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EOY4 > Medical Conditions in Pregnancy > Flashcards

Medical Conditions in Pregnancy Flashcards

1
Q

What are the physiological thyroid changes during pregnancy?

A

Pregnancy may mimic hyperthyroidism as hCG is a TSH analogue

↑ TBG and T4 output to ↑ free T4

TSH may ↓ to below pre-pregnancy levels in T1 (due to ↑hCG)

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2
Q

Which are the best tests to order to monitor thyroid function during pregnancy?

A

Free T4, free T3, TSH

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3
Q

Which is the most common thyroid disorder during pregnancy?

A

Grave’s Disease

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4
Q

What are the risk of hyperthyroidism during pregnancy?

A

↑ risk of prematurity

Foetal loss

Malformations

Thyroid Storm

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5
Q

What is a thyroid storm?

A

Fever, tachycardia, change in mental state that may be precipitated by labour, delivery or surgery

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6
Q

What are the causes of foetal thyrotoxicosis?

A

Premature delivery

Foetal goitre = polyhydramnios

Extended neck in labour

F. Tachycardia

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7
Q

What are the consequences of hypothyroidism during pregnancy?

A

Increased rates of miscarriage, stillbirth, PROM

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8
Q

What is the management of hyperthyroidism during pregnancy?

A

Prophylthiouracil

Low dose + monthly monitoring as can cross placenta

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9
Q

What is the management of hypothyroidism during pregnancy?

A

↑ levothyroxine by 30% once pregnant and monitor 6 weekly

Optimise T4 before conception

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10
Q

When is a women at the greatest risk of cardiomyopathy?

A

1 month before and 5 month after delivery

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11
Q

What are the risk factors for cardiomyopathy?

A

> 35

Afrocarribean

Multiple gestations

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12
Q

What are some symptoms of cardiac disease during pregnancy?

A

Dyspnoea, fatigue and ankle oedema (also symptoms of pregnancy).

SO nocturnal dyspnoea and cough and chest pain = 🚩 🚩 🚩 🚩 🚩 🚩 🚩 🚩

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13
Q

What is the general management of cardiac disease during pregnancy?

A

MDT management with both cardiologists and obstetricians

Prevention of things that could exacerbate e.g. anaemia, smoking, obesity, hypertension

Vasodilators e.g. hydralazine can be given to ↓ after load due to ventricular dysfunction

Diuretics to get rid of pulmonary oedema

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14
Q

Which anticonvulsants are to be avoided during pregnancy?

A

Valproate has biggest risk of congenital malformations

Carbamezapine also has big risk

Lamotrigine also has big risk but smallest risk overall

All are to be avoided in breastfeeding

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15
Q

What are is the management of epilepsy pre-conception?

A

Specialist referral

Take folic acid 5mg before conceiving

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16
Q

What are is the antenatal management of epilepsy?

A

Assess for eclampsia if having seizures in 2nd half of pregnancy

Concentration of medication in plasma can change

Foetus may be at relatively higher risk of harm during a generalised tonic-clonic seizure

↑ chance of difficulties during labour and delivery e.g. failure to progress, chance of c-section

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17
Q

What is the antepartum management of epilepsy?

A

Continue to take AEDs

Not birthing pool

IV access - can give IV Benzos if seizing

Avoid maternal exhaustion

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18
Q

What is the postpartum management of epilepsy?

A

Neonatal withdrawal might happen

Routine injections of vitamin K to baby = ↓ risk of neonatal haemorrhage

Breastfeeding encouraged

Enough Sleep!

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19
Q

How can the risk of vertical transmission of HIV be increased? (5)

A

Vaginal delivery

Breast feeding

ROM for >4hours

PROM

Viral load >400

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20
Q

What is the antenatal management of a mother with HIV?

A

Offer testing at booking

Have to inform staff of HIV status + MDT management

Vaccines: influenze, hep b, pneumococcal

Bloods for other infections: hep b&c, TORCH, measles

Maternal Antiretroviral therapy from week 24 (HAART)

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21
Q

What is the intrapartum management of a mother with HIV?

