Medical Problems In Pregnancy (CVD, Asthma, VTE, Obstetric Cholestasis, Connective Tissue, Epilepsy, Obesity) Flashcards by Claire O'Regan

Most common causes of maternal death in pregnancy? (Top 3)

Cardiac disease,
Thrombosis/thromboembolism,
Neurological

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List 7 types of heart disease that may present/need monitoring during pregnancy

Pulmonary hypertension, 
Congenital heart disease,
 Acquired heart disease,
Cardiomyopathy, (incl. peri-partum cardiomyopathy) 
Artificial heart valves, 
Ischaemic heart disease, 
Arrhythmias

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Prevalence of heart disease in pregnancy is rising. Pregnancy with a heart disease is associated with x _ risk oof MI?

x3-4 times risk

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Most women with heart disease in pregnancy have no previous history so should all receive ECG if present with chest pain. T/F?

True

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Orthopnoea is associated with what heart disease in pregnancy?

Peri-partum cardiomyopathy

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If pregnant woman presents with palpitations, what are 6 possible causes and which are normal in pregnancy?

Physiological - normal
Ectopic beat, normal 
Sinus tachycardia - normal, 
SVT, 
Hyperthyroidism, 
Phaeochromocytoma

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How do palpitations caused by physiological palps present?

Palpitations occur at rest/lying down

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How do palpitations caused by ectopic beats tend to occur?

Thumping,

Relieved by exercise

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How does palpitations caused by phaeochromocytoma present?

With headache, sweating and hypertension

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What investigation should be carried out in pregnant women with palpitations caused by ectopic beats?

ECG

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What investigations should be carried out in pregnant women with palpitations caused by sinus tachycardia? (4)

ECG,
FBC,
TFT,
Echo

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What investigations should be carried out in pregnant women with palpitations caused by SVT? (4)

ECG,
24hr ECG, (cos paroxysmal)
TFT,
Echo

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What investigations should be carried out in pregnant women with palpitations caused by hyperthyroidism? (2)

ECG,

TFT incl FT4

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What investigations should be carried out in pregnant women with palpitations caused by phaeochromocytoma? (2)

24hr catecholamines,

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Lung function during pregnancy - which increase and which decrease? O2 consumption, metabolic rate, tidal volume, functional residual capacity, PaO2, PaCO2, arterial pH

O2 consumption - up,
metabolic rate - up, 
tidal volume - up,
functional residual capacity - down, 
PaO2 - up,
PaCO2 - down,
arterial pH - up

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Breathlessness in pregnancy is very common/very rare and tends to improve/worsen with exertion?

Very common - up to 75% of women, improves with exertion

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What is most common chronic medical disorder to complicate pregnancy?

Asthma

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Asthma affects pregnant women in 1/3s. Explain this?

1/3 worsen,
1/3 stay the same,
1/3 improve

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5 step management for asthma is same for pregnant women and non-pregnant. What are the 5 steps?

1: inhaled SABA,
2: inhaled steroid & SABA,
3: add LABA, if good continue, if ok but not good enough continue LABA and increase steroid, if no response stop LABA and increase steroid,
4: trial inhaled high dose steroid/add 4th drug e.g. leukotriene receptor antagonist, SR theophylline or oral B2 agonist,
5: oral steroids on top of inhaled

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Why is acute asthma unlikely during labour?

Due to endogenous steroids

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Asthma management stays the same during pregnancy as effects of medication less on pregnancy than asthma attack has. T/F?

True

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In pregnancy there are two main severe clinical pathologies in terms of thrombosis. What are they?

Dural vein sinus thrombosis - brain failure,

Pulmonary artery thromboembolism - heart & lung failure

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Presentation for dural venous sinus thrombosis and diagnosis?

Headache,
Neurological symptoms e.g. dizziness/stroke symptoms, seizure,
Diagnosis on magentic resonance venogram

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Why women in pregnancy more prone to VTE?

Virchow’s triad - hyper-coagulability, venous stasis, vascular damage

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Signs and symptoms of DVT (8)

``` Oedema & swelling, Leg pain/discomfort, Groin pain, Lower abdo pain, Tenderness, Increased leg temp, Elevated white cell count, Fever ```

List 3 types of thrombophilia that makes pregnant patients risk higher for VTE?

Antithrombin deficiency, APS, Protein c deficiency

How many times more likely is VTE to occur in pregnancy than in non-pregnancy?

X4-6 times more likely in pregnancy

85-90% of DVTs occuring during pregnancy arise in the right leg. True/false?

False!! LEFT LEG

>70% of DVTs in pregnancy are ileo-femoral so beware of groin pain. T/F?

True

What period of pregnancy is highest risk of VTE?

Puerperium

Investigation for VTE in pregnant women?

Compression duplex USS of whole leg, Re-scan in 1 week and treat during that week if clinically suspicious, May need MRI venogram

Prophylaxis for VTE for high/intermediate risk patients?

LWMH

For women with low risk factors (e.g. obesity BMI >30kg, age >35, parity >3, smoker, current pre-eclamspia, multiple pregnancy), women with 4 or more should receive LMWH from when and women with 3 risk factors should receive LMWH from when?

4 or more - from first trimester, | 3 - from 28 weeks

LMWH cross placenta. T/F?

False! Does not cross placenta

Symptoms and signs of PTE? (8)

``` Dyspnoea, Chest pain, Faintness, Collapse, Haemoptysis, Raised JVP, Focal signs in chest, Symptoms associated with DVT ```

Investigations for PE? (4)

CXR, ECG, V/Q first in pregnancy as low dose radiation, CTPA less used as slightly increased risk to breast tissue

Warfarin crosses placenta is teratogenic. T/F?

