Maternal Medicine Flashcards

Question

What is the preferred mode of screening for metastases of breast cancer diagnosed in pregnancy? a. PET CT b. MRI with gadolinium contrast c. DEXA bone scan d. USS Liver and CXR e. CT with contrast

Answer 1

D - USS Liver and CXR When breast cancer is confirmed, screening for metastases in pregnancy is only indicated if there is a high clinical suspicion and should comprise a chest x-ray and liver ultrasound. Gadolinium contrast MRI is not recommended unless a specific need exists – while data on its safety is limited, no adverse effects of gadolinium have been reported on the fetus. DEXA and CT are avoided owing to the effect of irradiation on the fetus. There is no role for tumours markers in pregnancy.

Answer 2

D - Ondansetron and Dexamethasone Standard chemotherapy anti-emetic regimens should be used in pregnancy – 5HT3-serotonin receptor antagonists (ondansetron) and dexamethasone are most effective.

Answer 3

E - Avoid breastfeeding entirely while on chemo Breastfeeding while on chemotherapy is not advised as the drugs cross into milk and may cause neonatal leucopoenia. An interval of 14 days after the last chemotherapy session is advised prior to commencing feeding to enable drug clearance from milk.

Answer 4

D - 2-3 weeks Most women affected by breast cancer in pregnancy should deliver at term and aim for normal vaginal delivery. Where possible, birth should be deferred until 2-3 weeks from the last chemotherapy session to allow bone marrow recovery and minimise problems of neutropenia.

Answer 5

B - 5 years Women with estrogen-receptor positive breast tumours should be advised that tamoxifen treatment is recommended for 5 years. There is a general consensus that women should defer pregnancy for a minimum of 2 years after breast cancer, though this must be weighed against the risk of infertility with the passage of time in certain women. Liaison with the patient’s oncologist and consideration of the specifics of her cancer can be useful in guiding individualised management recommendations.

Answer 6

B - 3 months Tamoxifen has a relatively long half-life (5-7 days on average – for most drugs half-life is a matter of hours). For this reason, postponing pregnancy for a minimum of 3 months after stopping tamoxifen is advised.

Answer 7

E - Echocardiography There is a dose dependent association between anthracycline chemotherapy agents (doxorubicin) and left-ventricular dysfunction which may be exacerbated by pregnancy. In severe cases, this can even lead to cardiomyopathy. As such, all patients previously treated with anthracyclines should undergo an echocardiography to assess LV function in pregnancy

Answer 8

C - Breastfeeding from unaffected breast safe; avoid tamoxifen while breastfeeding There is no evidence to suggest breastfeeding increases recurrence risk of breast cancer. While surgery in itself may not inhibit lactation in the affected breast, radiation causes fibrosis which may well do – feeding from the contralateral, unaffected breast is usually possible and safe however. It is unknown whether or not tamoxifen is transmitted in breast milk, thus feeding on tamoxifen is not recommended.

Answer 9

C - 20mg The standard dose for tamoxifen in women with previous breast cancer is 20mg OD. This is the same dose as when used for most other indications.

Answer 10

A - USS Ultrasound is the first line imaging modality in women with suspected breast cancer in pregnancy. If cancer is confirmed, mammography with fetal shielding may be necessary to assess the extent of disease and involvement of the contralateral breast.

Answer 11

B - 0.7% In British obstetric practice, 0.7% of pregnancies (roughly 1 in 140) are affected by obstetric cholestasis though the condition has a varied prevalence amongst ethnic groups – rates in Indian/Pakistani women are approximately twice that of British Caucasians, while rates of 2.4% are seen in Chilean women and up to 5% in Auricanian-Indians of South America.

Answer 12

A - 1-2 weekly Pruritus is a common symptom in pregnancy affecting up to 23%. Based on a prevalence of ~0.7% for obstetric cholestasis, this would suggest that only around 1 in 30 women with pruritus could be expected to have OC. Some women may have pruritus of OC for some time (days or weeks) prior to the onset of derangement in their liver function tests. Women with persistent pruritus despite initial normal liver function should have their LFTS repeated every 1-2 weeks.

Answer 13

D - 25% 23% of women are thought to report itching at some point in pregnancy, only ~3% of whom have OC.

Answer 14

C - Weekly Following a diagnosis of OC, women should have their LFTs measured weekly until delivery along with a general review, urine and BP measurement. The rise in transaminases may range from just above normal to several hundreds. A rapid rise should prompt consideration of alterative diagnoses as – while such a pattern may occasionally be seen in OC – it is not typical. Similarly if LFTs return to normal antenatally, OC is unlikely to be the root cause.

Answer 15

B - 10 days Postnatally, liver function testing in women with obstetric cholestasis should be deferred for at least 10 days - postnatal resolution is essential to confirm the diagnosis. Even in normal pregnancy, a transient rise in LFTs may be seen in the first 10 days. In OC pregnancies LFTs should ideally be performed beyond this time.

Answer 16

E - IUGR There appears to be a small increased risk of both PPH and caesarean section in women with obstetric cholestasis though both may be multifactorial. The risk of stillbirth has yet to be fully determined but any increased risk, if present, if likely to be small. Premature birth is increased in OC pregnancies though a good deal of this is thought to be iatrogenic and the spontaneous preterm rate raised only minimally. There is a well described increased incidence of meconium passage. There is no known association between obstetric cholestasis and fetal growth restriction.

Answer 17

C - 7-11% There is a widely adopted practice in obstetric cholestasis of offering elective delivery at 37 weeks though this is not evidence based and as such the potential consequences of iatrogenic early delivery must be considered – the risk of admission to SCBU with elective caesarean is 7-11% at 37/40; 6% at 38/40 and falls to 1.5% at 39/40.

Answer 18

A - 6% at 38/40; 1.5% at 39/40 There is a widely adopted practice in obstetric cholestasis of offering elective delivery at 37 weeks though this is not evidence based and as such the potential consequences of iatrogenic early delivery must be considered – the risk of admission to SCBU with elective caesarean is 7-11% at 37/40; 6% at 38/40 and falls to 1.5% at 39/40.

Answer 19

E - None of the above As it stands, no known drug therapy has been proven to improve fetal nor neonatal outcomes in mothers affected by OC in pregnancy. As such, any proposed therapy should be discussed with this in mind. Ursodeoxycholic acid has been shown to improve pruritus and LFTs though robust data on protection against stillbirth or indeed its safety is lacking.

