Mat Med Flashcards

Question

Most common type of MS

Answer 1

85% - RRMS Relapsing remitting MS Breast feeding has beneficial effects on MS relapse Fewer relapses in the first 3-4 months of preg.

Answer 2

At the time of stroke/presentation do; ECG (will prob have ST changes) , then 24H Holter monitoring A prolonged cardiac monitor or implantable loop recorder should be considered for cryptogenic strokes potentially caused by paroxysmal atrial fibrillation Loop recorder is superior to a holter monitor for diagnosis in pregnancy Transthoracic echo is the BEST 1st line investigation - a BUBBLE TEST or contrast echo can be performed from the cardiac apex which involves the use of agitated saline and a salsalva manoeuvre to demonstrate an intra-atrial shunt Transoesophageal echo (TOE) can be performed if the transthoracis echo gives equivocal results TOE remains the optimum investigation to rule out aortic arch atheroma , left atrial appendage thrombus , PFO A thrombophilia screen shoul be done 6 weeks postanally as some components may not be accurate in the setting of pregnancy and postpartum

Answer 3

If woman has a concurrent thrombiphilia- 20% If PFO that is now closed - its 1% Outside of pregnancy is 0.5%

Answer 4

Paired serum and urine osmolality IN DI urine will be dilute with a U:P ratio of <2 In pregnancy normal plasma osmolality is approx 270 (normally >285 max 295 and urine <300 if non preggo ) , so if osmolality levels in pregnancy are normal like for a non preggp person that is abnormal In pregnancy plasma sodium is also reduced by 4-5 mmol/l

Answer 5

Intracerebral haemorrhage Suspected subarachnoid haemorrhage even if normal on CT Neurosurgery/head trauma in last 3 months BP>185, 105 Hx of intracereral haemorrhage ….

Answer 6

Increased risk of FGR

Answer 7

7% Normal population rate is 4%

Answer 8

16% Vs 15-20 in normal ppl

Answer 9

Can take it till 28w then stop Very high levels in baby, long half life Anti TNG activity used to treat conditions such as RA, JIA, psoriasis, psoriatic arthritis, akylosing spon, IBD sarcoidosis It is a IGG1 monoclonal antibody

Answer 10

Depo provera

Answer 11

Planned CS , risk of uterine rupture if in labour ad sever haemorrhage if contractions start

Answer 12

Yes if flare up of chron;s occurs or ?IBD can start predinioslone and adalimumab but it takes 6 weeks for it to start working

Answer 13

Headache worse at coughing associated with nausea blurred vision and diplopia , papilloedema , visual field defect with enlarged blind spot, reduced visual acuity, reduced colour vision and sixth nerve palsy Lumbar CSF opening pressure > than 250 mmH20 measured in the lateral decubitus position to diagnose IIH High BMI usually Main goals of treatment are symptom control and preservation of vision Tx options: Acetazolamide - analgesics for headache, diuretics to reduce CSF production, dietary modification to aid weight loss Surgical tx options: repeated lumbar puncture ,optic nerve sheath fenestration CSF diversion procedures

Answer 14

Modified dandy criteria used for diagnosis

Answer 15

USS then MRI liver gadolinium contrast

Answer 16

Hepatic adenoma - risk of haemorrhage is 27.2% and 15.8% of rupture Lesion greater than 10cm confer the highest risk and risk of rupture in pregnant women is highest in 3rd trimester

Answer 17

PRES is a clinical-neuroradiological entity associated with pre-eclampsia Headache, vision disturbances, nausea vomiting, seizures, altered metal state ON MRI- edema in the posterior circulation of the brain - parietal and occipital lobe contrivance and suboptimal signal changes are hyper tense on T2 and FLAIR sequences Tx: PET algorithm, delivery

Answer 18

6 months Confirmation of no early recurrence is with negative colposcopic assessment, vaginal vault and isthmic smear and pelvic MRI

Answer 19

1st) IV lorazepam if don’t work use …. 2n line) loading dose phenytoin 10-15mg/kg

Answer 20

Desmopressin - is an ADH analogue - DDAVP, has a different N terminal that renders it immune to metabolism from vaso[ressinase Can be take PO, SL , intranasally , SC, IM IV Can be taken in preg and breastfeeding In neurogenic DI in pregnancy DDAVP must be increased in pregnancy and decreased post partum In nephrogenic DI treatment is based around correcting hypercalcaemia and hypokalaemia

Answer 21

gestational diabetes GDM

Answer 22

Signs and symptoms - productive cough, SOB when lying flat, bilateral ankle oedema , tachycardia, normal stats , raised JVP, fine bilateral crepitations at lung bases Definition: Left ventricular ejection fraction LVEF below 45% If left ventricular end diastolic diameter LVEDD is >6cm and LVEF <30% are indicative of a decreased prospect of spontaneous recovery and an increased likelihood of mechanical support, transplant and death

Answer 23

Non-enhanted CT head

Answer 24

Cerebral infarction, cerebral vein thrombosis CVT, intracranial haemorrhage ICH, subarachnoid haemorrhage 90% of strokes occur peripartum pr in the 6 weeks post delivery In general population most strokes are ischaemic 80-85% In preg- ischaemia, haemorrhage and venous thrombosis have similar contribution to aetiology

