Maternal medicine

Question 1

Adnexal mass in pregnancy differentials and initial work up

Answer 1

Differential for mass
▪	EOC (50% invasive 50% borderline)
▪	Germ cell
▪	TOA
▪	Dermoid
▪	Endometrioma
▪	corpus luteum
▪	non-ovarian pathology e.g. pedunculated fibroid

Management initial
▪ MRI (avoid gadolinium)
▪ TMs (note difficult in pregnancy)
▪ Come to hospital with pain - risk of torsion
▪ GONC opinion
▪ May need surgery either in 2nd trimester (if symptomatic) or at time of CS or postpartum
why 2nd trimester (functional have resolved, organogenesis complete, hormonal function of corpus luteum replaced by placenta, spont pregnancy loss already occurred)

Question 2

Chemo in pregnancy

Answer 2

▪ Breastfeeding contraindicated
▪ Avoid up to 20 weeks
▪ Risk of IUGR, myelosuppression - stop 3 weeks pre-delivery
▪ Can delay if maternal wish in early stage (recommend not in advanced – start 2-4 weeks post op)

Question 3

High BMI in pregnancy risks

Answer 3

▪ To mum: PET HTN GDM, caesarean, perineal trauma with LGA, breastfeeding issues, PPH, PND, VTE, difficulties with analgesia in labour, wound infection, maternal death
▪ To baby: miscarriage, stillbirth, congenital abnormalities, LGA/ SGA, PTB, NICU admission

Question 4

Care beyond routine in high BMI

Answer 4

▪ GTT 16 weeks and 24-28 weeks
▪ 5-9kg weight gain
▪ MDT: obstetric lead, dietitian, anaesthetics, consider notification of theatre team in advance
▪ Consider VTE risk +/- clexane
▪ Growth scans in 3 rd trimester due to unreliable SFH 28/32/36
▪ Discuss labour and delivery, advise no such thing as emergency CS, discuss possibility of suprapannus incision depending on fat distribution
▪ PET monitoring 3 weekly from 24 weeks and fortnightly from 32
▪ Intrapartum: deliver in hospital, increased risk of emLSCS, IVL, CEFM, active 3rd stage, early epidural + notify anaesthetics
▪ Postpartum: EPND, lactation support, VTE prophylaxis, early mobilisation

Question 5

Smoking in pregnancy and stillbirth risks

Answer 5

Risks:
▪	Mum VTE, smoking related illness
▪	Fetus IUGR, stillbirth, abruption
Risk factors for stillbirth:
▪	Anatomy scan with uterine artery dopplers 
▪	Growth scans
▪	Vigilance re: FM
▪	Smoking cessation
▪	Sleep on side 
▪	Timing of birth TBC closer to due date

Question 6

IUGR risks and management

Answer 6

Risks:
o Stillbirth
o Labour intolerance + need for intervention
o Need for neonatal admission – BSL, thermoregulation, jaundice
Management:
o Vigilance re: FM
o PET screen
o Twice weekly L+D, CTG and review for movements and PET
o Fortnightly growth
o IOL by 38/40 with low threshold for earlier delivery

Question 7

SLE in pregnancy management

Answer 7

o MDT Rheum/Anaes/LMC/Obs clinic
o MSS1/screening
o HbA1C booking, GTT 16, 24 weeks
o Morphology
o Uterine art dopplers 20/40
o MFM referral and reg tertiary scans to rule out heart block and hydrops
o 4 weekly growth from 24-28 weeks – high risk for IUGR
o Regular bloods (FBC, UEC, urine protein, dsDNA and complement)
o Regular BP checks and urine dipstick – high risk for PET

Question 8

Pre-conception counselling in SLE

Answer 8

• Pregnancy best if disease quiescent, at least 6/12.
• Pregnancy says incr risk of flare by 40-60%
• No effect on fertility
• If has disease involvement, can worsen this if flares in preg eg Nephritis
Maternal risks
o HTN
o PET
o VTE
o Complications if nephritis
Fetal risks
o IUGR (related to Ro/La and ACLs)
o Prematurity
o Fetal loss
o Congenital heart block
o Neonatal lupus
Anti Ro+ve
o 1% risk fetal lupus as AB cross placenta
o Characterised by
 Anaemia, thrombocytomenia, complete heart block (hydrops fetalis, or pacemaker as a child, cutaneous lesions
o Needs tertiary scanning, highest risk braycardia 18-24 weeks
Anticardiolipin Abs
o Unable to Dx antiphosphospholipid syndrome
o No prev VTE
o Incr risk VTE
o Consider prophylactic clexane

Question 9

Effect of pregnancy on fibroid

Answer 9

Likely to increase in size in 1st trimester then remain stable or decrease in size
Most common complication is pain - more likely if fibroid is >5cm and during 2nd and 3rd trimesters related to red degeneration or torsion if pedunculated.
Care antenatally
Optimise Hb
Serial growth scans
Had myomectomy c-section

Question 10

Effect of fibroid on pregnancy

Answer 10

Prevalence 10% 
Associations or complications develop in 10-30%
PPH needing hysterectomy or MROP
Malpresentation
Preterm labour
C-section in labour
Placental abruption
Placenta preavia
IUGR

Question 11

Cystic Fibrosis gene carriers

Answer 11

Cystic fibrosis is an autosomal recessive disorder, affects trasmembrane transport in affected individuals. This causes an abnormal amount of thick and sticky mucus to buildup within the lungs, airways and digestive system, causing pancreatic impairment and recurrent respiratory infections. Ultimately life expectancy is significantly shortened due to respiratory compromise. Significant amounts of medical support and physiotherapy are required for an individual affected by CF.
- Chances of having an affected child where they are both carriers is 25%, 50% chance of having a carrier child and 25% chance of a non carrier/normal child
- Options are:
o Do nothing and proceed with trying for pregnancy, take chances as above
o Fertility referral and PIGD prior to IVF (risks associated with IVF are OHSS and multiple pregnancy) this is expensive and is not perfect at ruling out affected embryos
o Proceed with spontaneous pregnancy then undergo chorionic villus sampling 10-14 weeks gestation (risks are) or amniocentesis after 14-15 weeks gestation (risks are) – would need to consider termination at this stage if positive diagnosis and having a child with CF is not an acceptable option for you
o Consider adoption or sperm donor – would not be own genetic child

