Medical conditions pregnancy Flashcards

Question

vWD and pregnancy - Effect of pregnancy on vWD - Effect of vWD on pregnancy - management

Answer 1

Effect of pregnancy on vWD - pregnancy can normalise vWF and VIII levels, drop PP Effect of vWD on pregnancy - Early gestation vWF levels may not have increased enough - increased bleeding with ectopic, miscarriage, CVS - No increased risk APH / miscarriage - By 3rd trimester vWF increased enough that no need for alternate measures in labour - active mx 3rd stage Management - Ascertain subtype of vWD pre-pregnancy and whether responds to DDAVP (type 1 responds to DDAVP - it stimulates release of vWF). Can give in pregnancy - No aspirin or NSAIDs

Answer 2

Periconceptual * Enquire about systems affected: joint involvement (90% arthritis), skin (80%), raynauds, pleuritis, pericarditis, renal glomerulonpehritis, neurological (psychosis, seizures, chorea), haematoligcal (haemolytic anaemia, thrombocytopenia, lymphopenia, leukopenia) * Counsel risks - higher if untreated or flare <6months or renal lupus. Miscarriage, early onset FGR, PTB, HTN, PET, VTE, Stillbirth, neonatal lupus. * Review medications usually benefit > risk but NOT for methotrexate. Continue hydroxychloroquinine. * Baseline ANA titre, c3/c4 (if low risk of flare), anti ds DNA (gives info about disease activity), CBC, Renal, LFTs, urine ACR (helps understand disease status) (may need serial measurements), anticardiolipin ab (risk of VTE) * Anti Ro/La screen (30% have - if present 5% risk cutaneous lupus and 2% risk CHB) Antenatal * MDT - high risk obs, rheum, anaesthetics * Aspirin (LMWH if APLs or prev VTE or lupus nephritis) * Fetal heart auscultation if Anti Ro/La weekly from 16weeks * FAS + uterine artery doppler * Growth surveillance from 24weeks * BP, PET surveillance * Screen for flares (rising dsDNA titre indicates flare, also symptoms, or fall in complement levels - can help differentiate PET from lupus flare). Actively manage flares with corticosteroids. Azathioprine, NSAIDs and aspirin can also be used. Hydroxychloroquine should be continued * Flares: UV light, viral infection Delivery * Aim VB * IOL 38+ * CTG * Active 3rd stage * Hydrocortisone if high dose/long term steroids Postnatal * Neonatal review * Breastfeeding support * VTE prophylaxis * Contraception

Answer 3

No specific clinical or lab criteria - normocytic normochormic anaemia, neutropenia, thrombocytopenia, raised ESR Low complement ANA - 96% positive anti-dsDNA antiSm Glomerulonephritis occurs more commonly in women with antidsDNA and antiSm Also may have anti - Ro and anti - La ab, or anti-cardiolipin ab

Answer 4

Effect of pregnancy on SLE - Flares more common 50% - Flares more likely if disease active in last 6 months - Can be difficult to diagnose - lupus nephritis - if not well controlled, renal flare much more common - Women should delay pregnancy until at least 6 months after a lupus nephritis flare Effect of SLE on pregnancy - Increased risk of miscarriage, fetal death, PET, PTB, FGR This is related to anticardiolipin ab, or lupus anticoagulant, lupus nephritis or HTN and active disease at time of conception or first presentation of SLE in pregnancy Renal lupus biggest risk factor for fetal loss, PET, FGR, PTB

Answer 5

Neonatal lupus risk 5% CHB 2% Refer to MFM if has these Ab FH auscultation from 16 weeks Highest risk of CHB between 18 and 24/40 Hydrops and 15-20% mortality rate. Once a fetal bradycardia is recognized, detailed scanning of the fetal heart, showing AV dissociation confirms CHB. This is permanent and can't be reversed. Salbutamol can be beneficial to the fetus if bradycardia is causing heart failure. If infants survive they will need pacemaker as the anitbodies cause permanent fibrosis. Neonatal lupus: Erythematous skin lesions, will resolve within 4-6 months. Some hypopigmentation can last for up to 2 years.

