Medical Problems During Pregnancy Flashcards
what are the most common causes of maternal mortality
direct: cardiac disease, neurological, sepsis
indirect- VTE, psychiatric, haemorrhage
who is at higher risk of blood clots during early pregnancy
overweight/ obese women
what ethnicities have higher chance of dying during pregnancy
black 5x
asian 2x
what are MIs in pregnancy commonly misdiagnosed as
panic attacks
what should all women (pregnant or not) with chest pain get
ECG (+CT)
having what puts a lot more strain on the heart during pregnancy
heart conditions:
Pulmonary hypertension (incl. Eisenmenger’s)
Congenital heart disease
Acquired heart disease
Cardiomyopathy (incl. peri-partum cardiomyopathy)
Artificial heart valves
Ischaemic heart disease
Arrhythmias
what is peri partum cardiomyopathy associated with
orthopnoea
what cardiac event in increased risk in pregnancy
MI
what cardiac events are common and often benign in pregnancy
Palpitations, extra-systoles and systolic murmurs
what cardio pulmonary problems are often fatal in pregnancy
Pulmonary HT and fixed pulmonary vascular resistance
what is essential in women with heart disease considering conception
pre pregnancy councelling
what predicts poor adverse outcomes in cardiac conditions in pregnancy
Pulmonary hypertension NYHA functional classification Presence of cyanosis TIA / arrhythmia Heart failure Left heart obstruction Aortic root >45mm Myocardial dysfunction (EF < 40%) Who classification for cardiac problems in pregnancy
when do physiological palpitations happen in pregnancy
at rest/ lying down
what relives ectopic beats
exercise
what Ix for ectopic beats
ECG
what Ix for sinus tachy cardia in pregnancy, is it normal?
yes normal but do ECG, FBC (anaemia), TFT, echo to exluce pathology
what Ix for SVT in pregnancy
ECG, 24 hr ECG, TFT, echo
usually predates pregnancy
what Ix for hyperthyroidism in pregnancy
ECG, TFT, inc. FT4
how might hyperthyroidism present in pregnancy
ST, SVT or AF
how might a phaeochromocytoma present and what Ixs
(rare)
headache, sweating, HPTx
24hr catecholamines, US
what happens to lung function in pregnancy
increased:
- O2 consumption
- BMR
- resting minute ventilation
- tidal volume
- PaO2
- arterial Ph
decreased:
- functional residual capacity
- PaCO2 (maternal hyperventilation)
what improves/ worsens breathlessness in pregnancy
more common in 3rd trim
worse at rest/ talking
improves with exertion
how many women are breathless in pregnancy
up to 75%
when is breathlessness in pregnancy a red flag
when limits normal activities
how many women with asthma will have an acute exacerbation in pregnancy
~10%
during pregnancy asthma may improve, deteriorate or remain
Deterioration often due to decreased / cessation of therapy due to safety concerns
unchanged
Deterioration more likely in t2 and t3
if on steroids throughout pregnancy, what do you need to give during birth
IV steroids as body will have become used to that amount of steroids
does well controlled asthma adversely affects pregnancy outcomes
no
how might poorly controlled asthma affect pregnancy
associated with maternal mortality
might adversely affect fetal development (LBW, premature rupture of membranes, prematurity, HTPx disorders)
what is the stepwise management for asthma in adults
SABA \+ inhaled steroid \+ LABA increase steroids \+ LRTA/ theophylline/ oral B2 agonist oral steroids
what is the management plan for asthma in pregnancy
achieve good contorl
do not discontinue inhalers during pregnancy (Inhaled ß2-agonists do not impair uterine activity or delay the onset of labour)
IV Hydrocortisone during labour if oral steroids >2/52
Immunocompromise in pregnancy, encourage vaccinations for flu and whooping cough
aim for vaginal birth
where is DVT in pregnancy more common
left leg
70% are ileo femoral
when is risk of DVT highest
puerperium (6 weeks after birth)
what medication for VTE risk
