Medical Conditions in Labour (RCOG)

Question 1

Cardiac lesions for which fluid balance monitoring is critical in labour (6)?

Answer 1

1. Severe left sided stenotic lesions
2. hypertrophic cardiomyopathy
3. Cardiomyopathy with systolic ventricular dysfunction
4. pulmonary arterial hypertension
5. Fontan circulation and other univentricular circulations
6. NYHA class IV heart disease

Question 2

Heart lesions for which planned elective caesarean should be considered for (3)

Answer 2

1. any disease of the aorta assessed as high risk
2. pulmonary arterial hypertension
3. NYHA class III or IV disease

Question 3

Considerations for women requiring fluid balance in labour?

Answer 3

hourly fluid input and output
hourly obs
continuous ECG
continuous arterial BP
serial echocardiography for output

Question 4

How is LMWH titrated for mechanical heart valves?

Answer 4

Started on BD dose for latest weight

titrated by trough (pre dose) and peak (3-4hrs post dose) of anti-Xa levels

Question 5

Investigations for heart failure in labour?

Answer 5

electrolytes
FBC
arterial blood gas
ECG
CXR

cardiologist –> transthoracic echo, BNP

Question 6

When should regional analgesia be considered routine in the care of heart disease in labour?

Answer 6

WHO 3 and WHO 4 heart disease

low dose regional analgesia less likely to cause cardiac instability during labour and birth

Question 7

First and second Line uterotonics for significant aortopathy?

Answer 7

i.e. Marfan syndrome with dilatation>40mm, bicuspid aortopathy and dilatation >45mm, previous aortic dissection, Turner syndrome and aortic size >25cm/m2

1. Oxytocin
2. Misoprostol and Carboprost

avoid ergometrine due to HTN induced aortic dissection or rupture

Question 8

Uterotonic recommendations for limited or fixed low cardiac output, or preload dependent circulation?

Answer 8

i.e. severe systemic ventricular dysfunction, severe valvular stenosis, hypertrophic cardiomyopathy, with outflow obstruction, Fontan circulation, cyanotic heart disease.

1. slow infusion of oxytocin to avoid sudden haemodynamic change
2. misoprostol, carboprost.

Avoid long-acting oxytocin analogues and ergometrine

Question 9

Uterotonics for pulmonary artery hypertension?

Answer 9

1. oxytocin
2. misoprostol

Avoid ergometrine, carboprost, and long acting oxytocin analogues due to risk of worsening PAH

Question 10

Uterotonics appropriate in coronary artery disease?

Answer 10

1. Oxytocin
2. Misoprostol

Avoid ergometrine due to risk of coronary ischaemia.

Question 11

What prostaglandins are contraindicated with asthma?

Answer 11

prostaglandin F2 alpha = carboprost

prostaglandin E1 and E2 can be considered, no evidence for worsening. theoretical risk only.

Question 12

What is defined as long term oral steroid therapy?

Answer 12

5mg pre daily for more than 3 weeks

Question 13

Management of women in labour that has been on long term steroid therapy?

Answer 13

minimum dose IV/IM hydrocortisone 50mg every 6 hours until 5 hours after baby is born

Question 14

Treatment of known immune thrombocytopenia Purpura before admission for birth if platelets low?

Answer 14

consider giving steroids or IV immunoglobulin to raise platelet count

Question 15

If maternal immune TTP, what precautions should be taken for baby?

Answer 15

NICU aware
No FBS
Caution FSE
No ventouse
Caution mid cavity or rotational forceps
CS may not be protective
needs cord blood plt count.

Question 16

What conditions would a women have if classified as ‘low risk’ for intrapartum cranial bleeding?

Answer 16

1. fully treated cerebrovascular malformation

2. intracranial bleed of unknown cause after investigation, >2y ago.

Question 17

What conditions would put a woman at high risk of intracranial bleeding in labour?

Answer 17

• untreated or partially treated malformation with previous bleed
• aneurysm >7mm
• complex AV malformation
• cavernoma
• IC bleeding within the last 2 years

Question 18

Management of women at high risk of intracranial bleeding

Answer 18

consider CS

If wishing for VD, offer epidural and assisted second stage.

Question 19

Timing of delivery for CKD stage 5, or deterioration stage 3b or 4?

Answer 19

Before 34 weeks of pregnancy. No later than 38 weeks.