Answer 25

In subsequent pregnancy there is a risk of PPCM relapse, If persistent left ventricular dysfunction there is a 50% chance of further deterioration in LVF and increased morbidity and mortality rates - mortality may be as high as 20% If a woman has complete recovery of left ventricular function, prognosis appears to be better although 20% of women may have a further relapse If complete recovery of LVF long term outcome is unknown IF LVEF <25% at initial diagnosis or when the LVEF has not normalized over a course of time following adequate medical care, the woman should be counseled not to become pregnant

Answer 26

10% 50-80% of women diagnosed with PPCM achieve recovery in their LVEF >or equal to 50%. Mostly within the first 6 months after manifesting the disease PPCM assiciated with hypertension has been associated with a more successful recovery

Answer 27

Tx is vagal manoeuvres , if does not work then ADENOSINE Or beta-1-selective blockers- ie metoprolol or bisoprolol Tachyarrhythmias may present for the first time and become more frequent in pregnancy, particularly in older women and in women with congenital heart disease MOST FREQUENT arrhythmias: AF and paroxysmal supraventricular tachycardia (PSVT)

Answer 28

Any tachycardia with haemodynamic instability and for pre-excited atrial fibrillation

Answer 29

They are high risk mWHO class III Change from warfarin to therapeutic LMWH between week 6-12 then restart warfarin in second trimester Adjusted dose based on anti xa levels when on LMWH To stay on warfarin until get preggo- of dose is low can consider continuing it VKAs - vitamin K antagonists like warfarin have a small risk of embryopathy, fetal abnormalities and fetal loss but remain the most effective regimen to prevent valve thrombosis

Answer 30

Can be primary, secondary and tertiary Primary= adrenocortical disease , both glucocorticoid and mineralocorticoid deficiency’s Autoimmune atrophy of adrena gland accounts for 70-90% of primary AI. - other causes, haemorrhage from sepsis, major burns, lymphoma, metastasis, infections TB Secondary & tertiary= are associated with ACTH and corticotropin-releasing hormone (CRH) secretion disorders, mainly from cortisol deficiency Symptoms: low BP, hyper K, hypo Na, hypoglycemia, increased pigmentation - mostly of mucous membrane, extensor surfaces and non exposed regions of body

Answer 31

Don’t need to transfuse if HB above 80 in an untrasfused patient at 36 weeks - can be post post delivery Monitor bloods post transfusion since HB can drop Do transfusion if worsening maternal anaemia or evidence of FGR- consider regular transfusions for ex. Every two weeks Top up of HB below 100, aim is to continue transfusions until reaches HB 120 Another aim is pre transfusion HB around 100

Answer 32

IV antibiotics IV fluids to keep up with 3rd space loss and t maintain an adequate urine output. Increased vascular permeability means that 3rd space losses can be significant. Haematocrit can give an indication of these losses. In early severe actute pancreatitis fluid requirements of 150-300ml/hr would not be unusual- aim is for urine output of 0.5 ml/kg/hr Analgesia - will prob need opioids VTE prophylaxis Nutrition Consider critical care if organ support needed Antibiotics only if infection!!! Imaging - best done 5 days after onset of symptoms , CT or MRI Modification of risk factors to prevent more episode; cholecystectomy, manage lipids, alcohol - best cholecystectomy done with in 2 weeks of discharge , 12-24w gestation or after delivery Triglyceride levels will reduce by period of nil-by-mouth or use of a sliding scale Consider endocrine referral

Answer 33

To take aspirin 75mg and LMWH low dose

Answer 34

Hydrocortisone 5mg TDS and fludrocortisone 0.1mg BD Hydrocortisone is the preferred glucocorticoid because it does not pass the placenta Hydrocortisone has an mineralocorticoid effect: 40mg of HC equals 0.1mg of fludrocortisone, So and increase in fludrocortisone is not essential However prednisolone does not have an MC effect and the fludrocortisone dose might be increased by 20-30%

Answer 35

Generalized fatigue, increased weakness, High BP, high BMs, increase in weight Increased cortisol levels in the ACTH-dependent types and some adrenal concerns, elevated androgens. 60% of it accounts from adrenal adenoma in pregnancy , whereas pituitary dependent Cushing’s syndrome account for 70% of those outside of preg. Adrenal adenoma do not cause excess androgens secretion hence they are less likely to cause menstrual irregularities Adrenal hyperplasia and some adrenal carcinomas produce large amounts of androgens and spontaneous pregnancy is very unlikely

Answer 36

Onset occurring during gestation or with in 12 months of delivery or miscarriage - this may result from nodular hyperplasia of the adrenals stimulated by placentally produced ACTH or as a result of stimulation of ACTH receptors in a pre-existing but undiagnosed adrenal adenoma by ACTH from the placenta

Answer 37

It’s hard due to high levels of cortisol in pregnancy already, low dose Dexamethasone suppression test don’t work Do: Midnight plasma cortisol level OR Salivary cortisol @ night in combo with urinary free cortisol can be reliable , if 3x upper limit Cushing at preg.

