Module 9 - Maternal Medicine Flashcards
Obstetric Haemorrhage accounts for what percentage of maternal deaths?
10%
What are the levels for anaemia in pregnancy in the 1st trimester, 2nd trimester and post-partum?
The BCSH define anaemia in pregnancy as:
First trimester haemoglobin (Hb) < 110 g/l
Second/third trimester Hb < 105 g/l
Postpartum Hb < 100 g/l
How do you screen for anaemia in pregnancy?
Booking and at 28 weeks (group and screen also performed)
In multiple pregnancies additional FBC at 20-24 weeks
How do you screen for anaemia in multiple pregnancy?
Booking and at 28 weeks (group and screen also performed)
In multiple pregnancies additional FBC at 20-24 weeks
How long should you keep CTG traces for?
CTG traces should be kept for 25 years in uncomplicated delivery or indefinitely if there are concerns about future developmental delay
What is the live birth rate in women with antiphospholipid syndrome (APS) without taking medication?
10%
In women with antiphospholipid syndrome (APS) taking medication the combined use of aspirin and heparin reduces miscarriage rate by how much?
The combination of aspirin and heparin treatment reduces miscarriage rate by 54%
What is the risk of miscarriage in women aged 30-34?
15%
What is the risk of miscarriage in women aged 35-39?
25%
What is the risk of miscarriage in women aged 40-44?
51%
What is the risk of miscarriage in women aged 45 and above?
93%
What is the treatment for APS causing recurrent miscarriage?
Pregnant women with antiphospholipid syndrome should be considered for treatment with low-dose aspirin plus heparin to prevent further miscarriage
What is the most important treatable cause of recurrent miscarriage?
Antiphospholipid syndrome
How is APS diagnosed?
It is diagnosed by two positive tests (taken at least 12 weeks apart) for Lupus anticoagulant, anti-cardiolipin antibodies and anti B2 Glycoprotein I antibodies
What is the management of a single second trimester miscarriage?
1) Screen for inherited thrombophilias including factor V Leiden, factor II (prothrombin) gene mutation and protein S deficiency
2) Antiphospholipid antibodies
3) Pelvic ultrasound
What percentage of women are affected by recurrent miscarriage?
2%
What percentage of women with recurrent miscarriage have antiphospholipid antibodies?
15%
What are the antibodies tested for antiphospholipid syndrome?
1) Anticardiolipin
2) Anti-Beta-2 glycoprotein I (2GPI)
3) Lupus anticoagulant
What is the management of women with recurrent 1st trimester miscarriage?
1) Antiphospholipid antibody screen
2) Karyotype on products of conception
3) Pelvic ultrasound to exclude uterine abnormality
What is the risk of further miscarriage after three consecutive miscarriages?
40%
Risk of subsequent miscarriage increases after each miscarriage and reaches 40% after 3 consecutive pregnancy losses.
Note maternal age is another independent risk factor with worsening prognosis with advancing maternal age
Does having epilepsy make your pregnancy high risk?
Women with a history of epilepsy who are not considered to have a high risk of unprovoked seizures can be managed as low-risk women in pregnancy
What are the long-term neurodevelopmental outcomes of exposure to AEDs and maternal seizure in infants born to WWE (Women With Epilepsy)?
WWE and their partners need to be informed about the possible adverse impact on long-term neurodevelopment of the newborn following in-utero exposure to sodium valproate
There is very little evidence for levetiracetam and phenytoin
Based on limited evidence, in-utero exposure to carbamazepine and lamotrigine does not appear to adversely affect neurodevelopment of the offspring
Parents should be informed that evidence on long-term outcomes is based on small numbers of children.
How can you minimise congenital abnormalities in WWE?
1) Folic acid 5mg OD prior to conception and at least until the end of the 1st trimester to reduce the risk of congenital malformations and cognitive impairment
2) Lowest effective dose of the most appropriate AED
3) Switching from sodium valproate and avoiding AED polypharmacy. Change the medication prior to conception as recommended by an epilepsy specialist after evaluating potential risks and benefits
What is the effect of pregnancy on seizures in WWE?
1) 2/3 of WWE will not have seizure deterioration in pregnancy
2) WWE who have had a seizure in the year prior to conception need to be monitored closely
What is the risk of teratogenicity in women with epilepsy who are medicated?
6-8%
Epilepsy increases risk of teratogenicity (4% not on medication, 6-8% on treatment)
What is the risk of teratogenicity in women with epilepsy who are not medicated?
4%
Epilepsy increases risk of teratogenicity (4% not on medication, 6-8% on treatment)
What happens if a WWE unexpectedly falls pregnant?
She should be able to access an epilepsy specialist ASAP
It is never recommended to stop or switch AEDs abruptly without consultation with an epilepsy specialist
All pregnant WWE should be provided with information about the UK Epilepsy and Pregnancy Register and invited to register
What is the optimum method and timing of screening for detection of fetal abnormalities?
The fetal anomaly scan at 18+0–20+6 weeks of gestation can identify major cardiac defects in addition to neural tube defects
Should AED levels be monitored during pregnancy?
Based on current evidence, routine monitoring of serum AED levels in pregnancy is not recommended although individual circumstances may be taken into account
What are the adverse effects of AEDs in pregnancy on the mother and how can they be minimised?
Healthcare professionals should be alert to signs of depression, anxiety and any neuropsychiatric symptoms in mothers exposed to AEDs.
How should WWE be monitored in pregnancy?
Antenatally WWEs should be routinely asked about: risk factors for seizures (i.e. sleep deprivation and stress), their adherence to AEDs and seizure type and frequency
If they require admission antenatally and have a reasonable risk of seizure they should be provided with close observation by carer, partner or nursing staff
How should the fetus be monitored in pregnancy for WWE on AEDs?
Serial growth scans - 28, 32, 36/40 to detect SGA babies and to manage them appropriately
What is the role of vitamin K in preventing haemorrhagic disease of the newborn and maternal haemorrhage in WWE taking AEDs?
1) All babies born to WWE taking enzyme-inducing AEDs should be offered 1 mg of intramuscular vitamin K to prevent haemorrhagic disease of the newborn
2) There is insufficient evidence to recommend routine maternal use of oral vitamin K to prevent haemorrhagic disease of the newborn in WWE taking enzyme-inducing AEDs
3) There is insufficient evidence to recommend giving vitamin K to WWE to prevent postpartum haemorrhage
What is the optimal timing and mode of delivery for WWE based on seizure control?
WWE should be reassured that most will have an uncomplicated labour and delivery
The diagnosis of epilepsy per se is not an indication for planned caesarean section or IOL
How should women with non-epileptic attack disorder be counselled in pregnancy and how should their non-epileptic seizures be managed?
When there is a firm diagnosis of non-epileptic attack disorder these women should not be inappropriately started on AEDs or have iatrogenic early delivery
How are WWE managed during labour?
The risk of seizure in labour is low
WWE in labour should have risk factors for seizure minimised, i.e. insomnia, pain and dehydration - adequate analgesia and appropriate care is needed
AED intake should be continued during labour. If this cannot be tolerated orally, a parenteral alternative should be administered
Long-acting benzodiazepines, i.e. clobazam can be considered if there is a very high risk of seizures in the peripartum period
What is the risk of a tonic-clonic seizure during the labour and the 24 hours after birth?
1-4%
How are seizures managed in labour?
