OBS - Regular Conditions During Pregnancy

Question 1

Anaemia in Pregnancy

Pathophysiology
Clinical Features
Investigations
Management

Answer 1

1.) Pathophysiology - disproportionate ↑ in plasma volume –> reduction in Hb concentration
- needs optimisation so there are enough reserves in case of significant blood loss during delivery
- common causes: physiological (normal MCV),
iron deficiency (↓MCV), B12/folate deficiency (↑MCV)
- other causes: haemoglobinopathy (thalassaemia or sickle cell) which are screened for at booking

2. ) Clinical Features
   - potential sx: SOB, fatigue, dizziness, pallor and more rarely: koilonychia, angular cheilitis
   - often asymptomatic but can be picked up during routine screening at the booking clinic and at 28wks

3.) Investigations
- FBC: normal Hb conc during pregnancy are:
T1 >110, T2/3 >105, post-partum >100g/L
- other: serum ferritin, B12, folate
- haemoglobin electrophoresis in haemoglobinopathy

4.) Management
- iron: ferrous sulphate/fumarate 200/210mg TDS, continued for 3 months after correction to allow iron stores to be replenished
- iron infusions if non-compliant with tablets or malabsorption
- B12 deficiency: test for pernicious anaemia (IF Abs), advice from haematology regarding treatment:
IM hydroxocobalamin or PO cyanocobalamin
- folate deficiency: start on folic acid 5mg daily
- haemoglobinopathy: should be managed jointly with a specialist haematologist, may require transfusions

Question 2

UTI in Pregnancy

Asymptomatic Bacteriuria
Clinical Features
Management

Answer 2

1. ) Asymptomatic Bacteriuria - not usually tested for but pregnant women are the exception due to ↑risk of:
   - preterm delivery, SGW, pre-eclampsia
   - test at booking and routinely throughout pregnancy via urine dip and microscopy, culture, sensitivities
2. ) Clinical Features
   - lower UTI: dysuria, polyuria, urgency, haematuria, incontinence, suprapubic pain or discomfort
   - pyelonephritis: fever, loin/suprapubic/back pain, vomiting, loss of appetite, haematuria, renal angle tenderness on examination
3. ) Management - 7 days of antibiotics
   - nitrofurantoin: avoid in T3 (neonatal haemolysis)
   - amoxicillin (only after sensitivities are known)
   - cefalexin
   - trimethoprim is contraindicated in T1 but is generally avoided unless necessary, it is safe with breastfeeding so is first-line in the post-natal period

Question 3

Venous Thromboembolism in Pregnancy

Risk Factors
Indications for VTE Prophylaxis
VTE Prophylaxis
Diagnosis and Management

Answer 3

1. ) Risk Factors - some specific to pregnancy
   - pre-existing: >35, BMI >30, smoking, FH of VTE, varicose veins, paraplegia, thrombophilia (CLOT sy…)
   - obstetric: parity ≥ 3, multiple pregnancy, C-section, pre-eclampsia, PPH, pre-term/stillbirth, long labour
   - transient: hospital admission, surgical procedure, dehydration, systemic infection, long-distance travel, ovarian hyperstimulation syndrome
2. ) Indications for VTE Prophylaxis - all should have VTE risk assessment at booking and again after birth
   - at 28wks if 3 risk factors, first trimester if 4+
   - C-section: require a 10-day course of LMWH
   - previous VTE: LMWH throughout antenatal period
   - antithrombin deficiency or antiphospholipid syndrome: high dose LMWH (50-75% of treatment)
   - additional scenarios: hospital admission, surgical procedures, ovarian hyperstimulation syndrome
   - other medical conditions e.g. cancer or arthritis
3. ) VTE Prophylaxis
   - LMWH e.g. enoxaparin (Clexane), continued through the antenatal period and 6 weeks postnatally
   - temporarily stopped during labour then re-started immediately unless PPH, spinal anaesthesia, epidural
   - mechanical prophylaxis (LMWH contraindicated)
   - TED stockings, intermittent pneumatic compression
4. ) Diagnosis and Management
   - DVT: compression duplex US (can repeat on 1 wk)
   - PE: CXR+ECG, CTPA or VQ scan for definitive, CTPA is preferred if the CXR is abnormal
   - treatment is a therapeutic dose of LMWH for the duration of the pregnancy and 6weeks post-natally
   - treatment can be monitored by measuring anti-Xa activity in patients in extremes of body weight (<50kg or >90kg) or other factors such as renal impairment or recurrent VTEs
   - wells score is not validated in pregnancy

Question 4

Obstetric Cholestasis

What is it?
Clinical Features
Differential Diagnosis
Investigations 
Management

Answer 4

1. ) What is it? - reduced outflow of bile acids from the liver causing a build of bile acids in the blood
   - potentially due to ↑oestrogen and progesterone so it resolves after the delivery of the baby
   - more common in South Asian ethnicity
2. ) Clinical Features - often presents in 3rd trimester
   - pruritus (↑bile acids) w/o a rash, particularly affecting the palms of the hands and soles of the feet
   - other sx: fatigue, dark urine, pale stools, jaundice
3. ) Differential Diagnosis - pruritus with:
   - rash present: the polymorphic eruption of pregnancy, pemphigoid gestationis
   - deranged LFTs: gallstones, acute fatty liver, hepatitis
4. ) Investigations - LFTs, bile acids, clotting
   - ↑ALT (↑ALP >↑ALT), AST, GGT, ↑bile acids
   - ↑ALP is normal in pregnancy (placental production)
   - clotting: ↑PT because bile acids are required for the absorption of fat-soluble vitamins (e.g. vit K)
5. ) Management
   - ursodeoxycholic acid: improves sx and LFTs
   - symptomatic: emollients, antihistamines (sleep)
   - clotting: water-soluble vitamin K
   - weekly monitoring of LFTs and after 10d post-partum
   - early IOL after 37w if LFTs are severely deranged as this increases the risk of stillbirth

