Maternal Disorders in Pregnancy

Question 1

Most common causes of death in mothers related to pregnancy?

Answer 1

Direct: due to direct effects of pregnancy

• prolonged labour, trauma
• amniotic embolic and thrombotic emboli
• toxemia - infections (still high)
• hemorrhage
• puerperal sepsis
• TE/embolism

Indirect: underlying vunerability exacerbated by pregnancy

• psychiatric
• cardiac/heart disease
• diabetes

Not direct e.g. metastatic breast cancer, indirect: SAH berry aneurysm, direct: c-section PE 3 days post, direct: liver rupture following fulminant pre-eclampsia, direct: uterine rupture (in labour) - minimize that.

Question 2

Physiological changes in pregnancy?

Answer 2

Cardiac:

• increase CO
• reduced TPR (at 8 weeks).

Respiratory:

• increased maternal and O2 requirements
• Increased RR and tidal volume
• reduced residual volume

Renal

• increase in GFR

GI

• progesterone reduces LOS tone - GORD
• GI motility reduced

Haem

• dilutional anaemia and need more.
• hypercoagulable (clotting factors increase to stop PPH)

Immune

• T cell tolerance - immunosuppression
• B cells preserved - vaccines work
• heightened inflammation
• e.g. flu - doesn’t fight as a foriegner as well as she should.

Question 3

Maternal Resuscitation?

Answer 3

• supine hypotension
  
  • L tilt - off aorto-caval compression when supine
• increased blood volume, doses might be higher
• increased risk of aspiration - soft Lower eosophageal tone
• reduced functional residual capacity and increased BMR
  
  • adequate ventolation
• alpha and beta agonists - adrenaline don’t work well in fetus, reduce placental perfusion.
• Defibrillation safe for fetus.
• Peri-mortem CS helpful to mother within 4-5mins. Resus better. Restore AV shunt. Good for baby too.

Question 4

What are some ways to classify cardiac disease within pregnancy? What are the complications related to these conditions?

Answer 4

• Increase CO
  
  • LV dysfunction
  • fixed output (AS/MS)
  • aneurysm - can form or blow out. SAH and DTA increase
  • regurgitant valve better tolerated than stenosed
• Increased HR
  
  • mitral stenosis - more likely to get pulmonary oedema
• Prosthetic valves/valvular disease
  
  • warfarin is teratogenic
  • prosthetic less risky than bio-valves
  • often need to heparanise for 13 weeks and final weeks.
• Rapid volume changes
  
  • CO - dependent on preload - sudden increase APO, sudden decrease reduced coronary perfusion.
  • pulmonary HTN is top of the list for maternal mortality - termination.

Question 5

What do you do for a mother with cardiac issues while pregnant?

Answer 5

• Pre-pregnancy couselling
  
  • contraceptives
  • high-risk team
  • determine lesion + whether its correctable
• assess NYHA class
• advise prognosis
• consider whether lesions carries risk to offspring
• consider anticoag
• consider SBE prophylaxis (subacute bacterial endocarditis).

Question 6

Pre-pregnancy counselling to all women?

Answer 6

1. congratulate
2. prepregnancy folic acid - 5mg to high risk, 0.5mg standard
3. Prepregnancy live vaccines (Rubella, Varicella)
4. Education about normal conception and fertility
5. Lifestyle and BMI optimization
6. Pre-empt routine care
   
   • screening
   • genetics
   • place of birth

Question 7

How does VTE present in pregnancy? What do you do?

Answer 7

• 85% in LL
• US very sensitive, but repeat because a small % of false negative
• VQ scan +/- CTPA
• CXR
• treatment:
  
  • adequate anticoagulation
  • adequate duration for remainder of pregnancy

Question 8

What is the considerations of HbA1c in pregnancy?

Answer 8

4 Ms of HbA1c

• mortality
• malformations
• macrosomia
• miscarriage

Question 9

What can radiation exposure associated with diagnostic imaging in pregnancy result in?

