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P2 > Maternal medicine > Flashcards

Maternal medicine Flashcards

1
Q

Types of thrombocytopaenia in pregnancy

A

75% gestational
-natural fall in pregnancy: dilutional, increased destruction across placenta
- usually >100, can be >70
15-20% PET/ HELLP
<5% AFLP

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2
Q

Differential diagnosis thrombocytopaeni in pregnancy

A

Gestational - usually >100, normalises post pregnancy
Immune thrombocytopaenic purpura - diagnosis of exclusion. Normal BMAT and absence of other causes. Chronic: sx of menorrhagia/ bleeding episodes/ purpuric rash
HTN related
DIC
Sepsis
Antiphospholipid sx/ SLE
Viral infection
Drug-related (e.g. unfr heparin)

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3
Q

Test panel in thrombocytopaenia

A

U&E, including urate
LFTs (+ LDH if haemolysis suspected)
Clotting time, FDP and fibrinogen
Antinuclear Ab, anticardiolipin, lupus anticoagulant
Virology screen - TORCH, HIV, malaria

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4
Q

Management of thrombocytopaenia in pregnancy

A

Monitor plt at least monthly and on admission in labour
- <80: check BP, urine, PET bloods, blood film, refer to haem, anaesthetic r/v
- <50: above but urgently
Antenatal rx:
- steroids: trial if 50-70. Usually work within 7-14/7
- IVIG works within 48hours if not sustained
- cyclosporin
- Check renal fx and monitor fetal growth (FGR with steroids)
- platelet transfusion (may cause antibodies, avoid if possible)

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5
Q

Delivery in thrombocytopaenic pt

A

XMatch and plts on hold
Aim for plt count >50 for delivery
If for spinal - inform anaesthetics
Avoid kiwi and FBS
Neonate: if maternal plt <80, cord bloods for plt count (D1 & 4), hold IM vit K
Postnatal: check plt at D6 and 6/52 postpartum

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6
Q

Immune/ idiopathic thrombocytopaenic purpura incidence and MOA

A

Chronic condition
0.1-1/1000 pregnancies
3% of thrombocytopaenia
Ab to platelet surface glycoproteins

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7
Q

Management of ITP

A

Monitor
1st: prednisolone 20mg dly (low to reduce GDM/ PPP)
2nd: no response to pred –> IVIG
Delivery: plt close to 50, should have plt on standby
- epidural threshold usually 80
Neonatal:
- AN IG can cross placenta, risk of ICH. Cord sampling D1 and D4
- avoid IM vit K

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8
Q

Diagnosing HELLP

A

Bloods: microangiopathic haemolytic anaemia, thrombocytopaenia, raised LDH, raised bilirubin and abnormal LFTs

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9
Q

Incidence of DIC in HELLP

A

approx 20%

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10
Q

Management of HELLP

A

Delivery
If DIC: FFP +/- cryoprecipitate
May worsen in first 24-48 hours then improve

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11
Q

Incidence of thrombotic thrombocytopaenic purpura

A

1 in 25000

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12
Q

Diagnosis of TTP

A

Microangiopathic haemolytic anaemia, thrombocytopaenia, neurologic sx

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13
Q

Aetiology of TTP

A

Severe vWF cleaving protein ADAMTS 13
Acquired with autoantibodies or congenital deficiency (microthrombosis)

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14
Q

Management of TTP

A

Plasma exchange to remove antibodies
1-1.5l FFP

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15
Q

Incidence of obs chole

A

0.7% gen population
1.2-1.5% asian population

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16
Q

Typical timing of onset obs chole

A

Third trimester

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17
Q

Which patients have a higher incidence of Obs Chole

A

Prev hx
CLD
Hep C
AMA
Fam hx

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18
Q

Symptoms of obs chole

A

Itch
Dark urine
Steatorrhoea/ pale stools
Jaundice

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19
Q

Atypical features of obs chole

A

Elevated ALT/ AST
Early onset- T1/T2
Rapidly progressive
Liver failure
Delayed resolution

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20
Q

Diagnosis and grades of obs chole

A

Diagnosed on hx of gestational pruritis, abnormal LFTs and BAs >19
Gestational pruritis: itching + peak BA concentration<19
Mild ICP: itching+ BA 19-39micromol/L
Mod ICP: itching + BA 40-99 micromol/L
Severe ICP: itching + BA >100