Answer 20

A - Prolned PT Women with OC should have an informed discussion regarding Vitamin K. Where prothrombin time is prolonged, Vitamin K given at a daily dose of 5-10mg is advised though even where PT is normal there may be a role for its use, providing mothers are counselled regarding the small theoretical risk. Women with OC may be vitamin K deficient as – being a fat soluble vitamin depending on bile for its absorption – uptake from the GI tract can be reduced. There are historical fears regarding a possible risk of haemolytic anaemia (and thus kernicterus and hyperbilirubinaemia) in infants exposed through maternal use. Vitamin K is required for the synthesis of several important clotting factors including II, VII, IX and X thus deficiency carries potential severe consequences. Infants should be offered postnatal Vitamin K in the usual way at birth regardless of maternal use.

Answer 21

A - 5-10mg orally Women with OC should have an informed discussion regarding Vitamin K. Where prothrombin time is prolonged, Vitamin K given at a daily dose of 5-10mg is advised though even where PT is normal there may be a role for its use, providing mothers are counselled regarding the small theoretical risk. Women with OC may be vitamin K deficient as – being a fat soluble vitamin depending on bile for its absorption – uptake from the GI tract can be reduced. There are historical fears regarding a possible risk of haemolytic anaemia (and thus kernicterus and hyperbilirubinaemia) in infants exposed through maternal use. Vitamin K is required for the synthesis of several important clotting factors including II, VII, IX and X thus deficiency carries potential severe consequences. Infants should be offered postnatal Vitamin K in the usual way at birth regardless of maternal use.

Answer 22

D - Up to 90% Women with obstetric cholestasis should be reassured that there are no long term sequelae for mothers and babies though a rather considerable recurrence rate ranging from 45% to as high as 90%.

Answer 23

B - Combined pill The RCOG guideline suggests women with a history of OC avoid estrogen-containing contraceptives postnatally. The FSRH guidelines list a history of pregnancy–related cholestasis as a UKMEC 2 for the combined pill, advising that it may increase the risk of cholestasis associated with use of the pill itself (a history of non-obstetric cholestasis is UKMEC 3 for CHC)

Answer 24

E - South America Obstetric cholestasis has a varied prevalence amongst ethnic groups – rates in Indian/Pakistani women are approximately twice that of British Caucasians, while rates of 2.4% are seen in Chilean women and up to 5% in Auricanian-Indians of South America.

Answer 25

A - Falciparum Falciparum malaria is both the most common strain of the disease seen in UK practice (>75% of cases – mostly from West Africa) as well as that which causes the vast majority of malaria deaths worldwide. In travellers returning from the Indian subcontinent, Vivax is more likely and causes a relapsing type.

Answer 26

A - Falciparum Falciparum malaria is both the most common strain of the disease seen in UK practice (>75% of cases – mostly from West Africa) as well as that which causes the vast majority of malaria deaths worldwide. In travellers returning from the Indian subcontinent, Vivax is more likely and causes a relapsing type.

Answer 27

B - Vivax Falciparum malaria is both the most common strain of the disease seen in UK practice (>75% of cases – mostly from West Africa) as well as that which causes the vast majority of malaria deaths worldwide. In travellers returning from the Indian subcontinent, Vivax is more likely and causes a relapsing type.

Answer 28

B - 2x Pregnant women in malaria-endemic areas are twice as likely to be bitten, twice as likely to contract and twice as likely to die from malaria than their non-pregnant counterparts. The clinical manifestations of the disease in pregnancy is largely based on ‘premunition’ – the degree of naturally acquired host immunity to the condition.

Answer 29

C - 1 in 50 The uptake of chemoprophylaxis amongst women residing in the UK who later present with malaria is low. The risk of transmission is generally quoted for a one-month stay without chemoprophylaxis and varies enormously from one area to another – highest in endemic parts of Oceania and lowest in America and the Caribbean: ``` Oceania (Papua New Guinea, Solomon Islands and Vanuatu) 1 in 20 Sub-Saharan Africa 1 in 50 Indian Subcontinent and SE Asia 1 in 500 South America 1 in 2500 Central America/Caribbean 1 in 10,000 ```

Answer 30

E - 1 in 500 The uptake of chemoprophylaxis amongst women residing in the UK who later present with malaria is low. The risk of transmission is generally quoted for a one-month stay without chemoprophylaxis and varies enormously from one area to another – highest in endemic parts of Oceania and lowest in America and the Caribbean: ``` Oceania (Papua New Guinea, Solomon Islands and Vanuatu) 1 in 20 Sub-Saharan Africa 1 in 50 Indian Subcontinent and SE Asia 1 in 500 South America 1 in 2500 Central America/Caribbean 1 in 10,000 ```

Answer 31

B - Mefloquine Mefloquine, at a dose of 5mg/kg once weekly, is the recommended drug of choice for malarial chemoprophylaxis in the second and third trimesters. The majority of observational and clinical data suggests the drug is not associated with an increased risk of stillbirth nor congenital malformation at this dose. Available evidence does not support an association with embryotoxicity in the first trimester and thus use may be justified at this time in areas at high risk of falciparum infection. Contraindications to mefloquine include: current or previous depression; neuropsychiatric disorders, epilepsy or hypersensitivity to quinine. The alternative in such patients would be ‘Malarone’ – a combination of atovaquone and proguanil however there is insufficient data on its safety in pregnancy and cases should always be discussed with a malarial specialist prior to prescription in pregnancy.

Answer 32

B - Quinine and clindamycin The only recommended ‘standby’ treatment for pregnant women from the UK is quinine (600mg and clindamycin 450mg, both TDS, both for 7 days). This should be started in the event of a flu-like illness and temperature >38C in an area with no immediate access to medical care. If there is vomiting within 30 minutes, repeat the full dose; if within 30-60 minutes, repeat a half dose. Mefloquine should then be commenced 1 week after the last treatment dose.

Answer 33

B - Repeat half dose and continue next dose at the usual time The only recommended ‘standby’ treatment for pregnant women from the UK is quinine (600mg and clindamycin 450mg, both TDS, both for 7 days). This should be started in the event of a flu-like illness and temperature >38C in an area with no immediate access to medical care. If there is vomiting within 30 minutes, repeat the full dose; if within 30-60 minutes, repeat a half dose. Mefloquine should then be commenced 1 week after the last treatment dose.

Answer 34

A - 0.5-1% There are approximately 1500 cases of malaria diagnosed in the UK each year with 5-15 deaths (equivalent to a 0.5-1% mortality rate).

