Maternal Medicine Flashcards
Respiratory Indications for ECMO
ARDS
Pneumonia (infectious/aspiration/interstitial)
Severe asthma
Thoracic trauma causing lung contusion
Alveolar or pulmonary haemorrhage
Severe inhalation injury
Air leak syndromes (bronchopleural fistula)
Acute airway obstruction
Lung transplant
Cardiac indications for ECMO
Acute MI
Myocarditis
Cardiac arrest
Post heart transplant
Post cardiotomy
Hypothermia with cardiac instability
Postpartum acute cardiomyopathy
Drug intoxication
Septic cardiomyopathy
Arrhythmic storm
Interventional cardiac procedures
When to consider ECMO
When estimated mortality is in excess of 50-80% despite optimal medical management
Complications of ECMO
Intracranial haemorrhage
DIC
HIT
Bleeding
Hypertrophic cardiomyopathy incidence
0.1-0.5% of women
Symptoms/signs of hypertrophic cardiomyopathy
Syncope
Chest pain
Ejection systolic murmur
Pan-systolic murmur
Heart failure
Arrhythmias
Treatment of hypertrophic cardiomyopathy in pregnancy
B-blockers
Incidence of sarcoidosis in pregnancy
1 in 2000
Sarcoidosis site involvement
Lungs (1st)
Skin (commonest extra-pulmonary)
Heart (50%)
Brain
Eyes
Joints
Liver (20% hepatomegaly)
Pulmonary sarcoidosis presents as
Interstitial lung disease with fibrosis 20%
Pulmonary hypertension
Skin manifestations of sarcoidosis
Granuloma (lupus pernio)
Erythema nodosum
Erythema multiforme
Nummular eczema
Rate of myocardial infiltration with sarcoidosis
2-7%
Rate of CNS involvement with sarcoidosis and commonest site
5-13%
Cranial nerves
Pathogenesis of sarcoidosis
Th1 cell mediated
TNF-a
Interferon-y
Influx of CD14 macrophages
Investigations for sarcoidosis
CXR/CT
broncheolar lavage
Transbronchial biopsy
Cardiac MRI
ECG/echo
MRI head
EMG for myopathy
When is pregnancy is contraindicated in insterstitial lung disease?
When FVC<1-1.5L
Course of sarcoidosis in pregnancy
Majority have no change or improvement
Some worsen
Postnatal flare
Effects of sarcoidosis on pregnancy
PET
VTE
FGR
C/S
PPH
Baseline tests for sarcoidosis
FBC
U+E
LFT
Calcium
ACE
ECG
Echo if cardiac sarcoidosis is known
24hr tape if palpitations
Mycophenelate mofetil risks in pregnancy
Microtia (no ear cartilage)
Facial clefts
Micrognathia
Miscarriage
FGR
Washout period for mycophenelate
6 weeks
Washout period for MTXA
4 weeks
Give high dose folic acid
Leflunomide washout period
11 days with cholestyramine
When to discontinue adalimumab
28 weeks
When to discontinue infliximab
20 weeks
AN management of sarcoidosis
Aspirin
VTE
Growth scans
Enhanced BP monitoring
Investigate tachycardia and palpitations
Haemophilia A
Factor VIII deficiency
Haemophilia B
Factor IX deficiency
Impact of pregnancy on factor VIII
Increases x 3
Impact of pregnancy on factor IX
No effect
Normal range for factor VIII and IX outside of pregnancy
0.5-2.0 iu/ml
There is no family history in _____ of haemophilia patients
50%
Obligate haemophilia carrier status
Affected father
OR
Affected son and relative in maternal line
Risk of haemophilia in a male baby after a spontaneous affected sibling
45%
Classification of haemophilia A
Severe - <0.01 iu/ml
Moderate - 0.01 - 0.05 iu/ml
Mild - 0.06 - 0.4 iu/ml
Risk of resistance to clotting factor treatment
40%
Prenatal diagnosis of severe haemophilia
PGD
cell free fetal DNA for fetal sex
CVS for male fetus 11-14 weeks
Amniocentesis 3rd trimester to inform delivery options
Risk of intracranial and extra cranial haemorrhage with haemophilia