Question 12

Severe Mitral stenosis and pulmonary hypertension

Answer 12

Risks:
o Impact on pregnancy (risk of preterm labour, IUGR, stillbirth, fetal cardiac conditions)
o Pregnancy impact on disease process (increased risk of deterioration, arrythmia, heart failure and death in severe MS/pulm HTN – would offer termination as ideally would undergo balloon valvotomy pre pregnancy, prone to pulmonary oedema which can be fatal, careful fluid balance, management of taccycardia with beta blocker, refer to cardiology urgently, manage in high risk pregnancy clinic, consider clexane for VTE prophylaxis)
Management:
o Refer to cardiology
o Will need ECHO each trimester
o Consider clexane for thromboprophylaxis
o Intrapartum and delivery planning as above
Discuss pregnancy will be managed through high risk ANC with delivery in a tertiary centre, fluid balance +/- frusemide, beta blockers, telemetry, HDU/ICU, avoid Valsalva and have passive/instrumental delivery or CS, care with syntocinon and avoid syntometrine).

Question 13

Hep B in pregnancy

Answer 13

o 10% chronic carrier risk following acute infection and high chance of baby having chronic hep B via vertical transmission
o Sexually transmitted disease – recommend partner screening and treatment/vaccination of household members. Test for other STIs and Hep C.
o Vertical transmission increased if viral load high or if invasive procedures occur during antenatal or intrapartum e.g. FBS, FSE etc
Plan:
o Hb E antigen, Hb E antibody, hbv DNA (viral Load), LFTs
o Consider liver USS and coags
o If viral load >10^7 then give tenofovir from 30 weeks onwards (tenofovir no breastfeeding)
o HBIG and birth vaccine for baby
o Liase with gastroenterologist
o No mode of delivery improves outcomes, caesarean not indicated

Question 14

Epilepsy in pregnancy risks

Answer 14

• In most women, pregnancy does not alter seizure frequency (2/3 unchanged, 17% increase, 16% decrease)
• Poorly controlled (esp. >1 seizure/month) = more likely to deteriorate
• Highest risk in peripartum period (3.5% intrapartum)
• Common cause of indirect maternal death - aspiration or SUDEP
• Fetus relatively resistant to short period of hypoxia, no evidence single seizure –> adverse effects, can see fetal bradycardia post tonic-clonic seizure, long-term outcomes good
• No increased risk miscarriage or obstetric complications unless seizure –> abdominal trauma
• Status epilepticus = dangerous for mother and fetus, treat promptly/aggressively, but rare <2% of those with epilepsy
Main concern is risk of congenital abnormalities (with AED use):
o Neural tube defects (valproate = 1-3.8%, carbamazepine = 0.5-1.0%)
o Congenital heart defects (phenytoin and valproate)
o Urinary tract defects e.g. hypospadia
o Skeletal abnormalities
o Cleft palate (phenytoin and valproate)
o Fetal anticonvulsant syndrome
Counselling r/e risk for fetus of inheriting epilepsy:
• 4-5% if either parent affected

Question 15

Epilepsy in pregnancy management

Answer 15

• Review frequency and type of seizures, timing of last seizure, driving
• Review current medication and dose with neurologist to achieve either:
• If well-controlled and seizure free >2 years, consider slow withdrawal prior to conception (if appropriate)
• Monotherapy using AED that has lowest risk of adverse effects on fetal development
• Use smallest effective dose to achieve seizure control, discuss likely to need dose increase in pregnancy due to physiological changes
• Avoid sodium valproate as has highest risk of teratogenicity
Antenatal care:
• MDT care in high risk antenatal clinic
• Early anatomy review at NT scan and detailed anatomy +/- fetal ECHO
• 5mg folic acid to continue throughout pregnancy
• Serial growth scans in 3rd trimester
• Education with patient/family around care during seizure
• Consider monitoring of serum AED levels especially if frequent seizures
• Baseline level and serial for lamotrigine
• Lamotrigine often needs 2-3x increased dose during pregnancy
• Vitamin K to prevent haemorrhagic disease of the newborn (phenytoin and carbamazepine)
Intrapartum care:
• Discussion regarding intrapartum care (aim for NVD, birth at hospital), early epidural to avoid pain/anxiety which may precipitate seizure and post-partum care
• Time of increased seizure risk 1-2% respectively, women not to be alone
Postpartum:
• Care to keep mum/baby safe including changing nappies on floor, not bathing child alone, importance of sleep
• Encourage to breastfeed
• Plan for contraception

Question 16

Beta thamalasemia in pregnancy risks

Answer 16

 Anaemia

Iron overload as unable to have chelation pre-28 weeks

Increased risk of VTE

Diabetes (needs fructosamine levels checked as HbA1c inaccurate, recommend this be <300 for 3 months pre conception)

Cardiovascular disease may be present already due to iron overload and may worsen in pregnancy, risk of cardiac failure.

Liver cirrhosis

Osteoporosis

Red cell antibodies

Renal disease

IUGR, PTL, Fetal carriage of beta thallasaemia

Question 17

Care during pregnancy for beta thalasemia

Answer 17

Antenatal:

MDT involvement in a tertiary entre

Baseline assessment of organ involvement – serum fructosamine, ECHO, T2 Cardiac MRI, Liver T2 MRI, ferriscan and USS, DEXA scan

Recommend intensive chelation pre pregnancy depending on iron levels after above, need to stop this 3 months pre pregnancy

Administer vaccinations

High dose folic acid, vitamin D, aspirin

Early dating scan, monthly review

Monthly fructosamine if diabetic, TFTs 6 weekly if hypothyroid

Cardiac review at 28 weeks to assess need for chelation in pregnancy

Serial growth scans 28/32/36 

Monthly Hb

Antenatal transfusion to reach pre transfusion target of 100

Clexane during hospital admissions

Intrapartum/Postpartum:

Vaginal delivery in tertiary centre

Senior obs

CFM/IVL/G+S, may need cross match

Chelation in labour with IV desferrioxamine

Active 3rd stage

Post partum clexane 6/52

Breastfeeding

Restart regular chelation

Question 18

vWD in pregnancy

Answer 18

levels usually increase antepartum
Levels usually decrease postpartum
Optimise Hb antenatally
Risk of PPH for 3 weeks
In delivery aim for levels >50iu/dl & 50%
desmopressin theoretically causes contractions

