Mat Med Flashcards
MoD for women with heart disease - when to consider planned C/S?
- Any disease if the aorta assessed as high risk
- Pulmonary arterial hypertension
- NYHA class III or IV heart disease
WHO heart disease risk class III
III
- mechanical valve
- Fontan circulation
- cyanotic heart disease
- complex congenital heart disease
- Aortic dilatation 40-45mm in Marfans Syndrome
- Aortic dilatation 45-50mm in aortic disease associated with bicuspid aortic valve
WHO heart disease risk class IV:
** Extremely high risk of maternal mortality or severe morbidity; pregnancy contraindicated. If pregnancy occurs, discuss termination.
- pulmonary arterial hypertension (any cause)
- Severe systemic ventricular dysfunction (LVEF < 30%, NYHA III-IV)
- previous peripartum cardiomyopathy with any residual impairment of LVF
- severe symptomatic mitral or aortic stenosis
- Marfan syndrome with aorta > 45mm
- Aortic dilatation >50mm in aortic disease associated with bicuspid aortic valve
- native severe coarctation
New York Heart Association (NYHA) classification of heart failure:
I - no limitation of physical activity
II - slight limitation of physical activity
(Ordinary physical activity results in fatigue, palpitation, breathlessness or angina)
III - marked limitation of physical activity
(Comfortable at rest, less than ordinary activity will lead to symptoms)
IV - inability to carry out any physical activity without symptoms
When can you administer regional anaesthesia for patient taking:
1. Prophylactic LWMH
2. Therapeutic LMWH
- 12 hours after last dose
- 24 hours after last dose
What do you do with steroids in labour for women with primary adrenal insufficiency or taking long term steroids (5mg pred/day)?
- Continue regular steroids
AND
- When established in 1st stage of labour, add IV or IM hydrocortisone + consider minimum dose of 50mg every 6 hours until 6 hours after the baby is born.
What do you do with steroids for women having a planned or EmCS who have primary adrenal insufficiency or are on long term steroids?
- Continue regular oral steroids
- Give IV hydrocortisone when starting anaesthesia, the dose will depend on if the women received hydrocortisone in labour, for example:
a) consider giving 50mg if she has had hydrocortisone in labour
b) consider giving 100mg if she has not had hydrocortisone in labour
Give a further dose of hydrocortisone 6 hours after the baby is born (50mg IM or IV).
Risk of major congenital malformation in women who conceive on Sodium Valproate?
10% risk of major fetal congenital malformation.
No evidence to recommend earlier US than 20/40.
Odds of SGA fetus in medicated epileptic mum vs non medicated epileptic mum?
3.5x higher
Therefore offer growth scans 28, 32, 36 weeks to detect growth restriction.
Malaria:
1. Define uncomplicated and complicated
- Uncomplicated - <2% parasitised RBC’s in a women with no signs of severity and no complicating features
Complicated/Severe - >2% parasitised RBC’s with complicating features (resp distress, pulmonary oedema, hypoglycaemia, secondary gram negative sepsis)
Management of Uncomplicated Malaria:
a) P Falciparum or mixed
b) P vivax
c) P Ovale
d) P malariae
All patients should be admitted to Hospital.
a) P Falciparum or mixed - Quinine + Clindamycin
b) P vivax - Chlorquine
c) P Ovale - Chloroquine
d) P malariae - Chloroquine
Primaquine should not be used in Pregnancy.
Management of complicated malaria
All patients should be admitted to ICU.
All species - IV artesunate or IV quinine
Rubella:
1. Type of virus
2. Transmission
3. Incubation period
4. Infectious period
5. Congenital Rubella
- Togavirus, single stranded RNA genome
- Transmission by resp route
- Incubation period 12-23 days (average 14 days)
- Infectious 1 week before symptoms appear to 4 days after the onset of rash
- Congenital rubella tetratogenic with poor prognosis and significant complications (sensorineural deafness, cataracts, cardiac abnormalities)
Transient neonatal myasthenia gravis
- 20% of infants delivered by mothers with myasthenia gravis
- Caused by maternal antibodies crossing the placenta in the 2nd and 3rd trimesters
- Infants develop symptoms within 12 hours to 4 days after delivery
- Symptoms include: resp problems, muscle weakness, feeble cry, poor suckling, ptosis
- Symptoms resolve spontaneously after 3-4 weeks due to antibody degradation
Incidence of congenital rubella syndrome when contracted in or before 11th week of Pregnancy?
90%
(Rubella causes spontaneous abortion in the first trimester in about 20% of infected women)
Sensitivity of Amnio for diagnosis of fetal CMV infection?
75%
Amnio should not be performed for at least 6 weeks after maternal infection and not until 21/40.
Parvovirus
1. Incubation period
2. Infectivity period
3. Testing
4. Management
- Incubation period 7 days.
- Infectivity period is 7-10 days before the rash develops and 1 day after rash onset
- Parvovirus B19 IgG and IgM
IgG +ve / IgM -ve = immune
IgG -ve / IgM -ve = susceptible
Positive IgM = suggests recent infection
- Arrange urgent referral to FMU for serial fetal US scans and Doppler assessment to detect fetal anaemia, heart failure and hydrops
Parvovirus: risk of vertical transmission?
<15/40 - 15%
15-20 weeks - 25%
Term - 70%
Sickle cell disease: medication considerations
- Stop ACEi/ARB and hydroxycarbamide** pre conception
- Five influenza vaccine
- Folic acid 5mg daily
- Pneumococcal vaccine every 5 years
- Ensure on daily penicillin prophylaxis (Erythromycin if Pen Allergic)
- Aspirin 75mg daily from 12 weeks
- LMWH during hospital admissions
**Hydroxycarbamide has been demonstrated to decrease the incidence of acute painful crises and ACS in individuals with severe clinical manifestations of SCD.