RR 56% for ICH
RR 92% for ECH
Antepartum management of haemophilia
No ECV in severe haemophilia
TXA
Levels 0.5 iu/ml to cover surgical procedures and miscarriage
DDAVP with 1L fluid restriction in 24 hours to increase factor VIII
Recombinant factor VIII if DDAVP ineffective
Recombinant factor IX if <0.5 iu/ml (measure before and after, then 4-6h after rx)
Mode and timing of delivery with haemophilia
C/S for affected male babies/status unknown/severe haemophilia
No ventouse/midcavity NBFD
No FSE in severe or moderate haemophilia
Intracranial haemorrhage risk with ELLSCS vs forceps in haemophilia
OR 0.69 vs 2.8
(4x less)
Optimal level of factor VIII after DDAVP treatment
1.0 iu/ml
When to give DDAVP and TXA intrapartum for haemophilia
As close to delivery as possible
Postpartum management of haemophilia
Maintain factor VIII/IX above 0.5 for 3 days after SVD, 5 days after operative delivery
TXA until lochia is minimal
No VTE if level <0.6
Investigation of the neonate in haemophilia carrier mothers
Cord blood testing in males
Re-test 3-6 months
Follow up with haematology
Cranial USS screening prior to discharge if moderate/severe haemophilia
MRI head if symptoms/signs of ICH
Treatment in neonate with haemophilia
Short term prophylaxis if moderate/severe or preterm or trauma at delivery
Types of vWD
Type 1 - partial quantitative
Type 2 - qualitative
Type 3 - severe quantitative
Commonest bleeding disorder
vWD
Level of care for vWD according to type
Normal unit with haem input for mild/moderate type 1
Specialist input for type 2/3 or severe type 1
Target level for factor VIII and vWF:RCo
0.5 to cover for spontaneous miscarriage and surgical procedures
Prevalence of VWD
1 in 1000
Mode of inheritance for vWD
Type 1 - variable penetrance with multiple mutations
Type 2B - dominant
Type 2N - recessive
Type 3 - recessive
Prevalence of type 3 vWD
1 in 1 million
Higher in consanguineous communities
Antenatal Treatment of vWD
DDAVP
Restrict fluid 1 litre in 24 hours
Contraindication to DDAVP
PET
Arterial disease
Uncontrolled hypertension
Side effects of DDAVP in VWD
Type 2B can develop thrombocytopenia
Intrapartum management of type 2/3 vWD
Avoid FBS, FSE, ECV, ventouse and mid cavity forceps
Postpartum care in vWD
TXA for 14 days
Keep factor VIII above 0.5 for 3 days after SVD or 5 days after operative delivery
Neonatal management with VWD
Oral vit K
Cord blood testing in type 2/3
Retest at 3-6 months for type 2/3
Cranial US +/- MRI head for type 2/3
Inform parent of signs for ICH
Dose of DDAVP
0.3 micrograms/kg of pregnancy body weight
Treatment for acute haemorrhage in vWD
DDAVP
Viral inactivated concentrate with VWF and factor VIII (hep A and parvo resistant to inactivation)
Factor XI deficiency inheritance
Autosomal dominant
Autosomal recessive
Factor XI prevalence
1 in 1 million general population
8% Ashkenazi Jews heterozygous
0.2 - 0.5% Ashkenazi Jews homozygous
Factor XI maintenance levels
0.5 iu/ml
Effects of pregnancy on Factor XI levels
No effect
Antepartum monitoring of factor XI
Booking
3rd tri
Prior to invasive procedures
Bleeding risk with factor XI deficiency
Type O
High risk phenotype
Testing in neonate for factor XI deficiency
No testing unless mum is homozygous or compound heterozygosity
Management of factor XI deficiency
Exclude compounding vWF/thrombocytopenia
Can give TXA OR factor XI concentrate (both together increase risk of VTE) or FFP
What are the rare bleeding disorders?