Answer 38

Proximal myopathy Easy bruising Osteopenia/osteoperosis induced fractures Hirsutism from androgens Early onset hypertension in preg Reds or purple stria

Answer 39

Sick day rules - aimed to prevent the occurrence of adrenal crisis -always wear a medical alert bracelet/necklace -double the dose of oral glucocorticoid in cases of fever or illness requiring bed rest -provide intramuscular hydrocortisone for self-administration in cases of gastroenteritis or during fasting

Answer 40

Should receive IV HC typically between 100 and 200mg/day together with appropriate fluid resuscitation During labour delivery stress doses of GC should be administered -no studies on this

Answer 41

In primary aldosteronism (PA) - aldosterone production is inappropriately high for Na status, relatively autonomous of the major regulator of secretion (Angiotensin II and plasma potassium concentration) and non-suppressible by sodium loading The inappropriately elevated aldosterone leads to tissue damage suppression of plasma renin and hypokalaemia, sodium retention, hypertension, cardiovascular and renovascular diseases. Th most common causes of primary aldosteronism are **bilateral idiopathic hyperaldosteronism (60-70%) ** and **unilateral adrenal adenoma (30-40%)** . unilateral adrenal hyperplasia, familial hyperaldosteronism type 1 and pure aldosterone-producing adrenocortial carcinoma are rare causes. In the non pregnant state, PA was estimated to account for <1% of hypertension owing to the detection method that required the presence of hypokalaemia. Since hypokalaemia is no longer a prerequisite, PA is currently estimated to account for 3-15% of all pateints with hypertension. MAIN CLASSICAL PRESENTION IS HYPERTENSION AND MAY HAVE HYPOKALAEMIA and resistant hypertension - especially if before 20 w. The diagnosis of PA in pregnancy is based on suppressed renin and elevated aldosterone-to renin ratio. . Confirmatory testes is required if hypokalaemia but also if K+ normal because it could lead to critical volume expansion. MRI may be performed during the second or third trimesters to determine the subtype of PA. Whereas adrenal vein sampling is not performed because of high radiation exposure. If surgery is not considered as a treatment for PA during pregnancy, both MRi of adrenals and adrenal veins sampling which helps localize the site of the tumor for surgery should be postponed until after delivery.

Answer 42

Pheochromocytoma and paragangliomas (PPGL) are rare neuroendocrine tumors arising from neural crest-derived cells of the sympathetic and parasympathetic nervous systems. A Pheochromocytoma is a tumor causing excessive production of catecholamines, adrenaline, noradrenaline and dopamine, by the chromaffin cells of the adrenal medulla. A paraganglioma results from excessive production of catecholamines by the chromaffin cells located int he extra-adrenal sympathetic paraganglia, typically in the abdomen and pelvis. PPGL can be sporadic or hereditary such as von hipped Linus syndrome , MEN2, neurofibrimatosis type 1 - all Are autosomal dominant SYMPTOMS: Headache, sweating tachycardia - classic triad but is not common in preggo In preggo- orthostatic hypotension, arrhythmia, chest pains convulsions, syncope, blurring of vision, weight loss, papilloedema, insulin resistance, hyperglymaemia, high ESR, phsych disorders and erythrocytes is

Answer 43

Is part of the neonatal lupus erythrematous spectrum - manifests as annular inflammatory lesions which appear much like lesions of subacute cutanous SLE -it occurs in 5% of infants corn to anti RO/La+ave mother - lesions usually on face and scalp and usually appear after UV exposure on the first 2 weeks of life but up tp 3-6 months post partum - rash lasts usually 6 months until baby clears maternal antibodies

Answer 44

Congenital Adrenal hyperplasia - AR disorder , impaired cortisol synthesis secondary to enzyme deficiency 22 MC enzyme def. Is 21-hydroxylase def. (21 HD) Others: 11b-hydroxylase deficiency and 17a-hydroxyl are deficiency 21- HD- can classicary present at birth w, enhanced ACTh drives excess adrenal androgen production = clitoral enlargement, labial fusion, secular ambiguity at birth, even ininnapropate sex assignment 755 of patient of birth genders present at birth with sever hypo-Na caused by salt wasting as a result of severe aldosterone deficiency - non classical CAH secondary to 21 HD have features similar to PCOD including hirsutism primary or secondary amenorrhea or anuvulatory infertility

Answer 45

hypertension, proteinuria with or without haematuria and renal impairment Is caused by autoantibodies which produce immune complexes these are deposited in the kidneys and they activate the complement cascade causing a generalized inflammatory response The presence of haematuria or red cell casts as well as rise in anti-dsDNA titres or fall in complement levels help to distinguish this from PET The only tool to properly distinguish PET from lupus rephritis is a renal biopsy In cases of lupus nephritis that fail to respond to increasing dosages of steroids and azathioprine and where there is a deterioration of renal function and or hypertension other immunosuppressive drugs may be considered such as mycophenolate mofetil or tacrolismus

Answer 46

MIR pituitary will usually show avascular necrosis

Answer 47

35% 30-40 out of the 100 children exposed to valproic acid in utero with have lifelong difficulties, learning, thinking

Answer 48

2% Antibodies Ro and la cross the placenta and destroy baby purkinje system Usually presents as fixed fetal bradycardia of 60-80 beats per minutes on USS Recurrence rate of 16% in subsequent pregnancies Usually about half of infants need pacing by the first year of life The heart block develops between 18-28 weeks of gestation and fetal echo should be performed around this time to detect it Hydrops fetalis can occur in utero and is thought to be due to the degree of endomyocardial fibrosis and associated myocarditis

Answer 49

Microscopy, of thick and thin blood films for parasites and rapid diagnostic tests are the standard tools available Rapid detection tests may miss low parasitaemia which is more likely in pregnant women and rapid detection tests are relatively insensitive in P vivax malaria A positive rapid diagnostic tests should be followed by microscopy to quantify the number of infected red blood cells parasitaemia and to confirm the species and the stage of parasites