LWMH - dose weight dependent
what scan for leg pain in pregnancy
led dopppler )whole leg as can be in groin)
what are you worries about for VTE in pregnancy
PE
why are you more likely to get VTEs in pregnancy
virchows triad:
- hypercoagulability
- venous stasis
- vascular damage
Increased von Williebrand factor Increased factors VII, IX, X, XII Increased fibrinogen Reduced protein S Acquired aPC resistance Impaired fibrinolytic activity slowed blood flow (vasodilation to cope with increased CO)
what do people with intermediate or high risk of VTE need
prophylaxis with LWMH
if 4+ RF start 2st trim
3 RF start from 28 weeks
what do women with lower risk of VTE need
mobilisation and hydration
do LMWH or unfractionated heparin cross the placenta
no
what is the agent of choice for antenatal thromboprophylaxis
LMWH- fragmin
what are the signs and symptoms of a DVT in pregnancy
Swelling Oedema Leg pain or discomfort, may be unable to weight bear Tenderness Increased leg temperature Lower abdominal pain Elevated white cell count
what Ix for DVT
compression duplex USS
if normal repeat in one week, treat as DVT
if iliac VTE suspected (whole leg swollen + back pain) consider MRI venography
what are the signs and symptoms of a PTE
Dyspnoea Chest pain Faintness Collapse Haemoptysis Raised JVP Focal signs in the chest Symptoms and signs associated with DVT
what Ix for PTE
ECG and CXR
V/Q (as less risk of breast cancer than CTPA)
does warfarin cross the placenta
yes and is teratogenic
what can warfarin cause in babies
Warfarin embryopathy
- midface hypoplasia
- stippled chondral calcification
- short proximal limbs
- short phalanges
- scoliosis
risk dose dependent
when should you have converted warfarin to LMWH in pregnancy
by 6 weeks
can you give warfarin when breastfeeding
yes
what can you give for post natal anticoagulation
either heparin or warfarin as neither CI in breastfeeding
start warfarin % days post natal (risk of PPH)
continue for 6 weeks- 3 months
what are the possible complications of connective tissue disease in pregnancy
Miscarriage PET Abruption FGR Stillbirth Preterm birth Labour / delivery Post-natal Lupus Flare Renal Haematological APS Thrombosis arterial/venous Rheumatoid Scleroderma Renal Pulmonary HT
treatment: Teratogenic Fetotoxic Sepsis Diabetes (steroids) Osteoporosis (long term steroids)
what tends to happens with CTDs in pregnancy
autoimmune conditions tend to improve in pregnancy
what CTD drugs are safe in pregnancy
Steroids Azathioprine Sulfasalazine Hydroxychloroquine Aspirin (Etanercept / Infliximab / Adalimumab) (Rituximab)
what CTD drugs are NOT safe in pregnancy
NSAIDs (>32 weeks) Cyclophosphamide Methotrexate Chlorambucil Gold Penicillamine MMF Leflunamide
what type of disease is APS
acquired thrombophilia
what causes the symptoms in APS
Antiphospholipid antibodies (aPL) - autoantibodies that react with the phospholipid component of the cell membrane
what antibody markers in APS
anticardiolipin antibodies (aCL) lupus anticoagulant (LA) antiphospholipid antibodies (aPL)
what are the clinical features of APS
Arterial / venous thrombosis
Recurrent early pregnancy loss
Late pregnancy loss - usually preceded by FGR
Placental abruption
Severe early onset pre-eclampsia (PET)
Severe early onset Fetal Growth Restriction (FGR)
how do you clinically diagnose APS
Vascular Thrombosis
-Venous / Arterial / Small Vessel
Pregnancy Morbidity
- ≥ 3 miscarriages <10 weeks
- ≥ 1 fetal loss >10 weeks (morphologically normal fetus)
- ≥1 preterm birth (<34 weeks) due to PET or utero-placental insufficiency
how do you diagnose APS via tests
IgM / IgG aCL (medium / high titre)
LA
x2 >6 weeks apart
Cautions:
Acute infections = transient +ve results
Chronic infections (HIV, Hep C, Malaria, Syphilis) = persistent +ve results
what are common pregnancy outcomes in APS
early pregnancy loss
T2/T3 IUD
preterm birth (<34weeks)
FGR
what is the management for ASP in pregnancy