A

Offer caesarean if maternal viral load is >50copies/ml. Offer at 38 weeks.

Give Zidovudine infusion 4 hours BEFORE caesarean

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22
Q

Can a vaginal delivery be offered to a pregnant mother with HIV?

A

Yes if maternal viral load is <50copies/ml

Have to minimise trauma to baby as much as poss

Continue HAART during labour

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23
Q

Can a mother with HIV breastfeed?

A

Not recommended!!

Give Cabergline PO to suppress lactation

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24
Q

What is the management of a baby born to a mother with HIV?

A

Zidovudine for baby twice a day for 2 weeks.

Give baby zidovudine if maternal viral load is below 50.

Otherwise give triple therapy for 4-6 weeks

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25
Q

What happens if a mother with HIV has PROM?

A

ROM <34 weeks = Give steroids and erythromycin

> 34 weeks = Deliver baby regardless of viral load

MDT management

Ensure HAART still taken

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26
Q

What are the physiological haematological changes that occur during pregnancy? (2)

A

↑ plasma volume. More than red cell volume

Dilutional anaemia = ↓ in Hb and ↓ haematocrit. This is at maximum effect at 28-30/40.

Also may have neutrophilia, thrombocytopenia, ↓cell-mediated immunity = PREDISPOSES TO SEPSIS

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27
Q

What are the adverse effects of an increase in plasma volume during pregnancy?

A

Net fluid gain = too much oxytocin used can cause fluid overload as is similar to ADH

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28
Q

What is the main cause of anaemia during pregnancy?

A

Iron deficiency anaemia is the most common - baby needs A LOT of Iron.

Significant if menorrhagia is baseline.

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29
Q

What are the effects of anaemia on mam?

A

normal anaemia signs e.g.

fatigue,

immunosuppression

poor concentration

low mood

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30
Q

What are the foetal effects of anaemia?

A

Low birth weight

preterm delivery

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31
Q

What is the management of anaemia during pregnancy?

A

Routine supplementation not recommended

Eat lots of iron rich food

If have to, treat with 100-200mg or oral elemental iron per day for 3 months and continue fr 6 weeks postpartum

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32
Q

How does pregnancy predispose VTE?

A

Blood stickier anyway

Baby can compress veins therefore predisposing stasis

Commonly compresses the left ileofemoral.

Common iliac artery crosses over common iliac vein on right more than left so left is more exposed to be compressed.

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33
Q

What are the issues with diagnosing VTE during pregnancy?

A

Big symptom cross over

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34
Q

What are the signs and symptoms of a DVT?

A

Signs = ↑ temp and WCC

Symptoms = Swollen leg +/- pain, abdominal pain

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35
Q

What are the signs and symptoms of a PE?

A

Signs = tachypnoea + tachycardia

Symptoms = pleuritic chest pain, haemoptysis, dyspnoea (exertion → rest)

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36
Q

What are the investigations for DVT during pregnancy?

A

Well’s Score

LMWH before diagnosis unless CI e.g. epidural

Urgent duplex doppler scan

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37
Q

Based on the results of a duplex doppler scan, when would a DVT be treated during pregnancy?

A
  • Negative + low suspicion of DVT = discontinue treatment

- Negative + high suspicion of DVT = continue to anticoagulate and repeat in 1 week

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38
Q

What are the investigations of a PE during pregnancy?

A

Well’s Score

CXR
= Normal - do a doppler

= normal but still suspect a PE = VQ scan or CTPA but watch radiation

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39
Q

Why are D-dimers shit in pregnancy?

A

Raised during pregnancy anyway. Do clinical assessment and imaging. Always do a Well’s score.

40
Q

What is the management of VTE during pregnancy?

A

LMWH

NOT WARFARIN AS TERATOGENIC

IV unfractionated heparin can be used if massive PE

41
Q

What are the rules for using LMWH in pregnancy?