Answer 6

Multisystem vasculopathy - Increased risk VTE, miscarriage, thrombocytopenia CLOT - Coagulation defects - Livedo reticularis - Obstetric complications - Thrombocytopenia Other features - Haemolytic anaemia - Cerebral involvement: epilepsy, infarction, migraines - Heart valve disease - mitral valve - HTN - Pulm HTN - Leg ulcers

Answer 7

Two or more positive readings for lupus anticoagulant and / or anticardiolipin and / or antibeta2glycoprotein1 at least 12/52 apart. PLUS fulfill clinical criteria - Thrombosis or pregnancy morbidity (3 consec miscarriages, 1 fetal death >10/40, ≥1 premature birth <34/40 due to PET or placental insufficiency

Answer 8

Effect of pregnancy on APS - Thrombosis increased - thrombocytopenia worsens Effect of APS on pregnancy - Miscsarriage - IUGR (30%) - Abruption - SB - PET - PTB (30%)

Answer 9

Periconceptual * Screen for disease sequalae * Counsel risks - miscarriage, early onset FGR, PTB, HTN, PET, abruption, VTE, stillbirth, neonatal lupus. * Review medications - May be on Warfarin - need to switch to aspirin and LMWH 5/52 prior to conception. If no hx thrombosis start on aspirin (CNP also says give LMWH if miscarriages with aspirin) * Baseline CBC, Renal, LFTs, urine ACR * Anti Ro/La screen (30% have - if present 5% risk cutaneous lupus and 2% risk CHB) Antenatal * MDT - high risk obs, haem, anaesthetics * Aspirin + LMWH (prophylactic, intermediate if prev VTE (40 BD) and therapeutic if on treatment prior) * Fetal heart auscultation if Anti Ro/La weekly from 16weeks * FAS + uterine artery doppler * Growth surveillance from 24weeks * BP, PET surveillance * Pscyhological support (especially if recurrent losses) * Immunosupression - no good evidence. Delivery * Aim VB * IOL 38+ * CTG * Active 3rd stage Postnatal * Neonatal review * Breastfeeding support * VTE prophylaxis * Contraception - avoid COCP *Recommence Warfarin 5-7 days PP if was on, discontinue LMWH when INR >2

Answer 10

Non inflammatory disorder - widespread vasculpathy and fibrosis - autoimmune - obliteration of vessel lumens Involves - Skin (fixed mouth, facial expression) - oesophagus - lungs - heart - kidneys

Answer 11

Effect of pregnancy on scleroderma - If renal invovlement risk of deterioration - Raynauds improves - Oesophagtitis worsens - Those with interstital lung disease and pulm HTN - high risk PP deteroiration Effect of scleroderma on pregnancy - Success = 80% - Increased risk PTB - Increased risk PET / PGR / perinatal mortality - IVL etc difficult - GA difficult

Answer 12

Pre pregnancy - Stablize disease - Lung function tests and ECHO - Multiple organ invovlement - advise against pregnancy AN - PPIs for oesphagitis - MDT - Regular BP - Anesthetic review - Steroids - avoid as can precipitate renal crisis

Answer 13

Group of disorders Mostly autosomal dominantly inherited Defects of collagen metabolism Joint hypermobility, poor wound healing, easily bruised, rupture blood vessels / internal organs Type 1: classic Type III: commonest form - hypermobile - not assoicated with heart disease Type IV: vascular - highest risk

Answer 14

Pregnancy risks to EDS Maternal mortality 25% in type IV - aortic rupture / visceral rupture. WHO GRADE 4 risk increased joint and back pain EDS risk to pregnancy - Vascular EDS: uterine rupture, PTB, poor healing, severe tears, PPH - Hypermobile EDS: PROM, preterm birth, precipitous labour, poor healing

Answer 15

Essential to know which type - refer to geneticist if don't know which type Terminate if eDS type IV- if dont terminate then offer ELCS at 34/40 (reduces risk of uterine and aortic rupture) Increased resistance to local anaesthetics - refer to obs anaesthetics

