Liver and GI Flashcards

Question

Primary biliary cirrhosis

Answer 1

Usually presents with pruritis Raised ALP and GGT Diagnosis confirmed with anti-mitochondrial antibodies Pruritis may worsen in pregnancy, UCDA can be continued or added

Answer 2

If severe often infertile Liver disease may decompensate during pregnancy, therefore discourage pregnancy in women with severe impairment of hepatic function Bleeding from oesophageal varices is a rise if portal HTN, especially in second and third trimester - Stabilise on beta blockers, continue throughout pregnancy

Answer 3

Fertility may return to normal after transplant - Should have contraception arranged Postpone pregnancy for >18/12 to stabilise and reduce drugs post-op Usually on tacrolimus, prednisone and azathioprine - All safe in pregnancy 92% LBR Graft function and survival do not appear to be affected by pregnancy Increased risk of PET, IUGR, PTB, GDM

Answer 4

1/3 of women with gallstones become symptomatic when pregnancy Oestrogen ---> increased cholesterol production Pregnancy improves gallbladder contractility --> forms sludge and gallstones Gallstones are more common in multip Acute cholecystitis occurs in 0.1% of pregnancies ``` Management - As for non-pregnancy - Conservative management - NBM, NG, IVF, antibiotics, analgesia (resolution in 3/4) - Surgery best done in second trimester ERCP - risk of pancreatitis ```

Answer 5

Unknown, likely multifactorial Primarily thought to be a/w rising levels of hCG - Conditions with higher levels of hCG a/w increased severity of NVP - Also HCG peaks in the first trimester when HG is normally seen - However high HCG levels are not consistently a/w n/v Elevated serum concentrations of oestrogen and progesterone - Relax smooth muscle --> slow GI transit time, may alter gastric emptying - However these levels peak in third trimester when NVP or HG has usually resolved H. pylori may play a role in some women - H. pylori infection a/w increased likelihood of HG during pregnancy Genetic factors - increased risk of developing HG among relatives of women previously affected

Answer 6

SOMANZ – any nausea or vomiting 69% 1.1% Typically starts between 4th and 7th week Peaks ~9/40 Resolves by 20/40 in 90%

Answer 7

Nausea and vomiting of pregnancy (NVP) - Diagnose when onset of symptoms (nausea, vomiting, dry retching) in the first trimester and other causes of n/v excluded ``` Hyperemesis gravidarum (HG) - Nausea and/or vomiting caused by pregnancy leading to significant reduction of oral intake and weight loss of >5% compared with pre-pregnancy, with or without dehydration and/or electrolyte abnormalities ```

Answer 8

~50% of women who become pregnant are either overweight or obese BMI >30 pre-pregnancy or at booking visit

Answer 9

``` Miscarriage GDM Fetal congenital abnormalities Stillbirth PET - If BMI >35 Thromboembolism - Risk of PE > DVT Abnormalities in fetal growth Obstructive sleep apnoea Preterm birth Maternal death ```

Answer 10

``` IOL, prolonged labour and failure to progress Rate of instrumental delivery Failed instrumental delivery Shoulder dystocia Caesarean section - BMI >40 = 52% of CS Difficulties with fetal heart rate monitoring PPH Peripartum death ```

Answer 11

Difficulties with labour analgesia - Correct siting within the epidural space - Increased risk of dislodgement Use of GA Difficultly maintaining an adequate airway, failed intubation Increased risk of need for ICU care post-op Difficult IV access

Answer 12

Delayed wound healing and infection Thromboembolic disease Greater likelihood of needing support with breastfeeding establishment and continuation Postnatal depression - Up to 40% Long term neonatal consequences - Neonatal body composition - Infant weight gain - Obesity

Answer 13

Normal weight - 11.5 to 16kg Obese (includes all classes) - 5 to 9.1kg Losing weight during pregnancy is not recommended - Increased risk of low birth weight baby Low gestational weight gain is associated with: - PTB - Increased risk of SGA

Answer 14

Discuss impact of obesity on fertility and pregnancy outcomes Medications or surgery for weight management are not recommended around the time of conception High dose (5mg) folate is recommend if BMI >30 Address psychosocial concerns Offer contraception to allow time for weight optimisation Weight loss between pregnancies: - Reduces the risk of: stillbirth, hypertensive complications, fetal macrosomia - Increases the chances of successful VBAC

Answer 15

MDT Nutritional supplementation: - 5mg folic acid and 150mcg iodine - Obese women are at increased risk of iron and vitamin D deficiency Flu vaccination - increased risk of major maternal morbidity with influenza during pregnancy At subsequent follow up appointments check BP (with correct size cuff) and urinalysis Offer early OGTT, with repeat at 28/40 if the early test was normal Anaesthetic assessment Consider aspirin to lower risk of PET from 12/40 FHx PET, multiple pregnancy Consider VTE risk Ultrasound - Anatomy scan less accurate (fat --> scatter effect) - BMI>35 should have serial USS

