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Medical Problems in Pregnancy Flashcards

1
Q

What are some heart conditions that can be affected by pregnancy?

A

Pulmonary hypertension, congenital heart disease, acquired heart disease, cardiomyopathy, artificial heart valves, ischaemic heart disease, arrhythmia

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2
Q

What is the ability to tolerate pregnancy predicted by?

A

Pulmonary hypertension, NYHA classification, presence of cyanosis, TIA/arrhythmia, heart failure, left heart obstruction, aortic root >45mm, myocardial dysfunction (EF <40)

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3
Q

What is the NYHA classification of heart disease?

A 
1 = no limitation of normal physical activity
2 = mild symptoms only in normal activity
3 = marked symptoms during daily activities (not rest)
4 = severe limitations with symptoms even at rest
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4
Q

What are some heart diseases that occur frequently in pregnancy?

A

Palpitations, extra-systoles and systolic murmurs are very common and mostly benign

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5
Q

What are some heart conditions that can be fatal in pregnancy?

A

Pulmonary hypertension and fixed pulmonary vascular resistance

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6
Q

What are some arrhythmias that commonly occur in pregnancy?

A

Physiological = occur at rest/lying down
Ectopic beats = thumping, relieved by exercise, ECG
Sinus tachycardia = part of normal pregnancy

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7
Q

What are some features of SVT?

A

Paroxysmal and usually predates pregnancy

Investigations = ECG, 24h ECG, TFT, echocardiogram

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8
Q

How can hyperthyroidism present with arrhythmia?

A

May present with sinus tachycardia, SVT or AF

Investigations = ECG, TFT, T4

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9
Q

What are some features of phaeochromocytoma as a cause of palpitations in pregnancy?

A

Rare = headache with sweating and hypertension

Investigate with 24h catecholamines and US

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10
Q

What are some features of breathlessness in pregnancy?

A

Very common = up to 75% women
More common in third trimester
Occurs at rest/talking and improves with exertion
usually doesn’t limit normal activity

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11
Q

What is the commonest chronic medical disorder to complicate pregnancy?

A

Asthma = 10% will have acute exacerbation during pregnancy

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12
Q

How may asthma change during pregnancy?

A

May improve, deteriorate or stay the same

Those who improve may deteriorate in puerperium

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13
Q

What causes deterioration of asthma during pregnancy?

A

Often due to reduction/cessation of therapy due to safety concerns = more likely in 2nd and 3rd trimester

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14
Q

What are severe exacerbations or poorly controlled asthma risk factors for?

A

Low birth weight babies, premature membrane rupture, premature delivery, hypertensive disorders

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15
Q

Why is acute asthma during labour unlikely?

A

Due to endogenous steroids

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16
Q

Should asthma inhalers be stopped during labour?

A

No = inhaled beta2 agonists don’t impair uterine activity or delay labour onset

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17
Q

What are women with moderate-severe asthma at risk of in labour?

A

More likely to need a C-section

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18
Q

What can be given to women on oral steroids for asthma during labour?

A

100mg IV hydrocortisone until oral steroids can be recommenced

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19
Q

How does pregnancy affect risk of VTE?

A

4-6 times increase in risk = daily risk is 5 times higher in puerperium compared to antenatal period

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20
Q

What are some features of DVTs during pregnancy?

A

85-90% occurring pregnancy arise in left leg

>70% are ileo-femoral

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21
Q

What is the pathogenesis of VTE in pregnancy?

A

Increased VW factor, factors 7/9/10/12 and fibrinogen
Reduced protein S and fibrinolytic activity
Acquired aPC resistance

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22
Q

What happens to blood flow in the legs during pregnancy?

A

Slows down = lowest at 34-36 weeks gestation, takes 6 weeks to return to normal postnatally

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23
Q

What women are considered high risk of VTE during pregnancy?

A

Previous VTE (except single event related to major surgery) = require antenatal prophylaxis with LMWH

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24
Q

What women are considered at intermediate risk of VTE during pregnancy?

A

Hospital admission, single previous VTE related to major surgery, high risk thrombophilia + no VTE, medical co-morbidities, any surgical procedure, OHSS in first trimester only

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25
Q

What should be considered in women at intermediate risk of VTE?

A

Antenatal prophylaxis with LMWH

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26
Q

What are the risk factors for VTE during pregnancy?

