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Haematology > Haematology 9 - Obstetric haematology > Flashcards

Haematology 9 - Obstetric haematology Flashcards

1
Q

What change in Hb concentration occurs in pregnancy and why?

A

Lower concentration (mild anaemia)
Red cell mass rises 125%
Plasma volume rises 150%
So [Hb] falls

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2
Q

By which trimester is dilution of plasma volume complete?

A

2nd trimester

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3
Q

What is the most common cause of anaemia in pregnancy?

A

Physiological rather than a deficiency

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4
Q

Why do you get macrocytosis in pregnancy?

A

Could be because of vitamin B12/folate deficiency

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5
Q

What change occurs in the neutrophil count in pregnancy?

A

You get a neutrophilia

**think of it as an imflammatory process**

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6
Q

How do platelets change in pregnancy?

A

Increase in size (but decrease in number)
Because of increased turnover–>increased number of immature platelets released into the circulation

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7
Q

What is the foetal and maternal requirement of iron in pregnancy?

A

300mg to foetus

500mg to mother for increased RBC production

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8
Q

Differentials of micrcocytic anaemia in pregnancy

A
  1. IDA
  2. Thalassaemia trait (haemoglobinopathy)
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9
Q

What is the RDA of iron in pregnancy?

A

30mg

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10
Q

Why is iron deficiency risky during pregnancy?

A

Risk of IUGR, post partum haemorrhage, prematurity

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11
Q

When do you consider iron supplementation in pregnancy?

What supplements exist and for how long do you need to take them?

A

If ferritin <30 ug/L

Supplements:
a) Ferrous sulphate

b) Pregaday
c) Pregnacare

**must continue for 3 months following correction of Hb

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12
Q

When is the folic acid supplement recommended in pregnancy?

A

400 ug (300ug more than normal): Before conception until 12 weeks gestation

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13
Q

What are the cutoffs for anaemia in each trimester of pregnancy?

A

1: <110g/l
2: <105g/l
3: <100g/l
*so Hb falls as you go through the pregnancy

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14
Q

What are the most important differentials in microcytic anaemia in pregnancy to consider?

A

IDA
Thalassaemia trait

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15
Q

What might cause thrombocytopaenia in pregnancy?

A
  1. Mostly gestational (physiological) thrombocytopaenia
  2. Pre-eclampsia (often causes DIC)
  3. Immune thrompocytopaenia (ITP) - this can be unmasked by pregnancy (but would be present already)

*difficult to distinguish b/w physiological and ITP*

  1. Microangiopathic syndromes
  2. All other causes: bone marrow failure, leukaemia, hyperplenism, DIC etc.
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16
Q

What platelet count is necessary for a woman to have spinal anaesthesia when giving birth?

A

>70x10^9/l

Below this there is a risk of spinal haematoma formation

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17
Q

WHat is the mechanism of physioogical trhombocytopaenia in pregnancy?

A

Unknown but could be because of

a) Dilution
b) Increased activation and consumption of platelets

**platelet count returns to normal day 2-5 after delivery

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18
Q

What is the mechanism of microangiopathic thrombocytopaenia in pregnancy?

A

Deposition of platelet rich thrombi within teh blood vessels

As the platelets are within the clots they don’t get counted in the blood count

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19
Q

Examples of microangiopathic syndromes in pregnancy

A

TTP

HUS

Pre-eclampsia

HELPP syndrome

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20
Q

Give 2 options for ITP treatment in pregnancy

A

IV immunoglobin

Steroids/azothioprine to immunosuppress

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21
Q

In which type of thrombocytopaenia in pregnancy can the baby be affected?

A

ITP

This is because IgG can cross the placenta

22
Q

What is the key feature of MAHA?

A

Deposition of platelet-rich clots in blood vessels (rather than fibrin-rich)

23
Q

What will be seen on a blood film of someone with MAHA?

A

Shistocytes (red cell fragments)

24
Q

Mechanism of thrombocytopaenia in pre-eclampsia

A
25
Q

How is DIC in pregnancy different to DIC otherwise?

A

In normal DIC you get prolonged PT/APTT because clotting factors are used up

IN pregnancy DIC- because clotting factors actually increase, you don’t get prolonged PT/APTT.

