Disorders in pregnancy 3

Question 1

What are the common presentations of VTE in pregnant women?

Answer 1

PE: leading cause of maternal death (chest pain, dyspnoea, tachycardia, aside RR and JVP)
DVT: thromboses are more often iliofemoral and on the left (doppler examination and venogram or pelvic MRI are used)
Central venous thrombosis: particularly during the puerperium (headache and or stroke) imaging with MRI is best

Question 2

What is required before treatment with LMWH?

Answer 2

dosing is weight based and adjusted according to the anti-Factor Xa level
more is needed than in a non-pregnant women as clearance is rapid
if possible treatment is stopped shortly before labour, but restarted and continued into the puerperium

Question 3

Why isn’t warfarin used in pregnancy?

Answer 3

teratogenic and may cause foetal bleeding

both LMWH and warfarin can be used in breastfeeding women

Question 4

When is prophylaxis used for VTE?

Answer 4

• Antenatal prophylaxis: restricted to high risk women, previous VTE
Postpartum prophylaxis: if it has been used antenatally it is continued, or if there is a major or intermediate risk factor, or two or more minor risk factors- LMWH is prescribed for at least 10 days and can usually be given 12hrs after delivery

Question 5

What are the moderate risk factors for VTE?

Answer 5

BMI>30
Age >35 or parity >3
Smoker
Elective caesarean 
Varicose veins
Current infection 
Pre-eclampsia
Immobility
PPH
Rotational delivery 
Labour >24 hrs
1 WEEK LMEH IF 2+

Question 6

What are the intermediated risk factors for VTE?

Answer 6

Thrombophilia 
Caesarian in labour
BMI>40
Prolonged hospitalisation 
IV drug abuser
Medical illness
I WEEK LMWH IF 1+

Question 7

What are the high risk factors for VTE?

Answer 7

If used antenatally
Previous VTE
6 WEEKS LMWH

Question 8

What do obese women have a higher risk of?

Answer 8

o	Thromboembolism
o	Pre-eclampsia
o	Diabetes
o	C-section
o	Wound infection
o	Difficult surgery
o	Postpartum haemorrhage
o	Maternal death
Congenital abnormalities (NTD)

Question 9

What is the management for obesity in pregnancy?

Answer 9

• High dose folic acid (5mg) is recommended, as is vitamin D
screening for diabetes and closer BP surveillance are required
• A formal anaesthetic risk assessment and antenatal thromboprophylaxis are recommended if BMI ≥40
• There is an increasing trend towards elective C-section in very obese women

Question 10

What are the red flag signs that need referral for senior psychiatric assessment?

Answer 10

o Recent significant change in mental state
o Emergence of new symptoms
o New thought
o Acts of violent self-harm
o New & persistent expressions of incompetency as a mother
o Estrangement from the infant

Question 11

What is postpartum psychosis?

Answer 11

• Severe mental illness that can affect 1-2 in 1000 women
psychiatric emergency in early postnatal period
• There may be an acute risk of suicide, self-harm or neglect, neglect of the baby
intentional self-harm to the baby is rare

Question 12

What are the anxiety disorders that can present in pregnancy?

Answer 12

Incidence of OCD can increase in perinatal period
PTSD- triggered by traumatic experience during delivery
Tokophobia- fear of childbirth (indication for c-section in really severe
benzodiazepines are not recommended in pregnancy dur to risk of dependency, neonatal withdrawal and oversedation

Question 13

How do illegal drugs affect pregnancy and the foetus?

Answer 13

Opiates: not teratogenic, preterm, IUGR, stillbirth, developmental delay, SIDS. Methadone maintenance is advised, neonates can experience withdrawal
Cocaine: teratogenic, intellectual impairment, IUGR, placental abruption, preterm, stillbirth, SIDS
Ecstasy: teratogenic, cardiac defects and gastroschisis (pregnancy complications like cocaine)
Benzodiazepines: foetal clefts, neonatal hypotonia and withdraws symptoms
Cannabis: IUGR and affect development

Question 14

How does alcohol affect pregnancy?

Answer 14

10% admit to drinking more than 3 units a week- below this level there is no consistent evidence of harm- may cause miscarriage in the first 12 week
IUGR, birth defects, foetal alcohol syndrome
• Alcohol spectrum disorder (9 in 1000) encompasses lesser variants of the syndrome- USS may not detect the syndrome, but is used to monitor foetal growth

Question 15

How does smoking affect pregnancy?

Answer 15

o	Miscarriage
o	IUGR
o	Preterm birth
o	Placental abruption
o	Stillbirth
o	SIDS
o	Associated with a variety of childhood illnesses
•	Pre-eclampsia is less common, but more severe if it does occur

Question 16

How are iron levels affected in pregnancy?

Answer 16

• There is a 40% increase in blood volume in pregnancy: net fall in Hb concentration, such that the lower limit of normal is 11.0g/dL
• Iron and folic acid requirements increase- iron absorption increased threefold
• A high Hb level is associated with an increased risk of pregnancy complications (preterm and IUGR), possibly because it reflects low blood volume, as found in pre-eclampsia and because of its associated with smoking

Question 17

How does IDA present?

Answer 17

• Affects >10% of pregnant women
• Symptoms are usually absent unless the Hb is <9g/dL- the MCV reduces, but is often initially normal,
ferratin levels are reduced
• Treatment with oral iron, achieving an increase of up to 0.8g/dL/week, but can cause GI upset, in severe cases, IV iron is quicker and may prevent the need for blood transfusion

Question 18

What prophylaxis is used against anaemia?

Answer 18

• Iron is often poorly tolerated and routine supplementation is not universal, all women are given dietary advice and the Hb is checked at booking, 28 & 34 weeks
• Iron ± folic acid are given if the Hb is <11g/dL in the 1st and 3rd trimester and if <10.5g/dL in 2nd trimester
• In those with epilepsy, diabetes, obesity or previous history of NTD a higher dose of folic acid is given (5mg)-
normal dose in 0.4mg

Question 19

What is the management for influenza in pregnancy?

Answer 19

• Influenza accounted for 10% of all maternal deaths in the UK and US during 2009-10 swine flu
early use of Relenza (zanamivir) is recommended, with more severe or pre-existing chest disease, then Tamiflu (oseltamivir) is recommended
• ICU and extracorporeal membrane oxygenation (ECMO) may be required in severe cases
vaccination of pregnant women at any stage of pregnancy is strongly advised during winter months