Medical Problems in Pregnancy Flashcards
75% of direct causes of maternal mortality is d.t ________
haemorrhage/ Hypertension/ Sepsis
Highest cause of maternal death?
cardiac disease
- followed by thrombosis/ thromboembolism
What CVS changes occur in mother during pregnancy?
- Increase in:
- blood volume (by 30%)
- stroke volume
- plasma volume
- CO
- HR (by 15-25%) - Decrease in peripheral vascular resistance ! (15-20%)
What cardiac conditions is an expecting mother at risk of?
- pulmonary hypertension
- congenital heart diease
- acquired heart disease
- cardiomyopathy (peri-partum cardiomyopathy)
- artifical heart valves
- IHD
- Arrhythmias
What is to be observed in a mother with a heart condition?
- arrhythmia
- heart failure
- left heart obstruction
- aortic root >45mm
- myocardial dysfxn (EF <40 )
- presence of arrhythmias and cyanosis
What heart conditions is usually benign, and is common?
- palpitations
- extra-systoles
- systolic murmurs
WHat heart conditions are often FATAL in pregnancy?
pulmonary HT
- fixed pulmonary vascular resistance
What precautions to take with a mother who has a heart condition?
- pre-pregnancy counselling
- if contraindicated, women should receive contraception!
- implications of anti-coagulants in women with VALVULAR heart disease
- MDT support through preg.
- need for support for LABOUR and BIRTH
Causes of palpitations?
- physiological (when lying down)
- ectopic beats
- sinus tachycardia (to exclude pathology/ could be normal)
- SVT
- Hyperthyroidism
- Phaeochromocytoma
What ivx to confirm hyperthyroidism?
ECG
TFT
FT4
What invx to do phaeochromocytoma?
- 24h Catecholamines
- US
Why may alkalosis develop in the mother?
Maternal hyperventilation incr by 40%, whilst total oxygen consumption incr. only by 20-33%
- – causes PaO2 to INCR. and PCO2 to FALL
- —consequent fall in serum bicarbonate!
Why does functional residual capacity decr. in pregnancy?
d.t diaphragmatic elevation!
What drives the incr. oxygen demands of pregnancy?
— caused by the incr. METABOLIC rates met by —-driven by HIGH PROGESTERONE levels (INCR. ventilation (up to 40%) )
What lung fxns increase during pregnancy?
- INcreased:
- O2 consumption
- metabolic rate
- resting minute ventilation
- tidal volume
- PaO2
- Arterial pH
What lung fxns DECLINE during pregnancy?
functional residual capacity
PaCO2
When is physiological palpitations during pregnancy worse?
- when lying down!
How common is breathlessness in pregnancy?
When is it often seen?
- up to 75% of women !
- —more common in 3RD trimester
- breathlessness when RESTING and TALKING; improved with exertion!
- – does not Llimit normal activities
What is the risk of an un-managed asthmatic mother?
- those who are poorly controlled, may adversely affect fetal devleopment!
- —greater risk than the medication used to PREVENT the asthma
- —LOW birth weight babies
- —PROM
- –premature delivery —- hypertensive delivery
Why is asthma known as a the MOST commonest chronic medical disorder to complicate pregnancy?
- often undiagnosed and under-treated
- –pregnancy is an ideal time to diagnose asthma; because 10% will have an ACUTE exacerbation during pregnancy
What does the intra-partum care encompass for asthma?
- aim for VAGINAL birth
- acute asthma during labour is UNLIKELY d.t endogenous steroids
- –DO NOT DIScontinue INHALERS during labour (inhaled Beta-agnoists; does NOT impair uterine activity)
- –IV hydrocortisone if oral steroids >2/52
How common is VTE in pregnancy?
- 4-6x the risk in preg
- 1-2 in every 1000 deliveries
Where and when does the VTE usually develop?
- 85-90% arise in the LEFT leg
- > 70% of DVTs in pregnancy are ILIO-FEMORAL
—-5x higher risk of VTE in the puerperium
What may cause a VTE?
- imbalance of virchow’s triad
- incr. vWF
- incr. in factors VII, IX, X, XII
- incr. in fibrinogen
- reduced protein S
- acquired aPC resistance
- impaired fibrinolytic activity
What is often the cause of VTE to result?
