medical problems in pregnancy Flashcards by holly strachan

what is a direct death

death caused by complications of pregnancy

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what increases the risk of maternal death in the uk

comorbidities
ethnicity (asian and black women more 3x more likely)
age
obesity

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obese women are at an increased risk of which complication of pregnancy

blood clots

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what is the leading direct cause of morbidity/mortality in pregnancy

venous thromboembolism

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cardiovascular changes in pregnancy

blood volume increases
plasma volume increases 
cardiac output increases
stroke volume increases
heart rate increases
peripheral vascular resistance decreases
central venous pressure unchanged

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heart disease that can affect pregnancy

pulmonary hypertensio
congenital heart disease
acquired heart disease 
cardiomyopathy 
artificial heart valves 
ischaemic heart disease 
arrhythmias

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why are rtes of heart disease in pregnancy increasing

increasing age of pregnant women
obesity
congenital heart disease

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peri-partum cardiomyopathy

heart failure in the third trimester of pregnancy

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common cardiac signs in pregnancy

palpitations
extra-systoles
systolic murmurs

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risks of anticoagulation in pregnancy

warfarin is teratogenic

switch to LMWH

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the ability to tolerate pregnancy is related to…

cardiac features

pulmonary HTN
NYHA functional classification
presence of cyanosis
TIA/arrythmia 
heart failure 
left heart obstruction 
aortic root >45 mm (increased risk of aortic dissection)
myocardial dysfunction (EF <40%)

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characteristics of physiological palpitations during pregnancy

occur at rest/lying down

relieved by standing/movement

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characteristics of ectopic beats during pregnancy

constant ‘thumping’ in chest

relieved by exercise

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investigation of sinus tachycardia in pregnancy

ECG, FBC, TFT, echo

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alternative causes of sinus tachycardia in pregnancy

thyroid

cardiomyopathy

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signs of phaeochromocytoma

rare
associated with sweating, headache, anxiety
hypertension

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diagnosis of pheochromocytoma

24 hour urinary catecholamines 
adrenal imaging (US)

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lung function during pregnancy

increased O2 consumption
increased metabolic rate 
increased resting minute ventilation 
increase in tidal volume
unchanged respiratory rate 
reduced functional residual capacity
unchanged vital capacity
unchanged FEV1 and PEFR
increased PaO2
decreased PaCO2
increased arterial pH

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when is breathlessness most common

third trimester

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asthma in pregnancy outcome

1/3 improve
1/3
deteriorate
1/3 remain unchanged

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why might there be a deterioration in asthma control in the first trimester

many women stop or decrease their medications during pregnancy

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management of asthma in pregnancy

1 - SABA
2 - plus ICS
3 - plus LABA (if no response increase ICS)
4 - high dose ICS/4th drug 
5- oral steroids

asthma birth plan

aim for vaginal birth
should not discontinue inhalers
IV hydrocortisone if oral steroids >2 weeks
increased risk of C-section with moderate-severe asthma

what is the increase in risk of VTE in pregnancy

4-6x increase

where is the most common site of DVTs in pregnancy

left leg | ileo-femoral

when is the highest risk time for VTE

puerperium

factors that increase the risk of VTE during/post pregnancy

``` increased von willebrand factor increased factors VII, IX, X, XII increased fibrinogen reduced protein S acquired aPC resistance impaired fibrinolytic activity ```

high risk for VTE

previous VTE except a single event related to a major surgery

intermediate risk for VTE

``` hospital admission single previous VTE related to major surgery high risk thrombophilia medical comorbidities surgical procedure OHSS ```

risk factors that may indicate VTE prophylaxis

``` obesity age >35 parity >3 smoker gross varicose vein current pre-eclampsia immobility family history of unprovoked or oestrogen-provoked VTE in first degree relative low-risk thrombophilia multiple pregnancy IVF/ART ```

criteria for VTE prophylaxis in pregnancy

four or more risk factors = prophylaxis from first trimester three risk factors = prophylaxis from 28-weeks

what is used as VTE prophylaxis in pregnancy

LMWH (dalteparin)

symptoms/signs of DVT in pregnancy

``` swelling oedema leg pain or discomfort tenderness increased leg temperature lower abdominal pain elevated white cell count ```

objective testing for DVT

compression duplex ultrasound

interpretation of compression duplex US

normal = vein should be easily compressible

why is d-dimer not a useful screening test in pregnancy

d-dimers are nearly always raised in pregnancy

symptoms/signs of PTE

``` dyspnoea chest pain (pleuritic) faintness collapse haemoptysis raised JVP focal signs in the chest symptoms and signs associated with DVT ```

imaging for PTE

CTPA or V/Q CTPA has higher radiation to mother V/Q higher radiation to fetus

signs of warfarin embryopathy

``` midface hypoplasia stipple chondral calcification short proemial limbs short phalanges scoliosis ```

is anti-coagulation a contraindication for breast feeding

neither heparin nor warfarin are contraindications

why is warfarin started on 5th post-natal day

first 5 days have increased risk of haemorrhage

which CTD drugs are not safe in pregnancy

NSAIDs (>32 weeks)

what are the antiphospholipid antibodies

anticardiolipin | lupus anticoagulant

clinical features of APS

``` arterial/venous thrombosis recurrent early pregnancy loss late pregnancy loss placental abruption severe early onset pre-ecplampsia severe early onset fatal growth restriction ```

diagnosis of APS

clinical - vascular thrombosis pregnancy morbidity - >3 miscarriages/>1 foetal loss >10 weeks/>1 preterm birth lab - IgM/IgG aCL and LA twice 6 weeks apart

APS management | no thrombosis/adverse pregnancy outcome

LDA | maternal and fatal surveillance

APS management | previous thrombosis

stop warfarin | LDA and LMWH (treatment dose)

APS management | recurrent early pregnancy loss

LDA and LMWH (prophylactic dose)

APS management | late fatal loss/severe PET/FGR

LDA and LMWH (prophylaxis dose)

seizure frequency in pregnancy

improved or unchanged

obstetric complications of epilepsy

``` spontaneous miscarriage ante-partum haemorrhage HTN/PET induction of labour c-section preterm birth fatal growth restriction post partum haemorrhage ```

fetal risks in epilepsy from maternal seizure

maternal abdominal trauma PPROM preterm birth hypoxia/acidosis

fetal risks of epilepsy

``` major congenital malformation minor malformations adverse perinatal outcomes long-term developmental effects haemorrhage disease of the newborn risk of childhood epilepsy ```

folic acid dose in pregnancy

5 mg