Medical Problems in Pregnancy Flashcards
what is the uk maternal mortality rate
- 8/100,000
- 8 women died per every 100,000
ethnicity, age and weight associated with increased risk
overweight women have a higher risk of blood clots
what are some common medical problems in pregnancy
Diabetes Hypertension Cardiac disease Respiratory disease - asthma Venous thromboembolism Connective tissue disease - anti-phospholipid syndrome Epilepsy Obesity
what to consider if someone has a medical disorder in pregnancy
How does pregnancy affect disorder
How does disorder affect pregnancy
- for mother and fetus
- drugs
- consider impact on each trimester
How can you reduce risk and improve outcomes
common heart disease in pregnancy
pulmonary hypertension congenital heart disease acquired heart disease cardiomyopathy artificial heart valves ischaemic heart disease arrhythmias
what signs are negative predictions for the outcome of heart disease in pregnancy
pulmonary hypertension NYHA heart failure classification Presence of cyanosis TIA/arrythmia Heart failure Left heart obstruction Aortic root >45mm Myocardial dysfunction (EF<40%)
normal heart disease changes in pregnancy
palpitations
extra-systoles
systolic murmurs
what heart disease signs are often fatal in pregnancy
pulmonary hypertension
fixed pulmonary vascular resistance
what types of palpitations do you get in pregnancy
Physiological (common, occur at rest/lying down)
Ectopic beats (common thumping released by exercise)
Sinus tachycardia (part of normal pregnancy but need to exclude pathology)
SVT (super ventricular tachycardia) - usually predates pregnancy
what happens to lung function during pregnancy
Increased O2 consumption Increased metabolic rate Increased resting minute ventilation Tidal volume Respiratory rate stays the same Functional residual capacity decreases Vital capacity stays the same FEV1 and PEFR stays the same PaO2 increases PaCO2 decreases Arterial pH increases
characteristics of breathlessness in pregnancy
very common - up to 75% of women increased awareness of physiological hyperventilation more common in third trimester rest/talking makes it worse improves with exertion
what is the most common chronic medical disorder to complication pregnancy
Asthma
7% of women of child bearing age have it
10% will have an acute exacerbation in pregnancy
associated with maternal mortality
what is the prognosis of asthma in pregnancy
may improve, may deteriorate or may remain unchanged
deterioration often due to decreased therapy due to safety concerns
those who improve may have deterioration during post partum
impact of asthma on pregnancy
poorly controlled asthma may adversely affect fetal development
poorly controlled asthma is higher risk that the medication used to prevent it
asthma management
Step 1 - inhaled SABA
Step 2- inhaled pregnancy
Step 3 - add LABA, if LABA still not controlling, increase steroid, if no response to LABA stop LABA and increase inhaled steroid
asthma management specific to pregnancy
Aim for vaginal birth
Acute asthma during labour is unlikely due to endogenous steroids
increased risk of cystic fibrosis for women with moderate-severe asthma
Epidemiology of VTE in pregnancy
4-6x increase in risk of VTE in pregnancy
incidence 1-2 per 1000
85-90% of DVTs occurring during pregnancy arise in the left leg
what is Virchow’s triad
hyper coagulability
venous stasis
vascular damage
what are the symptoms of DVT
swelling oedema leg pain or discomfort tenderness increased leg temperature lower abdominal pain elevated white cell count
how do you test for DVT
Compression duplex ultrasound
if normal and clinical suspicion is high then repeat to exclude extending calf vein thrombosis
if iliac vein thrombosis is suspected consider MRI venography
Symptoms and signs of a pulmonary embolism
Dyspnoea Chest pain Faintness Collapse Haemoptysis Raised JVP Focal signs in the chest Symptoms and signs associated with DVT
what are the 2 investigations for PTE
CT pulmonary angiogram
V/Q scan
benefits to CTPA
