General medical disorders

Question 1

Effects of pregnancy on CVS

Answer 1

40% increase in CO and blood volume (90% will have ejection systolic murmur due to increased blood flow)
50% drop in SVR
BP - initial drop, starts to rise in second trimester —> normal at term

Question 2

Pre-existing cardiac problems

Answer 2

Increased CO acts as ‘exercise test’

Manifests >28 weeks (particularly labour)
Decompensation with blood loss and fluid overload

Management:
Assessment before pregnancy - echo
Control HTN and fluid balance

Elective epidural analgesia - reduces afterload
Elective forceps - reduces stress of pushing

Question 3

Epilepsy

Answer 3

0.5% - seizure control reduced during pregnancy, esp. labour

Management:
lamotrigine and carbemazapine safest (avoid SV)
5mg folic acid
36 weeks - 10mg vit k orally

Question 4

Hypothyroid

Answer 4

1% pregnant women

Untreated –> miscarriage, preterm delivery, intellectual impairment of child

Management:
Thyroxine (TSH lowered in pregnancy so expect to increase dose)
TSH levels measured every 6 weeks

Question 5

Hyperthyroidism

Answer 5

0.2%
Antithyroid Ab can cross -placenta –> neonatal thyrotoxicosis

Poor control –> thyroid storm (+++ symptoms and HF), esp. near delivery date

Management: Propylthiouracil (PTU) instead of carbimazole

Question 6

Postpartum thyroiditis

Answer 6

5-10% (can cause postnatal depression)

RF: antithyroid Ab, DMTI

Subclinical hyperthyroidism - usually 3 months postpartum, then ~4 months hypothyroid (permanant in 20%)

Question 7

Acute fatty liver of pregnancy presentation

Answer 7

Acute hepatorenal failure, DIC and hypoglycaemia:

• Abdo pain
• N+V
• Jaundice
• Headache
• Fever
• Confusion or coma

Question 8

Investigations into acute fatty liver of pregnancy

Answer 8

FBC and film
LFT - ALT raised
Clotting
U+E
Urate
Blood gas

Question 9

Management of acute fatty liver of pregnancy?

Answer 9

ICU setting:
Treat hypoglycaemia
Correct coagulopathy with IV vit K and fresh frozen plasma
Delivery

Question 10

Intrahepatic cholestasis in pregnancy

Answer 10

0.7% pregnancies - more common in asians (1/3 have FH)
Occurs in 3rd trimester - resolves after pregnancy

Symptoms:
Pruritus without a rash (often worse at night)
Anorexia and malaise
Epigastric discomfort
Steatorrhoea and dark urine
Jaundice

Question 11

Investigations for obstetric cholestasis

Answer 11

LFTs - abnormal
Bloods - raised bilirubin and bile acids

USS of liver and biliary tree
Viral serology
Autoimmune screen

Question 12

Management of cholestasis?

Answer 12

Vit K supplementation
Ursodeoxycholic acid (UDCA) - reduces itching
Topical emolients
Foetal surveillance - USS and CTG

Question 13

Pregnancy specific causes of jaundice in pregnancy

Answer 13

Hyperemesis gravidarum
Pre-eclampsia/HELLP
Acute fatty liver
Obstetric cholestasis

Question 14

Affect of pregnancy on renal system?

Answer 14

Increase in eGFR (40%) –> decreased urea + creatinine

0.2% pregnant women - pregnancy not advised if creatinine is >200mmol/L

Question 15

Chronic renal disease complications

Answer 15

Dependant on HTN and renal function:

• Pre-eclampsia
• IUGR
• polyhydramnios
• preterm delivery

NB. Protein urea may lead to confusion with pre-eclampsia

Question 16

Management of CKD

Answer 16

USS for foetal growth
Measure renal function
Screen for urinary infection
Control HTN
vaginal delivery is appropriate

Question 17

Obesity comoplications

Answer 17

20% have BMI >30

Maternal:

• VTE
• Pre-eclampsia
• DM
• C-section
• Wound infections
• PPH

Foetal:

• NTD abnomailities
• Perinatal moratlity

Question 18

Management for obese patients

Answer 18

5mg folic acid
Vit D 
Screen for GDM and close BP monitoring
If BMI>40 - formal anaesthetic assessment
VTE prophylaxis

Question 19

Mental illness

Answer 19

Bipolar - 1%
Depression - 3% taking A/D (paroxetine not advised)
Schizophrenia - 1% (avoid clozapine and olanzapine)

Question 20

Lithium

Answer 20

Teratogenic but can be continued if required

Close monitoring of levels as pregnancy increases excretion

Question 21

Recreational drugs

Answer 21

Increased risk of STIs, HIV, HepC and maternal death

MDT and social support
- child may need care order

Cocaine and ecstasy = teratogenic

Question 22

Alcohol

Answer 22

Avoid in first 12 weeks

Foetal alcohol syndrome: IUGR, small/abnormal brain (>18 units a day)

Question 23

Tobacco

Answer 23

Increased risk of miscarriage, IUGR, preterm birth, placental abruption, stillbirth + SIDS

Encourage women to stop, at least cut-down
Nicotine replacement therapy
Pregnancy is considered high risk

Question 24

Medications for:

• N+V
• Epilepsy
• Hyperthyroid
• HTN
• UTI

Answer 24

N+V: prochlorperazine and cyclizine (st line oral), metaclopramide, domperidone, odeansatron

Epilepsy: lamotrigine, carbemazapine (CI = SV)

Hyperthyroid: Proplythiouracil (PTU) (CI = carbimazole)

HTN: labetalol, methyldopa, nifedepine (CI = AC Ei)

UTI: Nitrofurantoin 1st trimester (avoid at term), Trimethoprim after 1st trimester