1) Every obstetric unit should have written guidelines on the management of seizures in labour
2) Stopping seizures ASAP is the priority to minimise the risk of maternal and/or fetal hypoxia and fetal acidosis. Benzodiazepines are the drug of choice
3) Continuous CTG is required for women at high risk of seizure during labour and if they have just had a seizure in labour
What are the recommended methods of analgesia in labour for WWE?
Pain management should be prioritised in WWE in labour. TENS (Transcutaneous Electrical Nerve Stimulation), Entonox and Epidural are options
Avoid Pethidine if possible and use Diamorphine instead
What is the most suitable place of delivery for WWE?
1) For WWE at risk of seizure they should be on labour ward with 1-1 midwifery care with access to maternal and fetal resuscitation
2) If the woman is not taking AEDs and has been seizure-free for a significant period of time she may have a Water Birth if deemed appropriate by an epilepsy specialist
What is the risk of seizure deterioration postpartum and how can this be minimised?
Despite the risk of seizures during and immediately after delivery are low, the risk is relatively higher than during pregnancy
WWEs need to continue to take their AEDs postnatally
WWEs need to be supported by their partners, carers, HCPs to reduce triggers and thus decrease risk of seizure, i.e. prevent sleep deprivation, pain, dehydration, stress
Is there a need to modify the dose of AED after delivery for WWE?
If the dose of AED was increased during pregnancy then this needs to be reviewed within 10 days, to prevent postpartum toxicity
What are the effects of AED exposure on the newborn from breast milk?
WWE on AEDs should be encouraged to breastfeed
WWE on AEDs should be informed that from current evidence there is no increased risk of cognitive impairment of babies exposed to breast milk with AEDs
What contraception can be safely offered to women taking AEDs?
WWE should be offered effective contraception to avoid unplanned pregnancies
Copper IUD, Mirena IUS and Depot injection are all safe and reliable options for WWE taking enzyme-inducing AEDs (Carbamazepine, Phenytoin, Phenobarbitol, Topiramate)
Hormonal contraceptives, i.e. COCP, POP, Transdermal patch, vaginal ring, Implanon may be affected by enzyme-inducing AEDs
WWE taking non-enzyme-inducing AEDs, i.e. sodium valproate (epilim), gabapentin, pregabalin, levetiracetam (keppra), clobazam, clonazepam, lamotrigine can take ALL forms of contraception
A WWE taking Carbamazepine had unprotected vaginal intercourse 3 days ago. She says her LMP was roughly two weeks ago. What form of emergency contraception do you offer her?
Copper Coil
WWE taking enzyme-inducing AEDs should be informed that a copper IUD is the preferred choice for emergency contraception
Emergency contraception pills with levonorgestrel and ulipristal acetate (EllaOne) are affected by enzyme-inducing AEDs
A WWE taking Sodium Valproate had unprotected vaginal intercourse 3 days ago. She says her LMP was roughly two weeks ago. What form of emergency contraception do you offer her?
Any form of emergency contraception - Copper IUD, Levonorgestrel, Ulipristal acetate
Emergency contraception pills with levonorgestrel and ulipristal acetate (EllaOne) are affected by enzyme-inducing AEDs. Sodium valproate is a non-enzyme-inducing AED
A WWE taking Lamotrigine presents to the Community Sexual Health Clinic enquiring about contraception. She previously had a Mirena coil and found insertion painful. Which one should she be prescribed?
Implanon or Depot injection
Women taking lamotrigine monotherapy and oestrogen-containing contraceptives should be informed of the potential increase in seizures due to a fall in the levels of lamotrigine
Lamotrigine may also have an effect on POP
Lamotrigine (antiepileptic) and griseofulvin (antifungal) are not thought to be enzyme-inducing drugs; however, contraceptive efficacy may be reduced by concurrent use. The clinical significance of this effect is unknown
What is the prevalence of epilepsy in pregnancy?
0.5-1%
Epilepsy is one of the most common neurological conditions in pregnancy, with a prevalence of 0.5–1%
What is the comparative risk of death for pregnant WWE vs non-pregnant WWE?
10x increase in risk of death
When are women considered not to have epilepsy anymore?
1) If they have gone 10 years seizure-free (with the last 5 years being off AEDs)
2) If they had childhood epilepsy syndrome and have reached adulthood seizure-free or without AEDs
Which AEDs have the lowest risk of congenital malformation to the offspring?
Lamotrigine (non-enzyme-inducing)
Carbamazepine (enzyme-inducing)
What are the most common major congenital malformations associated with AEDs?
Neural tube defects (spina bifida, anencephaly)
Congenital heart defects
Urinary tract abnormalities
Skeletal abnormalities
Cleft palate
What is the risk of recurrence of major congenital malformation in WWE who have previously had one?
16.8%
What are the definitions of Thalassaemia major, Thalassaemia intermedia and Thalassaemia carriers?
Thal major - >7 blood transfusions/year
Thal intermedia - ≤7 blood transfusions/year
Thal carrier - do not require transfusions
Beta-thalassaemia is encoded for by which chromosome?
The β-globin chains are encoded by a single gene on chromosome 11
Alpha-thalassaemia is encoded for by which chromosome?
α-globin chains are encoded by two closely linked genes on chromosome 16
What is the pathophysiology of thalassaemia syndromes?
The basic defect in thalassaemia syndromes is reduced globin chain synthesis (Hb normally made up of 2 alpha and 2 beta globin chains), the resultant RBCs have reduced Hb
Pathophysiology - ineffective erythropoiesis causes damaged RBCs and erythroid precursors which undergo extravascular haemolysis once released into the peripheral circulation
In Thalassaemia how long should pregnancy be avoided for until iron overload is controlled?
12 months
How does Thalassaemia major (homozygous beta thalassaemia) occur and what manifestations arise?
Individual inherits a defective beta globin gene from each parent. This causes a severe transfusion-dependent anaemia
How does Thalassaemia minor/trait occur and what manifestations arise?
Individual inherits one faulty thalassaemia gene. It only causes a mild-moderate microcytic anaemia with no significant detrimental effect on overall health
What are the adverse complications of multiple transfusions?
Multiple transfusions can cause iron overload, causing:
Hepatic, cardiac and endocrine dysfunction
The anterior pituitary is very sensitive to iron overload and evidence of dysfunction is common
Most of these women are subfertile due to hypogonadotrophic hypogonadism and therefore require ovulation induction therapy with gonadrotrophins to achieve pregnancy
What is the primary cause of death in 50% of cases of iron overload caused by multiple transfusions?
Cardiac failure
What are the cornerstones of modern treatment in beta thalassaemia?
Blood transfusion
Iron chelation therapy
Antenatally if women with thalassaemia major receive little or no chelation what can happen to them?
They can develop cardiomyopathy and endocrinopathies, i.e.:
- Diabetes
- Hypothyroidism
- Hypoparathyroidism
Due to the increasing iron burden
What interventions can be done prenatally to reduce the risk of morbidity for patients with thalassaemia major?
Aggressive iron chelation therapy can reduce and optimise body iron burden and reduce end-organ damage. Studies show these women are less likely to suffer with cardiomyopathies and endocrinopathies
Can iron chelation therapy be given in pregnancy?
All chelation should be regarded as teratogenic in the 1st trimester
Desferrioxamine is the only chelation agent with a body of evidence for use in the 2nd and 3rd trimester
The optimisation of iron burden is therefore critical prior to pregnancy, as iron accumulates with each blood transfusion. With the absence of chelation it may expose women to a high risk of new complications
Which endocrine condition is most common in thalassaemia: diabetes, hypothyrodisim or hypoparathyrodisim?
