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RACP Written 2018 > Pregnancy > Flashcards

Pregnancy Flashcards

1
Q

CARDIOLOGY:

What are the highest maternal risk factors?

A
  • severe pulmonary hypertension
  • Eisenmenger
  • Cardiomyopathy with EF<40% and NYHA II
  • Severe obstructive cardiac lesions (AS, PS, MS)
  • Marfans with Ao root >40mm
  • Previous severe peripartum CM
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2
Q

CARDIOLOGY:

ASD in pregnancy?

A

ASDs are usually well tolerated but there is risk of paradoxical embolism

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3
Q

CARDIOLOGY:

VSD in pregnancy?

A

VSD is okay if it is restrictive

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4
Q

CARDIOLOGY:

Marfan, Bicuspid Ao and Coarctation in pregnancy?

A

Risk for dissection

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5
Q

CARDIOLOGY:

Peripartum cardiomyopathy features?

A

Last trimetester, or early postpartum

LVEF improves in 50% at 6 months post partum

High recurrence risk

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6
Q

CARDIOLOGY:

What are the changes to the cardiovascular physiology that occur in pregnancy?

A
  • increased plasma volume
  • increased total blood volume
  • relative anaemia
  • increased heart rate and cardiac output
  • decreased systemic vascular resistance
  • decreased mean arterial pressure
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7
Q

CARDIOLOGY:

How do you estimate CVS complications in pregnancy in women with CVS disease?

A

CARPREG index.

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8
Q

CARDIOLOGY:

Which delivery method is preferred in pregnancy with hx of CVS disease?

A

Vaginal delivery

BUT if they are on warfarin then prefer caesarian to reduce risk of foetal intracranial haemorrhage

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9
Q

CARDIOLOGY:

Risk factors for peri-partum cardiomyopathy?

A 
Multiparous
Older age >30yrs
Black
Multifoetal
Gestational hypertension
Preeclampsia
Treatment with tocolytics
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10
Q

CARDIOLOGY:

Which antihypertensive treatments BUT you avoid due to teratotoxicity?

A

ACEi, ARB and aldosterone antagonists

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11
Q

CARDIOLOGY:

In which conditions is pregnancy contraindicated?

A
  • pulmonary arterial hypertension of any cause
  • severe systemic ventricular dysfunction with EF<30, NYHA III-IV
  • Pervious peripartum cardiomyopathy with any residual impairment of LVEF
  • Marfan with Ao dilated >45mm
    or Aortic dilation >50mm in aortic disease with BICUSPID valve
  • severe mitral stenosis or severe symptomatic aortic stenosis
  • native severe coarctation
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12
Q

CARDIOLOGY:

Recommendations for mitral stenosis in pregnancy?

A
  • Intervention prior to pregnancy
  • If symptoms or pulmonary hypertension then restrict activities and give beta-1 selective blockers
  • Diuretics if congestive symptoms despite beta blockers
  • Anticoagulate if AF, atrial thrombus or previous embolism
  • Consider percutaneous mitral commissurotomy if pregnant with severe symptoms or systolic PAP>50mmHg despite medications
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13
Q

CARDIOLOGY:

Recommendations for aortic stenosis in pregnancy?

A

Undergo interventio prior to pregnancy if:

  • symptomatic
  • LVEF<50%

Asymptomatic patients need exercise testing pre-pregnancy

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14
Q

THYROID:

What is the relationship between betahCG and TSH?

A

betahCG and TSH share a common alpha-subunit

–> so beta-hCG mildly suppresses TSH

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15
Q

THROID:

Hyperemesis in the 1st trimester is associated with what abnormalities of thyroid function?

A

Hyperemesis in 1st trimester is associated with HIGH beta-HCG –> Suppresses TSH and High T3/T4

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16
Q

THROID:

What to do with thyroxine dose in pregnancy?

A

Increase the dose!!

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17
Q

THROID:

Antithyroid antibodies are associated with what in pregnancy?

A

Anti-thyroid antibodies are a risk factor for:

  • miscarriage
  • prematurity

Anti-TSH-R antibodies are associated with:
- increased risk neonatal thyrotoxicosis

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18
Q

THROID:

When does the foetus produce its own thyroid hormone?