Answer 35

D - Placental parasitaemia The hallmark of falciparum malarial infection in pregnancy is the sequestration of parasites in the placenta which can evade host defence mechanisms such as splenic processing and filtration. This is not known to occur in the ‘benign’ malarias. Parasitaemia itself can lead to fetal growth restriction and low birthweight as well as maternal and fetal anaemia.

Answer 36

D - Three, 24 hours apart Malaria may be diagnosed both by microscopy and rapid-diagnostic tests. Microscopy – allowing both species identification and estimation of parasitaemia – is considered the gold standard. Rapid detection tests may miss low-parasitaemia which is more likely in pregnancy women. They are also relatively insensitive in Vivax malaria. In any event, a positive rapid detection test should always be followed by microscopy. In a febrile patient with suspected malaria, 3 negative blood smears 12-24 hours apart effectively rule out the diagnosis of malaria.

Answer 37

E - 50% Mortality rates in severe pregnancy are high – up to 50% (compared with 15-20% in the non-pregnant population). Non-falciparum species are rarely fatal though caution should nonetheless be observed. Mortality in uncomplicated malaria is very low – 0.1%.

Answer 38

B - IV Artesunate

Answer 39

C - Oral artesunate and oral clindamycin

Answer 40

A - 2% Regardless of clinical presentation, signs or symptoms, patients with parasitaemia greater than 2% should be treated as ‘severe’ malaria.

Answer 41

A - Hypoglycaemia The most common and important side effect of quinine therapy is hypoglycaemia, which is secondary to hyperinsulinaemia. While this is commonly asymptomatic, it may be associated with fetal bradycardia.

Answer 42

C - Thromboembolism Venous thromboembolism (1.39 per 100,000) and cardiac disease (2.39 per 100,000) were the most common direct and indirect causes of maternal death respectively in the most recent (2014-2016) MBBRACE report, and indeed this has been the case for some time.

Answer 43

B - Cardiac disease Venous thromboembolism (1.39 per 100,000) and cardiac disease (2.39 per 100,000) were the most common direct and indirect causes of maternal death respectively in the most recent (2014-2016) MBBRACE report, and indeed this has been the case for some time.

Answer 44

D - 50% Plasma volume increases by up to 50% in pregnancy, resulting in both dilutional anaemia and a reduced oxygen carrying capacity of the blood. Pulse increases by 15-20 beats per minute though together these changes increase cardiac output by only 40%. Arterial blood pressure drops by 10-15mmHg

Answer 45

D - Rise 15-20 bpm Plasma volume increases by up to 50% in pregnancy, resulting in both dilutional anaemia and a reduced oxygen carrying capacity of the blood. Pulse increases by 15-20 beats per minute though together these changes increase cardiac output by only 40%. Arterial blood pressure drops by 10-15mmHg

Answer 46

B - 1/10 The uterus receives 10% of total cardiac output at term.

Answer 47

C - 15 degrees A left lateral tilt of 15 degrees on a firm surface will relieve aorto-caval compression in most pregnant women and still permit effective chest compressions.

Answer 48

C - 4 minutes If there is no response to correctly performed CPR within 4 minutes of a maternal collapse or if resuscitation is continued beyond this in women >20/40, delivery should be achieved within 5 minutes of the collapse in order to assist resuscitation. Delivery of the fetus/placenta reduces oxygen consumption, improves venous return and cardiac output, facilitates cardiac compressions and renders ventilation easier. Prior to 20/40 there is no proven benefit from delivery of the fetus.

Answer 49

B - 8mmHg In the event of severe hypotension despite initial fluid resuscitation, the aim should be to achieve a CVP >8mmHg with aggressive fluid replacement (or >12mmHg in women on mechanical ventilation).

Answer 50

E 10ml 10% Calcium Gluconate The antidote to magnesium sulphate is 10ml of 10% calcium gluconate given slow IV.

Answer 51

C - 1.5ml/kg loading; 0.25ml/kg/minute So-called ‘lipid-rescue’ is the treatment of choice for suspected local anaesthetic toxicity. This consists of an IV bolus of 20% Intralipid at a dose of 1.5ml/kg over 1 minute (can be repeated a further 2 times at five minute intervals) following by an infusion of 0.25ml/kg/min, increased to 0.5ml/kg/min after 5 minutes.

Answer 52

D - 500mcg adrenaline IM 500 micrograms of IM adrenaline (0.5ml of 1:1000) is the definitive treatment for suspected anaphylaxis as described here. This can be repeated after 5 minutes if there is no effect. In experienced hands it may be given IV as a 50 microgram bolus (0.5ml of 1:10,000). Chlorphenamine 10mg and hydrocortisone 200mg (both IM or IV) form adjuvant treatment.

Answer 53

B - Increases 40% Plasma volume increases by up to 50% in pregnancy, resulting in both dilutional anaemia and a reduced oxygen carrying capacity of the blood. Pulse increases by 15-20 beats per minute though together these changes increase cardiac output by only 40%. Arterial blood pressure drops by 10-15mmHg.

Answer 54

D - UTI Patients with sickle cell trait – one copy of HbS and one normal HbA – are asymptomatic. They require little, if any, additional attention in pregnancy from a maternal point of view. Interestingly the only complication noted is an increased incidence of microscopic haematuria and UTI.

Answer 55

B - 100-500 Sickle cell disease is the most common inherited condition worldwide around 300,000 affected children born each year. There are thought to be around 12-15,000 people in the UK with sickle cell and around 100-200 pregnancies in affected women each year. 300 babies are born on average in the UK every year with the condition.

Answer 56

D - Mid-50s SCD has previously been associated with a high early mortality rate though the majority of children born in the UK today with SCD live past reproductive age and average life expectancy is well into the mid-50s.

Answer 57

B - Pulmonary hypertension Where opportunity for pre-conceptual screening arises, patients with SCD should undergo an echocardiogram to screen for pulmonary hypertension. Incidence of pulmonary hypertension is increased in patients with SCD and there is a significant association with increased mortality. A tricuspid jet velocity of >2.5m/second is associated with a high risk of PH. Where not performed in the last year, this should be done antenatally if possible.

Answer 58

E - 5mg in pregnancy; 1mg outwith Women with SCD are advised to take 1mg folic acid every day outwith pregnancy owing to the increased risk of folate deficiency in haemolytic anaemia. In pregnancy, this should be increased to 5mg to guard against neural tube defects in the first trimester and protect against the increased demands for folate during the second and third.