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21
Q

Maternal risks assoc w obs chole

A

Higher risk PET (3.4 - 12.2%)
Higher risk of GDM (5.9 - 13.%)
Increase in hepatobiliary disease later

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22
Q

Fetal effects related to obs chole

A

Increased risk SB
- Only in population w BA>100
- Risk of SB when BA 19-39: same as general population
- Risk of SB when BA 40-99: same risk until 38-39/40
- presence of other RF (PET/ GDM) increase r/o SB
- higher risk of SB if twin + ICP
Preterm delivery - iatrogenic d/t IOL
Inc risk of mec and fetal distress, NICU

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23
Q

Management of obs chole

A

Monitoring:
- bloods every 1-2/52
— mild: weekly approaching 38/40
— mod: weekly approaching 35/40
— severe: further testing +/- hepatology r/v
- Monitor FM
Topical emollients
Antihistamines - chlorphenamine
Ursofalk- no evidence of benefit

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24
Q

Delivery timing in obs chole

A

Mild: delivery at term
Mod: IOL 38-39/40
Severe: 35-36/40 w CEFM

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25
Q

Postnatal follow up in obs chole

A

Bloods 4-6/52
Hepatology if non-resolving or symptomatic
Inc chance of recurrence in future pregnancy
- LFTs and BAs at booking

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26
Q

Classification of liver disease in pregnancy

A

Pregnancy-related:
- Hyperemesis gravidarum
- PET
- ICP
- HELLP
- AFLP
Non pregnancy-related:
- Pre-existing liver disease
— cirrhosis + portal hypotension
— Hep B, C, E
— NAFLD
— Wilson’s disease
— AI liver disease
- Co-incident with pregnancy:
— Viral hepatitis
— Biliary disease (cholelithiasis, PSC)
— vascular alterations (eg Budd-Chiari syndrome)
— DILI
— liver transplant

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27
Q

Deranged LFTs in HG- incidence, onset, ix, rx, cx

A

0.3 - 3.6%
Onset T1/2
Ix: normal bloods & USS
Rx: supportive, anti-emetics, vit supplements
Cx: hyponatraemia, encephalopathy

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28
Q

Deranged LFTs in ICP: incidence, onset, ix, rx, cx

A

0.1 - 5%
Onset: T2/3
Ix: bloods- clotting prolonged, USS- exclude cholelithiasis
Rx: antihistamines, emollients, monitoring
Cx: PTL, SB

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29
Q

Deranged LFTs in PET. - incidence, onset, ix, rx, cx

A

5-10%
Onset> 20/40
Ix: proteinuria, bloods: haemolysis, thrombocytopaenia, inc LDH, r/o DIC, aki. USS: hepatic rupture, haematoma, infarcts
Rx: anti-HTN, MgSO4, delivery
Cx: eclampsia, mortality

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30
Q

Deranged LFTs in HELLP - incidence, onset, ix, rx, cx

A

0.2-0.6%
Onset: T2/3, postnatal
Ix: proteinuria, bloods: haemolysis, thrombocytopaenia, inc LDH>600, risk of DIC, AKI. USS: hepatic rupture, haematoma, infarcts
Rx: anti-HTN, MgSO4, delivery
Cx: liver rupture, mortality

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31
Q

Deranged LFTs in AFLP- incidence, onset, ix, rx, cx

A

0.01%
Onset T2/3, postnatal
Ix: proteinuria, bloods: thrombocytopaenia, inc LDH, prolonged PT/APTT, hypoglycaemia, AKI. USS: normal, looks brighter
Rx: correct coag, rx hypoglycaemia, delivery
Cx: fulminant liver failure, mortality

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32
Q

Swansea criteria for dx AFLP

A

6+ of the following in the absence of another explanation:
- vomiting
- abdo pain
- polydipsia/ polyuria
- encephalopathy
- high bilirubin. (>14)
- hypoglycaemia (<4)
- high uric acid (>340)
- Leucocytosis (>11)
- ascites or bright liver on ultrasound
- high AST/ ALT (>42)
- high ammonia (>47)
- renal impairment, creat > 150
- coagulopathy (PT> 14 sec, APTT> 34 sec)
- microvesicular steatosis on liver biopsy

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33
Q

Incidence of liver disease in pregnancy

A

3-5%

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34
Q

Rx Wilsons disease in pregnancy

A

Penicillamine, zinc

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35
Q

Rx biliary disease in pregnancy

A

ERCP if severe - biliary pancreatitis, symp choledocholithiasis, cholangitis
- endoscopy safe but defer to T2
Lap chole if severe sx cholecystitis