Cervical length and risk of PTB @ 20-24/40.
1. < 25mm
2. < 20mm
- < 25mm - 25% risk of delivery before 28/40
- < 20mm - 42.4% risk of delivery before 32/40
<20mm - 62% risk of delivery before 34/40
Diabetes:
1. Target HbA1c pre conception
2. HbA1c where pregnancy strongly avoided
1.HbA1c < 48mmol/L (6.5%)
- Avoid pregnancy if HbA1c > 86 mmol/L
Incidence of diabetes insipidus?
2-4/100,000
Usually arises 3rd trimester and remits spontaneously 4-6 weeks PP
Diabetes Insipidus - clinical findings ?
- Polydipsia and dilute polyuria
- True polydipsia (drinking > 3L per day) and polyuria (passing > 3L urine per day)
Conditions causing hepatic dysfunction such as HELLP may cause DI to develop.
Diabetes Insipidus: classification
- Neurogenic - CNS pathology, ADH deficiency as reduced production by hypothalamus/post pituitary
- Nephrogenic - Reduced sensitivity of Kidneys to ADH
- Gestational - Transient deficiency ADH
- Psychogenic - Excessive water consumption
Gest HTN in previous pregnancy - risk of hypertensive disorders in future pregnancies?
- Gest HTN
- PET
- Any hypertensive disease
- Gest HTN - 11-15%
- PET - 7%
- Any hypertensive disease - 22%
AFLP
1. Aetiology
2. Incidence
3. Complication
Rare obstetric emergency.
- Deficient LCHAD leading to accumulation of medium and long chain fatty acids
- 5 cases per 100,000 in the UK
- AKI is a common complication. 14% of patients develop renal impairment. 3.5% require dialysis.
T1DM, pre pregnancy:
1. Blood glucose targets
2. HbA1c targets
- Fasting glucose 5-7mmol/L
Plasma glucose 4-7mmol/L before meals - Aim HbA1c < 48mmol/L (6.5%)
Avoid pregnancy if HbA1c > 86mmol/L (10%)
What are:
1. Aspart
2. Lispio
Rapid acting insulin analogues.
- Aspart - Novorapid
- Lispro - Humalog
Long acting insulin in Pregnancy recommendations.
- Use ISOPHANE INSULIN as first choice (Humilin I, Insulatard)
- Use long acting INSULIN ANALOGUES for women with diabetes who have established good blood glucose control before Pregnancy.
-> insulin glargine: Lantus, Toujeo
-> insulin detemir: Levemir
Consider referral to nephrologist in women with diabetes before stopping contraception, if:
- Serum creat > 120mmol/L
- Urine ACR > 30mmol/L
- eGFR < 45
GDM Risk Factors:
- BMI > 30
- Prev GDM
- Prev macrosomic baby > 4.5kg
- 1st degree relative with DM
- Ethnicity
Glycosuria detected by routine antenatal testing;
Consider further testing to exclude GDM in women who have the following:
- Glycosuria of 2+ or above on 1 occasion
- Glycosuria of 1+ or above on 2 or more occasions
At time of diagnosis for GDM;
1. If fasting < 7mmol/L
2. If fasting > 7mmol/L
3. If fasting 6.0 - 6.9mmol/L + macrosomia/poly
- Trial of diet/exercise for 1-2 weeks. If targets not met, add MF. If targets not met with MF, add insulin.
- Immediate insulin, with or without MF. Diet + exercise too.
- Consider, immediate insulin, with or without MF. Diet + exercise.
Frequency of blood sugar testing in T1DM.
- Fasting
- Pre meal and 1 hour post meal
- Bed time
Blood sugar testing in T2DM or GDM:
1. Multiple daily insulin
2. Diet/MF/Single intermediate or long acting insulin dose
- Fasting, pre meal, 1 Hr post meal and bed time
- Fasting, 1 hour post meal
Target blood glucose levels in Pregnancy;
- Fasting < 5.3
- Post meal < 7.8
Advise all women taking insulin to aim for fasting > 4mmol/L.
Pre Existing diabetes- retinal assessment following 1st antenatal clinic apt
- Offer retinal assessment with digital imaging with mydriasis using tropicamide (unless assessment in the last 3 months)
- If diabetic retinopathy- offer additional assessment at 16-20/40.
- Offer another retinal assessment @ 28/40.
Diabetic retinopathy NOT a CI for Vaginal Birth.
Renal assessment during pregnancy in women with pre existing diabetes:
- Refer to nephrologist if:
a) serum creat > 120
b) Urine ACR > 30
c) Total protein excretion exceeds 0.5g/day
Do NOT use eGFR to measure kidney function in Pregnancy.
Consider thromboprophylaxis if nephrotic range proteinuria > 5g/day (urine ACR > 220mg/mmol).
Postnatal fasting plasma glucose:
1. <6mmol/L
2. 6 - 6.9 mmol/L
3. > 7mmol/L
- < 6mmol/L
- low probability of having T2DM
- need annual test to check blood glucose levels
- moderate risk of developing T2DM long term - 6 - 6.9 mmol/L
- High risk of developing T2DM - > 7mmol/L
- likely to have T2DM and offer test to confirm this
Postnatal HbA1c
1. <39
2. 39 - 47
3. > 48
- <39mmol/mol
- low probability of current diabetes
- annual glucose check
- moderate risk of developing T2DM - 39 - 47mmol/mol
- high risk of developing T2DM - > 48mmol/mol
- diagnostic of T2DM and refer for further care
What % of women diagnosed with GDM in Pregnancy willl develop T2DM within 5 years from Birth?
50%
Prevalence of Epilepsy?
Proportion of these women of reproductive age?