A

20 weeks

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19
Q

THROID:
Complications of hypothyroidism in pregnancy?
What to do with hypothyroidism in pregnancy?

A

Complications of hypothyroidism in pregnancy:

  • impaired foetal cognitive and neuropsych development
  • miscarriage
  • IUGR
  • Preeclampsia

Treat to target TSH <2.5 and (controversial) if antibody positive

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20
Q

THROID:

Causes of hyperthyroidism in pregnancy?

A

Transient hCG effect
Hyperemesis
Graves is MOST COMMON

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21
Q

THROID:

Treatment of hyperthyroidism in pregnancy?

A

Aim to start if T4 is upper limit of normal

PTU in 1st trimester
CBZ/methimazole in 2nd and 3rd trimesters and postpartum

22
Q

ENDOCRINE:

Role of progesterone?

A

During the first 2 weeks stimulates the fallopian tubes to secrete the nutrients the zygote/blastocyst requires

Placenta starts production at 6 weeks and takes over at 12 weeks

Progesterone inhibits uterine contractions by

  1. Inhibiting production of prostaglandins
  2. Decreasing sensitivity to oxytocin

Stimulates development of lobules and alveoli

23
Q

ENDOCRINE:

Oestrogen in pregnancy?

A

Oestriol is major oestrogen (not oestradiol)

Stimulates the continued growth of the myometrium

Stimulates the growth of the ductal system of the breasts

24
Q

ENDOCRINE:

Role of prolactin?

A

Increase during pregnancy probably due to oestrogen rise

Initiates and maintains milk secretion of the mammary gland

Essential for the expression of the mammotropic effects of oestrogen and progesterone

Oestrogen and progesterone directly antagonises the stimulating effects of prolactin on milk synthesis

25
Q

ENDOCRINE:

Role of hCG

A

Secreted by syncitiotrophoblast,

Stimulated by GnRH produced in adjacent cytotrophoblast

Can be detected within 9 days, peak secretion at 9 weeks

Mimics LH, thus rescuing the corpus luteum from degenerating and ensuring early oestrogen and progesterone secretion

Stimulates production of relaxin

May inhibit contractions induced by oxytocin

26
Q

ENDOCRINE:

What is relaxin?

A

suppresses myometrial contractions and relaxes the pelvic ligaments and pubic symphysis

27
Q

ENDOCRINE:

What is hPL?

A

has lactogenic actions (insignificant with respect to prolactin)

  • antagonises insulin, therefore making less glucose available to the mother
  • enhances protein metabolism
28
Q

PHYSIOLOGY:

What happens to plasma volume in pregnancy

A

Increased plasma volume

29
Q

PHYSIOLOGY:

What happens to red cell mass in pregnancy?

A

Increased red cell mass (but less than plasma volume)

30
Q

PHYSIOLOGY:

What happens to plasma oncotic pressure in pregnancy?

A

Decreased plasma oncotic pressure

31
Q

PHYSIOLOGY:

What happens to peripheral vascular resistance in pregnancy?

A

Decreased peripheral vascular resistance

32
Q

PHYSIOLOGY:

What happens to cardiac output in pregnancy?

A

Increased cardiac output (with increased stroke volume and increased heart rate)

33
Q

PHYSIOLOGY:

What happens to GFR in pregnancy?

A

Increased GFR in pregnancy

34
Q

PHYSIOLOGY:

What happens to respiratory tidal volume in pregnancy?

A

Increased respiratory tidal volume

35
Q

PHYSIOLOGY:

What happens to functional residual capacity in pregnancy?

A

Decreased functional residual capacity

36
Q

HYPERTENSION:

What drug to select for antihypertensives in pregnancy?

A 
Methyldopa
Clonidine
Labetolol
Oxprenolol
Nifedipine
Prazocin
Hydralazine
37
Q

HYPERTENSION:

What BP should be aimed for when managing a woman with essential hypertension in pregnancy?

A

135/80

38
Q

HYPERTENSION:

Effect on tight versus less tight blood pressure control on baby?