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36
Q

Rx AI hepatitis in pregnancy

A

Steroids
AZA

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37
Q

Mx liver masses in pregnancy

A

Asymptomatic haemangioma: no monitoring
Adenomas: monitor and if >5cm, refer for resection

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38
Q

Reduction in transmission of hep B with appropriate intervention

A

90-95%

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39
Q

Modifications in intrapartum monitoring with hep B

A

Minimise direct exposure
Avoid invasive monitoring

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40
Q

Neonatal hep B immunisations

A

Mother HbsAg +ve: hepB immunoglobulin and hep B vaccine ASAP, w/in 12 hours of delivery

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41
Q

Hep B results interpretation

A

HBsAG -ve, anti-HBc -ve, anti-HBs -ve = susceptible
HBsAG -ve, anti-HBc +ve, anti-HBs +ve = immune due to natural infection
HBsAG -ve, anti-HBc -ve, anti-HBs +ve = immune d/t vaccination
HBsAG +ve, anti-HBc +ve, IgM anti-HBc +ve, anti-HBs -ve = acutely infected
HBsAG +ve, anti-HBc +ve, IgM anti-HBc -ve, anti-HBs -ve = chronically infected

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42
Q

When to test for Hep C

A

HIV+
Hep B +ve
Risk factors: recreational drugs, tattoos, partner w Hep C

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43
Q

Risk of HIV transmission when on ART and VL suppressed

A

1 in 1000

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44
Q

Antenatal monitoring in HIV +ve

A

MDT
Refer to HIV service ASAP, full STI screen
Assess for co-infection
Late bookers: urgent HIV test, start ART immediately
Start ART immediately after T1
Combined screening/NIPT, avoid/ minimise invasive testing
If invasive testing required - ideally VL<50

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45
Q

Blood monitoring antepartum in HIV

A

If conceived on ART:
- min CD4 count at baseline and delivery
If started in pregnancy:
- CD4 count at start
- every 2-4/52 post starting
- Every trimester, 36/40 and delivery
VL monitoring:
- if <50, check adherence, test for resistance, optimise regimen +/- therapeutic level monitoring

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46
Q

Modifications in intrapartum management of HIV+ve mother

A

Avoid ARM, FBS
Limit ROM - w/in 24 hours
Oral ART during labour
Zidovudine no longer necessary if VL suppressed
IV zidovudine:
- PTL/ PROM < 37/40
- receiving ZDV monotherapy
- 36/40 and VL>40
- <4/52 ART
- Non-adherent to rx
- ELCS

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47
Q

MOD in HIV +ve mother

A

Determined by 36/40 VL
<40 - SVD
40-400 - guided by RFs. Duration of AN ART, VL response to ART, maternal adherence
>400 - ELCS at 38-39/40

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48
Q

Neonatal ART prophylaxis

A

4/52 ZDV if virally suppressed
Otherwise:
Triple therapy (4/52 zidovudine + lamivudine, + 2 doses NVP w/in 48-72 hours)

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49
Q

Breast feeding advise HIV +ve mothers

A

Avoid, recommendation is formula feeding
Risk on ART: 1% at 6/12, as low as 0.3-0.6% at 1 year if continue ART
Increased r/o transmission if detectable VL, advanced disease, longer duration of feeding, breast/ nipple infection, infant mouth/ gum infection
Can offer cabergoline to suppress lactation

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50
Q

Monitoring HIV +ve mums & babies if BF

A

Monthly maternal VL
Infant monthly testing for duration of BF and 2/12 post cessation

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51
Q

Postpartum cardiomyopathy defn

A

dilated cardiomyopathy of unknown origin
Occurs in final month to 5 months PP
Absence of any other identifiable cause of HF
LV systolic dysfunction w LVEF <40% with or without LV dilatation
** leading cause of direct and overall maternal death

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52
Q

Morbidity assoc w PPCMO

A

5-7%

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53
Q

Incidence of PPCMO

A

1 in 1000-4000
Highest incidence in Nigeria and Haiti
<0.1% patients

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54
Q

Risk factors for PPCMO

A

Multiparity >4
Multiple pregnancy
Obesity
Chronic HTN/ PET
Cocaine abuse
PET (22% women w PPCMO)
AMA>30

