Obs Flashcards
Pregnant lady severe sudden tearing chest pain
Clammy, cold, hypertensive
Murmur - Diastolic murmur
Investigations to do
What may be seen on ECG
Management
Aortic dissection. Aortic regurgitation murmur.
Associated with Mafan’s, congenital heart disease and HTN
Do an ECG and MRI, troponin
ECG may show:
RCA involvement - II, III, avF ST elevation
- aka inferior MI caused
Management
<28/40: Aortic repair, keep fetus in utero
>32/40: C-section then aortic repair in same op
In between - depends on fetal condition
Most common cardiac abnormality in preganncy
Mitral stenosis
Mid diastolic murmur (in left lateral position)
Less common in UK as associated with RF
AF is a risk (40%)
Physiological changes in pregnancy –> rapid deterioration
Rx: Balloon valvuloplasty
Aortic stenosis in pregnancy
Can’t meet CO need so should be corrected prior to surgery with beta blockers
Epidural contraindicated?
Thromboprophylaxis for replaced aortic valves
Contraindicated medicines whilst breastfeeding
Aspirin Amiodarone Methotrexate Cytotoxic drugs Sulfonyureas
Psych drugs:
- Lithium
- Benzodiazepines
- Clozapine
Antibiotics:
- Ciprofloxacin
- Chloramphenicol
- Sulphonamides
- Tetracycline
Contraindicated medications in pregnancy
Cardiac
Diabetes
UTI
AEDs
Cardiac
- ACEi
- Warfarin
- Statin
Diabetes: Only metformin and insulin ok
UTI: 7 days- Use nitrofurantoin (not at term - cephalexin/amoxicillin)
- Trimethoprim
AEDs: lamotrigine best, carbemazapine ok
- Sodium valproate (neural tube defects)
Pregnancy effect on FBC
Neutrophilia
Dilution anaemia
- RBC up by 18% - need more iron and folate
- Blood volume up by 30ml/kg
Hypercoaguable state
- Increase VIII, IX, X
- increased fibrinogen
- Decreased antithrombin and protein S
- Decreased fibrolytic activity
Anaemia in pregnancy cut offs
Management
When is Hb checked in pregnancy
1st trimester <110
2nd/3rd trimester <105
Postpartum <100
Trial of oral iron +/- folic acid
Investigate further only if no rise in Hb after 2 weeks
Can be due to folate, B12 or iron deficiency
Hb is checked at booking and 28 weeks
SCD risks in pregnancy
Management
Mother
- Increased risk of crisis
- Pre-eclampsia
- Thrombosis
- Infection
Fetus
- Miscarriage
- IUGR
- Preterm labour
- Death
Management - Regular exchange transfusions - Infection screen - Hydration maintenance - HIGH DOSE FOLIC ACID (5mg) \+ ASPIRIN from 12/40 --> birth (75mg/OD)
I think labour timing/method matters due to risk of crisis
VTE risk factors pregnancy
When to consider and what to do about them
Low risk factors Age >35 BMI >30 Parity 3 or more Smoker Pre-eclampsia currently Multiple pregnancy IVF Immobility FH of VTE Low risk thrombophilia
4 or more –> Immediate LMWH until 6 weeks after birth
If 3 –> LMWH from 28 weeks until 6 weeks after birth
If personal hx of VTE –> Need antenatal LMWH and specialist care
Intermediate risk = consider LMWH
Hospital admission
High risk thrombophilia
Medical conditions: Cancer, SCD, IBD, IVDU
Suspected DVT approach
LMWH immediately
Compression duplex US
- If dx: continue anticoagulation for remainder
of the pregnancy and for at least 6 weeks postnatally and until at least 3 months of treatment has been given in total
For all pts also do ECG and CXR + FBC, U&Es, LFTs
Suspected PE approach
VQ vs CTPA
LMWH as soon as suspected
For all pts also do ECG and CXR + FBC, U&Es, LFTs
- Also compression duplex US if suspect DVT
If DVT confirmed - donzo and continue LMWH for remainder of the pregnancy and for at least 6 weeks postnatally and until at least 3 months of treatment has
been given in total
If CXR is abnormal –> CTPA. if not choice:
V/Q or CTPA
- CTPA: Maternal breast ca risk (13.6% from 5%)
- V/Q: Childhood ca risk (1/50,000 from 1 in 1,000,000)
