Medical Problems in Pregnancy Flashcards
What is done at the booking visit?
general pregnancy advice; identify if low/high risk; info on choices for place of birth; discuss screening; BMI; BP; arrange dating USS; arrange booking bloods
When is the booking visit done?
8-12 weeks
When is the dating USS done?
11-12 weeks
When is the anomaly scan done?
20 weeks
When are anti-D injections given?
28 weeks and 24 weeks
How often do women have visits with the midwife between 20-28 weeks?
monthly
How often do women have midwife visit between 28 and 26 weeks?
fortnightly
How often do women have a midwife visit after 37 weeks?
weekly
What is the commonest medical problem in pregnancy?
HT
What is chronic hypertension in pregnancy?
HT present at booking or <20 weeks
what is gestational hypertension?
new HT >20 weeks without signif proteinuria
What is pre-eclampsia?
new HT >20 weeks and significant proteinuria
What are the life-threatening complications of hypertension in pregnnacy?
HELLP syndrome and eclampsia
What is HELLP syndrome?
haemolysis; elevated liver enzymes and low platelets
What anti-hypertensives are used in pregnancy?
labetalol; methyldopa; nifedipine; hydralazine
what anti-hypertensives should be stoppped?
ACEi and ARBs
What is the target for BP in pregnnacy?
<150/80-100
What is the BP target in pregnnacy with end organ damage
<140/90
What is the pathophysiology of pre-eclampsia?
deficient trophoblastic invasion which prevents development of high flow; low impedence uteroplacental circulation—-dysunfction of vascular endothelial cells–vasconstriction and no insensitivty to vasocontrictors
What are the effects o hypertensive disorders on the fetus?
IUGR; abruption; IUD
When should the baby be delivered in pre-eclampsia?
37 weeks
What is the effect of pregnnacy on diabetes?
poorer control; deterioration of renal function and retionopathy
What are the effects of diabetes on pregnnacy?
miscarriage; fetal malformations; IUGR; macrosomia; IUD; PET
What fetal malformations are diabetics more at risk of?
cardiac; neural tube defects; caudal regressions syndrome
When should labour be induced by in diabetics?
37-38 weeks
What does neonatal hypoglycaemia carry the risk of?
CP
Why is there fetal polycythaemia in DM?
due to hyperinsulinaemia; increased metabolism so tissue hypoxia which stimulates increased erythopoeitin and polychythaemia
How often should babies of diabetic mother have growth scnas?
28,32,36 weeks
When should babies be delivered with pre-existing DM?
37-38 weeks
How long after delivery should BMs be monitored with GDM?
48 hours
When is C/S recommended in macrosomia?
EFW >4000g
What is the effect of polycythaemia on the fetus?
thrombotic; jaundice
What is the risk of polyhydramnios?
fetal malpresentations and increased risk of preterm labour
What is the main direct cause of maternal death in UK?
VTE
What is thought to be the reason for increased clotting factors in pregnancy?
evolutionary to decrease risk of PPH
What factors are increased in pregnancy?
VII; VIII; X and fibrinogen
What are the VTE risk factors?
obesity; age >35; parity =>3; smoker; gross varicose veins; current pre-eclampsia; immobility; FHx; multiple pregnancy; IVF
How many risk factors means you should give prophylaxis in the 1st trimester?
4 or more
Who should get prophylaxis from 28 weeks?
3 risk factors
Which leg do pregnnat women tend to develop DVT in?
left >right 8:1
What is the difficulty with DVT in pregnancy?
50% early DVTs are asymptomatic
How is DVT diagnosed in pregnancy?
duplex US on lower limb - not d-dimer
What is the dose for heparin in pregnnacy?
1mg/kg twice daily
How long should LMWH be continued after DVT?
3 months after delivery or 6 months after treatment
What are the SE of heparin?
haemorrhage; hypersensitivity; allergy at injection site; heparin induced thrombocytopenia; oesopenia
What may PE cause that can be seen on CXR?
atelectasis; effusion; focal opacities; regional oligaemia or pulmonary oedema
What is the first line ix for PE in pregnnacy?
CXR and ABGs
What are the risks of CTPA?
less childhood cancer but increased breast cancer
Why should warfarin be avoided in pregnancy?
teratogenic- miscarriage; neuro problems; still birth
When should CTPA done in pregnancy?
if CXR is abnormal and high clinical suspicion of PE
When should warfarin be used after birth?
day 2 or 3
Is warfarin safe to use in breastfeeding?
yes
How is hypothyroidism affected by pregnance?
need higher levothyroxine dose- 25-50mcg more;
How often should TFTs be checked in hypothyroid pregnnacy?
every trimester
What happens in the pregnnacy with hyperthyroidism?
gets worse in first trimester due to hCG but improves second and thrid trimesters
What are the effects of being hyperthyroid on the pregnnacy?
IUGR; preterm labour and thyroid storm
What is the problem with beta blockers eg propanolol in pregnnacy?
IUGR
When is the greatest risk of deterioration for severe asthmatics?
thrid trimester
What is the most common for deterioration of asthma in pregnancy?
reduction or cessation of medications due to unfounded safety fears
What is the risk of maternal death with epilepsy?
aspiration
What dose of folic acid should pregnant epileptics be on?
5mg folic acid
Why is there an increased risk of seizures in epilepsy in the 1st trimester?
hyperemesis and haemodilution
When is the greatest risk of seizures in pregnnacy?
peripartum
Why is there a deterioration of control of epilepsy in pregnancy?
poor compliance-safety fears; decreased drug levels due to vomiting; decreased drug due to increased volume of distribution and drug clearance; lack of sleep towards term; lack of absorption of drugs during labour; hyperventialtion during labour
When is epilepsy a risk to the fetus?
status epilepticus- fetus is resistant to short-term hypoxia but not prolonged
What are the major malformations with anticonvulsants?
neural tube defects; orofacial celfts and cardiac defects
What anticonvulsants are implicated in NTDs?
valproate (1-2%) and caramazepine (0.5-1%)
What anticonvulsants are implicated in orofacial defects?
phenytoin especially
which anticonvulsants are implicated in cardiac defects?
phenytoin and valproate
What is fetal anticonvulsant syndrome?
dysmorphic features; hypertelorism; hypoplastic nails and distal digits
What is hypertelorism?
increased distnace between two organs or body parts eg between eyes
What are the dysmorphic features seen with fetal anticonvulsant syndrome?
V-shaped eyebrows; lowset ears; broad nasal bridge; irregular teeth
What is the teratogenic risk with any one anticonvulsant of a major malformation?
6-7%
What is though to be the mechanism of teratogenesis with anticonvulsants?
folate deficiency
What should epileptic women take if on an enzyme inducer?
vit K from 34-36 weeks
Why should women on enzyme inducer take vitamin K?
risk of fetal vit K defieicney and haemorrhagic disease of the newborn
When should LSCS be done in epileptics?
only if recurrent generalised seizures in late pregnancy/labour
What pain relief during labour should epileptics be given?
early peidural to reduce pain/anxiety
What is given to neonate of epileptic mother after birth?
1mg IM vit K
How does the risk of SUDEP change in pregnancy?
increases in pregnnacy and postnatal period
