Med obs Flashcards
Is elevated WCC abnormal in pregnancy?
No
WCC can be up to 16 in absence of pathology
How do you check for B12 deficiency?
Holotranscobalamin level (due to changes in binding proteins in pregnancy)
What do you expect to happen in Hb in pregnancy?
To fall
Hb <105 = anaemia in 3rd trimester
Hb <100 = anaemia in post-partum
What’s gestational thrombocytopenia?
Platelets can be reduced in normal pregnancy.
Thrombocytopenia is significant when plat <100 in 3rd trimester
However 10% of women will have platelet <100 with normal levels before and after pregnancy, in absence of disease or neonatal thrombocytopenia = gestational thrombocytopenia
This is a diagnosis of exclusion
What happens to spirometry in pregnancy?
Generally unchanged
However lung volumes can change significantly with
(1) increase in inspiratory capacity and
(2) reduction in FRC and RV
= Reduced physiological reserve
Also get
(3) increase in minute ventilation and RR
Advice for pregnant women with asthma
Women with mild disease are still at risk of exacerbations in pregnancy
Exacerbations, oral steroid use and severe asthma increase the risk of preterm delivery, pre-eclampsia, small gestational age infant
Infants of women with well-controlled asthma are less likely to have recurrent bronchiolitis or croup in the first year of life
- Continue asthma treatment including preventer medication (ICS such as budesonide has the best safety data)
- Stop smoking
- Manage GORD and rhinitis
- Flu vaccine (pregnancy is a risk factor for severe influenza)
What should women taking AEDs take prior to conception?
High dose folate (5mg) should be taken for 1/12 pre-pregnancy and through the first trimester
Should women taking AEDs for epilepsy continue taking them throughout pregnancy?
Yes! Some AEDs may even require dose increases to keep levels therapeutic.
Exception in sodium valproate - should change to another AED if appropriate or reduce the dose
Risk of minor and major congenital malformations (up to 10%) and neurodevelopmental effects (up to 40%)
When should women with epilepsy conceive?
Aim for seizure control for 6/12 prior to conception on the lowest dose of the safest AED appropriate
What should be done at 20 weeks for pregnant women who are taking AEDs?
Morphology scan at 20 weeks gestation due to increased risk of congenital malformation (especially if on valproate)
What should pregnant women on enzyme inducing AEDs be taking in the last 4/52 of their pregnancy?
Oral vitamin K
Enzyme inducing AEDs are carbamazapine, oxcarbazepine, phenobarbitone, phenytoin, primidone, topiramate
How do uncontrolled seizures affect the foetus?
TC seizures can cause foetal hypoxia particularly in labour
Partial, absence and myoclonic seizures do not affect the foetus unless the woman injures herself
List potential adverse effects to baby in women taking AEDs
Small gestational age Congenital malformation (neural tube defect, orofacial malformations, congenital heart disease) Neurodevelopmental delay (valproate)
Which AEDs are most associated with congenital malformations?
Older AEDs
Valproate (also neurodevelopmental delay) Carbamazepine Phenobarbitone Phenytoin Primidone Possibly lamotrigine
Which AED is most preferred in pregnancy?
Levetiracetam
What are ineffective contraceptives in women taking AEDs?
Progesterone only pill (POP)
Implanon
What is an effective contraceptive in women taking AEDs?
Mirena
Use at least 50microg EE and increase if breakthrough bleeding
Which AED increases OCP metabolism?
Lamotrigine
Should you breastfeed while on AED?
Yes
Caution with lamotrigine - rash and drowsiness
Which types of seizures affect the fetus?
Partial, absence and myoclonic seizures do not affect the fetus unless the woman injures herself
TCS can cause fetal hypoxia particularly in labour
Describe the change in pregnancy:
1) Peripheral vasculature
2) CO
3) Plasma flow
4) Blood volume
5) Collecting system
1) Dilation –> fall in systemic vascular resistance –> need for increased CO
2) Increases –> increases renal perfusion
3) Increases –> increased GFR –> hyperfiltration, proteinuria
4) Increases from water and sodium retention –> haemodilution
5) Dilation –> hydronephrosis –> increased frequency and severity of cystitis and pyelonephritis
What happens to the following blood tests in pregnancy?