A

Use throughout and for 3 months after

42
Q

Should you ever stop anticoagulating during pregnancy?

A

Yes have to stop for labour to reduce PPH risk and so anaesthesia can be used

Stop at first signs of labour or 24 hours before morning of admission if elective

43
Q

What is the definition of chronic hypertension during pregnancy?

A

HTN >140/90 but is present before pregnancy OR during the first 20 weeks

44
Q

What is the definition of pre-eclampsia?

A

Pre-eclampsia = NEW hypertension after first 20 weeks and proteinuria (>300mg/24hrs) +/- oedema

45
Q

What is the definition of gestational hypertension?

A

ew-onset and after 20 weeks. Often leads to pre-eclampsia.

46
Q

What are the physiological changes in pregnancy that relate to blood pressure?

A

⬆️ blood volume by 50%

⬆️ cardiac output ( ⬆️ HR and SV)

Initial ⬇️ in blood pressure due to: ⬆️ progesterone = vasodilation. Returns to what it was before pregnancy @ 36 weeks.

47
Q

What is the pathophysiology of pre-eclampsia?

A

Abnormal remodelling of the spiral arteries (T1-20/40).

Cytotrophoblasts in the placenta don’t penetrate the myometrial segment of the spiral arteries properly = narrow and high resistance within the blood vessels

Mam produces ↓PIGF and ↑sFLT-1 = less angiogenesis. PIGF might be new test?

48
Q

Which IUGR is associated with pre-eclampsia and why?

A

Asymmetrical IUGR - blood shunted to vital bits

49
Q

What are the maternal symptoms of pre-eclampsia? (5)

A

Severe headache - throbbing/pounding. Do they suffer from migraines anyway?

Severe epigastric pain
Can move to R flank + back

Tender liver on palpation (stretching Glisson’s capsule)

N&V

Sudden swelling of hands and feet

Visual Changes
Flashing lights
End stage PE

50
Q

What are the maternal signs of pre-eclampsia? (5)

A

Hypertension

Hyperreflexia (about to seize!!)
Sustained ankle clonus
Papilloedma

Weight gain due to fluid retention/ sudden oedema/ pulmonary oedema

51
Q

What are the foetal signs of pre-elampsia?

A

Asymmetrical IUGR

Foetal Distress

Reduced foetal movements

52
Q

What are the maternal investigations for pre-eclampsia?

A
  • Bed - urinalysis = +1 is diagnostic then do a protein:creatinine ratio

Bloods
FBC - ↓ platelets and WBC
U&E - ↑ creatinine, monitor kidney function
LFT - deranged if severe PE + ↑bili = ?haemolysis

53
Q

What are the foetal investigations for pre-eclampsia?

A

CTG

Uterine artery doppler - identifying high risk women

USS - oligohydramnios for growth restriction

54
Q

What is the preventative management of pre-eclampsia?

A

75mg aspirin daily from 12 weeks to birth IF one high risk or two low risk so you’d have to bloody take it

Aspirin prevents platelet aggregation and is pro-angiogenic

55
Q

What is the conservative management of pre-eclampsia and when should you do it?

A

Manage conservatively until 34/40. Can deliver after this if given corticosteroids and deliver after 37/40 if mild-mod.

56
Q

What is the management of severe pre-eclampsia?

A

Delivery after 34 weeks or give steroids and antihypertensives until they can make it to this

Magnesium Sulphate if severe (seizure prevention)

57
Q

What is the postnatal management of pre-eclampsia?

A

Measure BP QDS whilst in
Then, day 3 and 5 if no anti-HTN taken or 1-2 for 2/52 if taken
BP >150/100mmHg = start meds UNLESS methyldopa (PN depression)

58
Q

Which antihypertensives should be avoided during pregnancy?

A

ACEI and ARBs!!!! Teratogenic!!! Effect on foetal kidneys!! (can use enalapril after when breastfeeding though)

59
Q

What is the management of chronic hypertension during pregnancy?