A

BMI >30, age >35, parity >=3, smoking, gross varicose veins, current pre-eclampsia, immobility, first degree relative affected, low risk thrombophilia, multiple pregnancy, IVF/ART

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27
Q

How should women with four or more risk factors for VTE be managed?

A

Prophylaxis from first trimester

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28
Q

How should women with 3 risk factors for VTE be managed?

A

Prophylaxis from 28 weeks

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29
Q

What women are considered at lower risk for VTE during pregnancy?

A

<3 risk factors = manage with mobilisation and avoid dehydration

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30
Q

Are anticoagulative medications safe during pregnancy?

A

Mostly yes = neither UFH nor LMWH cross placenta, heparins aren’t secreted in breastmilk

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31
Q

Why are LMWH first line for antenatal thromboprophylaxis?

A

Better side effect profile

32
Q

What are the symptoms and signs of a VTE?

A

Swelling, oedema, leg pain, tenderness, increased leg temperature, lower abdominal pain, elevated WCC

33
Q

What is done to test for a VTE?

A

Compression duplex US = repeat after 1 week if normal but there is high clinical suspicion to rule out extending calf vein thrombosis

34
Q

When would you do MRI venography for a VTE?

A

If iliac vein thrombosis is suspected = whole leg swollen plus back pain

35
Q

What are the symptoms and signs of a PE?

A

Dyspnoea, chest pain, dizziness, collapse, haemoptysis, raised JVP, focal chest signs, symptoms of DVT

36
Q

What investigations can be done for a PE?

A

ECG and CXR

May do CTPA or V/Q scan

37
Q

What are the features of CTPA?

A

Readily available and may detect other pathology
Better sensitivity and specificity
Low radiation dose to foetus
Increases risk of breast cancer

38
Q

What are the benefits of a V/Q scan?

A

High negative predictive value in pregnancy

Low radiation dose to maternal breast tissue

39
Q

Why is warfarin avoided in pregnancy?

A

Crosses placenta and is teratogenic in first trimester

40
Q

What congenital abnormality does warfarin cause?

A

Warfarin embryopathy (chondrodysplasia punctata) = midface hypoplasia, stippled chondral calcification, short proximal limbs, short phalanges, scoliosis

41
Q

What dose of warfarin is associated with congenital abnormalities?

A

> 5 mg/day

42
Q

What should warfarin be switched to?

A

Covert to heparin 6 weeks

43
Q

Can anticoagulation be continued when breastfeeding?

A

Yes = neither heparin nor warfarin are contraindicated in breastfeeding

44
Q

When should postnatal anticoagulation be started?

A

Commence warfarin on 5th postnatal day

45
Q

How long should postnatal anticoagulation be continued for?

A

Until at least 6 weeks post-natal and 3 months post-partum

46
Q

What are some pregnancy related complications of connective tissue disorders that may occur during pregnancy?

A

Miscarriage, pre-eclampsia, abruption, foetal growth retardation, stillbirth, preterm birth

47
Q

What are some pregnancy complications that can occur in women with connective tissue disorders?

A

Treatment related = teratogenic, sepsis, diabetes, osteoporosis
Disease-related = lupus flare, thrombosis, pulmonary hypertension

48
Q

What antibodies are present in patients with antiphospholipid syndrome?

A

Antiphospholipid antibodies (aPL), anticardiolipin antibodies (aCL) and lupus anticoagulant (LA)

49
Q

What are antiphospholipid antibodies (aPL)?

A

Autoantibodies that react with the phospholipid component of the cell membrane

50
Q

What are the features of antiphospholipid syndrome?

A

Thrombosis, recurrent early pregnancy loss, late pregnancy loss (usually preceded by FGR), placental abruption, severe early onset pre-eclampsia, severe early onset FGR

51
Q

How is antiphospholipid syndrome diagnosed clinically?

A

Vascular thrombosis
Pregnancy morbidity = >=3 miscarriages <10 weeks, >= 1
foetal loss >10 weeks, >=1 preterm birth (<34 weeks) due to pre-eclampsia or uteroplacental insufficiency

52
Q

What is the lab diagnosis of antiphospholipid syndrome?

A

2 readings taken 6 weeks apart = IgM/IgG anticardiolipin

53
Q

What are some of the outcomes of pregnancy in antiphospholipid syndrome?