Question 5

Acute Fatty Liver of Pregnancy

Pathophysiology
Clinical Features
Investigations
Management

Answer 5

1. ) Pathophysiology - rapid accumulation of fatty acids within hepatocytes causing acute hepatitis due to impaired processing of fatty acids in the placenta
   - due to LCHAD (enzyme) deficiency in the fetus, causes build-up of FAs entering maternal circulation
   - accumulation of fatty acids in the mother’s liver leads to inflammation and liver failure
   - LCHAD deficiency is autosomal recessive
2. ) Clinical Features - occurs in the third trimester
   - vague symptoms associated with hepatitis:
   - general malaise, fatigue, N+V, jaundice, abdo pain, anorexia (lack of appetite), ascites
3. ) Investigations - bloods
   - LFTs: elevated ALT and AST (↑ALT >↑ALP)
   - other: ↑bilirubin, ↑WCC, ↓plts, deranged clotting
4. ) Management - obstetric emergency
   - high risk of liver failure, mortality for mother+fetus
   - requires admission and delivery of the baby
   - most patients will recover after delivery
   - treatment of acute liver failure if it occurs, including consideration of liver transplant

Question 6

Cardiac Arrest In Pregnancy

Reversible Causes of Cardiac Arrest
Aortocaval Compression
Delivery

Answer 6

1. ) Reversible Causes of Cardiac Arrest
   - 4Ts: thrombosis (PE or MI), tension pneumothorax, toxins, tamponade (cardiac)
   - 4Hs: hypoxia, hypovolemia, hypothermia, hyper-kalaemia, hypoglycaemia, other metabolic disturbance
   - others: eclampsia, intracranial haemorrhage
   - major causes in pregnancy: obstetric haemorrhage causing hypovolemia, PE, septic shock/acidosis
2. ) Aortocaval Compression - uterus compresses on the IVC (and aorta) –> ↓venous return –> hypotension/↓CO
   - occurs after >20wks, when the woman is lying supine
   - IVC is slightly to the right side of the body so the solution is to have her in the left lateral position, lying on her left side to relieve the compression
3. ) Delivery
   - immediate delivery improves the survival of the mother due to ↑venous return to the heart, it also helps with ventilation and chest compressions
   - immediate C-section is performed when:
   - no response after 4mins to CPR performed correctly
   - CPR continues for > 4mins in a woman >20 weeks
   - the aim is to deliver the baby and placenta within 5 mins of CPR commencing, the operation is performed at the site of the arrest e.g. in A&E resus or on the ward

Question 7

Rashes in Pregnancy

Polymorphic Eruption of Pregnancy
Atopic Eruption of Pregnancy
Melasma 
Pyogenic Granuloma
Pemphigoid Gestationis

Answer 7

1. ) Polymorphic Eruption of Pregnancy
   - pruritic and urticarial papules, wheals and plaques
   - begins on the abdomen, associated w/ striae
   - starts in T3 but gets better towards post-partum
   - Mx: emollients, antihistamines, topical/PO steroids
2. ) Atopic Eruption of Pregnancy - flare-up of eczema during pregnancy (don’t need pre-existing eczema)
   - eczema-type: eczematous, inflamed, red and itchy skin, typically affecting the insides of the elbows, back of knees, neck, face and chest
   - prurigo-type: intensely itchy papules (spots) typically affecting the abdomen, back and limbs.
   - presents in the first and second trimesters
   - Mx: topical emollients and steroids, oral steroids or phototherapy (UVB) may be used in severe cases
3. ) Melasma - mask of pregnancy,
   - ↑pigmentation to patches of the skin on the face
   - symmetrical and flat, affects sun-exposed areas
   - due to ↑sex hormones (also seen w/COCP, HRT)
   - associated w/ sun exposure, thyroid disease, FH
   - Mx: suncare, makeup, skin lightening cream etc…
4. ) Pyogenic Granuloma - AKA lobular capillary hemangioma (benign tumour of capillaries)
   - occur on fingers, upper chest, back, neck or head
   - discrete lump with a red or dark appearance, may cause profuse bleeding and ulceration if injured
   - ↑prevalence in pregnancy, associated w/ hormonal contraceptives, can be triggered by trauma/infection
   - must exclude a nodular melanoma
   - resolve w/o treatment after delivery, other Tx is surgical removal w/ histology to confirm a diagnosis

5.) Pemphigoid Gestationis

Question 8

Pemphigoid Gestationis

Pathophysiology
Clinical Features
Management
Neonatal Complications

Answer 8

1. ) Pathophysiology - a rare autoimmune skin condition
   - autoantibodies damaging the connection between the epidermis and the dermis are produced by the mother in response to placental tissue
   - this causes the epidermis and dermis to separate, creating a space that fills with fluid –> fluid-filled blisters
2. ) Clinical Features - occurs in the 2nd or 3rd trimester
   - itchy red papular or blistering rash around the umbilicus, that then spreads to other parts of the body
   - over several weeks, large fluid-filled blisters form
   - may go through fluctuating stages during pregnancy and after birth but the blisters heal without scarring
3. ) Management
   - often resolves w/o treatment after delivery
   - topical emollients and topical steroids
   - oral steroids or immunosuppressants (severe cases)
   - antibiotics may be necessary if infection occurs
4. ) Neonatal Complications
   - fetal growth restriction, preterm delivery
   - blistering rash after delivery (antibodies pass to baby)