A

Labetalol
B blocker - not for asthmatics
Also not for T1DM as palpitations are a warning for hypoglycaemia so will stop this. AND NOT pheochromocytoma AND NOT afro-carribean

Nifedipine
Calcium Channel Blocker
Good for afrocarribean women

Methyldopa
Asthmatic and already on ACEI. Good in early pregnancy.
Not if depressed and STOP within 2 days of delivery

Hydralazine
Only if IV labetalol or if other CI
GIVE IV - NOT IF severe tachy / recent MI/ SLE / before T3

60
Q

What are the side effects of nifedipine?

A

Can stop contractions/labour

Headaches.

flushing/dizzy

Fluid retention

NO GRAPEFRUIT JUICE AFFECTED BY CYP

61
Q

What are the maternal complications of pre-eclampsia? (5)

A

Eclampsia

Placental Abruption

Haemorrhage ⇢ AKI

HELLP

↑ risk C-seciton

62
Q

What is HELLP?

A

Haemolysis
Elevated Liver Enzymes
Low Platelets

Deliver baby ASAP

63
Q

What is eclampsia?

A

Seizures during pregnancy

64
Q

What are the foetal complications of pre-eclampsia? (4)

A

Preterm

Asymmetrical IUGR

Placental abruption

Stillbirth

65
Q

What is the definition of gestational diabetes?

A

Glucose intolerance with onset/diagnosis during pregnancy (24 to 28 weeks). Usually resolves after delivery.

66
Q

What are the endocrine changes during trimester 1?

A

↓ insulin requirement.
Human Placental Lactogen causes maternal insulin resistance so that there is a big enough glucose gradient for foetal uptake @ placenta via facilitated diffusion.

hPL = increase blood glucose.

Human somatomammotropin = decrease blood glucose.

67
Q

What are the insulin changes during trimester 2?

A

↑ insulin requirement

68
Q

What are the insulin changes during trimester 3?

A

↓ insulin requirement (late on)

69
Q

What is the pathophysiology of gestational diabetes?

A

Insufficient insulin production from maternal pancreatic beta cells = gestational diabetes

70
Q

What are the complications of hyperglycaemia during trimester 1?

A

Foetal hyperglycaemia in T1 is teratogenic (NTD, Cardiac, renal)

71
Q

What are the complications of hyperglycaemia after T1?

A

hyperinsulinaemia and as insulin is anabolic leads to macrosomia and organomegaly

↑ o2 demand of foetus = hypoxia + acidosis

Macrosomia = ↑ risk of birth complications

Enlarged kidneys = ↑ erythropoiesis and neonatal polycythaemia (blood gets stickier)

72
Q

What are the risk factors for gestational diabetes?

A

Non-modifiable

  • Previous macrocosmic baby
  • Previous GD
  • South asian
  • Multip (bigger placenta)

Modifiable
- BMI >30kg/m2

73
Q

What are the symptoms of gestational diabetes?

A

usually asymptomatic but may come about if hyperglycaemic

polydipsia, polyuria, thirsty/dry mouth, fatigued

74
Q

What are the signs of gestational diabetes?

A

Fasting plasma glucose = >5.6 mmol/L

2-hour plasma glucose = >7.8 mmol/L at 2 hours

Do a fasting plasma glucose then an oral glucose tolerance test

75
Q

What are the investigations for gestational diabetes?

A

OGTT
In the morning after an overnight fast (8 hours)
1 abnormality is enough to diagnose

76
Q

what is the conservative management of gestational diabetes?

A

self monitoring of blood glucose

diet + exercise

Offer IOL or c-section at term (37-38+6/40)

77
Q

What is the medical management of gestational diabetes?

A

Metformin is first line

Offer if blood sugar are uncontrolled 1-2 weeks after diet and exercise OR > 7 mmol/L fasting

Insulin Therapy
If metformin is contraindicated
BG >7 mmol/L + complications e.g. macrosomia/hydramnios

Can also give Glibenclamide (sulfonylurea) if don’t want insulin

78
Q

What is the conservative management of pre-existing diabetes during pregnancy?

