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YR5 Haematology > Obstetric Haematology > Flashcards

Obstetric Haematology Flashcards

1
Q

What is the normal full blood count in pregnancy?

A

Mild anaemia: Red cell mass rises (120 -130%), plasma volume rises (150%)- net dilution

Macrocytosis: Phsyiological (+/- folate or B12 deficiency)

Neutrophilia

Thrombocytopenia: Increased turnover + platelet size

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2
Q

What is the blood iron requirement of pregnancy?

A

Fetus: 300mg

Maternal increased red cell mass: 500mg

RDA 30mg

Increase in daily iron absorption: from 1-2mg to 6mg

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3
Q

What is the folate requirement of pregnancy?

A

Increases for growth + cell division

~ additional 200mcg/day

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4
Q

What may iron deficiency in pregnancy cause?

A

IUGR

Prematurity

Postpartum haemorrhage

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5
Q

What is the importance of folic acid in pregnancy? What is the normal supplementation of folic acid in pregnancy?

A

Reduces risk of neural tube defects

Supplement before conception + for ≥ 12w gestation

Dose 400μg/day

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6
Q

What is the definition of anaemia in each trimester and postpartum?

A

1: Hb < 110 g/l

2 + 3: Hb <105 g/l

Postpartum: <100g/l

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7
Q

What is defined as major haemorrhage during labour?

A

Blood loss 1L

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8
Q

What happens to platelets during pregnancy? What must be considered?

A

Platelet count falls due to increased turnover

Automated counter may not recognise giant platelets

Be aware of clumping- use film

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9
Q

What are 5 causes of thrombocytopaenia in pregnancy?

A

Physiological: ‘Gestational’/ incidental thrombocytopenia

Pre-eclampsia

Immune thrombocytopenia (ITP)

Microangiopathic syndromes

Normal causes: BM failure, leukaemia, hypersplenism, DIC

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10
Q

What is the likely cause of thrombocytopenia at each of the following platelet counts:

<150

<100

<70

A

<150: majority gestational, little preeclampsia, few ITP

<100: ½ gestational, ¼ ITP, ¼ preeclampsia

<70: ¼ gestational, majority ITP + Pre-eclampsia

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11
Q

What is gestational thrombocytopaenia?

A

Physiological decrease in platelet count ~ 10%

>50x10^9/l sufficient for delivery (>70 for epidural)

MOA: Dilution + increased consumption

Baby not affected

Platelet count rises 2–5d post delivery

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12
Q

What is the association between pre-eclampsia and thrombocytopenia?

A

50% with pre-eclampsia get thrombocytopenia

Proportionate to severity

MOA: Increased activation + consumption

A/w coagulation activation: incipient DIC

Usually remits following delivery

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13
Q

Why is a greater platelet count required for epidural?

A

Small risk of spinal haematoma when sticking needles around spine

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14
Q

What is the epidemiology of ITP?

A

Accounts for. 5% of thrombocytopenia in pregnancy

TP may precede pregnancy

Early onset

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15
Q

What are treatment options for bleeding or delivery in ITP?

A

IV immunoglobulin

Steroids etc.

Vontouse delivery/ certain forceps avoided

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16
Q

How are babies affected with maternal ITP?

A

Unpredictable effects (causes platelets <20 in 5%)

Check cord blood + then daily

May fall for 5d after delivery

Bleeding in 25% of severely affected (IVIG if low)

Usually normal delivery

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17
Q

What occurs in MAHA in pregnancy?

A

Deposition of platelets in small blood vessels- thrombocytopenia

Fragmentation + destruction of RBCs

Stress on BM to produce more RBCs- nucleated RBC on film

Can lead to organ damage

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18
Q

In which MAHA syndromes does delivery not alter the course?

A

TTP

HUS

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19
Q

Coagulation changes in pregnancy…

A. Increase the likelihood of bleeding

B. Result in hyperfibrinolytic state

C. Are mediated by BHCG hormone

D. Result in a leading cause of maternal mortality

A

D. Result in a leading cause of maternal mortality

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20
Q

Venous Thromboembolism during pregnancy…

A. Has a higher incidence period during the postnatal period

B. Is more common in women with high body mass index

C. Is more likely to occur following vaginal delivery than elective C section

D. Usually affects the right leg

A

B. Is more common in women with high body mass index

85% of clots in pregnant women in left leg

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21
Q

What is the direct leading cause of maternal death in the UK?