0.5 - 1%
1/3 of these women are of reproductive age
Conditions to be considered to ‘no longer have epilepsy’ ?
- Seizure free for 10 years and off AED’s for 5 years
- History of childhood epilepsy in those who have reached adulthood seizure free and treatment free
At what GA do placental changes prevent significant passage of maternal thyroxine across the placenta?
Prior to 12/40, maternal thyroxine (fT4 not fT3) crosses the placenta.
From 12/40 placental changed prevent significant passage of maternal thyroxine and fetal thyroid function becomes independently controlled from the mother.
Incidence of Hyperthyroidism in Pregnancy?
2/1000
Haemophilia A inheritance
X linked genetic condition - clotting factor VIII deficiency
HIV and MoD:
1. < 50 copies
2. 50-399 copies
3. > 400 copies
- Vaginal Delivery
- PLCS considered. Take into account viral load, trajectory, length of time on treatment, adherence.
- PLCS
Hepatic Adenoma:
1. Risk of haemorrhage
2. Risk of rupture
3. Risk of malignant transformation
- Haemorrhage: 27%
- Rupture: 17%
- Malignant Transformation: 5%
When should pharmacological thromboprophylaxis be avoided postpartum in carriers of Haemophilia?
When factor level is 0.6iu/ml or below.
Pharmacological methods of raising factor levels are Txa, DDAVP and recombinant factor VIII/IX.
What % of Myaesthenia Gravis have worsening symptoms during Pregnancy?
40%
Hepatic Adenoma, risk of:
1. Haemorrhage
2. Rupture with intraperitoneal bleeding
3. Risk of malignant transformation
- Haemorrhage: 27%
- Rupture: 17%
- Malignant Transformation: 5%
First line treatment for Myaesthenia Gravis in Pregnancy?
Pyridostigmine - acetylcholine esterase inhibitor
Does not cross the placenta.
Ok if BF.
Sodium Valproate is associated with which congenital malformations?
- Neural tube defects
- Facial cleft
- Hypospadias
Congenital malformations associated with phenytoin and phenobarbital?
Cardiac malformations
Phenytoin + carbamazepine - cleft palate
Risk of congenital malformation for WWE, not on treatment compared to background population risk?
2.8% vs 2.3% background risk
Risk of congenital malformation in those taking Sodium Valproate?
10%
Risk of congenital malformation in WWE taking AED poly therapy?
16.8%
Risk of recurrence of major congenital malformation in WWE with a previous child with major congenital malformation?
16.8%
There was no significant association between epilepsy type and tonic-clonic seizures in the first trimester and major congenital malformations.
Effect of pregnancy on seizures in WWE?
67% do not experience a seizure in pregnancy.
The seizure free duration is the most important factor in assessing the risk of seizure deterioration.
In women who were seizure free for at least 9 months to 1 year prior to Pregnancy, 74-92% continued to be seizure free in Pregnancy.
Risk of tonic clinic seizure in labour ?
1-2%
And a further 1-2% within 24 hours of delivery.
When is prophylactic clobazam considered Intrapartum for WWE?
- Recent convulsive seizures
- Recent history of seizure provocation by stress or sleep deprivation
- History of seizures in a previous labour
The risks of clobazam, such as resp depression in the newborn need to be balanced agains the benefit due to seizure prevention.
Risk of seizure lasting > 5mins in labour ?
1% of pregnancies in WWE.
Optimal management of status epilepticus in labour?
- IV Access
- IV Lorazepam 0.1mg/kg (4mg bolus with a further dose after 10-20 minutes)
- IV Diazepam 5-10mg slow infusion is an alternative - No IV Access
- Rectal diazepam 10-20mg repeated once 15 mins later if there is continued risk of status epilepticus
- Midazolam 10mg as a buccal preparation is suitable
Postpartum management of WWE?
When is period of maximal
Seizure exacerbation?
- 3 day postpartum period
- If AED dose was increased in pregnancy, review within 10/7 to avoid AED toxicity (drowsiness, Diplopia, unsteadiness)
- Risk of adverse cognitive outcomes is not increased in children exposed to AEDs through breast milk
Risk of PP depression in WWE compared to those without?
29% vs 11%
What causes subfertility in women with B thalassaemia?
Fertility may be reduced in transfusion dependent individuals where iron chelation has been suboptimal and iron overload has occurred resulting in damage to the anterior pituitary.
This can cause hypogonadotrophic hypogonadism and therefore individuals may require ovulation induction to achieve a pregnancy.
Safety data re iron chelation therapy in those with Thalassaemia?
- Avoid in first trimester - regard as tetratogenic due to lack of safety data
- Desferrioxamine is the only chelation agent with a body of evidence for use in 2nd and 3rd trimesters.
How to monitor diabetic control
Preconceptually in women with Thalasseamia?
Aim serum fructosamine < 300 mmol/L for at least 3/12 prior to conception.
Equivalent to HbA1c 43
Aim for liver iron in thalasseamia patients pre conception?
< 7mg/g (dry weight)
Recommended because iron chelation is stopped during pregnancy and therefore transfusional iron burden and the risk of iron overload complications increases.
Recommended management if liver iron exceeds 15mg/g (dry weight) prior to conception?
Iron chelation with low dose desferrioxamine should be commenced between 20 - 28/40 under guidance from haemoglobinopathy team.
Incidence of alloimmunity in patients with thalassaemia?
16.8%
Immunisation and antibiotic prophylaxis in women with thalassaemia ?
- Hep B vaccine recommended
- Determine Hep C status
- If Splenectomy:
- ensure penicillin prophylaxis
- vaccinate for pneumococcus and H Influenzae B
Antenatal appointments and US schedule in women with Thalassaemia?
Every 4 weeks until 28/40, then 2 weekly thereafter.
