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RACP 2023 > OBSTETRICS > Flashcards

OBSTETRICS Flashcards

1
Q

What happens to diabetic control during pregnancy?

A

Start: improvement in control as fetal demand for glucose
2nd trimester onwards: hormones increase insulin resistance –> hyperglycaemia –> increasing insulin requirements

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2
Q

How do you investigate/diagnose DM in pregnancy?

A

1st trimester: Hba1c
2nd trimester: OGTT

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3
Q

Why can’t you use Hba1c in the 2nd trimester onwards?

A

Increased cell turnover

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4
Q

Management of DM during pregnancy?

A

Insulin
Metformin: may be assoc with poorer outcomes?

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5
Q

Normal thyroid changes in pregnancy?

A

HCG triggers T3/T4/TGB –> increases TSH/T4/T3 –> then TSH slowly corrects

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6
Q

Causes of hyperthyroidism in pregnancy + blood tests?

A

Beta HCG mediated: normal or borderline T3/T4, low TSH
Hyperemesis gravidarum: mildly elevated to high T4/T4, normal TSH
Graves: as per normal

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7
Q

Treatment for hyperthyroidism in pregnancy?

A

PTU 1st trimester
PTU/CMZ 2nd trimester

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8
Q

Significance of thyroid antibodies in pregnancy?

A

Can be normal

IF previous Graves
§ Check TRAB early in pregnancy and again 18-22 weeks
□ PREDICTS RISK OF NEONATAL THYROTOXICOSIS
If positive: serial fetal US and TFTs

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9
Q

Why check TRAb in T3?

A

Check TRAB early in pregnancy and again 18-22 weeks
PREDICTS RISK OF NEONATAL THYROTOXICOSIS

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10
Q

Preferred anti epileptic in pregnancy?

A

Lamotrigine/levetiracetam monotherapy preferred
§ Lowest structural + neurodevelopmental teratogenic risk
Cont AE therapy at lowest possible dose

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11
Q

Maternal CHD assoc with greatest risk?

A

Eisenmenger syndrome

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12
Q

Risk factors for pre-eclampsia?

A

○ Nulliparity
○ DM
○ Hx of renal disease/ chronic HTN
○ Prev preeclampsia = HIGHEST
○ >35, <15
○ Obesity
○ Family history preeclampsia
○ APS
○ Multiple gestation
○ NOT SMOKING
Condom use for contraception

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13
Q

Link between gestation at delivery and pre eclampsia recurrence risk?

A

Earlier delivery = higher risk of recurrence of pre eclampsia

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14
Q

Pre eclampsia pathogenesis?

A

Uteroplacental ischaemia from impaired trophoblast invasion/ endometrial + myometrial poor preparation –> Placentta releases anti-angiogenic factors –> prevents vasodilation –> pre-eclampsia
* VEGF
* PIGF
* FLT1
* sFLT1

* Systemic endothelial activation --> vasospasm --> elevates resistance --> HTN
* Endothelial cell injury --> produce less NO + may secrete substances that promote coagulation + sensitivity vasopressors
* Reduced VEGF signalling  Can happen in molar pregnancy
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15
Q

Pre eclampsia prevention?

A
  • Regular exercise
    • Low dose aspirin reduces the risk of preeclampsia in women at high risk for developing the disease- start from 10-14 weeks
      Caltrate

ANTIHYPERTENSIVES DONT REDUCE RISK

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16
Q

Pre eclampsia treatment

A

Labetalol
CCB
Methyldopa
Hydralazine
Diuretics: HCT/Loop IF OVERLOADED
CAN USE MRA IF FETUS IS XX

17
Q

Testing for pre-eclampsia?

A

PREDICTIVE OF IMMINENT DELIVERY

Papp-A MoM level
§ Picks up women who will develop pre-term pre-eclampsia

VEGF + TGF antagonists
§ Anti-angiogenic: pro angiogenic ratio increases
§ sFlt-1: PIGF RATIO (<38 rules out PE, 38-85 monitoring and resets, >85 inpatient monitoring)

Oxidative stress + placental hypoxia –> inflammation
§ EOPE: dysfunctional perfusion ofplacenta
§ LOPE: increasing mismatch between normal maternal perfusion and metabolic demands of placenta/fetus

18
Q

Pre eclampsia complications?

A

○ Increased risk of stroke
○ IHD
○ PVD
○ Metabolic syndrome
○ DVT
○ T2DM
○ Chronic HTN
○ Renal failure
® Risk increases with no of pregnancies affected by pre-eclampsia
○ Hepatic failure
○ Abruptio placentae
Growth restriction and oligohydramnios –> straight to admission

19
Q

TREATMENT ECLAMPSIA?

A

Treatment of severe hypertension, if present

Prevention of recurrent seizures
§ MgSO4 –> vasodilates
§ Ongoign seizures –> more Mg

Evaluation for prompt delivery
§ Consider in pregnancy 32-34 weeks
Favourable Bishop score if earlier

20
Q

Risks of asthma during pregnancy?

