Pregnancy

Question 1

Below what body fat percentage does ovulation cease?

Answer 1

22%.

Question 2

Below what body mass is amenorrhoea a risk?

Answer 2

<47 kg.

Question 3

List 3 features of the changes of maternal physiology.

Answer 3

1) Anticipatory —> precedes foetal growth and demand
2) In excess —> in excess of foetal demand
3) Dynamic —> changes vary through the trimesters

Question 4

List 3 symptoms that occur due to changes to the renal system during pregnancy.

Answer 4

1) Generalised oedema
2) Increased thirst
3) Decreased urine output

Question 5

List 3 physiological features that occur due to changes to the renal symptoms.

Answer 5

1) Increased creatinine output
2) Glucosuria
3) Aminoaciduria

Question 6

List 2 conditions that are at risk due to changes to the renal system during pregnancy.

Answer 6

1) Hydronephrosis (esp. RHS)

2) Pyelonephritis (esp. RHS)

Question 7

How does total plasma volume change during pregnancy?

Answer 7

Increases, 1-2 L (30-50%).

Question 7

How does plasma osmolality change during pregnancy?

Answer 7

Decreases, 280 mosmol/kg (NP) —> 270 mosmol/kg (T).

Question 8

List 2 natriuretic factors during pregnancy.

Answer 8

1) Progesterone

2) Atrial natriuretic peptide

Question 9

List 4 antinatriuretic factors during pregnancy.

Answer 9

1) Aldosterone
2) Renin
3) Angiotensin
4) Deocycorticosterone

Question 10

Why is eGFR not a valid measure of kidney function during pregnancy?

Answer 10

1) Creatinine output increases

2) Plasma creatinine decreases

Question 11

How does kidney size change during pregnancy?

Answer 11

Increases, 20% by term.

Question 12

List 4 signs that occur due to changes to the cardiovascular system during pregnancy.

Answer 12

1) Decreased blood pressure (early/mid pregnancy)
2) Increased blood pressure (late pregnancy)
3) Altered heart sounds
4) Altered ECG trace

Question 13

List 2 physiological features that occur due to changes to the cardiovascular system during pregnancy.

Answer 13

1) Increased cardiac output

2) Increased pulmonary flow

Question 14

List 2 conditions that are at risk due to changes to the cardiovascular system during pregnancy.

Answer 14

1) Dilutional anaemia

2) Thromboembolism

Question 15

How does cardiac output change during pregnancy?

Answer 15

Increases, 30-50%.

Question 16

How long postpartum does the risk of thromboembolism persist?

Answer 16

6-8 months.

Question 17

Which 3 clotting factors increase during pregnancy?

Answer 17

1) VII
2) VIII
3) X

Question 18

List 7 cardiac anatomical changes that occur during pregnancy.

Answer 18

1) Diaphragm elevates 4 cm
2) Heart displaces superiorly and laterally
3) Apex displaces laterally
4) Heart is more horizontal
5) Increased left atrium size
6) Increased left ventricle size
7) Increased ventricular muscle mass

Question 19

List 4 ECG abnormalities found during pregnancy.

Answer 19

1) Lead III —> inverted T wave
2) Lead III —> prominent Q wave
3) Lead aVF —> prominent Q wave
4) 15 degree left axis deviation

Question 20

List 3 lung function test changes that occur due to changes to the respiratory system during pregnancy.

Answer 20

1) Increased tidal volume
2) Increased vital capacity
3) Decreased total lung volume

Question 21

List 4 respiratory anatomical changes that occur during pregnancy.

Answer 21

1) Diaphragm elevates 4 cm
2) Increased subcostal angle (70 degrees (NP) —> 105 degrees (T))
3) Increased thoracic circumference
4) Decreased chest compliance

Question 22

How does tidal volume change during pregnancy?

Answer 22

Increases, 450 ml (NP) —> 650 ml (T), 200ml (40%).

Question 23

Explain why pregnant women experience subjective dyspnoea.

Answer 23

Due to the increased tidal volume, pregnant women take deeper breaths, so they feel as though they are out of breath.

Question 24

How does total lung volume change during pregnancy?

Answer 24

Decreases, 4200 ml (NP) —> 4000 ml (T), 200 ml.

Question 25

List 5 lung function tests that are unchanged during pregnancy.

Answer 25

1) Respiratory rate 2) FEV1 3) FVC 4) FEV1/FVC 5) Peak flow

Question 26

How does PCO2 change during pregnancy?

Answer 26

Decreases, 4.7 kPa (NP) —> 4.0 kPa (T).