Answer 59

D - Stop 3 months pre-conceptually; restart postnatally Hydroxyurea (hydroxycarbamide) is a drug known to decrease the incidence of painful crises and acute chest syndrome in patients with SCD. It is known however, to be teratogenic in animal studies – thus advice currently is that women on Hydroxyurea use effective contraception and stop the drug 3 month pre-conceptually. This said there are reports of women continuing through pregnancy on the drug without any adverse effects which may help in counselling women who become pregnant while taking – in such a setting, it should be stopped and detailed ultrasound performed by a fetal medicine specialist looking for abnormality, though is not an indication for TOP in isolation.

Answer 60

D - Antibiotics and aspirin Patients with SCD are hypo-splenic and at an increased risk of infection, especially from encapsulated bacteria – N. Meningitidis; Strep. Pneumoniae and H. Influenzae. There is clear evidence of benefit to this end from penicillin antibiotic prophylaxis in children (though data is lacking on adults/pregnancy) and guidance suggests this should be given to all patients in and out of pregnancy. Penicillin is first line, erythromycin second if allergic. The flu, hepatitis B and meningococcal vaccines should also be up to date as well as pneumococcal ever 5 years. In addition, women with SCD should be considered for aspirin for PET prophylaxis at the usual dose (consider SCD a mild risk factor). Heparin should be given at prophylactic dose during any inpatient admissions.

Answer 61

B - 12-28 weeks NSAIDs may be used as effective pain relief for women with a painful sickle cell crisis though are only suitable for use between 12 and 28 weeks of pregnancy.

Answer 62

A - early viability and 4-weekly biometry from 24/40 In addition to routine scans, women with SCD should be offered an early viability scan at 7-9 weeks and serial fetal biometry on a 4-weekly basis from 24/40. A number of studies have pointed to an increased risk of fetal growth restriction and pre-eclampsia.

Answer 63

A - Painful crises Routine prophylactic transfusion for women with SCD in pregnancy was a historic norm as it was associated with decreased perinatal morbidity and mortality compared with historic controls. It has since been argued however that the appreciable risks of transfusion (alloimmunisation [seen in up to 36%], reactions, iron overload, infection etc.) may outweigh this and as such, routine transfusion is no longer recommended. There are a few instances however in which transfusion IS considered best practice: • Where Hb <6 or falls > 2 units from baseline • Acute chest syndrome • Acute stroke • Twin pregnancy • Women with previous serious medical, obstetric or fetal complications • Women on a pre-pregnancy transfusion regimen for prevention of secondary stroke or severe complications – this should be continued through pregnancy

Answer 64

D - Up to 40% Routine prophylactic transfusion for women with SCD in pregnancy was a historic norm as it was associated with decreased perinatal morbidity and mortality compared with historic controls. It has since been argued however that the appreciable risks of transfusion (alloimmunisation [seen in up to 36%], reactions, iron overload, infection etc.) may outweigh this and as such, routine transfusion is no longer recommended. There are a few instances however in which transfusion IS considered best practice: • Where Hb <6 or falls > 2 units from baseline • Acute chest syndrome • Acute stroke • Twin pregnancy • Women with previous serious medical, obstetric or fetal complications • Women on a pre-pregnancy transfusion regimen for prevention of secondary stroke or severe complications – this should be continued through pregnancy

Answer 65

C - 25-50% 25-50% of patients with SCD will experience a painful sickling crises in pregnancy and is the most common cause of hospital admission in this cohort. Avoiding precipitants is highly advisable – excessive exercise, cold, dehydration and stress. Women who do not settle with simple analgesia, are febrile, have atypical pain or chest symptoms should be referred to hospital. Fluid intake should be encouraged with a target of 60ml/kg/24 hours (4.2L for a 70kg woman).

Answer 66

C - 60ml/kg/24 hours 25-50% of patients with SCD will experience a painful sickling crises in pregnancy and is the most common cause of hospital admission in this cohort. Avoiding precipitants is highly advisable – excessive exercise, cold, dehydration and stress. Women who do not settle with simple analgesia, are febrile, have atypical pain or chest symptoms should be referred to hospital. Fluid intake should be encouraged with a target of 60ml/kg/24 hours (4.2L for a 70kg woman).

Answer 67

E - Pneumonia Acute chest syndrome is the second most common complication of SCD seen in pregnant women, occurring in up to 20% of pregnancies. This condition is characterised by respiratory symptoms – tachypnoea, chest pain, cough, SOB – which may mimic pneumonia. To further confuse matters, the presence of a new infiltrate may be seen on CXR. As such, it is advised that patients be treated for both and given antibiotics in addition to oxygen and top-up blood transfusion. If there is any suspicion of PE – treatment dose heparin until excluded is appropriate.

Answer 68

C - IOL at 38/40 SCD is not an indication in itself for caesarean delivery, nor a contraindication in itself to attempting VBAC, though the recommendation is that patients be delivered electively from 38 weeks either via LSCS or IOL. Blood should be cross-matched for delivery in the presence of atypical antibodies – otherwise a group and save will suffice.

Answer 69

C - Pethidine Patients with SCD can have almost all means of analgesia available to other women in labour with the exception of pethidine owing to its known association with seizures.

Answer 70

B - Administer oxygen and check ABG The demand for oxygen in sickle cell disease is increased during the intrapartum period and use of pulse oximetry to detect hypoxia in the mother should be employed during labour. Arterial blood gas should be performed and oxygen therapy commenced where oxygen saturations fall to 94% or less.

Answer 71

D - Respiratory Failure The basic defect in thalassaemia is reduced globin chain synthesis meaning resultant red cells have inadequate haemoglobin content. Pathophysiology is characterised by extravascular haemolysis due to release into the peripheral circulation of damaged red cells and erythroid precursors due to ineffective erythropoiesis. As a result patients require multiple transfusions per year which may lead to iron overload and resultant organ damage. The condition affects multiple organ systems including the pancreas (diabetes common secondary to insulin resistance and iron-induced islet cell deficiency); thyroid; heart (iron related cardiomyopathy); liver (cirrhosis) and bone (osteoporosis). Patients with thalassaemia tend to suffer from subfertility also. There is no association with lung disease.

Answer 72

A - Lung function testing In view of the multiple co-morbidities which may be found in thalassaemia, pre-conceptual planning and counselling is of the utmost importance. It is recommended that prior to embarking upon a pregnancy, patients undergo screening for end-organ damage including both echocardiography and cardiac MRI as well as bone density scanning, diabetes testing (using serum fructosamine concentrations) and thyroid function testing.

Answer 73

D - 100g/L The majority of women with thalassaemia major are already established on a transfusion regimen pre-pregnancy which may continue. Patients with thalassaemia require transfusion on a regular basis and should aim for a pre-transfusion Hb of 100g/L. Initially 2-3 units should be transfused with an additional top up the following week until Hb reaches 120g/L. Hb should be re-checked 2 weeks later and a further 2 units transfused if <100g/L.