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55
Q

Pathogenesis PPCMO - 3 theories

A

2hit hypothesis
- genetic predisposition + vascular hormonal insult
- a vascular input secondary to hormonal effects of advanced pregnancy

Theories
- excessive prolactin excretion, viral myocarditis, abnormal immune response to pregnancy, stress-activated cytokines, maladaptive response to haemodynamic changes in pregnancy, prolonged tocolysis

Vasc hormonal models:
- STAT3; prolactin secretion

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56
Q

Symptoms of PPCMO

A

Dyspnoea
Orthopnoea
Unexplained cough
Palpitations
Dizziness
Leg swelling
Weight gain
Abdo discomfort - hepatic congestion, praecordial pain

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57
Q

Clinical findings in PPCMO

A

Sinus tachy
Raised JVP
Hypoxia
Lung creps
Third HS
Displaced apex
Arrhythmias - AF, flutter, VT

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58
Q

Differential diagnosis PPCMO

A

VHD
ACS
CAD
PE
AFE

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59
Q

Onset of PPCMO

A

78% 4 months after birth
9% last 2/12 of pregnancy
13% prior to a month before or 4 months after delivery
Less common <36/40

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60
Q

Ix and findings in PPCMO

A

ECG: non-specific, sinus tachy, LVH
Labs: BNF, FBC, troponin
CXR: alveolar shadowing, septal lines, cardiomegaly, pulm oedema, pleural effusion
ECHO:LVEF<45%, LVED diameter >6cm, global dilation, hypokenises, valvular dysfunction
Cardiac MRI: cardiac tissue injury
Endomyocardial biopsy: rare

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61
Q

ECHO findings in PPCMO

A

Severely impaired LV systolic function
LVEF = 20% at most
LV wall motion is globally hypokinetic
LV severely dilated at 6cm
Severe, wide, turbulent jets of mitral and tricuspid regurg
Marked bi-atrial enlargement

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62
Q

Management PPCMO

A

As for CHF:
- diuretics, B-blockers, hydralazine and nitrates, dig, anti-coags
- avoid ACEI/ARBs in pregnancy
O2
Optimise preload
Haemodynamic support w inotropes and vasopressors
Relief of symptoms
Institute therapies for LT outcomes
ECHO every 6/12

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63
Q

CVS changes in pregnancy

A

Increase in blood volume
Increase HR
Increase CO
Changes peak at 28-32/40

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64
Q

Implications and causes of mitral stenosis

A

Causes: rheumatic fever
Obstructs LV inflow
Severe MS–> decreased CO, increased LA volume, LA pressure, pulm congestions and HTN, R-sided dilatations

65
Q

CVS changes with MS

A

Mild- normally tolerate pregnancy well
Can cause decompensation of previously asymptomatic MS

66
Q

Prepregnancy counselling in pts w MS

A

Optimise MS
Correction- surgery or percutaneous intervention (intervention after 4th month if not optimised before)
Cardiology input+ ECHO
Control tachycardia - increased HR increases pressure on valve. Rx w beta-blockers but ARDS= fetal brady and IUGR

67
Q

Antepartum monitoring in pt w MS

A

MDT
Cardiology
Anaesthetics
Cardiac exam: MS murmur diminishes in pregnancy (decrease in regurg volume caused by reduction of SVR)
Serial USS: inc risk of IUGR
Fluid monitoring
Red flags- HF symptoms

68
Q

Intrapartum monitoring/ management of pt w MS

A

Mortality greatest intrapartum and PP - sudden increase in preload –> pulm oedema
Symptomatic severe MS= high risk of pulm oedema during SVD. Advise planned elective CS
Mild MS: SVD w epidural appropriate
Augment 2nd stage

69
Q

Impact of thyrotoxicosis on pregnancy

A

Miscarriage
PTL
FGR
SB
Perinatal mortality
Sinus tachy/ SVT/ AF –>. thyroid storm. around timeof delivery
R/O heart failure
Retrosternal extension of goitre

70
Q

Impact of pregnancy on thyrotoxicosis

A

Often improves
May exacerbate T1due to presence of HCG and in puerperium
No effect on opthalmology

71
Q

Incidence of thyrotoxicosis in pregnancy

A

1 in 2000

72
Q

Causes of thyrotoxicosis in pregnancy

A

Graves - most common, affects 1% of pregnancies
Toxic nodules
Toxic multinodular goitre
Subacute thyroiditis
Trophoblastic disease