- early scan 7-9/40
- first trimester scan
- anomaly scan
- 4 weekly biometry from 24/40
Antenatal thromboprophylaxis recommendations in women with Thalassaemia?
- Splenectomy OR plt count > 600 = take low dose aspirin
- Splenectomy AND plt count > 600 = prophylactic LMWH + Aspirin
- Women with thalassaemia who are not already using LMWH should be advised to use it during Hospital admissions.
Intrapartum care for women with Thalassaemia considerations?
- If red cell antibodies, ensure C match
- In women with Thalassaemia major, IV desferroxamine 2g over 24 hours should be administered for the duration of labour
- CEFM
- Active mgmt 3rd stage
Drug of choice for malaria prophylaxis in Pregnancy?
Mefloquine (5mg/kg once a week) in 2nd and 3rd trimesters.
Very few areas in the world free from Chloroquine resistance.
Cautions:
Epilepsy
Neuropsychiatric disorders
Previous depression
Hypersensitivity to Mefloquine
Classify severity of Haemophilia by factor plasma concentration:
1. Severe haemophilia
2. Moderate haemophilia
3. Mild haemophilia
- Severe - factor conc < 0.01
- Moderate - factor conc 0.01 - 0.05
- Mild - factor conc 0.06 - 0.40
Neonate (male) with Haemophilia.
Risk of:
1. Intracranial Haemorrhage
2. Extra cranial Haemorrhage
- ICH - 2.5%
- ECH - 3.7%
Maternal Haemophilia Carrier:
- Target factor VIII/IX to cover surgical or invasive procedures or spontaneous miscarriage ?
- Target factor VIII/IX if treatment is required ?
- Aim above 0.5
- Aim above 1.0 and ensure do not fall below 0.5 until haemostasis is secure
Haemophilia - how to optimise factor VIII/IX levels?
- Txa - consider in combination with treatment for those with levels < 0.5 or as sole therapy for those with levels > 0.5 if clinically indicated.
- Desmopressin - can be used antenatally to increase factor VIII levels. (Due to antidiuretic effect, fluids should be restricted to 1L for 24 hours after use)
- Recombinant Factor VII - should be used if levels obtained with DDAVP insufficient or in a known nonresponder.
- Recombinant factor IX - required to cover invasive of surgical procedures in women with factor levels < 0.5
Haemophilia.
What happens to factor VIII and factor IX in pregnancy?
- Factor VIII rises
- Factor IX tends to remain stable
Von Willebrand Disease
- Type 1
- Type 2
- Type 3
- Type 1 - partial quantitative, deficiency of VWF
- Type 2 - qualitative, dominant inheritance, thrombocytopaenia may be exacerbated in pregnancy
- Type 3 - quantitative, virtually absent VWF, significant lower factor VIII levels, recessive inheritance, consanguinity
Von Willebrand Disease, increased risk of:
1. APH
2. Primary PPH
3. Secondary PPH
4. Blood transfusion
5. Mortality
- APH increased 10 fold
- Primary PPH occurs in 15-30% of women
- Secondary PPH occurs in 25% of women
- Need for transfusion increases 5 fold
- Mortality increased 10 fold
Bernard Soulier Syndrome.
- What is the aetiology?
- What is the inheritance?
- What are the maternal risks?
- Management of labour/delivery
- Genetic abnormality of an important platelet adhesion receptor, often associated with a severe bleeding phenotype.
- Autosomal recessive
- Primary PPH, secondary PPH, wound haematoma.
- Plt transfusion prophylactically at delivery or before LSCS, in combination with Txa. (Plts should be HLA matched to reduce alloimmunisation).
- Txa should be given at onset of labour and continued regularly until lochia is minimal.
- DDAVP has variable efficacy and is unlikely to be useful as sole therapy in BSS.
- central neuraxial anaesthesia should be avoided
Glanzmann’s Thrombastenia (GT)
- Aetiology
- Maternal risks
- Fetal risks
- Treatment options
- Disorder of plt function with autosomal recessive inheritance and often associated with severe bleeding tendency
- Intrapartum and PPH. HLA matched plt transfusion and /or recombinant factor VIII should be given prophylactically at delivery.
- DDAVP not effective
- Txa at onset of labour and continued PP
- avoid central nauraxial anaesthesia - Maternal alloimmunisation to paternally derived fetal plt antigens May cause fetal thrombocytopaenia and risk ICH and other fetal bleeding
- Monitor women for Plt specific antibodies at booking, 28 and 34 weeks
Sickle Cell Disease - pre conceptual assessment for chronic disease complications include..
- Screen for pulmonary HTN - ECHO
- BP + Urine - HTN and proteinuria, check U&E and LFT annually to exclude SC nephropathy or deranged hepatic function.
- Retinal screening - proliferative retinopathy is common.
- Screen for Iron Overload - T2 cardiac MRI in those who have received multiple transfusions. Aggressive iron chelation pre conceptually if high iron
- Screening for red cell antibodies - risk of HDFN
75% of cases of Malaria are causes by..
P. Falciparum
Lab Test abnormalities in Malaria?
- Severe anaemia (Hb < 80)
- Thrombocytopaenia
- Hypoglycaemia (BGL < 2.2)
- Acidosis
- Renal impairment
- Inc Lactate
- ‘Algid Malaria’ - gram -ve septicaemia
- Hyperparasitaemia (>2% parasitised RBC’s)
- LP to exclude meningitis
Asthma complicates what proportion of pregnancies?
10%
Asthma in Pregnancy - cautions
- Very small associated with cleft palate if oral steroids used in 1st trimester.
- Avoid Carboprost - prostaglandin F2 alpha, associated with bronchoconstriction
- Anti IgE not recommended in Pregnancy
Veno-Venous ECMO
Blood drained from a vein and returned to a vein. Supports the right ventricle by reducing preload.