A

Exacerbations, PO steroids, severe asthma increases risk of pre-term delivery

21
Q

How to differentiate causes of abdo pain during pregnancy?

A

Check notes

22
Q

UTI treatment in pregnancy?

A

Cystitis
○ Nitrofurantoin 100mg QID, 5 days
○ Cefalexin 500mg BD, 5 days
○ Trimethoprim 300mg daily for 3 days ONLY IN 2ND AND 3RD TRIMESTERS
○ Can stepdown to amoxicillin 500mg TDS for 5 days / augmentin DF

Pyelonephritis
○ Assoc with adverse materanl + fetal outcomes
○ Amp + gentamicin OR cefriaxone/ cefotaxime

Prophylaxis
I: recurrent bacteriuria, bacteriuria + risk factors (immunocompromised, diabetes, neurogenic bladder)
Cefalexin 250mg for remainder of pregnancy / nitrofurantoin 50mg for remainder of pregnancy

23
Q

Treatment for HG?

A
  • B6 (pyridoxine)
    • Doxylamine-pyridoxine
    • Ginger
    • Stop above, start another antihistamine
      ○ Dimenhydrinate
      ○ Mocelizine
      ○ Diphenhydramine
    • Add dopamine antagonist
      ○ Metaclopramide
      ○ Phenothiazines
      ○ Droperidol
    • Add a serotonin antagonist
      Ondansetron may have small association with congenital anomalies
24
Q

DVT highest risk?

A

More common postpartum < antepartum
§ Risk persists until 12 week
However lost risk 6-12 weeks

25
Biggest risk factor for DVT in pregnancy?
Personal history of thombosis - provoked or unprovoked - BIGGEST ○ Thrombophilia ○ Estrogen medication ○ Previous pregnancy
26
Imaging choice for DVT/PE in pregnancy?
Fetal radiation low with both ○ V/Q preferred § Differentiating factor is maternal radiation § Can be done with half dose of nuclear isotopes § Noninferior to CTPA in diagnosis ○ Do CTPA if another cause suspected E.g. pneumonia, pleural effusion
27
DVT/PE treatment in pregnancy?
LMWH 1mg/kg BD/ UFH Warfarin - do not use during pregnancy but can use after ○ CI in 1st trimester  Assoc with fetal chondrodysplasia punctate ○ CI in 2nd/3rd trimesters  may cause fetal optic atrophy + mental retardation ○ ONLY USE IN WOMEN WITH MECHANICAL HEART VALVES ○ NOT CI IN BREAST FEEDING WOMEN § Start 2-5 days PP when risk of bleeding has passed AFTER DELIVERY - At risk of thrombosis up to 12 weeks PP ○ Restarts 12 hours post if not significant weight loss ○ Aim total duration 4-6 months for those with transient risk factors
28
DVT/PE prophylaxis in pregnancy; indications
- High risk ○ Prior unprovoked VTE ○ Pregnancy related VTE ○ Multiple unprovoked VTE ○ Known thrombophilia ○ Caesar + addition risk factors - Monitoring ○ VTE from transient risk factor - PP prophylaxis only: prophylactic LMWH/ Vit K blockers INR 2-3 Prior VTE
29
Psychosis treatment in pregnancy:
(1) Lamotrigine (2) Quetiapine/ ripsperidone (3) Lithium - Cautious use - Can be assoc with heart defect Regular monitoring needed
30
Acceptable drugs of rheumatic diseases in pregnancy?
○ Hydroxychloroquine ○ Selfasalazine Azathioprine
31
What to do with dialysis in pregnancy?
Increasing dose of dilaysis = better outcomes ○ Reduces HTN, pre-eclampsia, polyhydramnios ○ Normalisaiton of CV physiology § BP § LVH ○ Biochemical normalisation § Ur § Ph clearance § Anemia ○ Biological effects § Endothelial function § Inflammation Placentation
32
Which Abx not to use in pregnancy?
○ DON’T USE FLUOQUINOLONES/ TETRACYCLINES
33
VZ treatment in pregnancy? Post exposure prophylaxis?
Post exposure prophylaxis - VZ IG Uncomplicated - Aciclovir 800mg x5 for 1 week Pneumonia - Medical emergency - IV aciclovir HZ Same as non-pregnant
34
Highest cardiac cause of maternal mortality in pregnancy?
Highest maternal mortality = Eisenmeiger's Syndrome - Rare but mortality 30-56% - High tisk of fetal death + premature delivery - Maternal death occurs last trimester + first months of pregnancy ○ Pulmonary hypertensive crises ○ PE Refractory HF
34
Highest cardiac cause of maternal mortality in pregnancy?
Highest maternal mortality = Eisenmeiger's Syndrome - Rare but mortality 30-56% - High tisk of fetal death + premature delivery - Maternal death occurs last trimester + first months of pregnancy ○ Pulmonary hypertensive crises ○ PE Refractory HF
35
Preferred anti epileptic in pregnancy?
Lamotrigine/levetiracetam monotherapy preferred Lowest structural + neurodevelopmental teratogenic risk

RACP 2023 (17 decks)

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