Medical Problems in Pregnancy Flashcards
What are the main medical problems in pregnancy?
DM Obesity HIV and pregnancy Thrombophilia Pre-existing hypertx Epilepsy Cardiac disease Asthma CTS
Main CVS changes in pregnancy?
Blood volume; increased 30% PV; increased 45% CO; increased 30-50% SV; increased 25% HR; increases to 90 bpm PVR; decreases by 15-20%
What are the types of heart conditions that can be present in pregnant women?
Pulmonary hypertx Congenital heart disease; PDA, AVSD, AS, CoA, marfans, fallot's Acquired heart disease Cardiomyopathy Artificial heart valves Ischaemic heart disease Arrhythmias
What are physiological heart conditions in pregnancy?
Palpitation
Extra-systoles
Systolic/ functional murmurs
What heart conditions tend to be fatal in pregnancy?
Pulmonary HT
Fixed pulmonary vascular resistance
What are the implications of anti-coagulation in pregnancy?
Need if artificial or valvular heart disease
NHYA class of breathlessness?
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
What is the ability to tolerate pregnancy related to in terms of cardiac conditions?
Pulmonary HT NYHA functional classification Presence of cyanosis TIA/ arrhythmia Heart failure Left heart obstruction Aortic root >45mm Myocardial dysfunction (EF <40%)
How is peripartum cardiomyopathy diagnosed?
Echo; assoc with orthopnoea
What is an ectopic beat?
Common “thumping”, relieved by exercise
What is sinus tachycardia and what should the investigations be in pregnancy?
Can be normal If above 120/130 think anaemia or PE Do; ECG FBC TFT Echo
Describe SVT in pregnancy and the ix required?
Paroxysmal, usually predates pregnancy
24hr ecg
TFT
Echo
What is a rare cause of palpitations?
Phaeochromocytoma
Assoc with headache, sweating and hypertx
How does lung function change in pregnancy?
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
What is the most common reason for breathlessness in pregnancy?
Physiological hyperventilation
Most common in 3rd trim
IMPROVES with exertion
How asthma tend to behave in pregnancy?
Rule of 1/3rds;
1/3rd stay same, 1/3rd improve, 1/3rd get worse
What tends to be the driver of the deterioration of asthma seen in pregnancy?
Reduced compliance with inhalers due to safety concerns
Risks of steroids in pregnancy?
Immunocompromisation
Wt gain; screen for diabetes
If on daily steroids, IV steroids are required in labour
Will poorly controlled asthma affect the developing foetus?
Yes; severe poorly controlled asthma will adversely affect foetal development: Low birth weight PROM Preterm delivery Hypertensive disorders
Is vaginal delivery appropriate in vaginal delivery?
Yes; acute asthma attacks are very unlikely due to endogenous steroids
Do inhaled beta agonists impair uterine activity or onset of labour?
No
Are IV steroids required in labour with asthmatic women?
Yes; IV hydrocortisone if woman has been on oral steroids for more than 2 weeks
What medications should be avoided in pregnant asthmatics?
NSAIDs
Hemabate (prostaglandin used for PPH)
Where are DVTs most common in pregnancy?
Ileo-femoral
Very important if doppler requested to scan WHOLE leg
What is the frequency and dose of LMWH?
Twice daily
Weight based dosing; check BNF
Virchow’s triad?
Hypercoagulability
Venous stasis
Vascular damage
What is a high risk for VTE?
Previous VTE
What are intermediate risks for VTE?
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
What are less worrying risk factors, but still important (if 4 or more, LMWH prophylaxis from 1st trim, 3; prophylaxis from 28 wks)?
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
What are transient risk factors for VTE in pregnancy?
Dehydration
HG
Current systemic infection
Long distance travel
Is heparin secreted in breast milk?
No
Si and Sy of DVT?
Swelling Oedema Leg pain/ tenderness Increased leg temp Lower abdo pain Increased WBC
What is the objective test for DVT?
