Intrapartum care w medical conditions

Question 1

Heart disease assessment

Answer 1

• Hx and examination
• Modified WHO classification
• NYHA class

Question 2

Mechanical valves anti-coag AN

Answer 2

• Discuss anti-coag- switch to LMWH
• If taking warfarin- change to LMWH at 36w
• Stop warfarin, 24h later start LMWH- BD doses by wt
• Check anti Xa levels (Peak- 1-1.2, pre-dose >0.6) and ajust dose

Question 3

AN care- heart disease

Answer 3

• Joint care
• Plan for MOD- including emergency plan if pt presents in labour w booked CS
• Plan fluid balance

Question 4

MOD plan

Answer 4

Consider CS for:
- Mechanical valves
- Aortic disease
- Pulmonary HTN
- NYHA class III or IV

Question 5

Labour w anti-coag

Answer 5

• Decide when to stop LMWH
• Think about heparin
• Reassess need for LMWH every 12h

Question 6

Warfarin in labour

Answer 6

• Check INR
• Contact heam cons
• Obs rv in 2h and discuss MOD + anti coag

Question 7

PN plan for mechanical valves

Answer 7

• PN obs +anaesthetic rv in 3-4h after birth
• Aim to restart LMWH at 4-6h PN

Question 8

Warfarin PN

Answer 8

• Consider delaying restart to 7 days PN

Question 9

Close fluid balance in labour

Answer 9

• Esp if class IV NYHA, Fontan circulation, Pulmonary arterial HTN, cardiomyopathy, severe Lsided stenosis
• Hourly input output
• Cont ECG + sats
• Arterial BP monitoring

Question 10

Heart failur symptoms

Answer 10

• SOB when lying down
• unexplained cough w pink sputum
• Paroxysmal nocturnal dyspnoea
• Palpitations

Question 11

HF signs

Answer 11

• HR>110
• RR >20
• Hypotension
• Sats <95%
• Elevated JVP
• Murmur
• Red air entry/crackles

Question 12

HF mx

Answer 12

• Cannula
• Bloods- FBC, U+E, ABG, BNP
• ECG
• CXR
• ECHO
• Cardio rv

Question 13

Anaesthetic for heart disease

Answer 13

• WHO 1/2- Normal advise
• WHO 3/4- Regional unless contraindicated
• Lower dose - less cardiac instability
• Arterial BP monitoring

Question 14

LMWH + regional

Answer 14

• Wait 12h after prophylactic dose
• Wait 24h after treatment dose
• Once regional removed, wait 4h to give LMWH

Question 15

3rd stage w heart disease

Answer 15

• First line- oxytocin
• 2nd line- Misoprostol/carboprost

Question 16

Women w asthma - care

Answer 16

• Same AN care
• Avoid carboprost in PPH due to bronchospasm

Question 17

Steroids in Asthma

Answer 17

If on 5mg or > for >3w:

• Labour:
  Give 50mg IM hydrocortisone every 6h from first stage to 6h PN
• CS:
  100mg hydrocortisone IV
  or 50mg if had in labour

Question 18

ITP care in labour

Answer 18

• Deliver on LW
• Check plt on admission in labour

Question 19

Plt count and mx

Answer 19

Plt >80- treat as normal
Plt 50-80- Consider regional, rv hx
Plts <50- GA, avoid regional

Question 20

ITP- baby care

Answer 20

• Treat as it has a bleeding risk
• No ventouse/FBS/FSE
• No mid cavity/rotational forceps
• Check plts in cord blood

Question 21

ITP risks in labour

Answer 21

• Inc risk of PPH
• Active 3rd stage - give IV not IM drugs

Question 22

Sub-arch bleed/AV malformations MOD

Answer 22

• MDT discussion

Question 23

Sub-arch bleed/AV malformations Low risk if

Answer 23

• Fully treated AV mal
• ICB of unknown cause >2years ago

Question 24

Sub-arch bleed/AV malformations high risk if

Answer 24

• Complex/ Untreated/partially rx AV malformation
• Large aneursym 7mm>
• Cavernoma
• ICB in last 2 years

Offer CS

Question 25

Sub-arch bleed/AV malformations if decline CS/ in 2nd stage

Answer 25

• Offer regional anaesthetic
• Offer assisted birth vs active pushing

Question 26

CKD/AKI mx in labour

Answer 26

• Mat HR every 1h
• Every 4h- BP, RR +chest sounds, fluid balance, Sats
• U+E every 24h

Monitor all obs +fluid balance every 4h till 24h PN

Question 27

Timing of delivery

Answer 27

• CKD stage 1, stable U+E and PCR <300mg - obs discussion
• CKD S1 + PCR>300 or CKD 2-4 w stable U+E- IOL at 40w
• CKD 5 or 3b/4 w unstable U+E- Delivery at or < 34w, latest by 38w
• Kidney transplant- MDT discussion