73
Q

Definition and management of gestational hyperthyroidism

A

1-3% pregnancies.
Due. to stimulation of TSH receptors by b-hcg
bhcg normalises in T2
Supportive mx

74
Q

Maternal concerns if hyperthyroidism present

A

Heart failure- myocardial effects of T4 worsened by PET, anaemia, infection
Thyroid storm
PET

75
Q

Fetal effects of hyperthyroidism

A

PTL
IUGR
Fetal/ neonatal thyrotoxicosis - crossing of AB and T4
- affects 10% babies of mothers with graves
- TSH and T3 don’t cross placenta
- NB to take cord blood and neonatal TFTs
In utero: fetal tachy/ FGR/ goitre
Rx w antithyroid meds as they cross placenta
No rx: mortality 25%

76
Q

Medications. to rx hyperthyroidism

A

PTU- blocks thyroixine synthesis and converts. T4–>T3
Carbimazole - blocks thyroxine synthesis

77
Q

ADRs to hyperthryoid meds

A

PTU: maternal hepatotoxicity
Carbimazole: possible teratogen, not used in T1
Combo of both:
- rash
- agranulocytosis 0.2%
- fever
- crosses placenta
- small risk of aplasia cutis (absent skin on scalp)

78
Q

Why is PTU preferred rx in hyperthyroidism

A

Reduced level teratogenicity

79
Q

Signs and symptoms of thyroid storm

A

Fever
Tachycardia
Cardiac failure
Restlessness
Coma
Seizures
GI
* medical emergency

80
Q

Target T4 level

A

1.2 - 1.8

81
Q

Management of thyroid storm

A

TFTs
Endo review
Large dose PTU/ carbimazole
K iodide
Dexamethasone
Propanolol
Supportive: IV fluids, O2, antipyretic

82
Q

Incidence of hypothyroidism in pregnancy

A

1-3 per 1000

83
Q

Implication of overt hypothyroidism

A

0.5% fertility reduction
Increase in T1 miscarriage

84
Q

Causes of hypothyroidism

A

Hasimotos- thyroid peroxidase AB and antithyroglobulin AB
Post-surgery
Post-iodine

85
Q

Maternal concerns in light of hypothyroidism

A

PET
PTL

86
Q

Fetal concerns in light of hypothyroidism

A

Fetal requirement of T4 until 12/40 for neurodevelopment
Rare: neonatal hypothyroidism due to TSH receptor blocking antibodies crossing placenta

87
Q

Target TSH in hypothyroidism

A

<2 iu/l

88
Q

Complications of hypothyroidism - maternal

A

Anaemia
PPH
Cardiac dysfunction
PET
Placental abruption

89
Q

Complications of hypotyroidism - fetal

A

FD in labour
Prematurity/ LBW
Congenital malformations
Perinatal death
SB
Neurodevelopmental delay
Congenital hypothyroidism (if autoimmune)

90
Q

Risks assoc w sickle cell disease in pregnancy

A

Increased miscarriage
Painful crises
Worsening anaemia
Increased infections
FGR
PTL
CS
VTE

91
Q

NB hx to note in sickle cell disease

A

Crises - frequency and severity
Bone problems
Chest problems
Pulm HTN
Retinal disease

92
Q

Incidence/ prevalence of sickle cell disease

A

Higher in African, Caribbean and middle eastern descent
MC inherited condition WW
UK: 12000-15000 affected
Affects 100-200 pregnancies per year

93
Q

Preconception advise and workup- sickle cell

A

Education
Contraception
Partner haemoglobinopathy. - screen partner or CVS in pregnancy to determine fetal status
Updated vaccination status
Folic acid 5mg
Penicillin prophylaxis
Meds review: stop ACEI, stop hydroxycarbamide (hydroxyurea) 3/12 before conception
Bloods: LFTs, U&E, cardiac fx, Hb, iron studies +/- need for chelation
RC AB reg transfusions

94
Q

Mx acute painful crisis (Sickle cell)

A

MDT
No pethidine - increased seizure risk, diamorphine
IV fluids
O2
VTE prophylaxis
Awareness of other complications - ACS, stroke, acute anaemia
LMWH

