Medical Problems in Pregnancy and Labour Flashcards
most common causes of maternal mortality in order?
cardiac disease
thrombosis/thromboembolism
other indirect cause
neurological
what medical problems are common in pregnancy?
diabetes and hypertension mainly cardiac disease resp disease - asthma venous thromboembolism connective tissue disease epilepsy obesity
what cardiac changes are seen in pregnancy?
blood volume increases by 30% plasma volume increases 45% CO increases 30-50% stroke volume increases 25% HR increases 15-25% peripheral vascular resistance decreases 15-20% CVP unchaged
what cardiac factors can predict ability to tolerate pregnancy and any adverse outcomes?
pulmonary hypertension NYHA heart failure classification presence of cyanosis TIA arhythmia heart failure left heart obstruction (MV <2cm, AV <1.5cm or >30mm) aortic root >45mm myocardial dysfunction (EF <40%)
what benign cardio symptoms are common in pregnancy?
palpitations
extra-systoles
systolic murmurs
what cardiac symptoms are more likely to be fatal in pregnancy?
pulmonary hypertension
fixed pulmonary vascular resistance
implications of anti-coagulation in women with valvular heart disease should be considered
what can cause palpitations in pregnancy?
physiological (common, occur at rest)
ectopic beats (common, thumping relieved by exercise)
sinus tachycardia (normal but should investigate to rule out pathology)
SVT (paroxysmal, usually predates pregnancy)
hyperthyroidism
phaeochromocytoma (rae, associated with headache, sweating and hypertension)
how are palpitations investigated in pregnancy?
ECG ECHO FBC TFT 24 hr ECG if SVT suspected free T4 if thyroid suspected 24hr catecholamines and US if phaeochromocytoma suspected
what lung functions increase in pregnancy?
O2 consumption (higher demand) metabolic rate resting minute ventilation tidal volume PaO2 arterial pH
what lung functions decrease in pregnancy?
functional residual capacity
PaCO2
what lung functions stay the same in pregnancy?
resp rate
vital capacity
FEV1 and PEFR
what ABG result is common to see in pregnancy?
compensated resp alkalosis
how does breathlessness commonly present in pregnancy?
seen in up to 75%
increased awareness of physiological hyperventilation
more common in 3rd trimester
often at rest or while talking
improves with exertion
shouldnt limit normal activities but can lead to indigiestion
commonest chronic medical disorder to complicate pregnancy?
asthma
how does pregnancy affect asthma?
may improve deteriorate or remain unchanged
clinical features same as non-pregnant
can deteriorate due to reduction or cessation of therapy due to safety concerns
those who improve may experience deterioration during puerperium
course of asthma similar in successive pregnancies
does asthma cause a risk in pregnancy?
well controlled asthma has no effect on pregnancy outcome
- can cause problems if severe or poorly controlled, poorly controlled is a bigger risk than the medications used to treat it
step up asthma treatment?
- SABA
- SABA + steroid
- add LABA
- increase steroid
- add 4th drug (LTRA, theophylline
- oral steroid
intra-partum care in asthma?
aim for vaginal birth
asthma attack during labour is rare due to endogenous steroids but should not stop inhalers anyway
IV hydrocortisone if oral steroids >2 weeks
VTE risk in pregnancy?
increased risk during pregnancy and in puerperium
what blood factors can cause hypercoagulability?
increased von willebrand factor increased factors 7, 9, 10 and 12 increased fibrinogen reduced protein S acquired aPC resistance impaired fibrinolytic activity
when is VTE prophylaxis given in pregnancy?
4+ risk factors = prophylaxis from 1st trimester 3 risk factors = prophylaxis from 28 weeks major risk factor = antenatal prophylaxis with LMWH high risk (previous VTE) = must give LMWH and refer to thrombosis in pregnancy team
agent of choice for antenatal thromboprophylaxis?
LMWH
- safe in pregnancy
- once daily dosing
- enoxaparin
- dalteparin
- tinzaparin
symptoms and signs of DVT?
swelling oedema leg pain/discomfort tenderness increased leg temp lower abdo pain elevated WCC
objective testing for DVT?
compression duplex US scan
if normal but clinical suspicion is high then repeat test after 1 week to exclude extending calf vein thrombosis
if iliac vein thrombosis is suspected (whole leg swollen + back pain) then consider MRI venography
symptoms and signs of PE?
dyspnoea chest pain faintness collapse haemoptysis raised JVP focal signs in the chest symptoms and signs associated with DVT
how is PE diagnosed?
CTPA = gold standard
V/Q scan also used
why is warfarin not used in pregnancy, what is used instead?
crosses the placenta and is teratogenic causes face and limb abnormalities (warfrin embryopathy) - midface hypoplasia - stippled chondral calcification - short proximal limbs - short phalanges - scoliosis
use LMWH instead (convert by 6 weeks)
what anticoagulation is used in post-natal period?
heparin and warfarin are both safe in breastfeeding
commence warfarin on 5th day post-natal
continue until at least 6 weeks post natal and until 3 months post partum
pregnancy related complications of connective tissue disease (CTD)?
miscarriage PET abruption Fetal growth restriction stillbirth preterm birth labour/delivery post-natal
treatment related complications of CTD?
teratogenic fetotoxic sepsis diabetes osteoporosis
disease related complications of CTD?
lupus flare = renal and haematological problems
APS = thrombosis
rheumatoid flare
scleroderma = renal issues, pulmonary hypertension
what CTD drugs are safe in pregnancy?
steroids azathioprine sulfasalazine hydroxychloroquine aspirin etanercept/infliximab/adalimumab) rituximab
what CTD drugs are not safe in pregnancy?