- failure to recognise symptoms
- inadequate thromboprophylaxis
- delayed ivx/dx
- lack of consultant input
- delayed and inadequate rx
Why is the use of heparin not c.i in preg.?
- neither UFH nor LMWH cross the placenta
- –heparins are NOT secreted in breast milk
LMWH is safer for use and as effective than UFH
Name LMWH drugs,
Dalteparin
Tinzaparin
How does a DVT appear?
- swelling
- oedema
- leg pain
- tenderness
- incr. LEG temperature
- lower abdominal pain
- elevated white cell count
How to screen for DVT>
- compression duplex ultrasound
- if normal, but HIGH clinical suspicion, test should be repeated in 1/52
What to do if iliac vein thrombosis is suspected?
- whole leg and back pain
- MRI venography
What are the symptoms of PTE?
- dyspnoea
- chest pain
- faintness
- collapse
- haemoptysis
- raised JVP
- focal signs in chest
- symptoms and signs a.w with dvt
What are 2 diagnostic procedures than can be conducted for dx Pulmonary embolism?
- CTPA- ct pulmonary angiogram
2. V/W perfusion scan (nuclear imaging - examines airflow and bloodflow)
Which gives a higher cancer risk for PTE; CTPA or V/Q scan?
- perfusion scan (1 in 280,000)
2. CTPA (1 in 1, 000,000)
What are the advs of CTPA?
- readily available
- detects other pathology
- better sensitivity and specificity
- LOW radiation to fetus
What are the advs of V/Q Perfusion scan?
- high negative predictive value in pregnancy
- low radiation dose to maternal breast tissue
Risk of warfarin use in pregnant lady?
- its teratogenic!
- —embryopathy (midface hypoplasia/ stippled chondral calcification/ short proximal limbs/ short phalanges/ scoliosis)
Is warfarin $ risk dose dependant?
YES
- – >5mg/day
- —SWITCH TO LMWH by 6 weeks
Are warfarin and Hepain c.i for breast-feeding?
NO
—-can start warfarin 5th post-natal day !
How lonog should anti-coagulant therapy be continued?
- until at least 6 weeks post-natal and at least 3 months post-partum
What complications may connective tissue disease bring about?
- miscarriage
- PET
- ABRUPTION
- FGR
- stillbirth
- preterm birth
- labour/ delivery
- postnatal
What should NOT be given to a pregnant lady with CONNECTIVE TISSUE DISEASE?
- NSAIDs (>32weeks)
- cyclophosphamide
- methotrexate
- chlorambucil
- Gold
- penicillamine
- MMF - mycophenolate
- leflunamide
What is APS?
- anti-phospholipid syndrome
- –> acquired thrombophilia with variable pres. and severityd.t antiphospholipid antibodies; autoantibodies that react with the phospholipid component of the cell membrane
What are the fts of APS?
- arterial/ venous thrombosis
- recurrent early pregnancy loss
- late preg. loss (preceded by FGR)
- placental abruption
- severe early onset PRE-ECLAMPSIA (PET)
- FGR
When to suspect APS?
- hx of vascular thrombosis
- hx of pregnancy morbidity:
- > 3 Miscarriages (<10 weeks)
- >1 fetal loss (10-34 weeks) —normal fetus !
- > 1 preterm birth (<34 weeks)
Preterm birth often result in _____ % of APS pregnancies.
Preterm loss of baby usually occurs d.t ________
35%
PET or Utero-placental insufficiency
Lab findings for APS?
IgM/ IgG aCL (medium/ high titre)
- LA
What are some causes of false postive for lab findings in APS?
- acute infections
2. chronic infections ( PERSISTENT +ve) - Hep C/ HIV/ Malaria/ Syphilis
How to manage APS?
LDA + LMWH (prophylaxis)
3 scenarios where the above is given:
- previous thrombosis (STOP warfarin)
- recurrent early pregnancy loss
- Late fetal loss/ Severe PET/ FGR
What is done as prophylaxis if the pt is +ve of anti-phospholipid abs but has no thrombosis of hx of adverse preg. outcome?
- LDA +maternal and fetal surveillance
