Maternal Health Flashcards
What normally happens to blood pressure in pregnancy?
Fall during first trimester - lowest at 20wks
Increase again to pre-pregnancy levels by term
How can hypertension in pregnancy be categorised?
Pre-existing - >140/90 before 20wks
Gestational - >140/90 after 20wks or >30/15 rise in booking BP
Pre-eclampsia - hypertension + proteinurea (+- oedema)
What complications are associated with hypertension in pregnancy?
Pre-eclampsia Placental abruption IUGR Intrauterine death Prematurity DIC Cardiovascular disease later in life
How should pre-existing hypertension be managed?
What BP should be aimed for?
!! Labetalol (Can continue normal BP meds if not ACE-i or ARB)
!! 75mg aspirin daily - 12 weeks to birth
Urine dip at each antenatal visit
Assess for pre-eclampsia
Obstetrician review - give lifestyle advice
Aim for <150/100
When should a patient with gestational hypertension be urgently admitted for obstetric review?
Signs of pre-eclampsia
BP >160/110
How should patients with gestational hypertension be managed?
Regular BP and urine dip monitoring
!! Labetalol
!! Aspirin 75mg daily from week 12
Foetal growth and amniotic fluid volume measured
Monitor postnatally and stop antihypertensives as appropriate
What medication can be used in the management of hypertension in pregnancy?
Labetalol
Nifedipine
Methyldopa
Hydralazine
What class of drug is labetalol? What are the CI’s and SE’s?
Beta-blocker
CI - asthma and cardiogenic shock
SE - Postural hypo , fatigue, headache, N&V, epigastric pain
What class of drug is nifedipine? What are the CI’s and SE’s?
Calcium channel blocker
CI - angina and aortic stenosis
SE - Peripheral oedema, flushing, headache, constipation
What class of drug is methyldopa? What are the CI’s and SE’s?
Alpha-agonist
CI - depression
SE - drowsiness, headache, oedema, GI disturbance, dry mouth, postural hypo, bradycardia, hepatotoxicity
What class of drug is hydralazine? What are the CI’s and SE’s?
Vasodilator
CI - Heart failure and cor pulmonale
SE - Angina, diarrhoea, dizziness, headache
How is pre-eclampsia defined?
Seen after 20 weeks
Pregnancy induced hypertension
Proteinurea (>0.3g in 24hrs
Oedema)
What is the pathophysiology of pre-eclampsia?
Inadequate remodelling of spiral arteries
Constrictive muscular walls of spiral arteries maintained - high resistance, low flow
Maternal inflammatory response and endothelial dysfunction - leaky vessels
What women are at high risk of pre-eclampsia?
Hypertension/pre-eclampsia/eclampsia in past pregnancy
Chronic hypertension
CKD
Autoimmune disease - SLE/antiphospholipid
T1/T2 Diabetes Mellitus
How should women at high risk of pre-eclampsia be managed?
75mg aspirin daily from 12 weeks
What symptoms are associated with pre-eclampsia?
Often asymptomatic
Severe headache - frontal
Visual problems - blurring/flashing before eyes (papilledema)
Severe epigastric pain - hepatic capsule distention
Vomiting
Swelling - hands, face or feet
Hypereflexic
What could bloods reveal in patients with pre-eclampsia?
Falling platelet count <100
Raised ALT/AST
HELLP syndrome
What would place a patient at moderate risk of pre-eclampsia?
First pregnancy Multiple pregnancy >10yr since last pregnancy Age >40 BMI >35 Family Hx of pre-eclampsia
How would patients at moderate risk of pre-eclampsia be managed?
75mg aspirin daily from 12 weeks
What are the risks of pre-eclampsia?
Fetal
- IUGR
- Premature birth
- Hypoxia = neurological damage
Maternal
- Eclampsia
- Placental abruption
- AKI
- DIC
- Cerebrovascular haemorrhage
- Multi-organ failure
How should patients with pre-eclampsia be managed postnatally?