Answer 74

C - 75mg aspirin alone Women with thalassaemia who have either previously undergone a splenectomy or have a current platelet count >600, should be commenced on low-dose aspirin (75mg OD). Women with both risk factors should commence both aspirin as well as low-molecular weight heparin.

Answer 75

C - 75mg aspirin alone Women with thalassaemia who have either previously undergone a splenectomy or have a current platelet count >600, should be commenced on low-dose aspirin (75mg OD). Women with both risk factors should commence both aspirin as well as low-molecular weight heparin.

Answer 76

B - Prophylactic dose LMWH and 75mg aspirin Women with thalassaemia who have either previously undergone a splenectomy or have a current platelet count >600, should be commenced on low-dose aspirin (75mg OD). Women with both risk factors should commence both aspirin as well as low-molecular weight heparin.

Answer 77

E - Vaginal delivery, administer 2 grams desferrioxamine, cross-match 2 units RBCs Thalassaemia is not in itself an indication for delivery by caesarean section though patients should be adequately prepared for labour. High levels of circulating toxic non-transferrin bound iron may pre-dispose to cardiac dysrhythmias during labour. As such, chelation with desferrioxamine 2g over 24 hours should be given for the duration of labour. Patients in whom Hb is found to be <100g/L upon admission to labour ward should have 2 units of RBCs cross-matched.

Answer 78

C - Cardiac arrhythmias Thalassaemia is not in itself an indication for delivery by caesarean section though patients should be adequately prepared for labour. High levels of circulating toxic non-transferrin bound iron may pre-dispose to cardiac dysrhythmias during labour. As such, chelation with desferrioxamine 2g over 24 hours should be given for the duration of labour. Patients in whom Hb is found to be <100g/L upon admission to labour ward should have 2 units of RBCs cross-matched.

Answer 79

B - 7 Thalassaemia major describes women who require in excess of 7 transfusions per year, while intermedia refers to women requiring less than 7. Women who are heterozygotes - i.e. minor – do not require transfusion though may suffer from some degree of mild-moderate anaemia.

Answer 80

D - <300 HbA1C is unreliable in women with thalassaemia as repeated transfusions dilute levels resulting in underestimation. Serum fructosamine is preferred for monitoring. The pre-pregnancy target is <300nmol/L for 3 months which is equivalent to an HbA1C of <43.

Answer 81

B - <7mg/g Women embarking on pregnancy should be assessed for liver iron concentration – ideally liver iron should be <7mg/g (dry weight).

Answer 82

C - 1/6 16.5% (or 1/6) of women with thalassaemia have some degree of alloimmunisation pre-pregnancy owing to recurrent transfusions.

Answer 83

E - HbC Other haemoglobinopathies in the partner of a women affected by beta-thalassaemia may carry significant implications for her offspring as follows: ``` Risk of serious haemoglobinopathy: HbS HbE Delat-beta thalassaemia Hb Lepore HbO Arab Hb Constant Spring ``` Risk of mild-moderate disorder only: HbC Other variant Hb

Answer 84

D - Viability, Dating, Anomaly, Serial from 24/40 In terms of the antenatal ultrasound schedule for women with thalassaemia, they should undergo an early viability scan at 7-9 weeks, routine dating and anomaly followed by serial growth scanning from 24/40 on a 4-weekly basis. The risk of early pregnancy loss is higher in such women and severe maternal anaemia which often co-exists predisposes to fetal growth restriction.

Answer 85

C - 10 fold Epilepsy is amongst the most common neurological conditions in pregnancy with a prevalence of 1 in 100-200. The risk of death in women with epilepsy (WWE) is increased ten-fold compared with women without the condition.

Answer 86

C - 10 years (5 off medication) Women who have remained seizure free for at least 10 years – with the last 5 of those off anti-epileptic drugs – may be considered to no longer have epilepsy.

Answer 87

E - Tonic clonic Unsurprisingly of all seizure sub-types, tonic-clonic seizures carry the highest risk of sudden, unexplained death in epilepsy in pregnancy (SUDEP). SUDEP is defined as ‘sudden, unexpected, witness or un-witnessed non-traumatic and non-drowning death in patients with epilepsy with or without evidence of a seizure and excluding status epilepticus in which post-mortem does not reveal an anatomic or toxicological cause of death’

Answer 88

D - Magnesium Sulphate This patient has no documented medical history and is presenting for what we must assume is her first ever seizure, in pregnancy. The most common cause of fitting in such an instance is eclampsia rather than epilepsy and as such, magnesium sulphate is the most appropriate treatment here. This should be the case in any instance of diagnostic uncertainty.

Answer 89

C - 10% The risk of congenital abnormality is highest amongst women taking sodium valproate at ~10.7 per 100 (or 10-11%). The most commonly seen abnormalities in patients on valproate are neural tube defects, facial clefts and hypospadias.

Answer 90

D - Micrognathia The risk of congenital abnormality is highest amongst women taking sodium valproate at ~10.7 per 100 (or 10-11%). The most commonly seen abnormalities in patients on valproate are neural tube defects, facial clefts and hypospadias.

Answer 91

A - Cardiac Phenytoin (and phenobarbital) use in pregnancy is associated chiefly with cardiac defects and facial cleft.

Answer 92

B - AFP Biochemical screening with maternal serum AFP combined with ultrasonography increases the detection rate of NTDs to 94-100%.

Answer 93

B - Pethidine Most forms of analgesia are perfectly safe for use in labour amongst women with epilepsy and indeed pain relief should be regarded as a priority amongst such women. The only exception is pethidine which should be used with caution in WWE (diamorphine is preferable) – pethidine is metabolised to norpethidine which is known to epileptogenic when given in high doses.

Answer 94

C - Maternal Hypoxia Seizures in labour may lead to maternal hypoxia (secondary to apnoea during the seizure itself) as well as fetal hypoxia and acidosis secondary to sustained uterine hypertonus. This may relieved in part (especially if seizures on-going) by the administration of a tocolytic.

Answer 95

C - Lorazepam There are no studies examining the optimum management of epileptic seizures in labour thus regimens used outwith pregnancy are generally employed – lorazepam (0.1mg/kg) or diazepam IV in those with IV access or 10-20mg diazepam rectally in those without (can be repeated 15 minutes later). Where seizures remain uncontrolled, phenytoin is the next drug which should be used (loading 10-15mg/kg).