NSAIDs (>32 weeks) cyclophosphamide methotrexate chlorambucil gold penicillamine MMF leflunamide
what is APS?
antiphospholipid syndrome acquired thrombophillia with variable presentation and severity antiphospholipid antibodies (anticardiolipin and lupus anticoagulant) react with the phospholipid component of the cell membrane
clinical features of APS?
arterial/venous thrombosis
recurrent early pregnancy loss
late pregnancy loss (usually preceeded by late FGR)
placental abruption
severe early onset pre-eclampsia
severe early onset fetal growth restriction
how is APS diagnosed?
clinical
- vascular thrombosis
- pregnancy morbidity (3+ miscarriages at < weeks or 1+ fetal losses >10 weeks when fetus is morphologically normal or 1+ preterm birth due to pre-eclampsia or utero placental insufficiency)
lab diagnosis
- IgM/IgG aCL (anti cardiolipin)
- LA (lupus anticoagulant)
- both must be present on 2 occasions >6 weeks apart
what pregnancy problems can APS cause?
early pregnancy loss
IUD in 2nd or 3rd trimester
preterm birth
fetal growth restriction
how is APS managed?
no thrombosis or pregnancy problem
= LDA, surveillance
previous thrombosis
= stop warfarin, start LDA + LMWH (treatment dose)
recurrent early pregnancy loss
= LDA + LMWH (prophylaxis dose)
late fetal loss/severe pre-eclampsia/FGR
= LDA + LMWH (prophylaxis dose)
how does epilepsy change in pregnancy?
seizure frequency is improved or unchanged in most
>50% have no seizures during pregnancy
up to 92% will remain seizure free in pregnancy if there were no seizures in 9 months leading up to pregnancy
does epilepsy cause adverse pregnancy outcomes?
potentially
has been associated with spontaneous miscarriage, haemorrhage, hypertension/PET, early labour, C section and fetal growth restriction
risks to fetus of a maternal seizure?
maternal abdominal trauma PPROM (pre term premature rupture of membranes) preterm birth hypoxia/acidosis major/minor congenital malformations adverse perinatal outcomes long term developmental defects haemorrhagic disease of newborn risk of childhood epilepsy
all women taking anti epileptic medication should be offered a detailed US scan assessment of fetal anatomy at which week?
19-20 weeks
most common major congenital malformations associated with anti epileptics?
neural tube defects
congenital heart disorders
urinary tract and skeletal abnormalities
cleft palate
valproate should not be prescribed to female children, female adolescents, women of child bearing potential or pregnant women, when might this not be true?
if valproate is the onyl drug which effectively controls their epilepsy
in this case treatment decisions should be had about risks
how can risk in epilepsy be reduced?
5mg folic acid 3 months before conception and until end of first trimester
use lowest effective dose of anti epileptic medication
minimise exposure to valproate or polytherapy by changing medication prior to conception ( as recommended by epilepsy specialist after evaluation of risks and benefits)
labour and birth in epileptic mothers?
most have normal labour and vaginal birth
only 2.6% have a seizure
- if general tonic clonic seizure occurs, can cause maternal hypoxia, fetal hypoxia and acidosis
stress, pain, sleep deprivation, over-breathing and dehydration can increase risk of seizure
how is an intra-partum seizure managed?
benzodiazepines are drug of choice left lateral tilt IV lorazepam/diazepam PR diazepam/buccal midazolam IV phenytoin may need C/section give magnesium sulphate if theres no history of epilepsy
how measures can help protect the baby after birth when mother is epileptic?
avoid excessive maternal fatigue safe area for baby if mother feels unwell safe feeding position lowest setting for high chairs dress baby on floor carry baby in padded sling/carrycot handle-release pram brake additional support for bathing
risks of obesity at each stage of reproductive life?
pre-pregnancy = mesntrual disorders, subfertility
early pregnancy = miscarriage
antenatal = fetal anomalies, PET, GD, VTE
labour/delivery = IOL, dysfunctional labour, C section needed
post-natal = haemorrhage, infection, VTE, breast feeding issues
fetal/neonatal = macrosomnia, birth injury, perinatal mortality
post menopausal = endometrial hyperplasia, prolapse, incontinence of urine
main maternal risks in obesity?
miscarriage GDM hypertension PET VTE CS PPH wound infection
examples of congenital anomalies which obesity pre-disposes to?
neural tube defects
CV defects
cleft palate/lip
potential perinatal outcomes in obesity?
congenital anomaly macrosomnia shoulder dystocia SCBU admission still birth neonatal death
non-medical problems of obesity in pregnancy?
regional anaesthesia (e.g epidural) doesnt work as well
general pregnancy management guidance?
check maternal BMI and inter-pregnancy weight change PET prophylaxis (aspirin) thromboprophylaxis detailed US OGTT obstetric US to assess growth anaesthetic review at 34 weeks MDT plan for labour and birth
