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Obs & Gynae > Maternal Disorders in Pregnancy > Flashcards

Maternal Disorders in Pregnancy Flashcards

1
Q

What is the fall in BP during pregnancy?

A

30/15 mmHg during the second trimester

Returns to pre-pregnant levels by term

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2
Q

What causes hypertension in pregnancy?

A

Pregnancy-induced - BP rises above 140/90 after 20 weeks

  • pre-eclampsia
  • transient hypertension

Pre-existing - BP above 140/90 before 20 weeks

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3
Q

What is pre-eclampsia?

A

Hypertension
Proteinuria

Blood vessel endothelial damage + exaggerated immune response -> vasospasm, increased permeability and clotting dysfunction

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4
Q

What are risk factors for pre-eclampsia?

A 
Nulliparity
Previous history
Family history
Older age
Chronic HTN
Diabetes
Twin pregnancy
Autoimmune disease
Renal disease
Obesity
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5
Q

What are the classifications for pre-eclampsia?

A

Mild

  • proteinuria
  • mild/moderate HTN

Moderate

  • proteinuria
  • severe HTN with no complications

Severe

  • proteinuria
  • HTN before 34 weeks or with complications
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6
Q

How does pre-eclampsia occur?

A

Incomplete trophoblastic invasion of spiral arterioles so decreased uteroplacental blood flow

Ischaemic placenta + exaggerated maternal inflammatory response causes

  • widespread endothelial cell damage
  • vasoconstriction
  • increased vascular permeability
  • Clotting dysfunction
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7
Q

How does pre-eclampsia present?

A 
Asymptomatic
Headache
Drowsiness
Visual disturbances
Nausea/vomiting
Epigastric pain - complications impending
HTN
Oedema
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8
Q

What are maternal complications of pre-eclampsia?

A

Early onset more severe, any of these is indication to deliver

Eclampsia - grand mal seizure from cerebrovascular vasospasm -> hypoxia
Tx: magnesium sulphate

Cerebrovascular haemorrhage

Liver and coagulation problems - haemolysis (dark urine), elevated liver enzymes, low platelet count, DIC -> epigastric pain
Tx: magnesium sulphate

Renal failure

Pulmonary oedema -> adult respiratory distress syndrome
Tx: oxygen and frusemide

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9
Q

What are fetal complications of pre-eclampsia?

A

IUGR
Preterm delivery
Placental abruption
Morbidity and mortality

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10
Q

What investigations are done for pre-eclampsia?

A

Dipstick urine - if positive, rule out infection with culture

Protein:creatinine ratio (PCR) >30

Blood: high uric acid and Hb

  • rapid fall in platelets
  • rise in LFTs

USS - assess fetal growth
Umbilical artery Doppler and CTG

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11
Q

What is given to reduce risk of pre-eclampsia?

A

75mg aspirin

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12
Q

How is the severity of pre-eclampsia assessed?

A

Woman with new onset HTN is assessed in day unit

If symptomatic, proteineuria 2+, BP >160/110 or suspected fetal compromise then admitted

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13
Q

What medication is used in pre-eclampsia?

A

Antihypertensives if BP >150/10

  • oral nifedipine
  • IV labetalol

Magnesium sulphate

  • prevents eclampsia
  • increases cerebral perfusion
  • indicates delivery should be done
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14
Q

When should babies be delivered with pre-eclampsia?

A

One or more complications are likely within 2 weeks of onset of proteinuria

Mild - deliver by 37 weeks
Moderate - 34-36 weeks
Severe - whatever the gestation by c-section

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15
Q

What medications can be used during labour with pre-eclampsia?

A

Induction with prostaglandin
Epidural
Antihypertensives
Oxytocin rather than ergometrine for 3rd stage

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16
Q

What postnatal care is done for pre-eclampsia?

A

Blood - LFT, platelets and renal monitored
Fluid balance
BP - beta-blocker, nifedipine, ACE inhibitor

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17
Q

What are risk factors for HTN before 20 weeks?

A

Older women
Obesity
FH
HTN with COCP

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18
Q

What blood pressure medication is contraindicated in pregnancy?

A

ACE inhibitors - give labetalol, methyldopa or nifedpine instead

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19
Q

What is red blood cell isoimmunisation?

A

Mother mounts immune response against antigens on fetal RBC

Antibodies cross placenta and cause fetal RBC destruction

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20
Q

What makes up the rhesus system?

A

Three linked gene pairs
Cc Dd Ee
DD or Dd is Rhesus positive
dd is Rhesus negative

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21
Q

What sensitizing events can occur in Rhesus disease?

A

TOP or ERPC after miscarriage
Ectopic pregnancy
Vaginal bleeding

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22
Q

How is Rhesus disease prevented?