Diabetes
Women with diabetes should be referred to a diabetes specialist. Good glycaemic control is essential prenatally
What level of glycaemic control should diabetic women with thalassaemia have prior to conception?
Serum fructosamine levels <300 nmol/l at least 3 months before conception
This is equivalent to HbA1c <43 mmol/mol - this is associated with a reduced risk of congenital abnormalities
HbA1c is not a reliable marker of glycaemic control as it is diluted by transfused blood and can cause underestimation - so serum fructosamine is preferred for monitoring
Does thyroid function need to be checked prior to conception in thalassaemia women?
Thyroid function should be determined. The woman should be euthyroid prepregnancy
What cardiac tests should be performed prior to pregnancy in thalassaemia women?
All women should be assessed by a cardiologist with expertise in thalassaemia and/or iron overload prior to embarking on a pregnancy
They need to have had an:
1) Echo
2) ECG
3) T2 Cardiac MRI
It is important to determine how well the cardiac status of the woman will support a pregnancy as well as the severity of any iron-related cardiomyopathy. Cardiac arrhythmias are more likely in older patients who have previously had severe myocardial iron overload and are now clear of cardiac iron
What levels on T2 Cardiac MRI do you aim for in prenatal women with thalassaemia?
The aim is for no cardiac iron, but this can take years to achieve so care should be individualised to the woman
T2 Cardiac MRI >20ms is considered normal. Aim for this as it reflects minimum iron in the heart
However, pregnancies with successful maternal and fetal outcomes have occurred with lower cardiac T2 values
What T2 Cardiac MRI level is associated with an increased risk of cardiac failure with women with thalassamia?
T2 < 10 ms
A reduced ejection fraction is a relative contraindication to pregnancy and the management should be the subject of multidisciplinary discussions involving a cardiologist with experience of cardiac pathology in pregnancy, a maternal medicine specialist, a haematologist and an obstetric anaesthetist
How do you assess liver iron concentration in thalassaemia and what levels do you want pre-pregnancy?
Women should be assessed for liver iron concentration using a FerriScan® or liver T2*. Ideally the liver iron should be < 7 mg/g (dry weight) (dw)
If liver iron exceeds the target range, a period of intensive preconception chelation is required to optimise liver iron burden
For women with thalassaemia, at what level of iron at Ferriscan/T2 Liver is it advised to undergo chelation and when is it advised?
If liver iron exceeds 15 mg/g (dw) prior to conception, the risk of myocardial iron loading increases, so iron chelation with low-dose desferrioxamine should be commenced between 20 and 28 weeks under guidance from the haemoglobinopathy team
Name two common conditions caused by haemolytic anaemia in thalassaemia?
Cholelithiasis
Cholecystitis
How do you investigate for osteoporosis in thalassaemia?
All women should be offered a bone density scan to document pre-existing osteoporosis
What causes osteoporosis in thalassaemia?
Osteoporosis is a common finding in adults with thalassaemia. The pathology
is complex, but thought to be due to a variety of factors:
1) Calcium chelation by iron chelation therapy
2) Thalassaemic bone disease
3) Hypogonadism
4) Vitamin D deficiency
Most women with thalassaemia syndromes are vitamin D deficient and often osteoporotic as well. All women should have vitamin D levels optimised before pregnancy and thereafter maintained in the normal range
What is the incidence of alloimmunity in individuals with thalassaemia?
Alloimmunity occurs in 16.5% of individuals with thalassaemia.
ABO and full blood group genotype and antibody titres should be measured.
Red cell antibodies may indicate a risk of haemolytic disease of the fetus and newborn. If antibodies are present there may be challenges in obtaining suitable blood for transfusion, therefore these women should be cross-matched during labour
What medications should be reviewed preconceptually in women with thalassaemia?
Iron chelators should be reviewed and deferasirox and deferiprone ideally discontinued 3 months before conception
All bisphosphonates are contraindicated in pregnancy and should ideally be discontinued 3 months prior to conception in accordance with the product safety information sheet
What is the importance of genetic screening and what procedure(s) are involved for women with thalassaemia?
IVF and ICSI with PGD (Pre-implantation Diagnosis) should be performed in couples with thalassaemias to avoid homozygous or heterozygous pregnancy.
Preconception counselling for women with thalassaemia includes partner screening and genetic counselling as well as the methods and risks of prenatal diagnosis and termination of pregnancy.
In high-risk couples PGD is an option. If the partner is unavailable, an offer of prenatal testing is appropriate. Due to the risk of a haemoglobinopathy, potential egg and sperm donors are screened for haemoglobinopathies
Which transfusion-related infections are common in thalassaemia patients?
Hep B - Hep B vaccine should be given to all HBsAg negative women who are transfused or who may be transfused
Check Hep C status. Any woman who tests positive for Hep C needs RNA titres and to be referred to a hepatologist
Give HiB (Haemophillus influenza B) and Meningococcoal C vaccine to all women who have not had as part of their childhood vaccinations
What is the management of thalassaemia patients post-splenectomy?
Daily Penicillin prophylaxis - if allergic use erythromycin
Pneumoccoccal (Pneumovax II) vaccine every 5 years
Women who have undergone splenectomy are at risk of infection from encapsulated bacteria such as Neisseria meningitidis, Streptococcus pneumoniae and Haemophilus influenzae type b
Women should be given Haemophilus influenzae type b and the conjugated meningococcal C vaccine as a single dose if they have not received it as part of primary vaccination
What vitamin supplements are recommended in women with thalassaemia prenatally?
Folic acid (5 mg) is recommended preconceptually to all women to prevent neural tube defects
Women with thalassaemia have a much higher demand for folic acid so high-dose supplementation is needed. Folic acid 5 mg daily should be commenced 3 months prior to conception
How often should women with thalassaemia be reviewed?
4 weekly until 28/40, then 2 weekly
Women with thalassaemia should be reviewed monthly until 28 weeks of gestation and fortnightly thereafter. The multidisciplinary team should provide routine as well as specialist antenatal care
How often should women with thalassaemia and diabetes be monitored and seen antenatally?
They should have monthly serum fructosamine levels review in the specialist diabetic pregnancy clinic
When should women with thalassaemia major undergo cardiac assessment antenatally?
28 weeks
All women with thalassaemia major should undergo specialist cardiac assessment at 28 weeks of gestation and thereafter as appropriate.
Cardiac assessment is important to determine cardiac function and possible further iron chelation as well as planning for labour
When should thyroid function be measured in pregnant women with thalassaemia?
Prior to conception women should be euthyroid. Thyroid function should be monitored throughout pregnancy. If hypothyroid then the dosage of thyroxine needs to be adjusted
What is the recommended schedule of ultrasound scanning during pregnancy?
1) Early scan - 7-9/40
2) Dating scan - 11-14/40
3) Detailed anomaly scan - 18-20+6/40
4) Serial growth scans - 24, 28, 32, 36 weeks
Women with both thalassaemia and diabetes are at an increased risk of early miscarriage.
Women with thalassaemia often require IVF with ovulation induction, therefore the early stage is to determine viability of the foetus and to detect potential multiple pregnancy.
Severe maternal anaemia caused by thalassaemia can affect maternal transfer of nutrients to the fetus, and thus cause IUGR
How should the transfusion regimen be managed during pregnancy in women with thalassaemia major?
