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Y4 Obstetrics and Gynaecology > Medical problems in pregnancy > Flashcards

Medical problems in pregnancy Flashcards

1
Q

Palpitations, extra-systoles and systolic murmurs are very common and mostly benign - T or F?

A

True

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2
Q

Although rare what is the main direct cause of maternal death in the UK?

A

VTE

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3
Q

Why is pregnancy a pro-thrombotic state ?

A

Consider virchows triad:

  1. There is stasis of blood flow in pregnancy due to venous compression by the pregnant uterus
  2. It is hypercoagulable
  3. Endothelial/vascular damage occurs due to varicose vein development
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4
Q

What are the reasons why pregnancy is hypercoagulable ?

A
  • Increased levels of factors 7,8,9,10&11
  • Increased numbers of platelets
  • Decreased levels of factor 11 & antithrombin 3
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5
Q

Regarding VTE risk what should all pregnant women undergo ?

A

They should all undergo a documented assessment of risk factors for VTE in early pregnancy or pre-pregnancy

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6
Q

What is given as thromboprophylaxis in pregnancy ?

A

LMWH

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7
Q

Go over the risk factors for VTE antenatally and state what the management is depending on the score they get from the risk assessment

A
  • If score ≥ 4 antenatally, consider thromboprophylaxis from the 1st trimester
  • If score = 3 antenatally, consider thromboprophylaxis from 28 weeks
  • If score < 3 antenatally, dont offer thromboprophylaxis, they are considered low risk and mobilisation + avoidance of dehydration is only needed
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8
Q

Following the early pregnancy risk assessment for VTE, when do pregnant women recieve another risk assessment ?

A

Done in the delivery suite to determine if postnatal prophylaxis is required (as slight changes in the risk factors)

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9
Q

If a pregnant women is admitted to the hospital what should be considered ?

A

VTE thromboprophylaxis (think cause they will be pretty immobile)

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10
Q

What are the risk factors for postnatal VTE and what are the relevent scores in terms of prophylactic management

A
  • If < 2 risk factors (from low risk) then just need early mobilisation & avoidance of dehyrdation
  • If ≥ 2 risk factors (from low risk) or an intermediate (3 point) risk factor then at least 10 days of LMWH with consideration to prolonge if persisting or > 3 risk factors
  • If any high risk factors (score ≥ 4) then 6 weeks of LMWH given
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11
Q

What is a DVT ?

A

This is a thrombosis in one of the deep veins of the leg

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12
Q

Which leg is more commonly affected by DVT’s in pregnancy ?

A

The left (8:1)

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13
Q

What are the symptoms of DVT in pregnancy ?

A
  • Swelling
  • Oedema
  • Leg pain or discomfort
  • Tenderness
  • Increased leg temperature
  • Lower abdominal pain
  • Elevated white cell count

Note that 50% are asymptomatic

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14
Q

How is DVT diagnosed in pregnancy ?

A

1st line = compression duplex U/S on lower limb

  • if U/S is -ve & low level of clinical suspicion then anticoagulation can be stopped
  • if U/S is -ve but high level of clinical suspicion then repeat U/S 1/52 before discontinuation of anticoagulation

Note - you treat then investigate in pregnancy

If iliac vein thrombosis is suspected (whole leg swollen + back pain) - consider MRI venography

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15
Q

Is D-dimer used in investigation of DVT in pregnancy ?

A

No

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16
Q

What is the treatment of DVT in pregnancy ?

A
  • Any women showing signs/symptoms of DVT should have investigations performed asap but treatment should be given immediately with LMWH regardless i.e. TREAT then SEE
  • Graduated compression stockings & mobilisation is also encouraged (TED stockings)
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17
Q

How long can TED stockings be used to help treat/prevent DVT?

A
  • They can be used acutely & upto 2 years after DVT. They ae recommended to be worn following one.
  • They can also be used to prevent DVT in women who are hospitalised & travelling long distances (immobile) who are at high risk
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18
Q

How long is LMWH treatment continued after DVT in pregnancy?

