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Reproductive - Pregnancy > Medical Problems in Pregnancy > Flashcards

Medical Problems in Pregnancy Flashcards

1
Q

What are some risk factors for maternal mortality?

A

Black/Asian ethnicity, aged > 40, medical co-morbidities

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2
Q

In general, what happens to symptoms of pre-existing cardiac disease in pregnancy? Why?

A

They tend to get worse due to the increased blood volume and greater demands on the heart

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3
Q

Describe what happens in peri-partum cardiomyopathy?

A

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

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4
Q

What are some common cardiac problems to occur in pregnancy which are mostly benign?

A

Palpitations, extra-systoles and systolic murmurs

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5
Q

What are some poor prognostic signs with regards to cardiac disease in pregnancy, with high rates of maternal mortality?

A

Pulmonary hypertension and fixed pulmonary vascular resistance

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6
Q

What is the change in management in pregnancy for women with valvular heart disease?

A

Swap from warfarin to LMWH

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7
Q

What are some causes of palpitations in pregnancy?

A

Physiological, ectopic beats, sinus tachycardia, supraventricular tachycardia, hyperthyroidism, phaeochromocytoma (rare)

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8
Q

When do physiological palpitations of pregnancy tend to occur?

A

At rest/when lying down

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9
Q

Describe what an ectopic beat will feel like in pregnancy? What will make them better? What investigation should be used?

A

A thumping sensation, made better with exercise / ECG

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10
Q

What investigations should be used for sinus tachycardia and supraventricular tachycardia associated with palpitations in pregnancy?

A

ECG, 24h ECG, TFTs and ECHO

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11
Q

How may hyperthyroidism in a pregnancy present? What investigations should be done?

A

Sinus tachycardia, supraventricular tachycardia or AF / ECG, TFTs and free T4

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12
Q

What may be some associated symptoms of a phaeochromocytoma? What investigations should be done?

A

Sweating, headache, hypertension / 24h catecholamines and ultrasound

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13
Q

85-90% of DVTs in pregnancy arise where? > 70% are what type?

A

Left leg / ileo-femoral

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14
Q

When is the risk of VTE highest in ‘pregnancy’?

A

Th puerperium

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15
Q

Describe why pregnant women are at increased risk of VTE?

A

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

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16
Q

When does blood flow in the legs reach its lowest in pregnancy? When does it return to normal?

A

34-36 weeks / 6 weeks postnatally

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17
Q

To cause a PE, a clot gets lodged where?

A

A pulmonary artery

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18
Q

When should a woman’s risk of developing VTE get assessed?

A

At booking, and again if she gets admitted

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19
Q

What is the main high risk factor for VTE that indicates a pregnant woman should receive thromboprophylaxis?

A

Previous DVT not related to major surgery

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20
Q

What medication is used for VTE prophylaxis in pregnancy? Why?

A

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

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21
Q

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

a) start thromboprophylaxis from trimester 1 b) start thromboprophylaxis from 28 weeks c) advise mobilisation and avoidance of dehydration

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22
Q

What is the relationship between warfarin and pregnancy?

A

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

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23
Q

Is warfarin safe in breastfeeding?

A

Yes

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24
Q

When should people on warfarin who get pregnant be converted to LMWH?

A

By 6 weeks

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25
Q

When can warfarin be commenced after delivery? How long should anti-coagulation be given for after delivery?

A

5 days / 6 weeks

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26
Q

What are the main symptoms of a DVT?

A

Acute onset of a swollen, painful, hot lower limb

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27
Q

Pregnant women are at increased risk of developing a pelvic DVT - how does this present?

A

Constant lower abdominal pain

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28
Q

What is the main investigation for a DVT? If this is negative but you still have clinical suspicion, when should lit be repeated?

A

Duplex ultrasound of the lower limb / 1 week

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29
Q

What clinical features may make you suspicious of an iliac vein thrombosis? What investigations should be done for this?

A

Whole swollen leg and back pain / MRI venography

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30
Q

If a Duplex ultrasound scan is negative and a PE is suspected, what are the next investigations?

A

CXR, ECG and CTPA or V/Q scan

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31
Q

Are measurements of D-dimers useful in diagnosing a PE in pregnancy?

A

No, because they are raised in pregnancy anyway

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32
Q

What are the main symptoms of a PE?

A

Chest pain, dyspnoea, faintness, collapse, haemoptysis

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33
Q

What is the most common ECG change seen in a PE?

A

Sinus tachycardia

34
Q

What are the a) advantages and b) disadvantages of a CTPA compared to a V/Q scan?

A

a) more accurate test, more readily available, lower radiation dose to the foetus b) increased risk of breast cancer later in life

35
Q

What are the a) advantages and b) disadvantages of a V/Q scan compared to a CTPA?

A

a) less radiation to the breast b) not as accurate, higher radiation dose to the foetus

36
Q

What is the mainstay of treatment for VTE? When should this be started?

A

S/C LMWH - start while investigations are still ongoing

37
Q

How long should anti-embolism stockings be worn for after a VTE in pregnancy?

A

2 years

38
Q

What is the management of a massive PE in pregnancy which causes the woman to collapse?

A

Streptokinase

39
Q

What happens to PEFR and FEV1 in pregnancy? What is significant about this?

A

They do not change - can still be used to monitor asthma in pregnancy

40
Q

By the end of the 3rd trimester, the uterus lies underneath the diaphragm which causes what?

A

A decreased functional residual capacity

41
Q

Breathlessness in pregnancy is most common in which trimester? When does it usually come on? What makes it better?

