Medical Problems in Pregnancy Flashcards by Zoe Doak

Maternal mortality is highest in what geographical region?

Central Africa

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What are the most common causes of maternal death in the UK?

Cardiac causes

- VTE

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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

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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

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Why is heart disease a common complication of pregnancy?

Heart works around 40% harder during pregnancy

- increased CO

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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)

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Why do acquired heart conditions obviously start in pregnancy?

Heart is asked to work a lot harder

=> disease traits may start to show

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When is peri-partum cardiomyopathy usually diagnosed?

At time of birth

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What symptoms are common with peri-partum cardiomyopathy?

Orthopnoea

=> breathlessness lying down

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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

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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

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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

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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

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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

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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

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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 ```