Deficiencies of fibrinogen
Factor II, V, VII, X and XIII
Combined factor V and VIII deficiencies
Congenital deficiency of vit K dependent factors
Maintenance level for the rare bleeding disorders
Aim >0.2 iu/ml
Management of rare bleeding disorders
TXA 15-20 mg/kg or 1g QDS for minor bleeds
+/- factor replacement
Factor II deficiency is AKA
Prothrombin deficiency
Management of prothrombin (factor II) deficiency
If bleeding/labour or for c/s and <0.2/ml give prothrombin complex concentrate 10-20 iu/kg at 48 hour intervals
Maintain level >0.2 for 3 days minimum
If already receiving prophylactic prothrombin complex then continue through pregnancy
Management of factor V deficiency
If activity <0.2/bleeding/delivery then give 15-25ml/kg FFP
Further FFP at 10ml/kg 12 hourly to maintain activity 0.2-0.4 for 3 days
Consider platelets for severe bleeding or c/s
Factor VII deficiency management
Recombinant factor VIIa 15-30 micrograms/kg every 4-6 hours to maintain level >0.2
3-5 days after c/s
Only in response to severe bleeding for other women
Severe factor X deficiency management
Antenatal prophylaxis 2-3x/week for recurrent bleeding or adverse pregnancy outcome with prothrombin complex concentrate
Give 20-40iu/kg prothrombin complex concentrate for bleeding or c/s to maintain activity >0.4
10-20 iu/kg daily for 3 days maintenance
Severe factor XIII deficiency management
Factor XIII plasma concentrate prophylaxis every 14-21 days
Maintain activity >0.2
Consider additional 10-40 iu/kg in established labour/ prior to c/s
Factor V and factor VIII deficiency management
Consider FFP 15-25 ml/kg in established labour or before c/s. Maintain level 0.2-0.4 iu/ml
Consider factor VIII if less than 0.5 iu/kg in third trimester
Fibrinogen disorders and their inheritance
Afibrogenaemia - recessive (bleeding)
Hypfribrinogenaemia with or without qualitative defects (dysfribrinogenaemia) - dominant (variable bleeding/thrombosis risk)
Pregnancy outcomes with fibrinogen disorders
APH
PPH
VTE
pregnancy loss
ICH
Umbilical bleeding
Management of fibrinogen deficiency
Maintain levels 0.5-1 g/litre antepartum and 3 days post partum
TXA for minor bleeding
Fibrinogen concentrate 50-100mg/kg through pregnancy 2x/week - consider LMWH if low risk for bleeding
What is Bernard Soulier syndrome? (BSS)
Deficiency of membrane GP Ib-IX-V complex
Causes abnormal adhesion of platelets
Inheritance of BSS
Autosomal recessive
Management of BSS
TXA at outset of labour until lochia is minimal
Platelets prophylactically before delivery
No central neuraxial analgesia
Platelets should be HLA matched
Consider DDAVP (variable response)
Maternal risks of BSS
PPH
Wound haematoma
What is Glanzmann’s thrombasthenia? (GT)
Non-functioning GP IIb/IIIa caused by missense mutation in ITGA2B and ITGB3
Platelet-platelet aggregation is impaired
Inheritance of GT
Autosomal recessive
Maternal and fetal risks of GT
APH
PPH
Fetal thrombocytopenia
Fetal ICH/bleeding
Management of GT
HLA matched platelet transfusion and/or recombinant factor VIIa prophylactically at delivery
TXA in established labour until lochia is minimal
No central neuraxial anaesthesia
Management of platelet fetal allo-immunisation in GT
Check antibodies at 28 and 34 weeks
FMU referral
IV IgG +/- steroids
Cord platelets
Oral vit K until platelet level is back
Check again day 3-5