Should resolve following delivery of placenta
Monitor for 24hr - risk of seizure
Day 5 - considered safe
How is pre-eclampsia managed?
Monitoring - BP, urinalysis, blood tests, fetal growth, CTG
Aspirin - 75mg daily from 12 weeks
Antihypertensives - Labetalol (Nifedipine/methyldopa)
VTE prophylaxis - LMWH
Delivery - cure for pre-eclampsia, balance risks and benefits. If <34 weeks, IM steroids
What is eclampsia?
Seizures in association with pre-eclampsia
Tonic-clonic normally
When do eclamptic convulsions occur?
Postnatal - 44%
Antepartum - 38%
Intrapartum - 18%
What investigations would you request for eclampsia?
Look for complications:
FBC - DIC
CTG - fetal distress
etc.
How is eclampsia managed?
ABCDE - resus in left lateral position
- Magnesium sulphate -continue for 24hr after delivery or last seizure
- IV antihypertensives
- Delivery of baby - only when mother stable
- Fluid restrict
What are the signs of hypermagnesaemia?
How is hypermagnesemia reversed?
Hyper-reflexia
Respiratory depression
Calcium gluconate
What is HELLP syndrome?
Haemolysis
Elevated Liver enzymes
Low Platelet count
How does HELLP syndrome present?
RUQ pain - liver distention
Tiredness
N&V
+/- headache and vision problems
How is HELLP syndrome managed?
Delivery of baby
Blood transfusion
Antihypertensives
What are the complications of HELLP syndrome?
DIC
Liver rupture
Placental abruption
How many pregnancies does HELLP syndrome affect?
0.1-0.6% of all pregnancies
15% of pre-eclampsia
What general advice is given for women with diabetes in pregnancy?
Role of diet, body weight and exercise - individualised
BMI >27 - lose weight
Risks of hypoglycaemia and to be aware of it
Effect of vomiting on blood glucose
Assess diabetic retinopathy and nephropathy
Possibility of temporary health problems in baby in neonatal period
Risk of poor glycemic control
What are the maternal complications of diabetes in pregnancy?
Hypertension and pre-eclampsia
Injury from delivering large baby
Worsening retinopathy and nephropathy
CVS risks
What are the foetal complications of diabetes in pregnancy?
Hyperinsulinaemia Miscarriage or still birth Pre-term labour Birth adaptions - hypoglycaemia, jaundice Obesity and diabetes later in life Transient tachypnoea of newborn
What can foetal hyperinsulinaemia cause?
Macrosomia and shoulder dystocia
Polyhydramnios
Cardiomegaly
Erythropoiesis causing polycythaemia
Why does foetal hyperinsulinaemia cause problems?
Glucose can cross placenta but insulin can’t
Maternal hyperglycaemia = fetal hyperglycaemia = fetal increase in insulin levels
Insulin similar structure to growth promoters
Insulin cause reduced pulmonary phospholipids = reduced surfactant = transient tachypnoea of newborn
What is the capillary glucose target for pregnant women?
Fasting <5.3mmol/L
1hr after meal <7.8mmol/L
2hr after meal <6.4mmol/L
What fetal monitoring is done for pregnant women with diabetes?
20 week scan - structural abnormalities
Amniotic fluid volume assessment - 28 weeks
How should delivery be planned for pregnant women with diabetes?
Induction of labour or C-Section between 37 and 38+6 weeks
If macrosomia diagnosed - advice on risks and benefits of vaginal delivery
For a mother with diabetes, how should the newborn baby be cared for?
Feeding within 30 mins
Test blood glucose 2-4hr post birth unless signs of hypo - test immediately
What are the signs of hypoglycaemia in a newborn and how is it managed?
Abnormal muscle tone
Apnoea
Fits
Loss of consciousness
IV dextrose
What is the postnatal care plan for mothers with diabetes?
Reduce insulin immediately - monitor carefully
Risk of hypo while breastfeeding so advise to snack during feeding
What medication can be used for a breastfeeding mother with diabetes?