Answer 50

If PEF > 80% = good control of asthma Step 1- Mild intermittent asthma treatment = inhaled short acting reliever (B2 agonist) medication PRN Step 2 - If usage of reliever B2-agonist exceeds 3 times per weeks, regular inhaled anti-inflamatory meds with a steroid preventer needed eg beclomethasone inhaler 400nanog/day Step 3- either addition of a long acting reliever B2 agonist (LABA) eg. salmeterol or and increase int he dose if inhaled steroid (800nanog/day) Step 4- trial of additional therapies eg. Leukotriene receptor antagonist , slow release oral theophylline or oral B2 agonist . Alternatively the dose of inhaled steroid can be increased to 2000nanog/day Step 5- If these measures fail to achieve control then continuous or frequent use of oral steroids becomes necessary All patients with acute asthma attacks should get oral steroids

Answer 51

P vivax Ovals Malarial They do not cause sequestration like in the more fatal one P falciparum where parasites are found sequestered in the placenta

Answer 52

Vertical transmission occurs if parasites in the placenta All babies whose mom had malaria in preg. Need to be screened with standard microscopy of thick and thin blood films at birth and weekly blood films for 28 days.

Answer 53

Mefloquine is the recommended drug of choice for prophylaxis int he second and 3rd trimesters for chloroquine- resistant areas. With very few areas in the world free from chloroquine resistance , mefloquine is essentially the only drug considered safe for prophylaxis in pregnant travelers

Answer 54

Chemoprophylaxis can be causal or suppressive Sausal prophylaxis is directed against liver schizont stage which takes approximately 7 days to develop so these drugs ex. Atovaquione-proguanil need to be continued for 7 days after leaving a malarias area Suppressive prophylaxis such as mefloquine is directed against liver against the red blood cell stages of the malaria parasite and so should be continued for 4 weeks after leaving a malaria area

Answer 55

Needs to be CMV negative Kell typing, CDE compatibility

Answer 56

HbC All others are serious haemogloninopathies

Answer 57

Parvovirus B19- erythrovirus infection - causes a red cell maturation arrest and an aplastic crisis characterized by a reticulocytopenia. Reticulocyte count should be requested in any woman presenting with an acute anaemia and if low may indicate infection with erythrovirus Treatment = blood transfusion and isolation for woman With erythrovirus infection there is risk of vertical transmission to the fetus which can results in hydrops fetalis

Answer 58

Acute painful cases - causes haemoytic anaemia and vaso-occlusion on the small blood vessels Stroke Pulmonary hypertension Renal dysfunction Retinal disease Leg ulcers Cholelithiasis A vascular necrosis- femoral head may need dip replacement

Answer 59

Screening for pulmonary hypertension with echo Incidence of pulmonary hypertension in increased in patients with SCD . A tricuspid regurgitation jet velocity of >2.5m/s is associated with a height risk of pulmonary hypertension . Needs an echo if one not done in last year Blood pressure and urinalysis should be performed to identify women with hypertension and or proteinuria . Renal and liver function test should be done annually to indtify sickle nephropathy and or deranged hepatitic function Retinal screening. Proliferation retinopathy is common in patients with SCD, especially patients with HBSC. And can lead to vision loss. Recommended that women be screened pre conception Screening for iron overload in women who have had multiple transfusions in the past and how have a high ferritin lever. T2 cardiac magnetic resonance imaging may be helpful to assess body iron loading . Agressive iron chelation before conception is advisable in women who are significantly iron loaded Screening for red cell antibodies. Red cell antibodies may indicate an increased risk of haemolytic disease of the newborn

Answer 60

Known as sickle trait (AS) It is asymptomatic except for a possible increased risk of UTId and microscopic haematuria HBSS = sickle cell anaemia HbSC HbSB thalassaemia

Answer 61

Is a cerebrovascular disorder associated with multifocal arterial constriction and dilation. It has a significant association with the postpartum period. RCVS is characterized by recurrent sudden onset and severe deadaches over 1-3 weeks. Often accompanies by nausea, vomiting, photophobia, confusion and blurred vision. Diagnosis requires the demonstration of diffuse arterial beading on **cerebral angiography** with resolution within 1-3 months. It is in the differenctial of a postpartum thunderclap headache often made after subarachnoid haemorrhage has been excluded but the headaches recur. Treatment is currently based on expert opinion including the use of calcium channel blockers, high-dose corticosteroids and magnesium sulphate.

Answer 62

AD- 50 % risk of fetus affected by cagenital heart disease With aortic root dimension of 25mm there is a 10-20% risk of maternal cardiac event Aortic root dimension of 45mm there is a risk of 40-100% risk of maternal cardiac event

Answer 63

2.5-5% with risk of fetus affected by congenital heart disease at 1%

Answer 64

Autosomal dominant - CATCH22 C- cardiac defects A- Abnormal fancies T- thymi’s aphasia C- cleft palate H- Hypocalcaemia 22- Chromosome 22 deletion Cardiac defects may be - associated with tetralogy of fallot (pulmonary stenosis with ventricular septal defect and overriding aorta with right ventricular hypertrophy. - has a **5-10% risk of maternal cardiac event** - carrier of the 22Q11.2 deletion

Answer 65

ECG = torsade de pointes LQTS is characterized by prolonged QT interval on the ECG secondary to a disorder of ventricular myocardial repolarisation , this can lead tp verntricuarl arrhythmias typically torsade de points and risk of sudden death There is a significant increase in the risk of cardiac events in the postpartum period especially if has type 2 LQTS , less in pregnancy. ,

Answer 66

AD typically- autosomal dominant 10-20% risk of maternal cardiac event 50% risk of fetus affected

