Medical disorders in pregnancy Flashcards
Give me an overview of how medical disorders in pregnancy are dealt with.
pre conception counselling
med adjustments + vits
MDT
see regularly + plan
What Hb counts as low in preg?
<11g/dL
what are Hb units?
g/dL
What does pregnancy do to respiratory rate?
no change
What does pregnancy do to tidal vol?
pregnancy increases tidal vol
For what proportion of women does their asthma get worse in pregnancy?
one third
one third better, one third same
(drugs safe)
What is the top indirect cause of maternal mortality?
cardiac disease
What does pregnancy do to systemic vascular resistance?
pregnancy decreases systemic vascular resistance
What does pregnancy do to cardiac output?
pregnancy increases cardiac output
Is it normal to have ejection systolic murmur and altered ECG in preg?
yes
Name four heart drugs contraindicated in pregnancy…
ACE-I / ARBs
warfarin
statins
what steps might need to be taken for a mother who has at risk of cardiac disease in preg.
- alter meds
- LMWH
- monitor echo/ECG
- epidural / caesarean
what kind of delivery for mother with moderate cardiac risk
epidural
what kind of delivery for mother with high cardiac risk
caesarean
when is there a big risk of cardiac failure for a pregnant mum who has pre-existing cardiac disease?
RIGHT AFTER BIRTH
spike in blood vol and BP once placenta released
Pregnancy lady with thirst, vom, epigastric pain, jaundice. progresses to DIC. What’s this?
acute fatty liver of preg (v rare)
ITCHING WITHOUT SKIN RASH AND WITH ABNORMAL LFTs =
obstetric cholestasis
obstetric cholestasis presentation?
ITCHING WITHOUT SKIN RASH AND WITH ABNORMAL LFTs
Pregnant woman presents with itching. No skin rash. But abnormal LFTs. You suspect obstetric cholestasis. Investigations?
NON-INVASIVE LIVER SCREEN (it’s a condition of exclusion)
serum BILE ACIDS (raised)
What is treatment for obstetric cholestasis?
ursodeoxycholic acid
vit K @36wks in case haemorrhage
INDUCE @37wks
Does obstetric cholestasis resolve after delivery?
yes but high recurrence
What is commonest cause of hypothyroidism in preg?
Hashimoto’s (anti-TPO)
thyroid requirement goes up in early preg
Management of hypothyroidism in preg?
increase thryoxine dose
monitor TSH weekly
When does neuro dev happen?
1st and 2nd trimester
What is commonest cause of hyperthyroidism in preg?
Graves disease
often improves in preg!
What is maternal risk of hyperthyroidism in preg?
thyroid storm
What is foetal risk of hyperthyroidism in preg?
neonatal thyrotoxicosis
anti-T3/4 antibodies cross placenta
What tends to happen with epilepsy in pregnancy?
seizures get more frequent, especially in labour.
Maternal epilepsy increases risk of WHAT?
neural tube defects
Mothers normally take 400mcg of folic acid a day. What should mothers with epilepsy take?
5 mg - risk of neural tube defects
Mothers usually take 400mcg of folic acid a day until when?
12 weeks
Which epilepsy drugs are safest in preg?
carabamazepine
lamotrigine
Mother has epilepsy. What chance does the newborn have of getting it?
3%
What happens to GFR in preg?
INCREASES
(more leaky)
so urea and creatinine levels decrease
Why is there a risk of urinary stasis and bacturia in pregnancy?
uterus pressure on ureters
If you have chronic renal disease and want to get pregnant…
have a transplant first
PREGNANCY IS A ___THROMBOTIC STATE.
PREGNANCY IS A PROTHROMBOTIC STATE.
Give four good reasons why pregnancy is a prothrombotic state plz Kate.
- increased clotting factors
- decreased fibrinolysiss
- blood flow obstruction
- immobility
Give me four good ways of preventing PE / DVT in pregnancy.
- LMWH
- stockings
- mobilize
- hydration
if high risk - referral to join obstetric/haematology clinic
Give me 2 risk factors that count as HIGH risk for thromboembolism in preg.