A

3rd / when at rest or when talking / exertion

42
Q

What happens to asthma in pregnancy?

A

1/3rd get worse, 1/3rd stay the same and 1/3rd improve

43
Q

Those women whose asthma improves in pregnancy may find what?

A

It deteriorates in the puerperium

44
Q

Why does deterioration of asthma most commonly occur in pregnancy? What is important to know about this?

A

Because of cessation of medications - risk of uncontrolled asthma is higher than the risk of the medications

45
Q

Severe, poorly controlled asthma in pregnancy may cause what complications?

A

Low birth weight, P-PROM, premature delivery and hypertension

46
Q

If a pregnant woman with asthma has been given oral steroids for 2 weeks, what should you do?

A

Give IV hydrocortisone

47
Q

Acute asthma during labour is unlikely why?

A

Endogenous steroids are produced

48
Q

What are some connective tissue diseases which may flare up during pregnancy?

A

Rheumatoid arthritis, scleroderma, SLE, anti-phospholipid syndrome

49
Q

What are some common medications used in connective tissue diseases that are safe to use in pregnancy?

A

Steroids, hydrochloroquine, sulfasalazine, azathioprine, monoclonal antibodies

50
Q

What are some common medications used in connective tissue diseases that are not safe to use in pregnancy?

A

Cyclophophamide, methotrexate, leflunomide

51
Q

What medication often used in connective tissue diseases cannot be used > 32 weeks gestation?

A

NSAIDs

52
Q

What is anti-phospholipid syndrome?

A

An acquired thrombophilia with variable presentation and severity

53
Q

What autoantibodies can be seen in anti-phospholipid syndrome? When should these be measured if you have clinical suspicion?

A

Anti-phospholipid, anti-cardiolipin antibodies and lupus anticoagulant - measure twice, 6 weeks apart

54
Q

What are some complications of anti-phospholipid syndrome?

A

Arterial/venous thrombosis, recurrent early pregnancy loss, late pregnancy loss (usually preceded by FGR), placental abruption, severe pre-eclampsia, severe FGR

55
Q

Describe the pregnancy morbidity which can occur in APS?

A

3+ miscarriages < 10 weeks, 1 morphologically normal foetal loss > 10 weeks, 1 birth < 34 weeks due to PET or utero-placental insufficiency

56
Q

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

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

57
Q

A first seizure in pregnancy is due to what until proven otherwise?

A

Eclampsia

58
Q

What happens to seizure frequency in women with epilepsy in pregnancy? What is the biggest predictor of seizure deterioration in pregnancy?

A

Usually is improved or unchanged / seizure free duration before pregnancy

59
Q

What are some risks of epilepsy in pregnancy in terms of obstetrics?

A

Miscarriage, haemorrhage, PET, preterm birth, FGR

60
Q

What type of maternal seizures cause a risk to the foetus?

A

Only those which cause loss of consciousness

61
Q

If a maternal seizure occurs during pregnancy, what are the main risks?

A

Maternal hypoxia, foetal hypoxia, foetal acidosis

62
Q

Women taking AEDs which are enzyme inducing should be advised to take supplements of what? These should also be given when? Why?

A

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

63
Q

Among anti-epileptic drugs, which have the least risk of major congenital malformation in the offspring?

A

Lamotrigine, carbamazepine, levetiracetam

64
Q

What are the most common congenital anomalies to occur when taking AEDs?

A

Neural tube defects, cardiac abnormalities, skeletal and urinary tract abnormalities, cleft palate

65
Q

What two factors regarding AED use increase the risk of foetal malformation the most?

A

Using sodium valproate, and being on polytherapy

66
Q

Should AEDs be continued in pregnancy?

A

Generally, AEDs should be continued in pregnancy because the risk of uncontrolled seizures generally outweighs the risk of teratogenicity

67
Q

What is the management of women taking valproate if they want to become pregnant?

A

They should be encouraged to switch to a different drug unless this is the only one which effectively controls their seizures

68
Q

What are some ways to reduce the risks of teratogenicity of AEDs?

A

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

69
Q

Describe the labour and birth seen in women with epilepsy?

A

Should be aiming for a normal labour and vaginal birth

70
Q

What are some risk factors for an intra-partum seizure? How can this be reduced?

A

Stress, pain, sleep deprivation / early epidural anaesthetic

71
Q

What medications are generally used to manage a seizure in labour?

A

Benzodiazepines (IV lorazepam or diazepam/PR diazepam/buccal midazolam)

72
Q

What medication is used to treat an intra-partum seizure if the woman is not known to have epilepsy?

A

Magnesium sulphate

73
Q

Should AED intake be continued in labour?

A

Yes

74
Q

What is a problem in early pregnancy that can be caused by obesity?

A

Miscarriage

75
Q

What are some problems antenatally that can be caused by obesity?

A

Foetal anomalies, PET, GDM, VTE

76
Q

What are some problems in labour that can be caused by obesity?

A

Dysfunctional labour, unsatisfactory anaesthesia

77
Q

What are some problems postnatally that can be caused by obesity?

A

Haemorrhage, infection, VTE, problems breastfeeding

78
Q

What medications are important to give to obese pregnant women?

A

Folic acid and vitamin D supplements, low dose aspirin, consider thromboprophylaxis

79
Q

What should obese pregnant women receive at 34 weeks?

A

Anaesthetic review to discuss potential difficulties with venepuncture, IV access and regional anaesthesia

80
Q

Why should obese pregnant women be encouraged to breastfeed?

A

Increase calorie expenditure and reduce childhood diabetes risk

Reproductive - Pregnancy (11 decks)

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