A

No difference in outcomes in babies.

No difference in perinatal death or small gestational age

39
Q

HYPERTENSION:

Effect of tight versus less tight blood pressure control on mother?

A

No difference to composite outcomes
No difference to preeclampsia (but serious complications were more likely in women with pre eclampsia)

MORE LIKELY to get severe hypertension if less tight control

–> aim for BP 135/80mmHg

40
Q

PREECLAMPSIA:

Effect of aspirin on preventing pre eclampsia?

A

Aspirin DOES NOT prevent TERM >37 weeks pre-eclampsia

BUT

It DOES prevent pre-term pre-eclampsia <34 weeks

** need to commence it BEFORE 16 weeks **

41
Q

Use of hydroxychoroquine in pregnancy

  • is it safe?
  • benefits in SLE?
A

No increase in congenital abnormalities
No increase in miscarriage or stillbirths

Reduces SLE flares
Reduces incidence of complete heart block

42
Q

Use of prednisolone in pregnancy?

  • does it cause complications?
  • risk of adrenal suppression?
  • which don’t cross the placenta?
A

Complications:

  • small risk of orofacial clefts in 1st trimester exposure
  • increased risk GDM and pregnancy induced hypertension
  • increased risk PPROM
  • increased risk osteoporosis

Adrenal suppression in prolonged use >20mg for >3 weeks

Hydrocortisone and cortisol don’t cross the placenta

43
Q 
THROMBOCYTOPENIA:
Gestational thrombocytopenia
- prevalence by term?
- risk of foetal/neonatal thrombocytopenia?
- management?
A

Normal platelet count in early pregnancy

5-10% prevalence by term

Low risk of foetal / neonatal thrombocytopenia

Monitor platelet count but usually no intervention required

44
Q

THROMBOCYTPENIA:
ITP in Pregnancy
- risk of foetal/neonatal thrombocytopenia?
- treatments?

A

15% of neonatal / foetal thrombocytopenia

IVIG
Azathioprine
Anti D
Cyclosporin
Platelet transfusions if needed
45
Q

VTE in PREGNANCY:

When is risk of VTE greatest?

A

Risk of pregnancy provoked DVT is greatest postpartum

DURING pregnancy there is no change in risk based on trimester

46
Q

VTE in PREGNANCY:
Prevention of VTE:

Single prior unprovoked VTE
or prior pregnancy associated VTE
or previous recurrent prevoked

A

Antenatal prophylaxis

Postpartum for 6 weeks

47
Q

VTE in PREGNANCY:
Prevention of VTE:

Single prior VTE with combined OCP

A

Prophylaxis only if other risk factor, or previous PE and/or proximal DVT

48
Q

VTE in PREGNANCY:
Prevention of VTE:

Single provoked VTE

A

Antenatal observe

Postpartum prophylaxis for 6 weeks

49
Q

VTE in PREGNANCY:
Prevention of VTE:

Recurrent unprovoked VTE
Any previous VTE and antithrombin deficiency

A

Antenatal therapeutic anticoagulation

Postpartum 6 weeks therapeutic dose anticoagulation

50
Q

LIVER DISEASE:

Risk factors for Acute Fatty Liver of Pregnancy?

A 
Primiparity
Male foetus
Obesity
Multiple pregnancy
LCHAD deficiency
51
Q

LIVER DISEASE

Swansea Criteria: six of the following WHAT (

A

1) Vomiting
2) Abdo pain
3) Polydipsia/polyuria
4) Encephalopathy
5) Elevated bilirubin
6) Hypoglycaemia
7) Elevated uric acid
8) Leukocytosis >11
9) Ascites or bright liver on US
10) Elevated transaminases
11) Elevated ammonia
12) Renal impairment
13) Coagulopathy
14) Microvesicular steatosis on biopsy

52
Q

LIVER DISEASE

What features would make you think Acute Fatty Liver of Pregnancy rather than HELLP?

A 
Vomiting
Renal impairment
Hypoglycaemia
DIC
Male foetus

** and HELLP more likely to have thrombocytopenia **

RACP Written 2018 (167 decks)

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