Mortality associated with congenital heart block

A

15-20% (in utero or early neonatal)

41
Q

Treatments for congenital heart block

A
  • None which reverse heart block

- Dexamethasone may reverse lesser degrees of heart block and prevent progression to complete HB

42
Q

What proportion of infants with congenital heart block need pacing in infancy?

A

50-60%

43
Q

What type of drug infliximab?

A

anti-TNF

44
Q

What type of drug etanercept?

A

anti-TNF

45
Q

What type of drug adalimumab?

A

anti-TNF

46
Q

What type of drug golimumab?

A

anti-TNF

47
Q

What type of drug certolizumab?

A

anti-TNF

48
Q

What type of drug anakinra?

A

Anti-IL1

49
Q

What type of drug tociluzumab?

A

Anti-IL6

50
Q

What type of drug abatacept?

A

T cell modulator

51
Q

What type of drug rituximab?

A

B cell depleting agent

52
Q

What type of drug belimumab?

A

B cell depleting agent

53
Q

What should be screened for before starting anti-TNF agent?

A

Latent TB

Cervical smear

54
Q

Which vaccines should be avoided when on anti-TNF?

A 
Live vaccines:
BCG
MMR
Oral polio
Yellow fever
Rotavirus
55
Q

What to do if someone with latent TB needs anti-TNF?

A

Prophylaxis isoniazid + rifampicin

56
Q

Risk of immediate hypersensitivity reaction during first anti-TNF infusion?

A

3-5%

57
Q

Which type of reaction to anti-TNF is common?

A

Type alpha reactions - fever, headaches, myalgia (cytokine mediated)

58
Q

Risk of anti-TNF on congenital malformations

A

None!

59
Q

Which anti-TNF agents are actively transported across placenta?

A

Infliximab
Etanercept
Adalimumab
Golimumab

60
Q

When should infliximab be stopped in pregnancy?

A

16 weeks

61
Q

When should etanercept be stopped in pregnancy?

A

28 weeks

62
Q

When should adalimumab be stopped in pregnancy?

A

28 weeks

63
Q

When should certolizumab be stopped in pregnancy?

A

Doesn’t need to be :)

64
Q

When can you restart anti-TNF agents after pregnancy?

A

Immediately but allow a few days if CS wound or perineal wound to reduce risk infection.

65
Q

Breastfeeding with anti-TNF

A

Yes

66
Q

Risk to neonate if receive anti-TNF later than advised in pregnancy

A

High neonatal levels with risk of infection.
In particular risk of disseminated infection after live vaccination therefore live vaccines should be delayed 6 months if neonate exposed after the suggested gestation.

67
Q

Adverse effects of B cell depleting agents

A

Cause transient cytopenias and neonatal B cell depletion that can persist up to 6 months

68
Q

How long to avoid pregnancy after rituximab?

A

12 months

Laura MRCOG Part 2 (56 decks)

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