Question 19

Kell antibodies

Answer 19

Kell negative 90 percent of population .AntIbodies to Kell can only be formed if the Patient
is Kell ANTIGEN NEGATIVE
Fetus will only be affected if it is Kell antigen positive
Check Husbands genotype if Kell antigen p
ositive subsequent pregnancies at risk
Kell anti bodies do not correspond to titres
They act by inhibiting erythropoiesis not haemolysis
Check fetal antigen to see if Kell antigen positive
If positive then
Serial USS for developing fetal hydrops
MCA PSV
fortnightly from 18 weeks
developing anaemia
Cordocentesis /fetal sampling if su
spicion
Can have IUT

Question 20

Bloods to test for coagulopathy

Answer 20

Factor V Leiden
Protein S & C
Antithrombin III
Prothrombin gene mutation
Lupus anticoagulant
anti-cardiolipin antibodies

Question 21

H1N1 in pregnancy

Answer 21

MDT involving ICU
FBC, ABG, nasopharyngeal swabs, CXR
O2, fluid resus and nurse in left lateral
Anti-viral oseltamivir 75mg BD 5 days +/- antibiotic cover
Steroid cover
Infection control for staff and isolates woman
fetal impacts:
- Congenital impacts secondary to hyperthermia (cleft palate/NTDs/cardiac)
- Miscarriages
- SGA
- PTB
- Fetal Death

Question 22

Crohn’s in pregnancy

Answer 22

Crohn’s risks to pregnancy:
PTB
IUGR 
miscarriage
SB
Risk of Pregnancy on Crohn’s
most will not have a flare
most at risk of flare if have active disease at conception or new dx crohns in pregnancy
Effect on pregnancy:
Risk of relapse per year is similar in pregnancy to outside 30-50%

Question 23

WHO cardiac classification
Class IV
Condition are associated with extremely high risks of maternal mortality or severe morbidity
Pregnancy is Contraindicated

Answer 23

Severe mitral stenosis
Symptomatic severe aortic stenosis
Bicuspid aortic valve with ascending aorta diameter > 5cm
Marfan’s syndrome with aorta >45mm
Severe systemic ventricular systolic dysfunction with LVEF < 30%
NYHA III-IV
Native severe coarctation
Fontan circulation with associated complications
Significant pulmonary arterial hypertension

Question 24

DKA in pregnancy

Answer 24

Diabetic ketoacidosis is a complex disordered metabolic state characterised by:
• hyperglycaemia (capillary blood glucose >11mmol/l)
• acidosis (venous pH <7.3 and/or venous bicarbonate <15)
• ketonaemia or ketonuria (capillary ketones >3 mmol/l or urine ketones more than 2+)
Manage:
1. Complete a clinical assessment to look for any precipitating factors such as intercurrent infections, fetal growth restriction or pre-eclampsia.

2. Admit to the consultant-led delivery suite and initiate investigations (urinalysis ± MSU, FBC, venous glucose, urea and electrolytes, bicarbonate and others as indicated).
3. You should have a high suspicion of ketoacidosis. Symptoms and signs that would suggest this include nausea, vomiting, abdominal pain, hyperventilation, ketotic breath, tachycardia, hypotension and disorientation. If ketoacidosis is suspected the woman should be admitted to an obstetric high-dependency unit or level 2 critical care ward for medical and obstetric care.
4. IV access, hydration (aggressive volume replacement is required in ketoacidosis) and a sliding scale regimen of insulin and KCl in normal saline to regulate glycaemic control. Careful attention to electrolyte balance is required particularly potassium.
5. Liaise with diabetes/medical for further management.
6. Continuous fetal heart monitoring. Once hyperglycaemia and any acidosis has been reversed and maternal stabilisation is acheived, fetal compromise may no longer be evident.

Question 25

Hyperthyroidism

Answer 25

Fort hose with good control on anti-thyroid medications carbimazole <15mg/day and PTU <150mg/day or with previously treated and in remission the maternal and fetal outcome is usually good and unaffected by thyrotoxicosis. Graves often improves during pregnancy but may flare PP.
Neonatal thyrotoxicosis results from transplacental passage of thryoid stimulating antibodies. IT occurs in 1% of babies with mothers’ with past history of Graves’ more common with active disease in third trimester. Symptoms include poor weight gain, tachy, jittery, eye changes and mortality 15%.
If antibodies detected in late pregnancy then cord blood and neonatal TFTs should be performed.
If condition develops in utero - fetal tachy, goitre or IUGR. Mortality 25%.
If hyperthyroid woman is stable do TFTs each trimester. New diagnosis 4 weekly or 4 weeks after any change in medication.

Question 26

Drugs in hyperthyroid

Answer 26

Carbimazole can be associated with aplasia cutis 17:1000)
PTU can cause liver failure but less congenital malformations (8:1000)
Very little excreted in breastmilk so both are sfe in breastfeeding.
B-Blockers symptom control. Long term can lead to IUGR and fetus should be monitored with USS.

Question 27

Thyrotoxic crisis

Answer 27

Rare sudden and life threatening condition in poorly controlled or undiagnosed hyperthyroid. This sudden flare of symptoms can be precipitated by labour, infection or surgery.
Symptoms and signs include: fever, tachycardia, hypertension, high output cardiac failure, GI upset.
Principles of management:
- TFTs
- Admission to HDU/ICU
- MDT including endocrine
- Treat with high doses of PTU and potassium or sodium iodide (to suppress conversion of t4 to t3)
- Supportive cares IV fluids, O2 and paracetamol

Question 28

Hypothyroid

Answer 28

Untreated associated with infertility, miscarriage and fetal loss.
For those with an adequate replacement maternal and fetal outcome very good.
Very little thyroxine passes through the placenta to the fetus so it is not at risk of thyrotoxicosis.
Check TFTs once each trimester and 4 weeks after any dose adjusements.
Untreated overt hypothyroidism associated with reduced IQ and neurodevelopment delay.
Neonatal hypothyroid (1:180,000) from transplacental passage of TSH receptor blocking antibodies which are more common in those with atrophic should be suspected if neonatal goitre present. TSH is measured as part of the Guthrie.

