Medical Problems in Pregnancy Flashcards
What are some risk factors for maternal mortality?
Black/Asian ethnicity, aged > 40, medical co-morbidities
In general, what happens to symptoms of pre-existing cardiac disease in pregnancy? Why?
They tend to get worse due to the increased blood volume and greater demands on the heart
Describe what happens in peri-partum cardiomyopathy?
Cardiomyopathy which occurs due to increased demands on the heart in pregnancy, can present in the last month of pregnancy up to 6 months after with signs of heart failure
What are some common cardiac problems to occur in pregnancy which are mostly benign?
Palpitations, extra-systoles and systolic murmurs
What are some poor prognostic signs with regards to cardiac disease in pregnancy, with high rates of maternal mortality?
Pulmonary hypertension and fixed pulmonary vascular resistance
What is the change in management in pregnancy for women with valvular heart disease?
Swap from warfarin to LMWH
What are some causes of palpitations in pregnancy?
Physiological, ectopic beats, sinus tachycardia, supraventricular tachycardia, hyperthyroidism, phaeochromocytoma (rare)
When do physiological palpitations of pregnancy tend to occur?
At rest/when lying down
Describe what an ectopic beat will feel like in pregnancy? What will make them better? What investigation should be used?
A thumping sensation, made better with exercise / ECG
What investigations should be used for sinus tachycardia and supraventricular tachycardia associated with palpitations in pregnancy?
ECG, 24h ECG, TFTs and ECHO
How may hyperthyroidism in a pregnancy present? What investigations should be done?
Sinus tachycardia, supraventricular tachycardia or AF / ECG, TFTs and free T4
What may be some associated symptoms of a phaeochromocytoma? What investigations should be done?
Sweating, headache, hypertension / 24h catecholamines and ultrasound
85-90% of DVTs in pregnancy arise where? > 70% are what type?
Left leg / ileo-femoral
When is the risk of VTE highest in ‘pregnancy’?
Th puerperium
Describe why pregnant women are at increased risk of VTE?
Pregnancy is a hypercoagulable state, blood flow to the lower limbs is reduced due to compression of the iliac veins, vascular damage occurs during delivery
When does blood flow in the legs reach its lowest in pregnancy? When does it return to normal?
34-36 weeks / 6 weeks postnatally
To cause a PE, a clot gets lodged where?
A pulmonary artery
When should a woman’s risk of developing VTE get assessed?
At booking, and again if she gets admitted
What is the main high risk factor for VTE that indicates a pregnant woman should receive thromboprophylaxis?
Previous DVT not related to major surgery
What medication is used for VTE prophylaxis in pregnancy? Why?
LMWH - does not cross the placenta and is not secreted in breast milk, also has a good side effect profile and only requires once daily dosing
If a) 4 or more or b) 3 or c) fewer than 3 minor risk factors for VTE are present in a pregnant woman, what is done?
a) start thromboprophylaxis from trimester 1 b) start thromboprophylaxis from 28 weeks c) advise mobilisation and avoidance of dehydration
What is the relationship between warfarin and pregnancy?
Teratogenic in the first trimester if > 5mg/day and so should be avoided in pregnancy - can cause midface hypoplasia, short proximal limbs and phalanges and scoliosis
Is warfarin safe in breastfeeding?
Yes
When should people on warfarin who get pregnant be converted to LMWH?
By 6 weeks
When can warfarin be commenced after delivery? How long should anti-coagulation be given for after delivery?
5 days / 6 weeks
What are the main symptoms of a DVT?
Acute onset of a swollen, painful, hot lower limb
Pregnant women are at increased risk of developing a pelvic DVT - how does this present?
Constant lower abdominal pain
What is the main investigation for a DVT? If this is negative but you still have clinical suspicion, when should lit be repeated?
Duplex ultrasound of the lower limb / 1 week
What clinical features may make you suspicious of an iliac vein thrombosis? What investigations should be done for this?
Whole swollen leg and back pain / MRI venography
If a Duplex ultrasound scan is negative and a PE is suspected, what are the next investigations?
CXR, ECG and CTPA or V/Q scan
Are measurements of D-dimers useful in diagnosing a PE in pregnancy?
No, because they are raised in pregnancy anyway
What are the main symptoms of a PE?
Chest pain, dyspnoea, faintness, collapse, haemoptysis
What is the most common ECG change seen in a PE?
Sinus tachycardia
What are the a) advantages and b) disadvantages of a CTPA compared to a V/Q scan?
a) more accurate test, more readily available, lower radiation dose to the foetus b) increased risk of breast cancer later in life
What are the a) advantages and b) disadvantages of a V/Q scan compared to a CTPA?
a) less radiation to the breast b) not as accurate, higher radiation dose to the foetus
What is the mainstay of treatment for VTE? When should this be started?
S/C LMWH - start while investigations are still ongoing
How long should anti-embolism stockings be worn for after a VTE in pregnancy?
2 years
What is the management of a massive PE in pregnancy which causes the woman to collapse?
Streptokinase
What happens to PEFR and FEV1 in pregnancy? What is significant about this?
They do not change - can still be used to monitor asthma in pregnancy
By the end of the 3rd trimester, the uterus lies underneath the diaphragm which causes what?
A decreased functional residual capacity
Breathlessness in pregnancy is most common in which trimester? When does it usually come on? What makes it better?
3rd / when at rest or when talking / exertion
What happens to asthma in pregnancy?
