Maternal Medicine Flashcards
Does cardiac output change in pregnancy? By how much?
Yes, 30-50%.
Starting at 6 weeks and peaking at 24 weeks
Why should women not sleep on their back after 28 weeks?
Due to uterus compression of the superior vena cava.
What happens if the Superior vena cava is compressed? What is this called?
Drop in blood pressure. It is termed supine hypotension syndrome
Why are doctors concerned about supine hypotension syndrome?
It doubles risk of stillbirth
What ECG changes can be seen in the third trimester? (4)
PR interval shortens Left axis deviation T wave inversion in leads III and V2. Q waves in lead III and aVF Always compare ECGs to previous
Is pregnancy an antithrombotic or prothrombtic state?
Prothrombotic
This is to try and reduce risk of haemorrhage intro and post-partum. However, increases risk of venous thromboembolism.
What clotting factors increase in pregnancy? (5)
VII,IX,X,XII Fibrongen Plasminogen D-dimer vWF
What clotting factors are reduced during pregnancy?
XI
Protein S
Does tidal volume increase or decrease in pregnancy?
Tidal volume increase by roughly 50%
Is functional residual capacity increased or decreased in pregnancy
Decreased - this means the pregnant woman has lower oxygen reserves.
Does a pregnant woman have to change her calorie intake and when during pregnancy?
Yes it is recommended that mothers need to ingest 200 extra kcal/day in the third trimester
They are not eating for two!
What is human placental lactogen?
Produced at week 5 of pregnancy. Acts similar to growth hormone, decreases insulin sensitivity in mother and aids in breast development
What are the risk factors associate with anaemia in pregnancy? (4)
Multiple pregnancy
Poor diet
Menorrhagia (Pre pregnancy anaemia)
Short interval between pregnancy
What impact does anaemia have on the fetus? (3)
Preterm birth
Low birth weight
Iron deficiency in first year of life
What is the common cause of anaemia in pregnancy?
Iron deficiency
What physiological changes impact anaemia during pregnancy? (2)
increase in red cell ass
Increase in plasma volume
When do we screen for anaemia in pregnancy? (2)
Booking bloods
28 weeks
What is defined as anaemia in pregnancy in 1st trimester?
<110g/l
What is defined as anaemia in pregnancy in the 2nd trimester?
<105g/l
What is defined as anaemia in pregnancy in 3rd trimester?
100g/l
What is first line treatment for those diagnosed with anaemia in pregnancy?
Oral iron supplements alongside dietary advice.
What foods are recommended for those with iron deficiency?
Red meat, fish and poultry
Pulses, dark green vegetables, wholemeal bread and dried fruit.
What is the recommended. dose for iron supplements?
100-200mg daily
What vitamin aids in iron absorption?
Vitamin C. Medication should be taken with a glass of orange juice
What drinks should women be advised to avoid when taking iron supplements?
Teat and coffee as it inhibits absorption.
List side effects of taking iron? (2)
Constipation and gastric irritation
If iron deficiency presents later in pregnancy what should management be?
Active management of third stage to minimise blood loss.
What level of haemoglobin warrants a transfusion in labour?
<70g/l
What are the risk factors for Obstetric Cholestasis? (5)
Ethnicity (Indian-Asian, Paikstani Asian) FHx Personal Hx (90% recurrences rate) Hep C Multiple Pregnancy
What complications to fetus are associated with Obstetric Cholestasis?
Preterm Birth
Fetal Death
Fetal Distress
Pregnant woman presents at 20 weeks with intense itch particularly on palms and soles of feet. What is the most likely diagnosis?
Obstetric Cholestasis
What LFTs is raised in obstetric cholestasis?
Liver transaminases and/or bile acids raised
What is the management for Obstetric Cholestasis?
Weekly LFTs until delivery
Symptomatic relief with antihistamines
Ursedoxycholic acid
What gestation are women with Obstetric cholestasis recommended to be induced?
38 weeks.
What are the risk factors for acute fatty liver of pregnancy?
Multiple pregnancy
First pregnancy
Male fetal gender
G15528C genetic mutation
What complications are associated with acute fatty liver of pregnancy?
High maternal mortality
Due to secondary hepatic encephalopathy
Haemorrhage
DIC
Woman of 39 weeks gestation presents with nausea, vomiting, malaise and abdominal pain. Liver and renal function are both abnormal. Blood glucose is low. What is the most likely diagnosis?
Acute Fatty Liver of pregnancy
Woman of 39 weeks gestation presents with nausea, vomiting, malaise and abdominal pain. Liver and renal function are both abnormal. Blood glucose is low. What is the management plan?
MDT management
Coagulopathy should be corrected
IV glucose if hypoglycaemic
Once stabilised delivery should be expedited.
What are the screening bloods done at booking for hepatitis and other infections?
Hep B
HIV
Syphilis
What type of hepatitis requires babies to be vaccinated after birth? How effective is the proctection?
Hep B
90-95% effective
When is the Hep B vaccination given to babies?
4, 8, 12, 16 weeks. Final dose at 12 months.