1) Urea
2) Creatinine
3) Albumin
4) ALT
5) ALP
1-4 All fall due to haemodilution
Albumin is often lower in absence of disease
5) Rise due to production by placenta
Ways to optimise pre-pregnancy in CKD
- Intense BP control. Aim <140/90
- Suppress proteinuria with maximal ACEI/ARB until attempting conception
- Lose weight
- Switch mycophenolate to alternative agent e.g. azathioprine or calcineurin inhibitor
- Optimise pre-existing condition e.g. lupus activity for 6/12. Consider repeat kidney biopsy if remission status is unclear
- Avoid estrogen containing preparations in women with HTN, vascular disease, or significant proteinuria or smokers
- IUDs are not CI in women on immunosuppression
- Pre-natal vitamins
- Stop medications not compatible with pregnancy e.g. statins
Which contraceptives should be used in Rheumatic disease?
Contraceptives with low failure rate e.g. implanon, mirena should be used
Estrogen containing contraceptives should be avoided due to increased risk of VTE
Which DMARDs are accepted for use in pregnancy?
Hydroxychloroquine
Sulfasalazine
Azathioprine
There is increasing experience and data with biologics such as TNFi
Anti Ro and anti La antibodies are associated with…
How to prevent or treat this?
Neonatal lupus and congenital heart block
Prevention and tx with IVIG, PLEX, Aza, steroids ineffective. Some evidence with HCQ, studies ongoing
DDx of epigastric pain
GORD MSK rib stretch Gallstones Pre-eclampsia Pancreatitis
What’s hypertension?
BP >140/90 taken on 2 occasions over several hours
BP >=160/90 is an emergency
What happens to FBC?
Platelet falls and WCC increases
IDA common
Does haemolysis occur in pregnancy?
Haemolysis rare
DDx: preeclampsia, microangiopathies HUS/TTP
Raised LFTs in pregnancy
MIldly raised AST ALT DDx
- Preeclamspai
- Drugs - labetalol
- Cholestasis of pregnancy
- Non-pregnant conditions e.g. fatty liver
HIgh ALP is normal in pregnancy - produced by placenta
DDx of HTN
Preeclampsia - systemic disease, HTN + involvement of one other organ
Gestational HTN >140/90 after 20/40 pregnancy
Chronic HTN
Chronic HTN with superimposed preeclampsia - go into pregnancy with chronic HTN then develop preeclampsia
Masked HTN
HELLP syndrome - haemolysis, elevated liver enzymes, low platelets (serious), manifestation of preclampsia
CVS change of normal pregnancy
SVR drops 25%
PVR drops 25%
Plasma volume increases 25% to fill this increase SVR
50% increase in CO –> LL oedema
50% increase in HR
Increase in SV, RVOT velocity (systolic murmur)
Pathophysiology preclampsia
Defective placental implantation –> placental ischaemia –> message from the placenta –> endothelial dysfunction –> reduced perfusion of affected organs
Placental factors
- sFLT-1
Pathophysiology preclampsia
Defective placental implantation –> placental ischaemia –> message from the placenta –> endothelial dysfunction –> reduced perfusion of affected organs
Placental factors
- sFLT-1 produced by the ischaemic placenta and circulates in the blood. Competes with normal endothelial VEGF and stops it from binding to the endothelial receptors –> HTN, proteinuria, raised liver enzyme etc
- Anti-androgenic factor
Preeclampsia affects which organs?
HTN Liver Kidney Haem Brain Foetus
Preeclampsia manifestations
Glomeruloendothelials
- Tubular lesion –» protein leak
- Raised
Haem
- Subclinical/clinical DIC
- Thrombocytopenia
- Haemolysis
Liver
- Ischaemia
- Haemorrhage
- Epigastric/RUQ pain, nausea
- Abnormal LFTs - AST, ALT
Brain
- Headache, visual disturbance
- Retinal vasospasm
- Hyperreflexia + clonus
- Ischaemia, haemorrhage
- Eclampsia - seizures
- Stroke
Foetus
- IUGR
- Placenta ischaemia, haemorrhage
Rx seizures in preeclampsia
Severe preeclampsia
GTCS
Rx:
Always lower the BP
Magnesium sulphate IV - load dose + infusion
What tools can be used to predict early preeclampsia?