**thrombocytopaenia may be the only sign of DIC

26
Q

Why do you get prothrombotic state even though you have low platelets in pregnancy?

A

Because of the low quality of platelets- they are actually more likely to clot

27
Q

Which causes of thrombocytopaenia in pregnancy DO NOT RESOLVE after delivery?

A

TTP and HUS

All others i.e. gestational thrombocytoapenia, ITP and pre-eclampsia will resolve after delivery

28
Q

How does platelet count change post-delivery in gestational thrombocytopaenia vs ITP?

A

GT: increases 3-5 days post-delivery

ITP: remits after delivery

29
Q

What factors cause pro-coagulable state in pregnancy?

A

All elements of virchow’s triad are altered in pregnancy

a) Vessel wall injury- due to oestrogen
b) Hypercoagulable state- clotting factors increase, clotting inhibitors decrease
c) Stasis- decreased venous return to the heart

30
Q

When is risk of venous thromboembolism most likely in pregnancy?

A

6 weeks after pregnancy

31
Q

Where is venous thromboembolism most common in pregnancy?

A

Left leg

32
Q

Is venous thromboembolism more likely in vaginal birth or C section?

A

C section

More likely in emergency c-section than elective c-section

33
Q

What is the leading cause of mortality in pregnancy?

A

Venous thromboembolism

34
Q

What are the main changes to clotting factors during pregnancy?

A
35
Q

Why does pregnancy cause a hypofibrinolytic state?

A

Increase in PAI-2
PAI inhibits Urokinase and Tissue Plasminogen Activator which both promote fibrolysis
Therefore more PAI –> less fibrinolysis

36
Q

How do you investigate VTE in pregnancy?

A

Dopplers are the safest

37
Q

Why do you not do a D-dimer in pregnancy when there is suspected VTE?

A

Because it will be raised anyway

**weirdly, D-dimer is raised in pregnancy despite pregnancy being a hypofibrinolytic state

38
Q

Which anti-coagulant should never be used in pregnancy?

A

Warfarin (cross the placenta)

39
Q

What are the risk factors for VTE in pregnancy?

A
  1. gestation- most common 6 weeks post delivery
  2. increaeed maternal age
  3. parity
  4. multiple pregnancy
  5. obesity
  6. hyperemesis gravidarum
  7. ovarian hyperstimulation syndrome
  8. delivery method- operative delivery higher risk
  9. family history/personal history
  10. air travel
40
Q

VTE prophylaxis in pregnancy

A
41
Q

treatment of thromboembolic disease in pregnancy

A
42
Q

Complications of thrombophilia in pregnancy

A
43
Q

How does APLS present in pregnancy? How is it treated?

A
44
Q

Post-partum. haemorrhage

A

>500ml blood loss

RF: tone, tissue, trauma, thrombin

**mostly caused by uterine atony

*see O&G

45
Q

Pregnancy and DIC

A

Pregnancy preidposes to DIC

DIC is precipitated by:

a) amniotic fluid embolism
b) missed miscarriage
c) placental abruption
d) severe pre-eclampsia

46
Q

What is amniotic fluid embolism? When does it presesent?

A

Happens when tissue factor goes from amniotic fluid to the maternal blood and triggers DIC.

Usually happens in third trimester

Risk is increaeed with labour inducing drugs

47
Q

What is the point of haemoglobinopathy screening?

A

To identify alpha and beta zero thalassaemia, sickle cell and other compound syndromes (eg SC sickle cell anaemia)

48
Q

Which thalasseamia cannot be identified by HPLC?

A

Alpha 0 thalassaemia

Needs molecular diagnosis via DNA analysis

49
Q

When do you see pencil cells?

A

Iron deficiency anaemia

50
Q

How do you distinguish between HELPP syndrome and DIC?

A

HELPP syndrome: normal APTT and PT

DIC: increased APTT and PT

51
Q

summarise the main changes in haematology in pregnancy

A
52
Q

When does ITP happen compared to gestational thrombocytopaenia?

A

ITP- first trimester

Gestational thrombodytopaenia- 3rd trimester

Haematology (16 decks)

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