95
Q

Antenatal care of pt w sickle cell disease

A

MDT
Medical review by haematology to assess end organ review
Avoid precipitating factors
Persistent vomiting –>deydration and SC crisis
Monthly MSU
Meds: FA, Fe, Px AB, aspirin, LMWH as inpatient, influenza vaccine
Crises: pain relief, hydration, use of antibiotics
US: viability at7-9/40, routine T1 and anomaly, 4 weekly growth scan from 24/40

96
Q

Intrapartum mx of SCD

A

Normal growth, no complications –> delivery after 38/40
No CI to SVD
Crossmatch if atypical AB
Position discussion if hip replacements (AVN)
Keep warm and hydrated
CEFM
Analgesia- anaesthetic RV in T3, regional for CS, no pethidine

97
Q

Postpartum mx SCD

A

Early neonatal testing if high risk
Maintain O2 sats >94%
Adequate hydration
LMWH: SVD x 7/7, CSx 6/52
Contraception: progesterone only first line, E second line
CuIUD= r/o anaemia
Depo reduces SC crises

98
Q

Preconceptual counselling in T1DM

A

Education
FA 5mg 3/12 preconception
Glycaemic control:
- fasting: 3.5-5; 1 hr postprandial <7
Aim for HbA1c <48
Do not conceive w HbA1c >86
Screening for DM complications: renal, retinopathy, neuropathy, CVS, thyroid
Med review: stop ACE, statins
Contraception until optimised
Optimise weight

99
Q

Benefits of glycaemic control in DM

A

Reduces risk of:
Miscarriage
Congenital malformations
SB
NND

100
Q

Complications of DM neuropathy antenatally

A

UTIs from bladder atony
N&V
Uterine atony. - PPH
Autonomic dysfunction –> lack of FM detection

101
Q

Complications of T1DM

A

PET : 4x more common
PTL : may require AN steroids (*compromised HGT control)
Macrosomia+/-shoulder dystocia

102
Q

Delivery timing and monitoring T1DM

A

37-38+6 if no complications
37 if complications
CEFM
1 hourly BSL

103
Q

Risk factors for GDM

A

PCOS
BMI >30
Prev macrosomic baby >4.5kg
Prev GDM
Fam hx DM
Ethnicity

104
Q

Diagnosing GDM

A

Screening: glycosuria 2+ on 1 occasion, 1+ on 2 occasions –> test
OGTT 24-28/40
OGTT: 75g 2 hrs
-fasting 5.6
- 2 hour 7.8
USS: poly/LGA

105
Q

When to assess for retinopathy in. T1DM

A

T1
16-20/40
28/40
* allow SVD

106
Q

When to get nephrology r/v

A

Creat=/> 120
uACR >30
Protein >0.5g/day

107
Q

Risk factors for LGA

A

Male
Multiparity
White
DM
GA > 41/40

108
Q

Complications of LGA

A

CS
Shoulder dystocia
Chorioamnionitis
4th degree tear
PPH
Long stay

108
Q

Longterm health risks LGA

A

Asthma
Life time risk of breast Ca
Incr BMI

109
Q

Incidence of LGA

A

15-25%

110
Q

Contributing factors to increased incidence LGA

A

Increase in:
maternal height
BMI
gestational weight gain
DM
reduced smoking
change in economy

111
Q

Definition of LGA

A

weight > 90th centile or 2SD from mean

112
Q

Definition of thalassaemia

A

Inherited disorder of globin chain synthesis
- alpha: 1-4 chains of alpha genes deleted
- beta: 1-2 of the genes defective

113
Q

Implications of alpha thalassaemia major

A

No functional alpha genes –> incompatible with life

114
Q

Management of patients with beta thal trait

A

Asymptomatic
Folic acid 5mg
Iron supplement if ferritin low

115
Q

Implications and mx beta thal major

A

Defective B gene from both parents
Require regular transfusions
Counselling NB:
- iron overload d/t rpt transfusions
- hepatic, endocrine, cardiac & bone deformities
- endo deformities: DM, hypogonadism, hypothyroid

116
Q

Pre-pregnancy end organ assessment in thalassaemia

A

Pancreas:
- diabetes screening
- serum fructosamine <300nmol/l for 3/12 preconception (= HbA1c 43)
Cardiac:
- cardio r/v w ECG, ECHO
Thyroid:
- TFTs
Liver:
- LFTs, ferriscan <7mg/g
- US to o/r cholelithiasis, cirrhosis from overload, transfusion-related hepatitis
Bone density scan

