Week 12 - pregnancy and prescribing

Question 1

gender inclusive language

Answer 1

important to consider inclusivity of language
treat patients as individuals, try to avoid assumptions
read clinical notes before seeing patients

Question 2

definition of sex

Answer 2

refers to biological aspects of an individual as manifested by their anatomy, which are determined by their genes, hormones and interactions

Question 3

definition of gender

Answer 3

more complex, is a personal, internal perception of oneself as a man, woman or neither. gender may not match sex assigned at birth

Question 4

gender inclusive language in pregnancy

Answer 4

pregnant woman
pregnant person

Question 5

folic acid

Answer 5

required for purine and pyrimidine synthesis
amino acid conversions
closure of neural tube requires rapid proliferation or neuroepithelial cells - requires significant nucleic acid synthesis
woman advised to take folic acid 400mcgms daily when trying to conceive until 12 weeks of pregnancy - start as soon as they are aware of pregnancy if not taking

Question 6

alcohol in pregnancy

Answer 6

no safe level of consumption
more significant exposure causes foetal alcohol syndrome

Question 7

alcohol screening - TACE

Answer 7

tolerance - how many drinks does it take to feel a buzz/get drunk
annoyed - by people asking you to cut down
have you ever felt need to CUT down
eye opener - drink first thing in the morning

Question 8

foetal alcohol spectrum disorder

Answer 8

leading preventable cause of birth defects
alcohol is teratogen with irreversible CNS effects
facial dysmorphism common

Question 9

characteristic facial features of foetal alcohol spectrum disorder

Answer 9

low nasal bridge
thin upper lip
smooth philtrum
small palpebral fissures

Question 10

methotrextate

Answer 10

common drug treatment in RA
can cause miscarriage and/or serious birth defects, can affect growth in utero

Question 11

dihydrofolate reductase

Answer 11

converts dihydrofolate to tetrahydrofolate - involved in purine and pyrimidine synthesis
methotrexate is competitive inhibitor of DHF
- reduces cell division
- reduces amino acid synthesis
- antagonises action of folic acid
multiple case reports and series of congenital defects - cranial anomalies, congenital heart disease, limb defects

Question 12

pregnancy and RA

Answer 12

pre-pregnancy counselling with rheumatologist and obstetrician
should be off methotrexate for 3 months before conception
disease under control - hydroxychloroquine, sulfasalazine are safe DMARDs

Question 13

sodium valproate

Answer 13

used in epilepsy treatment
seizure - sudden change in behaviour caused by electrical hypersynchronisation of neuronal networks in cerebral cortex
epilepsy is recurrent seizures

Question 14

sodium valproate and pregnancy

Answer 14

neural tube like defects occur in 1-2% of foetuses (20x risk of general population)
associated with cardiac, oral and urogenital malformations
must not be used in women or girls of child bearing age unless in pregnancy prevention programme

Question 15

pregnancy prevention programme

Answer 15

GP recall relevant patients taking sodium valproate - give counselling and information leaflet, ensure highly effective contraception
review by specialist - is drug indicated? give patient information, ensure highly effective contraception, signed consent

Question 16

angiotensin converting enzyme inhibitor (ACEi)

Answer 16

treatment for hypertension, heart failure, renal failure
angiotensin receptor blockers (ARBs) have similar uses

Question 17

what does angiotensin converting enzyme do

Answer 17

converts angiotensin 1 to angiotensin 2

Question 18

what do ACE inhibitors do

Answer 18

block conversion of angiotensin 1 to angiotensin 2

Question 19

what do ARBs do

Answer 19

block reception of angiotensin 2

Question 20

ACEi/ARB in pregnancy

Answer 20

exposure in second and third trimester associated with:
- oligohydramnios (reduced amount of amniotic fluid)
- renal failure
- low blood pressure
- pulmonary hypoplasia
- respiratory distress syndrome

fetal circulation has low perfusion pressures
has high angiotensin 2 levels to maintain renal function - reduced renal function, less amniotic fluid
ACEi/ARB may also reduce placental blood flow - reduced foetal growth

Question 21

ACEi/ARB in first trimester

Answer 21

explain data to patient
use alternative if possible - not always in diabetic renal disease
if planning on conceiving detect pregnancy early, if period delayed withhold ACEi/ARB and get pregnancy test
stop for duration of any pregnancy

Question 22

non steroidal anti inflammatory drugs in pregnancy

Answer 22

avoid during 3rd trimester
may cause rare but serious kidney problems leading to reduced amniotic fluid and associated complications

Question 23

foetal circulation

Answer 23

ductus arteriosus enables oxygenated blood to pass from pulmonary artery to aorta, thereby bypassing lung
right ventricle have 65% of cardiac output
pulmonary vascular resistance high

Question 24

circulation after birth

Answer 24

ductus arteriosus closes
functional closure in 24 hours
complete anatomic closure takes 2-3 weeks

Question 25

ductus arteriosus (DA)

Answer 25

blood vessel kept open by prostaglandin E (PGE) which causes vascular smooth muscle to relax
PGE produced by placenta and by DA
PGE levels drop after birth allowing closure of DA

Question 26

NSAIDs mechanism of action

Answer 26

arachidonic acid > endoperoxidase via cyclooxgyenase > prostaglandins, thromboxan and prostacyclin

NSAID inhibits cyclooxygenase resulting in loss of prostaglandins - loss of PGE

Question 27

premature closure of DA

Answer 27

cardiac output directed through pulmonary circulation
leads to pulmonary hypertension - cardiac failure, foetal hydrops (fluid accumulation in tissues and organs