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YEAR 4 REPRO > Pregnancy: Effects on pre-existing conditions > Flashcards

Pregnancy: Effects on pre-existing conditions Flashcards

Incl Asthma Epilepsy DM cardiac disease

1
Q

Recap: pathophysiology of asthma?

A
  • Reversible bronchoconstriction of airways from smooth muscle spasm.
  • Damage airway epithelial cells - get shedding, subepithelial fibrosis, and basement membrane thickening.
  • Inflammatory reaction characterised by eosinophils, Th2 cells and mast cells. Inflammatory mediators released include histamine, leukotrines and prostaglandins.
  • Increased mucus production due to increased number of mucus secreting goblet cells.
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2
Q

Symptoms of asthma?

A

Cough
Breathlessness
Wheeze
Chest tightness
Diurnal variation
Hx of atopy - eczema and hayfever

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3
Q

Differentials for pt presenting with wheeze?

A

Acute asthma exacerbation
Bronchitis - viral or bacterial
PE
GORD
Allergy
Hyperventilation/ Psychosocial

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4
Q

How is asthma diagnosed in pregnancy?

A

Based on Hx
>20% diurnal variation in PEFR for 3+ days
>15% improvment in FEV1 after inhaled bronchodilators.

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5
Q

How can pre-existing asthma be affected in pregnancy?

A

May remain unchanged
If poorly controlled before pregnancy, asthma may worsen

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6
Q

How can asthma affect fetus?

A

Can result in fetal growth restriction
Can result in preterm labour

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7
Q

Management of asthma in pregnancy?

A
  • Focus on preventing acute attacks
  • follow BTS guideline (picture)
  • Most meds are safe in preg –> do NOT start leukotriene receptor antagonist
  • Continue usual medication and treat as for non-pregnant patient
  • Check inhaler technique
  • Smoking cessation advice
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8
Q

Why are asthma attacks in pregnancy rare?

A

Due to endogenous steriod production

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9
Q

Triggers for asthma exacerbation?

A

Pollen
Animal fur
Dust
Exercise
Cold
Emotion
URTI
Medications - aspirin (preeclampsia), beta blockers

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10
Q

Carboprost is given in PPH. How would you go about using this in an asthmatic mother?

A

With caution - as it can cause bronchospasm

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11
Q

Differentials/Causes of seizures in pregnancy?

A

Epilepsy
Eclampsia
Cerebral vein thrombosis
Intracranial mass
Stroke
Hypogylcaemia
Hyponatraemia
Drugs and withdrawal
Infection

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12
Q

How would you manage epilepsy preconception?

A
  • Involve neurologist to confirm Dx
  • Optimise treatment - aim for seizure control on lowest dose to minimize risk of congenital malformation. Can consider withdrawing if seizure free for 2yrs.
  • Folic acid 5mg daily needs to be taken >3months preconception
  • Discuss increased risk of epilepsy in children (4-5% if just mother affects, 20% if both parents affected)
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13
Q

Discuss AEDs and congenital malformations (CMs):
* which AEDs can lead to CMs?
* What CMs can they cause?

A

Which AEDs?
* Sodium valproate, carbamazepine = should not be prescribed if child bearing age.

Valproate: highest rate of CMs –> NTDs, craniofacial abnormalities, neurodevelopmental problems

Carbamazepine: increased rates of NTDs

Lamotrigine: malformation rate of 2.1%. Need bloods checked regularly. Avoid in breastfeeding.

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14
Q

How would you manage a pregant lady with epilepsy in antenatal care?

A
  • needs to attend a consultant led obstetric clinic
  • aim for vaginal delivery
  • do not change epilepsy drugs without advice from epilepsy specialist
  • if unplanned preg - need to see epilepsy specialist ASAP to talk through AEDs
  • needs to have nuchal translucency and anomaly scans, as well as serial growth scans in 3rd trimester (risk of SGA fetus)
  • discuss that sleep deprivation and stress can increase seizure risk - so avoid wherever possible (esp in labour)
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15
Q

What intrapartum care would you discuss with pregnant lady with epilepsy?

A
  • Aim for vaginal delivery unless obstetric indications require C section.
  • Having a fit in labour is not an indication for C section unless it is status epilepticus.
  • delivery should be in hospital and AEDs should be continued in labour
  • pain relief is priority - epidural is safe
  • use benzos if seizure not self terminating = lorazepam 4mg IV, diazepam 10-20mg IV.
  • Seizures are more common intrapartum and postpartum due to sleep deprivation and reduced drug absoroption
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16
Q

What postnatal care would you put in place for new mother with epilepsy?