Metformin and Glibenclamide
Other hypoglycaemic agents should be avoided
What are the pre-conception glucose targets for a woman with pre-existing diabetes?
Capillary glucose normal
HbA1C <48 (6.5%)
Strongly advise against pregnancy if HbA1C >10% (86)
What medication (diabetes related and other) is used for women with pre-existing diabetes?
Stop all oral hypoglycaemics except Metformin
Commence insulin - isophane insulin
Commence 75mg aspirin daily from week 12
Folic acid 5mg until 12 weeks
What is gestational diabetes and how common is it?
Any degree of glucose intolerance beginning in pregnancy
2-5% of pregnancies
What are the risk factors for gestational diabetes?
BMI>30 Previous gestational diabetes Previous macrosomic baby >4.5kg Family Hx of diabetes (1st degree relative) PCOS Asian
How is gestational diabetes screened? When is screening done?
Oral Glucose Tolerance Test - fasting, 75g glucose drink, test again 2hr later
If previous GD - booking and 24-28 weeks
If risk factor - 24-28 weeks
How is gestational diabetes diagnosed?
Fasting >5.6mmol/L
OGGT (2 hours post glucose) - >7.8mmol/L
What happens to insulin in pregnancy?
Progressive resistance meaning more insulin is needed
Women’s borderline pancreatic reserves unable to respond to need - transient hyperglycaemia
How does gestational diabetes present?
Normally asymptomatic
As with any diabetes - polydipsia, polyuria, fatigue
What is the specific management for gestational diabetes?
Fasting glucose 5.6 - 7:
1 - Trial of exercise and diet changes for 2 wks
2 - + Metformin
3 - + Insulin
Fasting glucose >7 or >6 with macrosomia/polyhydramnios
1 - Insulin + diet and exercise changes +- metformin
When should birth be scheduled for in gestational diabetes?
No later than 40+6 weeks
How are women with gestational diabetes followed up?
Fasting glucose test 6-13 weeks post birth - exclude diabetes
Continue to advise regarding weight, diet and exercise
Annual HbA1C
What happens in obstetric cholestasis?
What are the key points to remember about its presentation?
Impaired bile flow allow bile salts to be deposited in skin and placenta
Abnormal LFT’s + intense pruritis
What effects do bile acids have?
Vasoconstrict placental veins - sudden asphyxial events
Increase oxytocin receptor expression - increased response to oxytocin
What are the risk factors for obstetric cholestasis?
Past obstetric cholestasis Family Hx Multiple pregnancy Gallstones Hep C
How may obstetric cholestasis present?
3rd trimester
Intense itching - palms, soles and abdomen worst, worst at night, excoriation marks but NO rash
Pale stools and dark urine
Jaundice
What are the differentials for obstetric cholestasis?
HELLP syndrome Hep C Acute fatty liver of pregnancy Polymorphic eruption of pregnancy Pemphigoid gestationis
What are the risks associated with obstetric cholestasis?
Fetal distress - meconium passage
Intrauterine death
Pre-term delivery
PPH due to reduced vit K
What should you be aware of when interpreting blood results in obstetric cholestasis?
LFT’s have pregnancy specific ranges - UL 20% lower than in non-pregnant level
How is obstetric cholestasis managed?
Weekly LFT monitoring
Topical antihistamines
Ursodeoxycholic acid
Vit K - esp if steatorrhoea or clotting affected
Delivery is only cure - often induced at 37 weeks
When is a pregnant women at highest risk of VTE?
Post-partum
What pre-existing factors increase risk of VTE during pregnancy?
Thrombophilia Co-morbidities - cancer Age >35 BMI >30 Parity >3 Smoking Varicose veins Paraplegia
What obstetric factors/conditions increase risk of VTE?
Multiple pregnancy Pre-eclampsia C-Section Prolonged labour Stillbirth Preterm birth PPH Hyperemesis (dehydration) Ovarian hyperstimulation syndrome Immobility eg pubic symphysis dysfunction
How do VTE’s present?