Give platelets if <30 x 10(9)/litre
Spinal epidural anaesthesia should never be given to patients with _____
Type 3 vWD
Clotting factors that increase in pregnancy
VIII
IX
X
Fibrinogen (50%)
DVT vs PE proportions
75% DVT
25% PE
VTE incidence in pregnancy
1-2/1000
RR of VTE in pregnancy
4-6 x
Sites of DVT in pregnancy
85% left sided
72% iliofemoral
Inherited Thrombophilias
Anti-thrombin III (highest risk)
Protein C deficiency
Protein S deficiency
Activated protein C resistance
Prothrombin gene mutation
Factor V Leiden
Hyperhomocystinaemia
Acquired thrombophilia
Antiphospholipid
Lupus anticoagulant
High anti-cardiolipin antibody
B glycoproteins 1 antibodies
Pulmonary hypertension risk after PE
3-4%
Recurrent DVT risk outside of pregnancy
3.7%
Recurrent DVT risk outside pregnancy
10.9%
Most common acquired thrombophilia
APLS
Risks associated with APLS
Pregnancy loss
PET
PTB
FHR
VTE
Anti-coagulation regimen for APLS
If on long term anti-coagulation = intermediate/therapeutic dose LMWH
If no long term anti-coagulation = intermediate/high dose prophylaxis LMWH
LMWH for previous VTE and inherited thrombophilia
Antithrombin deficiency - high dose LMWH (50% or 75% or treatment dose)
Give standard prophylaxis for other thrombophilias
Low risk inheritable thrombophilias
Heterozygous factor V Leiden
Heterozygous prothrombin mutation
Investigation of DVT
Compression duplex USS - repeat day 3 + 7 if negative but still suspected
Pelvic US colour Doppler (pelvic vessels)
MRV or contrast venography (iliac vein)
PE is diagnosed in _____% of women with symptoms
5
ECG changes in PE
Sinus tachycardia
RBBB
Peaked P waves lead III
S1, T3, Q3 (rare)
Breastfeeding advice after V/Q scan
Discard milk for 48 hours
Increased risk of breast Cancer after CTPA
> 13%
Investigations for PE
V/Q scan if CXR normal
CTPA if CXR abnormal
Use unfractionated heparin for
Massive PE
Rapid reversal needed
Heparin monitoring
Measure APTT 4-6 hours after loading dose
6 hours after dose change
Twice daily once in therapeutic range
Life threatening PE treatment
Thrombolysis in combination with unfractionated heparin (omit loading dose)
Treatment of VTE
LMWH
UFH
Thrombolysis
Pulmonary embolectomy
IVC filter for iliac thrombosis
Length of treatment time after VTE
Minimum 6/52 postpartum
At least 3 months to prevent post thrombotic syndrome
LMWH and labour management
Stop 24 hours before planned delivery or when labour starts
Wear stockings until LMWH can be resumed
Staples or interrupted skin sutures for c/s
Risk of wound haematoma after c/s on LMWH/UFH
2%
Side effects of LMWH
Thrombocytopenia
Allergy
Osteoporosis 1 in 500
Bruising
Side effects UFH
Vertebral fractures 2%
Allergy
HIT
Indications for high dose LMWH
Antithrombin deficiency
Previous VTE whilst anti-coagulated
APLS + previous VTE
Timing of Regional analgesia when on LMWH
> 12 hours after last dose of prophylactic
24 hours if therapeutic LMWH
Epidural catheter and LMWH management
Perform 12h after last dose of prophylactic, 24h if therapeutic
Next dose LMWH 4 hours after removal
Flying VTE risk
3x increase
Additional 18% for every 2 hours
Reducing VTE risk when flying
Aisle seat
Mobilise in seat and in the aisle
Fluid intake
Minimise caffeine
TEDS if >4hr flight
LMWH if other risk factors
Commonest inherited thrombophilia
Factor V Leiden
Prevalence of factor V Leiden
3-5% U.K.
