Maternal Medicine Flashcards
Why is maternal medicine important?
- pre-existing maternal disease can have an adverse effect on pregnancy
- pregnancy can have an adverse effect on pre-existing maternal disease
- there is increased maternal / fetal mortality
What is the major indirect cause of maternal mortality and why?
cardiovascular disease
- more women with cardiac anomalies are surviving into adulthood
- there is a higher incidence of older women becoming pregnant
- higher incidence of obesity
the overall incidence of maternal deaths is 8-10 per 100,000
Why is it important to consider health inequalities in maternal mortality?
ethnic group:
- the proportion of black women giving birth and those who died do not correlate
socioeconomic status:
- due to language barriers, social barriers (e.g. children at home), higher incidence of HTN & diabetes
How is maternal death defined?
- death during pregnancy or within 6 weeks of the end of pregnancy
- this includes giving birth, ectopic pregnancy, miscarriage or termination
death can occur up to 1 year following pregnancy, but it most commonly occurs within the 6 weeks after birth
What is meant by direct maternal mortality?
- results from obstetric complications of the pregnant state
- this can be due to interventions, omissions, incorrect treatment or a chain of events
the death is directly related to the pregnancy
What is meant by indirect maternal mortality?
- death results from pre-existing disease or a disease that developed during pregnancy
- it is NOT due to obstetric causes
- but it is aggravated by the physiological effects of being pregnant
What is meant by a late maternal death?
- maternal death occurring between 6 weeks and 1 year after the end of pregnancy
- this could be due to direct or indirect maternal causes
What is meant by a coincidental / fortuitous maternal death?
- from unrelated causes which happen to occur in pregnancy or puerperium
- e.g. car accident
What is the most common direct cause of maternal mortality?
venous thromboembolism (VTE)
What are the maternal and foetal risks associated with maternal diabetes?
maternal risks:
- hypo-/hyperglycaemia
- DKA in T1DM (rare)
- hypertension, eclampsia & pre-eclampsia
foetal risks:
- congenital abnormalities
- stillbirth
- shoulder dystocia
- neonatal hypoglycaemia
- babies are usually bigger in diabetics due to increased glucose intake
- this increases the risk of shoulder dystocia / difficult delivery
- after birth, the baby may not be able to effectively manage their own blood sugars due to lack of insulin
How are patients with maternal diabetes managed differently?
- high risk groups are offered screening
- a high dose of 5mg folic acid daily is given to prevent NTDs
- planned early delivery
high risk groups - diabetic in previous pregnancy, FHx of diabetes, certain ethnic groups, large baby in past
How is diabetes in pregnancy managed?
- some women with gestational diabetes may not require medication
- only insulin and metformin are used in pregnancy
- they can be used alone or in combination
What is important to give all pregnant women with epilepsy?
folic acid 5mg daily
- this reduces the risk of NTDs
- ideally, it should be given prior to conception
How can pregnancy affect seizure activity?
What effect does this have on the fetus?
- pregnancy can worsen / change seizure activity due to:
- additional stress
- lack of sleep
- altered medication regimes
- seizures are not harmful in pregnancy, except for risk of physical injury
How is epilepsy ideally managed prior to conception?
- ideally, medication regime should be changed prior to conception
- a single anti-epileptic drug should be used for control
What are the safest anti-epileptics to use in pregnancy?
- lamotrigine
- carbamazepine
- levetiracetam
What anti-epileptics should be avoided during pregnancy?
sodium valproate:
- can cause NTDs and developmental delay
phenytoin:
- causes cleft lip / palate
What are the NICE guidelines surrounding use of sodium valproate?
- it must be avoided in girls / women unless there are no suitable alternatives
- strict criteria must be met to ensure they do not get pregnant
it is highly teratogenic
How might dose of anti-epileptic drugs need to change in pregnancy?
What needs to be given in addition?
- the doses may need to be increased
- drug clearance is faster in pregnancy
- oral vitamin K is given in the last 4 weeks
How is VTE diagnosed in pregnancy?
- through risk assessment + symptoms/signs
- Well’s score is NOT used in pregnancy (they are already high risk)
- D-dimer is NOT used (it is raised in pregnancy)
What are the risk factors for DVT in pregnancy?
- smoking
- parity 3+
- age > 35
- BMI > 30
- reduced mobility
- multiple pregnancy
- pre-eclampsia
- gross varicose veins
- family history of VTE
- thrombophilia
- IVF pregnancy
the risk is already increased due to hypercoaguability
When should VTE prophylaxis be started in pregnancy?
- prophylaxis started from 28 weeks if there are 3 risk factors
- prophylaxis started from the first trimester if there are 4+ risk factors
When might VTE prophylaxis be considered in pregnancy in the absence of other RFs?