Question 27

Describe how compensated respiratory alkalosis occurs during pregnancy. (6)

Answer 27

1) Progesterone mediated increased CO2 sensitivity of respiratory centre chemoreceptors 2) Increased tidal volume 3) Increased CO2 exhaled 4) Decreased PCO2 5) Respiratory alkalosis 6) Excess HCO3- renally excreted

Question 28

Describe how respiratory alkalosis enables placental CO2 exchange during pregnancy. (5)

Answer 28

1) Foetal PCO2 —> 5.0 kPa 2) Maternal PCO2 —> 4.0 kPa 3) Foetal PCO2 > maternal PCO2 4) Foetal:maternal CO2 diffusion gradient 5) CO2 diffusion across placenta

Question 29

How does oxygen consumption change during pregnancy?

Answer 29

Increases, 250 ml/min (NP) —> 300 ml/min (P) (15-20%).

Question 30

Describe how maternal and foetal erythrocytes enable placental O2 exchange. (4,3)

Answer 30

Maternal erythrocytes 1) Increased 2,3-diphosphoglycerate (DPG) 2) Increased DPG O2 binding in M erythrocytes 3) Decreased M erythrocyte O2 affinity 4) Favours M erythrocyte O2 unloading Foetal erythrocytes 1) F haemoglobin contains 2 alpha and 2 gamma chains 2) Increased F erythrocyte O2 affinity 3) Favours F erythrocyte O2 loading

Question 31

Describe the double Bohr effect during placental O2 exchange. (7)

Answer 31

1) Placental CO2 exchange 2) Relative high M CO2 3) Acidic M blood 4) Favours M O2 unloading 5) Relative low F CO2 6) Alkaline F blood 7) Favours F O2 loading

Question 32

List 4 conditions that are at risk due to changes to the gastrointestinal and hepatic system during pregnancy.

Answer 32

1) Gastro-oesophageal reflux 2) Aspiration pneumonitis 3) Cholelithiasis 4) Obstetric Cholestasis

Question 33

List 4 symptoms that occur due to changes to the gastrointestinal and hepatic system during pregnancy.

Answer 33

1) Constipation 2) Vomiting 3) Excess salivation 4) Altered appetite (inc. pica)

Question 34

Define pica.

Answer 34

Ingestion of non-nutritive substances.

Question 35

List 6 reasons why drug metabolism alters during pregnancy.

Answer 35

1) Decreased gastric pH 2) Decreased gastric emptying 3) Increased gastric transit time 4) Altered cytochrome P450 enzyme activity 5) Increased ECF volume 6) Increased GFR

Question 36

How does gut transmit time change during pregnancy?

Answer 36

Increases, 52 hours (NP) —> 58 hours (P).

Question 37

List 3 conditions that are at risk due to changes to the metabolic system during pregnancy.

Answer 37

1) Hyperlipidaemia 2) Gestational diabetes mellitus 3) Diabetes ketoacidosis

Question 38

When does hyperlipidaemia occur during pregnancy?

Answer 38

During early pregnancy, to build fat reserves.

Question 39

What is the incidence of gestational diabetes mellitus?

Answer 39

1-2%.

Question 40

When is diabetic ketoacidosis likely to occur during pregnancy?

Answer 40

Overnight.

Question 41

List 2 anatomical changes that occur due to changes to the reproductive system during pregnancy.

Answer 41

1) Increased uterine mass | 2) Increased breast volume

Question 42

How does uterine mass change during pregnancy?

Answer 42

Increases, 46 g (PT) —> 1012 g (T).

Question 43

List 2 ways how uterine mass increases during pregnancy.

Answer 43

1) Smooth muscle hyperplasia | 2) Smooth muscle hypertrophy

Question 44

Describe how uroplacental blood flow is established. (4)

Answer 44

1) placental extravillous trophoblasts invade uterine decidual spinal arteries 2) Spinal arteries are remodelled 3) Endovascular invasion of placenta 4) Placenta acquires maternal blood supply

Question 45

List 5 conditions that are at risk due to failed endovascular invasion.

Answer 45

1) Pre-eclampsia 2) Premature birth 3) Recurrent miscarriage 4) Placental abruption 5) Foetal growth restriction

Question 46

What proportion of maternal deaths are caused by medical and mental health problems versus direct pregnancy complications? (2)

Answer 46

1) medical and mental health —> 2/3 | 2) direct pregnancy complications —> 1/3

Question 47

List 3 considerations during a preconception assessment for a woman with a pre-existing medical condition.

Answer 47

1) effect of pregnancy on medical condition 2) effect of medical condition on pregnancy 3) effect of maternal medication on pregnancy

Question 48

List 4 treatment aims during a preconception assessment for a woman with a pre-existing medical condition.

Answer 48

1) optimise disease control —> stable 2) rationalise drug therapy —> minimise effects on baby 3) advise on risks to mother and baby 4) effective contraception until ready to conceive

Question 49

List 3 healthcare professionals involved in a joint obstetric-medical clinic.

