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Repro and Sexual Health > Medical Problems in Pregnancy > Flashcards

Medical Problems in Pregnancy Flashcards

1
Q

What are the main medical problems in pregnancy?

A 
DM
Obesity
HIV and pregnancy
Thrombophilia
Pre-existing hypertx
Epilepsy
Cardiac disease 
Asthma
CTS
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2
Q

Main CVS changes in pregnancy?

A 
Blood volume; increased 30% 
PV; increased 45% 
CO; increased 30-50% 
SV; increased 25%
HR; increases to 90 bpm
PVR; decreases by 15-20%
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3
Q

What are the types of heart conditions that can be present in pregnant women?

A 
Pulmonary hypertx 
Congenital heart disease; PDA, AVSD, AS, CoA, marfans, fallot's 
Acquired heart disease
Cardiomyopathy
Artificial heart valves
Ischaemic heart disease
Arrhythmias
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4
Q

What are physiological heart conditions in pregnancy?

A

Palpitation
Extra-systoles
Systolic/ functional murmurs

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5
Q

What heart conditions tend to be fatal in pregnancy?

A

Pulmonary HT

Fixed pulmonary vascular resistance

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6
Q

What are the implications of anti-coagulation in pregnancy?

A

Need if artificial or valvular heart disease

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7
Q

NHYA class of breathlessness?

A

1; no limitations
2; mild symptoms in normal activity
3; marked symptoms during daily activities, asymptomatic only at rest
4; severe limitations, present at rest

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8
Q

What is the ability to tolerate pregnancy related to in terms of cardiac conditions?

A 
Pulmonary HT
NYHA functional classification 
Presence of cyanosis
TIA/ arrhythmia
Heart failure
Left heart obstruction 
Aortic root >45mm
Myocardial dysfunction (EF <40%)
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9
Q

How is peripartum cardiomyopathy diagnosed?

A

Echo; assoc with orthopnoea

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10
Q

What is an ectopic beat?

A

Common “thumping”, relieved by exercise

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11
Q

What is sinus tachycardia and what should the investigations be in pregnancy?

A 
Can be normal 
If above 120/130 think anaemia or PE 
Do; 
ECG
FBC
TFT
Echo
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12
Q

Describe SVT in pregnancy and the ix required?

A

Paroxysmal, usually predates pregnancy
24hr ecg
TFT
Echo

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13
Q

What is a rare cause of palpitations?

A

Phaeochromocytoma

Assoc with headache, sweating and hypertx

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14
Q

How does lung function change in pregnancy?

A 
Increased O2 consumption
Increased metabolic rate
Increased resting minute ventilation 
Increased tidal volume
Decreased functional residual capacity 
Increased PaO2 
Decreased Pa CO2
Increased arterial pH
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15
Q

What is the most common reason for breathlessness in pregnancy?

A

Physiological hyperventilation
Most common in 3rd trim
IMPROVES with exertion

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16
Q

How asthma tend to behave in pregnancy?

A

Rule of 1/3rds;

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

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17
Q

What tends to be the driver of the deterioration of asthma seen in pregnancy?

A

Reduced compliance with inhalers due to safety concerns

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18
Q

Risks of steroids in pregnancy?

A

Immunocompromisation
Wt gain; screen for diabetes
If on daily steroids, IV steroids are required in labour

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19
Q

Will poorly controlled asthma affect the developing foetus?

A 
Yes; severe poorly controlled asthma will adversely affect foetal development: 
Low birth weight 
PROM
Preterm delivery 
Hypertensive disorders
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20
Q

Is vaginal delivery appropriate in vaginal delivery?

A

Yes; acute asthma attacks are very unlikely due to endogenous steroids

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21
Q

Do inhaled beta agonists impair uterine activity or onset of labour?

A

No

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22
Q

Are IV steroids required in labour with asthmatic women?

A

Yes; IV hydrocortisone if woman has been on oral steroids for more than 2 weeks

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23
Q

What medications should be avoided in pregnant asthmatics?

A

NSAIDs

Hemabate (prostaglandin used for PPH)

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24
Q

Where are DVTs most common in pregnancy?