low in black/asian populations
Sweden - 15%
Monitor platelets in women at risk of VTE if ____ every ____
On UFH or treatment dose LMWH
Every 14 days
Fetal Radiation exposure with CTPA and V/Q
0.1 mGy
0.5 mGy
Radiation to breast of CTPA
10 mGy
Reducing risk of post thrombotic syndrome
Graduated elastic compression stockings for 2 years
Essential HTN pregnancy outcomes
PET 25.9%
C/S 41.4%
SGA 16.9%
NNU admission 20.5%
Perinatal death 4%
Aspirin reduces early onset PET in ____ women
60%
Effect of Severe hypertension on NNU admission
Increases risk from 23% to 47%
Negative predictive value for PlGF or sFlt is for ____
2 weeks
Chance of complications with PET <37 weeks
50%
Target HbA1c preconception
48
Risk of congenital abnormalities in women with pre-existing diabetes is highest if ____
HbA1c >86
Pre-pregnancy Glycaemic targets with pre-existing diabetes
Waking 5-7
Fasting 4-7
Risk of stillbirth with pre-existing diabetes is highest at ____ HbA1c
> 60
BM peak time after steroids
6-8 hours
DKA risk in T1DM
1-2%
Risk of stillbirth with DKA
160 per 1000 births
How long does hyperglycaemic effect of steroids last?
24 hours
Elective birth for T1/T2DM timing
37-38+6 if no complications
Before 37 weeks if maternal or fetal complications
Refer to nephrologist for diabetic women with _________
Creatinine >120 OR
Urinary ACR >30 OR
Total protein excretion >0.5g/day
Proteinuria level to consider VTE prophylaxis
> 5g/day OR
ACR >220
Incidence of solid organ transplants in pregnant women
50-60 per year (30-40 kidneys)
Most common solid organ transplant
Kidney
Risk of organ rejection in first year of transplant
10-15%
Prevalence of pre-pregnancy hypertension in women with renal transplants
50%
Risk of new HTN in pregnancy after renal transplant
16%
Increased risk of loss of renal function after pregnancy if _____
Pre-pregnancy proteinuria is 1g/day
Which immunosuppressive drugs increase risk of GDM
Steroids
Tacrolimus
Ciclosporin
Risk of GDM is ____ in patients after renal transplant
Doubled
Risk ratio for PET after renal transplant
6x
Risk of caesarean delivery after renal transplant
64%
Risk of PTB after renal transplant
52% late PTB
9% early PTB
Risk of SGA after renal transplant
24% (3x higher)
Risk of neonatal unit admission after renal transplant
38%
Kidney graft rejection rate in pregnancy
2-4.2%
Effect of pregnancy on tacrolimus and ciclosporin
Reduces serum levels
Effect of pregnancy on erythropoetin requirement
Increases
Target MgSO4 level if required for renal transplant patients
<3.5 mmol/L
Check 3-6 hours after commencing
Risk of trauma to renal graft during c/s
1-2%
Consider midline incision
Surgical review should be at ____ weeks gestation for women with kidney-pancreas transplants
30-34 weeks
Incidence of pregnancy after liver transplant
12 per year
GDM screening for patients with the following solid organ transplants
Kidney
Pancreas
Liver
Lung (Cystic fibrosis is indication)
Pre-conceptual investigation after cardiac transplant
ECG
Echo
Angiography
Endomyocardial biopsy as clinically indicated
Highest risk organ transplant for pregnancy is ____
Lung - pregnancy loss and graft rejection is highest
Detection of lung graft rejection is by
Decreased FEV1 or FVC as these are unchanged by pregnancy
DKA incidence
6.3 per 100 000
Incidence of DKA for T1DM
85%
Incidence of DKA in third trimester
71%
Commonest causes of DKA
Infection
Vomiting
Steroid therapy
Medication errors
Perinatal mortality for DKA
16%
Diagnosis criteria for DKA
Blood ketones 3.0 or urine ketones 2+
BM 11.0 or known DM
Bicarbonate <15 or pH <7.3
IV fluid management in DKA
10-15ml/kg/hr in the first hour
OR
1L for 1 hour, 500ml/hr for 4 hours, 250ml/hr for 8 hours then 150ml/hr maintenance
Management of K+ in DKA
Give K+ if <3.3 and don’t give insulin
Give K+ with insulin if 3.3-5.5
Give insulin without K+ if >5.5
Metabolic targets in DKA treatment
Fall in ketones 0.5mmol per hour
Increase bicarbonate by 3mmol/hr
Decrease in BM by 3mmol/l/hr
Insulin regime in DKA
0.1 unit/kg/hr
Do not exceed 15 units/hr
When to stop insulin
When eating and drinking
Five rapid insulin and take down FRII after 30-60 minutes
Phosphate replacement in DKA is recommended when ___
Levels <0.32
Cardiac impairment
Resp depression
Monitoring response to treatment of DKA
First 6 hours:
Hourly blood ketones
2 hourly VBG
Time taken for FHR to normalise after DKA treatment
4-8 hours
PPCM ejection fraction
<45%
Incidence of PPCM
1 in 1000 - 4000 pregnancies
PET prevalence in PPCM
22% (4x higher risk)
When do women with PPCM present?