Answer 49

1) obstetrician with medical expertise 2) physician with pregnancy expertise 3) nurse/midwife specialist

Question 50

List 3 advantages of a joint obstetric-medical clinics.

Answer 50

1) improved communication 2) loss hospital visits 3) facilitates audits and research

Question 51

List 4 considerations for delivery and postpartum care during a joint obstetric-medical clinics.

Answer 51

1) safest mode of delivery 2) neonatal support 3) anaesthetic expertise 4) available HDU/ITU facilities

Question 52

List 2 pregnancy risks due to iron deficiency anaemia.

Answer 52

1) low birthweight | 2) preterm delivery

Question 53

List 2 pregnancy risks due to asthma.

Answer 53

1) foetal growth restriction | 2) premature delivery

Question 54

When is an asthmatic exacerbation during pregnancy most likely?

Answer 54

3rd trimester.

Question 55

What is the leading cause maternal death during pregnancy?

Answer 55

Cardiac disease.

Question 56

List 4 high risk cardiac lesions during pregnancy.

Answer 56

1) aortic stenosis 2) coarctation of aorta 3) prosthetic valves 4) cyanosis

Question 57

List 4 low risk cardiac lesions during pregnancy.

Answer 57

1) mitral regurgitation 2) aortic regurgitation 3) atrial septal defect 4) ventricular septal defect

Question 58

How do you manage cardiac disease during pregnancy? (5)

Answer 58

1) screen for heart failure (echo, ECG) 2) anticoagulation (mechanical heart valves) 3) rationalising drug therapy 4) monitor foetal growth and wellbeing (scans) 5) plan delivery (timing and mode)

Question 59

List 4 pregnancy risks due to hyperthyroidism.

Answer 59

1) maternal thyroid crisis with cardiac failure 2) maternal propylthiouracil induced liver failure 3) foetal thyrotoxicosis 3) foetal carbimazole induced abnormalities

Question 60

List 2 pregnancy risks due to hypothyroidism.

Answer 60

1) foetal impaired neurodevelopmental | 2) foetal death

Question 61

Define gestational diabetes mellitus.

Answer 61

Carbohydrate intolerance first recognised in pregnancy.

Question 62

What is the period of risk for developing type 2 diabetes mellitus following gestational diabetes mellitus?

Answer 62

Within 10-15 years of pregnancy.

Question 63

How do you manage diabetes mellitus during pregnancy? (5)

Answer 63

1) HbA1c < 48 mM 2) folic acid 5 mg 3) stop ACEi and statins 4) retinal screening 5) renal screening

Question 64

List 4 maternal risks associated with diabetes during pregnancy.

Answer 64

1) diabetic ketoacidosis 2) hypoglycaemia 3) retinopathy 4) pre-eclampsia

Question 65

List 6 foetal risks associated with diabetes during pregnancy.

Answer 65

1) miscarriage 2) prematurity 3) still birth 4) macrosomia 4) foetal abnormalities 5) hypoglycaemia 6) respiratory distress

Question 66

List 3 drugs used for diabetes mellitus during pregnancy.

Answer 66

1) insulin (basal bolus regime) 2) metformin 3) glibenclamide

Question 67

List 4 maternal risks associated with chronic kidney disease during pregnancy.

Answer 67

1) severe hypertension 2) renal function deterioration 3) pre-eclampsia 4) Caesarean section

Question 68

List 4 foetal risks associated with diabetes during pregnancy.

Answer 68

1) prematurity 2) stillbirth 3) growth restriction 4) foetal abnormalities (iatrogenic)

Question 69

List 4 factors that determine the outcome of a pregnancy for a mother with chronic kidney disease.

Answer 69

1) degree of renal dysfunction 2) blood pressure 3) creatinine level 4) proteinuria

Question 70

How does seizure frequency change during pregnancy?

Answer 70

Increases, 25-33%.

Question 71

Why is SUDEP more common during pregnancy?

Answer 71

Increased likelihood of non-compliance to anticonvulsants due to fear of harming baby.

Question 72

List 2 foetal risks associated with epilepsy during pregnancy.

Answer 72

1) foetal abnormality (iatrogenic) | 2) hypoxia (associated with maternal seizures

Question 73

How do you manage epilepsy during pregnancy? (5)

Answer 73

1) high dose folic acid 2) screen for foetal abnormalities 3) control seizures 4) plan for delivery (paint relief) 5) avoid prolonged labour

Question 74

List 5 risks of in utero exposure to valproate. (7)

Answer 74

1) spina bifida 2) atrial septal defect 3) cleft palate 4) hypospadias 5) polydactyly 6) reduced IQ 7) autistic spectrum disorder

Question 75

List 3 risk factors for thromboembolism in pregnancy.

Answer 75

1) maternal age 2) BMI 3) operative delivery

Question 76

What is the VTE of choice during pregnancy?

Answer 76

Low molecular weight heparin.