A
  • Baby needs 1mg vit K (for haemorrhagic disease of newborn)
  • avoid early discharge - needs to be in hosp for 24hrs
  • discuss strategies for avoiding dropping baby during seizure (eg change baby on floor)
  • encourage breastfeeding
  • review AED dose within 10 days of delivery to avoid toxicity
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17
Q

A lady with known epilepsy has just given birth. She wants to discuss contraception. What would you inform her?

A

If she takes enzyme inducing AEDs - use copper/mirena coil and injected progestogens
If on non-enzyme inducing AEDs, can take any contraception

Oestrogen containing contraception increases seizure risk if she is taking lamotrigine due to reduced drug levels.

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18
Q

Define HTN in pregnancy

A

systolic > 140 mmHg or diastolic > 90 mmHg
or
an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic

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19
Q

Define HTN in pregnancy

A

systolic > 140 mmHg or diastolic > 90 mmHg
or
an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic

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20
Q

Describe clinical features of pre-existing HTN in pregnancy

A

A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation

No proteinuria, no oedema

More common in older women

21
Q

Describe clinical features of pregnancy induced hypertension (aka gestational HTN)

A

HTN occuring in the second half of pregnancy (after 20wks)

No proteinuria, no odema

Resolves following birth (usually after 1 month)

22
Q

What are women with pregnancy induced (gestational) HTN at increased risk of?

A

Future pre-eclampsia
HTN in later life

23
Q

Desrcribe clinical features of pre-eclampsia, and compare this to pregnancy induced (gestational) HTN

A

Pre-eclampsia: Preg-induced HTN in association with proteinuria (>0.3g/24hrs)
Odema may occur.
After 20weeks

PIH: HTN occuring in second half of pregnancy. No proteinuria and no odema.

24
Q

A pregnant woman has pre-existing HTN and is on ramipril, an ACEi. How should you manage this?

A

Stop ACEi or ARB immediately.
Alternative antihypertensive (labetalol) should be started whilst awaiting a specialist review

25
Q

What are the different classifications of hypertensive disorders in pregnancy?

A

Gestational / Pregnancy induced HTN
Pre existing HTN / Chronic HTN
Pre-eclampsia
Pre-eclampsia superimposed on chronic HTN
Eclampsia

26
Q

Describe trend in BP in pregnancy

A

In early pregnancy to 24 weeks, BP falls due to fall in vascular resistance
After this time, stroke volume increases, leading to a rise in BP.

27
Q

What BP in pregnancy is considered a medical emergency?

A

BP of >160/110 mmHg

28
Q

Women with chronic HTN have higher risks of….WHAT?

A
  • pre-eclampsia
  • fetal growth restriction
  • placental abruption
29
Q

How would you pharmacologically manage women at high risk of developing pre-eclampsia?

A

Aspirin 75mg OD from 12weeks - birth of baby

30
Q

Management of HTN in pregnancy?

A

Management
* oral labetalol is now first-line following the 2010 NICE guidelines
* oral nifedipine (e.g. if asthmatic) and hydralazine

31
Q

A woman presents for the first time with HTN in pregnany. What other causes of HTN should you rule out?

A

Coarctation
Renal artery stenosis
Other renal disease
Rare: Conn syndrome, Cushing syndrome, phaeochromocytoma

32
Q

A woman has HTN in pregnancy. What antenatal care should you have in place from 28weeks and why?

A

Fetal US every 4 weeks from 28/40 to assess:
- fetal growth
- amniotic fluid volume
umbilical artery doppler

33
Q

Oxytocin may be given in third stage of labour to prevent PPH. Why is ergometrine NOT given for this in a woman with HTN?

A

ergometrine causes severe HTN - which is a huge RF for stroke.

34
Q

Maternal risks of DM in pregnancy?
Fetal risks of DM in pregnancy?

A

Maternal:
Hypoglycaemia unawareness
Increased risk of pre-eclampsia
Increased risk of infection
Higher rates of C section

Fetal:
Miscarriage
Congenital malformation rates increase (but reduced by good glycaemic control)
Macrosomia –> shoulder dystocia
Growth restricted fetus
Polyhydraminos
Pre-term labour
Stillbirth

35
Q

What pre-conception counselling would you discuss for women with pre-existing DM?