78% 4 months post delivery
9% final month of pregnancy
13% before final month and after 4 months
Complications of PPCM
Ventricular arrhythmias 20%
Intracardiac thrombus
Cardiogenic shock
VTE 6.8%
Investigations for PPCM
ECG
FBC, Trop T, BNP/NT-proBNP, CRP
Echo
CXR
cardiac MRI (thrombus)
Endomyocardial biopsy
Management of PPCM when haemodynamically stable and pregnancy
Salt restriction
Loop diuretics
B-1 antagonists
Hydralazine
LMWH
Management of PPCM (postpartum and breastfeeding)
ACEI or ARB
Aldosterone antagonists
Management of PPCM postpartum not breast feeding
DOAC
SGLT2 inhibitors
Angiotensin receptor nephrilysin inhibitors (ARNI)
PPCM management haemodynamically unstable
Delivery
Optimise preload (diuretics)
O2
Inotropes/vasopressors
Bromocriptine
ECMO or cardiac transplant
Cardioversion and defribilation (ICD for 3-6 month)
Mode of delivery for PPCM
Aim vaginal if NYHA class I-II
C/S if class III-IV
Intrapartum care for PPCM
Continuous ECG and pulse oximetry
Intra-arterial BP monitoring
30 degree left lateral tilt
Regional analgesia NYHA class III-IV
Limit 2nd stage
Avoid ergometrine
Prognosis for PPCM
10% mortality risk
50-80% recover 6 months from diagnosis
Worse recovery if LVEF <30% at diagnosis or black women
Advice for future pregnancies
50% chance of deterioration with 20% mortality risk if LV dysfunction persists (advice against further pregnancy)
20% chance of recurrence after full recovery
No further pregnancy advised if LVEF <25% at diagnosis
Pregnancy management after PPCM
Preconceptual counselling
BNP levels
Echo
Serial scans 24/40
LMWH
Deliver 37/40
Echo schedule for previous PPCM
Preconceptual
1st trimester
2nd trimester
One month before delivery
Immediately after delivery (before discharge)
1 month after delivery
Bromocriptine dose in PPCM
2.5mg OD for 7/7 if uncomplicated
2.5mg BD for 2/52 then OD for 6/52 if LVEF <25%
Bromocriptine increases risk of?
VTE
Rates of ACS
0.6 to 10 per 100 000 pregnancies
Mortality risk after ACS
5-11%
Which trimester is ACS most likely to occur?
3rd
Proportion of NSTEMI in pregnancy?
75%
Causes of ACS in pregnancy
PASCAD (27%)
Atherosclerosis (39%)
Thrombosis (10-20%)
Coronary artery spasm 2%
Causes of raised Trop
ACS
PET
HTN
cardiomyopathy
PE
Takotsubo
Myocarditis
Renal failure
Autoimmune disease with cardiac involvement