A

PE

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22
Q

Which coagulation factors increase in pregnancy creating a hypercoaguable state?

A

Factor VIII + vWF x 3-5

Fibrinogen x 2

Factor VII x 0.5

Factor X

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23
Q

Which coagulation factors change in pregnancy creating a hypofibrinolytic state?

A

Protein S falls to ½

PAI-1 increases 5-fold

PA-2 produced by placenta

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24
Q

What do the coagulation changes in pregnancy result in?

A

Hypercoaguable hypofibrinolytic state

Rapid control of bleeding from placental site (700ml/min) at time of delivery

25
Q

Why can D-dimers not be used in pregnancy?

A

D dimers rise in pregnancy due to inflammation

Pregnancy: hypercoaguable + HYPOfibrinolytic

D dimers in non-pregnant are used as markers of fibrinolysis

26
Q

Summarise the net effect of coagulation changes in pregnancy

A

Procoagulant state:

Increased thrombin generation

Increased fibrin cleavage

Reduced fibrinolysis

Increased rate of thrombosis

27
Q

Which tests are used to identify VTE in pregnancy?

A

VQ perfusion or Doppler

(NOT D-Dimer)

28
Q

What are factors which increase risk of VTE in all pregnant women? (Virchows triad)

A

Blood changes: hypercoagulable

Developing gravid uterus presses down, reduced venous return- venous stasis

Changes in vessel wall related to hormones

29
Q

Why does 85% od DVT occur in the left leg in pregnancy compared to 55% in the left leg in the non pregnant state?

A

Anatomy: compression of left common iliac vein by right common iliac artery is accentuated by enlarging uterus

More pressure on left side

30
Q

When is risk of VTE highest in pregnancy?

A

Postpartum

Up till 6w after birth

31
Q

What has a ‘dose dependent’ effect on risk of PE death in pregnancy?

A

BMI

32
Q

What 11 variable factors which increase risk of VTE in pregnant women?

A

Hyperemesis/ dehydration

Bed rest

Obesity: BMI>29 3x risk of PE

Pre-eclampsia

Operative delivery

Previous thrombosis/ thrombophilia

Age

Parity (>4)

Multiple pregnancy

Other medical problems: HbSS, nephrotic syndrome

IVF: ovarian hyperstimulation

33
Q

Which women are identified to seek advice before becoming pregnant to reduce risk of VTE?

A

Overweight

FH VTE

PMH VTE

34
Q

Give 4 symptoms of VTE in early pregnancy

A

Chest pain

SOB

Tachycardia

Leg pain

35
Q

What preventative measures are recommended for women with risk factors for VTE during pregnancy?

A

Prophylactic LMWH: either throughout or in peri-post-partum

TED stockings

Early mobilisation

Maintain hydration

36
Q

What is the treatment for VTE in pregnancy?

A

LMWH as for non-pregnant; does not cross placenta.

RCOG recommend OD/ BD

Do not convert to warfarin (crosses placenta)

After 1st trimester monitor anti-Xa: 4 hour post 0.5-1.0u/ml

37
Q

How long before an epidural should LMWH be stopped?

A

Wait 24h after tx dose

12h after prophylactic dose

38
Q

Give 7 signs of chondrodysplasia punctata

A

Abnormal cartilage + bone formation

Early fusion of epiphyses

Nasal hypoplasia

Short stature

Asplenia

Deafness

Seizures

39
Q

Why should warfarin not be given?

A

Warfarin is teratogenic in the 1st trimester

Can cause Chondrodysplasia Punctata

40
Q

What is antiphospholipid syndrome?

A

Recurrent miscarriage + persistent Lupus anticoagulant (LA) +/- antiphospholipid antibodies

41
Q

What are the three potential presentations of antiphospholipid syndrome?

A

Adverse pregnancy outcome: >,3 consecutive miscarriages before 10w gestation.

>,1 morphologically normal fetal losses after 10w gestation.

