Anaemia, VTE pregnancy,

Question 1

What is anaemia?

Answer 1

Defined as low concentration of haemoglobin blood

Question 2

When are women routinely screened for anaemia?

Answer 2

Twice during pregnancy
Booking clinic
28 weeks gestation

Question 3

What happens during pregnancy that causes anaemia?

Answer 3

During pregnancy, the plasma volume increases. This results in a reduction in the haemoglobin concentration. The blood is diluted due to the higher plasma volume.

Question 4

What are the S+S of anaemia in pregnancy?

Answer 4

Often anaemia in pregnancy is asymptomatic. Women may have:

Shortness of breath
Fatigue
Dizziness
Pallor

Question 5

What are the investigations for anaemia and normal ranges?

Answer 5

Time | Haemoglobin Concentration

Booking bloods| > 110 g/l

28 weeks gestation | > 105 g/l

Post partum |> 100 g/l

Question 6

How can the MCV indicate the cause of anaemia?

Answer 6

• Low MCV may indicate iron deficiency
• Normal MCV may indicate a physiological anaemia due to the increased plasma volume of pregnancy
• Raised MCV may indicate B12 or folate deficiency

Question 7

What are women offered at the clinic

Answer 7

Women are offered haemoglobinopathy screening at the booking clinic for thalassaemia (all women) and sickle cell disease (women at higher risk). Both are causes of significant anaemia in pregnancy.

Question 8

What is the management for iron deficiency in pregnant women?

Answer 8

Women with anaemia in pregnancy are started on iron replacement (e.g. ferrous sulphate 200mg three times daily). When women are not anaemic, but have a low ferritin (indicating low iron stores), they may be started on supplementary iron.

Question 9

What is the management for women with B12 deficiency in pregnant women?

Answer 9

The increased plasma volume and B12 requirements often result in a low B12 in pregnancy. Women with low B12 should be tested for pernicious anaemia (checking for intrinsic factor antibodies).

Advice should be sought from a haematologist regarding further investigations and treatment of low B12 in pregnancy. Treatment options for low B12 are:

Intramuscular hydroxocobalamin injections
Oral cyanocobalamin tablets

Question 10

Folate management in pregnancy?

Answer 10

All women should already be taking folic acid 400mcg per day. Women with folate deficiency are started on folic acid 5mg daily.

Question 11

Management for thalassaemia and SCA in pregnancy?

Answer 11

Women with a haemoglobinopathy will be managed jointly with a specialist haematologist. They require high dose folic acid (5mg), close monitoring and transfusions when required.

Question 12

What is VTE?

Answer 12

Venous thromboembolism is a common and potentially fatal condition. It involves blood clots (thrombosis) developing in the circulation. Thrombosis occurs as a result of stagnation of blood, and in hyper-coagulable states, such as pregnancy

Question 13

Features of VTE

Answer 13

• Risk increases with gestational age, reaching a maximum just after the birth
• The relative risk postpartum is five-fold higher compared to antepartum
• The absolute risk peaks in the first 3 weeks postpartum (22-fold increase in risk)
• This risk persists up to 6 weeks postpartum

Question 14

What are the RFs for a VTE in pregnancy?

Answer 14

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
Prev VTE
Anyone requiring antenatal LMWH

Question 15

When do the RCOG guidelines advise starting prophylaxis from?

Answer 15

28 weeks if there are three risk factors
First trimester if there are four or more of these risk factors

Question 16

What are the additional scenarios where prophylaxis is considered, even in absence of other RFs?

Answer 16

• Hospital admission
• Surgical procedures
• Previous VTE
• Medical conditions such as cancer or arthritis
• High-risk thrombophilias
• Ovarian hyperstimulation syndrome

Question 17

When should all pregnant women have a risk assessment for VTE?

Answer 17

At booking at 12 weeks
And after birth
Additionally if admitted to hospital, undergo a procedure, or develop significant immobility.

Question 18

What should women with increased risk of VTE receive for prophylaxis?

Answer 18

LMWH unless contraindicated
EG dalteparin, enoxaparin, tinzaparin

Question 19

When is prophylaxis started in patients?

Answer 19

Prophylaxis is started as soon as possible in very high risk patients and at 28 weeks in those at high risk. It is continued throughout the antenatal period and for six weeks postnatally.

Question 20

When is prophylaxis temporarily stopped?

Answer 20

woman goes into labour, and can be started immediately after delivery (except with postpartum haemorrhage, spinal anaesthesia and epidurals).

Question 21

When is mechanical prophylaxis considered?

Answer 21

in women with contraindications to LMWH. The options for mechanical prophylaxis are:

• Intermittent pneumatic compression with equipment that inflates and deflates to massage the legs
• Anti-embolic compression stockings

Question 22

What are S + S of DVT’s?

Answer 22

Unilateral (most of time)
Calf or leg swelling
Dilated superficial veins
Tenderness to the calf (particularly over the deep veins)
Oedema
Colour changes to the leg

Question 23

How do we examine the leg swelling?

Answer 23

To examine for leg swelling measure the circumference of the calf 10cm below the tibial tuberosity. More than 3cm difference between calves is significant.

Question 24

What are the S + S of PE?

Answer 24

Shortness of breath
Cough with or without blood (haemoptysis)
Pleuritic chest pain
Hypoxia
Tachycardia (this can be difficult to distinguish from the normal physiological changes in pregnancy)
Raised respiratory rate
Low-grade fever
Haemodynamic instability causing hypotension

Question 25

What are the investigations of VTE in pregnanc?