What are the risk factors that make mothers high risk for developing Hep B?(12)
Injection drug users or partner who injects drugs
Change their sexual partners frequently
Babies born to infected mothers
Close family or sexual partner with Hep B
Anyone who receives regular blood transfusions or blood products and their carers
Any form of chronic liver disease
Chronic kidney disease
People travelling to high risk countries
Sex workers
Peoples whose work put them at high risk e.g. doctors, nurses, prison staff, dentists, lab staff.
Prisoners
Family adopting or fostering children from high risk countries.
What are the risks associated with smoking during pregnancy? (9)
Miscarriage Ectopic Pregnancy Still Birth Fetal Abnormalities Fetal growth restrictions Placental abruption Premature birth Sudden Infant death syndrome Asthma
Stopping Smoking improves breast milk quality and production.
True or False
True
Can women be given nicotine replacement therapy?
Yes it is safe to use in pregnancy.
What is the safe level of alcohol during pregnancy and when breastfeeding?
None, there is no safe level.
What are the risks of drinking heavily during pregnancy? (7)
Miscarriage Fetal growth restriction Stillbirth preterm labour learning difficulties behavioural problems fetal alcohol syndrome
What is associated with fetal alcohol spectrum disorder and fetal alcohol syndrome?
Small Head Learning difficulties Movement and balance problems ADHD Hearing and vision problems Liver, kidney, heart damage.
Women have an increased risk of up to 20 times to develop a VTE when pregnant.
True or False
False, they are 10 times more likely. This is due to physiological changes in pregnancy
What are the obstetric risk factors associated with VTE?
Multiple pregnancy Current pre-eclampsia Caesarean section Prolong labour (>24hrs) Mid-cavity or rotational operative delivery Stillbirth Preterm birth Postpartum haemorrhage To read more about other risk factors check out Cogtext chapter page 18.
Women presents at 30 weeks gestation who has collpased. She also describes new onset pleuritic chest pain and shortness of breath. Chest X-ray was normal. ECG showed sinus rhythm with RBBB. What is the most likely diagnosis?
Pulmonary Embolism. IT IS THE LEADING CAUSE OF MATERNAL DEATH IN THE UK.
Women presents at 30 weeks gestation who has collpased. She also describes new onset pleuritic chest pain and shortness of breath. Chest X-ray was normal. ECG showed sinus rhythm with RBBB. What is the treatment and for how long?
LMWH which should be continued for the rest of the pregnancy and at least 6 weeks postnatally. (There should be at least 3 months of treatment in total)
During booking a woman says she has a thrombophilia. What would be the management of this during pregnancy?
LMWH if have a risk of VTE. Should be discussed with haematologist.
A woman has presented at 8 weeks it is confirmed that she has miscarried. This is her third miscarriage and all have occurred before 10 weeks. What is the most likely diagnosis?
Antiphospholipid syndrome
What are women with antiphospholipid syndrome at risk of?
Arterial/venous thrombosis
Recurrent early pregnancy loss
Late pregrnancy loss - usually preceded by FGR
Placental abruption
Severe early onset pre-eclampsia
Severe early onset fetal growth restriction (FGR)
Who are investigated for antiphospholipid syndrome?
> 3 miscarriages <10weeks
1 fetal loss >10 weeks
preterm birth. (<34 weeks) bue to PET or placental insufficiency
How do you diagnose antiphospholipid syndrome?
Two positive blood tests 12 weeks apart.
A woman has presented at 8 weeks it is confirmed that she has miscarried. This is her third miscarriage and all have occurred before 10 weeks. What is the management for this?
Low dose aspirin and prophylactic dose of LMWH
What are the risks associated with contracting COVID-19 during pregnancy?
3 times greater risk of preterm birth, higher risk of intensive care admission and increased rate of caesarean section.
What are the risk factors associated with a hospital admission if COVID-19 is contracted during pregnancy? (5)
BAME background
Being overweight or obese
Pre-pregnancy co-morbidity such as pre-existing diabetes or hypertension
Maternal age of 35 years or older
Living in areas or households of increased socioeconomic deprivation.
What vaccinations can women have during pregnancy?
Flu, COVID and Whooping cough
Why are woman offered a urinalysis at booking?
This is due to asymptomatic bacteriuria. During pregnancy potential of colonisation increases.due to increase urinary stasis.
What is the most common causative organism for UTI?
Escheria coli (80-90%)
What are the adverse maternal outcomes associated with bacteriuria during pregnancy?
Preterm labour Prematurity Low birth weight Maternal sepsis Perinatal mortality.
What is the management for asymptomatic bacteriuria and cystitis during 1st and 2nd trimester?
Nitrofurantoin 100mg bd or 50mg qds for 7 days
What is the management for asymptomatic bacteriuria and cystitis during 3rd trimester?
Trimethoprim 200mg bd
2nd line cefalexin 500mg tds. 7 days
Do we offer test of cure for asymptomatic bacteriuria or cystitis?
Yes to confirm treatment has been effective.