117
Q

Changes in mx if prev. splenectomy/ at risk transfusion viral hepatitis

A

Penicillin prophylaxis
Vaccination- HiB, pneumococcus, hep B

118
Q

Antenatal care thalassaemia

A

Monthly r/v until 28/40, then 2 weekly
Monthly fructosamine if diabetic
Thal major: cardiac assessment at 28/40
Monthly TFTs if hypothyroid
USS: 7-9/40, routine T1, anomaly, growth scan every 4 weeks from 28/40
Transfusions: thal major reg transfusions; aim for pre-TF Hb>10
VTE prophylaxis: abN red cell fragments and high plt count
Aspirin if plt >600, LMWH if splenectomy
Monitor for cardiac decompensation

119
Q

Mx of delivery in thalassaemia

A

MDT opinion
Check Hb prior - Xmatch 2u
Thal Maj- IV desferrioxamine 2g over 24 hours
Cont CTG
Active mx 3rd stage
LMWH post delivery

120
Q

Timing of use of desferrioxamine

A

Stop 3/12 preconception
Start after 20/40

121
Q

When to give prophylactic progesterone

A

Hx of spontaneous PTL <34/40
Pregnancy loss from 16/40
Cx length </= 25mm on TVUS from 16-24/40

122
Q

American College of Rheumatology classification criteria for SLE

A

MD SOAP BRAIN
M- Malar rash
D- discoid rash
S- Serositis
O- Oral ulcers
A- arthritis
P- photosensitivity
B- blood: all low, anaemia, leukopaenia, thrombocytopaenia
R- renal, proteinuria
A- ANA +ve
I- immunologic, anti-DNA
N0 neurologic; seizures, psych

123
Q

Implications of antiphospholipid ab

A

Assoc w art/venous thrombosis
recurrent miscarriage
FGR
fetal loss
PTL d/t placental insufficiency

124
Q

Neonatal implications anti-Ro/La and antiphospholipid abs

A

Congenital heart block
Neonatal cutaneous lupus syndrome

125
Q

SLE meds and fertility

A

Cyclophosphamide –> ovarian failure
NSAIDs –> inhibit COX, which controls ovulation –> infertility

126
Q

TOP offered/ PTL in SLE if

A

Uncontrolled HTN
- with optimal pharmacology
Active nephritis with HTN and proteinuria
Use of cyclophosphamide and mycophenolate mofetil
- teratogenic in T1

127
Q

Features of high risk SLE patient

A

History of nephritis
HTN
APS
Active SLE
Anti-Ro/La

128
Q

Meds in APLS

A

Aspirin 75mg preconception
LMWH when PT+ve

129
Q

Definition and mx lupus nephritis

A

Autoantibody complexes deposited in kidneys –> activate compliment cascade –> inflammatory response
Haematuria and rise in dsDNA titre= lupus nephritis
Usually have hx of LN
Definitive diagnosis = renal biopsy; only done in pregnancy if it would change management
Typical management: steroids, azathioprine

130
Q

Investigations for assessment of SLE disease activity pre-pregnancy

A

Cardiac:
- complications: pulm HTN, VHD, cardiomyopathy
- ECHO
Respiratory:
- cx: pulm fibrosis
- CXR, CT chest, PFTs
Renal:
- nephritis, pre-existing renal dysfx
- urine dipstick, uPCR
Haem/ immunology:
- cx thrombosis - assess risk and need for anticoag
- FBC to determine anaemia, neutropaenia, thrombocytopaenia
- autoantibody profile: aPL, anticardiolipin, anti lupus coagulant, anti-dsDNA, anti-Ro/ anti-La, complement C3/C4 levels

131
Q

Incidence of FGR with SLE

A

1 in 40

132
Q

Cause, incidence, diagnosis, prognosis congenital heart block

A

Anti-Ro/La AB cross placenta and destroy Purkinje fibres
Usually presents with fixed fetal brady 60-80bpm
Affects 2-3% pregnancy, recurrence of 16% in future pregnancies
Develops from 18-28/40, noted on fetal ECHO
Significant endomyocardial fibrosis and myocarditis –> hydrops

