Medical Conditions in Pregnancy Flashcards
Most maternal mortality during pregnancy is from _____ causes of pregnancy
Direct
Give examples of some causes of mortality during pregnancy.
- Haemorrhage
- Sepsis
- Hypertension
What is the most common cause of mortality during pregnancy?
Cardiac disease
Obese + pregnant women are more at risk of?
Blood clots
What is the normal HR for a full term pregnant lady?
90-100 bmp
Peripheral vascular resistance increases in pregnancy
F - it decreases
What should all pregnant women with chest pain get?
ECG + CT
** ALL PREGNANT WOMEN WITH CHEST PAIN SHOULD GET AN ECG + CT **
T
List reasons of why heart disease in pregnancy is rising
- More obesity
- More older women having babies
- More CHD (congenital heart disease)
Palpitations are very common physiologically in pregnancy
T
Most palpitations in pregnancy are something to worry about
F - most are benign
What often causes the onset of palpitations (physiologiclally) in pregnant women?
Rest and when patient is lying on their side
How can pregnant women get rid of physiological palpitations?
By getting up and moving around
WARFARIN IS TERATOGENIC
T
What anticoagulant should never be prescribed to pregnant women as it is teratogenic?
Warfarin
How do women with ectopic beats in pregnancy describe these beats?
Thumping
Can ectopic beats be seen on an ECG?
Yes
Sinus tachycardia is part of a normal pregnancy BUT must be ____________
Investigated
When investigating sinus tachycardia, what are you trying to exclude?
- Sepsis
* PE
What 4 investigations should be done in a pregnant woman with tachycardia?
ECG, FBC, TFT, ECHO
If someone has SVT in pregnancy, when is it likely to have occurred?
Before pregnancy
What investigations need to be done for a pregnant lady with SVT?
- ECG
- 24H ECG
- TFT
- ECHO
What investigations need to be done for a pregnant lady with SVT? (hint: these are the same as with sinus tachycardia)
- ECG
- 24H ECG
- TFT
- ECHO
Name a thyroid problem that could result in palpitations.
Hyperthyroidism
How is hyperthyroidism investigated?
ECG, TFT (+ FT4)
How is a pheochromocytoma investigated?
24h catecholamines + US
Functional residual capacity of the lungs decreases during pregnancy
T
PaCO2 increases during pregnancy
F - decreases
Around __ % of women will be breathless during pregnancy meaning this is very common
75%
In what trimester is breathlessness most common?
3rd
The increased demands for O2 during pregnancy are facilitated via INCREASED VENTILATION
T
Breathless during pregnancy is i) made worse by ii) relieved by?
i) rest + talking
ii) exertion
What is the commonest medical condition to complicate pregnancy?
ASTHMA
__% of women with asthma will have an acute exacerbate during pregnancy
10%
During pregnancy asthma can …
- Get better
- Stay the same
- Get worse
Why might asthma get worse during pregnancy?
Many women when they find out they are pregnant will stop taking their medication for asthma because they think it might harm the baby
Women with severe asthmatic disease are at risk of deterioration, especially in 3rd trimester
T
Well controlled asthma …
Will not adversely affect the baby
Poorly controlled asthma …
Worse than the effects of the medication for the baby
What kind of birth should mothers with asthma aim for?
Vaginal
Women should stop using inhalers during pregnancy
F - during pregnancy women should continue to use their inhalers
For a woman with asthma during labour, what is the 1st step that should be done?
Increase dose and frequency of inhaled steroids
If a woman with asthma has been on oral steroids for more than 2 weeks prior to labour, what should be done? Why?
IV hydrocortisone should be given during labour
In labour women cannot make their own steroids
Outline the treatment for asthma.
- Short acting B2 agonist (SABA)
- Add inhaled steroid
- Add LABA
- If LABA helps then continue LABA
- If LABA doesn’t help much then keep LABA and increase steroid dose
- If LABA helps none then stop LABA and increase steroid - Increase steroid to 2000mg and consider adding leukotriene receptor antagonist
- Oral steroid tablet
What is the leading cause of maternal mortality?
VTE
By how much does a woman’s risk of a VTE increase while being pregnant?
5 x’s
90% of DVT’s during pregnancy occur in the ______ leg
LEFT
70% of DVT’s in pregnancy are ilii-femoral
T
How can the pathogenesis of a VTE be explained?
Virchows triad
Outline virchow’s triad and how it is altered in pregnancy.
1 – Stasis (venous)
Secondary to venous compression by pregnant uterus
2 – Hypercoagulability
Effects of pregnancy
3 – Vascular damage - this is the valves (not the wall)
Varicose veins
Pregnancy is a hyper-coagulable state
T
A pregnant lady with a previous VTE is regarded as high risk. What do they need to be prescribed at the start of pregnancy?
LMWH
In a high risk mother, how long after pregnancy do they need to take LMWH?
6 weeks
How is a low risk mother managed in terms of preventing VTE risk?
Told to keep mobile and hydrated
3 VTE risk factors…
LMWH for 28 weeks
3 VTE risk factors…
LMWH from 28 weeks to pregnancy
4 VTE risk factors ….
LMWH from 1st trimester to pregnancy
What signs can help us to diagnose a DVT?