True - try to change by 6 weeks if mother already on

Treatment for PE should not be delayed for women at high risk of PE, even for investigations. What treatment should be considered? (2)

Thrombolysis or, | Surgical embolectomy

Post-natal anticoagulation types and for how long?

LMWH or warfarin, warfarin commenced on 5th post-natal day. Anticoagulation should be continued until at least 6 weeks post-natal

Think of VTE if patient presents with which symptoms? (3)

Groin pain! Fever! Headache!

Obstetric cholestasis presentation? (Commonly and very rare presentations)

Commonly: Severe pruritus (w/o rash) particularly palms and soles in second half of pregnancy, Rarely: dark urine, anorexia and steatorrhoea

What are biochemistry findings in obstetric cholestasis?

LFTs deranged, | Raised ALT, bilirubin and bile acids

Obstetric cholestasis is a diagnosis of exclusion. What investigations are done to rule out other causes? (3)

Liver USS, Viral serology to rule out hepatitis, CMV, EBV, Liver auto antibodies

Risk recurrence of obstetric cholestasis is 50%. However it usually disappears how long after pregnancy?

2 weeks

Obstetric cholestasis causes increased risk of what? (4)

Fetal distress, Amniotic fluid meconium aspiration, IUD, Need for preterm delivery

What treatments for obstetric cholestasis?

Ursodeoxycholic acid, Piriton, Aqueous cream with menthol

What are two managements for babies with mothers with obstetric cholestasis?

CTG in labour, | IM Vit K after birth

What are 3 drugs commonly used for CTD that are contraindicated in pregnancy?

NSAIDs contraindicated >32 weeks, Cyclophosphamide, Methotrexate

What is APS?

Syndrome caused by acquired thombophilia where antiphospholipid antibodies react with phospholipid component of cell membrane

Clinical features of APS? (6)

``` Arterial/venous thrombosis, Recurrent early pregnancy loss, Late pregnancy loss usually preceded by FGR, Placental abruption, Severe early onset-preeclamspia, Severe early onset FGR ```

What are clinical parameters for diagnosing APS?

Vascular thrombosis, Pregnancy morbidity e.g. >3 miscarriages <10 weeks, >1 fetal loss >10 weeks with normal feotus, >1 preterm birth due to PET or utero-placental insufficiency

What lab tests are used to diagnose APS? (2)

IgM/IgG anticardiolipin antibody, Lupus anticoagulant Tested twice >6 weeks apart

APS management if no thrombosis/adverse pregnancy outcome? | APS management if previous thrombosis/adverse fetal outcome?

If no previous: LDA + close surveillance, | If previous: LDA + LMWH

For most women with epilepsy, seizure frequency can be both improved or unchanged. >50% of pregnant women with epilepsy will have no seizures during pregnancy. T/F?

Good seizure control in epileptic patients in first trimester is associated with what?

Associated with less seizures in late pregnancy

Risks to fetus from maternal seizure? (4)

Maternal abdo trauma, PPROM, Preterm birth, Hypoxia/acidosis

Risks to fetus from mother with epilepsy? (5)

``` Major/minor congenital malformations, Adverse perinatal outcomes, Long-term developmental effects, Haemorrhagic disease of the newborn, Risk of childhood epilepsy ```

anti-epileptic drugs increase risk of teratogenecity by how much?

X2-3 times - so scan offered at 18-20wks | E.g. cleft lip, spina bifida, heart defect

Sodium valproate is ok to give pregnant women. T/F?

False!! Only give it absolutely have to

Drug management for women with epilepsy during pregnancy? (4)

5mg folic acid, Lowest effective dose of AEDs, Avoid sodium valproate, Avoid polytherapy

What aspects of labour may increase risk of intra-partum seizures? (5)

``` Stress, Pain, Sleep deprivation, Over-breathing, Dehydration ```

Treatment for intra-partum seizures? (4)

Left lateral tilt, IV lorazepam/diazepam OR PR diazempam/buccal midazolam, IV phenytoin, May need to expedite delivery

Obesity increases risk of what pre-pregnancy? (2)

Menstrual disorders, | Subfertility

Obesity increases risk of what in early pregnancy? (1)

Miscarriage

Obesity increases risk of what in antenatal period? (4)

Fetal anomalies, PET, GDM, VTE

Obesity causes and increased risk of what during labour? (3)

IOL, Dysfunctional labour, Operative delivery

Obesity increases risk of what during post-natal period? (4)

Haemorrhage, Infection, VTE, Breastfeeding difficulty

Obesity causes increased risk of what to fetus? (4)

Macrosomia, Birth injury, Perinatal mortality, Congenital anomaly

Obesity causes increased risk of what during post menopausal period? (3)

Endometrial hyperplasia/cancer, Prolapse, Urinary incontinence

Obesity in pregnancy management considerations? (6)

``` Anaesthetic review, PET prophylaxis - aspirin, Thrombophylaxis, Detailed US, OGTT, MDT plan for labour & birth ```