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
