Pregnancy Related Conditions Flashcards

Question

How to prevent coagulation problems in pregnant patients with heart failure

Answer 1

Anticipate the need to switch from warfarin to heparin from 6- 12 weeks. From 12-36 weeks consider choice of anticoagulation balancing maternal and fetal risk From 36 weeks if using warfarin need to switch back to heparin to avoid labouring while on warfarin (maternal and fetal risks) Omit anticoagulation in labour. If planning delivery time (induction or CS) create a “window” of opportunity Meticulous detail to bleeding and haemostasis at delivery Timing of re-intiation of anticoagulation: start with heparin, delay warfarin for up to 48 hours. Close monitoring of anticoagulation Watch for haematoma formation.

Answer 2

HBA1C of <6.1 BMI<27

Answer 3

One criteria needed Prev GD 1st degree elation 2 episodes of glycosuria High BMI Asian Macrosomia, Polyhydramnios 2needed Prev Big baby Previous Term Stillbirth Prev RDS at term Age >35

Answer 4

>8.0mmol/l Two digits Go on and screen using OGTT

Answer 5

Normal fasting:<5.5 Normal after glucose: <7.8 GDM Fasting: >7 After glucose: >11

Answer 6

Macrosomia Neonatal hypoglycaemia

Answer 7

Hyperinsulinaemia Relativehypoxia and polycythemia then Jaundice, kernicterus or Stillbirth

Answer 8

All pregnant diabetics at 38weeks Whee lung maturity is uncertain do amniocentesis and bubble test on it. If amniocentesis is contraindicated (HI unsurprised), deliver at 39weeks

Answer 9

If the EFW > 4kg and AC (abdo circumference)> P97, delivery by caesarean section is offered. Any contraindicated to IOL

Answer 10

Hypo/hyperglycemia Ketoacidosis Fetal distress

Answer 11

A. IGT & GDM Not on Treatment/ Metformin Only 1. These patients can have light meals until they are contracting, at which time the Metformin is discontinued. 2. Blood glucose monitoring by glucose strips every 4 hours (keep 4-7mmol/l) 3. If values remain above 7, 0 mmol/l, a continuous subcutaneous insulin pump is commenced to control glucose, with the settings adjusted every 2 hours to keep the readings in an acceptable range B. Diabetic Patients on Insulin: All oral drugs are stopped. A continuous subcutaneous insulin infusion is commenced. (This is battery- operated and portable. The patient is then completely mobile. It is usually positioned under the axilla and a scalp vein needle is placed subcutaneously above the breast. Twenty units of insulin are drawn up into the syringe and then normal saline is drawn up to 5ml. At a drive rate of 1mm per hour the patient will get 0.5 units Insulin. The patient is usually started on 2mm per hour (1 unit per hour). Glucose readings are done every 2 hours while the patient is being induced. If not in labour yet: patients will continue normal meals and normal ixed doses of insulin pre meals. The pump is therefor used as top -up, as and if needed. Once in labour, patient will be kept nil by mouth (NPO). She cannot receive her normal ixed doses of insulin if not eating, therefore a 5% dextrose drip is commenced (@ 68ml/hr), and the pump used to control the glucose levels.

Answer 12

Maternal side of family Fertility drugs Race (black) Age (older)

Answer 13

Hyperremesis gravidum Multiple gestational sacs Uterus larger than dates Polyhydramnios Early onset GOH

Answer 14

Maternal Indications: Placenta praevia Previous classical CS Previous uterine surgery, e.g. CS, myomectomy Cervical carcinoma Serious medical conditions Bearing down efforts contraindicated, eg. cerebral aneurysm Uterine rupture Previous vaginal repair or surgery for urinary incontinence Fetal Indications: Fetal distress Prolapsed cord with live baby Abruption placenta with live baby Breech presentation Transverse lie Brow or mento-posterior face presentation Multiple pregnancy, particularly monochorionic or abnormal lies Macrosomia, particularly when associated with maternal diabetes Certain congenital abnormalities, eg. hydrocephalus, gastroschisis Combined Fetal and Maternal Indications: Failure to progress in labour, eg CPD, abnormal position Failed forceps or vacuum delivery Failed induction of labour

Answer 15

Previous Classical C/Section Two or more previous Caesarean sections Patient refusal No recourse to emergency Caesarean section Very large baby Malpresentation or other complication Multiple pregnancy Placenta praevia

Answer 16

- Abnormal pain, especially between contractions. - Vaginal bleeding. - Fetal distress. - Evidence of hypovolaemic shock (hypotension, tachycardia, low Hb). - Diminished or altered uterine activity. - Alterations in fetal position (fetus palpated separate to uterus). - Haematuria.

Answer 17

Interval>2years Baby<4kg Spontaneous labour Previous successful VBAC or NVD

Answer 18

Expansion of red cell mass Fetus and placenta Increase in plasma volume leading to hemodilutuon

Answer 19

4mg/day in early pregnancy 6-8mg/day by 32 weeks (In a normal person 2mg/day)

Answer 20

Low Hb Low McV Low MCH Low McHC Low serum iron Low ferritin Increased Transferritin Increased zinc protoporphyrin Bone marrow iron (invasive, only do if no invasive tests not useful

Answer 21

1. Identify cause eg diet, stool for worms and urine for schistosomiasis Treat infection if present 2. Oral Iron (ferrous sulphate or gluconate) 3. Parenteral iron supplement (IV) in selected esp if noncompliance late pregnancy 4. Blood transfusions in severe anaemia esp in 36 weeks gestation 5. Replenish stores by - prolonging oral meds -IV iron 6. Prevention: All antenatal should receive ferrous sulphate 200mg daily especially where iron deficiency is prevalent

