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FRACP written exam preparation > OBGYN > Flashcards

OBGYN Flashcards

1
Q

Adverse pregnancy outcomes associated with CKD?

A
  1. SGA
  2. NICU
  3. Premature delivery
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2
Q

What are the specific therapies for CKD in pregnancy

A
  1. BP control with labetalol, nifedipine
  2. Low dose aspirin
  3. Treat anaemia with iron +/- EPO
  4. Calcium and phosphate balance
  5. Albumin - underlying proteinuria increased in pregnancy due to increase in RBF. Start anticoagulation if albumin <20g or >3gm protein/day
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3
Q

What modality of dialysis has been proven to be effective in pregnancy?

A

Nocturnal haemodialysis. Allows longer dialysis with more gentler regime.

Toronto study showed 48% live birth rates with <20hrs of dialysis vs 86% live births with >36 hours.

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4
Q

Name 5 complications associated with pregnancy in renal transplant patients.

A
  1. Hypertension - 7x risk
  2. GDM increased (due to CNI)
  3. Infections - CMV
  4. Increased risk of PET
  5. SGA
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5
Q

5 Criterias which needs to be met for optimal pregnancy in renal transplant?

A
  1. Beyond 1 year after transplant
  2. Stable renal function
  3. Off teratogenic meds (such as ACEI, mTOR inhibitors)
  4. CMV infection risk is low
  5. Good BP control
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6
Q

When are ACEI and ARB most teratogenic?

A

Between 2nd and 3rd trimester.

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7
Q

What is the difference between liver and kidney transplant in terms of their outcome in pregnancy?

A

Liver transplant -
Less PET
Higher rejection rate

Renal transplant -
Higher PET
Less rejection risk than liver transplant

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8
Q

What are the 3 risk factors for HLA antibodies formation?

A
  1. Pregnancy
  2. Previous solid organ transplant
  3. Blood transfusions
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9
Q

What immunological changes occur in pregnancy?

A

Th1 switch to Th2 which is mainly humoral immunity response

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10
Q

What are the 3 most common clinical manifestations of lupus in pregnancy?

A
  1. Cutaneous
  2. Arthritis
  3. Haematological

Need to think about risk of lupus flare post partum!!

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11
Q

What are the 4 benefits of HCQ in lupus pregnancy?

A
  1. Safe in pregnancy and breastfeeding
  2. Anti-thrombotic effects - especially important in APLS
  3. Lipid/glucose lowering effect, prevents osteoporosis
  4. UV protection - important for skin control
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12
Q

What are the 4 bad prognostic signs in lupus pregnancy?

A
  1. Hypertension
  2. Active disease during pregnancy
  3. Proteinuria >1g
  4. Higher creatinine
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13
Q

General principles of management of lupus in pregnancy

A
  1. Aspirin to decrease risk of IUGR/PET
  2. High dose folic acid
  3. Monthly blood monitoring to monitor disease activity
  4. Regular follow up
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14
Q

Importance of checking Anti-Ro/La in lupus pregnancy?

A

Associated with:

  1. Neonatal lupus (5%) - mainly skin manifestations
  2. Complete HB in 2-4% - associated with high mortality
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15
Q

How would you differentiate between PET and lupus nephritis?

A

Both PET and lupus nephritis share common signs including HTN, oedema, however:

PET: RUQ tenderness and neurological changes predominate, occurs after 20 weeks
Lupus nephritis: active urinary sediments, arthralgia, low complements, positive anti-dsDNA, raised creatinine, and occurs throughout pregnancy.

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16
Q

What phenotypes are important in APLS?

A

Thrombosis is associated with significantly higher rates of preeclampsia and preterm delivery compared to recurrent miscarriages and adverse obstetric event

17
Q

What is your approach to the management of APLS in following setting:

  1. Positive antibodies only
  2. APLS with previous venous and arterial thrombosis
  3. APLS with previous fetal loss, PET, IUGR
  4. APLS and recurrent pregnancy loss
A
  1. Aspirin only at 100mg
  2. LMWH at therapeutic dose and aspirin
  3. Aspirin and LMWH 40mg
  4. Aspirin and LMWH in the first instance. Consider steroids if fetal loss despite this.
18
Q

When should TNF alpha inhibitors stopped in pregnancy?

A

Around 32 weeks. This is when IgG transfer across the placenta reaches a significant level.

19
Q

What changes occur in pregnancy to following:

  1. PCO2
  2. Blood pH
A

PCO2 decreases and pH increases.

This is due to hormonal changes resulting in increase in minute and alveolar ventilation.

20
Q

What is the effect of pregnancy in asthma?

A

1/3 rule - better, stable, worsen.

21
Q

What are the 3 consequences of bad asthma control in pregnancy?

A
  1. PET
  2. IUGR
  3. Premature delivery
22
Q

How are Zika virus transmitted? (2)

A
  1. Via mosquitos (Aedes aegypti)

2. Sexual transmission (many reports of male to female transmission)

23
Q

How long do you need to wait for sexual intercourse if you have a confirmed or suspected illness in male for Zika virus?

A

6 months

24
Q

20 year old primigravida, 1st trimester, presenting with severe nausea and vomiting with deranged LFTs (mainly AST/ALT 4x ULN). USS of the fetus revealed twin pregnancy. TFTs normal.

