Medical Problems in Labour Flashcards
What increases risk of maternal mortality
- Ethnicity
- black 5x
- asian 2x
- age
- >40 3x
Which women are at higher risk of blood clots in early pregnancy?
Overweight/obese women
What are the medical problems in pregnancy?
- diabetes
- hypertension
- cardiac disease
- respiratory disease- asthma
- VTE
- connective tissue disease
- epilepsy
- obesity
what are the benign cardiovascular findings in pregnancy?
- palpitations
- extra-systoles
- systolic murmurs
what heart diseases are often fatal in pregnancy
pulmonary hypertension
fixed pulmonary vascular resistance
Describe physiological palpitations in pregnancy
Common, occur at rest/lying down
Describe ectopic beats in pregnancy
Common
Thumping in chest
Relieved by exercise
(ECG)
Describe sinus tachycardia in pregnancy
Part of normal pregnancy, need to investigate to exclude pathology
ECG, FBC, TFT, Echocardiocraphy
Describe SVT in pregnancy
Paroxysmal, usually predates pregnancy
ECG, 24hr ECG, TFT, echocardiography
What may hyperthyroidism present with?
What should be tested?
ST, SVT or AF
ECG, TFT including FT4
Describe phaeochromocytoma in pregnancy
Rare
Associated headache, sweating, hypertension
24hr catehcolamines, US
What percentage of women feel breathless in pregnancy?
75%
When does breathlessness in pregnancy get better?
With exertion
What is the commonest chronic medical disorder to complicate pregnancy?
Asthma
What often causes deterioration of asthma during pregnancy?
Decrease/cessation of therapy due to safety concerns
What is the effect of asthma in pregnancy
one-third of patients will improve, one-third will stay the same and one-third will worsen.
What may poorly controlled asthma affect?
Fetal development
risk factor for low birth weight babies, premature rupture of membranes, premature delivery and hypertensive disorders.
What kind of delivery should be aimed for in asthma?
Vaginal birth
Why is acute asthma during labour unlikely?
Endogenous steroids
What is the increase in risk fo VTE in pregnancy?
4-6x
What should women be given if they have been on oral steroids for >2/52?
IV hydrocortisone
85-90% of VTEs occurring during pregnancy arise in the ____ leg
left
>70% of DVTs in pregnancy are __________
ileofemoral
The daily risk of VTE is 5x higher in the ______ compared to the _______ period
The daily risk of VTE is 5x higher in the puerperium compared to the antenatal period
What happens to blood flow to the legs in normal pregnancy?
blood flow in the legs slows down during normal pregnancy, reaching it’s lowest level at 34-36 weeks and taking 6 weeks to return to normal in the postnatal period.
What confers high risk of VTE?
Any previous VTE except a single event related to major surgery
What does high risk of VTE require?
Antenatal prophylaxis if LMWH
Refer to trust-nominated thombosis in pregnancy expert/team
What confers intermediate risk of VTE?
- hospital admission
- single previous VTE related to major surgery
- high-risk thrombophilia + no VTE
- medical comorbidities
- cancer
- heart failure
- active SLE
- IBD
- inflammatory polyarthropathy
- nephrotic syndrome
- T1DM with nephropathy
- sickle cell disease
- current IVDU
- any surgical procedure e.g. appendicectomy
- OHSS (first trimester only)
What is the managment of intermediate risk of VTE?
Consider antenatal prophylaxis with LMWH
Does heparin cross the placenta or into milk?
NO
LMWH are now widely used in pregnancy because of a better ____-_____ ______ and once daily dosing for thromboprophylaxis
LMWHs are the agents of choice for antenatal thromboprophylaxis. They are at least as effective and safer than UFH
________, _______, ________
LMWH are now widely used in pregnancy because of a better side-effect profile and once daily dosing for thromboprophylaxis
LMWHs are the agents of choice for antenatal thromboprophylaxis. They are at least as effective and safer than UFH
Enoxaparin, Dalteparin, Tinzaparin
The symptoms and signs of DVT are common during normal pregnancy. These include;
- swelling
- oedema
- leg pain or discomfort
- tenderness
- increased leg temperature
- lower abdominal pain
- elevated WCC
What is the testing for DVT?
Compression duplex ultrasound
If normal repeat at 1/52 to exclude extending calf vein thrombosis
When would iliac vein thromosis be suspected?
Whole leg swollen + back pain
What should be considered if iliac vein thrombosis is suspected?
MRI venography
What are the symptoms and signs of PTE?
- Dyspnoea
- Chest pain
- Faintness
- Collapse
- Haemoptysis
- Raised JVP
- Focal signs in the chest
- Symptoms and signs associated with DVT
What are the benefits of CTPA?
- readily available
- may detect other pathology
- better sensitivity & specificity
- low radiation dose to foetus
What are the benefits of V/Q scan?
High negative predictive value in pregnancy
Low radiation dose to maternal breast tissue
What does warfarin cause?
It is teratogenic
Warfarin embryopathy (6.4%)
- midface hypoplasia
- stippled chondral calcification*
- short proximal limbs*
- short phalanges*
- scoliosis*
What is the risk of warfarin dependant on and what should be done?