A
  • avoid unplanned pregnancy
  • Use contraception until good blood glucose has been achieved < 48mmol/mol
  • folic acid 5mg daily until 12 weeks gestation
  • BMI < 27
  • Stop oral hypoglycaemics (apart from metformin), statins, ACEi
  • Treat retinopathy pre-pregnancy
36
Q

What antenatal care would you discuss with woman who has pre-existing DM?

A
  • Need joint clinic with diabetologist, diabetes specialist nurse, obstetrician, midwife
  • folic acid 5mg from preconception
  • aspirin 75mg OD from 1st trimester to reduce risk of HTN and pre-eclampsia
  • meaure HbA1c at booking
  • Discuss use of insulin
  • Educate about benefits of normal blood sugar levels
  • Discuss hypoglycaemia awareness
  • Give glucogel and glucagon kit
  • Early USS at 7-9 weeks to confirm gestation. Offer combined screening at 12wks, detailed anomaly scan 18-20weeks and growth scans from 28-36weeks
37
Q

When is delivery recommended for women with pre-existing DM?

A

In hospital
At 37-38 +6 weeks
C section discussion required if fetus is macrosomic
If preterm - corticosteriods should be given to promote fetal lung maturity

38
Q

A pregnant woman who has a PMH of VTE is attending your clinic.
1. Is she low risk or high risk?
2. What management does she need?

A
  1. high risk
  2. needs LMWH throughout antenatal period - the dose depends on body weight
39
Q

Assessment at booking should include RFs that increase a woman’s likelihood of developing a VTE. What are these RFs?

A
  • Age > 35
  • Body mass index > 30
  • Parity > 3
  • Smoker
  • Gross varicose veins
  • Current pre-eclampsia
  • Immobility
  • Family history of unprovoked VTE
  • Low risk thrombophilia
  • Multiple pregnancy
  • IVF pregnancy
  • Previous VTE
40
Q

At booking, an assessment of RF for VTE is done. How many RFs warrant immediate treatment with LMWH?

A

4 + RF = immediate treatment

3 RF - LMWH should be started at 28weeks and continued until 6weeks postpartum.

41
Q

For VTE, what treatments are avoided in pregnancy?

A

DOACs
Warfarin

42
Q

What are RFs for having VTE during pregnancy?

A

If you…
* are admitted to hospital
* are carrying more than one baby (multiple pregnancy)
* become dehydrated or less mobile in pregnancy due to, for example, vomiting in early pregnancy, being in hospital with a severe infection such as appendicitis or a kidney infection or if you are unwell from fertility treatment (ovarian hyperstimulation syndrome)
* are immobile for long periods of time, for example after an operation or when travelling for 4 hours or longer (by air, car or train)
* have pre-eclampsia

43
Q

RF for VTE following birth?

A

If you..
* have a very long labour (more than 24 hours)
* have had a caesarean section
* lose a lot of blood after you have had your baby
* receive a blood transfusion

44
Q

Investigations for PE?

A
  • a chest X-ray (after birth)– this can also identify common problems that could be the cause of your symptoms, such as a chest infection
  • a CT scan (specialised X-ray) of your lungs
  • a VQ scan (ventilation/perfusion scan) of your lungs – this involves a drip into a vein in your arm
  • an ultrasound scan of both your legs if you have any symptoms of a DVT.
45
Q

How can a woman reduce her risk of getting a DVT/PE when pregnant/after birth?
(conservative management)

A
  • stay as active as you can
  • wear special stockings (graduated elastic compression stockings) to help prevent blood clots
  • keep hydrated by drinking normal amounts of fluids
  • stop smoking
  • lose weight before pregnancy if you are overweight
46
Q

Why is LMWH safe to give to pregnant lady?

A

It does not cross the placenta, so does not pose any harm to the baby

47
Q

What is the risk of using nifedipine during pregnancy?

A

Nifedipine may cause a sudden, severe drop in blood pressure and compromise the uteroplacental circulation and in turn the foetus

48
Q

Management of pre-exisiting DM in pregancy?

A
  • weight loss for women with BMI of > 27 kg/m^2
  • stop oral hypoglycaemic agents, apart from metformin, and commence insulin
  • folic acid 5 mg/day from pre-conception to 12 weeks gestation
  • detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
  • tight glycaemic control reduces complication rates
  • treat retinopathy as can worsen during pregnancy

YEAR 4 REPRO (26 decks)

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