Medical Problems in Pregnancy Flashcards
Maternal mortality is highest in what geographical region?
Central Africa
What are the most common causes of maternal death in the UK?
- Cardiac causes
- VTE
What factors increase the risk of maternal mortality in pregnancy?
- multiple health problems
- vulnerabilities (children in social services, drug/alcohol abuse)
- Ethnicity
- Age
- Medication
- Overweight / obese
What are the most common medical problems (Both direct and indirect) in pregnancy?
- Diabetes
- Hypertension
- Cardiac disease
- Respiratory disease - Asthma
- VTE
- Connective tissue disease - APS/Lupus
- Epilepsy
Why is heart disease a common complication of pregnancy?
Heart works around 40% harder during pregnancy
- increased CO
If patients have a previously known congenital cardiac condition, how should they be managed in pregnancy?
- Pre-pregnancy counselling (especially on medication)
- Maximise scans (regular ECHO)
Why do acquired heart conditions obviously start in pregnancy?
Heart is asked to work a lot harder
=> disease traits may start to show
When is peri-partum cardiomyopathy usually diagnosed?
At time of birth
What symptoms are common with peri-partum cardiomyopathy?
Orthopnoea
=> breathlessness lying down
HOw is continuity of care across different specialities managed in pregnant women with underlying conditions?
Hand held/ One track records
=> these can be accessed by any clinician the pregnant patient sees
BY how much does pregnancy increase the risk of MI, and how is this prevented?
3-4 x increased risk check ECG (+CT) if required
The presence of what cardiac features would predict poor outcomes in pregnancy?
- Pulmonary hypertension
- Cyanosis
- TIA
- Arrhythmia
- Heart failure
- Left heart obstruction
- Aortic dissection
- MI
If patients have valvular heart disease or arrhythmias increasing risk of stroke, how should they be anticoagulated in pregnancy?
- LMWH used as it doesnt cross placenta (Warfarin teratogenic)
- Stop before delivery due to haemorrhage risk
- Warfarin can be recommenced 5 days post natal and is safe in breastfeeding
What palpitations can occur in pregnancy?
- Physiological (at rest/lying down)
- Ectopic beats (relieved by exercise)
- Sinus Tachycardia (normal in pregnancy)
- SVT (usually predates pregnancy)
- Hyperthyroidism
- Phaeochromocytoma - RARE assoc. headache, sweating, HT
Describe the main respiratory changes that occur during pregnancy?
- less residual capacity
- increased O2 capacity to take in enough O2 for mother and foetus
- SOB common in 3rd trimester
- SOB often improves with exertion (walking along corridor)
- Asthma = common in pregnancy
How is asthma normally treated in pregnancy?
- treated as if patient is not pregnant
- steroids safe for use in pregnancy
- minimise asthma attacks as this can affect mother, placenta and => foetal development
Acute asthma during labour is unlikely. TRUE/FALSE?
TRUE
due to endogenous steroids
What vascular factors cause increased risk of VTE in pregnancy?
VIRCHOW’S TRIAD:
- hypercoagulability
- venous stasis
- vascular damage
How should VTE be screened for?
DVT - look for symptoms/signs (swollen, hot, red limb)
PE - pleuritic pain, SOB etc
If suspicious of DVT
- Whole leg doppler (inc. groin)
- if negative, repeat in 1 week
HOw is a suspected DVT managed?
LMWH (Weight based)
Taken twice daily
- Enoxaparin/Dalteparin
What investigations can be used to investigate a PE, and which of these may be avoided in pregnant women?
CTPA
- Not used often in preg. due to increased breast tissue and vasculature that can take up radiation => risk of breast cancer
V/Q Scan
What teratogenic effects can warfarin cause?
- midface hypoplasia
- stippled chondral calcification
- short proximal limbs
- short phalanges
- scoliosis
For how long should anticoagulation be continued after pregnancy?
until at least 6 weeks post-natal
AND until at least 3 months post-partum
Connective tissue diseases such as antiphospholipid and lupus can cause what complications to the actual pregnancy?
- Miscarriage
- Pre eclampsia
- Abruption
- growth restriction (due to small vessel disease also affecting placenta => supply baby less)
- Still OR Preterm birth
What complications can connective tissue disease drug treatments cause?
Teratogenic Fetotoxic Sepsis Diabetes Osteoporosis
What drugs that may be used in connective tissue disease are NOT safe in pregnancy?
- NSAIDs
- Cyclophosphamide
- Methotrexate
- Penicillamine
How are patients normally diagnosed with Antiphospholipid syndrome?
- Antiphospholipid autoantibodies - positive on 2 tests >6 weeks apart
- clinical disease picture (i.e. recurrent miscarriage/ clotting, severe pre-eclampsia etc)
What pregnancy outcomes are common for patients with antiphospholipid?
- Early Pregnancy Loss
- T2 / T3 IUD
- Preterm Birth (<34 weeks
- Foetal Growth Restriction
How are patients with antiphospholipid normally managed in pregnancy?
- if no previous complications = foetal and maternal surveillance
- Others = low dose aspirin and LMWH during preg.
Consider prophylaxis also
What is the most important risk factor for determining seizure deterioration in pregnancy?
Seizure free period
no seizure in 9 months prior to pregnancy, up to 92% of mothers will remain seizure free
What obstetric complications can occur as a result of a woman having epilepsy during pregnancy?
Miscarriage antepartum haemorrhage Pre-eclampsia IOL/C-section PPH
What are the largest risks to the foetus if a mother has a seizure during pregnancy?
- Maternal abdominal trauma - Foetal-maternal haemorrhage
- Preterm birth
- Hypoxia/acidosis
By how much do AEDs increase the risk of teratogenicity in a foetus and how can this be minimised?
2-3X increased risk for any single AED
- reduce Polytherapy as this increases risk
- use lowest effective dose where possible
- avoid valproate in women of reproductive age
- counsel epileptic patients on contraception
Give examples of foetal malformations from AEDs which can be visualised on a 20 week anomaly scan?
Spina Bifida Heart defects (e.g. septal) Lip defects (cleft-lip palate)
Seizure risk is higher during labour. TRUE/FALSE?
TRUE
Stress, pain, sleep deprivation, over-breathing and dehydration increase the risk of intra-partum seizures
If status epilepticus occurs during labour, what procedure is carried out?
Left lateral tilt
takes pressure of uterus off of aortic/caval vessels
What “baby-safety” measures have been put in place for mothers with epilepsy?
- Avoid excessive fatigue
- Safe feeding position
- Lowest setting for high chairs
- Dress baby on the floor
- Use padded sling / carrycot
What perinatal outcomes are common in pregnant mothers who are obese?
congenital abnormalities
macrosomia
shoulder dystocia
stillbirth
How should pregnant mothers who are obese be managed during pregnancy?
Check BMI at bookin appt. PET prophylaxis - Aspirin Thromboprophylaxis OGTT at 26-28 weeks Anaesthetic Review @ 34 weeks MDT plan for labour & birth