Maternal risk factors
MAP
+/-
mean uterine artery pulsatility index
Serum levels of PIGF or PAPP-A
Put into risk score of early onset preeclampsia
If >1:100 risk of preterm preeclampsia, recommend aspirin prophylaxis (decrease risk of preeclampsia)
Role of angiogenic markers
PLGF >100 - unlikely to get preeclampsia in the next 14 days
Low <12 - likely to get preeclampsia
Ratio sFLT/PIGF
Rule out <38, Rule in >85-110
Management of preeclampsia
Admit Maternal ax Foetal ax Monitor mother and foetus Plan delivery - if you remove the placenta the disease is cured Control BP Stabilise fluid status Treat coagulopathy, thrombocytopenia But whatever we do doesn't alter what's happening in the placenta
Cure is achieved by delivery
Which antihypertensives in preeclampsia?
- Labetalol, alpha methyldopa, nifedipine, hydralazine
- Avoid diuretics, ACEI
Prevent preeclampsia
Previous preeclampsia >32/40
Aspirin low dose
Calcium
Risk of ESKD in preeclampsia
ESKD risk increases with every pregnancy with preeclampsia
Hyperemesis gravidarum is associated with which abnormal bloods?
Raised AST ALT Due to starvation
Rx: PPI, laxative, antiemetics, feeding if required
Acute liver failure of pregnancy
Sudden catastrophic illness
Liver failure + coagulopathy + encephalopathy
Microvascular fatty infiltration of hepatocytes
Maternal and foetal mortality
Present with malaise, N&V, epigastric pain, jaundice, impaired GCS, symptoms of preeclampsia (but extent of LFT dysfunction is out of proportion)
Rx: delivery of the foetus is the only treatment
Criteria used to diagnose acute liver failure of pregnancy
Swansea criteria
Bloods in acute liver failure of pregnancy
Raised bili, AST< ALT
Low alb, glucose, fibrinogen
Coexist: Increased WCC, clotting times, urate, creatinine, uric, acid, decreased platelets
Intrahepatic cholestasis of pregnancy presentation
Common
Reversible
Associated with pruritis in 3rd trimester
Jaundice, N&V, steartorrhoea rare
Associated with gallstones
Foetal complications of intrahepatic cholestasis of pregnancy
Preterm labour
meconium stained amniotic fluid
fetal distress in labour
Stillbirth after 37/40
Stillbirth correlate with bile acid levels (especially if >100; increased risk if >40)
Rx intrahepatic cholestasis of pregnancy
Consider early delivery if bile acid >40 and recommended in BA >100
Rx: ursodeoxycholic acid
VTE in pregnancy/postpartum when and why?
Increased risk especially after 28/40 and marked increase in the 6/52 post delivery
Coagulation factors»_space;> anticoagulation factors
Endothelial damage - instrumentation during delivery
Stasis
D-dimer in pregnancy
Increases with increased trimester
Negative d-dimer does not exclude VTE
CTPA or VQ for PE in pregnancy?
Foetal radiation dose is very low, below 1mGy with both CTPA and VQ, but the maternal breast dose with CTPA is significantly greater than with VQ
Technical factors such as hyperdynamic circulation, haemodilution, poor lung expansion and breath holding secondary to gravid uterus
Availability of the scan
Is there an alternative diagnosis that can be picked up by CTPA?
Both very good at excluding PE. VQ has better sensitivity than CTPA
Below knee DVT Rx
Therapeutic clexane for 3/12
Consider reducing to prophylaxis after 3/12 until delivery + 6/52
Be aware of upper limb DVT associated with hyperstimluation syndrome i.e. IVF
PE Rx
Therapeutic clexane 3-6/12 + 6/52 post partum
Classification of APS
1 clinical + 1 lab criteria
Rx antiphospholipid syndrome
Aspirin +/- therapeutic clexane
List Teratogenic drugs
Teratogenesis only first 10/40
>10/40: foetal toxic
BAD drugs: retinoids, thalidomide, sodium valproate, mycophenolate, warfarin, MTX
Foetal toxics: ACEI, NSAIDS
Can use many chemotherapy agents, aspirin, lamotrigine, levetiracetam, most vaccines especially influenza, antivirals
IS RA likely to flare in pregnancy?
No
Only autoimmune condition that reduces during pregnancy
But can flare postpartum
COVID in pregnancy
Increased risk of becoming severely unwell
Pregnancy complications like preterm birth/stillbirth
Vaccination is recommended at all stages
Remdisivir is ok
Prednisone preferred over dexamethasone (crosses placenta)
Tocilizumab is recommended (CRP >75) rather than baricitinib (CI in pregnancy)
Aim SpO2 >94%
Can’t use d-dimer to monitor