Answer 16

Periconceptual: - Counsel risks: >50% improve in pregnancy, 90% flare PP. Atlanto-axial subluxation if GA (rare), PTB, IUGR, impacts of medications, GDM if on steroids, neonatal SLE if anti-Ro/La, - Review meds: Azathioprine, hydroxycholorquinine, sulfasalazine okay. Biologics okay but avoid in late 3rd trimester (neonatal suppression effect). NSAIDs okay in 2nd trimester. Stop MTX and defer for 3months - Anti Ro/La screen Antenatal: - MDT: High risk obs, rheumatology, obs physcians, anaesthetists - Review joints - BSL monitoring if on prednisone - Monitor Hb and supplement Intrapartum: - Aim vaginal birth - Stress dose monitoring if on prednisone - Mindful of maternal positioning (hips) - Alert anaesthetics (risk of axial/atlantosubluxation) Postpartum: - Re-establish medications - Monitor for flare - Breastfeeding support (meds dependent) - VTE prophylaxis - Contraception

Answer 17

Pulmonary hypertension Eisenmengers syndrome Peripartum cardiomyopathy (25-50% risk) Previous MI (20-45%) Class III - IV NYHA Severe MS/ symptomatic AS Severe aortic coarctation Aorta >4.5cm in Marfans (>4cm HIGH risk also) Vascular EDS

Answer 18

Pre pregnancy - Mortality rate 10-25% -Actively advise against pregnancy - TOP should be considered if get pregnant (Even TOP ass with 7% risk mortality) Issues - Increasing R -> L shunt with those with Eisenmengers syndrome - R heart failure - Escalating pulmonary htn with crisis Antenatal - Continue therapies - Phosphodiesterase inhibitors - sildenafil - promote blood vessel dilation Stop endothelin receptor antagonists Postanoid analogies - can continue - Thormboprohylaxis not usually recommended - Elective admission for bed rest, oxygen therapy, escalation of targeted therapies. - Delivery: no evidence CS better - Avoid hypovolaemia - maintain preload - Avoid acidosis - Avoid thromboembolism - Avoid system vasodilation (caution with regional anaesthesia and syntocinon) DON'T give beta blocker - reduces afterload. can use nifedipine

Answer 19

Autosomal dominant 80% have cardiac involvement - MV prolapse - MV regurg - Aortic root dilation (>4cm very high risk, >4.5cm contraindication) Risk aortic dissection and aortic rupture. (10% if >4cm) Give beta blockers to reduce rate of aortic dilation ECHO ELCS if >4,5cm

Answer 20

2-5% risk fetus having heart disease (higher if mother c.f father) ASD 5-10% AS 18-20%

Answer 21

Death 10-20% if aortic root >4cm Symptoms: asymptomatic, dyspnoiea, orthopnoea, PND, cough Signs: mitral facies, cold peripheries, pulmonary oedema Effects on rpegnancy - Pulmonary oedema and deterioration, often precipitated y tachycardia (e.g. exercise, pain, anxiety, failure to adequately increase stroke volume) Poor prognostic factors - MV <1cm2 - Mod - severe symptoms pre pregnancy Management - Baseline ECG - ECHO each trimester - MDT care - Optimise iron - Aspirin and /or clexane - Beta blockers - Balloon valvotomy if non calcified valve Surgery prior to pregnancy!! IP - Avoid fluid overload as well as severe maternal tachycardia - Careful fluid balance - Passive 2nd stage - Early epidural - NVB OK as long as can cardiac monitor - IV access - Continuous CTG - Biggest risk to mother is second stage and immediately after delivery - Consider frusemide if overload (e..g autotransfusion 3rd stage) - Active mx 3rd stage but avoid syntometrine and carboprost - Treat AF aggressively with digoxin and beta blockers Avoid supine and lithotomy Pulmonary oedema - treat with oxygen diamorphine and diuretics PP - Ongoing telemetry - Strict fluid balance - HDU cares - VTE prophylaxis - Advice for next pregnancy - Consider bloods / BNP - BF support - Contraception

Answer 22

Class I: no breathlessness Class II: Breathlessness on slight exertion Class III: Breathlessness on mild exertion Class IV: Breathlessness at rest

Answer 23

HF development at end of pregnancy or in months following pregnancy, where no other cause is found Risk factors - Multiples - HTN in pregnancy - Muliparity - AMA - Afro-carribean Symptoms - Dyspnoea - Reduced exercise tolerance - Palpitation - Pulmonary or peripheral oedema - Symptoms related to peripheral cerebral emboli Signs - Tachycardia, tachypnoea - Pulmonary oedema - CHF - Dysrhythmia - unknown aetiology ?autoimmune