Dose dependant >5mg/day
Convert to LMWH by 6 weeks
Are heparin or warfarin contraindications to breast feeding?
No
When should post-natal anticoagulation commence?
on 5th post-natal day
Anticoagulant therapy should be continued until at least _ _____ post-natal and until at least _ _____ post-partum
Anticoagulant therapy should be continued until at least 6 weeks post-natal and until at least 3 months post-partum
What are the pregnancy related complications of connective tissue disease?
- Miscarriage
- PET
- Abruption
- FGR
- Stillbirth
- Preterm birth
- Labour / delivery
- Post-natal
What are the treatment related complications of connective tissue disease?
- teratogenic
- fetotoxic
- sepsis
- diabetes
- osteoporosis
What are the connective tissue disease related complications in pregnancy?
- Lupus flare
- renal
- haematological
- APS
- thrombosis arterial/venous
- rheumatoid
- scleroderma
- renal
- pulmonary HT
Which connective tissue disease treatments are not safe in pregnancy?
- NSAID >32 weeks
- cyclophosphamide
- methotrexate
- chlorambucil
- gold
- penicillamine
- MMF
- leflunamide
What CTD therapies are safe in pregnancy?
- steroids
- azathioprine
- sulfasalazine
- hydroxychloroquine
- aspirin
- entercept/infliximab/adalimumab
- rituximab
What is APS?
An acquired thrombophilia with variable presentation and severity
Clinical syndrome associated with; aPL, aCL and LA antibodies
What do aPL autoantibodies do?
Antiphospholipid autoantibodies react with the phospholipid component of the cell membrane
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
- severe early onset fetal growth restriction
How is APS diagnosed clinically?
- vascular thrombosis
- venous/arterial/small vessel
- pregnancy morbidity
- ≥ 3 miscarriages <10 weeks
- ≥ 1 fetal loss > 10 weeks (morphologically normal foetus)
- ≥ preterm birth (<34 weeks) due to PET or utero-placental insufficiency
How is APS diagnosed in the lab?
IgM / IgG aCL (medium/high titre)
LA
X2 / > 6 weeks apart
How is APS managed if there is no thrombosis/adverse pregnancy outcome?
LDA, maternal + fetal surveillance
How is APS managed if there has been previous thrombosis?
On warfarin -> stop warfarin
LDA + LMWH (treatment dose)
How is APS managed if there has been recurrent early pregnancy loss?
LDA + LMWH (propylaxis dose)
How is APS managed if there has been late fetal loss/severe PET/FGR?
LDA + LMWH (prophylaxis dose)
What happens to seizure frequency when women become pregnant?
Most people find it improves or is unchanged
- >__% of pregnant women with epilepsy will have no seizures during pregnancy
- If no seizure in _ months prior to pregnancy, up to 92% will remain seizure free
- >50% of pregnant women with epilepsy will have no seizures during pregnancy
- If no seizure in 9 months prior to pregnancy, up to 92% will remain seizure free
What are the fetal risks from maternal seizure?
- Maternal abdominal trauma
- Preterm Premature Rupture of Membranes (PPROM)
- Preterm borth
- Hypoxia/acidosis
- major congenital malformations
- minor malformations
- adverse perinatal outcomes
- long-term developmental defects
- haemorrhagic disease of the newborn
- risk of childhood epilepsy
How much does the risk of teratogenicity increase for AED ?
2-3X increased for any single AED
Polytherapy risk 16%
What are the most common major congenital malformations associated with AEDs?
Neural tube defects, congenital heart disorders, urinary tract and skeletal abnormalities and cleft palate
What is sodium valproate associated with?
Neural tube defects, facial cleft and hypospadias
What are phenobarbital and phenytoin associated with?
Cardiac malformations
What are phenytoin and carbamazepine associated with?
cleft palate
What should women taking sodium valproate or other AED have?
Discussion about risks and benefits
5mg/day folic acid
What increases the risk of intra-partum seizure?
Stress
Pain
Sleep deprivation
Over-breathing
Dehydration
What is the risk with generalised tonic-clonic seizures occur in labour?
Maternal hypoxia, fetal hypoxia and acidosis
What should be considered if high risk of intra-partum seizures?
- IV lorazepam / diazepam
- PR diazepam / buccal midazolam
- IV Phenytoin
- May need to expedite delivery by CS
What should be done if a women with no history of epilepsy has an intrapartum seizure?
MgSO4
What measures should be taken to ensure baby safety in maternal epilepsy?
- avoid excessive maternal fatigue
- safe area for baby if mother feels unwell
- safe feeding position
- lowest setting for high chairs
- dress baby on floor
- carry baby in padded sling/carrycot
- handle-release pram brake
- additional support for bathing
What are the early pregnancy complications of obesity?
Miscarriage
What are the antenatal complications of obesity?
Fetal anomalies, PET, GDM, VTE
What are the labour/delivery complications of obesity?
IOL, dysfunctional labour, operative delivery
What are the post-natal complications of obesity?
Haemorrhage, infection, VTE, breast-feeding
What are the foetal/neonatal complications of obesity?
Macrosomia, birth injury, perinatal mortality
How should obesity be managed 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
- difficulties with venepuncture/obtaining IV access
- MDT plan for labour & birth
- P/N Review