133
Q

Maternal ARDS antenatal low dose steroids

A

weight gain
immunosuppression
acne
GI irritation
glucose intolerance
GDM

134
Q

When to withdraw anti-epileptic drugs

A

seizure free x 2 years
minimal doses of AEDs
Negative EEG
6/12 before pregnancy

135
Q

Seizure trigger risks

A

Sleep deprivation
Stress
AED adherence
Seizure type and frequency

136
Q

Best contraceptives in epilepsy

A

CuICD, mirena, depot

137
Q

Meds to avoid in epilepsy

A

Avoid stemetil
No pethidine 0 use diamorhpine instead

138
Q

Associations with weight loss

A

Reduce incidence of:
stillbirth
HTN
macrosomia

Inc rate of VBAC

139
Q

Risks assoc. w increased BMI

A

PET
VTE
mental health
SB
difficult US
sleep apnoea
macrosomia

140
Q

Considerations in pt with bariatric surgery

A

Recommend delaying conception for 12-18/12
High risk pregnancies in consultant led care
Dietician input

141
Q

Thromboprophylaxis regimen in pregnancy in women with mechanical heart valves

A

Therapeutic LMWH in BD doses from 13/40- late third trimester
If on warfarin, change to LMWH at 34-36/40
IV unfractionated heparin before planned induction and stop once labour commences or 4-6 hours prior to planned LSCS
Recommence unfractionated herparin or prophylactic LMWH 4-6 hours post delivery
Warfarin may be recommenced after 48 hours - therapeutic LMWH should be continued until INR in therapeutic range

142
Q

Risk of VTE in pregnancy

A

6x increase
More common in left than right
More ileofemoral in pregnancy

143
Q

Interpretation of compression duplex USS for DVT

A

Negative - discontinue LMWH
Negative but high suspicion - discontinue LMWH, but repeat USS D3 and D7
Positive: LMWH x 3/12 or 6/52 postpartum (whichever first) + TEDS x 12/12

144
Q

Diagnosing PE

A

ECG: sinus tachy, right axis deviation, RBBB, peaked P waves (classical S1Q3T3 nor reliable)
CXR: atelectasis, wedge infarct, pleural effusion
ABD: hypoxia and hypocapnia
CTPA: slight increase risk of childhood Ca and low risk maternal breast Ca. Absolute risk very small

145
Q

Treatment PE

A

IV unfractionated heparin
Vena cava filter for recurrent despite full anticoagulation

146
Q

Effects of pregnancy on IBD

A

Disease in remission at time of conception = low risk for flares
2/3 pt with active disease at conception have persistant flares
Longer disease duration and use of immunosuppressives increases risk of relapse

147
Q

Effects of IBD on pregnancy

A

Similar fertility rates except if active disease or undergone major surgery
High rates of miscarriage, PTL, LBW

148
Q

Diagnosis of active IBD in pregnancy

A

CRP
Faecal calprotectin (indication of amount of neutrophil breakdown)
MRI if complex

149
Q

Medical management of IBD in pregnancy

A

No MTX or mycophenolate mofetil
Smallest dose to treat
Amniosalicylates, sulfasalazine, thiopurines = safe
High dose FA
Metronidazole for perianal CD
Corticosteroids: increase in cleft lip/ palate, maternal HTN, GDM, SGA, PROM, PTL. If on for >4/52, will need IV in labour
Biologics: stop by 30-32/40. Cause immunosuppression in neonate

150
Q

Considerations for labour and delivery in IBD

A

Episiotomy may trigger perianal disease
Active perianal disease –> LSCS
If prev on regulat po steroids, will need IV hydrocort in labour to reduce risk of adrenal crisis

151
Q

Signs and symptoms of methadone overdose

A

Resp depression
Pinpoint pupils
Hypotension
Circulatory failure
Pulmonary oedema
Coma
Death

152
Q

Benefits of methadone vs heroin

A

Improved perinatal outcomes
Higher birth weight
Fewer obstetric complications
Less PTB
Reduced neonatal morbidity

153
Q

Methadone dose

A

10mg every 4 hours as needed for withdrawal
To remain on ward 60-120 min after dose for observation
T1/2 24 hours
Highest risk of overdose mortality in first two weeks on methadone

154
Q

What is MBRACE-UK

A

Annual investigation into the deaths of women during pregnancy, childbirth and the year after birth

155
Q

At risk groups as highlighted in MBRACE

A

4 x black
3x mixed
2 x asian

AMA:
4 x >40
2 x 35-39

156
Q

Contribution of indirect causes of maternal morbidity in MBRACE

A

58%
Cardiac and neurological

157
Q

Direct causes of morbidity

A

VTE
Suicide

158
Q
A

P2 (11 decks)

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