Medical Problems in Pregnancy Flashcards
What are some heart conditions that can be affected by pregnancy?
Pulmonary hypertension, congenital heart disease, acquired heart disease, cardiomyopathy, artificial heart valves, ischaemic heart disease, arrhythmia
What is the ability to tolerate pregnancy predicted by?
Pulmonary hypertension, NYHA classification, presence of cyanosis, TIA/arrhythmia, heart failure, left heart obstruction, aortic root >45mm, myocardial dysfunction (EF <40)
What is the NYHA classification of heart disease?
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
What are some heart diseases that occur frequently in pregnancy?
Palpitations, extra-systoles and systolic murmurs are very common and mostly benign
What are some heart conditions that can be fatal in pregnancy?
Pulmonary hypertension and fixed pulmonary vascular resistance
What are some arrhythmias that commonly occur in pregnancy?
Physiological = occur at rest/lying down
Ectopic beats = thumping, relieved by exercise, ECG
Sinus tachycardia = part of normal pregnancy
What are some features of SVT?
Paroxysmal and usually predates pregnancy
Investigations = ECG, 24h ECG, TFT, echocardiogram
How can hyperthyroidism present with arrhythmia?
May present with sinus tachycardia, SVT or AF
Investigations = ECG, TFT, T4
What are some features of phaeochromocytoma as a cause of palpitations in pregnancy?
Rare = headache with sweating and hypertension
Investigate with 24h catecholamines and US
What are some features of breathlessness in pregnancy?
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
What is the commonest chronic medical disorder to complicate pregnancy?
Asthma = 10% will have acute exacerbation during pregnancy
How may asthma change during pregnancy?
May improve, deteriorate or stay the same
Those who improve may deteriorate in puerperium
What causes deterioration of asthma during pregnancy?
Often due to reduction/cessation of therapy due to safety concerns = more likely in 2nd and 3rd trimester
What are severe exacerbations or poorly controlled asthma risk factors for?
Low birth weight babies, premature membrane rupture, premature delivery, hypertensive disorders
Why is acute asthma during labour unlikely?
Due to endogenous steroids
Should asthma inhalers be stopped during labour?
No = inhaled beta2 agonists don’t impair uterine activity or delay labour onset
What are women with moderate-severe asthma at risk of in labour?
More likely to need a C-section
What can be given to women on oral steroids for asthma during labour?
100mg IV hydrocortisone until oral steroids can be recommenced
How does pregnancy affect risk of VTE?
4-6 times increase in risk = daily risk is 5 times higher in puerperium compared to antenatal period
What are some features of DVTs during pregnancy?
85-90% occurring pregnancy arise in left leg
>70% are ileo-femoral
What is the pathogenesis of VTE in pregnancy?
Increased VW factor, factors 7/9/10/12 and fibrinogen
Reduced protein S and fibrinolytic activity
Acquired aPC resistance
What happens to blood flow in the legs during pregnancy?
Slows down = lowest at 34-36 weeks gestation, takes 6 weeks to return to normal postnatally
What women are considered high risk of VTE during pregnancy?
Previous VTE (except single event related to major surgery) = require antenatal prophylaxis with LMWH
What women are considered at intermediate risk of VTE during pregnancy?
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
What should be considered in women at intermediate risk of VTE?
Antenatal prophylaxis with LMWH
What are the risk factors for VTE during pregnancy?
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
How should women with four or more risk factors for VTE be managed?
Prophylaxis from first trimester
How should women with 3 risk factors for VTE be managed?
Prophylaxis from 28 weeks
What women are considered at lower risk for VTE during pregnancy?
<3 risk factors = manage with mobilisation and avoid dehydration
Are anticoagulative medications safe during pregnancy?
Mostly yes = neither UFH nor LMWH cross placenta, heparins aren’t secreted in breastmilk
Why are LMWH first line for antenatal thromboprophylaxis?
Better side effect profile
What are the symptoms and signs of a VTE?
Swelling, oedema, leg pain, tenderness, increased leg temperature, lower abdominal pain, elevated WCC
What is done to test for a VTE?
Compression duplex US = repeat after 1 week if normal but there is high clinical suspicion to rule out extending calf vein thrombosis
When would you do MRI venography for a VTE?
If iliac vein thrombosis is suspected = whole leg swollen plus back pain
What are the symptoms and signs of a PE?
Dyspnoea, chest pain, dizziness, collapse, haemoptysis, raised JVP, focal chest signs, symptoms of DVT
What investigations can be done for a PE?
ECG and CXR
May do CTPA or V/Q scan
What are the features of CTPA?
Readily available and may detect other pathology
Better sensitivity and specificity
Low radiation dose to foetus
Increases risk of breast cancer
What are the benefits of a V/Q scan?
High negative predictive value in pregnancy
Low radiation dose to maternal breast tissue
Why is warfarin avoided in pregnancy?
Crosses placenta and is teratogenic in first trimester
What congenital abnormality does warfarin cause?
Warfarin embryopathy (chondrodysplasia punctata) = midface hypoplasia, stippled chondral calcification, short proximal limbs, short phalanges, scoliosis
What dose of warfarin is associated with congenital abnormalities?