- Swelling
- Oedema
- Leg pain or discomfort
- Tenderness
- Increased leg temperature
- Lower abdominal pain
- Elevated white cell count
Why is it difficult not to misdiagnose a DVT during pregnancy?
Because all the signs are present in normal pregnancy
How would you investigate DVT in a non pregnant person?
Do bloods to check for d-dimers
Why do you not check bloods for d-dimers in pregnant women?
Because d-dimers are elevated in normal pregnancy
How is a DVT diagnosed in pregnancy?
1st line – IMAGING - compression duplex US
2nd line – if iliac vein thrombosis is suspected (whole leg swollen + back pain) - consider MRI venography
Outline the symptoms of a PE.
- Dyspnoea
- Chest pain
- Faintness
- Collapse
- Haemoptysis
- Raised JVP
- Focal signs in the chest
How is a PE investigated in pregnancy?
ECG + CXR
What kind of foetal malformations can Warfarin cause if given to a pregnant lady?
- Midface hypoplasia
- Stippled chondral calcification
- Short proximal limbs
- Short phalanges
- Scoliosis
Warfarin can be teratogenic as it crosses the ________
Placenta
Prior to pregnancy, if someone is on Warfarin, what should this be changed to and when?
LMWH at 6 weeks
Can Warfarin and Heparin be used post-natal?
YES - none of these affect breastfeeding
When following birth, can warfarin be started?
5 days after birth
What is APS?
An acquired thrombophilia with variable presentation and severity
What do antiphospholipid antibodies in APS do?
Autoantibodies that react with the phospholipid component of the cell membrane and cause arterial and venous thrombosis
Outline some of the clinical features of APS.
- Arterial / venous thrombosis
- Recurrent early pregnancy loss
- Late pregnancy loss - usually preceded by FGR
- Placental abruption
- Severe early onset pre-eclampsia (PET)
- Severe early onset Fetal Growth Restriction (FGR)
How is APS diagnosed?
- Vascular thrombosis – arterial, venous, small vessel
+ - ≥ 3 miscarriages <10 weeks
- ≥ 1 fetal loss >10 weeks (morphologically normal fetus)
- ≥1 preterm birth (<34 weeks) due to PET or utero-placental insufficiency
+ - IgM / IgG aCL (medium / high titre)
- LA
How is APS managed if the woman has had no previous thrombosis or adverse pregnancy?
- Low dose aspirin
* Maternal + foetal surveillance
How is APS managed if the woman has had a previous thrombosis?
- On warfarin —– Stop warfarin
* LDA + LMWH (treatment dose)
How is APS managed if the woman has had a previous early pregnancy loss?
- Low dose aspirin + LMWH (prophylaxis dose)
How is APS managed if the woman has had a previous late pregnancy loss?
- Low dose aspirin + LMWH (prophylaxis dose)
In a pregnant woman with epilepsy, seizure frequency is either ________ or _________
- Improved
2. Unchanged
In a woman with epilepsy, if no seizure in 9 months prior to pregnancy, up to 92% will remain seizure free
T
Outline some of the MATERNAL risks if a pregnant lady has a seizure.
- Maternal abdominal trauma – foetomaternal haemorrhage
- PPROM – premature rupture of membranes
- Preterm birth
- Hypoxia/acidosis
How can a woman prevent having a seizure in late pregnancy?
By having good seizure control in the first trimester
Outline some of the FOETAL risks if a pregnant lady has a seizure.
- Major congenital malformations - this is what we worry about as the drugs used to treat epilepsy are teratogenic !!!!
- Minor malformations
- Adverse perinatal outcomes
- Long-term developmental effects
- Haemorrhagic disease of the newborn
- Risk of childhood epilepsy
Why do we worry about major congenital malformations in a baby whose mother is epileptic?
Because most of the drugs used to treat epilepsy are teratogenic
Many drugs affect liver enzymes, which affect vitamin K and thus the baby can get a haemorrhagic disorder of the newborn
T
2-3 x’s increase in risk of teratogenicity with a single AED’s
T
What should all pregnant women on an AED be offered?
All women should be offered a detailed ultrasound scan assessment of fetal anatomy at 18-20 weeks gestation
What are the most common congenital malformations with AED’s?
- Neural tube defects
- Congenital heart disorders
- Urinary tract
- Skeletal abnormalities
- Cleft palate
If a woman is having a seizure during pregnancy, what needs to be given ASAP?
Benzodiazepines
What do we worry about if someone is having a seizure during pregnancy?
- Maternal hypoxia
- Foetal hypoxia
- Foetal acidosis
Most women with epilepsy will have a normal labour and vaginal birth
T
What can increase the risk of having a seizure during pregnancy?
- Stress
- Pain
- Sleep deprivation
- Over-breathing
- Dehydration
What can women take to reduce to the risk of having AED related foetal abnormalities?
Folic acid
What is given as a pre-eclampsia prophylaxis in obese pregnant women?
Aspirin
What do obese pregnant women get at 34 weeks?
Anaesthetic review