Answer 67

A fib and A flutter are uncommon in pregnancy and usually associated with cardiac pathology such as Mitral stenosis Metabolic and electrolyte abnormalities Fibrillation - atrial muscle bites contract independently in an irregular manner ; absence of P waves and irregular ventricular contraction. Flutter- atria beat regularly at a rate of 300 beats per minute with ventricular rate of 150 1:2 conduction ; sew tooth appreareane on the ECG secondary

Answer 68

Atrial fibrillation or flutter increases the risk of systemic embolism in an already pro-thrombotic state of pregnancy. If persistent atrial fibrillation should be anticoagulated-LMWH

Answer 69

First line treatment is direct cardioversion Is stable can use pharmacological methods - IV Flecainide or butilide AV nodal blocking drugs are used as rate control in prophylaxis for paroxysmal episodes of if cardioversion cannot be achieved - ie beta blockers

Answer 70

Supraventricular tachycardia SVT Most commonly paroxysmal SVT PSVT is caused by an atrioventricular nodal re-entrant tachycardia - in this arrhythmia a re-entry circuit occurs via the AV noted and surrounding perinodal atrial tissue Another common cause of PSVT is the presence of an overt or concealed accessory pathway which allows conduction to bypass the AV node Wolf parkinson white syndrome- delta wave

Answer 71

Palpitation with abrupt onset and offset Symptoms of; syncope, chest pain, haemodynamic compromise are variable and in part influenced by whether structural heart disease is also present

Answer 72

Vagal manoeuvres ie valsalva manoeuvre or IC adenosine This terminated 90% of SVT in pregnancy Can also use verapamil, metoprolol , direct current cardioversion , particularly if there is haemodynamic compromise Prophylactics if know PSVT= beta blockers

Answer 73

Night time serum cortisol level A midnight plasma cortisol level could be used as the preliminary screening test because the diurnal variation of cortisol is maintained during pregnancy and with a higher lowest point what’s in the non-pregnant population. The use of salivary cortisol at night in the combination with urinary free cortisol are reliable confirmatory diagnostic tools in preggo. Late night salivary cortisol and urinary free cortisol greater than 3 times the upper limit of normal are diagnostic of Cushing’s syndrome on pregnancy. The low dose dexamethasone (1mg) suppression test may lead to false positive results because of pregnancy induced hypercortsolism. But **failure to suppress cortisol following a high dose of dexamethasone (8Mg) is in keeping with a diagnosis of Cushing’s syndrome in pregnancy.** The usual post dexamethasone ACTH suppression in Cushing;s syndrome which is confirmatory of diagnosis is often not observed in pregnancy, probably because placental ACTH production is not suppressed by dexamethasone.

Answer 74

Would not have cortisol suppression after high dose of dexamethasone and with a normal to low ACTH level are likely to have adrenal Cushing’s SYNDROME Normally - dexamethasone would suppress cortisol levels!

Answer 75

Would have cortisol suppression following dexamethasone (?high dose) but with a high ACTH MRI used for imaging modality for suspected pituitary lesions as well and adrenal masses

Answer 76

Morning serum cortisol and plasma ACTH levels Recap of symptoms: high K+, low Na, low BP, hypoglycemia, weight loss, prolonged vomiting hyperpigmentation in skin folds Physiological changes in preggo include increased cortisol 2-3 times higher at term than normal ppl due to , Estrogen induced increased corticosteroid binding globulin , increased cortisol half life secondary to decrease in hepatic clearance and placental production of cortisol--releasing hormone , which induces adrenal hypertrophy and enhances its responsiveness to synthetic ACTH administration. In normal people with addisons you find morning cortisol < 140 in combination with an elevated ACTH concentration. >2x above the upper limit of the reference interval. DO a short syntactin test! - this is when IV or IM 250 mcg of synthetic ACTh given in the mane -a normal response to the SST is a rise in serum cortisol concentration after 30-6 min to >500 - 550 Pregnant women with highly suggestive clinical features but an indeterminate SST should be offered treatment during pregnancy and retested after delivery

Answer 77

PA, primary hyperaldosteronism Diagnosis is challenging in preggo because of the physiological changes that leak to extra renal stimulation of the renin angiotensin aldosterone system Usually in a woman with high BP that is resistant and low K+ especially if **before 20w of gestation*

Answer 78

PA- primary hyperaldosteronism The diagnosis of PA in preggos based on the suppressed renin and elevated aldosterone to renin ratio Confirmatory test is not only needed in the presence of hypokalaemia but is also not recommended in normokalaemic subjects because saline induction could lead to critical volume expansion MRI may be performed during the second or third trimester to determine the subtype of PA, whereas adrenal vein sampling is not performed because of high radiation exposure If surgery is not considered as treatment for PA during pregnancy both MRI of adrenals and adrenal veins sampling which may help localize the site of the tumor for surgery, should be postponed until after delivery

Answer 79

Low BP/Na⁺ → Kidney → Renin → Renin + Angiotensinogen (from liver) → Angiotensin I → ACE (lungs) → Angiotensin II → 1. Vasoconstriction (↑ BP) 2. Aldosterone release → Na⁺/H₂O retention 3. ADH release → H₂O retention 4. ↑ Thirst → Final result: ↑ BP and blood volume

Answer 80

Older woman approx 25, recurrent miscarriage, early onset pubarche , irregular menstruation and hirsutism with acne 21 hydroxylase deficiency

Answer 81

Measure serum 17alpha-hydroxyprojesterone in the morning and between day 3 and 5 of the menstrual cycle if not preggo to reduce the possibility for false positive results

Answer 82

Similar in preggo and non preggo 24 hour urine collection for plasma free metanephrines or urinary fractionated metanephrines Meds that might cause false positives: tricyclic antidepressants, resperine, phenoxybenzamines, clonidine, levodopa, amphetamines, ethanol, most antipsychotics, decongestants, and procholperazine Then CT of the abdominal and functional meta-iodobenzylguanidine (MIBG) scans delivery large doses of radiation hence MRI is the imaging mode of choice for the adrenal gland.