A

Ileo-femoral

Very important if doppler requested to scan WHOLE leg

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25
Q

What is the frequency and dose of LMWH?

A

Twice daily

Weight based dosing; check BNF

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26
Q

Virchow’s triad?

A

Hypercoagulability
Venous stasis
Vascular damage

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27
Q

What is a high risk for VTE?

A

Previous VTE

28
Q

What are intermediate risks for VTE?

A

Hospital admission
Single previous VTE related to major surgery
High risk thrombophilia
Medical comorbidities; cancer, heart failure, active SLE, IBD, inflammatory arthropathy, nephrotic syndrome, T1DM with nephropathy, sickle cell, current IVDU
OHSS

29
Q

What are less worrying risk factors, but still important (if 4 or more, LMWH prophylaxis from 1st trim, 3; prophylaxis from 28 wks)?

A 
Obestiy; BMI >30 
Age >35
Parity >3 
Smoker
Gross varicose veins
Current PET 
Immobility 
FMHx of unprovoked VTE 
Low-risk thrombophilia
Multiple pregnancy
IVF/ ART
30
Q

What are transient risk factors for VTE in pregnancy?

A

Dehydration
HG
Current systemic infection
Long distance travel

31
Q

Is heparin secreted in breast milk?

A

No

32
Q

Si and Sy of DVT?

A 
Swelling
Oedema
Leg pain/ tenderness
Increased leg temp
Lower abdo pain
Increased WBC
33
Q

What is the objective test for DVT?

A

Compression duplex USS

If normal but clinical suspicion high; repeat in 1/52 to exclude calf vein thrombosis

34
Q

What should be performed if iliac vein thrombosis suspected (whole leg swollen + back pain)?

A

MRI veography

35
Q

Si and Sy Pe?

A 
Dyspnoea
Chest pain
Faintness
Collapse
Haemoptysis 
Raised JVP 
Focal signs in chest
Symptoms and signs assoc with DVT
36
Q

What are the investigations of choice in PTE?

A

ECG
CXR
V/Q scan over CTPA

37
Q

Is warfarin recommended in pregnancy?

A

No; crosses placenta and is teratogenic

38
Q

What are the defects that warfarin can cause in pregnancy?

A 
Midface hypoplasia
Stippled chondral calcification 
Short proximal limbs
Short phalanges
Scoliosis
39
Q

Can you give heparin or warfarin in breastfeeding?

A

Yes; not a CI

Commence warfarin 5th day PN due to risk of PPH

40
Q

For how long should anticoag therapy be continued in the PN period?

A

At least 3 months

41
Q

What are the pregnancy related complications of CTD?

A 
Miscarriage
PET
Abruption 
FGR
Stillbirth
Preterm labour
42
Q

What are the treatment related complications of CTD in pregnancy?

A 
Teratogenic
Fetotoxic; commonly renal 
Sepsis
Diabetes
Osteoporosis
43
Q

What are the disease related complications of CTD in pregnancy?

A

Lupus flare, renal or haematological
APS; arterial/ venous thrombosis
Rheumatoid
Scleroderma; renal, pulmonary HT

44
Q

Which drugs are approved for use in pregnancy in relation to CTD?

A 
Steroids
Azathioprine
Sulfasalazine
Hydroxychloroquine
Aspirin
Etanercept/ infliximab/ rituximab
45
Q

What drugs are not recommended for use in pregnancy in relation to CTD?

A 
NSAIDs > 32 weeks
Cyclophosphamide
Methotrexate
Gold
Penicillamine
MMF
Leflulnamide
46
Q

What is APS?

A

Autoimmune thrombophilic disease with variable presentation and severity
Autoantibodies formed that react with the phospholipid components of the cell membrane

47
Q

What antibodies are implicated in APS?

A

aCL (anticardiolipin)

Lupus anticoag

48
Q

What are the clinical features of APS?