- hospital admission
- previous VTE
- surgical procedures
- medical conditions - cancer / arthritis
- high risk thrombophilia
- ovarian hyperstimulation syndrome
When is VTE risk assessment performed?
- initial VTE risk assessment at booking
- should be performed again after birth
- additional ones may be performed e.g. if admitted to hospital
What is involved in VTE prophylaxis?
low molecular weight heparin (LMWH)
- enoxaparin
- dalteparin
- tinzaparin
unless this is contraindicated
How long is LMWH continued for in pregnancy?
When is it started?
- prophylaxis is started ASAP in very high risk patients (4+ RFs)
- it is started at 28 weeks in high risk patients (3 RFs)
- it is continued throughout pregnancy and for 6 weeks postnatally
Should LMWH prophylaxis be stopped at any time?
- LMWH should be stopped when the woman goes into labour
- it can be started immediately after delivery
UNLESS
- there is postpartum haemorrhage or presence of a spinal / epidural
What may be considered in women with contraindications to LMWH?
mechanical prophylaxis
- intermittent pneumatic compression
- anti-embolism stockings
How do you examine for DVT?
- measure the circumference of the calf 10cm below the tibial tuberosity
- more than 3cm difference between the calves is significant
What is the investigation of choice in suspected DVT?
Doppler USS
- this should be repeated on day 3 and day 7 if negative but high suspicion of DVT
What investigations are initially offered in suspected PE?
- CXR
- ECG
What are the 2 options for establishing a definitive diagnosis of PE?
Which is preferred?
- V/Q scan
- CTPA
- CTPA is the test of choice if an abnormality is detected on CXR
CTPA carries a small increased risk of breast cancer and childhood cancer in the fetus
What is the investigation if both DVT and PE are suspected?
- Doppler USS is performed initially
- if DVT is present, a V/Q scan or CTPA is NOT required
- the management for DVT and PE are the same
What is the management for VTE in pregnancy?
LMWH
- dose is based on weight at booking clinic
- should be started IMMEDIATELY before diagnosis is confirmed if there is a delay in getting a scan
- can be stopped if VTE is excluded
How long is LMWH continued for in VTE in pregnancy?
- continued throughout pregnancy and then for 6 weeks postnatally or 3 months (whichever is longer)
- can switch to warfarin or DOAC after delivery
What are the risks associated with pre-established essential HTN?
increased risk of:
- pre-eclampsia / eclampsia
- placental abruption
- haemorrhagic stroke
- foetal growth restriction +/- preterm delivery
What hypertensive medications must be stopped in pregnancy?
- ACE inhibitors (e.g. ramipril)
- ARBs (e.g. losartan)
- thiazide / thiazide-like diuretics (e.g. indapamide)
these may cause congenital abnormalities
What medications are safe to use to treat hypertension in pregnancy?
- labetalol (other beta-blockers may be harmful)
- nifedipine (and other CCBs)
- methyldopa
- alpha-blockers (e.g. doxazosin)
How is management for a hypertensive pregnant woman different?
- they have more frequent urine & BP checks to ensure they do not develop pre-eclampsia
- regular USS for foetal growth
What other medication may be given to a woman with pre-existing HTN?
aspirin
- given in early pregnancy to anyone at risk of pre-eclampsia
- improves the quality of the placenta formed by preventing microclots from forming
What is puerperal psychosis?
new onset severe mental health illness in the early postpartum period
- risk is massively increased if there is a family Hx of psychosis, personal Hx or both
What red flag features require urgent referral to a specialist perinatal mental health team?
- new thoughts of violent self harm
- sudden onset / rapidly worsening mental symptoms
- persistent feelings of estrangement from their baby
What are the adverse pregnancy outcomes associated with untreated / under-treated hypothyroidism?
- miscarriage
- anaemia
- small for gestational age
- pre-eclampsia
What is the management for hypothyroidism in pregnancy?
levothyroxine
- this can cross the placenta
- the dose needs to be increased in pregnancy
- increase by at least 25-50mcg (30-50%)
- titrate treatment based on TSH-level (aim for low-normal)
If someone has rheumatoid arthritis, what should they ensure prior to pregnancy?
- symptoms should be well controlled for at least 3 months prior to becoming pregnant
- symptoms may improve during pregnancy
- symptoms may flare up after delivery
What RA drugs are contraindicated in pregnancy?
methotrexate
- associated with miscarriage and congenital abnormalities
What drugs are considered safe in pregnancy for treating RA?
- hydroxychloroquine is first-line
- sulfasalazine is also considered sage
- corticosteroids can be used during flare-ups