Answer 83

T wave inversion S1Q3T3 pattern - S wave in lead 1, q wave in lead 3 inverted T wave in lead 3. RBBB

Answer 84

lateral cutaneous nerve of the thigh

Answer 85

L2, L3 Compression of the nerve as it exits the pelvis under the inguinal ligament can result in meralgia paraesthetica 2. symptoms, including numbness, pain, paraesthesia, hyperalgesia and hypersensitivity to heat. Specific to this condition, there are no motor symptoms, the sensory changes do not cross the midline of the thigh and the symptoms can be reproduced by pressure or Tinel’s test on the lateral inguinal ligament 3. 4. 5. Treatment relies on relieving nerve compression. Patients can be advised to lose excess weight and wear loose clothing In cases occurring in late gestation or labour, delivery of the fetus, the passage of time and simple analgesia should suffice Local corticosteroid injections, neuropathic pain medications (for example, amitriptylline, which is safe in breastfeeding) and, in severe cases, surgical decompression may also be needed

Answer 86

L4, L5 The lumbosacral trunk can be compressed between the sacrum and the fetal head or obstetric forceps. 2. The nerve fibres that are usually damaged contribute to the common peroneal nerve; therefore, lumbosacral trunk injuries cause foot drop and paraesthesia, or loss of sensation along the lateral calf and foot. 3. careful examination often shows mild weakness in other areas, such as knee flexion, hip abduction, extension and internal rotations. This enables lumbosacral trunk lesions to be distinguished from pure common peroneal nerve injuries 4. Treatment relies on physiotherapy and neuropathic pain medications.

Answer 87

L2, L3, L4 The course it takes means that femoral nerve injuries are caused by stretching or compression at the inguinal ligament rather than compression between the fetal head and pelvis. 2. 3. Femoral neuropathy results in weakness of knee extension with or without hip flexion, and pain, paraesthesia, or loss of sensation in the anterior thigh and medial calf. Femoral nerve lesions can be bilateral in up to 25% of cases, although bilateral symptoms postpartum should always prompt urgent investigation with magnetic resonance imaging (MRI) to rule out a central lesion. 4. Careful neurological examination is therefore always required TO DIFFRENTIATE between Lesions to the nerve roots (radiculopathy) of the upper lumbar plexus (L2/L3), retroperitoneal lesions and peripheral lesions. 5. Simple analgesia, neuropathic pain medication or femoral nerve blocks. Muscle weakness resulting in the knee ‘giving way’ can be managed with physiotherapy and a knee brace for support. The prognosis is usually excellent.

Answer 88

L2, L3, L4 Because it enters the true pelvis, it can also be damaged by compression by the fetal head. The lithotomy position stretches the nerve as it exits the obturator foramen and therefore may also predispose to injury The obturator nerve supplies motor nerves to the hip adductors and sensory nerves to the medial portion of the thigh. Obturator neuropathy is bilateral in around 25% of cases and results in isolated weakness of hip adduction and loss of sensation over the medial thigh. Treatment involves physiotherapy and reassurance; the prognosis is usually excellent.

Answer 89

The common peroneal nerve arises from the sciatic nerve in the posterior thigh and is vulnerable to compression (for example, from lithotomy supports) or traumatic injuries when it runs around the head of the fibula to reach the anterior calf causes foot drop and impaired sensation over the lateral and anterior calf and foot As noted above, pure common peroneal nerve injuries must be carefully distinguished from lumbosacral trunk injuries by examination and – possibly – by nerve conduction studies. 4. They should also be distinguished from injuries of the sciatic nerve, which will cause hamstring weakness and sensory/motor symptoms in the anterior/lateral/posterior lower leg, not just the anterolateral areas that are innervated by the common peroneal nerve. 5. Patients classically develop a high stepping gait to compensate for foot drop, but remain vulnerable to trips and falls. An ankle foot orthosis (AFO brace), supplied by a physiotherapist, will help reduce the risk.

Answer 90

An inherited bleeding disorder-common - THE MC one Results from a qualitative or quantitative deficiency of Von willebrand factor which is a large and complex glycoprotein essential for leveled dependant primary haemostasis and also for carriage of the factor 8 in the circulation Types: 1- partial quantitative 2- qualitative 3- severe quantitative All women with VWD should have VWF antigen levels and activity and factor 8 levels checked at booking in the third trimester and prior to any invasive procedures If Type 1 who have normal VWF levels can be safely managed in standard obs units in comb with haemophilia Centre staff

Answer 91

Synthetic reversible competitive inhibitor to the lysine receptor found on plasminogen. The binding of this receptor prevents plasmin (activated form of plasminogen) from blinding to and ultimately stabilizing the firin matrix Antifibrinolytic

Answer 92

TXA tranexamic acid should be considered in combination with treatment for all those with VWF activity less than 0.5iu/ml or as sole therapy for those with levels above 0.5iu/ml if clinically indicated This can be given orally or IV and can be started prior to delivery