All women with thalassaemia major should be receiving blood transfusions on a regular basis aiming for a pre-transfusion haemoglobin of 100 g/l. Monitor Hb every 2-3 weeks and transfuse if Hb <100 g/l.
Give 2-3 units, and additional units a week later to cause Hb of 120 g/l.
Women with thalassaemia minor aim for the same pre-transfusion Hb of 100 g/l.
Women with thalassaemia major will already be established on transfusion regimens which generally remain stable during pregnancy.
If there is worsening maternal anaemia or evidence of IUGR, regular transfusions should be considered.
Each woman’s haemoglobin falls at different rates after transfusion so close surveillance of pretransfusion haemoglobin concentrations is required.
What Hb level is safe for delivery in women with thalassaemia?
Generally, in non-transfused patients if the Hb is >80 g/l at 36/40 then you do not need to transfuse. Transfuse after delivery
If Hb <80 g/l then transfuse 2 units at 37-38/40
What antenatal thromboprophylaxis is recommended in thalassaemia?
1) If splenectomy OR Plt >600 - Aspirin 75 mg OD
2) If splenectomy AND Plt >600 - LMWH + Aspirin 75mg OD
3) If not on LMWH then give LMWH when admitted to hospital
Women with thalassaemia major or intermedia have a prothrombotic tendency due to the presence of abnormal red cell fragments, especially if they have undergone splenectomy.
These red cell fragments combined with a high platelet count significantly increase the risk of venous thromboembolism.
This risk is highest in splenectomised women with thalassaemia intermedia who are not receiving transfusions since a good transfusion regimen suppresses endogenous erythropoiesis
What level is significant for myocardial decompensation in pregnant women with thalassaemia? How might they present?
T2 Cardiac mri <10 ms
Signs/symptoms:
1) Dyspnoea
2) Paroxysmal noctural dyspnoea
3) Orthopnoea
4) Syncope
5) Palpitations
6) Peripheral oedema
Presentation in the 1st trimester is associated with adverse clinical outcome
What is the management of pregnant thalassaemia women at highest risk of cardiac decompensation? What treatment should they start?
Desferrioxamine s.c. 20mg/kg/day for a minimum of 4-5 days a week from 20-24 weeks gestation
What is the management of pregnant thalassaemia women with liver decompensation? What treatment should they start?
Start low dose desferrioxamine from 20 weeks gestation if T2 Liver >15mg/g dw.
Aim for <15mg/g dw to reduce the risk of myocardial iron overload
What is the best intrapartum management for women with thalassaemia major or intermedia?
1) Alert haematologist, anaesthetist, obstetrician as soon as patient arrives to labour ward
2) If red cell antibodies present - X-match 2 units blood. If no atypical antibodies then G+S suffices
3) If Hb <100g/l - X-match 2 units blood
4) Women with thalassaemia major give i.v. desferroxiamine 2g over 24 hours
5) Continuous CTG whilst in labour - increased risk of operative delivery due to higher risk of fetal hypoxia
6) Active management of 3rd stage of labour
What is the postpartum VTE prophylaxis for women with thalassaemia?
There is a high risk of venous thromboembolism due to the presence of abnormal red cells in the circulation.
LWMH throughout admission
NVD - 7 days LMWH
CS - 6 weeks LMWH
Can women with thalassaemia major breastfeed whilst on desferroxiamine?
Yes.
Once initial desferrioxamine infusion 2g/24 hours is given then re-commence it s.c. It is secreted in breastmilk but not absorbed orally so there are no safety concerns with the baby
In women who do not want to breastfeed whilst on desferrioxamine then continue infusion or s.c. injections until discharge or until resumption of her usual iron chelation therapy under hematology, whichever is sooner
What is the proportion of twins of all live births?
3%
Regarding Toxoplasmosis infection, what is the risk of fetal transmission if maternal infection occurs <4 weeks gestation?
<1%
Regarding Toxoplasmosis infection, what is the risk of fetal transmission if maternal infection occurs 36 weeks gestation?
> 60%
Regarding Toxoplasmosis infection, what is the risk of fetal transmission if maternal infection occurs 13 weeks gestation?
10%
What is the rate of spontaneous abortion amongst pregnant woman infected with Rubella in the first trimester?
20%
If Rubella is contracted <11/40 what percentage of babies will have congenital rubella syndrome?
90%
If Rubella is contracted 11-16/40 what percentage of babies will have congenital rubella syndrome?
20%
Rubella causes spontaneous abortion in the first trimester in what proportion of pregnant women?
20%
What proportion of pregnancies will have congenital rubella syndrome after 20 weeks gestation?
There have been no published case reports of CRS after 20 weeks’ gestation
A patient who is 23 weeks pregnant comes to see you as there has been a recent local outbreak of Rubella and a child at a recent party had a rash. How long are patients with rubella considered infectious for?
Individuals with rubella are usually infectious from 1 week before symptoms appear to 4 days after the onset of the rash
What is the incubation period for Rubella?
14 days (same as chickenpox)
Incubation period range 12-23 days (average 14 days)
What is the treatment for pregnancies affected by Rubella?
No specific treatment. Key is prevention through vaccination programme
What is the risk of PET in this pregnancy if the previous pregnancy had severe PET, HELLP or eclampsia and delivery <34/40?
25%
What is the risk of PET in this pregnancy if the previous pregnancy had eclampsia and delivery <28/40?
55%
What is the risk of PET in this pregnancy if the previous pregnancy had PET?
Up to 16%
What is the risk of congenital CMV infection with primary CMV infection during pregnancy?
Risk of congenital infection is 30-40% with primary infection during pregnancy
What is the risk of congenital CMV infection with recurrent CMV infection in pregnancy?
Risk of congenital infection is 1-2% with recurrent CMV infection in pregnancy
What percentage of neonates with congenital CMV infection will appear asymptomatic at birth?
87%
What percentage of neonates with congenital CMV infection who are asymptomatic at birth will later develop hearing loss?
15%
When should amniocentesis be delayed for in CMV infection?
Amniocentesis should not be performed for at least 6 weeks after maternal infection and not until the 21st week of gestation
What is the incubation period for CMV?
3-12 weeks
If amniocentesis confirms CMV infection then what investigation(s) are recommended?
Cerebral MRI is indicated at 28-32 weeks of gestation
Serial ultrasound examination of the fetus should also be performed every 2-3 weeks until deliver
What is the management of pregnant women who contract Genital herpes HSV in the 1st or 2nd trimester?
Aciclovir 400mg TDS for 5 days
THEN
Aciclovir 400mg TDS from 36/40 until term to reduce the need for CS
What is the management of pregnant women who contract Genital herpes HSV in the 3rd trimester?
Aciclovir 400mg TDS from 28/40 until delivery
Will need a CS if this is the first episode
What is the incidence of neonatal HSV infection?
3 in 100,000
When is the risk of neonatal HSV infection transmission the highest?
Within 6 weeks of delivery
Highest risk with primary herpes infection within 6 weeks of delivery. Viral shedding can continue after lesions have healed
What percentage of infants with neonatal herpes have disseminated and/or central nervous system (CNS) infection?
70%
What are the types of neonatal HSV infection?
1) Skin/superifical - least severe form
2) CNS involvement - 70% neurological sequelae, 6% mortality with anti-viral treatment
3) Disseminated disease - 17% neurological sequelae, 30% mortality with anti-viral treatment
70% have disseminated and/or CNS involvement
PET leads to AKI in what proportion of cases?