- previous DVT or PE
- antithrombin III deficiency
(need LMWH and urgent referral to ob/haem)
Investigations for suspected PE in preg
VQ scan / CTPA
Give me 5 risk factors that count as INTERMEDIATE risk for thromboembolism in preg.
sepsis antiphospholipid syndrome hyperemesis any surgery sickle cell IVDU
(need LMWH and stockings)
Give me some more general risk factors for thromboembolism in preg
smoking age >35 obesity pre-eclampsia multiparity FHx long distance travelz dehydration
Anitphospholipid syndrome is an autoimmune hypercoagulable state. What do the antibodies do?
“lupus anticoagulant antibodies” - a misnomer, they’re actually prothrombotic.
they make the blood more likely to clot
“lupus anticoagulant antibodies” (misnomer, they’re prothrombotic)
also anti-cardiolipin, and b2 glycoprotein
Before administering LMWH to pregnant ladies at risk of thromboembolism, what do you need to check?
bleeding risk.
e.g. placenta praevia, epidural soon, thrombocytopenia, etc.
Anti-phospholipid syndrome causes PLACENTAL CLOTS and RECURRENT MISCARRIAGES.
yes
Anti-phospholipid syndrome causes RECURRENT MISCARRIAGES and PLACENTAL CLOTS. Placental clots can result in WHAT TWO THINGS.
antiphospholipid:
- IUGR
- PRE-ECLAMPSIA.
What happens to glucose tolerance in preg?
glucose tolerance goes down in preg anyway
bad - gestational diabetes
Define gestational diabetes.
‘any degree of glucose intolerance with onset or first recognition during pregnancy’.
How many pregnancies affected by gestational DM?
1 in 5!
On average, insulin requirements ___ by ___% in pregnancy.
On average, insulin requirements rise by 30% in pregnancy.
Give me some risk factors for gestational diabetes.
previous gestational DM lol previous macrosomic baby BMI >30 asian FHx DM
(poor pancreatic reserve means that increased insulin requirements in preg more likely to tip you over into diabetes)
If a lady has one or more risk factors for gestational DM, you do ___ at ___wks.
oral GTT @ 28wks.
A lady has one or more risk factors for gestational DM, so you do an oral glucose tolerance test at 28wks. What results would prompt you to treat?
fasting >5.6 mmol/L
2hrs postprandial > 7.8 mmol/L
glucose levels units?
mmol/L
In what scenario would you offer oral GTT at booking visit?
previous gestational DM
What % of mums with gestational DM go on to develop type 2 later in life?
50%
For 2hrs postprandial glucose test (oral GTT), what amount of glucose is given in drink?
75g
how often should capillary blood glucose measurements be taken in gestational diabetes???
4 times a day!
give glucometer
what is the management of gestational diabetes?
diet + exercise
if bad - metformin
if awful - insulin
plus SERIAL GROWTH SCANS
raised foetal blood glucose = hyperinsulinaemia = increased fat deposition. This describes?
macrosomia from diabetes
4 FOETAL complications of pre-existing / gestational diabetes ?
macrosomia
polyhydramnios
preterm
neural tube defects
tell me about when delivery should happen in GESTATIONAL diabetes:
a) managed with diet alone
b) on metformin/insulin
a) diet - by 40wks
b) meds - 37wks
2 MATERNAL complications of pre-existing / gestational diabetes?
more @ risk of pre-eclampsia
infections!
more @ risk of instrumental / caesarean
how much periconceptual folic acid if mum has pre-existing diabetes?
5mg
what is important periconceptually if mum has pre-existing diabetes?
PERICONCEPTUAL GLUCOSE STABILISATION
+ 5mg folic acid
when to deliver by in PRE-EXISTING diabetes?
39wks
tell me about aspirin to prevent pre-eclampsia …
give if they have risk factors (eg diabetes, chronic HTN, heart disease) for pre-eclampsia
75mg OD
12 weeks to birth!!
if they have RFs for pre eclampsia give 75mg OD aspirin when??
12 weeks to birth!
tell me about foetal surveillance in pre-existing diabetes.
foetal echos
serial growth scans
if mum has pre-existing diabetes, need to screen mum for what complications during preg?
nephropathy
retinopathy screening
which are the only diabetes which are fine in preg?
insulin + metformin
explain why smoking causes feotal hypoxia basically
more carbon monoxide in blood = less oxygen to baby
treat pre-existing diabetes?
insulin + glucometer
aspirin
lots of surveillance