Compression duplex USS
If normal but clinical suspicion high; repeat in 1/52 to exclude calf vein thrombosis
What should be performed if iliac vein thrombosis suspected (whole leg swollen + back pain)?
MRI veography
Si and Sy Pe?
Dyspnoea Chest pain Faintness Collapse Haemoptysis Raised JVP Focal signs in chest Symptoms and signs assoc with DVT
What are the investigations of choice in PTE?
ECG
CXR
V/Q scan over CTPA
Is warfarin recommended in pregnancy?
No; crosses placenta and is teratogenic
What are the defects that warfarin can cause in pregnancy?
Midface hypoplasia Stippled chondral calcification Short proximal limbs Short phalanges Scoliosis
Can you give heparin or warfarin in breastfeeding?
Yes; not a CI
Commence warfarin 5th day PN due to risk of PPH
For how long should anticoag therapy be continued in the PN period?
At least 3 months
What are the pregnancy related complications of CTD?
Miscarriage PET Abruption FGR Stillbirth Preterm labour
What are the treatment related complications of CTD in pregnancy?
Teratogenic Fetotoxic; commonly renal Sepsis Diabetes Osteoporosis
What are the disease related complications of CTD in pregnancy?
Lupus flare, renal or haematological
APS; arterial/ venous thrombosis
Rheumatoid
Scleroderma; renal, pulmonary HT
Which drugs are approved for use in pregnancy in relation to CTD?
Steroids Azathioprine Sulfasalazine Hydroxychloroquine Aspirin Etanercept/ infliximab/ rituximab
What drugs are not recommended for use in pregnancy in relation to CTD?
NSAIDs > 32 weeks Cyclophosphamide Methotrexate Gold Penicillamine MMF Leflulnamide
What is APS?
Autoimmune thrombophilic disease with variable presentation and severity
Autoantibodies formed that react with the phospholipid components of the cell membrane
What antibodies are implicated in APS?
aCL (anticardiolipin)
Lupus anticoag
What are the clinical features of APS?
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
What can be done to prevent complications in future pregnancies with women who have APS?
Fragmin and low dose aspirin from 12 weeks
What is the pregnancy morbidity of APS?
> 3 miscarriages > 10 weeks
1 foetal loss > 10 weeks
1 preterm birth due to PET or uteroplacental insufficiency
Are antibody tests required to be done twice to diagnose APS?
Yes; 6 weeks apart to ensure no false positives
APS management
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)
What are the increased risks of epilepsy during pregnancy?
IOL
FGR
PPH
What are the foetal risks from a maternal seizure?
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
What are the most common congenital malformations assoc with AEDs?
Neural tube defects
Congenital heart disorders
Urinary tract and skeletal abnormalities
Cleft lip/ palate
What congenital malformations is valproate assoc with
Neural tube defects
Facial celft
Hypospadias
What congenital malformations are phenobarb and phenytoin assoc with?
Cardiac malformations
What congenital malformations are carbamazepine and phenytoin assoc with?
Cleft palate
How can risk of congenital malformations be reduced in women taking AEDs?
5mg folic acid 3 months prior to conception and first 3 months of pregnancy
Reduce exposure to sodium valproate and polytherapy
Can women with epilepsy have a vagain birth?
Yes
2.6% will have a seizure
Why are seizures increased in labour for WWE?
Stress Pain Sleep deprivation Over-breathing Dehydration
What can occur if a generalised tonic clonic seizure occurs in labour?
Maternal hypoxia
Foetal hypoxia
Acidosis
Management of status in a pregnant woman?
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
What are the recommendations for baby safety in WWE?
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
What contraceptives are recommended in women who take enzyme inducing drugs?
COC must have 50 micrograms of oestrogen
Depot, s/c progesterone
IUS
EC; double dose of levonorgestrel, UPA NOT recommended, IUD is good
What effect will obesity have on women’s reproductive health?
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
What is the basic management of obese women in pregnancy?
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