A 
Arterial/ venous thrombosis
Recurrent early pregnancy loss; 3 miscarriages in 1st trim
Late pregnancy loss; preceded by FGR
Placental abruption 
Severe early onset PET (before 34 weeks)
Severe early onset FGR
49
Q

What can be done to prevent complications in future pregnancies with women who have APS?

A

Fragmin and low dose aspirin from 12 weeks

50
Q

What is the pregnancy morbidity of APS?

A

> 3 miscarriages > 10 weeks
1 foetal loss > 10 weeks
1 preterm birth due to PET or uteroplacental insufficiency

51
Q

Are antibody tests required to be done twice to diagnose APS?

A

Yes; 6 weeks apart to ensure no false positives

52
Q

APS management

A

No thrombosis or adverse pregnancy outcomes: LDA, maternal and foetal surveillance
Previous thrombosis: LDA + LMWH
Recurrent early pregnancy loss: LDA + LMWH (prophylaxis)
Late foetal loss/ severe PET/ FGR: LDA + LMWH (prophylaxis)

53
Q

What are the increased risks of epilepsy during pregnancy?

A

IOL
FGR
PPH

54
Q

What are the foetal risks from a maternal seizure?

A 
Maternal abdo trauma
PPROM 
Preterm birth
Hypoxia/ acidosis 
Congenital malformations
Adverse perinatal outcomes
Long term developmental effects
Haemorrhagic disease of newborn 
Risk of childhood epilepsy
55
Q

What are the most common congenital malformations assoc with AEDs?

A

Neural tube defects
Congenital heart disorders
Urinary tract and skeletal abnormalities
Cleft lip/ palate

56
Q

What congenital malformations is valproate assoc with

A

Neural tube defects
Facial celft
Hypospadias

57
Q

What congenital malformations are phenobarb and phenytoin assoc with?

A

Cardiac malformations

58
Q

What congenital malformations are carbamazepine and phenytoin assoc with?

A

Cleft palate

59
Q

How can risk of congenital malformations be reduced in women taking AEDs?

A

5mg folic acid 3 months prior to conception and first 3 months of pregnancy
Reduce exposure to sodium valproate and polytherapy

60
Q

Can women with epilepsy have a vagain birth?

A

Yes

2.6% will have a seizure

61
Q

Why are seizures increased in labour for WWE?

A 
Stress
Pain
Sleep deprivation 
Over-breathing 
Dehydration
62
Q

What can occur if a generalised tonic clonic seizure occurs in labour?

A

Maternal hypoxia
Foetal hypoxia
Acidosis

63
Q

Management of status in a pregnant woman?

A

Left lateral tilst
IV lorazepam
Buccal midazolam if no IV access
IV phenytoin
Expedite delivery by C/S if due to eclampsia
If no history of epilepsy; give mag sulphate

64
Q

What are the recommendations for baby safety in WWE?

A

Avoid excessive fatigue e.g. express to allow partner to do night feeds
Safe area for baby if mother feels unwell
Safe feeding position
Lowest setting for high chairs
Dress baby on floor
Carry baby in padded sling
Handle release pram brake

65
Q

What contraceptives are recommended in women who take enzyme inducing drugs?

A

COC must have 50 micrograms of oestrogen
Depot, s/c progesterone
IUS
EC; double dose of levonorgestrel, UPA NOT recommended, IUD is good

66
Q

What effect will obesity have on women’s reproductive health?

A

Pre pregnancy; menstrual disorders, subfertility
Early pregnancy; miscarriage
Antenatal; foetal anomalies, PET, GDM, VTE
Labour; IOL, dysfunctional labour, operative delivery
Post-natal; haemorrhage, infection, VTE, breast feeding
Foetal/ neonatal; macrosomia, birth injury, perinatal mortality
Post-menopausal; endometrial hyperplasia, prolapse, incontinence of urine

67
Q

What is the basic management of obese women in pregnancy?

A 
PET prophylaxis; aspiring
Thromboprophylaxis
Detailed US 
OGTT
Obstetric US to assess foetal growth 
If over BMI 40; anaesthetic review at 34 weeks 
MDT plan for labour and birth

Repro and Sexual Health (77 decks)

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