Answer 22

Multiple pregnancy Anticonvulsants Grand parity with short intervals in between Excessive alcohol use

Answer 23

Increase MCV Peripheral smear shows oval macrocytes and hyper segmented neutrophil nuclei Low reticulocyte count Red cell folate Serum folate Bone marrow for patients with pancytopenia

Answer 24

Folic acid 5mg tablets As little as 1mg folic acid per day produces marked haematological response in 4-7days

Answer 25

Pallor Tachycardia Ejection systolic murmur

Answer 26

Ferrous sulphate tablets 200mg Folic acid 5mg tablets Advice on balanced diet Continue their pills in breastfeeding

Answer 27

All pregnant women should have an Hb measurement at the 1st antenatal visit: If Hb ≥10 g/dL, repeat between 28 and 32 weeks and again at 36 weeks. If Hb <10 g/dL, follow up with more frequent Hb measurements after initiating treatment. A haemoglobinometer should be used, so that the result is available at the same visit.

Answer 28

Depends on 1. Severity 2. Duration of pregnancy 3. Presence of symptoms or complications 4. Type of anaemia 5. Underlying cause Management a Mild Dietary advice – give dietary advice pamphlet Ferrous sulphate 200 mg with folic acid 5 mg orally daily. Counsel regarding compliance. (See above) If < 36 weeks, follow up with a repeat Hb after four weeks. If there is no response to oral iron/ folate treatment, or if ≥36 weeks, request a Full Blood Count (FBC). The mean cell volume (MCV) indicates the probable cause of the anaemia: - A below-normal MCV suggests iron de iciency anaemia (microcytic) - a normal MCV suggests anaemia of chronic disease (normocytic) - an above-normal MCV suggests folate or vitamin B12 de iciency anaemia (macrocytic) If the FBC shows a microcytic picture, it is reasonable to treat as iron-de iciency anaemia- Cosmofer if the FBC shows a normocytic or macrocytic picture, do further tests to identify the cause: o Iron studies o Red cell folate o Vitamin B12 levels If suggestive of iron de iciency, consider transfusion with intravenous iron (Cosmofer)

Answer 29

b) Moderate to severe Take blood for a full blood count (FBC) and evaluate the MCV Try and identify a possible cause of the anaemia: o Dietary history o Urine microscopy and culture + parasites o Malaria smear where relevant Start treatment for anaemia with ferrous sulphate 200 mg and folic acid 5 mg oral daily Treat with Mebendazole 500mg stat po Follow up FBC result in 1 week: - If the FBC shows a microcytic picture, treat as iron-de iciency anaemia - If the FBC shows a normocytic or macrocytic picture, do further tests to identify the cause: o Iron studies o Red cell folate o Vitamin B12 levels

Answer 30

Refer to hospital for iron or blood transfusion depending on clinical picture If symptomatic (dizziness, SOB, tachycardia) transfuse

Answer 31

Hb < 9g/d and/ or if patient is at high risk for blood loss (e.g. APH, C/Section, ibroid uterus, grandmultiparity, PPH), send a specimen to the WCBS (Western Cape Blood Service) for group and save. Do not cross-match blood unless indicated. All anaemic patients must have an intravenous line during delivery. Postpartum haemorrhage must be prevented, and managed aggressively if occurs. Haematinics must be continued after delivery.

Answer 32

Hb<6 and woman is in labour Hb<8 in a patient going for emergency CS Patients should be transfused with atleast 1unit of packed Red cells

Answer 33

25mg daily for two weeks, 25mg twice daily for two weeks, 25mg morning dose and 50mg evening dose for a week and 50mg twice daily respectively.

Answer 34

Clobazam Start at 5mg-10mg daily at night Increase once a week up to 20-30m Once lamotrigine therapeutic levels are achieved stop calabazas

Answer 35

Fetal Hyadantoin Syndrome P- cleft lip, palate H- hirsutism, hypoplastic nails, head small E-embryology N- neurodevelopmental delay

Answer 36

Vit K 20mg orally once daily from 36weeks

Answer 37

Lorazepam 2-4mg IV blouses every 10-20min Or Diazepam 5-10mg IV or IM

Answer 38

propylthiouracil (PTU) 100-200mg orneomercazole (NMZ). PTU is preferred at Groote Schuur Hospital as it acts more rapidly and has both a central and peripheral effect.

Answer 39

1. IV line and adequate rehydration 2. Bloods: FBC, haemotocrit, UEC, TFTs 3. Anti thyroid meds in large doses- Propylthiouracil PO/IV 4. After atleast an hour of anti thyroid drugs: Give Na or K iodide should be given to inhibit release of Thyroid hormone 5. Propanolol May be given only if not in heart failure to reduce tachycardia and restlessness 6. Chlorpromazine for hypothermic and sedative effects 7. Corticosteroid May be given to reduce peripheral conversion of T4 to T3 8. Deliver that baby (esp since you gave iodide) even if not viable. 9. Don’t give Aspirin as it displaces thyroid hormone from TBG and May worsen condition

Answer 40

Hypothermia Hypotension Hyponatremia Hypoglycemia Dehydration N&V, abdo pain, fatigue

Answer 41

Resuscitate Hydrocortisone 120mg IVI stat and every 6hourly

Answer 42

Hydrocortisone 20mg in the morning and 10mg mid afternoon

Answer 43

Cervical dilation Position Effacement Consistency Station (-3 to 3) >9 favourable cervix 5-8 intermediate <4 unfavourable cervix <3 delivery with induction usually fails