Maternal medicine Flashcards by Tom Grainger

Which two anti-epileptic drugs do not seem to cause neurodevelopmental delay?

Carbamazepine
Lamotrigine

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What is the effect of pregnancy on seizures in women with epilepsy?

Two thirds will not have seizure deterioration in pregnancy

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What are the adverse effects of anti-epileptic drugs on the mother during pregnancy?

Depression, anxiety, neuropsychiatric symptoms

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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

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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

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What is the drug of choice for termination of intrapartum seizures?

Benzodiazepines

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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

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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

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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

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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

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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

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Which anti-epileptic drug may have a reduced effect when taking alongside oestrogen-containing contraceptives, possibly resulting in reduced seizure threshold?

Lamotrigine

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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

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What is caused by B thalassaemia trait? (the heterozygous state)

Mild to moderate microcytic anaemia

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Why is puberty often delayed in children with B thalassaemia major?

The pituitary gland is very sensitive to iron overload

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What is the cause of subfertility in women with B Thalassaemia major?

Hypogonadotrophic hypogonadism

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What is the commonest cause of death in women with B Thalassaemia?

Cardiac failure

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From which country do the majority of individuals in the UK with B Thalassaemia major originate?

Cyprus

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What conditions are women with B Thalassaemia at risk of in pregnancy?

Cardiomyopathy
Diabetes
Hypothyroidism
Hypoparathyroidism

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Which fertility intervention is likely to be needed in patients with B Thalassaemia major who have had suboptimal iron chelation?

Ovulation induction with Gonadotrophins

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Which iron chelating agent can be used in pregnancy for women with B Thalassaemia?

Desferrioxamine

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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)

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What cardiac investigations should be performed for a woman with B Thalassaemia prior to pregnancy?

Echocardiogram, ECG and T2 cardiac MRI

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What cardiac T2* value suggests minimal iron in the heart?

T2* >20ms

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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?

1. Pneumococcus 2. 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?

1. An early scan at 7-9 weeks 2. 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?

1. If their platelet count increases above 600 2. 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?

1. Chorionic villus sampling at 11-14 weeks 2. 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?

1. Avoid instrumental birth with either forceps or ventouse 2. 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?

1. Stroke volume increases in the first half of pregnancy 2. 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

What is the maternal mortality rate in the UK?

8.76 per 100,000

What is the rate of miscarriage following maternal infection with Rubella in the first trimester?

20%

Babies born to mother's taking which anti-epileptic should receive IM Vitamin K?

Carbamazepine (or any other enzyme-inducing AED)

What is the most common benign liver tumour?

Hepatic haemangioma

What risks are increased with spinal cord injury above T10?

Perception of fetal movements is altered Perception of uterine contractions is altered Higher frequency of malpresentation

What medication is used for control of bladder spasms in women with spinal cord injury in pregnancy?

Oxybutinin

What is the incidence of worsening spasticity in pregnancy for women with spinal cord injury?

12%

What is the effect of anti-TNFs on the risk of fetal malformations?

Risk of fetal malformations for women taking anti-TNFs similar to risk in the general population

Which anti-TNF is safe in all trimesters of pregnancy?

Certolizumab

What is the lifetime risk of rupture of a hepatic adenoma?

17%

What is the best monitoring test for diabetes in pregnant women with b-Thalassaemia?

Serum Fructosamine

What percentage of women with Myasthenia Gravis will have a remission of symptoms in pregnancy?

30%

What is the most common presentation of autonomic dysreflexia?

Hypertension and bradycardia

What is the singular indication for Warfarin in pregnancy?

Mechanical heart valve