Used in SEVERE RESPIRATORY FAILURE eg. ARDS, asthma, pneumonia.
This ECMO does not support systemic circulation.
Veno-Arterial ECMO.
Blood is drained from a vein and returned to an artery.
Supports both CVS and respiratory system.
Used for cardiac failure eg. MI or myocarditis. Acute PE leading indication for cardiac ECMO.
When to consider and recommend ECMO?
Consider if mortality > 50%
Recommend if mortality > 80%
Maternal and neonatal survival following ECMO?
Maternal > 75%
Neonatal 65 - 100%
Fetal monitoring during maternal ECMO?
Below viability - IA
Some case series monitor fetal growth and wellbeing.
Main reason for delivery is to improve maternal condition.
Maintain L lateral tilt.
Development of PET on ECMO?
Should prompt delivery.
If aiming to deliver, up to 6 hours off anticoagulation is deemed safe.
Commonest cause of MI in Pregnancy?
Hypertriglyceridaemia
By what % do cholesterol/lipids naturally increase by in Pregnancy?
Approx 50%
To meet fetal needs but will fall back to normal 72hrs PP.
How much to triglycerides increase by in Pregnancy?
2 - 4x
Risks associated with Hypertriglyceridaemia in Pregnancy?
- PET (2 fold increase)
- GDM (TG levels are the strongest predictor of fetal weight in GDM pregnancies)
- LGA (19%)
- Acute Pancreatitis (58% of pancreatitis in pregnancy. Risk increases progressively with increased levels of TG)
How to treat Hypertriglyceridaemia in Pregnancy?
- Dietary change
- Omega 3 (4g/day)
- Cholestyramine (NOT in women with high TGs)
- Fibrates (only from 2nd trimester if TGs > 5.6)
- IV insulin/dextrose can be used to rapidly reduce TGs or TG associated pancreatitis.
Statins and plasmapheresis should only be used when needed to dramatically decrease levels. Should be stopped when levels < 11.3.
Moderate Hypertriglyceridaemia.
Severe Hypertriglyceridaemia.
Moderate: TG 5.6 - 11.3
5% risk of Pancreatitis
Severe: TG > 11.4
Typically occurs in 3rd trim
10% risk of pancreatitis
TGs > 22.6 = 20% risk of pancreatitis
Risks if TB in Pregnancy?
- PTB
- Miscarriage/IUD
- Anaemia
- SGA
- HTN
- GDM
- PPROM
- Cholestasis
Treatment of TB in Pregnancy?
- Treat with RIPE for 2 months
- Then just RI (Rifampicin and Isoniazid) for 4 months
- If CNS involvement, continue RI for 10 months.
Treatment of latent TB?
6 months Isoniazid
Risk of death following childhood cancer following pelvic CT in Pregnancy?
2/2000 from 1/2000 without CT
Risk effectively doubles.
Risk of heart failure in women with severe Mitral Stenosis in Pregnancy ?
Up to 50% with severe MS
Should be counselled again pregnancy and use a LARC.
Risk of heart failure in moderate Mitral Stenosis?
1/3
Prematurity and FGR in 30%
Mod-severe will need therapeutic anticoag due to risk of AF (10%)
Risk of heart failure with Aortic Stenosis in Pregnancy ?
25% risk of heart failure if symptomatic.
If asymptomatic, HF risk < 10%
Pre Pregnancy: needs Bruce protocol exercise test. Measure BNP.
Risk of tetratogenicity with Warfarin? Features of Warfarin embryopathy?
5 - 6% chance of warfarin embryopathy
Nasal hypoplasia, short long bones, stippled epiphyses
Clot risk switching Warfarin to LMWH for mechanical valves?
10% Inc risk of clots
Therapeutic Anti Xa levels when using LMWH for prosthetic valves?
0.8 - 1.2
When to switch to LMWH if using Warfarin in Pregnancy?
2 weeks prior to delivery.
INR must be < 1.5 before spinal.
If warfarin hasn’t been stopped 2 weeks prior to delivery, LSCS I’d recommended to reduce the risk of neonatal haemorrhage.
Warfarin and BF?
Safe - secreted as an inactive metabolite.
Stenotic Valve lesions, most common:
1. Mitral
2. Aortic
- Mitral - rheumatic heart disease
- Aortic - congenital bicuspid valve (with calcifications)
Most common Regurgitant valvular lesions?
- Rheumatic
- Congenital
- Degenerative
Regurgitant valve lesions are tolerated better than stenosis.
SLE in Pregnancy - important antibodies?
Determine anti Ro/la antibodies and antiphospholipid antibodies
Associated with congenital heart block and neonatal cutaneous lupus syndrome.
Antiphospholipid antibodies are present in what % of women with SLE?
30%
Antibodies associated with diagnosis of SLE?
- Serum Anticardiolipin IgG/IgM
- Positive lupus anticoagulant
- Anti DNA
- Anti Smooth Muscle
Management of a patient with SLE of anti ro/la antibodies are detected?
- Fetal ECHO at 20/40 and 28/40
- Anti ro/la cross the placenta and destroy the purkinje fibres causing fixed fetal bradycardia - 2-3% of fetuses
16% recurrence in future pregnancies.
1/2 of these babies will need pacing in first year of life.
Lupus nephritis vs PET
- Nephritis will have haematuria/ red cell casts
- A fall In complement levels (due to Inc renal deposits)
- Rise in anti dsDNA
May need to consider cyclophosphamide or mycophenalate in worsening renal function/HTN however both associated with risk of congenital malformations.
Only definitive way is a renal biopsy.
SLE treatment in Pregnancy?