DVT - unilateral leg pain and swelling +- pitting oedema +- pyrexia
PE - Sudden dyspnoea, pleuritic chest pain, cough
How are DVT’s diagnosed in pregnancy?
Compression duplex ultrasound
How are PE’s diagnosed in pregnancy?
Initial ECG and CXR
Weigh up need for imaging vs risk:
CTPA = maternal breast cancer
V/Q mismatch = childhood cancer
D-dimer raised anyway so useless
When is VTE prophylaxis given?
Previous VTE - LMWH post partum
BMI >40 or emergency C-section - 7 days LMWH post delivery
Risk factor dependant
3 = from wk 28 - 6wk post
4 = immediate - 6wk post
(RF: Age >35, BMI >30, thrombophilia, immobile, smoker, varicose veins, parity >3)
How are VTE’s managed?
Immediate LMWH until diagnosis confirmed
Once confirmed - LMWH for remainder of pregnancy and until 6-12 weeks post partum
What should happen in an emergency VTE situation?
IV unfractionated heparin in major life threatening situation
What should happen to LMWH dose when a women is in labour?
Omit 24 hrs before induction
OR
Stop as soon as they think they are going into labour
How safe are VTE medications in breastfeeding?
LMWH - safe as not absorbed through GI tract
Warfarin - safe as metabolites not active
When do you check for maternal anaemia? What is the cut off for anaemia at these points?
Booking visit <11g/dl
28 weeks <10.5g/dl
Post partum <10g/dl
What are your differentials for anaemia in pregnancy?
Iron deficient
Thalasaemia (carriers are asymptomatic until pregnancy)
Sickle cell
What should be done if a pregnant woman is diagnosed with a thalassaemia?
Folate supplementation and blood transfusion
Paternal testing
Genetic counselling
How may sickle cell affect a pregnant woman and how should it be managed?
25% chance of miscarriage
10% chance of stillbirth
Folate and iron supplementation required
If a pregnant woman is found to have micro or normocytic anaemia, what is the most likely cause and how would it be managed?
Iron deficiency anaemia
Trial oral iron (100-200mg) and repeat FBC after 2 weeks of treatment
If no rise then further diagnostic testing
What are the effects of anaemia on pregnancy?
Prematurity
Low birth weight
Increased maternal mortality from haemorrhage
What is the overarching principle of epilepsy management in pregnancy?
Aim for monotherapy
What is the major risk associated with anti-epileptic drugs in pregnancy?
Neural tube defects
How should pregnant (or planning to be) women on anti-epileptic medication be managed?
What is given to the newborn and why?
Folic acid 5mg per day before conception if planning pregnancy
18-20 week scan for abnormalities
1mg vit K at delivery - reduce risk of neonatal haemorrhage
What is the risk of sodium valproate in pregnancy?
Neural tube defects
ADHD
Reduced cognitive ability
NOT USED
What is the risk of Carbamazepine in pregnancy?
Lower IQ
NOT USED
What is the risk of Phenytoin in pregnancy? How is one of these risks minimised?
Cleft palate
Newborn clotting disorders: women takes vit K in last month
If a pregnant women takes lamotrigine, what needs to be remembered/ considered?
Dose may need to be increased since oestrogen can result in significantly lower levels
What is the risk of Topiramate in pregnancy?
Cleft palate
What is the risk of Phenobarbital and Benzodiazepines in pregnancy?
Withdrawal effects in baby
What emergency contraception should be used for a women on AEDs?
Copper IUD
What contraception can epileptic women use?
Depot medroxyprogesterone acetate Copper IUD Levonorgestrel IUS Barrier methods Family planning methods
How is the foetus affected by seizures?
Fetus at higher risk of harm during tonic-clonic seizure
- Hypoxia, acidosis, fall trauma, miscarriage
Fetus not affected by other seizure types (unless fall trauma)
What is the guidance on breastfeeding while taking anti-epileptic medication?
Safe and encouraged
What do women who have seizures in the 2nd half of pregnancy need to be assessed for?