Answer 93

An X-linked condition associated with reduction or absence of clotting factor 8 (haemophilia A) or 9 (haemiphilia B) Known or potential female carriers may have low factor 8/9 levels. Levels need to be checked prior to invasive procedures or in association with bleeding symptoms . They are at risk of bleeding at procedures like terminations, miscarriage and at time of delivery All carriers of haemophilia with male fetuses should be offered third time steer amnicentesis if diagnostic investigations have not previously been performed to determine haemiphilia status to inform options for delivery

Answer 94

Recombinant factor 9 is required to cover invasive or surgical procedures in women with factor levels less than 0.5iu/ml

Answer 95

Prothrombin complex concentrate

Answer 96

Rare bleeding disorders have been defined as monogenic bleeding disorders caused by deficiency of a soluble coag factor other than VWD and haemiphilia A or B They represent 3-5% of all inherited coagulation deficiencies and include inherited deficiencies of fibrinogen , all the factors mentioned above , combined factor 5+8 deficiencies and congenial deficiency of vitamin K dependent factors

Answer 97

If factor 2 if less than 0.2 is/ml and there is significant bleeding established labour or prior to CS , prothrombin complex concentrate 20-40iu/kg should be given to achieve factor II activity 0.2-0.4 iu/ml. further prothrombin complex concentrate 10-20 iu/kg at 48-hour intervals should be considered to maintain factor II activity moreover than 0.2 iu/ml for at least 3 days. Women already receiving prophylactic prothrombin complex concentrate can continue it throughout pregnancy

Answer 98

Give desmopressin Desmopressin can be given to raise factor antenatally if factor 9 or 8 are under 0.5 iu/ml

Answer 99

Widespread urticarial papules over the abdomen in a linear pattern matching the areas of excoriation It’s one of the most common types of urticaria’s affecting 2-5% of the population The condition manifests as an allergic like reaction causing a warm red wheal to appear on the skin, it is often the result of scratches involving contact which other materials , it can be confused with an allergic reaction when it fact it is the act of being scratched that causes a wheal to appear.

Answer 100

Women who have migraines are 2 times more likely to have PET 17 times more likely to have a stroke 4x more likely to have an MI Can treat with triptans in preggo and low does amitriptyline

Answer 101

1. Thrombosis of the Sagittarius sinus with secondary extension Gino the orbital begins 2. Primary thrombosis of the cortical veins

Answer 102

MRV - magnetic resonance imaging with T2 weighted imaging and magnetic resonance venography CT- only catch 30% of them Suspected to do FU MRC at 3-6 months post to see if recanalisation of the occluded sinuses

Answer 103

Headache focal neurological sign - 6th cranial nerve palsy , worsening headache, diplopia, confusion ( unilateral failure of abduction of the eye) The greatest risk is on the 3rd trimester and first 4 weeks postpartum

Answer 104

Worsening headache after epidural, which is fronto-occipital worse on standing and radiating to the neck Puncture of the dura occurs in 0.5-2.5% of epidurals and if there is accidental dural puncture with an epidural needle there is a 70-80% chance of psotdural puncture headache. Conservative management includes hydration and simple analgesics Untreated heache typically lasts for 7-10 days but can be up to 6 weeks Epidural blood patch has 60-90% cure rate

Answer 105

1. atrial and ventricular ectopics 2. left shift in the QRS axis 3. small Q wave and inverted T wave in lead III 4. ST segment depression and T wave inversion in the interior (II,III, aVF) and lateral leads (?I, aVL, V5,V6)

Answer 106

if a woman has a very early severe or atypical presentation of OC

Answer 107

if pruritus is associated with atypical clinical symptoms or early onset severe OC

Answer 108

once bile acids are 100 or more to 3.44% in moderate its unchanged until 39w then its 0.28

Answer 109

if bile acids 40 or more or women who're 34 weeks

Answer 110

if OC only if there appears to be reduced absorption of dietary fats ie steatorrhoea and or evidence of abnormal PT if coat studies are performed

Answer 111

after one week before making any clinical decisions

Answer 112

Mild- 19-39 test weekly as they approach 38w in order to inform birth moderate - 40-99 consider testing weekly around 35w as timing of birth may be influenced if levels go to 100 servere- 100 or more- may not need to test more because you know you have to deliver early , only if impact care plans

Answer 113

severe 35-36w moderate - 38-39 mild- by 40w

Answer 114

yes if severe OC offer CFM

Answer 115

yes do baseline LFTs and bile acids at booking

Answer 116

mild - 16% mod- 19% severe- 30%

Answer 117

VQ scan or a CTPA

Answer 118

do alternative or repeat testing and don't stop antigoaculatiojn until PE is def excluded

Answer 119

stop antigcoagulats but repeat USS on day 3 and 7

Answer 120

<50kg 40mg BD or 60mg OD 50-69kg 60mg BD or 90mg OD 70-89kg. 80mg BD or 120mg OD 90-109kg. 100mg BD of 150mg OD 110- 125kg 120mg BD or 180 mg OD >125kg DW haemtologia

Answer 121

echo and CTPA in 1 hour treat with IV unfractionated heparin - lower louver and anti xa 0.35-0.7

Answer 122

80units/kg then continued at 18units/kg/hr

Answer 123

platelet count on day 4 to 14 every 2-3 days

Answer 124

omit loading dose of unfractionaed heparin and just start infusion

Answer 125

yes , test APTT 4-6h post loading dose and 6h after any dose change

Answer 126

1.5- 2.5 time the average lab control value <1.2 +4 units/kg/h dose change 1.2-1.5 +2 1.5-2.5. no change 2.5-3. -2 >3 -3