1.5-2%
What level of urea in pregnancy is an indication for renal replacement therapy?
urea >17
A serum urea > 17 mmol/l despite medical management is a pregnancy-specific indicator for renal replacement therapy
AKI complicates what proportion of HELLP?
3-15%
AKI complicates 3-15% of cases of HELLP
How are women with bipolar disorder taking lithium managed?
Advise switch to Quietiapine (or other anti-psychotic)
Lithium is associated with fetal cardiac malformations and Ebstein anomaly (right ventricular outflow obstruction)
If stopping stop over 4 weeks
If continuing then measure plasma lithium levels every 4 weeks and then weekly from 36/40
What levels of Anti-D, Anti-c, Anti-E and Anti-K suggest moderate risk of HDFN and should trigger FMU referral?
Anti-D >4.0 (>15 confers severe risk of HDFN)
Anti-c >7.5 (>20 confers severe risk of HDFN)
Anti-E - if Anti-C is present
Anti-K - any level, as higher risk of HDFN
How often should MCA PSV be measured in women referred to FMU due to raised titres of antibodies?
Weekly
What level of MCA PSV should trigger invasive testing?
> 1.5x median
What is the incidence of Gestational Diabetes Insipidus?
2-4 in 100,000
What is the incidence of polyhydramnios?
1-1.5%
In regards to appendicitis in pregnancy, what is the rate of fetal loss with simple appendicitis?
1.5%
Fetal loss in simple appendicitis is 1.5%
In regards to appendicitis in pregnancy, what is the rate of fetal loss with appendicitis with peritonitis?
6%
Fetal loss in appendicitis with peritonitis 6%
In regards to appendicitis in pregnancy, what is the rate of fetal loss with a perforated appendix?
Fetal loss with perforated appendix 36%
Inherited Thrombophilia is present in what proportion of women with pregnancy associated VTE?
40%
Regarding thyroid function in pregnancy. At what gestational age do placental changes prevent significant passage of maternal thyroxine across the placenta?
12 weeks
Prior to 12 weeks gestation maternal thyroxine (fT4 not fT3) crosses the placenta. From 12 weeks placental changes prevent significant passage of maternal thyroxine and fetal thyroid function becomes independently controlled from the mother.
What is the incidence of hyperthyrodism in pregnancy in the UK?
Hyperthyroidism in pregnancy occurs in 2 in 1,000 pregnancies in the UK
What is the incidence of hypothyrodism in pregnancy in the UK?
1%
A 27 year old patient who is 34 weeks pregnant is admitted with vomiting and right upper quadrant pain. A diagnosis of acute fatty liver of pregnancy is subsequently made. What is the most common complication of acute fatty liver of pregnancy?
Renal impairment
AKI is a common complication. 14% of patients in the UK develop renal impairment
3.5% require renal replacement
What is the incidence of acute fatty liver disease in pregnancy?
5 in 100,000
What is the period of infectivity for parvovirus B19?
7-10 days before to 1 day after onset of the rash
What is the risk of vertical transmission of Parvovirus B19 from mother to baby <15 weeks gestation?
15%
What is the risk of vertical transmission of Parvovirus B19 from mother to baby 15-20 weeks gestation?
25%
What is the risk of vertical transmission of Parvovirus B19 from mother to baby at term?
70%
You are counselling a patient regarding investigations following a stillbirth. You advise that you will be carrying out karyotyping. What percentage of stillborn babies will have a chromosomal abnormality?
6%
6% of stillborn babies will have a chromosomal abnormality
What is the 1st line treatment for active TB in pregnancy?
IREP
Isoniazid
Rifampicin
Ethambutol
Pyrazinamide
What is the 1st line treatment for latent TB?
IR
Isoniazid
Rifampicin
Which TB medication has the highest risk of peripheral neuropathy?
Isoniazid
Isoniazid can cause neuropathy - vitamin B6 (pyridoxine) supplementation should be offered to avoid this
What proportion of individuals in the UK aged over 15 are seropositive for VZV IgG antibody?
> 90%
What is the incubation period for chickenpox?
14 days (same as Rubella)
What is the increased risk of spontaneous abortion/miscarriage in women who contract chickenpox in the 1st trimester?
No increased risk
What is the infectious period for women who develop chickenpox?
48 hours before the onset of the rash to the lesions have crusted over (usually 5 days after the onset of the rash)
Which type of virus is chickenpox caused by?
Chickenpox and shingles are caused by the double stranded DNA virus Varicella zoster
Women who are <28 weeks gestation who are infected with chickenpox have what likelihood of fetal varicella syndrome (FVS)?
<1%
If a woman has contact with chickenpox but does not receive VZIG when is she considered infectious from?
8 days - 21 days after contact
You are reviewing a 33 year old patient who is at 34 weeks gestation. She noticed a lump in her breast in early pregnancy and investigations confirmed breast cancer for which she has started chemotherapy. She wants advice from you regarding breastfeeding and chemotherapy. How long after chemo should she wait to breastfeed?
14 days
Patients should wait at least 14 days from last chemotherapy dose before breastfeeding
What is the incidence of breast cancer in pregnancy?
1 in 3,000 pregnancies
What age group does breast cancer in pregnancy normally affect?
32-38
What proportion of breast cancer women <45 years old are pregnant?
15%
What is the risk of PIH/PET in women with untreated anti-phospholipid syndrome?
30-50%
What is the risk of PIH/PET in women with treated anti-phospholipid syndrome?
10%
(30-50% if untreated)
What are the indications for starting ART (anti-retroviral treatment) in HIV positive patients in the 1st trimester?
- Presenting with opportunisitc infection
- Viral load >100,000 copies/ml
- CD4 count <200
What is the rate of vertical transmission of HIV if viral load is <50 copies/ml at delivery and on cART?
<0.5%
What is the overall incidence of Obstetric cholestasis?
0.7%
What is the incidence of Obstetric cholestasis in South East Asian populations?
1.2-1.5%
What is the maternal mortality rate in the UK?
8 in 100,00 pregnancies
How should lithium levels be monitored during pregnancy?
Every 4 weeks until 36/40
Then weekly until delivery
Measure within 24 hours of birth - adjust dose so that levels are just within lower limit of therapeutic range
What is the incidence of gestational thrombocytopaenia?
1 in every 20 pregnancies
What is the mortality rate of severe sepsis in pregnancy?
20-40%
What is the mortality rate of septic shock in pregnancy?
60%
A pregnant woman attends the maternal medicine clinic. She suffers CF.
What is the level of FEV1 below which there will be increased mortality during pregnancy?
FEV1 <60%
A healthy caucasian woman who father is known to have Haemophilia A is married to a healthy caucasian man with unknown status. She She attends the preconception clinic asking about possibility of having an affected son.
What will be the chance of having an affected son?
1/8
A 27 year old pregnant woman has a history of insulin-dependent diabetes mellitus since the age of 14. Her partner is normal.
What is the chance for her baby to be born with congenital heart disease?
5%
A 32 year old pregnant woman attends MAU complaining of pruritis of her body and scalp. All her blood tests are normal.
What is the incidence of this condition in pregnancy?
18%
Pruritis gravidarum
A 43 year old pregnant lady is admitted with acute myocardial infarction at 35 weeks.
After how long can it be safe for timed delivery?
2-3 weeks
Insertion of emergency cervical cerclage may delay delivery by how many days on average?