Question 29

Poor prognostic factors in COVID 19

Answer 29

Drowsy/agitated/confused
Pulse >110bpm
BP high >150/90 or low <90/60
RR >20
Sats <94%
Severe COVID:
RR >30
O2 sats <92% with 4L NP O2

Question 30

Maternal complications in COVID 19

Answer 30

Pneumonia, ARDS, respiratory failure
Placental insufficiency - IUGR
Pre-term birth (iatrogenic)
AKI
VTE
Cardiac - myopericarditis, arrythmia
Neurological headaches, strokes
Vasculitis

Question 31

Management of COVID 19

Answer 31

Clexane (>12 hours to delivery)
MDT: physicians, anaesthetics, HDU, ID and NICU
CXR
PO steroids if needing O2
IV fluids
O2 for sats >94%
Remdesivir >12 weeks and safe in breastfeeding
Follow up with:
Growth scan 14-21 days after discharge and ANC
IOL by 40 weeks
Vaccinate 4 weeks after recovery or give booster
Clexane 10 days

Question 32

COVID vaccination

Answer 32

Pregnant women have a higher risk of severe illness e.g. hospitilisation, admission to ICU and invasive ventilation.
This is due to physiological change sin pregnancy such as reduced lung function, increased O2 consumption and humoral antibody led immunity.
Pfizer mRNA does not contain live virus and if given in pregnancy evidence of antibody in cord blood and breast milk offer passive immunity to baby.
COVID also increases risk for the baby e.g. stillbirth and premature birth. Vaccination is the best way to prevent these risks and can be done in any trimester.
It does not affect fertility and miscarraige rates. It does not increase risk of VTE and no precautions need to be taken.

Question 33

Mitral stenosis in pregnancy

Answer 33

↓ preload to L) ventricle and dilation of L) atrium which can lead to → atrial fibrillation and risk of thrombus formation
Prone to pulmonary oedema as a result of ↑ L) atrial pressures – can be exacerbated by fluid overload or tachycardia
In pregnancy →↑ HR and ↑ hypervolemia. This will further exacerbate the restrictive diastolic LV filling with mitral stenosis and lead to →↑ left atrial pressure
↑ risks of pulmonary congestion
↑ risks of atrial arrhythmia e.g. AF →↑ Stroke risks
Inability to produce adequate ↑CO required in pregnancy
↑ risks of HF

Question 34

Mitral stenosis care: preconception, AN, IP and PP

Answer 34

preconception:
Review medication
ECHO, BP, ECG
Establish functional status to ascertain maternal risks
Prev hx of pulmonary oedema, arrhythmias, TIA, stroke
Central cyanosis
Mitral valve area and extent of MS, LVEF
Women with severe valvular disease should be offered corrective surgery prior e.g. Valvotomy or valvuloplasty

Antenatal:
MDT
B blockers are good for slowing heart rate and allow the L) atrium more time to empty
AF should be treated with digoxin and B blockers and anticoagulants
If pulmonary oedema this should be managed with admission, treatment with oxygen, morphine and diuretics
Each visit
History or signs of functional class deterioration
Arrhythmias
Pulmonary congestion
If indication for percutaneous mitral balloon valvotomy
Ideally after 20 w (organogenesis) before mid-to late third trimester due to gravid uterus interfering with catheter access
IOL or planned delivery if severe risks

Intra-partum:
Delivery in tertiary center
Avoid supine and lithotomy positions that could ↓ preload
Regional anaesthesia to reduce the spikes in CO during labour
Avoid fluid overload or overdoing IV fluids, may want to give frusemide (risk of pulmonary oedema)
Risk of heart failure due to low fixed output state – avoid hypotension or PPH as may result in heart failure
Telemetry in labour and metoprolol and clexane – cover for LA thrombus, AF risk and tachycardia control
Maintain euvolemia
Short second stage ± instrumental

Post-partum:
Avoid syntometrine as this leads to rapid autotransfusion
Consider diuretics if pulmonary oedema from increase in pre-load post-delivery

Question 35

Pulmonary hypertension

Answer 35

High resistance system in the lungs means there is backup into the R) heart and reduced supply to the L) heart
Maternal mortality rate up to 40%, High risks of RV failure, ventricular arrhythmia, sudden death
Management:
MDT
TOP should be considered
Start VTE prophylaxis
Consider admission for O2 bed rest and diuretics
May need caesarean delivery.
Intensive care environment
Telemetry
Avoid hypovolaemia by maintaining preload – can monitor RV filling with echo
Avoid acidosis
Avoid VTE
Avoid systemic vasodilation (take care with regional anesthesia and drug administration e.g. syntocinon)
PP - Aggressive diuresis

Question 36

Marfan’s

Answer 36

Autosomal dominant - 50% chance of affected child. PIGD or CVS/Amnio for diagnosis.
80% have cardiac involvement ; Mitral regurgitation, aortic root dilatation, mitral valve prolapse
Risks of aortic dissection and rupture in Pregnancy 10% >4cm risk.

Pre-conception:
ECHO - aortic root dilatation (If aortic root >4cm pregnancy is contraindicated and should have elective aortic root replacement prior to pregnancy)
BP and optimise health
Contraception

Antenatal:
MDT
Beta-blockers ↓ rate of dilatation and aortic stress
Strict BP control (SBP <130)
Regular ECHOs to be carried out throughout pregnancy to monitor the aortic root (4-8w)
Growth scans of fetus
Anesthetic review

Intra-partum:
CS if aortic root >4.5cm or rapidly dilating root
Deliver in Hospital with Cardiothoracic support if aortic root >4cm or history of aortic dissection
No strong consensus of mode of delivery -European Society of Cardiology state can consider Vaginal delivery if <4cm, with epidural and short second stage to minimise Valsalva
Continue beta blockers during labour and early epidural recommended

Post-partum:
Aortic dissection risks persist therefore need monitoring for complications. Advice to present if chest or back discomfort
Contraception

Question 37

Rheumatic heart disease

Answer 37

Significant cause of heart disease in indigenous communities.
Symptoms: malaise, rash, migratory polyarthritis and heart murmurs.
Evidence of recent streptococcal infection is needed for diagnosis.
After episodes of infection accelerated degeneration of cardiac valves occurs mot commonly mitral or aortic.

