Medical obstetrics

Question 1

What is the treatment of choice for anti-phospholipid syndrome in patients who are pregnant?

Answer 1

Low dose aspirin with daily prophylactic low molecular weight heparin

Question 2

Does asthma improve or get worse during pregnancy?

Answer 2

Improves in about 1/4, worsens in about 1/3

Question 3

What deformity has been reported as of an increased risk with with oral steroid use during first trimester pregnancy?

Answer 3

Cleft palette

Question 4

What congenital deformity has has been associated with ondansetron use during the first trimester?

Answer 4

Cleft palette and cleft lip.

Question 5

What is the first line phrarmacological treatment for hyperemesis gravidarum?

Answer 5

First line should be doxylamine-pyridoxine (B6). Doxylamine is a sedating antihistamine, but has the best evidence for pregnancy associated nause and voming.

Question 6

What is second line pharmacological management for hyperemesis gravidarum not causing hypovolaemia?

Answer 6

Diphenhydramine (another antihistamine)

Question 7

Whast is thrid line pharmacoligical management for hyperemesis gravidarum not causing hypovolaemia?

Answer 7

Addition of metoclopramide, prochlorperazine

Question 8

What is fourth line pharmacoligcal management for hyperemesis gravidarum not causing hypovolaemia, or for when it is causing hypovolaemia?

Answer 8

Ondansetron - alone if hypovolaemia present. If up to 4th line non-hypovolaemic vomiting: add to metolopramide or prochlorperaixine AND diphenhydramaine.

Question 9

What is fifth line pharmacological management for hyperemesis gravidarum not causing hypovolaemia, or 2nd line for when it is causing hypovolaemia?

Answer 9

Add glucocorticoids to ondansetron for hypovolaemic hyperemesis gravidarum. Add glucocorticoids to ondansetron, metoclopromide OR prochlorperazine, AND diphenhydramine if reached 5th line treating euvolaemic hyperemesis gravidarum.

Question 10

What is required to diagnose hyperemesis gravidarum?

Answer 10

5% pre-pregnancy weight loss or electrolyte imbalance caused by nausea and vomiting

Question 11

Are ACEi and metoprolol safe in pregnancy?

Answer 11

No

Question 12

What are the preferred agents for treatment of hypertesnion (not pre-eclampsia) in pregnancy?

Answer 12

Nifedipine, labetalol, or methyldopa. Patients whould also be offered 75-150mg of aspirin from 12 weeks of preganancy.

Question 13

What is the role of placental growth factor testing?

Answer 13

Offered in patients with hypertension during pregnancy that may have been pre-existing during 20-35 weeks to test for impending pre-ecclampsia.

Question 14

What effect does b-HCG produced during pregnancy have on the mothers thyroid gland?

Answer 14

Has structural similarity to TSH and so binds to and stimulates the production of T3/T4.

Question 15

What effect does b-HCG stimulating T3/T4 production have on TSH levels during the first trimester?

Answer 15

Reduction in TSH levels

Question 16

In hypothyroid patients taking replacement thyroxine, what should they do after becoming pregnant?

Answer 16

Anticipating the increased consumption of T3/T4 hormones, replacment should be increased by 20-30% targeting a normal TSH concentration.

Question 17

What happens to soluble fms-like tyrosine kinase 1 (sFlt-1) levels during pregnancy?

Answer 17

This is an anti-angiogenic factor that increases during pre-eclampsia. Cf placental growth factor (PlGF) and VEFG which decrease during pre-eclampsia. A ratio of sFlt-1L: PlGF is used to define risk of preeclampsia.

Question 18

If patients have had previously had ecclampsia/preeclampsia during pregnancy, what medication should the take for subsequent pregnancies?

Answer 18

Aspirin 150mg per day

Question 19

Which of the transplant immunosuppressants must be stopped during pregnancy? Caclcineurin inhibitors, mTOR inhibitors, mycophenolate, azathioprine, prednisolone.

Answer 19

mTOR inhibitors and mycophenolate must be stopped. Low risk of foetal abnormalities with calcineurin inhibitors. Pred and azathioprine considered safe.

Question 20

Is bactrim safe during pregnancy?

Answer 20

No.

Question 21

What do platelet counts during pregnancy?

Answer 21

Begin to decline in the first trimester and then hit their nadir around delivery. Likely secondary to increased spleen size (50% increase) and increased plasma.

Question 22

What does haemoglobin concentration do during pregnancy?

Answer 22

Decreases in the first trimester than remains stable to delivery. Note that although the Hb concentration may be below normal levels, blood volume is markedly increased during pregnancy.

Question 23

What does D-dimer do during pregnancy?

Answer 23

Slowly rises, peaking at the end of the 3rd trimester. Not a helpful test during pregnancy.