Diagnosis and management?

A

Diagnosis likely hyperemesis gravidarum.
Risk factors include twin/molar pregnancy, increased BMI, diabetes and hyperthyroidism.
Unlikely other causes of LFT derangements such as PET or AFLP given early presentation.

Supportive measures include IVF, electrolyte replacements, ginger, pyridoxine, thiamine and antiemetics.

LFT derangements usually improve as symptoms improve.

25
Q

25 year old female, primigravida, presenting with nausea and vomiting during 3rd trimester. Complaining of RUQ tenderness on exam. Hypertensive at 170/100. Bloods show thrombocytopenia of 90,000, elevated AST/ALT with signs of intravascular haemolysis on blood film.

Diagnosis and management?

A

HELLP.

Needs platelet transfusion and urgent delivery.
Mg support.

26
Q

A women presenting with acute fatty liver of pregnancy. What disorder is associated with this?

A

LCHAD. Has a 79% chance of developing AFLD or HELLP.

Test for carnitine and acylcarnitine profile.

27
Q

30 year old female, G2P1, presenting at 3rd trimester with intense itch of hands and soles of feet. Bilirubin and GGT is normal, but ALP is high.

Diagnosis and management plan?

A

Intrahepatic cholestasis.

Misnomer as no actual cholestasis but fasting bile acid level is increased.
Genetic predisposition exists with 15% MDR3 mutation.

Treatment with Ursodeoxycholic acid.
Other measures such as topical aqueous methol cream, avoid heat, moisturiser.

28
Q

What are the consequences of intrahepatic cholestasis of pregnancy on fetal outcome?

A
  1. Premature delivery
  2. Meconium stained amniotic fluid - may be because bile acid causes increased colonic motility
  3. Respiratory distress
  4. Stillbirth.
29
Q

What are the minimal platelet count required for:

  1. Intrumental delivery
  2. Epidural/spinal
A
  1. > 50,000

2. >80,000

30
Q

Which of the following medications are contraindicated in pregnancy:

Cyclophosphamide
Hydroxychloroquine
Corticosteroids
MMF
Azathioprine
Methotrexate
Rituximab
Warfarin
Valproate
A

Methotrexate, MMF, cyclophosphamide.

Warfarin <5mg generally safe, but >5mg is contraindicated

Valproate. Use levetiracetam or lamotrigine with high folic acid supplementation.

Cyclosporin, tacrolimus is deemed safe in pregnancy.
Azathioprine is safe as despite crossing placenta, fetus lacks enzymes to activate it to 6MP.

31
Q

Benefit of lowering diastolic BP to <85 in pregnant women

A

Reduced risk of severe maternal hypertension

32
Q

4 risk factors for hyperemesis gravidarum

A
  1. Type 2 DM
  2. Increased BMI
  3. Hyperthyroidism
  4. Molar pregnancy/twin pregnancy
33
Q

Lupus pregnancy outcomes

A
  1. Most commonly premature births <37/40 in 40%
  2. Unsuccessful pregnancy in ~25%
  3. IUGR in 12%

Maternal-specific complications:

  1. Lupus flare 25%
  2. HTN 16%
  3. Nephritis 16%
  4. Preeclapsia in 8%
34
Q

Diagnosis of antiphospholipid syndrome

A

Clinical criteria:

  1. Arterial/venous thrombosis or
  2. Pregnancy related complications:
    - Recurrent miscarriages x3 <10 weeks
    - Neonatal death after 10 weeks due to placental insufficiency
    - Delivery <34/40 due to placental insufficiency (IUGR, PET, abruption, HELLP)

Also laboratory evidence of APLS with ACLA, LAC, AB2GP positivity in high titres x2 over 12 weeks

35
Q

Management of APLS in pregnancy

A

If positive antibodies only, aspirin only
If positive antibodies and previous clot - Clexane and aspirin
If APL with recurrent fetal loss, PET, IUGR, then Clexane and aspirin

In APL and recurrent pregnancy loss, could try aspirin in the first instance, then if loss while on aspirin, then Clexane.

36
Q

What does raised bilirubin with significantly elevated ALT usually signify in pregnancy?

A

HELLP or acute fatty liver of pregnancy.
Both occurs in 3rd trimester or post partum
Other disorders (intrahepatic cholestasis, preeclapsia with hepatic derangement and hyperemesis gravidarum usually have milder LFT derangement and normal bilirubin.)

HELLP is more common than acute fatty liver.

37
Q

HELLP

A

Characterized by haemolysis, elevated liver enzyme and thrombocytopenia.
70% occurs antepartum, but 30% occurs in post partum period, and recurrence is common upto 40%

Symptoms include nausea, vomiting, RUQ pain.

Treatment is MgSO4 and prompt delivery

38
Q

Management of acute fatty liver

A
  1. Prompt delivery after stabilisation
  2. NAC
  3. Plasma exchange to get rid of LCFA
  4. Correct hypoglycaemia, coagulopathy
  5. May need liver transplant…
39
Q

Treatment of TTP

A
  1. Plasma exchange to remove antibody against ADAMTS-13
  2. Plasma infusion to replace ADAMTS-13
  3. Rituximab and prednisone to decrease formation of antibody

FRACP written exam preparation (18 decks)

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