Question 38

Peripartum cardiomyopathy

Answer 38

Development of Heart failure in last month of pregnancy or within 5 months PP.
Diagnosis echo showing global dilatation in all 4 chambers, LVEF <45%.
More common in older multiparous women who breastfeed and have a history of hypertenison, PET or multiple pregnancy with poor nutrition.
Symptoms: dyspnoea, fatigue, chest pain, palpitations and oedema.
Invetsigations:
ECG, Chest X-ray and echo.

Management:
Deliver if antenatal
If haemodynamically stable, vaginal delivery with close monitoring and epidural anaesthesia is recommended
CS if women requires inotropic therapy or mechanical circulatory support
Anticoagulants due to risk of intracardiac thrombus and arrhythmias
Manage arrhythmias - beta blockers, digoxin
HF, Inotropes if required or vasopressors, Optimising preload
Diuretics - frusemide, hydralazine
Vasodilator; Nitrates
And Ace-i after delivery
Oxygen supplement if required
Careful fluid balance with restriction if needed.

Question 39

Effect of pregnancy on pre-existing diabetes on woman

Answer 39

Increase hypoglycaemia
Early pregnancy as more insulin sensitive, tighter control requirements and unawareness. More likely in HbA1c 33 or less.
Increase in insulin requirements
Particularly 28-32 weeks and in T1DM
Diabetic ketoacidosis
Especially in hyper-emesis, infections, use of b agonists or steroids. Women should be given a meter.
Retinopathy
Progression in pre-existing disease 2-fold due to increased retinal blood flow due to tight control. Associated with hypertension and PET risk. Offer screening first appointment and 28 weeks
Nephropathy
Increased risk of progression. PCR >30 before 20 weeks. If severe Cr >177 then progression to end stage renal disease is 33%. The risk of deterioration increases with co-existing hypertension.
Autonomic neuropathy
Gastroparesis, orthostatic hypotension or unawareness of hypos.
Normochromic normocytic anaemia
May only respond to EPO
Infection
UTI, oral, wound etc
PET
30% increased risk related to glycaemic control at beginning of pregnancy
Obstetric intervention
SVD only 24%. C-section risk 67%. 47% end up with c-section in labour and half of those are for fetal distress

Question 40

Effect of pre-existing diabetes on baby

Answer 40

Miscarriage: Linked to poor control

Major congenital abnormalities
Particularly to heart and neural tube defects. 
25% risk with HbA1c 100. 
HbA1c level is above 86 mmol/mol (10%) 
HbA1c 48 no increased risk

Macrosomia (>4kg or>90th centile)
Shoulder dystocia 8%
Insulin is growth promoting so maternal hyperglycaemia leads to neonatal hyperglycaemia. Increased risk linked to post prandial BSL >6.7

Preterm labour
Twice the risk majority iatrogenic

Perinatal morbidity and mortality
30% vs 10% risk of admission to NICU
Neonatal hypoglycaemia

Risk of unexplained still birth
Chronic hypoxia/acidosis caused by fetal insulinaemia increased fetal O2 requirements. Placenta vasculopathy. Risk highest at term.

Question 41

Care of pre-existing diabetes in pregnancy

Answer 41

Pre-conception/1st trimester
Dating scan 7-9 weeks
Discuss complication for both mum and baby
Provide education and advice regarding optimal blood sugar control. Review by Endocrine.
Screen for complications e.g. retinopathy, nephropathy and neuropathy
Retinal screening if not within last 3 months
See in joint DiP clinic 2 weekly
Measure HbA1c to convey level of risk
2nd trimester:
Aspirin and Calcium for PET
Fetal anatomy and echo
3rd trimester:
4 weekly growth scans
IOL 37-38+6 weeks
Intrapartum:
Deliver at a hospita;
CEFM
Check blood sugars hourly once in labour aim 4-7nmol/L
Peads present at birth
Early feeding of baby, check neonatal blood sugars at 2-4 hours
PP endocrine review as insulin requirements can rapidly fall
Contraception to plan next pregnancy

Question 42

GDM

Answer 42

Risk factors for GDM: screen at 16-18 weeks and 24-28 weeks:
• Previous GDM
• Ethnicity: Indian, Asian, Moari
• 1st degree relative diabetes or sister GDM
• BMI >35
• Age >40
• Previous fetal macrosomia >4.5kg >90th centile
• PCOS
• Drugs: corticosteroids, antipsychotics
Results:
Fasting level >5.1
1 hour level >10.0
2 hour level >8.5
HbA1c >48
Women diagnosed with GDM should have regular ongoing surveillance as they have an approximate 30% risk of a recurrence of their GDM in a subsequent pregnancy and up to 50% risk of developing type 2 DM within 10‐20 years.
Offer metformin to women with gestational diabetes if blood glucose targets are not met using changes in diet and exercise within 1–2 weeks.
Offer immediate treatment with insulin, with or without metformin , as well as changes in diet and exercise, to women with gestational diabetes who have a fasting plasma glucose level of 7.0 mmol/litre or above at diagnosis.

Question 43

Thrombocytopenia work up

Answer 43

Diagnosis platelets under 150
Pccurs in 7-12% women
DDx: Gestational, immune, hypertensive PET/HELLP, ALFD, thrombotic thrombocytopenia purpura, inherited or sepsis induced.
Examination:
Petechiae, purpura, ecchymoses
Lymphadenopathy
Splenomegaly
Gestational most common 70% unlikely to go <70
Only need other investigations when drop below 70
Check 4 weekly till 36 week then 2 weekly after
Gestational should normalise 6 weeks PP
Gestational does not normally affect neonate

Question 44

Management of thrombocytopenia if under 70

Answer 44

If drop below 70 investigate for alternative causes:
FBC, U&Es, LFTs, Co-ags and group and screen
uPCR - PET
Glucose - ALFP
LDH, reticulocyte count - HELLP
Leukemia - Blood film
Anti-nuclear antibody, antiphospholipid antibody - APLS/SLE
CMV/Toxo/Rubella/Hep/HIV - infective causes
Vitamin B12/folate
TFTs
Direct Coombs test - heamolytic anaemia

MDT - anaesthetics, heam, obs
Consider trial of PO Prednisone 20mg/d - stress dose in labour 50mg Q6H and 6 hours PP IV
C-section for obs indications only
Avoid FBS, FSE, midcavity/rotational ventouse
Epidural issues
Increased risk of PPH - Active management of 3rd stage, IVL G+H deliver in hospital
VTE prophylaxis avoid clexane if <50.