Once diagnosed: Continue LMWH for remainder of the pregnancy and for at least 6 weeks postnatally and until at least 3 months of treatment has been given in total
Antiphospholipid syndrome diagnosis for pregnancy
Risks
Management
Clinical
1) Vascular thrombisis >/= 1
2) Pregnancy morbidity:
- – 1 or more fetal death (from 10 weeks)
- – 1 or more premature birth before 34/40 due to pre-eclampsia
- – 3 or more consecutive losses before 10/40
Lab Any of on 2 occasions at least 12 weeks apart: Lupus anticoagulant Anticardiolipin antibodies Anti- B2 glycoprotein-I antibody
Risks
- IUGR
- Placental thrombosis
- Early pre-eclampsia
- Recurrent miscarriage
Management (only if syndrome)
HIGH RISK pregnancy –> serial US and elective induction of labour by term latest
- Aspirin + LMWH through pregnancy
Physiological respiratory changes in pregnancy
Higher O2 demand (20% greater)
Tachypnoea (Increases o2 and lowers CO2)
- Mild resp alkalosis normal
40-50% increase in minute ventilation
- TV increases by as much
- Increased resp reserve
- Unaltered RR and VC (and FEV1, PEFR, lunch compliance)
- Reduced residual volume, expiratory resererve, total lung volume and chest compliance
Anatomical
- Enlarged turbinate
- Bronchiole relaxation
- Decreased airway resistance
- Elevation of diaphragm in late pregnancy
Asthma in pregnancy
Management
1/3 better, 1/3 worse, 1/3 same
(Pregnancy = steroidogenic but immune system weaker)
Give flu vaccine
Treat asthma as normal
If severe: MDT approach
In acute exacerbation - Hx, PEFR, infective symptoms, medication compliance - Ix: PEFR, ABG, CXR, Bloods - ABC. All together give: - O xygen - S albutamol neb - H hydrocortisone (or preg PO) - Ipratropium (neb) Rest give with senior input if needed - T heophylinne: Aminophylline infusion - M agnesium sulohate (IV) - E scalate care
+ antibiotics
GI physiological changes in pregnancy
Reduction in GI motility
- Effect of progesterone - SM relaxation
- Delayed gastric emptying
- Relaxation of gastro-oesophageal sphincter
+ pressure on IAP from 10kg extra body weight and gravida uterus
More:
- N&V
- Heartburn
- Constipation
- Gingivitis
- Mendelson’s syndrome (aspirational pneumonia)
Liver physiological changes in pregnancy
Increased liver metabolism
- ALP 3 x norm (but placenta mainly)
- Reduced ALT and AST
- Reduced albumin (haeomodilation?)
Fibrinogen increase
Bilirubin normal ish
Gall bladder contractility reduced
–> Causing obstetric cholestasis, exacerbation of gall stones
Pregnant lady
Abdo pain, N&V, jaundice in 3rd trimester
Diagnosis
Management
Acute fatty liver
= Acute hepatorenal failure, DIC and hypoglycaemia
high fetal and maternal mortality :(
ALT typically >500
Features: Abdo pain, N&V, jaundice, headach, hypoglycaemia
- If severe - pre-eclampsia
1 in 9,000. 3rd trimester of postnatala
Management
- Correct clotting defects and hypoglycaemia
- Prompt delivery when stable = definitive
- Supportive: Dextrose, blood products, fluid balance, occassionally dialysis
Recurrence rate low
Obstetric cholestasis/intrahepatic cholestasis of pregnancy
0.7%. Asian. familial.
Reoccurs in 50%
= Pruritis in the absence of skin rash, with abnormal LFTs (and or raised bilirubin)
As inability to clear bile = toxic to baby and pruritus
Risks
- Sudden still birth (1%)
- Preterm delivery
- Haemorrhage tendence of mother and fetus
Investigations
- Clotting, LFTs, Bilirubin
Management
- Symptom relief - emoolient, antihistamine, cool baths, loose clothes
- Ursodeoxycholic acic (reduces itching)
- Vit K 10mg/day from 36/40
- Fetaul surveillance weekly CTG and USS
- Consultant led care - IOL ~ 37 weeks
- Post-partum - 6 weeks LFTs at GP. Don’t take OCP
Phsiological changes to urinary system in pregnancy
Dilation of urinary collecting ducts
- Up to 2cm hydronephrosis normal (worse on right)
Increased blood flow by 60-80%!!!
