Medical Problems in Pregnancy and Labour

Question 1

maternal mortality is highest in what geographical region?

Answer 1

central africa

Question 2

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

Answer 2

cardiac causes

VTE

Question 3

what factors increase the risk of maternal mortality in pregnancy?

Answer 3

multiple health problems

vulnerabilities (children in social services, drug/alcohol abuse)

ethnicity

age

medication

overweight / obese

Question 4

what are the most common medical problems (both direct and indirect) in pregnancy?

Answer 4

diabetes 
hypertension 
cardiac disease
respiratory disease
asthma 
VTE
connective tissue - APS / SLE
epilepsy

Question 5

why is heart disease a common complication of pregnancy?

Answer 5

heart works around 40% harder during pregnancy - increased CO

Question 6

if patients have a known congenital cardiac condition, how should they be managed in pregnancy?

Answer 6

pre-pregnancy counselling (esp on medication)

maximise scans (regular ECHO)

Question 7

why do acquired heart conditions obviously start in pregnancy?

Answer 7

heart is asked to work a lot harder so disease traits may start to show

Question 8

when is peri-partum cardiomyopathy usually diagnosed?

Answer 8

at time of birth

Question 9

what symptoms are common with peri-partum cardiomyopathy?

Answer 9

orthopnoea (breathless when lying down)

Question 10

how is continuity of care across different specialities managed in pregnant women with underlying conditions?

Answer 10

hand held / one track records

*these can be accessed by any clinician the pregnant patient sees

Question 11

by how much does pregnancy increase the risk of MI and how is this prevented?

Answer 11

3-4x increased risk

check ECG (+CT) if required

Question 12

the presence of what cardiac features would predict poor outcomes in pregnancy?

Answer 12

pulmonary hypertension 
cyanosis 
TIA
arrhythmia 
heart failure 
left heart obstruction 
aortic dissection 
MI

Question 13

if patients have valvular heart disease or arrhythmias increasing risk of stroke, how should they be anticoagulated in pregnancy?

Answer 13

LMWH (does not cross placenta)

stop before delivery due to haemorrhage risk

warfarin can be recommenced 5 days post natal and is safe in breastfeeding

Question 14

what palpitations can occur in pregnancy?

Answer 14

physiological (at rest / lying down)

ectopic beats (relieved by exercise)

sinus tachycardia (normal in pregnancy)

SVT (usually predates pregnancy)

hyperthyroidism

phaeochromocytoma (rare, associated with headache, sweating, HT)

Question 15

describe the main respiratory changes that occur during pregnancy?

Answer 15

less residual capacity

increased O2 capacity to take in enough O2 for mother and foetus

SOB is common in 3rd trimester

SOB often improves with exertion (walking along corridor)

asthma = common in pregnancy

Question 16

how is asthma normally treated in pregnancy?

Answer 16

treated as if patient is not pregnant

steroids safe for use in pregnancy

minimise asthma attacks as this can affect mother, placenta and thus foetal development

Question 17

acute asthma during labour is unlikely - true or false?

Answer 17

true - due to endogenous steroids

Question 18

what vascular factors cause increased risk of VTE in pregnancy?

Answer 18

virchow’s triad

• hyper coagulability
• venous stasis
• vascular damage

Question 19

how should VTE be screened for?

Answer 19

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

Question 20

how is a suspected DVT managed?

Answer 20

LMWH (weight based) taken twice daily

- enoxaparin / dalteparin

Question 21

what investigations can be used to investigate a PE, and which of these may be avoided in pregnant women?

Answer 21

CTPA
- not used in pregnancy due to increased breast tissue and vasculature that can take up radiation (risk of breast cancer)

V/Q scan

Question 22

what teratogenic effects can warfarin cause?

Answer 22

midface hypoplasia 
stippled chondral calcification 
short proximal limbs 
short phalanges 
scoliosis

Question 23

for how long should anticoagulation be continued after pregnancy?

Answer 23

until at least 6 weeks post-natal AND at least 3 months post-partum

Question 24

connective tissue diseases such as APS and SLE can cause what complications to the actual pregnancy?

Answer 24

miscarriage 
pre eclampsia 
abruption 
growth restriction (due to small vessel disease affecting placenta)
still or preterm birth

Question 25

what complications can connective tissue disease drug treatments cause?

Answer 25

teratogenic 
fetotoxic 
sepsis 
diabetes 
osteoporosis

Question 26

what drugs that may be used in connective tissue disease are not safe in pregnancy?

Answer 26

NSAIDs
cyclophosphamide
methotrexate
penicillamine

Question 27

how are patients normally diagnosed with APS?

Answer 27

antiphospholipid autoantibodies - positive on 2 tests >6 weeks apart

clinical disease picture (ie recurrent miscarriage / clotting, severe pre-eclampsia etc)

Question 28

what pregnancy outcomes are common for patients with APS?

Answer 28

early pregnancy loss
T2/T3 IUD
preterm birth
foetal growth restriction

Question 29

how are patients with APS normally managed in pregnancy?

Answer 29

if no previous complications = foetal and maternal surveillance

others = low dose aspirin and LMWH during pregnancy

*consider prophylaxis also

Question 30

what is the most important risk factor for determining seizure deterioration in pregnancy?

Answer 30

seizure free period

no seizure in 9 months prior to pregnancy, up to 92% of mothers will remain seizure free

Question 31

what obstetric complications can occur as a result of a woman having epilepsy during pregnancy?

Answer 31

miscarriage 
antepartum haemorrhage 
pre-eclampsia 
IOL/C-section 
PPH

Question 32

what are the largest risk to the foetus if a mother has a seizure during pregnancy?

Answer 32

maternal abdominal trauma - foetal-maternal haemorrhage

preterm birth

hypoxia / acidosis

Question 33

by how much do AEDs increase the risk of teratogenicity in a foetus and how can this be minimised?

Answer 33

2-3x increased risk for any AED

reduce polytherapy as this increases risk
use lowest effective dose where possible
avoid valproate
counsel epileptic patients on contraception

Question 34

give examples of foetal malformations from AEDs which can be visualised on a 20 week anomaly scan?

Answer 34

spina bifida

heart defects (eg septal)

lip defects (cleft-lip palate)

Question 35

seizure risk is higher during labour - true or false?

Answer 35

true

stress, pain, sleep deprivation, over-breathing and dehydration increase the risk of intra-partum seizures

Question 36

if status epilepticus occurs during labour, what procedure is carried out?

Answer 36

left lateral tilt - takes pressure of uterus off of aortic / caval vessels

Question 37

what “baby-safety” measures have been put in place for mothers with epilepsy?

Answer 37

avoid excessive fatigue 
safe feeding position 
lowest setting for high chairs 
dress baby on the floor 
using padded sling / carry cot

Question 38

what perinatal outcomes are common in pregnant mothers who are obese?

Answer 38

congenital abnormalities
macrosomia
shoulder dystocia
stillbirth

Question 39

how should pregnant mothers who are obese be managed during pregnancy?

Answer 39

check BMI at booking appointment

PET prophylaxis - aspirin

thromboprophylaxis

OFTT at 26-28 weeks

anaesthetic review at 34 weeks

MDT plan for labour and birth