Neonatal issues:
10-15% of neonates born to mothers with ITP have significant thrombocytopenia at birth.
Risk of intracranial heamorrhage during delivery <1%
Cord blood for platelet count at delivery if <20 consider IVIG

Question 45

Breast cancer in pregnancy

Answer 45

Investigation:
Ultrasound of breast: Safe
Core biopsy rather than FNA: Local anaesthetic.
Histology rather than cytology as proliferative change renders this inconclusive in many pregnant women.
Mammogram: Requires fetal shielding. Less sensitive in pregnant woman due to higher breast density, increased water and loss of fat. Lack of contrast – high false negative rate.

Management considerations:
- Suitable for chemotherapy from second trimester
Prior to second trimester associated with fetal anomalies.
- Radiotherapy contraindicated
May necessitate early delivery or induction of labour to allow full treatment of the woman.
- Mastectomy is suitable at all gestations
Reconstruction of breast should be delayed till afterwards to avoid prolonged analgesia and optimum symmetry of breasts.
- Breastfeeding
As long as not on Chemotherapy and depending on surgery should be encouraged to breastfeed if she can has no effect on stage or recurrence of breast Ca.
- Timing of delivery
The birth of the baby should be timed after MDT discussion but can go to full term and aim for vaginal delivery. If she is on chemotherapy birth should be more than 3 weeks after last dose (reduce risk of neonatal myelosuppression)
- Contraception
Should have non hormonal method e.g. Copper coil.
- Next pregnancy
Should wait at least 2 years after treatment as this is when the risk of cancer recurrance is highest. If taking adjuvant therapy such as Tamoxifen this needs to be stopped 3 months before conception.

Question 46

Cervical cancer in pregnancy

Answer 46

MDT: Gynae, gynae onc, radiation oncologist, oncologist, pathologist, social work, MFM, anaesthetics
Bloods: FBC UEC G&H
CXR: Metastases & Abdominal shielding
Pelvic examination +/- EUA
Consider: MRI to examine bladder/bowel/abdomen pelvis if anything more than microinvasive or 1A1 disease suspected

Consider lymphadenectomy for women at high
risk for LN mets who want to continue pregnancy
Pelvic lymph node dissection then cone/trachelectomy if negative
Or no PLND and chemo after cone/trachelectomy
Or delay treatment altogether until delivery if nodes negative

Indication for immediate definitive treatment regardless of GA:
- progression in pregnancy
- maternal decision for TOP ( cogniscent of local laws)
- documented LN metastases
Continuing pregnancy:
- Microinvasion
 cone
- Larger disease
 neoadjuvant chemo 3 weekly to 35ish weeks then deliver at term if poss, then complete surgical staging postpartum
Consider caesarean hysterectomy in more advanced cancer in women completing family weighing up increased morbidity of procedure
- Metastatic disease
RT contraindicated in pregnancy

Delivery
- Microinvasion and 1A1
 NVD ok, avoid episiotomy (for local mets)
- 1B1 recommend caesarean to reduce haematogenous spread

Surveillance
- Pelvic exam monthly +/- MRI

Question 47

Renal transplant advice

Answer 47

Advise stable on medications for 1-2 years before becoming pregnant so maintenance level of immunosuppressants can be reached.
Successful pregnancy outcome for those who reach second trimester is 95%.
Outcomes dependent on graft function at conception.
No adverse effects with Cr under 100.
Cr >130 65% graft survival at 3 years.
Chance of graft rejection 2% - check with USS and then renal biopsy.

Risk of PET, IUGR and pre-term delivery.
Vaginal delivery preferred mode of birth. Have higher rates of c-section. If c-section birth estimated 1-2% risk of surgical damage to the kidney or transplanted ureter.
Prophylactic IV antibiotics for any surgical procedure including episiotomy

Folic acid (5mg if diabetic or other risk factors)
Vitamin D supplement
Low dose aspirin and calcium supplementation
FBC for anaemia
can have Fe tabs and erythropoietin
VTE risk assessment
Nephrotic range proteinuria PCR >300 should be offered clexane prophylaxis
Review every hospital admission and postpartum.
Baseline PET bloods and PCR

Control BP
Monitor for PET regularly.
Monitor renal function regularly
Measure with creatine not eGFR.
Regular growth scans, uterine artery dopplers at anatomy.
Treat UTIs if develop to prevent pyelonephritis.

Strict fluid balance in labour.
IV hydrocortisone in labour if taking steroids antenatally.

Question 48

Sickle cell anaemia

Answer 48

Effect of pregnancy on sickle cell:
Increased frequency of sickling
Increased frequency of painful crises
Increased susceptibility to infection (hest, urinary tract)

Effect of sickle cell on pregnancy  
Fetal risks  
Miscarriage 
FGR 
PTB 
Fetal distress 
Perinatal mortality 4x  
Maternal risks  
PET 
Placental abruption 
Thromboembolism 
Bone marrow embolism (acute chest syndrome)  
Increased mortality  

Management 
MDT team  
Partner screening 
5mg folic acid throughout pregnancy 
Prophylactic penicillin 250mg BD 
Regular Hb, urinanalysis and BP 
Regular growth scans  
Thromboprophylaxis if needed  
Mode of birth for obstetric indications 
Continue penicillin 
Ensure adequate pain relief  
Continuous CTG 
Maintain hydration  
Consider post-partum thromboprophylaxis

Question 49

Heamophillia and VWD

Answer 49

Haemophilia A (factor 8): severity constant in a family  
Haemophilia B (factor 9): more mild 
vWD type 1: mild vWF and Factor VIII deficiency  
vWD type 2: qualitative defect, type 2b associated with thrombocytopenia 
vWD type 3: severe  

Effect of pregnancy on haemophilia and vWD
FVIII and vWF increase with increasing gestation so there is an improvement in both
Both rapidly fall after delivery
No increase in F IX levels in pregnancy (haemophilia B)
2b vWD thrombocytopenia worsens in pregnancy
3 vWD no increase in vWF with gestation