Answer 96

A - 1-2% Tonic clonic seizures occur in ~1-2% of women with epilepsy in labour and within 24 hours of delivery in a further 1-2%

Answer 97

E - Postnatal The immediate postpartum period appears to be the highest risk period for seizures owing in large part to the increased stress, sleep deprivation, missed medication and anxiety which characterises this time.

Answer 98

B - Phenytoin The enzyme inducing AEDs are as follows: carbamazepine, phenytoin, phenobarbital, primidone and oxcarbezine. Women should be counselled that the efficacy of oral contraceptives (combined and progesterone only), transdermal patches, vaginal ring and progesterone only implants may be affected by these. All contraceptive methods may be prescribed for those not on enzyme-inducing drugs.

Answer 99

E - Progesterone injection The enzyme inducing AEDs are as follows: carbamazepine, phenytoin, phenobarbital, primidone and oxcarbezine. Women should be counselled that the efficacy of oral contraceptives (combined and progesterone only), transdermal patches, vaginal ring and progesterone only implants may be affected by these. All contraceptive methods may be prescribed for those not on enzyme-inducing drugs.

Answer 100

C - 1/3 30% of women with epilepsy report a positive family history of the condition

Answer 101

B - 1/3 Seizure frequency for the vast majority of women with epilepsy does not change in pregnancy (65%) – amongst the remaining third who do experience a change, approximately half report an increase and the other half a decrease. Women who have been seizure free for many years are unlikely to fit in pregnancy unless they change or stop their medication.

Answer 102

B - 5% The risk of the child developing epilepsy is increased if either parent has epilepsy (4-5%) and increased considerably if both parents have epilepsy (15-20%). If a sibling is affected, the risk is 10%.

Answer 103

B - Stop gliclazide pre-pregnancy, continue metformin, consider starting insulin

Answer 104

C - Within 6 months of conception and yearly thereafter

Answer 105

A - Para 1; BMI 24; last baby weighed 4.25kg at birth

Answer 106

B - Fasting >5.6; 2-hour >7.8

Answer 107

A - Dietary advice and exercise

Answer 108

D - Insulin

Answer 109

D - Insulin

Answer 110

C - Metformin

Answer 111

D - Consider glibenclamide

Answer 112

A - At booking and again at 28/40

Answer 113

C - Terbutaline for uterine hyperstimulation

Answer 114

B - 30 minutes

Answer 115

A - <4 or >7

Answer 116

A - Within 30 minutes

Answer 117

E - Stop all therapy now – fasting plasma glucose at 6 week check

Answer 118

D - Advise the patient she may be a type 2 diabetic and arrange formal testing

Answer 119

B - Annual HbA1C

Answer 120

A - 42 year old, Para 3, BMI 25, known factor V leiden homozygote

Answer 121

B - <150/100mmHg

Answer 122

B - Moderate gestation hypertension

Answer 123

D - Start at 12/40, stop at delivery

Answer 124

D - 32 year old Para 1. Booking BMI 34. Medical history: DVT following orthopaedic procedure 5 years ago. Last pregnancy with a different partner 11 years ago.

Answer 125

E - Diabetes

Answer 126

B - 48 hours

Answer 127

E - >300mg

Answer 128

E - Do not commence antihypertensives, do not admit to hospital, recheck BP weekly

Answer 129

C - Commence antihypertensives, do not admit to hospital, recheck BP twice weekly

Answer 130

C - Twice weekly

Answer 131

A - Daily for first two days, once between days 3 and 5

Answer 132

B - Admit to hospital, do not start antihypertensives but repeat blood pressure 4x daily

Answer 133

E - No need to repeat once confirmed

Answer 134

A - 1 gram/hour

Answer 135

B - Pre-load with 500ml crystalloid

Answer 136

B - 80ml/hour

Answer 137

B - 6 months

Answer 138

A - Carbimazole Carbimazole and methimazole are associated with aplasia cutis congenita. This is a rare condition and - while propylthiouracil is preferred - these drugs may be used in pregnancy if required.

Answer 139

D - Sirolimus Steroids, hydroxychloraquine, azathioprine, ciclosporin and tacrolimus are the immunosuppressants known to be safe in pregnancy. Others - mycophenolate, sirolimus, cyclophosphamide and chlorambucil are teratogenic and should be avoided.

Answer 140

D - 24 months

Answer 141

E - 25% More likely where the woman is a heterozygote for LCHAD deficiency (implicated in 19% of cases). Offspring of affected mothers should be screened for the common mutation E474Q.

Answer 142

D - Pneumococcal The pneumococcal vaccine should be given to susceptible patients every 5 years. Hep B, HIB and Men C are given as a one-off. Influenza is given annually.

Answer 143

B - Regional analgesia is contraindicated ITP is a diagnosis of exclusion. There is an association with fetal/neonatal thrombocytopenia in 10% thus ventouse is generally best avoided though forceps may be used with caution. Regional analgesia is safe where platelet count is >80.

Answer 144

B - 1 in 10,000 CVT is rare but associated with a high mortality rate. Risk factors are very similar to those for VTE elsewhere and many cases are associated with heritable thrombophilia - all patients should be tested. MRI Venogram is the optimum imaging modality to demonstrate venous thrombosis. Source: HB of Obstetric Medicine

Answer 145

E - 3/4 The sensation of breathlessness in most women if probably a result of increased awareness of physiological hyperventilation causing a subjective feeling of breathlessness. This physiologically breathlessness is often paradoxically present at rest and improves with mild activity. Nevertheless there are clearly numerous specific causes which warrant exclusion. Source: HB of Obstetric Medicine

Answer 146

E - 1 in 25 CF is the most common autosomal recessive disorder in the UK with a carrier incidence of 1 in 25 amongst British caucasians. Although a specific mutation on chromosome 7 has been identified, only 2/3 of cases have this specific mutation.

Answer 147

E - Sjörgren’s syndrome A antibodies Anti-SSA antibodies - previously known as 'anti-Ro' are known to cause congenital heart block. Amongst mothers positive for anti-Ro/La, the risk of CHB is approximately 2%. Where the woman has a previously affected child the risk of recurrence is higher at 15%

Answer 148

C - 15% The risk of recurrence of congenital heart block is 15%

Answer 149

E - 26-30%

Answer 150

B - 20,000

Answer 151

E - At delivery

Answer 152

B - Commence cART at the beginning of the second trimester Where viral load is <100,000, cART should be started at the start of the second trimester providing CD4 count is >200. If either viral load is >100,00 or CD4 count <200, cART should be commenced as soon as possible, including in the first trimester if required. All women should be on cART by 24/40. Zidovudine monotherapy is not recommended except in women who decline cART, have a viral load <10,000 and are prepared to deliver by LSCS.