Eclampsia
What is fatal anticonvulsant syndrome?
Seen in children exposed to valproate and carbamazepine
Epicanthic folds Thin upper lip Abnormal philtrum (long) Triangular forehead Micrognathia Medial deficiency of eyebrows Anteverted nose
How common are mental health problems in pregnancy?
10-15% suffer from depression and/or anxiety
What can a low BMI during pregnancy predispose to?
Low birth weight
Pre-term delivery
Anaemia
How and when does baby-blues present?
First week post-partum
Tearful, anxious, irritable but it doesn’t impair function
How are baby blues managed?
Reassurance and support esp. from health visitor
What is the timing of postnatal depression?
Depressive episode within first 12 months postpartum
Generally start within 1 month and peak at 3
How is postnatal depression managed?
Reassure and support
CBT
Paroxetine or duloxetine
How does puerperal psychosis present?
First 2-3 weeks
Severe mood swings, disordered perceptions, hallucinations
How is puerperal psychosis managed?
Hospital admission
Future pregnancies req. monitoring
How is postnatal depression screened?
Edinburgh Postnatal Depression Scale
- 10 item questionnaire with max score of 30
- Indicate how mother feel in prev. week
- Score >13 indicate depressive illness
What is the guidance on antidepressants and breastfeeding?
Paroxetine recommended - low milk/plasma ratio
Fluoxetine avoided - long half life
Encourage women with mental health problem to breastfeed
How can HIV transmit to young children?
Usually mother-child transmission
Can be transplacentally - rare
What are the risk factors for mother-child HIV transmission?
Higher levels of maternal viraemia Low CD4 count HIV core antigens Instrumental delivery Premature rupture of membranes Vaginal delivery
How is HIV in pregnant women managed?
Early diagnosis reduce transmission - screening
Risk of transmission 1% if:
- Antiretroviral therapy - usually combined therapy
- Elective caesarian 38-39 weeks
- Avoid breastfeeding following delivery
When can vaginal delivery be planned for women with HIV?
Viral load <50copies/ml at 36 weeks
What is the period of greatest risk when prescribing medication in pregnancy?
Week 3-11
1st trimester - congenital malformations
What effect can drugs have on a foetus in 2nd and 3rd trimester of pregnancy?
Drugs can affect growth or functional development
Can have toxic effects on foetal tissues
What effects can medication around the time of labour?
Adverse effects on labour or neonate after delivery
What must you be aware of when prescribing in pregnancy?
Maternal drug doses may req. adjustment
Expected benefit must outweigh risk to foetus
No drug safe beyond all doubt
How does acute fatty liver of pregnancy present? (Timing, symptoms, bloods)
3rd trimester/ after delivery
- acute N&V, abdo pain, headache, pruritis, jaundice
- raised ALT, AST, bilirubin
- low fibrinogen and prolonged PTT
When is cervical circulate indicated?
Previous poor obstetric hx - >=3 2nd trimester losses
Cervical length shortening on USS - <25mm before 24 weeks and 2nd trimester loss
Symptomatic women with premature cervical dilatation and exposed foetal membranes
What are the complications of cervical cerclage?
Bleeding
Membrane rupture
Stimulate uterine contractions
What can women with a Hx of 2nd trimester miscarriage and cervical weakness who haven’t undergone cervical cerclage be offered?
Cervical sonographic surveillance
Which contraception should be avoided in a women who had obstetric cholestasis during pregnancy?
COCP - it can cause cholestasis to recur
What is polymorphic eruption of pregnancy?
itchy rash starting in the abdominal striae
What is pemphigoid gestationalis
itchy, blistering, periumbilical rash often occurring in multiparous women
What monitoring is required for women on LMWH?
Only if extremes of weight
Anti-Xa
A pregnant women has asymptomatic bacteriuria on culture, what should be done?
7 day course abx
What are your differentials for chest pain during pregnancy?
PE
Aortic dissection
Mitral stenosis
GORD