- GFR increased to 170ml/min
- -> Glycosuria, Proteinuria, Drug excretion, uric acid
- Increased renal secretion of Vit D, renin and EPO
- Salt and water retention –> oedema
Urine retention in labour
Post natal
- Diuresis for 7 days
- UTI risk 2x4 fold higher
UTI in pregnancy
Symptomatic bacteriuria should be treated with an antibiotic for 7 days - Use nitrofurantoin (not at term - cephalexin/amoxicillin)
A urine culture should be sent.
For asymptomatic pregnant women:
- Urine culture routine at the first antenatal visit
- If positive, a second urine culture should be sent to confirm the presence of bacteriuria
- SIGN recommend to treat asymptomatic bacteriuria detected during pregnancy with an antibiotic
- a 7 day course of antibiotics should be given
For all
TOC Urine culture should be sent following completion of treatment as a test of cure
Endocrine changes in pregnancy - glucose
Glucose mobilisation
- Increased anti-insulin hormones from placenta - cortisol, glucagons, human placental lactogen)
–> Insulin resistant state with relative glucose intolerance
= Reduced fasting blood glucose + Increased post meal glucose
Insulin production doubled in compensation
Endocrine changes in pregnancy - Thyroid
HCG weakly stimulating to thyroid
- T3/T4 increase (peaking in 2nd trimester)
- Reduced TSH due to -ve feedback
- Hepatic TBG increases
PTH should be same but hypocalcaemia and VIt d deficiency in pregnancy because
- Active transfer to fetus
- Increased GFR and loss of Ca
- Reduced serum albumin
Endocrine changes in pregnancy - Pituitary hormones
Adrenal gland activity
Anterior pituitary size increase by 35%
Hormonal changes
- Prolactin increase (10 fold)
- LH and FSH suppressed
- ADH and GH unchanged
- ACTH from pituitary unchanged BUT PLACENTA SECRETES ACTH AND CRH - increases MSH and melanin
Increased adrenal gland activity
- Increased cortisol (3 fold), AngII, Renin and Aldosterone
Hypothyroidism in pregnancy
Risks
Management
Risks if uncontrolled
Usually is Hashimoto’s or thyroid surgery
Risks
- Subfertility
- Miscarriage
- Preterm delivery
- Intellectual impairment in child
- Pre-eclampsia (especially if anti-thyroid antibodies)
Management
- Optimise levels pre-conception
- Check TFTs immediately when pregnant and maintain
- 6 weekly reviews of TSH
- Consider endo review as may NEED MORE thyroxine in pregancy as TSH lowered
Risks if uncontrolled:
- Mother: Anaemia, Pre-eclampsia, placental abruption
- Fetal: Premature, LBW, Cretinism
If hashimoto’s risk of other autoimmune diseases e.g DM, SLE
Hyperthyroid in pregnancy
Pre conception
CI to pregnancy
Antenatal care - meds + their risks
Mostly Graves - ANTI-TSH can cross placenta and may babies hyperythyoid
Treatment: Block and replase
Preconception
- Radioiodine in last 6 months is a contraindication to pregnancy
- Ideally well controlled TFTs
- Stop Carbimazole (congenital defects in 1st trimester)
- Propylthiouracil best in 1st trimester
Antenatal care
- Switch meds lol
(Propylthiouracil hepatotoxic)
BOTH MEDS CROSS PLACENTA AND CAN CAUSE FETAIL GOITRE AND HYPOTHYROID - lowest dose possible
Postpartum thyroiditis
Stages and management
Stages
1) Thyrotoxicosis ~ 3 months post-partum. Transient and subclinical - don’t use antithyroids. Propanolol if needed for symptoms
2) Hypothyroid (for 20% lifelong). Treated with thyroxine
3) Normal function (but high recurrence rate in future pregnancies)
TPO found in 90% of patients
Risk of AEDs in pregnancy
Management of epilepsy
Antenata
Intrapartum
Intrapartum care for Epilepsy
Managing seizures in labour
Can you induce labour?