No thrombosis / adverse pregnancy outcome
LDA, Maternal + Fetal Surveillance
Previous thrombosis
On warfarin = Stop warfarin
LDA + LMWH (treatment dose)
Recurrent early pregnancy loss
LDA + LMWH (prophylaxis dose)
Late fetal loss / Severe PET / FGR
LDA + LMWH (prophylaxis dose)
Consider earlier delivery
what usually happens to seizure frequency in epilepsy during pregnancy
improved/ unchanged
>50% will have no seizures
what are the possible complications of epilsepy in pregnancy
spontaneous miscarriage ante partum haemorrhage HPTx/ PET induction of labour C section preterm brth FGR PPH
what are the fetal risk from a maternal GTC seizure
maternal abdo trauma - fetal maternal haemorrhage
pre term rupture of membranes
preterm birth
hypoxia/ acidosis
what are the fetal risk in epilepsy
Major congenital malformations Minor malformations Adverse perinatal outcomes Long-term developmental effects Haemorrhagic disease of the newborn Risk of childhood epilepsy
what should be offered to women on anti epileptic drugs
detailed ultrasound scan assessment of fetal anatomy at 18-20 weeks
what is the risk of teratogenicity in anti epileptic drugs
2-3x background risk (2-3%) risk for single AED
16% risk in polytherapy
what AEDs have the lowest risk of teratogenicity
lamotrigine, levitiracetam and carbamazepine monotherapy at lower doses
what are the most common congential malformations with AEDs
neural tube defects, congenital heart disorders, urinary tract and skeletal abnormalities and cleft palate
what is sodium valporate associated with in babies
NT defects
facial cleft
hypodpadias
who should not get valproate
girls, women of child bearing age, pregnant
if have to take in pregnancy counsel about risks as also need to consider risks of seizures in pregnancy
when might women be advised to continue sodium valporate/ AED polytherapy in pregnancy
how do they reduce their risks
if the risk of maternal seizure deterioration from changing the AED is deemed to be high
folic acid 5mg/ day prior to conception till at least the end of first trimester
lowest doses possible
what needs to be considered in women with epilepsy during birth
(most will have normal labour and SVD, 2.6% will have seizure)
Stress, pain, sleep deprivation, over-breathing and dehydration increase the risk of intra-partum seizures
If generalised tonic-clonic seizures occur, maternal hypoxia, fetal hypoxia and acidosis may result
should AED intake be continued in labour
yes
what is the management for intra partum seizures
terminate seizure asap to avoid hypoxia and fetal acidosis benzodiazepines drug of choice Left lateral tilt (to take pressure of uterus of great vessels) IV lorazepam / diazepam PR diazepam / buccal midazolam IV Phenytoin May need to expedite delivery by CS If no history of epilepsy - MgSO4
how do you ensure baby safety whos parent has epilepsy
avoid excess fatigue- encourage family support
Safe area for baby if mother feels unwell
Safe feeding position
Lowest setting for high chairs
Dress baby on the floor
Carry baby in padded sling / carrycot
Handle-release pram brake
Additional support for bathing- try to just have showers
what are the maternal risks of obesity
Miscarriage GDM HPTx/PET VTE CS PPH wound infection UTI endometriosis breast feeding problems increased perinatal mortality
are congenital abnormalites are more common in obesity
yes
what perinatal outcomes are increased in obesity
Congenital Anomaly Macrosomia Shoulder Dystocia SCBU Admission still birth neonate death
what extra management is needed in obesity in pregnancy
Maternal BMI and inter-pregnancy weight change should be assessed at booking PET prophylaxis - Aspirin Thromboprophylaxis Detailed US (including MUAD) OGTT Obstetric US to assess fetal growth Anaesthetic Review @ 34 weeks (harder to do venopuncture, regional anaesthesia- asses for GA) MDT plan for labour & birth P/N Review