A

Continue for 3 months after delivery or 6 months after treatment was started (whichever is longer)

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19
Q

When a women is on anti-coagulation with LMWH what needs to be monitored ?

A

FBC, clotting, Us & Es, LFTs

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20
Q

Why is heparin used in pregnancy ?

A
  • Doesnt cross the placenta so safe for the fetus
  • Very effective in treating DVT & PE
  • Less haemorrhagic manifestation than other anti-coagulation options e.g. mortality, HIT (heparin induced thrombocytopenia), osteopenia.
  • Has a long duration of action so only needed to be given OD
21
Q

What are the possible side effects of heparin therapy ?

A
  • Haemorrhage
  • Hypersensitivity
  • Allergy at injection site
  • HIT
  • Osteopenia - possibly developing to osteoporosis with prolonged use
22
Q

How is PE diagnosed in pregnancy ?

A

1st line = ECG + CXR

  • if CXR is normal then 2nd line = bilateral compression duplex dopplers performed, if this confirms DVT then no further investigations needed & PE treatment initiated
  • if CXR abnormal + high clinical suspicion of PE then 2nd line = CTPA
  • if suspected PE without signs/symptoms of DVT then V/Q or CTPA done
23
Q

What is the management of PE in pregnancy ?

A

Anti-coagulation with LMWH until PE excluded

If PE diagnosed then continue anti-coagulation therapy the same as a DVT (if haemodynamically stable)

If massive life-threating PE in pregnancy/puerperium then 1st line = IV unfractionated heparin + urgent ECG & CTPA +/- thrombolysis considered

24
Q

What is the CXR radiation dose to the fetus ?

A

Negligable

25
Q

What are the radiation risks associated with V/Q scan vs CTPA ?

A

V/Q carriers a higher risk of childhood cancer than CTPA but a CTPA carries a higher risk of breast cancer to the mother

(hence if possible mothers should be involved in decision making process of investigation of PE)

26
Q

If a pregnant women is on anti-coagulation what should be done prior to labour & delivery?

A
  • Stop LMWH if she presents in labour and stop it theraptutic doses 24hrs prior to planned labours & prophylactic doses 12hrs prior to planned labours
  • This is done due to the bleeding risks of labour
27
Q

Why should women be offered a choice between LMWH & warfarin postnatally for anticoagulation ?

A

Because both options are safe when breastfedding ==> they should be given a choice

28
Q

Why is warfarin avoided in pregnancy ?

A

It is teratogenic - causes miscarriage, neurological problems & stillbirths (if used in weeks 6-12 of pregnancy)

29
Q

What changes need to be made to hypothryoidism treatment when a women becomes pregnant ?

A

Minimal changes, the dose of levothyroxine needs to be increased in the 1st trimester and there TFTs should be checked every trimester

30
Q

How does pregnancy affect hyperthyroidism ?

A
  • There are more changes than with hypothryoidism:
  • Hyperthryroidism may get worse in the 1st trimester due to HCG stimulating the thyroid to produce thyroid hormone. This worsening improves in the 2nd & 3rd trimesters
  • The condition is linked with pre-term labour, IUGR & thyroid storm
  • Beta blockers (propanolol) used in treatment are possibly linked to IUGR
31
Q

What is the treatment of hyperythyroidism in pregnancy ?

A
  • 1st line = propylthyiouracil (carbimazole 1st line when not pregnant)
  • Beta blockers used to control symptoms actuely e.g. palpatations
  • TFTs checked every trimester
32
Q

What is the commonest chronic medical illness to complicate pregnancies ?

A

Asthma

33
Q

How does pregnancy affect asthma ?

A

It may improve, deteriorate or not affect it at all

34
Q

What are the effects of asthma on pregnancy ?