Answer 9

• IUGR
• congenital malformation
• neurocognitive delay
• childhood malignancy
• depends on the dose - fetal shielding if possible, non-radiation method.
• Gestational sensitivities:
  
  • D0-9:
    
    • resorption >10rads
  • W3-11
    
    • risk damage
      
      • 12 rad 8-15wks
      • 21 rad 16-25wks
    • <5rads not grounds for TOP no adverse effects
  • W10-birth
    
    • growth restriction
    • risk childhood cancer esp. leukemia
    • neurodevelopmental delay

Question 10

What are some things to discuss in a women who has had a previous CS?

Answer 10

Previous CS/Procedures?

• type:
  
  • classical (9% risk of rupture)
  • LUSCS (1% risk of rupture)
  • myomectomy
• reasons for previous CS:
  
  • non-recurring (breech, PP, twins, fetal wellbeing)
  • recurring (dystocia - 60% success rate after previous dystocia)

Decision Making for VBAC/TOLAC:

• family size (3 or more?)
  
  • more CS = more difficult
  • risk of accreta, wound dehiscence.
  • Don’t offer TOLAC after 2, case series - excluded everything but best candidates (but if they really want it, but pass hurdles)
    
    • consider previous successful VD. Increased success.
• Risk of CS:
  
  • damage to viscera
  • bleeding
  • infection
  • DVT
  • privia increta
• TOLAC risk
  
  • risk of failing (uncertainty big)
  • rupture - signs (CTG decleration, persistent pain, loss of contractions (classic in TOLAC), tachycardia, hypotension, scar tissue rupture not that bad often thin).

Question 11

What are some things you should discuss in a women who has decided to have TOLAC?

Answer 11

Which group are they in? Differences in choice

• elective CS at 39 weeks but before that would do TOLAC
• convinced TOLAC (elective CS booked at 40-42weeks)
• never do CS (IOL in this group)
  
  • increased risk with IOL of 2%
  • only 1 means - ARM + syntocinon. (Prostin E doubles failure rates again).

Management of TOLAC:

• Present early
  
  • stay home until regular contractions (not seperated by 5mins - at risk from start).
• continous CTG
• IV

Question 12

A 34 year old 18 weeks gestation women presents with SOB and chest pain. What is your management?

Answer 12

• confirm diagnosis:
  
  • CTPA
  • pulmonary angiogram (gold standard)
• determine aetiology:
  
  • thrombophilia screen
• check contraindications for PE treatment:
  
  • PUD
  • recent surgery
  • HITS
• full dose of enoxaparin/clexane or heparin
  
  • warm about APH symptoms
• refer to anaesthetics (spinal agents)
• during labour:
  
  • cease 24 hours before induction for LMWH, 6 hours for heparin before ROM.
• postpartum give full dose again.

Question 13

What is the management of microcytic anaemia in pregnancy? What are the causes?

Answer 13

Causes: TAILS

• thalassemia (alpha/beta)
• Anaemia of chronic disease
• iron deficiency
• lead poisoning
• sideroblastic

Management: (check iron, test mum/dad, provide genetic tests).

• Investigate - perform haemogobin electrophoresis, ferritin/iron/MCV/Hb
  
  • only treat with Fe supplementation if ferritin <20.
• increase dose of folate

Question 14

A mother is found to have anti-D antibodies (indirect coomb’s titre) at 12 weeks gestation, what is your management?

Answer 14

• confirm fetal risk:
  
  • test the partner
  • reassure the mother - risk of alloimmunization is low.
• test anti-D each visit:
• treatment:
  
  • >64 - monitor MCA US doppler. evidence of anaemia do a transfusion of maternal matched blood.
• deliver at 38-40weeks - manage jaundice.

Question 15

What test is performed before anti-D is administered?

Answer 15

• Kleihauer - determine level of feto-maternal haemorrhage - adjust anti-D dose.
• Indirect Coombs’ test (mother already immunised?)
• baby’s blood group.