A

Exogenous anti-D is given to mother
This mops up any fetal RBC in mother to prevent recognition by mother’s immune system

Given even if “father” is also Rhesus negative
Pointless if maternal anti-D is already present

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23
Q

When is Anti-D given?

A

At 28 weeks
Given within 72hr of sensitising event
Postnatally again if baby is Rhesus postive
Kleihauer test - if large amount of fetal RBC then extra large dose of Anti-D given

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24
Q

How does Rhesus disease manifest?

A

Neonatal jaundice
Neonatal anaemia
In utero anaemia -> cardiac failure, ascites, oedema

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25
Q

How are Rhesus disease women identified?

A

Screening at booking and 28 weeks gestation

If anti-D less than 10, fetal problem unlikely and levels are checked every 2-4 weeks

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26
Q

How is severity of fetal anaemia assesed?

A

Doppler USS of middle cerebral artery has high sensitivity to significant anaemia
Done fortnightly

If severe FBS done

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27
Q

How is fetal anaemia treated in utero?

A

If anaemia confirmed during FBS, Rhesus negative, high haemocrit blood is injected into umbilical vein
Done in increasing intervals until 36 weeks when baby is delivered

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28
Q

What effect does pregnancy have on glucose levels?

A

Diabetogenic - women with impaired glucose tolerance deteriorate to be classed as diabetic

Kidneys start excreting glucose at a lower blood glucose level so glycosuria may occr at physiological concentrations

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29
Q

What is gestational diabetes?

A

Carbohydrate intolerance diagnosed in pregnancy which may or may not resolve after pregnancy

Fasting glucose >7mmol

30
Q

What fetal complications are associated with diabetes?

A

Congenital abnormalities (neural tube and cardiac) - 4x risk

Preterm labour - with reduced fetal lung maturity

Increased birthweight - fetal pancreatic islet cell hyperplasia -> hyperinsulinaemia and fat deposition

Polyhydramnios from increased urine output

Macrosomia -> shoulder dystocia and birth trauma

Increased fetal compromise, distress and sudden death

31
Q

What maternal complications are associated with diabetes?

A

Increased insulin requirement

UTI and wound/endometrial infection after delivery

Pre-eclampsia more common

Worsens IHD

C-section and instruments more likely

Diabetic retinopathy often deteriorates

32
Q

How is pre-existing diabetes managed in pregnancy?

A

Precise glucose control
Fetal monitoring for compromise

Appointments every 2 weeks up to 34 weeks and then weekly

Usual pregnancy scans + fetal echocardiogram

75mg aspirin from 12 weeks

33
Q

How are babies delivered in maternal diabetes?

A

By 39 weeks
Elective c-section if weight >4kg

Neonate commonly develops hypoglycaemia - breast feed

34
Q

What are risk factors for gestational diabetes?

A 
Previous history
Previous fetus >4,5kg
Previous unexplained stillbirth
First-degree relative with diabetes
BMI >30
South Asian/Black Caribbean/Middle Eastern
Polyhydramios
Persistant glycosuria
35
Q

How is gestational diabetes screened for?

A

Women with risk factors have GTT at 28 weeks

36
Q

How is gestational diabetes managed?

A

Diet and exercise

Oral metformin

Insulin

Stop insulin at birth and GTT at 3 months

37
Q

What are the physiological changes of cardiac function in pregnancy?

A

40% increase in cardiac output - increase in stroke volume and heart rate

40% increase in blood volume

38
Q

How does pregnancy change the ECG?

A

Ejection systolic murmur

Left axis shift and inverted T waves

39
Q

How does pregnancy affect women with pre-existing heart conditions?

A

Increased cardiac output acts as exercise test

Manifests after 28 weeks or during labour

40
Q

How is cardiac disease managed in pregnancy?

A

Warfarin -> LMWH
ACE inhibitors -> beta-blockers

USS at 20 weeks may pick up cardiac anomaly which is more common

Check for anaemia

41
Q

How is labour managed in ladies with cardiac disease?

A

Fluid balance check
Elective epidural
Elective forceps to reduce stress

42
Q

Which cardiac diseases cause little problem in pregnancy?

A

PDA
VSD
ASD

43
Q

Which cardiac diseases complicate pregnancy?

A

Pulmonary HTN (Eisenmenger’s syndrome) - pregnancy contraindicated

Aortic stenosis needs correcting before pregnancy - epidural may be contraindicated

Mitral valve disease - needs treating before

Peripartum cardiomyopathy - develops in last month of pregnancy or following 6 months

44
Q

How is respiratory disease managed in pregnancy and labour?

A

Long term steroids need upping in labour as chronically suppressed adrenal cortex unable to produce adequate steroids

45
Q

How does epilepsy affect pregnancy?