Answer 16

Check guidelines for local unit - Ensure appropriate equipment available Less likely to have a successful VBAC - Operative and anaesthetic risks of emergency CS are higher Timing of birth - No universal consensus - Observational data comparing outcomes before and after a protocol of delivery by 40/40 found a significant reduction in the risk of CS for obese women IV line on admission to labour ward May need to confirm presentation with USS FSE for monitoring Active management 3rd stage Increased dose of IV antibiotics for CS (e.g. 3g cefazolin) Awareness of increased risk of shoulder dystocia and PPH Operating theatre staff need to be altered regarding increased weight (usually >120kg)

Answer 17

BMI >40 --> 50% wound infection Breastfeeding support Consider VTE prophylaxis Weight management postpartum Screen for post-natal depression Consider appropriate contraception

Answer 18

Should be on lifelong vitamin supplementation Referral to dietician, especially if malabsorptive surgery - may require additional supplementation during pregnancy - vitamin B12, iron, folate, vitamin D, calcium Avoid pregnancy for 12-24 months after surgery and during the initial weight loss phase Require closer monitoring of their nutritional status and fetal growth Current evidence suggests a positive outcome in reduction of maternal risks during pregnancy, such as GDM, but with an increase risk of FGR and stillbirth Can't have OGTT due to dumping syndrome - HbA1c - BSLs for 1 week

Answer 19

``` TOXOPLASMOSIS Wash hands after handing raw meet Cook meet well Do not empty cat's litter tray Wash hands after touching animals ``` LISTERIA Wash, cook, cover and chill all food Do not eat leftovers - Listeria can grow at low temp including fridge Avoid high risk foods - Soft and semi soft pasteurized cheese - Raw milk cheeses and yoghurts - Cold chicken and other processed meets - Prepared salads - Raw seafood - Raw eggs - Hummus and tahini

Answer 20

Typically starts between 4th and 7th week Peaks ~9/40 Resolves by 20/40 in 90% Typically get hyponatraemia, hypokalaemia, low serum urea, hypochloraemia, hypomagnesaemia, metabolic hypochloraemic alkalosis If severe, metabolic acidaemia may develop Measure TFTs in women with HG or NVP refractory to treatment, or those with Sx of thyrotoxicosis - If TSH

Answer 21

Wernicke's encephalopathy -Due to vitamin B1 (thiamine) deficiency - Potentially fatal - can be precipitated by IV dextrose Hyponatraemia - Both severe hyponatraemia and rapid reversal can --> central pontine demyelination Pyridoxine (vitamin B6) deficiency - Causes anaemia and peripheral neuropathy ``` Acute kidney injury Oesophageal rupture Rhabdomyolysis Mallory-Weiss tears Malnutrition PTSD Thrombosis ```

Answer 22

``` MDT IVF and fluid balance Thrombo-prophylaxis Vitamin supplementation - thiamine 100mg po OD - folic acid 5mg - Iodine 150mcg - pyridoxine ``` Acid suppression - omeprazole Psychosocial support Manage/prevent constipation

Answer 23

1st Antihistamines (H1 receptor antagonists) - Cyclizine, Promethazine - decreasing stimulation of the vomiting centre Side effects: sedation, anti-cholinergic effects Prochlorperazine - Central and peripheral dopamine antagonists - Chance of extrapyramidal side effects, oculogyric crises 2nd Metoclopramide - Dopamine and serotonin receptor antagonist - Equal to ondansetron for nausea, but less effective for vomiting - Chance of extrapyramidal side effects Ondansetron - Serotonin receptor antagonists - Potentially a/w cleft palate, cardiac defects 3rd Steroids - Cochrane 2016 - no difference in days of hospital admission compared to placebo, but there was a decreased admission rate

Answer 24

Ginger ? Improves nausea but not vomiting - Ginger superior to placebo but less effective than metoclopramide Acupressure and acupuncture - Safe in pregnancy - Acupressure may improve NVP - Cochrane found no overall reduction in symptoms ``` Vitamin B6 (pyridoxine) - May improve nausea but not vomiting ```

Answer 25

Disease activity prior to conception - Remission >3/12 preconception --> good prognosis Hx of disease activity in previous pregnancy Crohn's tend to remit in pregnancy UC more likely to flare in pregnancy - In postpartum period flare is six times more common

Answer 26

Encourage to conceive when in remission Mycophenolate and methotrexate should be stopped/switched 3 months before trying to conceive. Sulphalazine (5mg folic acid) and Mesalalazine safe to use throughout pregnancy and breastfeeding. Azathioprine safe in pregnancy. anti-TNF agents i.e. infliximab have growing evidence of safety - Ideally stop in third trimester so baby can clear the drug prior to delivery - Babies should not have live vaccines until 6 months of age if mother on infliximab Correct any nutritional deficiencies due to malabsorption If symptoms deteriorate: - FBC, stool culture, CRP, flexible sigmoidoscopy - For flares of colonic disease use corticosteroid enemas or oral prednisone. Regular growth scans