A

17% early pregnancy loss, 35% preterm birth(<34 weeks), 14% foetal growth retardation

54
Q

What is the management of antiphospholipid syndrome during pregnancy?

A

No thrombosis = LDA, surveillance
Previous thrombosis = stop warfarin, LDA + LMWH
Recurrent early pregnancy loss/late foetal loss/severe PET or FGR = LDA + LMWH (prophylactic dose)

55
Q

How much does epilepsy increase the risk of maternal death?

A

10 times increase

56
Q

What effect does pregnancy have on epilepsy?

A

Seizure frequency is improved or unchanged in most

>50% will have no seizures during pregnancy

57
Q

What are the obstetric complications of epilepsy during pregnancy?

A

Miscarriage, antepartum haemorrhage, hypertension/PET, induction of labour, C-section, preterm birth, foetal growth restriction, postpartum haemorrhage

58
Q

What are the risks associated with maternal seizures during pregnancy?

A

Maternal abdominal trauma, PPROM, preterm birth, hypoxia/acidosis

59
Q

What are the foetal risks from epilepsy during pregnancy?

A

Major congenital malformations, adverse perinatal outcomes, long term developmental effects, haemorrhagic disease of the newborn, risk of childhood epilepsy

60
Q

What are the risks associated with anti-epileptic drugs during pregnancy?

A

Background risk of major congenital malformations = 2-3%

2-3x increased risk for monotherapy and 16% risk increase for polytherapy

61
Q

What anti-epileptic drugs pose the least risk during pregnancy?

A

Lamotrigine, levitiracem and carbamazepine monotherapy at low dose pose least risk

62
Q

What scan should all women be offered?

A

Detailed US at 18-20 weeks to assess for foetal abnormalities

63
Q

What anti-epileptic drug carried the most risk during pregnancy?

A

Valproate polytherapy regimes associated with significantly more major congenital malformations

64
Q

How is risk reduced in women with epilepsy during pregnancy?

A

5mg/day folic acid prior to conception and continue until end of 1st trimester
Limit polytherapy and sodium valproate use

65
Q

How common are seizures during pregnancy in women with epilepsy?

A

Up to 2.6% will have seizure = tonic-clonic seizures occur in about 1-2%

66
Q

What factors increase the risk of intra-partum seizures?

A

Stress, pain, sleep deprivation, overbreathing and dehydration

67
Q

What do tonic-clonic seizures increase the risk of?

A

Maternal and foetal hypoxia and acidosis

68
Q

How common is status epilepticus in women with epilepsy during pregnancy?

A

Complicates <1% of pregnancies

69
Q

When would you deliver by elective C-section in a woman with epilepsy?

A

Significant deterioration of seizures = recurrent and prolonged
Status epilepticus

70
Q

When would you give long acting benzodiazepines during labour to a woman with epilepsy?

A

If at very high risk of seizures in peripartum period

71
Q

What is given to treat seizures in women with no history of epilepsy?

A

Magnesium sulphate

72
Q

What are some baby safety measures for women with epilepsy?

A

Avoid excessive fatigue, safe area for baby if mother feels unwell, safe feeding position, lowest setting for high chair, dress baby on floor, handle-release pram

73
Q

What effects can obesity have on reproductive health?

A

Menstrual disorder, subfertility, miscarriage, pre-eclampsia, VTE, foetal abnormalities, dysfunctional labour, postpartum haemorrhage, macrosomia, endometrial prolapse

74
Q

What are the maternal risks during pregnancy associated with obesity?

A

Miscarriage. gestational diabetes, pre-eclampsia, VTE, C-section, PPH, wound infection

75
Q

What congenital abnormalities are associated with obesity during pregnancy?

A

Neural tube defects, spina bifida, CV abnormalities, hydrocephaly, anorectal atresia

76
Q

What perinatal outcomes are associated with obesity?

A

Congenital anomaly, macrosomia, shoulder dystocia, stillbirth, neonatal death

77
Q

What is the management for obesity during pregnancy?

A 
Aspirin for pre-eclampsia prophylaxis
Thromboprophylaxis and OGTT
Detailed US = including MUAD
Obstetric US to assess foetal growth
Anaesthetic review at 34 weeks

Reproduction (62 decks)

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