Answer 24

BNP raised ECHO: LVEF <45%, Global dilation with enlarged heart Ddx - PET - Massive PP haemorrhage can cause transient decrease in LVEF

Answer 25

A. B, C Elective delivery Thromboprophylaxis Diuretics Vasodilators - hydralazine and / or nitrates Cardioselective beta blockers: bisprolol, etc digoxin if AF inotropes if low EF and low BP ACEI after delivery Bromocriptine: can improve LVEF ECMO, cardiac transplant severe cases Prognosis 9% mortality 50% spont recovery Depends on normalization of left ventricular size and function within 6 months after delivery Risks if get pregnancy: arrhytmia, thromboembolism, MI, death Counsel against future pregnancies if LV size and function doesn't return to normal - HIGH risk recurrence - Worsening HF 50% - 25% death For those whose cardiomyopathy resolves, recurrence risk is unknown

Answer 26

Head: eclampsia, epilepsy, CVA, vasovagal Heart: MI, arrhtymia, Peripartum cardiomyopathy, Congenital heart disease, dissection thoracic aorta Hypoxia: asthma, PET, pulmonary oedema, anaphylaxis Haemorrhage: Abruption, uterine atony, genital tract trauma, uterine rupture, uterine inversion, ruptured aneurysm Whole body and hazards: hypoglycaemia, AFE, septic, trauma, complications anaesthesia, drug toxicity

Answer 27

Effect on pregnancy - Increased miscarriage, IUFD, PTB, perinatal morbidity and mortality - partly explained by diabetes, hypertension - Neonate at risk from adrenal insufficiency becasue of high maternal cortisol levels - Severe PET - Wound infection / poor healing - women with treated Cushing's do well in pregnancy Mx Surgery

Answer 28

Eclampsia Cerebral vein thrombosis PRES TTP Stroke SAH Drug and alcohol withdrawal Hypoglycaemia Hypocalcaemia Hyponatraemia Infections Post dural puncture Gestational epilepsy - seizures confined to pregnancy (syncope / vasovagal)

Answer 29

Effect of pregnancy on epilepsy - Mostly no effect - 2/3 won't have seizure deterioration (particularly if no seizures in last year) - Peripartum highest risk time - Death (10 fold) reasons for deterioration in seizure control - poor compliance, N+V = decreased drug levels, Increased volume of redistribution and increased drug clearance = decreased levels, lack of sleep, lack of absorption particularly in labour Effect of epilepsy on pregnancy - Long term cerebral damage not a feature as fetus resistant to short periods of hypoxia - Small increase in micarriage, APH, PPH, hypertensive disorders, IOL, CS, FGR, PTB - congenital abnormalities - Genetics of epilepsy: 5% if either parent has epilepsy, 10% if one sibling, 20% if both parents

Answer 30

Phenytoin, carbamazepine, sodium valproate, lamotrigine, toporimate, levetiracetam all cross placenta and are teratogenic Lowest risk with carbamazepine, lamotrigine, levetiracetam Major malformations - NTDs - Orofacial clefts - Cardiac defects - Urinary tract and skeletal malformations Fetal valproate syndrome - Abnormal facies Riks highest with valproate Risks increases with polypharmacy (10-15% with 2 drugs) Should take 5mg FOLATE

