Maternal Illness

Question 1

Describe the principals of managing epilepsy in pregnancy?

Answer 1

Fits are more damaging to foetus than risk of medications.

Management involves seizure control with as few drugs as possible at the lowest possible dose, together with folic acid (5mg/day) supplementation.

Safest drugs are Lamotrigine and Carbamazepine. (avoid sodium valproate)
Still hold a 4% risk of neural tube defects.

From 36 weeks give 10mg of Vit K
neonate 1mg Vit K IM

Question 2

Which cardiac diseases are the greatest risk in pregnancy?

Answer 2

Acquired or unrecognised congenital heart defects which become apparent in pregnancy.

Cause of significant maternal mortality.

Question 3

What does an ejection systolic murmur signify in pregnancy?

Answer 3

Due to a 40% increased cardiac output, ejection systolic murmur is very common in pregnancy (90% of women)

Question 4

What are the risks of having cardiac disease in pregnancy?

Answer 4

Maternal:
Decompensation
Infection (if mother has prosthetic valves as increased bacteraemia in pregnancy)
Death

Fetal:
Pre-term labour
IUGR

Question 5

How should you manage cardiac disease in pregnancy?

Answer 5

Cardiac assessment:
Maternal echo

Treat any HTN:
Labetalol

Thromboprophylaxis:
LMWH

Labour:
C-section if you do not think maternal heart will cope with the strain.

If able to cope:

• Consider induction so you can be prepared
• Maternal cardiac monitoring
• Adequate pain relief (epidural) less pain = less high BP response = lower after load
• Monitor fluid intake and output
• Active stage 3

Question 6

What is the leading cause of maternal mortality in the UK?

Answer 6

Thromboembolic disease

Question 7

What factors further increase a women thromboembolic risk?

Answer 7

C-section (immobilised)

+ usual (PMH, FH, obesity, smoking etc)

Question 8

How does a PE present and how is it managed?

Answer 8

Tachypnoea
Tachycardia
Pleuritic chest pain
Cough/haemoptysis

Manage with ABC and thrombolytics

Question 9

What methods are taken to prevent thromboembolic events in pregnancy?

Answer 9

Antenatal prophylaxis is risk factor dependent.

Prophylaxis involves compression stockings, mobilisation and LMWH.

Question 10

What is hyperemesis gravidarum?

Answer 10

Severe nausea and vomiting in the 1st trimester of pregnancy which causes severe dehydration and electrolyte disturbances.

Question 11

What are the predisposing factors for hyperemesis gravidarum?

Answer 11

UTI

Increased hCG due to:

• Molar pregnancy
• Multiple pregnancies

Question 12

What are the major complications of hyperemsis gravidarum?

Answer 12

Electrolyte imbalance (hponatraemia ca lead to central pontine myelosis)

Renal and liver damage

Wernicke’s encephalopathy (fetal death is likely in this scenario)

Question 13

How should you investigate hyperemesis gravidarum?

Answer 13

Exclude predisposing factors:
UTI, multiple pregnancy, molar pregnancy

Urinalysis (ketones)
MSU (rule out infection)

FBC (look at haematocrit)
U&E’s (electrolytes)
LFT’s

USS

Question 14

How should you manage hyperemesis gravidarum?

Answer 14

Admit if not tolerating oral fluids and replace with IV (Hartmann’s +KCL if necessary)

Daily U&E’s

Nil by mouth for 24hrs followed by gentle reintroduction of diet.

Replace thiamine if necessary.

Antiemetics:

• Promethazine/cyclizine 1st line
• Prochloroperaine 2nd line
• Ondasetron used 3rd line but not licensed in pregnancy

If vomiting remains unresponsive conisder a trial of corticosteroids (only in the most severe cases)