- Steroids and NSAIDs (avoid after 32/40)
- Azathioprine and hydroxychloroquine are safe
- Cyclosporine may be safe - used in renal transplant
- Mycophenalate and cyclophosphamide must be stopped - tetratogenic
SLE and postnatal contraception?
Avoid oestrogen containing contraception as these can cause flare.
Peripartum Cardiomyopathy - risk factors?
- Advanced age
- Multiple pregnancy
- Obesity
- PET (22% will have PET)
- Multiparty
Peripartum Cardiomyopathy - overall mortality?
10%
50-80% recover
Risk of PE vs Peripartum Cardiomyopathy In pregnancy and postpartum
Risk of PE 10x higher
Peripartum Cardiomyopathy - ejection fraction?
Almost always < 45%
If EF is < 35% there is an increased risk of developing intracardiac thrombus.
LV dilatation > 6cm and an EF < 30% are indicative of an unlikely spontaneous recovery.
Peripartum Cardiomyopathy - management?
- Salt restriction, Furosemide if needed for overload
- Selective B1 antagonist eg. Metoprolol
- Hydralazine and nitrates
(If PN, can use ACEi, ARBs and MRA spiromalactone therapy)
Bromocriptine can be supportive if EF < 25%.
Prophylactic VTE
Which AED is associated with HDFN?
Enzyme inducing AEDs
(Carbamazepine, phenytoin, phenobarbital, oxcarbazepine, topirimate)
Normal urine osmolality in non pregnant and pregnant women?
Non Pregnant:
- serum 285 - 295
- urine osmolality can be double this
Pregnant:
- serum 270
- serum Na+ drops by 4-5mmol/L
Treatment of choice for gestational and neurogenic diabetes Insipidus ?
Desmopressin (DDAVP)
- ADH analogue
Second line imaging for solid liver mass in Pregnancy following US?
MRI with gadolinium contrast which is considered safe in Pregnancy.
PRES (posterior reversible encephalopathy syndrome) features?
Headache, vomiting, visual disturbance, seizures, altered mental state
Radiological findings of oedema
In the post circulation of the brain.
Associated with PET.
Idiopathic Intracranial Hypertension - diagnostic criteria?
Modified Dandy Criteria:
1. Signs of raised ICP - headache, nausea, vomiting, transient obscurations of vision, papilloedema
2. No localising neurological signs, or unilateral or bilateral 6th nerve palsies
3. Inc CSF pressure (> 250mmHg)
4. Normal to small symmetrical ventricles
Idiopathic Intracranial Hypertension - treatment
Main goals of treatment are symptom
Control and preservation of vision.
- analgesia for headache
- diuretic to reduce CSF production
- dietary modification / weight loss
- optic symptoms - Acetazolamide
Diagnostic criteria for DKA in Pregnancy ?
- Blood ketone > 3 mmol/L or urine ketone more than 2+
- Blood glucose level > 11.0 or known DM
- Bicarb < 15 and it venous pH < 7.3
Treatment of autonomic dysreflexia?
Sublingual Nifedipine 10mg
IBD - risk of relapse during Pregnancy if disease in remission at time of conception ?
30%
IBD - risk of relapse in patients with active disease at conception?
2/3rds
Increased risk of FGR in women with MS ?
1.7x higher
Incidence of stroke in Pregnancy?
30/100,000
3x incidence when compared to non pregnant individuals
Risk factors for stroke in Pregnancy
- Gestational Diabetes (highest association with antenatal stroke)
- Migraine
- Pre existing HTN
- Pre eclampsia
- Age > 35
Management of acute stroke in Pregnancy?
- Aspirin should be avoided for the first 24 hours after thrombolysis as it increases the risk of subsequent intracranial haemorrhage.
- Thrombectomy with IV thrombolysis should be offered within 6 hours of stroke symptom onset if confirmed occlusion of the proximal anterior circulation is demonstrated by CTA
Or MRA.
Risk of stroke recurrence in a subsequent pregnancy if stroke with the first Pregnancy?
Risk in women with concurrent thrombophilias?
0 - 1.8%
In women with concurrent thrombophilias, risk has been quoted as high as 20%!
Risk of 2nd trimester miscarriage following trachelectomy?
7%
Risk in general population 4%.
Risk of first trimester miscarriage following trachelectomy?
16%
General population 15 - 20% so roughly the same.
Risk of PTB after trachelectomy?
20 - 30%
55% of women deliver in the 3rd trimester
How long an interval is advised between trachelectomy and TTC?
6 months
Primary adrenocortical insufficiency - management?
- Hydrocortisone (preferred glucocorticoid) - short acting, does not cross the placenta
-> 15-25mg in 2-3 divided doses - Fludrocortisone (preferred mineralocorticoid)
-> 0.05 - 0.1 mg/day
Primary adrenocortical insufficiency - steroid sick rules?
- Always wear a medical alert bracelet/ necklace
- Double the dose of oral Glucocorticoid in cases of fever or illness requiring bed rest
- Provide IM hydrocortisone for self administration in cases of gastroenteritis or during fasting
Congenital Adrenal hyperplasia inheritance ?
Autosomal recessive
CAH
- gene affected
- presenting features
CYP21A2 gene mutation.
Deficiency in 21-HD leads to blockage of cortisol and aldosterone synthesis.
In girls, enhanced ACTH levels drive excess androgen production leading to clitoral enlargement and labial fusion.
75% of patients of both genders present at birth with severe hyponatraemia caused by salt wasting as a result of severe aldosterone deficiency.
Non classical CAH have features similar to PCOS, including hirtuism, primary or secondary amenorrhoea or anovulatory infertility.
Incidence of transient cutaneous neonatal lupus in mothers with anti ro/la + SLE?
5%
Transient neonatal cutaneous lupus forms part of the neonatal lupus erythematous spectrum manifesting as annular inflammatory lesions.