>,1 preterm births before 34w gestation owing to placental disease.

42
Q

What is the potential treatment of antiphospholipid syndrome?

A

Aspirin + heparin

(Better than aspirin alone)

43
Q

What are the 4 Ts of postpartum haemorrhage?

A

Tone: Uterine atony

Trauma: Laceration/ Uterine rupture

Tissue: Retained placenta/ site of placenta

Thrombin: Coagulopathy

44
Q

What amount of blood loss defines post party haemorrhage?

A

>500ml

45
Q

All haematological factors are minor variables for post-partum haemorrhage except:

A

Dilutional coagulopathy after resuscitation

DIC caused by infection, placental abruption, amniotic fluid embolism etc.

46
Q

What is the relationship between Disseminated Intravascular Coagulation (DIC) and pregnancy?

A

Coagulation changes in pregnancy predispose to DIC.

47
Q

What is decomposition for DIC in pregnancy precipitated by?

A

Amniotic fluid embolism

Abruptio placentae

Retained dead fetus

Preeclampsia (severe)

Sepsis

48
Q

List 3 signs/ symptoms of amniotic fluid embolism

A

Sudden onset shivers

Vomiting

Shock

49
Q

Give 4 facts about amniotic fluid embolism

A

86% mortality

Presumed due to Tissue Factor in amniotic fluid entering maternal bloodstream

Majority >25y

Usually 3rd trimester: drugs used to induce labour e.g. Misoprolol increase risk

50
Q

The aims of haemoglobinopathy screening are to avoid birth of children with…

A

Alpha thalassaemia: death in uteru, hydros fetalis

Beta thalassaemia: Transfusion dependent

HbSS (sickle cell disease): Life expectancy 43y

Compound HbS syndromes: symptomatic, stroke

Compound thalassaemias: transfusion dependent, iron overload

51
Q

What elements are used for haemoglobinopathy detection?

A

Universal screening in areas with high background prevalence

Family origin questionnaire in less prevalent areas

FBC: Red cell indicies

HPLC

Molecular analysis

Aim to complete by 12/40w

52
Q

What should be considered in haemaglobinopathy counselling?

A

Important disorders are all recessive

Therefore if mother is heterozygous, partner should be tested

53
Q

Describe the following parameters in iron deficiency:

Hb

MCH

MCHC

RDW

RBC

A

Hb: Normal/ Low

MCH: Low (in proportion to Hb)

MCHC: Low

RDW: Increased

RBC: Low/ normal

Hb electrophoresis: Normal

54
Q

Describe the following parameters in thealassaemia trait:

Hb

MCH

MCHC

RDW

RBC

Hb electrophoresis

A

Hb: Normal (rarely low)

MCH: Lower for same Hb

MCHC: Relatively preserved

RDW: Normal

RBC: Increased

Hb electrophoresis: HbA2 in b thal trait, Normal in alpha thal trait

55
Q

What key difference in parameters distinguish thalassaemia trait from iron deficiency?

A

RBC cannot be increased in iron deficiency but is

ALWAYS increased in Thal trait

56
Q

Which of the following statements is correct?

A. In gestational thrombocytopenia the baby’s platelet count is usually affected

B. Thrombocytopenia is rarely found in association with pre-eclampsia

C. Thrombotic Thrombocytopenic purpura remits spontaneously following delivery

D. The platelet count may fall following delivery in baby’s born to mothers with ITP

A

D. The platelet count may fall following delivery in baby’s born to mothers with ITP

57
Q

A reduction in pregnancy-associated thrombosis mortality rate can be attributed to:

A. Lower obesity rates

B. Improved targeted thromboprophylaxis

C. Rising maternal age

D. Increase in prevalence of gestational thrombocytopenia

A

B. Improved targeted thromboprophylaxis

58
Q

Which of the following statements is correct?

A. ~1L blood loss can be considered normal following vaginal delivery

B. Uterine atony is a common cause of post partum haemorrhage

C. Post partum haemorrhage is often caused by the changes in coagulation factors in pregnancy

A

B. Uterine atony is a common cause of post partum haemorrhage

YR5 Haematology (20 decks)

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