1/3rd get worse, 1/3rd stay the same and 1/3rd improve
Those women whose asthma improves in pregnancy may find what?
It deteriorates in the puerperium
Why does deterioration of asthma most commonly occur in pregnancy? What is important to know about this?
Because of cessation of medications - risk of uncontrolled asthma is higher than the risk of the medications
Severe, poorly controlled asthma in pregnancy may cause what complications?
Low birth weight, P-PROM, premature delivery and hypertension
If a pregnant woman with asthma has been given oral steroids for 2 weeks, what should you do?
Give IV hydrocortisone
Acute asthma during labour is unlikely why?
Endogenous steroids are produced
What are some connective tissue diseases which may flare up during pregnancy?
Rheumatoid arthritis, scleroderma, SLE, anti-phospholipid syndrome
What are some common medications used in connective tissue diseases that are safe to use in pregnancy?
Steroids, hydrochloroquine, sulfasalazine, azathioprine, monoclonal antibodies
What are some common medications used in connective tissue diseases that are not safe to use in pregnancy?
Cyclophophamide, methotrexate, leflunomide
What medication often used in connective tissue diseases cannot be used > 32 weeks gestation?
NSAIDs
What is anti-phospholipid syndrome?
An acquired thrombophilia with variable presentation and severity
What autoantibodies can be seen in anti-phospholipid syndrome? When should these be measured if you have clinical suspicion?
Anti-phospholipid, anti-cardiolipin antibodies and lupus anticoagulant - measure twice, 6 weeks apart
What are some complications of anti-phospholipid syndrome?
Arterial/venous thrombosis, recurrent early pregnancy loss, late pregnancy loss (usually preceded by FGR), placental abruption, severe pre-eclampsia, severe FGR
Describe the pregnancy morbidity which can occur in APS?
3+ miscarriages < 10 weeks, 1 morphologically normal foetal loss > 10 weeks, 1 birth < 34 weeks due to PET or utero-placental insufficiency
What is the management for APS in pregnancy in each of the following situations: a) no previous thrombotic or adverse pregnancy events? b) previous thrombosis? c) previous recurrent early pregnancy loss? d) previous late foetal loss, severe PET or FGR?
a) LDA and surveillance b) stop warfarin, LDA and LMWH at therapeutic dose c) LDA and LMWH at prophylactic dose d) LDA and LMWH at prophylactic dose
A first seizure in pregnancy is due to what until proven otherwise?
Eclampsia
What happens to seizure frequency in women with epilepsy in pregnancy? What is the biggest predictor of seizure deterioration in pregnancy?
Usually is improved or unchanged / seizure free duration before pregnancy
What are some risks of epilepsy in pregnancy in terms of obstetrics?
Miscarriage, haemorrhage, PET, preterm birth, FGR
What type of maternal seizures cause a risk to the foetus?
Only those which cause loss of consciousness
If a maternal seizure occurs during pregnancy, what are the main risks?
Maternal hypoxia, foetal hypoxia, foetal acidosis
Women taking AEDs which are enzyme inducing should be advised to take supplements of what? These should also be given when? Why?
Vitamin K - should also be given as an IM injection to the baby at delivery to reduce the risk of haemorrhagic disease of the newborn
Among anti-epileptic drugs, which have the least risk of major congenital malformation in the offspring?
Lamotrigine, carbamazepine, levetiracetam
What are the most common congenital anomalies to occur when taking AEDs?
Neural tube defects, cardiac abnormalities, skeletal and urinary tract abnormalities, cleft palate
What two factors regarding AED use increase the risk of foetal malformation the most?
Using sodium valproate, and being on polytherapy
Should AEDs be continued in pregnancy?
Generally, AEDs should be continued in pregnancy because the risk of uncontrolled seizures generally outweighs the risk of teratogenicity
What is the management of women taking valproate if they want to become pregnant?
They should be encouraged to switch to a different drug unless this is the only one which effectively controls their seizures
What are some ways to reduce the risks of teratogenicity of AEDs?
Take 5mg/day of folic acid from pre-conception to 12 weeks gestation, use the lowest effective dose of AED, minimise exposure to valproate or polytherapy
Describe the labour and birth seen in women with epilepsy?
Should be aiming for a normal labour and vaginal birth
What are some risk factors for an intra-partum seizure? How can this be reduced?
Stress, pain, sleep deprivation / early epidural anaesthetic
What medications are generally used to manage a seizure in labour?
Benzodiazepines (IV lorazepam or diazepam/PR diazepam/buccal midazolam)
What medication is used to treat an intra-partum seizure if the woman is not known to have epilepsy?
Magnesium sulphate
Should AED intake be continued in labour?
Yes
What is a problem in early pregnancy that can be caused by obesity?
Miscarriage
What are some problems antenatally that can be caused by obesity?
Foetal anomalies, PET, GDM, VTE
What are some problems in labour that can be caused by obesity?
Dysfunctional labour, unsatisfactory anaesthesia
What are some problems postnatally that can be caused by obesity?
Haemorrhage, infection, VTE, problems breastfeeding
What medications are important to give to obese pregnant women?
Folic acid and vitamin D supplements, low dose aspirin, consider thromboprophylaxis
What should obese pregnant women receive at 34 weeks?
Anaesthetic review to discuss potential difficulties with venepuncture, IV access and regional anaesthesia
Why should obese pregnant women be encouraged to breastfeed?
Increase calorie expenditure and reduce childhood diabetes risk