34 days
Insertion of an emergency cervical cerclage may reduce the chances of pre-term birth <34/40 by how much?
2x reduction
At what gestation are history-indicated cervical cerclages inserted?
11 - 14 weeks
Which women should be offered a history-indicated cervical cerclage?
Only women who should be offered history-indicated cervical cerclage are:
- Hx of 3 or more pre-term births or 2nd trimester miscarriages
Done electively at 11 - 14 weeks
Which women should be offered a US-indicated cervical cerclage?
1) Women with a hx of 1 or more 2nd trimester miscarriage
OR
2) Women with a hx of 1 or more pre-term birth <34/40
AND
cervical length <25mm on TVS from 14-24 weeks
Which women should have serial transvaginal ultrasound surveillance for cervical length? When is this performed?
High-risk:
1) Hx of 1 or more pre-term birth or 2nd trimester miscarriage (16-34 weeks)
2) Hx of PPROM <34 weeks
3) Known uterine variant
4) Previous cervical cerclage
5) Hx of trachelectomy
Seen in pre-term birth clinic at 12 weeks. Offered serial TVS scans every 2-4 weeks from 16-24 weeks
Which women are deemed as intermediate risk for pre-term birth and what TVS ultrasound surveillance for cervical length are they offered?
1) Previous LLETZ/cone biopsy
2) Previous CS at full dilatation
They are offered at least one TVS US at 18-22 weeks as a minimum
What is the most common site for bladder injury during surgery?
0.8%
What is the risk of the baby having congenital heart disease if the mother has it?
6%
What is the risk of the baby having congenital heart disease if the father has it?
2%
What is the risk of the baby having congenital heart disease if there is a history of congenital heart disease with 1x previous baby?
2-5%
What is the risk of the baby having congenital heart disease if there is a history of congenital heart disease with 2x previous babies?
10-15%
Which specific lesion/site in congenital heart disease in pregnancy confers the highest risk for baby developing it?
Congenital aortic stenosis
1-20% risk
What is the mortality rate of pregnant women with Eisenmenger’s syndrome?
25-40%
What is the recurrence risk with obstetric cholestasis?
45 - 90%
What is the most common dermatoses of pregnancy? What is its incidence?
Atopic eruption in pregnancy
1 in 300
How should obstetric cholestasis be monitored?
Once OC has been diagnosed you should measure LFTs weekly until delivery
Measure LFTs at least 10 days after delivery
What is the increased risk of pre-eclampsia in women who experience migraines?
2x increase
What is the increased risk of acute myocardial infarction in women who experience migraines?
4x increase
What is the increased risk of stroke in women who experience migraines?
17x increase
What is the most common karyotype anomaly associated with truncus arteriosus?
DiGeorge syndrome (22q11.2 deletion syndrome)
At what gestational age does feticide need to be undertaken prior to a termination of pregnancy?
> 21+6 weeks gestation to ensure that there is not a live birth
Up to which gestation can an emergency cervical cerclage be considered?
27+6 weeks gestation
What is the definition/calculation for maternal mortality rate?
No. of maternal deaths/No. of live births x 100,000
What is the definition/calculation for perinatal mortality rate?
No. of stillbirths >28/40 + early neonatal deaths (<7 days) / No. of total births x 1,000
When is vitamin K recommended for cases of Obstetric cholestasis?
If the Prothrombin time is prolonged
Can give Vitamin K 5-10mg OD
What is the recurrence rate of acute fatty liver disease in pregnancy?
25%
What is the overall risk of pre-eclampsia if you had it previously?
1 in 6
16%
What is the risk of pre-eclampsia if you had it previously at 28-34 weeks gestation?
1 in 3
33%
What is the risk of pre-eclampsia if you had it previously 34 - 37 weeks?
1 in 4
23%
What is the difference in maternal mortality rates for black mothers compared to white mothers?
4x higher
What is the difference in maternal mortality rates for mixed race mothers compared to white mothers?
3x higher
What is the difference in maternal mortality rates for Asian mothers compared to white mothers?
2x higher
What is the difference in maternal mortality rates for women aged 40 or above compared to women in their early 20s?
4x higher
What is the difference in maternal mortality rates for women aged 35-39 years compared to women in their early 20s?
2x higher
Which condition(s) is associated with cystic hygroma?
Turners syndrome
Downs syndrome
Noonan syndrome
Fetal hydrops
A woman is 34 weeks gestation presents with blurred vision and headaches. Her BP is 165/102mmHg. She is given Labetalol 200mg stat to control it. What is a common side effect of this drug?
Neonatal hypoglycaemia
What is the accepted background cumulative dose of ionising radiation during pregnancy?
5 rad (50 mGy)
What is the natural background radiation during an entire pregnancy?
0.5 - 1.6mGy
Natural background radiation during an entire pregnancy is approximately 0.5 - 1.6 mGy
What are the most common teratogenic effects of ionising radiation to the pregnancy? When are these risks most dangerous?
CNS changes, causing microcephaly and severe mental retardation
Risk is highest during weeks 10-17
At what gestation is the risk of fetal growth restriction the highest from ionising radiation?
3-10 weeks
A dose of 250mGy radiation confers what risk of fetal malformation?
0.1%
What was the perinatal mortality rate in 2019?
4 per 1,000
Thrombocytopaenia occurs in what proportion of pregnancies?
8-10%
What is the definition of mild thrombocytopaenia?
> 100
What is the definition of moderate thrombocytopaenia?
50-100
What is the definition of severe thrombocytopaenia?
<50
Gestational thrombocytopaenia accounts for what proportion of thrombocytopaenia in pregnancy?
75%
PET accounts for what proportion of thrombocytopaenia in pregnancy?
15-20%
ITP (Imumme thrombocytopaenia of pregnancy) counts for what proportion of thrombocytopaenia in pregnancy?
3-4%
What is the incidence of gestational thrombocytopaenia in pregnancy?
8%
Platelet counts are typically 70 and usually 100
If maternal platelet counts are <80 what is the management for the baby?
Take cord sample and repeat bloods on day 1 and day 4 to check for neonatal thrombocytopaenia
What is the incidence of ITP (immune thrombocytopaenia in pregnancy) in pregnancies?
0.1-1 in 1,000 pregnancies
What is the incidence of TTP (thrombocytic thrombocytopaenic purpura) in pregnancy?
1 in 25,000 pregnancies
How many times more likely are pregnant women to die from trauma than their non-pregnant counterparts?
1.6x
What compared to age-matched controls who are non-pregnant, what is the increased risk of VTE with pregnancy?
5x higher
What is the additional risk of miscarriage when amniocentesis is performed by an adequately trained operator?
<0.5%
the addi
Worldwide what is the most common congenital infection?
Syphilis
What is the increased risk of preterm birth in women with symptomatic COVID-19 infection in pregnancy?
2-3x increase
If CVS is done <10+0 weeks what is the risk to the baby?
Oromandibular and limb defects
Which is the most prevalent HDFN causing red cell alloantibody?
Anti-E
When do the symptoms of peripartum cardiomyopathy usually present themselves?
4 months postpartum in 78% of cases
Which viral infection is the most common cause of viral-related fetal anaemia in the UK?
Parvovirus B19
What is the increased risk of stroke in pregnant vs non-pregnant women?
