Maternal medicine Flashcards
Which two anti-epileptic drugs do not seem to cause neurodevelopmental delay?
Carbamazepine
Lamotrigine
What is the effect of pregnancy on seizures in women with epilepsy?
Two thirds will not have seizure deterioration in pregnancy
What are the adverse effects of anti-epileptic drugs on the mother during pregnancy?
Depression, anxiety, neuropsychiatric symptoms
How should the foetus be monitored in pregnancy when a woman is taking anti-epileptic drugs?
Serial growth scans should be used to detect SGA babies
What is the optimal timing and mode of birth for women with epilepsy?
The diagnosis of epilepsy is not an indication for Caesarean section or induction of labour
What is the drug of choice for termination of intrapartum seizures?
Benzodiazepines
What advice should be given about opioid use in labour for women with epilepsy?
Pethidine should be used with caution
Diamorphine should be favoured over Pethidine
When is the highest risk time for seizures in pregnancy and how should this be managed?
The postnatal period is the time of highest risk for seizures
Sleep deprivation, stress and pain should be minimised
What advice should be given about breastfeeding for women taking anti-epileptic drugs?
Breastfeeding should be encouraged
The risk of adverse cognitive outcomes is not increased in children exposed to anti-epileptics through breast milk
What should women taking enzyme-inducing anti-epileptic drugs (Carbamazepine, Phenytoin) be advised about contraception?
Efficacy of oral contraceptives, implants and transdermal preparations may be reduced
Copper coil, Mirena and Depot are favoured
What should women taking non-enzyme-inducing anti-epileptic drugs (Valproate, Levetiracetam, Gabapentin) be advised about contraception?
All methods may be offered to these women
Which anti-epileptic drug may have a reduced effect when taking alongside oestrogen-containing contraceptives, possibly resulting in reduced seizure threshold?
Lamotrigine
What differentiates a woman with beta thalassaemia major from a woman with beta thalassaemia intermedia?
Beta thalassaemia major is those women who require more than 7 transfusion episodes per year
What is caused by B thalassaemia trait? (the heterozygous state)
Mild to moderate microcytic anaemia
Why is puberty often delayed in children with B thalassaemia major?
The pituitary gland is very sensitive to iron overload
What is the cause of subfertility in women with B Thalassaemia major?
Hypogonadotrophic hypogonadism
What is the commonest cause of death in women with B Thalassaemia?
Cardiac failure
From which country do the majority of individuals in the UK with B Thalassaemia major originate?
Cyprus
What conditions are women with B Thalassaemia at risk of in pregnancy?
Cardiomyopathy
Diabetes
Hypothyroidism
Hypoparathyroidism
Which fertility intervention is likely to be needed in patients with B Thalassaemia major who have had suboptimal iron chelation?
Ovulation induction with Gonadotrophins
Which iron chelating agent can be used in pregnancy for women with B Thalassaemia?
Desferrioxamine
What blood test is used to monitor glycaemic control in diabetic women with Thalassaemia?
Serum fructosamine
(HbA1c is not reliable as it is diluted by transfused blood)
What cardiac investigations should be performed for a woman with B Thalassaemia prior to pregnancy?
Echocardiogram, ECG and T2 cardiac MRI
What cardiac T2* value suggests minimal iron in the heart?
T2* >20ms
What liver iron concentration should be aimed for in pregnant women with B Thalassaemia?
<7mg/g
Above what liver iron concentration should iron chelation be started and at what gestation?
If liver iron exceeds 15mg/g prior to conception, Desferrioxamine should be started between 20-28 weeks gestation
What advice should be given about bisphosphonates in pregnancy?
All bisphosphonates are contraindicated in pregnancy
Which vaccinations are specifically recommended for pregnant women who have had a splenectomy?
- Pneumococcus
- Haemophilus influenza B
Which antibiotic should be given as prophylaxis for women who have had a splenectomy and are allergic to Penicillins?
Erythromycin
How often should serum Fructosamine be monitored for pregnant women with B Thalassaemia and diabetes?
Monthly
What is the recommended schedule of ultrasound scanning during pregnancy for women with B Thalassaemia?
- An early scan at 7-9 weeks
- Serial growth scans every 4 weeks from 24 weeks
What pre-transfusion haemoglobin should be targeted for pregnant women with B Thalassaemia?
Hb >= 100
What antenatal thromboprophylaxis is recommended for women with B Thalassaemia who have undergone splenectomy?
Aspirin 75mg OD
When should LMWH be added to the thromboprophylaxis regime for women with B Thalassaemia who have had a splenectomy?
- If their platelet count increases above 600
- If they are hospitalised
What medications are required intrapartum for women with B Thalassaemia?
IV Desferioxamine 2g over 24 hours should be administered for the duration of labour
Which clotting factor is affected in Haemophilia A?
Factor VIII
Which clotting factor is deficient in Haemophilia B?
Factor IX
What percentage of neonatal males with severe haemophilia have no family history of haemophilia?
50%
What diagnostic options should be offered to carriers of severe haemophilia with a male foetus at risk?
- Chorionic villus sampling at 11-14 weeks
- 3rd trimester amniocentesis if no testing previously performed
What factor VIII/IX levels should be aimed for prior to surgical or invasive procedures or in miscarriage for women carrying severe haemophilia?
At least 0.5iu/ml
What medication can be used antenatally to increase factor VIII levels and what adjunctive management must be observed?
a. Desmopressin (DDAVP)
b. Must be fluid restricted to 1L over 24 hours
How can factor IX levels be raised in pregnancy?
The only option is recombinant Factor IX
How should breech birth be managed in males affected or possibly affected by Haemophilia?