Risk of congenital heart block in maternal SLE with anti ro/la antibodies?
2%
Neuro developmental delay in children who’s mums have taken Sodium Valproate in Pregnancy ?
35%
Prevalence of congenital malaria?
8 - 33%
All neonates who’s mother developed malaria in pregnancy should have thick and thin blood films and birth and weekly blood films for 28/7.
Conditions requiring counselling and prenatal diagnosis offered when the mother is affected by SCD?
HbS (Haemoglobin S)
B Thalassaemia
O-Arab
HbC (Haemoglobin C)
D-Punjab
Symptoms of Addisons Disease in Pregnancy?
- Significant weight loss
- Hyperpigmentation in skin folds
- Vomiting
- Low Na+
- High K+
Treatment of addisonian crisis in pregnancy?
Sick day steroid rules?
- IV fluids
- IV Hydrocortisone
Sick day rules - double dose of hydrocortisone and IM supply in case fasting or vomiting.
Cause of Cushings Syndrome:
1. In pregnancy
2. Outside of pregnancy
- In Pregnancy - 60% adrenal Adenoma
- Outside of Pregnancy - 70% pituitary Adenoma (Cushings disease)
Pregnancy Associated Cushings Syndrome
1. Timeline
2. Symptoms
3. How to diagnose
- Occurs during or 12 months after a pregnancy. Placental ACTH can cause or exacerbate this.
- Differentiating symptoms in Pregnancy:
- proximal myopathy
- bruising
- osteoporosis
- fractures
- hirtuism
- early HTN
- red/purple striae - Salivary cortisol at night plus urinary free cortisol - need to be 3x normal limit
Can use high dose dexamethasone suppression test - low dose will be false Pos in pregnancy.
If cortisol suppressed but ACTH low/normal - likely ADRENAL CUSHINGS
If cortisol is suppressed but ACTH remains high - likely PITUITARY CUSHINGS
Risks with Cushings in Pregnancy:
1. Maternal
2. Fetal
- Maternal
- GDM
- PET
- HTN
- Wound infection
- Heart failure - Fetal
- FGR
- PTL
- Stillbirth
- neonatal adrenal insufficiency
Cushing’s Syndrome in Pregnancy treatment?
- First line - surgical
- Post op - should receive oral HC and treated as if now adrenal insufficiency
- Medical Rx can be second line - metyrapone (however Inc risk of HTN)
Encourage a vaginal birth as there can be secondary complications Inc wound breakdown with caesarean section.
Conns Syndrome (Primary hyperaldosteronism)
- Inappropriately high aldosterone production for sodium status
- Suppresses plasma renin
- low K+
- Na+ retention
- HTN - Most common causes
- 60-70% bilateral idiopathic hyperaldosteronism
- 30-40% unilateral Adenoma - Symptoms
- HTN
- Hypokalaemia
CAH
1. Inheritance
2. Gene
3. Incidence
4. Signs and symptoms
5. Treatment
- Autosomal recessive
- Enzyme deficiency - 21 hydroxylase deficiency
- 1/500 - 1/1000
- Excessive androgen release.
- clitoral enlargement
- labial fusion
- non classical: PCOS, amenorrhoea - Primary treatment is Hydrocortisone
Phaeochromocytoma
1. Cause
2. What % of patients with HTN have a phaeochromocytoma ?
3. Symptoms
4. Fetal risks
- Neuroendocrine tumour, arising from neural crest cells. Excessive production of catecholamines (adrenaline, noradrenaline, dopamine) by the chromaffin cells of the adrenal
Medulla. - 0.2-0.6% of people with HTN.
- Symptoms - headache, tachycardia, sweating
- Fetal risks - secondary FGR, hypoxia and death
Diagnosis of Phaeochromocytoma in Pregnancy?
- 24 Hr urine plasma free metanephrine collection
- If pos- MRI adrenal glands
- First line - surgical management ideally before 24/40
- Treat with alpha adrenergic receptors blockers - phenoxybenzamine and doxazocin
** important not to use a beta blocker without an alpha blocker - can have a hypertensive crisis.
Radiation from CT head?
0.005mGy
Accepted background radiation is 50mGy.
Migraine sufferers and pregnancy:
1. Risk of PET
2. Risk of stroke
3. Risk of MI
- 2x risk of PET
- 17x risk of stroke
- 4x risk of MI
Hyponatraemia management
1. > 130
2. 125 - 130
3. < 125
Women at risk of hyponatraemia?
- > 130: normal, rpt 8 hours
- 125 - 130: fluid restrict 80ml/hr, 4 hourly Na+
- < 125: fluid restrict to 30ml/hr, stop Oxytocin, rpt Na+ in 2 hours
Risk factors
- variable rate insulin
- +ve fluid balance 1500ml
- Oxytocin
PKU
1. Inheritance
2. Incidence
3. Treatment
4. Maternal PKU syndrome in the neonate if not treated?
5. Phe level ideally in pregnancy?
- Autosomal recessive
- 1/10,000
- Rx: Phe restricted diet
- Microcephaly, heat disease, IUGR, dysmorphism, rash, low IQ, decreased skin and hair pigmentation
- Phe levels 120 - 300
When should Anti Xa levels be checked in women on therapeutic LMWH?
Eg, for mechanical heart valve
Immediately before dose (ensure > 0.6h
and 3-4 hours after (aim for peak level between 1.0 - 1.2)
Fetal risks associated with phenytoin?
Cardiac defects
Cleft lip or palate
Skeletal malformation
Microcephaly
Coagulopathy occurs in 50% of babies born to mothers on Phenytoin.
Normal range for factor VIII and factor XI outside of Pregnancy?
0.5 - 2.0 iu/ml
Prevention of Congenital heart block in Neonatal Lupus?