3x more likely
25 years old primigravida presented with severe preeclampsia, on investigation found HB 100g/l, platelets 130,000/L PT 1 sec higher than control, APTT 2 seconds higher than control, fibrinogen 1.2. which of the following of these is most predictive of severity of DIC?
PT (Prothrombin Time)
What is the most common side effect of ursodeoxycholic acid?
GI upset
What is the most significant complication for women with very advanced maternal age?
Caesarean section
What is the recurrence rate of obstetric cholestasis?
45-90%
What happens to stroke volume during pregnancy?
It increases by 25-30%
What happens to systemic vascular resistance during pregnancy?
It decreases by 20-30%
What happens to cardiac output during pregnancy?
It increases by 30-50%
What happens to blood volume during pregnancy?
It increases by 40-50%
What happens to diastolic BP during pregnancy?
It decreases from 12-26 weeks, but rises again to pre-pregnancy levels by 36 weeks
When are cardiac issues likely to occur in pregnancy?
Early in pregnancy - 1st trimester
As most of the cardiovascular changes occur in the first 12 weeks of gestation cardiac problems are likely to present in early pregnancy
What is the incidence of hypertension disorders in pregnancy?
8-10%
What level of creatinine would prompt admission for a PIH/PET lady?
> 90
What level of ALT would prompt admission for a PIH/PET lady?
> 70
What is your risk of pre-eclamsia if you previously had Pre-eclampsia complicated by severe pre-eclampsia, HELLP syndrome or eclampsia and led to birth before 34 weeks?
25%
What is your risk of pre-eclamsia if you previously had Eclampsia and led to birth before 28 weeks?
55%
(Nicole)
What is the maternal death rate in the UK?
8 per 100,000
What is the risk of breast cancer during pregnancy?
Breast cancer during pregnancy is rare. Research shows that breast cancer is reported in 1 in every 3,000 pregnancies
What is the most common autosomal recessive condition in the UK?
Sickle cell anaemia
1 in 2,000 incidence
What is the most common autosomal recessive condition in the world?
Beta Thalassaemia
What proportion of women have pruritis in pregnancy?
25%
When does ICP normally occur in pregnancy?
3rd trimester
But can be earlier in pregnancy
What is the prevalence of ICP in Indian and Pakistani women?
1.2-1.5%
What is the prevalence of ICP?
0.7%
What is the definition of Gestational pruritis?
Itching + peak bile acid concentrations <19
What is the definition of mild ICP (Intrahepatic cholestasis?)
Itching + elevated peak bile acid concentrations 19-39
What is the definition of moderate ICP (Intrahepatic cholestasis?)
Itching + elevated peak bile acid concetrations 40-99
What is the definition of severe ICP (Intrahepatic cholestasis?)
Itching and elevated peak bile acid concentrations >100
What is the upper limit of normal bile acid concentrations in pregnancy?
18
How long after an initial diagnosis of gestational pruritus can women develop intrahepatic cholestatsis of pregnancy?
Up to 15 weeks after diagnosis
When do you test for Hepatitis C after a diagnosis of intrahepatic cholestasis of pregnancy has been made?
1) Very high transaminases (ALT/AST)
2) Rapidly progressive biochemical picture
3) ?acute infection
4) Features of liver failure
5) Early onset ICP in the 1st/2nd trimester
6) Resolution of itching or raised bile acids doesn’t occur within 4 weeks of delivery
When should specialist hepatology advice be sought?
When pregnant women have severe ICP, very early onset of ICP in the first/2nd trimester or atypical presentation of ICP
When does ICP normally resolve postnatally?
In the majority of women itching will resolve very soon (within hours or days after birth)
Test LFTs and bile acids at 4 weeks to check for resolution. If persistent then re-consider the diagnosis and perform other investigations
What is the risk of stillbirth with ICP?
Women with a singleton pregnancy and ICP the risk of stillbirth increases above population once bile acids >100
When should women with ICP be delivered?
1) Mild ICP - Peak bile acids 19-39. The risk of stillbirth is the same as the general population. The risk increases >40/40. Advise IOL at 40/40
2) Moderate ICP - Peak bile acids 40-99.The risk of stillbirth is the same as the general population until 38-39/40. Advise IOL at 38-39/40
3) Severe ICP - Peak bile acids >100. The risk of stillbirth is higher than the general population. Advise IOL at 35-36/40
What factors increase the risk of stillbirth in women with ICP? (3 points)
1) GDM
2) PET
3) Multiple pregnancy
What advice should be given to women with moderate or severe ICP?
1) Baby is more likely to have meconium-stained liquor
2) Baby is more likely to receive Neonatal care/support
3) Baby is more likely to be born pre-term (spontaneous or iatrogenic)
How should women with ICP be monitored?
After an initial raised bile acids repeat in 1 week to confirm the diagnosis, then monitor according to gestation and bile acid level - can perform weekly
When should vitamin K be prescribed in ICP?
If the woman has steatorrhoea (due to malabsorption of fat) then perform a Coagulation screen. If Prothrombin time (PT) is raised then likely vitamin K deficient
Prescribe a water soluble form - 10mg OD
Which women with ICP should have continuous CTG in labour?
For certain:
1) Severe ICP - bile acids >100
Optional:
2) Concomitant PET, GDM, multiple pregnancy
3) Meconium-stained liquor
At what gestation is the highest risk for fetal growth restriction from radiation exposure?
3-10 weeks
What proportion of the population are carriers of the CF gene mutation?
1 in 25
What proportion of SGA babies are constitutionally small?
50-70%
Antiphospholipid syndrome accounts for what proportion of recurrent miscarriages?
15%
If a woman had pre-eclampsia in a previous pregnancy, what is the risk of PIH in this pregnancy?
6-12%
If a woman had pre-eclampsia in a previous pregnancy, what is the risk of pre-eclampsia in this pregnancy?
Overall 16%
If a woman had pre-eclampsia in a previous pregnancy and delivered between 28-34 weeks, what is the risk of PIH in this pregnancy?
33%
If a woman had pre-eclampsia in a previous pregnancy and delivered between 34-37 weeks, what is the risk of PIH in this pregnancy?
23%
What is the lifetime risk of rupture of hepatic adenomas?
17%
Risk of haemorrhage and rupture appears to be highest with larger lesions and in the third trimester of pregnancy
What is the lifetime risk of haemorrhage of hepatic adenomas?
27%
Risk of haemorrhage and rupture appears to be highest with larger lesions and in the third trimester of pregnancy
What is the lifetime risk of malignant transformation with hepatic adenomas?
5%
What is the prevalence of TPOAb (Thyroid peroxidase Antibody) in women of reproductive age?
5-20%
Higher in women with subfertility (10-31%) and recurrent pregnancy loss (17-33%)
How do you manage women known to have TPOAb?
1) Test TFTs 6 months pre-conception - ensure normal
2) TFTs at 7-9 weeks
3) TFTs every trimester
There is a risk of progression to Subclinical hypothyroidism and Overt hypothyrodism
If TSH is high to give levothyroxine
How do you manage women known to have TPOAb?
1) Test TFTs 6 months pre-conception - ensure normal
2) TFTs at 7-9 weeks
3) TFTs every trimester
There is a risk of progression to Subclinical hypothyroidism and Overt hypothyrodism
If TSH is high to give levothyroxine
What is the incidence of Cerebral Venous Thrombosis (CVT) in pregnancy?
1 in 5,000
When is the greatest risk of CVT in pregnancy?
3rd trimester to 4 weeks postpartum
What is the incidence of placental abruption in the UK?