Answer 153

D - ECV from 36/40 In women with a viral load <50, ECV is appropriate; in primigravidae this should be performed from 36/40

Answer 154

D - El. LSCS at 38/40 Where the indication for CS is prevention of vertical transmission, this should be done from 38/40. If viral load <50 and CS is for obstetric indication alone, then from 39/40 is appropriate. Women with a viral load of 400 or more should be advised to deliver by LSCS.

Answer 155

A - Commence immediate induction of labour Women with an undetectable viral load, to some degree may be managed as per the HIV-negative population with respect to decision making around labour and delivery. The exception in in pre-labour membrane rupture in which delivery should be achieved within 24 hours in all over 34/40. Women with a viral load greater than 50 should generally be encouraged to deliver by LSCS though individualised care may be appropriate depending on the circumstances between 50 and 399. Those with a viral load of 400 or more should be delivered by LSCS. In those <34/40, a multi-disciplinary discussion regarding mode and timing of delivery should take place.

Answer 156

A - No prophylaxis required Where mum has been on cART for >10 weeks and has an undetectable viral load at 36/40 as well as twice, 4 weeks apart during pregnancy, the infant is considered to be at ‘very low risk’ of transmission and should receive 2 weeks of zidovudine monotherapy as prophylaxis. If any of these 3 criteria are not met but viral load <50 (or in any infant born <34/40), 4 weeks should be given. Where viral load is >50 or unknown, combination therapy is indicated.

Answer 157

B - 48 hours All infants, irrespective of risk status should be tested within 48 hours of birth and again prior to discharge home. Further testing is dependent on risk status and mode of infant feeding.

Answer 158

E - All of the above TOG 2017

Answer 159

C - Up to 40% TOG 2017

Answer 160

B - <48 TOG 2017

Answer 161

D - >84 TOG 2017

Answer 162

B - Blood glucose of more than 11mmol/l TOG 2017

Answer 163

E - 4-8 hours TOG 2017

Answer 164

B - Pulmonary Hypertension

Answer 165

C - Posterior pituitary

Answer 166

D - Oxytocin

Answer 167

D - Decrease by 4-5

Answer 168

A - Hypernatraemia

Answer 169

B - Improvement in response to treatment with vasopressin

Answer 170

C - 1 in 12,500

Answer 171

A - Haemorrhage

Answer 172

C - 4 minutes

Answer 173

B - 10/min

Answer 174

E - Reduces compression on the great vessels

Answer 175

C - 30 to 2

Answer 176

D - Dietary phenylalanine restriction

Answer 177

B - Hypospadias

Answer 178

C - Autosomal recessive

Answer 179

E - No restrictions on contraceptive use

Answer 180

A - 3x/weekly

Answer 181

C - Autosomal recessive

Answer 182

C - Autosomal recessive

Answer 183

D - It results from a point mutation on the beta-globin gene

Answer 184

A - Hypogonadotrophic hypogonadism

Answer 185

B - Markedly reduced beta globin production

Answer 186

E - By promoting the excretion of plasma non-transferrin-bound iron

Answer 187

A - Autosomal recessive

Answer 188

B - 2-3x/week

Answer 189

C - Farnesoid X Receptor The principal hepatic bile acid receptor is farnesoid X receptor - in response to elevated levels of intrahepatic bile acids, it is responsible for the coordinated downregulation of synthesis and upregulation of export. TOG 2016

Answer 190

D - Primiparity Numerous risk factors are described for obstetric cholestasis including: - Asian, Northern European or South American ethnicity - Multiple pregnancy - IVF - Existing liver disease (gallstones, hepatitis) - Advanced maternal age A family history is found (especially amongst sisters) in 10-15% of affected women suggesting a genetic component. While recurrence rates of up to 90% are described in the literature, parity itself is not a described risk. TOG 2016

Answer 191

B - 0.7% Obstetric cholestasis complicates 0.7% (~1 in 140) pregnancies in the UK TOG 2016

Answer 192

B - 1-2 weeks It is recommended that women with continuing pruritus but normal LFTs and bile acids have these repeated after 1-2 weeks. TOG 2016

Answer 193

E - Serum bile acids While all of the options given might reasonably be expected to be elevated in a patient with OC, serum bile acids are considered the most sensitive for making the diagnosis. ALP is elevated in normal pregnancy while AST is not specific to liver pathology (it is also produced by skeletal and cardiac muscle). Gamma GT is frequently normal in OC though may be elevated. Bilirubin is elevated in ~10%. TOG 2016

Answer 194

D - 6 weeks Resolution of liver function within 6 weeks of delivery is a requisite for confirmation of the diagnosis of OC TOG 2016

Answer 195

C - Cardiac Patients with a history of exposure to certain chemotherapy agents may be at an increased risk of certain complications. The most commonly reported are as follows: - Anthracyclines and taxanes: cardiac dysfunction - Alkylating agents: GDM - Bleomycin: respiratory disease Asymptomatic anthracycline-induced cardiac dysfunction is described in up to 57% of those with a history of exposure. RCOG guidelines advocate echocardiogram screening in such patients antenatally TOG 2016

Answer 196

B - Glucose tolerance test Patients with a history of exposure to certain chemotherapy agents may be at an increased risk of certain complications. The most commonly reported are as follows: - Anthracyclines and taxanes: cardiac dysfunction - Alkylating agents: GDM - Bleomycin: respiratory disease TOG 2016

Answer 197

C - Lung function testing Patients with a history of exposure to certain chemotherapy agents may be at an increased risk of certain complications. The most commonly reported are as follows: - Anthracyclines and taxanes: cardiac dysfunction - Alkylating agents: GDM - Bleomycin: respiratory disease TOG 2016

Answer 198

D - 2 years TOG 2016

Answer 199

B - Premature birth Women with a history of malignancy should be reassured that while a small increase in preterm birth is noted, there is no evidence to support an increase in congenital abnormality. Any increases in IUGR or stillbirth are related largely to specific exposure to pelvic radiotherapy in the past and are not universal risks. TOG 2016

Answer 200

E - >90% Intrahepatic cholestasis of pregnancy has a very high recurrence rate. It has been estimated to recur in over 90% of subsequent pregnancies. TOG StratOG Resource

Answer 201

E - Liver function and bile acid levels 42 days postpartum All women with intrahepatic cholestasis should have their liver function and serum bile acid levels checked at 6 weeks postpartum to ensure resolution. If the liver transaminases or serum bile acids remain elevated at the postnatal check, alternative causes for hepatic dysfunction should be sought and referral to a hepatologist should be considered. TOG StratOG Resource