- Anti Ro/SSA positive women - weekly fetal ECGO from 16-28/40
- Prior infant with neonatal lupus - weekly or fortnightly ECHO’s
To prevent CHB - hydroxychloroquine was recommended to commence pre pregnancy.
Infections in SLE?
What to measure ?
Patients with SLE may be functionally asplenic and at risk from encapsulated bacterial infections.
Infection can mimic a lupus flare.
ESR and CRP may be raised.
CRP changes more acutely, and the ESR lags behind disease changes.
Measurement of complement may be useful as C3 and C4 levels are reduced in patients with active SLE due to consumption by immune complex-induced inflammation.
What to recommend if both partners have haemoglobinopathies ?
Offer genetic counselling and partner testing.
Fetal exposure to radiation during VQ scan?
0.05 mGy
Fetal exposure to radiation following CTPA?
0.1mGy
What happens to T3, T4 and TSH in Pregnancy?
- Increased total T4 (occurring mainly in 1st trim)
- Increased total T3
- Free T3 and T4 remain unchanged over the course of Pregnancy
- TSH falls in the first trimester as HCG levels increase with a rise to pre pregnancy levels in the second trimester.
- TSH, T3 and T4 do not cross the placenta significantly.
Risk of maternal mortality from thyroid storm?
25%
How long must pregnancy be avoided for following radio-iodine treatment for hyperthyroidism?
4 months!
Incidence of agranulocytosis secondary to Carbimazole treatment ? Mortality?
0.3 - 0.6%
Mortality 21%
What is the recommended test to make a diagnosis of primary aldosteronism during Pregnancy?
Serum levels of suppressed renin and elevated aldosterone-to-renin ratio (ARR)
Addisons - management of glucocorticoids and mineralocorticoids during delivery and postnatally ?
- Delivery Day
- give 200mg/day of HC in divided doses, IV or Oral
- Hold fludrocortisone - Day 1 postnatal
- give 100mg/day of HC in divided doses, IV or oral
- hold fludrocortisone - Day 2 postnatal
- give 50mg/day of HC in divided doses, IV or oral
- hold fludrocortisone - Discharge
- 30-35mg/day of HC
- restart fludrocortisone dose
Mortality rate of pregnant women with severe malaria ?
50%
Consider anti coagulation in context of peripartum cardiomyopathy if EF ??
< 30%
Streptomycin CI in pregnancy for Rx of TB - why?
15% rate of neonatal deafness
Add pyridoxone in treatment of TB to mitigate neurological consequences of what antibiotic ?
Isoniazod
Neonatal mortality rate in TB?
1. Treated
2. Untreated
Treated 22%
Untreated 38%
Rate of maternal ACS?
0.6-10/10,000 pregnancies
Sulfasalazine is associated with which complication in the newborn?
Nephrotoxicity
Target urine output for women with severe pre eclampsia?
10ml/Hr - 40ml for first 4 hours
Main cardiac complication for pregnant patient with Tetralogy of fallot?
Right ventricular dysfunction
Mefloquine
- indication
- contraindication
Recommended drug of choice for malaria prophylaxis in the second and third trimesters for CHLOROQUINE RESISTANT areas.
CI:
- depression
- neuropsychiatric disorders
- epilepsy
- hypersensitivity to quinine or mefloquine
Most common causes of primary hyperaldosteronism? (Conns) + percentages
- Bilateral idiopathic aldosteronism (60-70%)
- Unilateral adrenal Adenoma (30-40%)
What is the most common cause of fetal arrhythmia?
SVT with 1:1 conduction - regular HR of 240-260bpm.
Account for 66% of fetal tachycardias.
Incidence of HDFN?
1 in 300 - 600
There are over 50 RBC alloantobodies, present in about 1/80 pregnant women, which cause HDFN in 300-600 live births.
What are the most commonly used drugs to treat fetal tachyarrhythmias in utero?
Digoxin
Flecanide
Less frequently - Sotalol
Incidence of peripartum cardiomyopathy ?
1/1000-4000
Highest incidence noted in Nigeria (1/100) and Haiti (1/300)
Which obstetric complication are women with MS most at risk of?
FGR - 1.7x more likely
Also slightly Inc risk of PTB < 37 weeks.
No Inc risk of SB, miscarriage or congenital abnormalities.
What proportion of women with MS will relapse during the first 3-4 months PP?
20-30%
CTA findings of reversible cerebral vasoconstriction syndrome (RCVS)?
Diffuse arterial BEADING on cerebral angiography
Reversible cerebral vasoconstriction syndrome features (RCVS)?
- post partum
- severe and sudden headaches over 1-3 weeks
- N/V, photophobia, confusion, blurred vision
FBN1 Gene
Marfan Syndrome
Zika virus - when to conceive?
3 months
- if both partners travelled or if just the male partner travelled
2 months
- if just the female partner travelled
Common US features of congenital
Syphillis ?
- Ascites
- Hepatosplenomegaly
- Intrahepatic calcification
- Placentomegaly
What % of fetal hydrops are associated with congenital infection?
6 - 10%
By what % does thyroid demand increase in Pregnancy?
20-30%
TSH levels for:
1. Normal
2. Subclinical HypoT
3. Overt HypoT
- TSH < 4
- TSH 4 - 10
- TSH > 10
Chromosomal defects associated with diaphragmatic hernia?
Found in 20% of cases.
T18
T13
Tetrasomy 12p or Pallister-Killian Syndrome
Exomphalos is associated with what chromosomal defects and generic syndromes?
T13/18
Beckwith Wiedemann Syndrome (10%)
Anti-Ro and Anti La antibody +ve in SLE.
Fetal ECHO ?
FH auscultation?
ECHO 18-20 and 28 weeks
FH auscultation at each visit.