Answer 31

5mg folic acid 12/40 prior to conception if on AEDs (continue throughout pregnancy) If on carbamazepine, lamotrigine, levetiracetam continue on these if epilepsy well controlled If on valproate ideally change, if unable wean to lowest dose possible as dose dependent effect (<600mg/day) and changes to a multiple times a day regimen to avoid peak concentrations Advise relatives how to place woman in recovery position if has tonic clonic seziure Bathe in shallow water Prenatal screening for congenital abnormalities with NT scanning and fetal cardiology assessment Often need to increase doses of AEDs - take baseline serum drug level to assess compliance and inform future changes in drug doses If having frequent seizures may need to increase doses significantly, sometimes to doses above maximum for non pregnant women, especially lamotrigine. If a woman is seizure free on an AED other than lamotrigine, no need to measure serial drug levels, or adjust dose unless she has a seizure 18 - 20/40 FAS assessing NTDs and cardiac anomalies Monitor for anxiety and depression symptoms Serial growth scans as increased risk SGA, particularly if taking AEDs. From 28/40 Vitamin K administered to mother to reduce risk of coagulopathy for enzyme inducing drugs - can give orally or IM Intrapartum - Epilepsy not an indication for IOL or CS - Deliver in hospital - 1-2% woman have a seizure in labour and 1-2% have postpartum seizure. Shoudn't be left unattended in first 24 hours - Uterine hypertonus can occur and cause fetal hypoxia - Early epidural to address pain and lack of sleep - continue regular AEDs in labour (consider IV if vomiting) - Avoid dehydration - Avoid pethidine / ketamine - lowers seizure threshold - If seizure lasts more than 5 mins = status epilepticus. Left lateral tilt, maintain airway, oxygen, IV lorazepam (4mg) or PR diazepam (10-20mg) - consider phenytoin if seizure still doesn't terminate - consider tocolytics if persistent uterine hypertonus Postnatal management - Day 3 highest risk - Continue AEDs - Neonates should definitely have vitamin K IM - Neonate withdrawal symptoms: lethargy, difficulty in feeding, sedation, inconsolable crying - BF encouraged (low secretion majority. Lamotrigine and phenobarbitone higher) - don't initiate lamotrigine postpartum as high transfer, but ok if on lamtorigine throughout pregnancy - Slowly reduce AEDs over the first few weeks postnatally. Decrease lamotrigine faster - Change nappies on floor - contraception - avoid COC, POP, Jadelle in enzyme inducers - carbamazepine and phenytoin. Depo, mirena and copper ok Lamotrigine - don't use COC either

Answer 32

Possible trauma to endothelial lining of cerebral sinuses and obstruction from clot. Oedema occurs and then venous haemorrhage can occur. Causes headache, seizures, impaired consciousness, signs of raised ICP, vomiting, photophobia , hemiparesis, fever, leukocytosis DDx: eclampsia, SAH, reversible cerebral vasoconstriction syndrome and herpes encephalitis Do CT venogram or MR venogram Management: hydration and anticoagulation, thrombophilia screen

Answer 33

Unilateral LMN lesion of the facial nerve Facial weakness, loss of power of frontalis muscle (can't wrinkle forehead) Ass pain around ear or loss of taste Occurs secondary to latent herpes virus (HSV1 and herpes zoster) - reactivated from cranial ganglia Occ due to swelling in the region PP dx: clinical Management - 95% improve spontaneously - Short course of corticosteroids can be given - Rule out Ramsay Hunt syndrome first - examine ear for vesicles

Answer 34

Chronic autoimmune demyelination of CNS (not PNS) - sensory or motor, relapsing, remitting course. MRI brain - 2 separate lesions at one time Genetic - ass with HLA system Presentations - Optic neuritis - Neurogenic bladder dysfunction - Impotence - Sensory deficits - UMN deficits - spasticity of legs - Cerebellar involvement - Vertigo

Answer 35

Effect of pregnancy on MS - Less likely to present or relapse in pregnancy, less disease activity - Increased UTIs in those with neuropathic bladders - Fatigue and balance can be an issue - Rate of relapse increases in first 3/12 following pregnancy, then declines back to baseline at 10/12 - Long term outcomes not altered MS doesn't cause issues for pregnancy Relapse can be treated with steroids Biologics

Answer 36

Dysfunction of all exocrine glands with abnormal mucus production Malnutrition Diabetes Persistent and recurrent lung infections Median age of death - 47 Effect of pregnancy on CF: - Mortality increased (not significantly increased above age matched non pregnant woman) Mortality increased in - Moderate to severe lung disease - FEV1 <50-60%, no adverse effect of pregnancy on long term survivial. - Maternal pulmonary hypertension - Cyanosis - Hypoxaemia Pregnancy contraindicated if - pulmonary hypertension - Cor pulmonale (RHF secondary to pulmonary hypertension) - FEV 1 <30-40% predicted - Burkholderia cepacian recent infection as can cause rapid deterioration in lung function - Cor pulmonale Maternal morbidity - Poor weight gain - Deterioration in lung functino with worsening dyspnoea, exercise tolerance, oxygen saturations - pulmonary infective exacerbations - CCF Effect of CF on pregnancy - PTB 10-25% - FGR - esp if chronic hypoxia and / or cyanosis and or FEV1 <50-60%

