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MRCOG Part 2 > Maternal medicine > Flashcards

Maternal medicine Flashcards

1
Q

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

A

Carbamazepine
Lamotrigine

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2
Q

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

A

Two thirds will not have seizure deterioration in pregnancy

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3
Q

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

A

Depression, anxiety, neuropsychiatric symptoms

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4
Q

How should the foetus be monitored in pregnancy when a woman is taking anti-epileptic drugs?

A

Serial growth scans should be used to detect SGA babies

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5
Q

What is the optimal timing and mode of birth for women with epilepsy?

A

The diagnosis of epilepsy is not an indication for Caesarean section or induction of labour

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6
Q

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

A

Benzodiazepines

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7
Q

What advice should be given about opioid use in labour for women with epilepsy?

A

Pethidine should be used with caution
Diamorphine should be favoured over Pethidine

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8
Q

When is the highest risk time for seizures in pregnancy and how should this be managed?

A

The postnatal period is the time of highest risk for seizures
Sleep deprivation, stress and pain should be minimised

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9
Q

What advice should be given about breastfeeding for women taking anti-epileptic drugs?

A

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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10
Q

What should women taking enzyme-inducing anti-epileptic drugs (Carbamazepine, Phenytoin) be advised about contraception?

A

Efficacy of oral contraceptives, implants and transdermal preparations may be reduced
Copper coil, Mirena and Depot are favoured

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11
Q

What should women taking non-enzyme-inducing anti-epileptic drugs (Valproate, Levetiracetam, Gabapentin) be advised about contraception?

A

All methods may be offered to these women

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12
Q

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

A

Lamotrigine

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13
Q

What differentiates a woman with beta thalassaemia major from a woman with beta thalassaemia intermedia?

A

Beta thalassaemia major is those women who require more than 7 transfusion episodes per year

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14
Q

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

A

Mild to moderate microcytic anaemia

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15
Q

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

A

The pituitary gland is very sensitive to iron overload

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16
Q

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

A

Hypogonadotrophic hypogonadism

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17
Q

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

A

Cardiac failure

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18
Q

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

A

Cyprus

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19
Q

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

A

Cardiomyopathy
Diabetes
Hypothyroidism
Hypoparathyroidism

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20
Q

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

A

Ovulation induction with Gonadotrophins

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21
Q

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

A

Desferrioxamine

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22
Q

What blood test is used to monitor glycaemic control in diabetic women with Thalassaemia?

A

Serum fructosamine
(HbA1c is not reliable as it is diluted by transfused blood)

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23
Q

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

A

Echocardiogram, ECG and T2 cardiac MRI

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24
Q

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

A

T2* >20ms

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25
Q

What liver iron concentration should be aimed for in pregnant women with B Thalassaemia?

A

<7mg/g

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26
Q

Above what liver iron concentration should iron chelation be started and at what gestation?

A

If liver iron exceeds 15mg/g prior to conception, Desferrioxamine should be started between 20-28 weeks gestation

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27
Q

What advice should be given about bisphosphonates in pregnancy?

A

All bisphosphonates are contraindicated in pregnancy

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28
Q

Which vaccinations are specifically recommended for pregnant women who have had a splenectomy?

A
  1. Pneumococcus
  2. Haemophilus influenza B
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29
Q

Which antibiotic should be given as prophylaxis for women who have had a splenectomy and are allergic to Penicillins?

A

Erythromycin

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29
Q

How often should serum Fructosamine be monitored for pregnant women with B Thalassaemia and diabetes?

A

Monthly

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30
Q

What is the recommended schedule of ultrasound scanning during pregnancy for women with B Thalassaemia?

A
  1. An early scan at 7-9 weeks
  2. Serial growth scans every 4 weeks from 24 weeks
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31
Q

What pre-transfusion haemoglobin should be targeted for pregnant women with B Thalassaemia?

A

Hb >= 100

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32
Q

What antenatal thromboprophylaxis is recommended for women with B Thalassaemia who have undergone splenectomy?

A

Aspirin 75mg OD

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33
Q

When should LMWH be added to the thromboprophylaxis regime for women with B Thalassaemia who have had a splenectomy?

A
  1. If their platelet count increases above 600
  2. If they are hospitalised
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34
Q

What medications are required intrapartum for women with B Thalassaemia?

A

IV Desferioxamine 2g over 24 hours should be administered for the duration of labour

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35
Q

Which clotting factor is affected in Haemophilia A?

A

Factor VIII

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36
Q

Which clotting factor is deficient in Haemophilia B?

A

Factor IX

37
Q

What percentage of neonatal males with severe haemophilia have no family history of haemophilia?

A

50%

38
Q

What diagnostic options should be offered to carriers of severe haemophilia with a male foetus at risk?

A
  1. Chorionic villus sampling at 11-14 weeks
  2. 3rd trimester amniocentesis if no testing previously performed
39
Q

What factor VIII/IX levels should be aimed for prior to surgical or invasive procedures or in miscarriage for women carrying severe haemophilia?

A

At least 0.5iu/ml

40
Q

What medication can be used antenatally to increase factor VIII levels and what adjunctive management must be observed?

A

a. Desmopressin (DDAVP)
b. Must be fluid restricted to 1L over 24 hours

41
Q

How can factor IX levels be raised in pregnancy?

A

The only option is recombinant Factor IX

42
Q

How should breech birth be managed in males affected or possibly affected by Haemophilia?

A

ECV should be avoided

43
Q

What intrapartum rules should be observed for women with a male fetus confirmed to have haemophilia?

A
  1. Avoid instrumental birth with either forceps or ventouse
  2. Avoid fetal blood sampling and fetal scalp electrode
44
Q

If clotting factor levels in a haemophilia carrier are low intrapartum, what concentration of Factor VIII/IX should be targeted?