Effect of haemophilia and vWD on pregnancy
Risk of excessive bleeding with early pregnancy miscarriage, ectopic, CVS
Increased risk PPH (20% in vWD, mainly secondary)
Spontaneous bleeding in affected fetus is rare
Traumatic delivery may cause ICH and cephalohaematoma

Severity of disease:
Bleeding disorder correlates with factor level: factor level >/= 40 is safe tor vaginal birth
If <40 then need Rx at the onset of labour

Management
Pre-pregnancy
MDT care, management with haematologists, haemophilia team
Genetic counselling
For haemophilia: confirm history and carrier status, consider PIGD
For vWD: assess subtype, avoid aspirin and NSAIDs in type 2b, offer hep A and B vaccine, assess the effect of DDAVP

Pregnancy
Test factor XIII and vWF levels in early pregnancy, 2nd and 3rd trimesters, and prior to delivery as may not need treatment if factor levels rise in pregnancy
Anaesthetic review to discuss regional analgesia
In labour- FBC and G&H, factor XIII and vWF
If levels <50 then start treatment at the onset of labour
DDAVP
Recombinant factor 8
TXA
If levels <40 then avoid IM injection
Avoid regional if factor levels not in normal range
When risk of affected baby:
Atraumatic unassisted vaginal delivery
Avoid FSE and FBS
Avoid ventouse and difficult forceps delivery
Low cavity forceps by an experienced operator is preferable to a difficult LSCS
Repair perineal trauma promptly
Monitor for bleeding from wound sites and for primary/secondary PPH
Maintain factor levels >40 for 3-4 days after vaginal delivery and 4-5 days after LSCS
Contraceptive advice
Cord bloods from baby for factor assay and avoid IM injections until haemophilila/vWD status known

Question 50

Thalassemia

Answer 50

Alpha thalassemia
Effect of pregnancy on alpha thal trait
Nil

Effect of alpha thal trait on pregnancy  
If the fetus is unaffected- normal outcome 
If fetus is affected- alpha thal major  
Fetal risks  
4 gene deletion: incompatible with life  
Severe anaemia  
Hydrops fetalis  
Hepatosplenomegaly  
Abnormal organogenesis  
Cardiac failure  
Polyhydramnios  
Placentomegaly  
Stillbirth  

Maternal risks (secondary to fetal and placental hydrops)  
HTN 
PET  
Placental abruption  
Obstructed labour  
APH and PPH  
DIC  

Beta thalassemia
Effect of pregnancy on beta thal
Trait: mild anaemia in pregnancy
Major: worsened disease and transfusion requirement
Effect of beta thal on pregnancy
Trait: normal outcome
Major: if Hb maintained >100, well chelated and no bone abnormalities, then good outcome
If maternal anaemia or inadequate transfusion: IUGR, preterm birth, fetal hypoxia
Maternal complications of iron overload
If short stature with bone abnormality then increased risk of cephalopelvic disproportion and LSCS

Management:
Transfusion dependent anaemias- general  
Pre-pregnancy  
Bloods: 
FBC, reticulocytes, ferritin, folate 
Hb electrophoresis  
UEC  (renal fx) 
First AN bloods (check antibody status)  
Screen iron overload: TFTs glucose LFTs 
Screen for iron overload: ECHO, fibroscan, TFTs glucose, ECG, LFTs 
Vaccines: Hep A & B vaccines  
Commence 
Folic acid 5mg/day  
Stop 
iron chelation therapy 3/12 prepregnancy after aggressive chelation (desferrioxamine in T2-T3 is potentially OK but aim to avoid)  
DO NOT prescribe iron

Partner screening
Alpha thal: fetal risk 25% if partner has alpha thal trait
Beta thal: fetal risk 25% if partner has beta thal trait, sickle cell trait or HbE
Counsel on maternal/fetal risks
Antenatal
If partner screening positive offer prenatal diagnosis
Continue folate 5mg/day through pregnancy
In splenectomy: give prophylactic penicillin and consider thromboprophylaxis
Monthly Hb checks
Check antibody status
Consider transfusion if Hb <100

Question 51

Thrombophilia Screen

Answer 51

Anticardiolipin Ab
Lupus antico-agulant
Protein C
Protein S - free
Anti-thrombin III
Factor V Leiden
Prothrombin mutation

Question 52

Obstetric Cholestasis

Answer 52

A multifactorial condition of pregnancy characterised by puritis in the absence of skin rash with abnormal LFTs neither of which have an alternative cause and both of which remit following delivery.

Risks to mum:
Sleep deprivation
GDM
PET
Abnormal Co-ags (?vitamin K)
Risks to fetus:
- Spontaneous and iatrogenic preterm birth
- Meconium stained liquor
- NICU amission
- Stillbirth if bile salts >100

Monitor weekly LFTs and bile salts
Emoillents calamine lotion or aqueous with menthol
URSO ?benefit as per PITCHES
Antihistamines

Bile salts >100 0r ALT >200 consider delivery
bile salts >40 offer IOL 38 weeks
Bile salts <40 offer IOL at term

Postnatal check LFTs return to normal at 3-6 weeks via GP
Lack of long term sequalae
High recurrence 45-90%
Caution with COCP

Question 53

Bipolar and Puerperal psychosis

Answer 53

Puerperal psychosis occurs in one to two per 1000 deliveries. It is more common in women with a close family member who has suffered from the condition. Those with a history of bipolar disorder also have an increased (one in five) chance of developing puerperal psychosis. Women with a history of bipolar disorder and a family history of postpartum psychosis in a first-degree relative have a 74% chance of developing postpartum psychosis.
All women with a history of psychotic disorder should be under the care of a psychiatric team ideally a perinatal mental health team.
Ideally, these women should have preconceptual counselling.
A birth-planning meeting at 32 weeks of gestation should be arranged to coordinate the health professionals involved in the care and to plan for delivery and the postpartum period.
Bipolar affective disorder is characterised by episodes of low mood and mania; approximately 20–30% of women with bipolar will develop postpartum psychosis.
Postpartum psychosis is a psychiatric emergency and women require assessment by a trained psychiatrist. In particular, they should pay attention to suicidal or infanticidal ideas. Up to 78% of women with puerperal psychosis have delusional ideas about their infant. While awaiting a psychiatric assessment woman should not be left alone and ideally should be supervised by a 1:1 registered mental health nurse (RMN).
Puerperal psychosis is particularly responsive to ECT but first line treatment is with Lithium.
Approximately 35–65% of women who suffer with an episode of postpartum psychosis will develop bipolar disorder, and mood stabilisers are recommended for the long-term treatment of bipolar disorder.