Continuous CTG needed
Postnatal
Postpartum epilepsy care
What is risk of seizures in this period
Breastfeeding on AEDS
Risk of congenital defects = 1-2% with epilepsy
Taking AEDs = 3-4%
AEDs also risk of SGA
Lamotrigine best (lowest dose) NO SODIUM VALP
5mg folate
10mg OD Vit D from 36/40
20/10 anomaly scan - look at heart + NTDs
>28/40: Serial growth scans if taking AEDs
INTRAPARTUM CARE
Delivery and timing not affected
Must be LW
Continue AEDs throughout
Terminate seizures immediately with benzos
Pain relief v important - all options, diamorph > pethidine
No CI to IOL
CTG not needed, but consider if high risk of seizure
POSTPARTUM CARE Continue AEDs but review in 10 days Higher risk of seizures post partum than in pregnancy but still low - avoid sleep deprivation, stress, pain - Don't bathe baby alone - Have support
Breastfeeding on AEDs = A OK
AED side effects in preganncy
Sodium valproate - NTD
Phenytoin - Cleft palate
Obesity in pregnancy pre-conception advise.
Antenatal care
Risks of obesity in pregnancy
Pre-conception: BMI >30 should lose weight
Obese = BMI >30
HIGH DOSE FOLIC ACID
Antenatal care: Booking: - BMI >40 - specialist care - Dietician - BMI >30: Screen for HTN
Aspirin 150mg from 12/40 if BMI >35 + one of
- 1st pregnancy
- Age >40
- FH of PET
- Multiple pregancy
Antenatal screening less accurate
BMI >35 Serial US as SFH not accurate
RIsks of obesity in pregnancy Mother: - HTN complications - VTE - GDM - Thrombosis - Mental health
Baby
- Miscarriage (1 in 4 chance) - national av = 20%
- Stillbirth (1 in 100) - national av = 1 in 200
- Foetal macrosomia
- NTD (double risk but still small)
Pre-existing HTN
vs
Pregnancy induced HTN
Pre-existing HTN
BP >/=140/90 pre pregnancy or <20 weeks
- or already on anti HTN
Pregnancy induced HTN
BP >/=140/90 after 20 weeks
- Either gestational HTN or pre-eclampsia
Physiological changes in BP during pregnancy
Falls in 2nd trimester (2ndary tofall in SVR)
Normalises by term
Protein excretion increased in pregnancy but in absence of renal disease is <0.3g/24h
Pre-existing HTN in pregnancy causes
Risk of developing pre-eclampsia
Investigations if HTN picked up <20/40
Management
What may predict pre-eclampsia
Primary = Essential HTN Secondary = Chronic renal disorder, CV disease, Endocrine (primary aldosteronism, phaeo)
Risk of developing pre-eclampsia
- 25%
Investigations if HTN picked up <20/40
- THINK WHY - hx for Conn’s, Cushing’s, phaeo
- Urinalysis (haem, proteinuria in renal disease)
- Check renal function, calcium , urinary catecholamines if appropriate
Management
- Review anti HTN med - change ACEi to labetolol/nifedipine
- Warn about PET signs
- Growth scans and uterine artery dopplers
- Low dose aspirin
- Check BP and urine regularly
Prediction of pre-eclampsia development
- Bilateral notching and increased pulsatility index at 24/40
Pregnancy induced HTN management
Risk of pre-eclampsia
Risk of pre-eclampsia
- 15%
BUT risk actually relative to gestation. 40% if <30/40, 7% if >38/40
Usually resolves within 6 weeks of delivery but may pesist
- Recurs often in subsequent pregnancies
Pre-eclampsia diagnosis
Hypertension AND Proteinuria
HTN >/=140/90 (2 readings 4 hrs apart)
Proteinuria (>0.3g/34h or PCR >30) - send MSU. Don’t repeat PCR
Pre -eclampsia risk factors and aspirin indication
5mg Aspirin from 12 weeks if
1 of:
- Pre-existing HTN
- HTN in prev pregnancy
- CKD
- Autoimmune - SLE, Antiphospholipid
- T1/T2 DM
- SCD
- PAPP-A <0.3
More than one of:
- 1st pregnancy (2-3fold)
- > 40yo
- Pregnancy interval >10y
- BMI >35 at 1st visit
- FH or PET
- Multiple pregnancy