A

Seizure control can decrease in pregnancy/labour

Sodium valproate - neural tube defect

Newborn has 3% risk of developing epilepsy

46
Q

What is optimum management of epilepsy in pregnancy?

A

Folic acid + carbamazepine or lamotrigine

Oral vit K

20 week USS and EKG important to rule out abnormalities

47
Q

What effect does hypothyroidism have on pregnancy?

A

Miscarriage
Preterm delivery
Intellectual impairment
Pre-eclampsia

Monitor TSH, dose may need increasing

48
Q

How does hyperthyroidism affect pregnancy?

A

Antithyroid antibodies can cross placenta -> neonatal thyrotoxicosis and goitre

Maternal thyrotoxicosis may improve in late pregnancy

If poorly controlled -> thyroid storm with acute symptoms and heart failure near delivery

49
Q

How is hyperthyroid treated in pregnancy?

A

PTU as less likely to cross placenta than carbimazole

Use lowest dose

Safe when breastfeeding

50
Q

What is postpartum thyroiditis?

A

Can cause postnatal depression

RF: antithyroid antibodies and type I diabetes

51
Q

What are risk factors for Acute Fatty Liver of Pregnancy?

A

Primips
Male babies
Twins

May be on spectrum of pre-eclampsia

52
Q

How does fatty liver present?

A 
Malaise
Vomiting
Jaundice
Vague epigastric pain
Thirst

Acute hepatorenal failure
DIC
Hypoglycaemia

53
Q

What is intrahepatic cholestasis of pregnancy?

A

Itching without skin rash and with abnormal LFTs

Abnormal sensitivity to cholestatic effects of oestrogen

54
Q

What is intrahepatic cholestasis of pregnancy associated with?

A

Sudden stillbirth
Preterm delivery
Maternal and fetal haemorrhage

Reocurrs

55
Q

How is intrahepatic cholestasis of pregnancy managed?

A

Vit K from 26 weeks
UDCA for itching

Induction at 38 weeks

56
Q

What is antiphospholipid syndrome (APS)?

A

Lupus anticoagulant +/- anticardiolipin antibodies occur in association with adverse pregnancy complications

Placental thrombosis
Recurrent miscarriage
IUGR
Early pre-eclampsia

57
Q

How is APS managed?

A

Aspirin and LMWH
Serial USS and elective induction at term

Postnatal anticoagulation to prevent VTE

58
Q

What is the impact of pregnancy on renal system?

A

GFR increases by 40%

Urea and creatinine levels decrease

59
Q

How is chronic renal disease managed in pregnancy?

A

Proteinuria can cause diagnostic confusion with pre-eclampsia

Pre-eclampsia
IUGR
Polyhydramnios
Preterm delivery

60
Q

What effect do urinary infection have on pregnancy?

A

Preterm labour
Anaemia
Pyelonephritis

61
Q

What effect does pregnancy have on the clotting system?

A

Pregnancy is prothrombotic - VTE 6x

Increased blood clotting factors
Decreased fibrinolytic activity

Pulmonary embolus and DVT need to be avoided - treat with LMWH

62
Q

What thromboprophylaxis is given in pregnancy?

A

Compression stockings

Antenatal and postnatal LMWH given if:

  • previous VTE or needed in pregnancy (6 weeks)
  • increased BMI, smoker, age, elective c-section, labour >24 hours
63
Q

What are complications of obesity in pregnancy?

A

Maternal

  • thromboembolism
  • pre-eclampsia
  • diabetes
  • C-section
  • wound infection
  • PPH

Fetal

  • congenital abnormalities
  • increased perinatal mortality
64
Q

How is obesity managed?

A

Folic acid and vit D

Maintain weight in pregnancy

65
Q

Which psychiatric drugs are used in pregnancy?

A

Prefer to stop lithium, but monthly monitoring if continued
SSRIs (preferably fluoxetine)

AVOID paroxetine, clozapine and olanzapine

66
Q

What risks are associated with opiate abuse?

A 
Preterm delivery
IUGR
Stillbirth
Developmental delay
SIDS
67
Q

What risks are associated with cocaine abuse?

A 
Teratogenic
IUGR
Placental abruption
Preterm delivery
Stillbirth
SIDS
68
Q

What risks are associated with ecstasy abuse?

A

Cardiac defects

Gastroschisis

69
Q

What risks are associated with benzo abuse?

A

Facial clefts

Neonatal hypotonia

70
Q

What does smoking increase the risk of?

A 
Miscarriage
IUGR
Preterm birth
Placental abruption
Stillbirth
SIDS
71
Q

What is the effect of pregnancy on anaemias?

A

Increase in blood volume leads to decrease in Hb concentration
New normal = 110

Give oral iron and folic acid

Obs & Gynae (20 decks)

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