Answer 202

C- Preterm Delivery Women who are survivors of childhood cancer and are embarking on pregnancy should be advised about the slightly increased risk of preterm birth. They can be reassured that the risk of congenital malformations is not greater than in the general population. However, for those women with a history of abdomino-pelvic radiation, or who have developed secondary medical conditions, there may be an increased risk of miscarriage, stillbirths and small for gestational age. For these women, growth scans may be appropriate. TOG StratOG Resource

Answer 203

D - Anti-TNF drugs are IgG molecules which cross the placenta with ease a) There is no evidence that biologic agents are teratogenic, the concern is related to risks of maternal and neonatal infection (as well as theoretical concern regarding fetal immune development) b) Women on biologics should be encouraged to breastfeed - the drugs are unlikely to survive passage through the infants GI tract to achieve plasma levels of any significance c) Live vaccinations such as BCG should be withheld when maternal exposure beyond the recommended gestation has occured (usually third trimester) - the risk from first trimester exposure is very low e) Women should be discouraged from stopping biologic therapy in anticipation of pregnancy owing to the detrimental effect such a period may have on their underlying condition - flares of disease are almost universally more harmful to mother and baby than biologic therapy itself TOG 2016

Answer 204

D - 6 months Live vaccines (BCG and rotavirus) should be withheld following exposure to biologics in the third trimester. Non-live vaccines are safe and should be given. TOG 2016

Answer 205

E - Beyond 28 weeks Most biologics are IgG molecules and cross the placenta easily - especially after 28 weeks TOG 2016

Answer 206

A - Certolizumab This pegylated anti-TNF agent does not easily cross the placenta and may well become the mainstay of biologic therapy in women of childbearing age in the near future TOG 2016

Answer 207

E - Haemangioma Hepatic haemangiomas are the most common liver tumours, seen in up to 20% of healthy individuals TOG 2016

Answer 208

D - They occur most commonly in adolescent males Hepatic haemangiomas occur most commonly in middle aged women TOG 2016

Answer 209

C - AFP There is a suggestion from small series that levels of AFP >1000 may be considered diagnostic even in pregnancy TOG 2016

Answer 210

B - Haemangioma Hepatic haemangiomas are the commonest benign tumours of the liver and are present in 2–20% of healthy individuals. They are more common in middle-aged women although it is uncertain if estrogen has a pathophysiological role. TOG StratOG Resource

Answer 211

B - Delay recommencing for seven days (1 week) Women on etanercept can resume their medication almost immediately after delivery. If they have a wound from a caesarean section, an episiotomy or a perineal tear, this should be delayed for a few days until the wound has healed to minimise the risk of wound infection. In most cases, this would be around 5–7 days. TOG StratOG Resource

Answer 212

A - Continue medication through to pregnancy and thereafter or switch to an alternative after discussion with Rheumatologist There is no evidence that biologic agents are teratogenic. Cessation in anticipation of pregnancy is therefore inadvisable due to the long lag time to conception, leading to the risk of flares just before pregnancy. Such flares tend to be harmful to both the mother and the fetus, leading to placental insufficiency complications such as miscarriages, preterm birth, fetal growth restriction and pre-eclampsia. Women on biologic agents are at a greater risk of infections. Offspring exposed to belimumab have normal growth and neurodevelopment. These are no contraindications in breastfeeding TOG StratOG Resource

Answer 213

C - CD56dim/CD16+ Central to the host defense mechanisms, are natural killer cells which play a vital role in the innate immune response. They are subtyped by virtue of their expression of CD56 and CD16 cell surface antigens. Most pNK cells exhibit CD16 but fewer CD56 surface antigens thus they are typically described as CD56dim/CD16+ TOG StratOG Resource

Answer 214

C - At least 30% Uterine natural killer (uNK) cells are the predominant leucocyte population of the endometrium and account for at least 30% of the endometrial stroma during the later secretory phase of the menstrual cycle where they are found surrounding the spiral arteries (but not the veins). TOG StratOG Resource

Answer 215

B - β-thalassaemia The most common autosomal recessive condition worldwide is β-thalassaemia. The most common autosomal recessive condition among Caucasians in Europe is cystic fibrosis. There are currently more than 1000 mutations responsible for cystic fibrosis and the most common is Δ508. TOG StratOG Resource

Answer 216

D - Pre-eclampsia More than one aetiology is responsible for AKI in pregnancy. Data from audit studies indicate that it complicates 1.4% of obstetric admissions in the UK and that the most common cause is pre-eclampsia. Most cases occur in women without pre-existing renal disease and over 40% go unrecognised by the treating clinical team. TOG StratOG Resource

Answer 217

E - Serum urea >17 mmol/l despite medical treatment The indications for renal replacement therapy in pregnancy mirror those in the nonpregnant population and include metabolic acidosis, hyperkalaemia and fluid overload refractory to medical management. In addition, urea is teratogenic and a serum urea of greater than 17 mmol/l, despite medical management, is a pregnancy-specific indication for renal replacement therapy. TOG StratOG Resource

Answer 218

C - A persistent increase in heart rate of >30 bpm For a diagnosis of PoTS, there has to be a persistent increase in heart rate of > 30 bpm when changing from lying to upright position in the absence of orthostatic hypotension. In severe cases, the standing heart rate is persistently >120 bpm. TOG StratOG Resource

Answer 219

D - Increase fluid and salt intake The initial mainstay of conservative management for PoTS is increased fluid (2-3 l/day) and salt intake (up to 10–12 g/day), which is aimed at increasing the circulating plasma volume and improving clinical symptoms. Other conservative strategies include physical manoeuvres such as making a fist, bending forward, placing a foot on a chair and pumping calves before standing. Compression stockings have been used effectively but caffeine intake should be limited as it may promote hypovolaemia by increasing diuresis. TOG StratOG Resource

Answer 220

D - Improves in most patients 60% of patients with PoTS report improvement in their symptoms in pregnancy; around 15% stay the same and 25% worsen. TOG 2018

Answer 221

D - Tilt table test The tilt table test is generally contraindicated in pregnancy. A stand test may be performed instead. TOG 2018

Answer 222

A - Hyperemesis gravidarum Women with PoTS have a higher rate of severe vomiting or hyperemesis gravidarum in the first trimester (50–60%) compared with the general population. TOG 2018

Answer 223

E - Dietary salt restriction An increase in salt consumption (10-12g/day) is recommended. TOG 2018