A

1iu/ml

45
Q

How long should Factor VIII/IX levels be monitored for following vaginal birth for women with Haemophilia?

A

3 days following spontaneous birth
5 days following instrumental birth or Caesarean

46
Q

What imaging is required for all neonates with severe or moderate haemophilia prior to discharge following birth?

A

Cranial ultrasound

47
Q

What are type 1, type 2 and type 3 von Willebrand’s disease?

A

Type 1: partial quantitative

Type 2: qualitative

Type 3: severe quantitative

48
Q

In addition to von Willebrand Factor antigen levels, what else must be checked at booking and in the third trimester for women with VWD?

A

Factor VIII levels

49
Q

What condition contraindicates DDAVP usage in von Willebrand Disease?

A

Pre-eclampsia

50
Q

Which electrolyte disturbance must be monitored for following administration of DDAVP?

A

Hyponatraemia

51
Q

What may develop following administration of DDAVP specifically in women with type 2B von Willebrand Disease?

A

Thrombocytopaenia

52
Q

What medication should be given as sole therapy for women who either carry Haemophilia or have VWD with factor levels >0.5iu/ml?

A

Tranexamic acid

53
Q

What is the inheritance pattern of factor XI deficiency?

A

Autosomal, both dominant and recessive forms exist

54
Q

Which population are at significantly increased risk of Factor XI deficiency compared to the general population?

A

Ashkenazi jews

55
Q

Which subgroup of women with Factor XI are most at risk of PPH?

A

Those with blood group O

56
Q

What is the genetic abnormality in Bernard Soulier Syndrome?

A

Abnormality in Glycoprotein Ib-IX-V

57
Q

What is the mode of inheritance of Bernard Soulier Syndrome?

A

Autosomal recessive

58
Q

What percentage of pregnancies are complicated by maternal cardiac disease?

A

1-4%

59
Q

What changes in pregnancy contribute to the 40-50% increase in cardiac output?

A
  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
60
Q

By how much does Creatinine fall in pregnancy?

A

35umol/L

61
Q

What percentage of pregnancies are complicated by AKI?

A

1.4%

62
Q

What condition should be considered where there is thrombocytopaenia, anaemia and AKI?

A

Microangiopathic haemolytic anaemia

63
Q

Above what value for serum urea is renal replacement therapy indicated in pregnancy and why?

A

Urea >17 should trigger referral for RRT as Urea is teratogenic

64
Q

What are the rules for dose adjustment of magnesium sulfate in AKI?

A

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)

65
Q

How are thrombotic thrombocytopaenic purpura and haemolytic uraemic syndrome differentiated clinically?

A

TTP - primarily neurological symptoms
HUS - redominant renal dysfunction

66
Q

How are TTP and HUS differentiated biochemically?

A

TTP has abnormalities in ADAMTS13
HUS has dysregulation of complement pathways

67
Q

What is the function of ADAMTS13 and why does its dysfunction lead to TTP?

A

ADAMTS13 breaks down vonWillebrand factor
Defective ADAMTS13 results in formation of platelet-rich thrombi

68
Q

What percentage of women with haemolytic uraemic syndrome in pregnancy go on to need renal replacement therapy?

A

76%

69
Q

How are TTP and HUS managed?

A

FFP infusion or plasma exchange

70
Q

Which monoclonal antibody is licensed for treatment of atypical haemolytic uraemic syndrome?

A

Eculizumab

71
Q

What is the incidence of acute fatty liver of pregnancy?

A

5 per 100,000 pregnancies

72
Q

Why is AKI common in acute fatty liver of pregnancy?

A

In AFLP there is renal tubular fatty acid deposition

73
Q

What are the symptoms and laboratory findings which suggest acute fatty liver instead of HELLP?

A

Low serum glucose
Raised serum ammonia
Prodromal vomiting

74
Q

Which immune suppressing drug commonly used for SLE is teratogenic and what should it be changed to in pregnancy?

A

Mycophenolate mofetil should be changed to azathioprine

75
Q

When can NSAIDs be used during pregnancy?

A

Prior to 30 weeks in conditions such as pleuritic pain, fibroid degeneration or musculoskeletal pain

76
Q

Which bacterial infection can cause chorioamnionitis in the absence of ROM?

A

Listeriosis

77
Q

What is the increase in risks to the pregnant woman of general anaesthetic over regional anaesthesia?

A

17-fold increase

78
Q

What should intra-abdominal pressure be limited to during laparoscopy in pregnancy?

A

12mmHg

79
Q

Why is the second trimester a better time than the third trimester for semi-elective abdominal surgery?

A

The rate of preterm delivery is 1% instead of 9%

80
Q

Which biological depletes B-cells with its anti-CD20 function?

A

Rituximab

81
Q

Which class of biologicals are particularly high risk for reactivation of latent TB?

A

Anti-TNFs

82
Q

Which anti-TB agents can be safely used in pregnancy?

A

Isoniazid and Rifampicin

83
Q

Which cancer are women on anti-TNFs particularly at risk of?

A

Cervical cancer

84
Q

Studies have shown that which biological can improve rates of pregnancy in women undergoing IVF?

A

Adalimumab

85
Q

Infliximab, Adalimumab and Golimumab are monoclona antibodies in which subclass?

A

IgG1

86
Q

Infliximab should be stopped by what gestation?

A

16 weeks

87
Q

Etanercept and Adalimumab should be stopped by what gestation?

A

28 weeks (3rd trimester)

88
Q

What advice is given pre-pregnancy to women on Rituximab?

A

Avoid for 12 months prior to pregnancy

89
Q
A

MRCOG Part 2 (11 decks)

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