A

Self monitoring

Healthy lifestyle

Aim for HbA1c of <6.5% before pregnancy

Monitor BM TDS, urine for ketones, optic funds at booking & 20/40 and growth chart

79
Q

What is the medical management of pre-existing diabetes during pregnancy?

A

Insulin

short acting @ mealtime TDS and long acting in background BD

80
Q

What are the maternal complications of pre-existing diabetes during pregnancy? (3)

A

miscarriage

pre-eclampsia

↑ risk T2DM in later life

81
Q

What are the foetal complications of pre-existing diabetes during pregnancy? (4)

A

↑ risk stillbirth

↑ risk congenital malformations

macrosomia + associated complications

preterm birth + RDS

82
Q

How is obstetric cholestasis diagnosed?

A

Diagnosis of exclusion so have to exclude other causes of liver disease first

83
Q

What is the main symptom of obstetric cholestasis?

A

Generalised itching

Worse on palms and soles of feet

Commonly in third trimester and worsens with gestation

NO RASH

84
Q

What are other symptoms of obstetric cholestasis? (5)

A 
Insomnia 
Malaise
Abdominal Pain
Pale stools +/ Steatorrhoea
Dark urine
85
Q

What is the pattern of jaundice associated with obstetric cholestasis?

A

Jaundice
Unusual
If it does happen then it’ll be around 2 weeks after pruritus develops and has quick onset with a rapid plateau. Constant til delivery.

86
Q

Give 3 differentials for similar presentations to obstetric cholestasis

A

Acute fatty liver disease of pregnancy (v rare but serious & associated with pre-eclampsia)

Hepatitis - viral/autoimmune/drug induced

extra hepatic obstruction from gallstones

87
Q

What are the blood tests for obstetric cholestasis and why?

A

LFTs - measure weekly until delivery

Moderately high ALT & AST

ALP IS VERY HIGH (high anyway in pregnancy so has to be ABNORMALLY high)

Increased serum total bile acid x10

Mild bili increase

88
Q

What is the maternal management of obstetric cholestasis?

A

inform of ↑ risk of passage of meconium and prematurity

oral vitamin k

ursodeoxycholic acid

topical calamine lotion or aqueous creams for symptom relief

89
Q

What is the role of vitamin K in the management of obstetric cholestasis?

A

Vit K is a fat soluble and have fat malabsorption in liver disease/ biliary dysfunction.

Vitamin K is needed for clotting and so is protective for PPH

90
Q

What is the role of ursodeoxycholic acid?

A

Displaces bile salts and protects hepatocytes

91
Q

What is the foetal management of obstetric cholestasis?

A

Increased foetal monitoring

92
Q

What are the maternal complications of obstetric cholestasis?

A

Liver disease

PPH

↑ prothrombin time

93
Q

What are the foetal complications of obstetric cholestasis?

A

Foetal distress

increased risk of intrauterine death, preterm birth

94
Q

Which anticonvulsant is the best to use in pregnancy?

A

Lamotrigine?

95
Q

What are the foetal abnormalities associated with sodium valproate and lithium?

A

Valproate = Neural tube defects

Lithium = Epstein’s abnormality (tricuspid valve doesn’t form properly)

96
Q

Define sensitisation (in the contest of RhD)

A

A process whereby fetal red blood cells (RhD-positive) enter the maternal circulation, where the mother is RhD-negative

The fetomaternal haemorrhage (FMH) can cause antibodies to form in the maternal circulation that can haemolyse fetal red blood cells.

Affects next pregnancies if baby is RhD+

97
Q

Give 5 potentially sensitising events during pregnancy

A

Ectopic pregnancy

CVS, amniocentesis

APH

Evacuation of retained products etc

Vag bleeding <12 if really heavy or painful OR just >12 weeks

EOY4 (22 decks)

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