Question 54

SSRIs e.g. citalopram, fluoxetine

Answer 54

First choice
Safe in pregnancy and breastfeeding
Risks:
- Persistent pulmonary hypertension of newborn
- Congenital abnormalities (CHD)
- Poor neonatal adaptation syndrome

Question 55

Lithium

Answer 55

Ebstein’s anomaly of heart
Poor neonatal adaptation syndrome
Thyroid dysfunction in neonate
Toxicity
Monitor levels monthly till 36 weeks then weekly
Complete passage via placenta
signs of toxicity - GI, tremor, agitation, ataxia, sizeures/coma
Peads at delivery
With-hold dose 24 hours prior to delivery
Recommence at pre-pregnancy doses
Cord blood for lithium levels

Question 56

Antipyschotics e.g. valproate, carbimazepine, lamotrigine

Answer 56

valproate & carbemazepine - increased NTD
Lamotrigine - cleft palate
- Poor neonatal adaptation syndrome 
- metabolic syndrome 
- GDM
- Hyperprolactinaemia

Question 57

FGM

Answer 57

Associated psychological, urinary, sexual and dysmenorrhoea as well as to prevent complications if/when pregnant.
Antenatal de-infibulation recommended normally 2nd trimester. Performed with local anaesthetic +/- epidural or general anaesthetic individualise for psychological risk factors.
Principles:
The incision should extend anteriorly enough to allow visualisation of the external urethral meatus but not far enough to injure the buried clitoris or clitoral stump (potential for heavy bleeding). The skin edges should be approximated with a fine absorbable suture.
Obstetric care is at increased risk of obstructed labour, prolonged second stage and c-section. Perineal trauma and assess need for episiotomy after deinfibulation.
Re-suturing in New Zealand and Australia is against the law. Female genital mutilation is prohibited by specific legislation in all States, Territories of Australia and in New Zealand. Moreover, there are provisions for mandatory reporting of children at risk.
The strongest risk factor for a woman to have undergone FGM is her country of origin, and specifically where she spent her childhood years. FGM is most commonly performed in parts of Africa (especially north-eastern Africa), with migrants from Somalia, Sudan, Ethiopa, and Egypt comprising the majority of affected women seen in Australia and NZ. In Sudan and Somalia more than 80% of women have undergone FGM (mostly Type 3). It is, however, also practised in a few populations in the Middle East and Asia.
Potential gynaecological consequences of FGM include:
• Impaired sexual function: apareunia, dyspareunia, anorgasmia, reduced sexual pleasure
• Urinary tract: recurrent urinary tract infections, prolonged voiding time, difficulty obtaining a mid-stream urine specimen for analysis
• Recurrent vaginal infections, infertility
• Menstrual problems: haematocolpos, retained menstrual clots, dysmenorrhoea
• Local scar complications: keloid, dermal cysts
• Local pain: chronic neuropathic pain
• Difficulty with minor gynaecological procedures: eg Pap smear, bladder catheterisation
• Psychological: post-traumatic stress disorder, anxiety, and depression

Question 58

HIV in pregnancy

Answer 58

It is estimated that if women with HIV infection are identified during pregnancy and use a combination of interventions the risk of HIV perinatal transmission can be reduced from 30% to less than 1%. These interventions include: antenatal care, maternal antiretroviral treatment in pregnancy and labour, consideration of mode of delivery, antiretroviral treatment for neonates and avoidance of breastfeeding.
MDT care: High risk pregnancy team, obstetric physician, ID/sexual health and anaesthetics.
Preconception:
Standard dose of folic acid (except dolutegravir or co-trimoxazole).
All pregnant women are offered the whooping cough vaccine. You will also be recommended to have vaccinations for hepatitis B (if you are not immune) and pneumococcus, and the flu vaccine (in the autumn/ winter months).
Antenatal:
A minimum of one CD4 cell count and viral load at baseline and one at delivery.
In women who commence cART in pregnancy, an HIV viral load should be performed 2–4 weeks after commencing cART, at least once every trimester, at 36 weeks and at delivery.
The combined screening test for fetal aneuploidies and non-invasive prenatal testing (NIPT) for those who screen as high risk is recommended as this has the best sensitivity and specificity and will minimise the number of women who may need invasive testing.
OGTT 24- 28 weeks as some medications increase risk of GDM.
External cephalic version (ECV) can be offered to women with plasma viral load.
Intrapartum:
Mode of delivery women with fully suppressed viral load should be able to give birth vaginally. Elective caesarean section has been shown to reduce the risk of perinatal transmission and should be offered at 38 weeks to pregnant women if the HIV viral load is VL > 1,000 copies/mL.
Intravenous zidovudine if the viral load is not suppressed adequately (> log 3 (1000) copies per ml) then it may be recommended for the woman to have an intravenous zidovudine infusion during labour or prior to caesarean section delivery. Zidovudine infusion continues until the baby is born and the cord is clamped. The infusion is then stopped.
The following invasive interventions should be avoided in labour as they may increase the risk of vertical transmission:
• Fetal scalp electrodes
• Lactate fetal blood sampling
• Artificial rupture of membranes
• Instrumental delivery (rotational delivery and ventouse)
There is a possible increase in transmission of HIV with > 4 hours of ruptured membranes. Labour should be augmented promptly following spontaneous rupture of membranes. A low threshold for treatment of maternal intrapartum pyrexia.
Care of the baby
The following steps are routine:
• Avoidance of breastfeeding
• Washing baby in a warm bath soon after birth and before Vitamin K or any intramuscular medications
• Intramuscular Vitamin K administration
• Administration of oral antiretroviral therapy within a few hours of birth. The neonate should be prescribed antiretroviral therapy for 4 weeks to reduce perinatal transmission of HIV virus.
• Avoidance of any live vaccinations e.g. BCG
• The baby should remain under paediatric care