1 in 200 pregnancies
At what gestation does placental abruption usually occur?
25/40
2nd trimester onwards
If you had a previous placental abruption what is your risk of having it in this pregnancy?
4.4%
If you have had 2x previous placental abruptions what is your risk of having it in this pregnancy?
19-25%
What are the risk factors for placental abruption? (14 points)
1) Previous placental abruption
2) Multiparity
3) Polyhydramnios
4) PROM
5) Chorioamnionitis
6) Non-vertex presentation
7) Low BMI
8) Smoker
9) Drug use (cocaine & amphetamines)
10) IVF pregnancy
11) Advanced maternal age
12) Abdominal trauma
13) PET
14) IUGR
If you have a live vaccine how long should you avoid pregnancy for?
1 month
In diabetic women, what level of HbA1c should they avoid pregnancy?
7% or 53 mmol/mol
What level of HbA1c can you diagnose GDM?
6.5% or 48 mmol/mol
What is the risk of recurrent Down’s Syndrome?
1%
What infection co-exists with Malaria?
Hepatitis C
Check Hep C Ab in malaria in pregnancy
In Thalassaemia how long should pregnancy be avoided for until iron overload is controlled?
12 months
You are called to see a patient in A&E who has complained of chest pain. She is currently 19 weeks pregnant and has a history of pneumothorax. She wants to know more about the risks of a chest X-ray to her unborn child. You explain that one chest X-ray is approximately equivalent to the radiation exposure one would experience from natural background radiation in how many days?
10 days
What is the increased risk of developing essential HTN in a woman who had PET in a pregnancy?
3x increase
What is the increased risk of developing essential HTN in a woman who had recurrent PET in pregnancy?
6x increase
According to the MBRRACE Report 2022 what are the leading direct causes of maternal death?
1) VTE
2) Suicide
3) Sepsis
4) Haemorrhage
According to the MBRRACE Report 2022 what are the leading indirect causes of maternal death?
1) Cardiac
2) COVID-19
3) Neurological
According to the MBRRACE Report 2022 what are the leading causes of maternal death from 6 weeks - 1 year postnatal?
1) Drug & Alcohol - 20%
2) Suicide - 18%
3) Coincidental malignancies - 18%
Psychiatric problems - 38%
What are the overall highest causes of maternal death in the UK, based on the MBRRACE Report 2022?
1) Cardiac
2) COVID
3) VTE
What is the most common cause of maternal cardiac arrest?
Anaesthetic - 25%
What is the most common cause of maternal collapse?
Haemorrhage
What is the risk of congenital heart disease if mother has SLE with anti-Ro and anti-La antibodies?
2-3%
What is the risk of congenital heart disease if mother has SLE with anti-Ro and anti-La antibodies and her previous baby had it?
16%
When should women with SLE and anti-Ro and anti-La antibodies have fetal echos?
Foetal echo at 18-20/40
AND
28/40
What is the treatment of SLE in pregnancy?
Hydroxychloroquine
Which are the safest AEDs in pregnancy?
1) Lamotrigine - safest
2) Carbamazepine
3) Levetiracetam (Keppra)
What effect does lamotrigine have on the fetus?
SGA
What effects does lamotrigine have on the fetus?
SGA
Cardiac defects
How do you manage a Hyponatraemia with a Na+ of 125-130?
Fluid restrict to 80ml/hr
Repeat U&Es in 4 hours
How do you manage a Hyponatraemia with a Na+ of <125?
Fluid restrict to 30ml/hr
Repeat U&Es in 2 hours
What size would you expect the fetal kidney to be at >20/40?
<7mm
If larger than this then give antibiotics at birth and perform a US
What size would you expect the fetal kidney to be at >28/40?
<10mm
If larger than this then give antibiotics at birth and perform a US
What dose of adrenaline do you give in CPR?
Adrenaline 1 in 10,000 i.v.
50 micrograms
0.5ml
What dose of adrenaline do you give in anaphylaxis?
Adrenaline 1 in 1,000 IM
500 micrograms
0.5ml
Which cART drug in pregnancy needs to be used with caution?
Dolutegravir
Stop <8/40 as it can cause neural tube defects
Continue >8/40 with high dose folic acid 5mg OD
What effect does NSAIDs have on the fetus?
1) Oligohydramnios
2) Premature closure of the ductus arteriosus
Give Indomethacin to close a patent ductus arteriosus
According to the MBRRACE 2022 report, what is the increased risk of stillbirth for black women?
2x higher
According to the MBRRACE 2022 report, what is the increased mortality rate for black women?
3.7x higher
According to the MBRRACE 2022 report, what is the increased mortality rate for women who live in deprived areas?
2.5x higher
According to the MBRRACE 2022 report, what is the increased mortality rate for asian women?
1.8x higher
According to the MBRRACE 2022 report, what is the increased mortality rate for mixed women?
1.3x higher
What are the features of Dengue fever?
Haemorrhagic fever - nosebleeds
Breakbone fever - bad myalgia
What is the increased risk of V/Q to the fetus?
Increased risk of childhood cancers
10x increased radiation risk to fetus
What is the risk of CTPA compared to V/Q scan for women with suspected PE?
13% increased risk of breast cancer vs V/Q
20-100x increased radiation to mother
CTPA is more sensitive and specific
What is the effect of SSRIs on the baby?
Persistent pulmonary HTN
Particularly Fluoxetine
What is the treatment of measles in pregnancy?
Measles causes a barking cough
Give HNIG (Human Immunoglobulin) to mother within 6 days of measles exposure
Can repeat it 3/52 after if a repeat exposure occurs
Give HNIG to babies born to mothers 6 days before or 6 days after the development of a measles rash
Can give up to 8 months
>8 months - give MMR vaccine
What is the treatment of COVID in pregnancy?
Hospital treatment:
1) Remdesivir - anti-viral. If at home or in hospital
2) Steroids - prednisolone 40mg OD or methylprednisolone 32mg OD or i.v. hydrocortisone 80mg BD for 10 days or until discharge
3) Clexane - 10 days
4) Tocilizumab - if hypoxic. If: SpO2 <92%, CRP >75 or requiring oxygen
COVID vaccine gives some immunity to baby
What is the most common gynaecological malignancy diagnosed during pregnancy?
Cervical cancer
What is the incidence of cervical cancer in pregnancy?
0.1-12 in 10,000 pregnancies
What is the recommended steroid course for an acute exacerbation of asthma in pregnancy?
Prednisolone 40-50mg OD for 5 days
When do you need to cover with steroids during labour?
Any woman who has had Prednisolone 5-20mg OD for ≥3 weeks (or equivalent)
They require in labour:
i.v. Hydrocortisone 50-100mg TDS for 24 hours
What are the sick day rules for pregnant women with adrenal insufficiency?
- Always wear a medical alert bracelet/necklase
- Double doses of HC + FC during fever or illness requiring bed rest
- Have I.M. HC to give in cases of gastroenteritis or fasting
1) Delivery day - i.v. or p.o. Hydrocortisone 200mg
Stop Fludrocortisone
2) D1 PN - i.v. or p.o. Hydrocortisone 100mg
3) D2 PN - i.v. or p.o. Hydrocortisone 50mg
4) Day of discharge - p.o. Hydrocortisone 30-35mg
Re-start Fludrocortisone
5) FU in endocrine clinic - Decrease Hydrocortisone down to pre-pregnancy levels
Encourage breastfeeding
