Medical Disorders in Pregnancy

Question 1

What is the medical complication most likely to result in direct maternal death?

Answer 1

Amniotic fluid embolism
Hypertensive disorder of pregnancy
Thrombosis and thromboembolism
Obstetric haemorrahge

Question 2

What is indirect maternal death?

Answer 2

Pre-existing disease or disease which developed during pregnancy, that was aggravated by physiological effect of pregnancy. Leading conditions are cardiac causes and psychological conditions

Question 3

What are cardiac physiological adaptations in pregnancy?

Answer 3

Cardiac output increases by 50 %

TPR - pulmonary and systemic vascular resistance falls

Question 4

What are respiratory physiological adaptations of pregnancy?

Answer 4

Increased maternal and fetal Oxygen requirement

1. Hyperventilation and increased tidal volume
2. In late gestation, reduced FRC with diaphragm elevation

Question 5

What are the renal physiological adaptations of pregnancy?

Answer 5

Renal GFR increases by 55%

Question 6

What are GI changes in Pregnancy?

Answer 6

Progesterone causes lower LOS tone, and GI motility

Question 7

What are metabolic physiological adaptations made in pregnancy?

Answer 7

Hepatic: Increased liver metabolism for placental steroids

Placental steroids are diabetogenic to supply fetal fluel substrate

Question 8

Haematological

Answer 8

Anaemia

Thrombogenic - increased fibrinogen, VIII, IX, X, reduced thrombolysis

Question 9

Clinical considerations for resuscitation of a pregnant woman?

Answer 9

• Slight left tilt to reduce aorto-caval compression and supine hypotension
• Increased blood volume so increased distribution of resus drugs throughout the body
• Increased risk of aspiration, early recourse to a cuffed endotracheal tube
• Decreased functional residual capacity and increased BMR
• Rapid development of hypoventilation
• ensure adequate ventilation

Question 10

What implications does increased cardiac output have?

Answer 10

Increased cardiac output increases the chances of LV dysfunction. It may lead to ischaemic heart disease, severe valvular disease, peripartum cardiomyopathy.

• It could precipitate AS, MS
• Increase aneurysm formation

Question 11

What are the implications of increased heart rate

Answer 11

Increased chances of mitral stenosis

Question 12

In labour there are rapid volume changes (Valsalva, epidural, sudden blood loss, contractions) these are poorly tolerated if?

Answer 12

• left ventricular dysfunction
• CO dependent on good preload, pulmonary hypertension
• CO is fixed
• sudden increases causes APO
• sudden decrease causes reduced coronary perfusion

Question 13

What does pain and anxiety in labour cause?

Answer 13

Tachycardia, reduces diastolic filling time if reduced MV area

Question 14

What are the cardiac physiological concerns post partum?

Answer 14

Rapid increase in preload post delivery, it is tolerated poorly by

• Fixed output lesions
• Poor LV function
• Pulmonary hypertension

Question 15

Management in Labour

Answer 15

• Vaginal delivery better overall with least uterine work
• Ensure haemodynamic stability
• Minimise blood loss
• L lateral, semi- Fowlers, feet dependent
• watch fluids
• If epidural slow onset

Monitoring
* maternal/ fetal

Antibiotics for SBE prophylaxis
Syntocinon for S3

Question 16

Post natal management

Answer 16

• maintain area of high dependency
• slow oxytocin infusion to prevent PPH
• early abulation
• contraception

Question 17

Name risk factors of thrombo-embolic disease in pregnancy. List 4 consideration

Answer 17

• Preexisting factors: age, obesity, smoking, thrombophilia, Phx
• Inter- current risk factors: Immobilisation, OHSS
• Delivery risk factors: long labour, dehydration, operative delivery, CS
• Post natal risk factors: immobilisation, inadequate hydration

Question 18

Detection and treatment of DVT

Answer 18

• ultrasound is very sensitive, a very small false negative, so repeat if clinical suspicion persists
• if PE consider VQ scan +/- CTPA
• Consider CXR

Question 19

Treatment of DVT in pregnancy

Answer 19

• adequate anticoagulation

- adequate duration of therapy

Question 20

What are the consequences of radiation on the fetus?

Answer 20

The consequences of radiation depends on the dose and gestation. Potential consequences include:

• Fetal death in utero
• Congenital malformations
• Disturbance of growth and development
• Neurone depletion and NDD
• Mutagenic and carcinogenic effects

Question 21

What are three broad things to pick up in a pre-pregnancy visit in terms of diseases?

Answer 21

• cardiac disease
• diabetes
• Epilepsy

Question 22

Recommendation for radiation

Answer 22

<5 Rad not associated with increased abnormality, abortion, IUGR, PNMR: no considered grounds for termination of pregnancy