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Y4 - GOSH > Maternal Medicine > Flashcards

Maternal Medicine Flashcards

1
Q

Why is maternal medicine important?

A
  • 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
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2
Q

What is the major indirect cause of maternal mortality and why?

A

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

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3
Q

Why is it important to consider health inequalities in maternal mortality?

A

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
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4
Q

How is maternal death defined?

A
  • 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

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5
Q

What is meant by direct maternal mortality?

A
  • 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

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6
Q

What is meant by indirect maternal mortality?

A
  • 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
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7
Q

What is meant by a late maternal death?

A
  • maternal death occurring between 6 weeks and 1 year after the end of pregnancy
  • this could be due to direct or indirect maternal causes
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8
Q

What is meant by a coincidental / fortuitous maternal death?

A
  • from unrelated causes which happen to occur in pregnancy or puerperium
  • e.g. car accident
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9
Q

What is the most common direct cause of maternal mortality?

A

venous thromboembolism (VTE)

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10
Q

What are the maternal and foetal risks associated with maternal diabetes?

A

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
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11
Q

How are patients with maternal diabetes managed differently?

A
  • 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

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12
Q

How is diabetes in pregnancy managed?

A
  • 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
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13
Q

What is important to give all pregnant women with epilepsy?

A

folic acid 5mg daily

  • this reduces the risk of NTDs
  • ideally, it should be given prior to conception
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14
Q

How can pregnancy affect seizure activity?

What effect does this have on the fetus?

A
  • pregnancy can worsen / change seizure activity due to:
  1. additional stress
  2. lack of sleep
  3. altered medication regimes
  • seizures are not harmful in pregnancy, except for risk of physical injury
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15
Q

How is epilepsy ideally managed prior to conception?

A
  • ideally, medication regime should be changed prior to conception
  • a single anti-epileptic drug should be used for control
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16
Q

What are the safest anti-epileptics to use in pregnancy?

A
  • lamotrigine
  • carbamazepine
  • levetiracetam
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17
Q

What anti-epileptics should be avoided during pregnancy?

A

sodium valproate:

  • can cause NTDs and developmental delay

phenytoin:

  • causes cleft lip / palate
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18
Q

What are the NICE guidelines surrounding use of sodium valproate?

A
  • 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

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19
Q

How might dose of anti-epileptic drugs need to change in pregnancy?

What needs to be given in addition?

A
  • the doses may need to be increased
  • drug clearance is faster in pregnancy
  • oral vitamin K is given in the last 4 weeks
20
Q

How is VTE diagnosed in pregnancy?

A
  • 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)
21
Q

What are the risk factors for DVT in pregnancy?

A
  • 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

22
Q

When should VTE prophylaxis be started in pregnancy?

A
  • prophylaxis started from 28 weeks if there are 3 risk factors
  • prophylaxis started from the first trimester if there are 4+ risk factors
23
Q

When might VTE prophylaxis be considered in pregnancy in the absence of other RFs?

A
  • hospital admission
  • previous VTE
  • surgical procedures
  • medical conditions - cancer / arthritis
  • high risk thrombophilia
  • ovarian hyperstimulation syndrome
24
Q

When is VTE risk assessment performed?

A
  • initial VTE risk assessment at booking
  • should be performed again after birth
  • additional ones may be performed e.g. if admitted to hospital
25
Q

What is involved in VTE prophylaxis?

A

low molecular weight heparin (LMWH)

  • enoxaparin
  • dalteparin
  • tinzaparin

unless this is contraindicated

26
Q

How long is LMWH continued for in pregnancy?

When is it started?

A
  • 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
27
Q

Should LMWH prophylaxis be stopped at any time?

A
  • 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
28
Q

What may be considered in women with contraindications to LMWH?

A

mechanical prophylaxis

  • intermittent pneumatic compression
  • anti-embolism stockings
29
Q

How do you examine for DVT?

A
  • measure the circumference of the calf 10cm below the tibial tuberosity
  • more than 3cm difference between the calves is significant
30
Q

What is the investigation of choice in suspected DVT?

A

Doppler USS

  • this should be repeated on day 3 and day 7 if negative but high suspicion of DVT
31
Q

What investigations are initially offered in suspected PE?

A
  • CXR
  • ECG
32
Q

What are the 2 options for establishing a definitive diagnosis of PE?

Which is preferred?

A
  • 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

33
Q

What is the investigation if both DVT and PE are suspected?

A
  • 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
34
Q

What is the management for VTE in pregnancy?

A

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
35
Q

How long is LMWH continued for in VTE in pregnancy?

A
  • continued throughout pregnancy and then for 6 weeks postnatally or 3 months (whichever is longer)
  • can switch to warfarin or DOAC after delivery
36
Q

What are the risks associated with pre-established essential HTN?

A

increased risk of:

  • pre-eclampsia / eclampsia
  • placental abruption
  • haemorrhagic stroke
  • foetal growth restriction +/- preterm delivery
37
Q

What hypertensive medications must be stopped in pregnancy?

A
  • ACE inhibitors (e.g. ramipril)
  • ARBs (e.g. losartan)
  • thiazide / thiazide-like diuretics (e.g. indapamide)

these may cause congenital abnormalities

38
Q

What medications are safe to use to treat hypertension in pregnancy?

A
  • labetalol (other beta-blockers may be harmful)
  • nifedipine (and other CCBs)
  • methyldopa
  • alpha-blockers (e.g. doxazosin)
39
Q

How is management for a hypertensive pregnant woman different?

A
  • they have more frequent urine & BP checks to ensure they do not develop pre-eclampsia
  • regular USS for foetal growth
40
Q

What other medication may be given to a woman with pre-existing HTN?

A

aspirin

  • given in early pregnancy to anyone at risk of pre-eclampsia
  • improves the quality of the placenta formed by preventing microclots from forming
41
Q

What is puerperal psychosis?

A

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
42
Q

What red flag features require urgent referral to a specialist perinatal mental health team?

A
  • new thoughts of violent self harm
  • sudden onset / rapidly worsening mental symptoms
  • persistent feelings of estrangement from their baby
43
Q

What are the adverse pregnancy outcomes associated with untreated / under-treated hypothyroidism?

A
  • miscarriage
  • anaemia
  • small for gestational age
  • pre-eclampsia
44
Q

What is the management for hypothyroidism in pregnancy?

A

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)
45
Q

If someone has rheumatoid arthritis, what should they ensure prior to pregnancy?

A
  • 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
46
Q

What RA drugs are contraindicated in pregnancy?

A

methotrexate

  • associated with miscarriage and congenital abnormalities
47
Q

What drugs are considered safe in pregnancy for treating RA?

A
  • hydroxychloroquine is first-line
  • sulfasalazine is also considered sage
  • corticosteroids can be used during flare-ups

Y4 - GOSH (62 decks)

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