Answer 25

1st line Doppler US
2nd line - repeating negative US on day 3 and 7 in patients with a high index of suspicions for DVT
PE investigations - Chest X-ray + ECG
GS - CTPA or VQ scan

Question 26

What is a CTPA?

Answer 26

CT pulmonary angiogram involves a chest CT scan with an intravenous contrast that highlights the pulmonary arteries to demonstrate any blood clots. This is usually the first choice for investigating a pulmonary embolism, as it tends to be more readily available,

Question 27

What is a VQ scan?

Answer 27

Ventilation-perfusion (VQ) scan involves using radioactive isotopes and a gamma camera, to compare the ventilation with the perfusion of the lungs. First, the isotopes are inhaled to fill the lungs, and a picture is taken to demonstrate ventilation. Next, a contrast containing isotopes is injected, and a picture is taken to demonstrate perfusion. The two images are compared. With a pulmonary embolism, there will be a deficit in perfusion, as the thrombus blocks blood flow to the lung tissue. This area of lung tissue will be ventilated but not perfused.

Question 28

How do we choose between CTPA and VQ scan?

Answer 28

CTPA is the test for choice for patients with an abnormal chest xray
CTPA carries a higher risk of breast cancer for the mother (minimal absolute risk)
VQ scan carriers a higher risk of childhood cancer for the fetus (minimal absolute risk)

Question 29

Overall investigations for a VTE

Answer 29

Patients with a suspected deep vein thrombosis and pulmonary embolism should have a Doppler ultrasound initially, and if a DVT is present, they do not require a VQ scan or CTPA to confirm a PE. The treatment for DVT and PE are the same.

Question 30

What is the management for a VTE?

Answer 30

Management of venous thromboembolism in pregnancy is with low molecular weight heparin (LMWH). Examples of LMWH are enoxaparin, dalteparin and tinzaparin. The dose is based on the woman’s weight at the booking clinic, or from early pregnancy.

LMWH should be started immediately, before confirming the diagnosis in patients where DVT or PE is suspected and there is a delay in getting the scan. Treatment can be stopped when the investigations exclude the diagnosis.

When the diagnosis is confirmed, LMWH is continued for the remained of pregnancy, plus six weeks postnatally, or three months in total (whichever is longer). There is an option to switch to oral anticoagulation (e.g. warfarin or a DOAC) after delivery

Question 31

What do we do to pregnant women with a massive PE and haemodynamic compromise?

Answer 31

need immediate management by an experienced team of medical doctors, obstetricians, radiologists and others. This is a life-threatening scenario. Treatment options are:

• Unfractionated heparin
• Thrombolysis
• Surgical embolectomy

Question 32

What is a post-dural puncture headache

Answer 32

Accidental dural puncture rate 1/100-1/500 procedures
Leakage of CSF and reduced pressure in fluid around the brain

Question 33

Symptoms of post-dural headache

Answer 33

• Headache
• worse on sitting or standing
• Starts 1-7 days after spinal/epidural sited
• Neck stiffness
• Dislike of bright lights

Question 34

Treatment of post-dural headache

Answer 34

Lying flat!
Simple analgesia
Fluids and caffeine??
Epidural blood patch

Question 35

What is urinary retention?

Answer 35

The abrupt onset of aching or inability to completely micturate, requiring urinary catheterization, over 12 h after giving birth, OR
not to void spontaneously within 6 h of vaginal delivery

Inappropriate diagnosis can lead to bladder dysfunction, UTI and catheter-related complications

Question 36

RFs for urinary retention

Answer 36

Epidural analgesia
Prolonged second stage of labour
Forceps or ventouse delivery
Extensive perineal lacerations
Poor labour bladder care

Question 37

Treatment for urinary retention

Answer 37

Varies locally and aims to:
Maintain bladder function
Minimise the risk of damage to the urethra/bladder
Provide appropriate management strategies for women who have problems with bladder emptying
Prevent long term problems with bladder emptying

Question 38

Factors that make it difficult to detect Mental Health Disorders in the Puerperium?

Answer 38

Fear of treatment
Fear of children being removed
Lurching from day to day “just coping”
Stigma of mental illness
Cultural lack of recognition
Belief that health workers not interested
Denial by woman / partner / family
Lack of recognition of seriousness from health practitioners

Question 39

Features of postnatal depression

Answer 39

Postnatal depression - 10% of new mothers
Depressed
Irritable
Tired
Sleepless
Appetite changes
Negative thoughts
Anxiety
Affects bonding

Question 40

PTSD in the puerperium

Answer 40

Presentation:
Anger, low mood, self-blame, suicidal ideation, isolation and dissociation
Intrusive and distressing flashbacks
Consequences:
Women may delay or avoid future pregnancies
Request caesarean sections to avoid vaginal delivery
Avoidance of intimate physical relationships
Impact on breastfeeding

Question 41

RFs of PTSD in puerperium

Answer 41

3.1% full symptoms
33% show some symptoms
Risk factors:
Perceived lack of care
Poor communication
Perceived unsafe care
Perceived focus on outcome over experience of the mother

Question 42

ICD-MM definitions of maternal death

Answer 42

The death of a woman while pregnant or within 42days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

Question 43

Maternal death: Direct reasons

Answer 43

1 Pregnancy with abortive outcome
2 Hypertensive disorders in pregnancy, childbirth, and the puerperium
3 Obstetric haemorrhage
4 Pregnancy related infection
5 Other obstetric complications
6 Unanticipated complications of management
7 Non-obstetric complications