A

Most people will experience no effects on their pregnancy, effects are more associated with poorly controlled asthma and the associated hypoxaemia, these effects can include:

  • PIH/PET
  • Pre-term labour/birth
  • LBW
  • IUGR
  • Neonatal morbidity e.g. TTN, hypoglycaemia, seizures
35
Q

What is the treatment of asthma in pregnancy ?

A

Drugs used are the exact same as in non-pregnant

  • 1st line = SABA
  • 2nd line = SABA + ICS
  • 3rd line = SABA + ICS + LTRA
  • 4th line = SABA + ICS + LABA +/- LTRA
  • 5th line = MART (LABA & ICS) + ICS +/- LTRA + SABA
  • 6th line = increasing ICS to high dose steriods
36
Q

How can pregnancy affect epilepsy?

A
  • There is an increased chance of seizures in the 1st trimester
  • 25-30% of patients experience increased seizure frequency
  • 54% experience no chance
  • Risk of seizures is highest in the postpartum period
37
Q

What are the reasons for decreased control of epilepsy during pregnancy ?

A
  • Pregnancy itself
  • Poor compliance (due to fears of teratogenesis from medications)
  • Decreased drug levels due to N&V (preventing them being absorbed) or due to increased volume of distribution & drug clearance
  • Lack of sleep towards term & during labour
38
Q

What are the effects of epilepsy on pregnancy ?

A
  • Fetus relatively resistant to short-term hypoxia (during seizures)
  • Major risk factor is teratogenicity of drugs - even women on no treatment have slightly increased risk of malformations
  • Also risk of child developing epilepsy (genetics)
39
Q

What are the teratogenetic risks of anti-convulsant epileptic drugs (AEDs)?

A

All are teratogenic

  • Major malformations include; neural tube defects, orofacial clefts & cardiac defects
  • Minor malformations include; dysmorphic features (low ears, broad nasal bridge), hypertelorism (big distance between eyes), hypoplastic nails & distal digits
40
Q

Which AED is most associated with neural tube defects?

A

Na valproate

41
Q

Which AED is most associated with orofacial clefts ?

A

Phenytoin

42
Q

Which AED is most associated with cardiac defects ?

A

Phenytoin & Na valproate

43
Q

What increases the risk of teratogenicity in epileptic pregnant women ?

A

Poor control & number of AED’s used

44
Q

Are benzodiazepines teratogenic ?

A

No

45
Q

There is little difference in risk of teratogenicity between different AED’s which one tho is avoided in women of childbearing age ?

A

Na valproate (this must have the highest risk of teratogenicity)

46
Q

What is teratogenicity thought to be due to ?

A

Folate deficiency

47
Q

Describe the management of epilepsy in pregnancy

A

Preconception:

  • Take folic acid at least 12 weeks prior to conception

Pregnancy:

  • Continue folic acid
  • Continue current AEDs if well controlled except wean off phenabarbitone due to risks of neonatal withdrawl convulsions
  • Detailed fetal U/S @ 18-20 weeks (as normal antenatal care)
  • Detailed fetal cardiac scan @ 22 weeks
  • Vit K given orally from 34-36 weeks if on enzyme inducers
  • Advise shallow baths or showering (risk of drowning if have a seizure during one)
  • If taking steroids increase dose if on enzyme inducing AEDs
48
Q

What is the intrapartum management of women with epilepsy?

A
  • Most have normal delvieries
  • LSCS done if having recurrent generalised seizures in late pregnancy/labour
  • Continue AEDs during labour
  • Offer early epidural to decrease pain& anxiety
  • Explain 1-2% fit during labour or 24hrs after delivery
49
Q

What is the postpartum management of pregnant women with epilepsy?

A
  • Neonate should have IM vit K
  • Encourage breastfeeding (AEDs ok in this)
  • Advise shallow baths or showering with door unlocked
  • Explain risk of SUDEP increased in pregnancy & postnatal period

Y4 Obstetrics and Gynaecology (63 decks)

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