> 5 mg/day
What should warfarin be switched to?
Covert to heparin 6 weeks
Can anticoagulation be continued when breastfeeding?
Yes = neither heparin nor warfarin are contraindicated in breastfeeding
When should postnatal anticoagulation be started?
Commence warfarin on 5th postnatal day
How long should postnatal anticoagulation be continued for?
Until at least 6 weeks post-natal and 3 months post-partum
What are some pregnancy related complications of connective tissue disorders that may occur during pregnancy?
Miscarriage, pre-eclampsia, abruption, foetal growth retardation, stillbirth, preterm birth
What are some pregnancy complications that can occur in women with connective tissue disorders?
Treatment related = teratogenic, sepsis, diabetes, osteoporosis
Disease-related = lupus flare, thrombosis, pulmonary hypertension
What antibodies are present in patients with antiphospholipid syndrome?
Antiphospholipid antibodies (aPL), anticardiolipin antibodies (aCL) and lupus anticoagulant (LA)
What are antiphospholipid antibodies (aPL)?
Autoantibodies that react with the phospholipid component of the cell membrane
What are the features of antiphospholipid syndrome?
Thrombosis, recurrent early pregnancy loss, late pregnancy loss (usually preceded by FGR), placental abruption, severe early onset pre-eclampsia, severe early onset FGR
How is antiphospholipid syndrome diagnosed clinically?
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
What is the lab diagnosis of antiphospholipid syndrome?
2 readings taken 6 weeks apart = IgM/IgG anticardiolipin
What are some of the outcomes of pregnancy in antiphospholipid syndrome?
17% early pregnancy loss, 35% preterm birth(<34 weeks), 14% foetal growth retardation
What is the management of antiphospholipid syndrome during pregnancy?
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)
How much does epilepsy increase the risk of maternal death?
10 times increase
What effect does pregnancy have on epilepsy?
Seizure frequency is improved or unchanged in most
>50% will have no seizures during pregnancy
What are the obstetric complications of epilepsy during pregnancy?
Miscarriage, antepartum haemorrhage, hypertension/PET, induction of labour, C-section, preterm birth, foetal growth restriction, postpartum haemorrhage
What are the risks associated with maternal seizures during pregnancy?
Maternal abdominal trauma, PPROM, preterm birth, hypoxia/acidosis
What are the foetal risks from epilepsy during pregnancy?
Major congenital malformations, adverse perinatal outcomes, long term developmental effects, haemorrhagic disease of the newborn, risk of childhood epilepsy
What are the risks associated with anti-epileptic drugs during pregnancy?
Background risk of major congenital malformations = 2-3%
2-3x increased risk for monotherapy and 16% risk increase for polytherapy
What anti-epileptic drugs pose the least risk during pregnancy?
Lamotrigine, levitiracem and carbamazepine monotherapy at low dose pose least risk
What scan should all women be offered?
Detailed US at 18-20 weeks to assess for foetal abnormalities
What anti-epileptic drug carried the most risk during pregnancy?
Valproate polytherapy regimes associated with significantly more major congenital malformations
How is risk reduced in women with epilepsy during pregnancy?
5mg/day folic acid prior to conception and continue until end of 1st trimester
Limit polytherapy and sodium valproate use
How common are seizures during pregnancy in women with epilepsy?
Up to 2.6% will have seizure = tonic-clonic seizures occur in about 1-2%
What factors increase the risk of intra-partum seizures?
Stress, pain, sleep deprivation, overbreathing and dehydration
What do tonic-clonic seizures increase the risk of?
Maternal and foetal hypoxia and acidosis
How common is status epilepticus in women with epilepsy during pregnancy?
Complicates <1% of pregnancies
When would you deliver by elective C-section in a woman with epilepsy?
Significant deterioration of seizures = recurrent and prolonged
Status epilepticus
When would you give long acting benzodiazepines during labour to a woman with epilepsy?
If at very high risk of seizures in peripartum period
What is given to treat seizures in women with no history of epilepsy?
Magnesium sulphate
What are some baby safety measures for women with epilepsy?
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
What effects can obesity have on reproductive health?
Menstrual disorder, subfertility, miscarriage, pre-eclampsia, VTE, foetal abnormalities, dysfunctional labour, postpartum haemorrhage, macrosomia, endometrial prolapse
What are the maternal risks during pregnancy associated with obesity?
Miscarriage. gestational diabetes, pre-eclampsia, VTE, C-section, PPH, wound infection
What congenital abnormalities are associated with obesity during pregnancy?
Neural tube defects, spina bifida, CV abnormalities, hydrocephaly, anorectal atresia
What perinatal outcomes are associated with obesity?
Congenital anomaly, macrosomia, shoulder dystocia, stillbirth, neonatal death
What is the management for obesity during pregnancy?
Aspirin for pre-eclampsia prophylaxis Thromboprophylaxis and OGTT Detailed US = including MUAD Obstetric US to assess foetal growth Anaesthetic review at 34 weeks