Answer 37

Pregnancy contraindicated if - pulmonary hypertension - Cor pulmonale (RHF secondary to pulmonary hypertension) - FEV 1 <30-40% predicted - Burkholderia cepacian recent infection as can cause rapid deterioration in lung function - Cor pulmonale Safe if FEV1 >70-80% Screen for diabetes All offsprine will be carriers of CF so recommend partner carrier screening (1:25 risk of carrier in general population, there 2% risk of CF in baby if partner status unknown)

Answer 38

MDT care Nutrition: 90% have pancreatic insufficiency and require enzyme supplements. Fat soluble vitamin supplements should be considered Involve dietician Pregnancy CI if - FEV1 <40% - Recent Burkholderia infection - Pulm HTN Pulmonary infections - Chest physio - Abx, avoid tetracyclines - Aggressive treatment of infections - IV penicillins, aminoglycosides, cephalosporins if resistant pseudomonas - Sometimes bronchodilators or steriods required - Inhaled recombinant human DNAse - reduces viscosity in sputum, dornase alfa Avoidance of prolonged hypoxia - Consider admission for bed rest and oxygen therapy if persistent low oxygen sats - Symptom deterioration may warrant delivery - most deliver vaginally at term - Consider instrumental to shorten second stage - patients with CF are prone to pneumothoraces which prolonged pushing can cause Regular growth assessment - bed rest and oxygen supplementation may improve growth BF - Encourages - Normal content to sodium and protein in breast milk If has had lung transplant outcomes less favourable after delivery - rejection much more common. Very high risk of PTB

Answer 39

Mortality rate 10-25% Pulm HTN can be idiopathic, drug related, CT disease such as scleroderma and SLE Related to congenital heart disease such as ASD, VSD, Eisenmenger syndrome, L heart disease, lung disease such as CF, interstitial lung disease, hypoxia, sleep disordered breathing, chronic thromboembolic pulm HTN Normally pulmonary vascular resistance will fall in pregnancy, with pulmonary hypertension this doesn't occur so pulmonary blood flow cannot increase to match CO Actively advise against pregnancy If do get pregnant - offer TOP - TOP itself has a 7% risk of mortality - Most women who die, do so soon after delivery - Problems relate to right heart failure, increasing right ot left shunt in eisenmengers syndrome (cyanotic heart disease), escalating pulmonary hypertension with pulmonary hypertensive crises Antenatal - Targeted therapies Phsophodiesterase inhibitors (sildenafil - promotes blood vessel dilation) safe in pregnancy STOP endothelin receptor antagonists e.g. bosentan, ambrisentan Safe to continue postanoid analogues e.g. iliprost, NO Thromboprophylaxis not routinely recommended Elective admission for bed rest and oxygen therapy No evidence CS is better Avoid hypovolaemia (monitor with ECHO) Avoid acidosis Avoid VTE Avoid systemic vasodilation (careful with regional anaesthesia, syntocinon. Don't given anything that decreases afterload (beta blockers). Can use nifedipine women with congneital heart disease should be referred for fetal ECHO - 2-5% risk of fetal cardiac disease, 5-10% if ASD, 20% if AS, Marfans and hypertrophic cardiomyopathy have AD inheritance

Answer 40

Most is ass with bicuspid aortic value - risk of dilated ascending aorta Significant obstruction aortic valve area <1cm2 Can get angina, hypertension, heart failure, sudden death Inability to increase BP with exertion, impaired LV function or symptoms Symptoms / HTN can be controlled with beta blockers Can do balloon valvotomy if severe

Answer 41

AD Abnormal thickeneing of myocardium Sudden death if non sustained VT, failure of BP to increase during exercis Well tolerated in pregnancy because of increase in LN size Beta blockers can be used.

Answer 42

- Mechanical: high risk thrombosis Balance risks and benefits of warfarin vs LMWH (higher risk of clot with LMWH) - Could use LMWH between 5 and 12 weeks and then switch back to warfarin Aim INR 2.5 - 3.5 If using LMWH do SC dosing. If using warfain stop 10-14 days prior to delivery so effects in fetus wear off Abx prophylaxis not usually recommended * Fetal warfarin syndrome o 5-10% of those exposed at 6-9 weeks o Nasal hypoplasia/absent nasal bridge o Wide spaced eyes o Microphthalmia o Limb hypoplasia o Stippled epiphysis o Intellectual abnormality