ECV should be avoided
What intrapartum rules should be observed for women with a male fetus confirmed to have haemophilia?
- Avoid instrumental birth with either forceps or ventouse
- Avoid fetal blood sampling and fetal scalp electrode
If clotting factor levels in a haemophilia carrier are low intrapartum, what concentration of Factor VIII/IX should be targeted?
1iu/ml
How long should Factor VIII/IX levels be monitored for following vaginal birth for women with Haemophilia?
3 days following spontaneous birth
5 days following instrumental birth or Caesarean
What imaging is required for all neonates with severe or moderate haemophilia prior to discharge following birth?
Cranial ultrasound
What are type 1, type 2 and type 3 von Willebrand’s disease?
Type 1: partial quantitative
Type 2: qualitative
Type 3: severe quantitative
In addition to von Willebrand Factor antigen levels, what else must be checked at booking and in the third trimester for women with VWD?
Factor VIII levels
What condition contraindicates DDAVP usage in von Willebrand Disease?
Pre-eclampsia
Which electrolyte disturbance must be monitored for following administration of DDAVP?
Hyponatraemia
What may develop following administration of DDAVP specifically in women with type 2B von Willebrand Disease?
Thrombocytopaenia
What medication should be given as sole therapy for women who either carry Haemophilia or have VWD with factor levels >0.5iu/ml?
Tranexamic acid
What is the inheritance pattern of factor XI deficiency?
Autosomal, both dominant and recessive forms exist
Which population are at significantly increased risk of Factor XI deficiency compared to the general population?
Ashkenazi jews
Which subgroup of women with Factor XI are most at risk of PPH?
Those with blood group O
What is the genetic abnormality in Bernard Soulier Syndrome?
Abnormality in Glycoprotein Ib-IX-V
What is the mode of inheritance of Bernard Soulier Syndrome?
Autosomal recessive
What percentage of pregnancies are complicated by maternal cardiac disease?
1-4%
What changes in pregnancy contribute to the 40-50% increase in cardiac output?
- Stroke volume increases in the first half of pregnancy
- There is a gradual increase in heart rate in the second half of pregnancy
By how much does Creatinine fall in pregnancy?
35umol/L
What percentage of pregnancies are complicated by AKI?
1.4%
What condition should be considered where there is thrombocytopaenia, anaemia and AKI?
Microangiopathic haemolytic anaemia
Above what value for serum urea is renal replacement therapy indicated in pregnancy and why?
Urea >17 should trigger referral for RRT as Urea is teratogenic
What are the rules for dose adjustment of magnesium sulfate in AKI?
If urine output falls below 20mls/hr or if Cr >90, a 50% dose reduction in magnesium sulfate should be considered
(MgSO4 is renally excreted)
How are thrombotic thrombocytopaenic purpura and haemolytic uraemic syndrome differentiated clinically?
TTP - primarily neurological symptoms
HUS - redominant renal dysfunction
How are TTP and HUS differentiated biochemically?
TTP has abnormalities in ADAMTS13
HUS has dysregulation of complement pathways
What is the function of ADAMTS13 and why does its dysfunction lead to TTP?
ADAMTS13 breaks down vonWillebrand factor
Defective ADAMTS13 results in formation of platelet-rich thrombi
What percentage of women with haemolytic uraemic syndrome in pregnancy go on to need renal replacement therapy?
76%
How are TTP and HUS managed?
FFP infusion or plasma exchange
Which monoclonal antibody is licensed for treatment of atypical haemolytic uraemic syndrome?
Eculizumab
What is the incidence of acute fatty liver of pregnancy?
5 per 100,000 pregnancies
Why is AKI common in acute fatty liver of pregnancy?
In AFLP there is renal tubular fatty acid deposition
What are the symptoms and laboratory findings which suggest acute fatty liver instead of HELLP?
Low serum glucose
Raised serum ammonia
Prodromal vomiting
Which immune suppressing drug commonly used for SLE is teratogenic and what should it be changed to in pregnancy?
Mycophenolate mofetil should be changed to azathioprine
When can NSAIDs be used during pregnancy?
Prior to 30 weeks in conditions such as pleuritic pain, fibroid degeneration or musculoskeletal pain
Which bacterial infection can cause chorioamnionitis in the absence of ROM?
Listeriosis
What is the increase in risks to the pregnant woman of general anaesthetic over regional anaesthesia?
17-fold increase
What should intra-abdominal pressure be limited to during laparoscopy in pregnancy?
12mmHg
Why is the second trimester a better time than the third trimester for semi-elective abdominal surgery?
The rate of preterm delivery is 1% instead of 9%
Which biological depletes B-cells with its anti-CD20 function?
Rituximab
Which class of biologicals are particularly high risk for reactivation of latent TB?
Anti-TNFs
Which anti-TB agents can be safely used in pregnancy?
Isoniazid and Rifampicin
Which cancer are women on anti-TNFs particularly at risk of?
Cervical cancer
Studies have shown that which biological can improve rates of pregnancy in women undergoing IVF?
Adalimumab
Infliximab, Adalimumab and Golimumab are monoclona antibodies in which subclass?
IgG1
Infliximab should be stopped by what gestation?
16 weeks
Etanercept and Adalimumab should be stopped by what gestation?
28 weeks (3rd trimester)
What advice is given pre-pregnancy to women on Rituximab?
Avoid for 12 months prior to pregnancy
Which receptor facilitates entry of SARS-COV-2 into host cells?
ACE-2
How long before birth should COVID vaccination ideally happen for antibody transfer?
> 9 days