readily available
may detect other pathology
better sensitivity and specificity
low radiation dose to fetus
benefits of V/Q scan
high negative predictive value in pregnancy
low radiation dose to maternal breast tissue
how do you treat PTE/DVT in pregnancy
LMWH
warfarin is teratogenic
what impact does warfarin have on a foetus
Warfarin embryopathy
- midphase hypoplasia
- stippled chondral calcification
- short proximal limbs
- short phalanges
- scoliosis
what anticoagulation can be used in post-natal
Heparin
Warfarin
neither are contraindicated in pregnancy
start warfarin on 5th post-natal day
anticoagulant therapy continued until at least 6 weeks post-natal until at least 3 months post partum
Connective tissue disease complications in pregnancy
Miscarriage Pre-eclamptic toxicity Abruption Foetal growth restriction Still birth preterm birth labour/delivery post-natal
Disease related
- lupus flare, renal haematological
- Antiphospholipid syndrome
- rheumatoid
- scleroderma
what drugs cannot be used to treat CTD in pregnancy
NSAIDS Clyclophosphamide Methotrexate Chlorambucil Gold Penicillamine MMF Leflunamife
what drugs can be used to treat CTD in pregnancy
Steroids Azathioprine Sulfsalazine Hydroxycholoquine Aspirin some biologics
what is antiphosphlipid syndrome
An acquired thrombophilia
aPL (antiphospholipid antibodies) - reacted with the phospholipid component of the cell membrane
anticardiolipin antibodies and lupus anticoagulant
APS described the clinical syndrome associated with these antibodies
what are the clinical features of anti-phospholipid syndrome
Arterial/venous thrombosis Recurrent early pregnancy loss Late pregnancy loss Placental abruption Severe early onset pre-eclampsie Severe early fetal growth restriction
how do you diagnose antiphospholipid syndrome
Vascular thrombosis
(venous, arterial, small vessel)
Pregnancy morbidity
(>3 miscarriages <10 weeks, >1 fetal loss >10 weeks, >1 preterm birth (less than 34 weeks))
LgM/LgG aCL
LA
How do you manage antiphospholipid syndrome in pregnancy
No thrombosis/adverse pregnancy outcome
- low dose aspirin
- maternal/ fetal observance
previous thrombosis
- stop warfarin
- give low dose aspirin and LMWH
recurrent early pregnancy loss
- LMWH
- Low dose aspirin
lade fetal loss/severe pre-eclampsia toxicity/ foetal growth restriction
- low dose aspirin
- LMWH
how does seizure frequency change in pregnancy
improved or unchanged
> 50% of women have no seizures during pregnancy
fetal risks of epilepsy seizures
Maternal abdominal trauma
PPROM (premature pre-rupture of membranes - early waters breaking)
Preterm birth
hypoxia/acidosis
congenital malformations adverse perinatal outcomes long-term developmental effect s haemorrhage disease of the new born risk of childhood epilepsy
how do you reduce the risk in women with epilepsy who are pregnancy
5mg daily of folic acid
Minimise exposure to valproate and other poly therapy - aim to change medication prior to conception
how does epilepsy effect labour and birth
most women have normal labour and vaginal birth
2.6% will have a seizure
what increases the risk of intrapartum seizure
stress pain sleep deprivation over-breathing dehydration
how do you treat seizures in labour
benzodiazepines- IV lorazepam/diazepam
IV phenytoin
may need to expedite deliver by CS
how to you reduce the risk to the baby if the mother has epilepsy
avoid maternal fatigue get a safe area for the 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 break additional support for bathing
what does obesity increase the risk of in pregnancy
miscarriage gestational diabetes hypertension/precelampsia VTE Cystic fibrosis Post partum haemorrhage wound infection congenital anomalies macrosomnia shoulder dystocia still birth neonatal death
management of obesity in pregnancy
Weight assessed at booking Pre-eclampsia prophylaxis - aspirin thromboprohpylaxis detailed US oral glucose tolerance test obstetric US to asses fetal growth anaesthetic review MDT plan for labour and birth post natal review
