General Flashcards
The CLASP Trial
- Journal/Author
- Objective
- Enrolment
- Primary outcome
- Findings
The Lancet 1994
Redman et.al.
Prospecitve, multicentre, double blind placebo control RCT
To reliably characterise the safety of LDA and to determine if Rx produces worthwhile effects in pregnancies considered at high risk of PET or IUGR.
9300 women, ’88-’92.
12-32 weeks
Clinician judged to ‘be at risk of PET’ enough for LDA to be contemplated > randomised to LDA or placebo.
> Prophylactic group (previous PET or IUGR, HTN, kidney dx, other RF)
> Rx group (symptoms or signs of PET or IUGR)
> > 60mg Aspirin or placebo from 12/40 to delivery
Primary:
- Proteinuric PET
- GA
- BW, and BW <20/40
- NON-SIG*
- 12% redn PET with proteinuria
- 1 day longer GA
- BW 32g heavier
- No increased bleeding risk (APH or abruption)
- No effect SB/NND/total mortality
Polyhydramnios - Causes
Maternal: - Diabetes Foetal: - Neurological impairment - GIT obstruction - Multiple gestation - Parvo infection - Other causes of high output heart failure e.g. foetomaternal haemorrhage or alloimmunisation - Aneuploidy Idiopathic
Heparin Induced Thombocytopaenia
5% of people on Heparin for >5/7
Usually develops within 5/7
Usually resolves after 7/7
Risk factors for VTE in Pregnancy and the Puerperium
> or = 3 consider AN prophylaxis; >= 2 consider 7/7 PN
- Previous VTE
- Thrombophilia
- Medical dx (heart, kidney, sickle, IVDU)
- > 35y
- BMI >30
- Parity >2
- Smoker
- Varicose veins
- Paraplegia
OBS - Multiple pregnancy
- PET
- CS
- OHSS
- IVF
- Prolonged labour or rotational delivery
- PPH > 1L
OTHER - Operation
- OHSS
- Hyperemesis
- Admission/immobility
- post part wound infection
- long distance travel
RR of VTE
- Non-preg
- LNG
- Gestodene
- Pregnancy
- Non=preg 5/100 000
- LNG RR 3
- Gesteodene RR 5
- Pregnancy RR 12
Contraindications for COCP (2 VTE risk)
- Current or previous VTE
- 1st degree relative w VTE < 45y
- Known thrombophilia
- Within the first 3/52 PP
- Immediately following T1/T2 TOP
- Smoking (within 1y) and >35y (20x risk)
Caution… - BMI > 35
- Superficial thrombophlebitis
- Immobilisation
- SLE
- 1/12 pre-op
Foetal risks of PD pregnancy
SB - at 41/40 RR 1.3 (0.1%), and 42/40 RR 2 Birth asphyxia Macrosomia IUGR Birth trauma - CPD, SD, #, BPI Mec asp Low apgars CP Early epilepsy
Maternal risks of PD pregnancy
CS/labour dystocia
3rd/4th degree tears
PPH
Failed VBAC
NNT PD IOL perinatal death
410
Cochrane PD IOL
- less CS
- fewer perinatal deaths
- less mec asp
Hannah et. al. NEJM 1992. IOL c.f. expectant mgt in PD preg.
Canadian multi centre RCT 3400 women >41/40, well, singleton IOL vs expectant (3x/wk CTG and AFI, kick counts) 1: PNM (underpowered) 2: MOD Findings: - more mech and foetal distress in expectant group - PNM not SS - less CS IOL (SS) - Similar rates of instrumental delivery
EDS = >13
PPV 62%
Neonates and SSRIs
Risk of ‘poor neonatal adaptation:
- poor sleep, irritability, hypoglycaemia
- 5-85%
- usually mild and self limiting
- resolve within 2/52
- 0.7% chance of seizure
Folate for prevention of NTD
RR 0.28
Causes of thrombocytopenia - Preg
- HELLP
- PET
- AFLP
- DIC
Causes of thrombocytopenia - Not pregnanct
Infection - malaria - HIV HUS Hypersplenism Spurious result Drugs - Heparin - Antiinflammatories - Antidepressants BM infiltration
Neonates affected by ITP
10-15% will have plt < 50
5% plt < 20
Rx ITP
Steroids
IVIG
RANZCOG 5 Principles of PPH
- Recognition
- Communication
- Resuscitation
- Monitoring and Ix
- Direct Rx
Anti D prophylaxis - reduction in alloimmunisation
1% to 0.3%
70% reduction
T1 indications for Anti-D
MC
TOP
Ectopic
CVS
T2/3 indictations for Anti-D
- ECV
- Abdo trauma
- APH
- Amnio/cordocentesis
Puerpeural psychosis - prevalence
0.1%
AN anxiety/depression
10%
PN anxiety/depression
16%
Post birth PTSD
2-3%
Breech - risk of DDH
Girl 12%
boy 2%
Timing of division of zygote in twins
DCDA 13 days
What ar the inherited thrombophilias?
Proteins: - Antithrombin III - Protein C - Protein S Genes: - Factor V Leidence (Activated protein C resistance) - Prothrombin gene mutation - Homozygote MTHFR``
What are the acquired thrombophilias?
Hyperhomocycteinaemia (no good evidence of increase in thrombotic disease)
Antiphospholipid syndrome
Platelet pathology
What is the baseline pregnancy risk of VTE?
1/1000
Why are 85% of DVTs in the L leg?
The iliac artery and ovarian artery cross over the iliac vein, thus compressing it. This does not occur on the R side.
Which 3 thrombophilias have the highest rate of VTE in pregnancy, and what is the relative risk?
Antithrombin 3 deficiency 5-20
Homozygote FVL 10-80
Homozygote prothrombin gene mutation 10-40
Compound heterozygote prothrombin gene mutation and FVL 10-100