Answer 127

protamine sulphate

Answer 128

1) cardiac failure in the last month of preg or within 6 months of del 2) no cause for cardiac failure 3) no recognizable heart disease in the last months of preg 4) left vent dysfunction - EF less than 45% or reduced shorting fraction

Answer 129

four times greater Than the 5% prev of PET in the general population world wide

Answer 130

IDC- idopathic dilated cardiomyopathy, and valvular heart disease

Answer 131

-Furosemide! -consider bromocriptine 2.5cm BD for 2 weeks followed by 2.5mg per day for 6 weeks - anticoagulation if EF < or equal to 35 or on bromo BROMO CAUSES CLOTS!! - if cardiogenic shock consider levosimendan instead of catecholamines

Answer 132

LEVOSIMENDAN

Answer 133

yes can also limi active phase with aid of instrumental delivery

Answer 134

slow- infusion of synto in the first line recommended drug to avoid sudden hemodynamic change

Answer 135

misoprostol and carboprost

Answer 136

in the hospital because they might have a vasovagal and if PPCM they have a high risk of cardiac arrhythmias and arrhythmias tend to cause vasovagal collapse

Answer 137

echo -pre conception end of 1st and second trimester once a month before delivery from the 3rd trimester post delivery one month after delivery

Answer 138

Stenotic and regurgitant STENOTIC causes: -rheumatic heart disease for mitral lesions - congenital bicuspid valves with SUPERIMPOSED calcification for aortic lesions THESE MAY LEAD TO PULMONARY OEDEMA REGURGItANt - both aortic and mitral regurgitation typically arise as complication of - rheumatic -congenital or -degenerative disease WOMEN WITH REGURGITANT lesions on valves tolerate preggo well since there is minimal impact on their ability to increase cardiac output compared to stenotic valves

Answer 139

mitral regurgitation dural abnormalities heart failure arrhythmias can get aneurysm or dissection anywhere

Answer 140

if ascending aorta >45mm (or > 40mm in family his of dissection or sudden death)

Answer 141

aortic stenosis or regurgitation can have aneurysm or dissection in the ascending aorta - risk is less than 1% of dissection

Answer 142

is ascending aorta is > 50mm

Answer 143

bicuspid aortic valve coarctation HTN may dissect or have aneurisms in ascending aorta, arch and descending aorta

Answer 144

if ASI > 25mm/m2 aortic size index

Answer 145

No at risk of uterine rupture

Answer 146

Fetal echo at 19-22w

Answer 147

Need B blockers if not in them outside of pregnancy

Answer 148

All by 40w Vaginal delivery for most

Answer 149

Preterm labour for women on PO anticoagulats Aggresive aortic pathology Acute intractable heart failure Sever pulmonary hypertension + eisenmenger’s

Answer 150

1. pulmonary hypertension 2. ejection fraction, less than 30% NYHA 3-4 3. severe coarctation 4. systemic right ventricle / Fontans circulation with recused function or comorbidities 5. vascular EDS 6. Aortic dilatation >4cm or Hx of aortic dissection 7. severe mitral stenosis 8. severe aortic stenosis if symptomatic , reduced LVF or fail ecervcise test 9. previous permpartum cardiomyopathy where LVEF not normalized

Answer 151

significantly increased risk of maternal mortality or severe morbidity expert counselling if pregnancy is decided upon mechanical valve systemic Right ventricle fontan cirulation cyanotic heart disease unprepared aortic dilation 40-45mm in marfans syndrome aortic dilatation 45-50mm in aortic disease associated with bicuspid aortic valve

Answer 152

20-50% TOp should be discussed

Answer 153

yes mortality 0-3% heart failure occurs in one 3rd of pregnancy women with moderate mitral stenosis and 50% of severe MS

Answer 154

1st line is valsalva maneuver if fails - IV adenosine alternatives - verapamil, metoprolol or direct current cardioversion- especially if haemodynamically unstable

Answer 155

beta blockers

Answer 156

IV Flecanide or Butilide if haemodynamically unstable patient for direct cardioversion

Answer 157

sotalol or flecanide if haemodynamically unstable patient for direct cardioversion

Answer 158

Torsade de pointes and a sudden death risk in preg long QT events are less common but after preg is the riskier time especially is type 2 LQTS WOMEN NEED TO STAY ON BETA BLOCKERS THROUGHOUT PREG AND AFTER!

Answer 159

SIDS - one study staid 10% of cases

Answer 160

In an emergency yes- overall no - risk of neonatal hypothyroidism

Answer 161

BMI >35 Other high risk patients such as those with previous DVT or thrombophilia will also need LMWH. Flying in Pregnancy Key Points Single pregnancy advise not to fly beyond 37 weeks Twin pregnancy advise not to fly beyond 32 weeks Flights < 4 hours typically require no special measures Flights > 4 hours use measures listed below Some patients at high risk will require heparin injection Measures to reduce DVT risk whilst flying Wear loose clothing/shoes Regular walks and mobilisation In-seat exercises every 30 minutes Good hydration Avoid alcohol or caffeine Graduated elastic compression stockings Contraindications to flying whilst pregnant Severe anaemia (hb <7.5 g/dl) Recent haemorrhage Otitis media and sinusitis Serious cardiac or respiratory disease Recent sickling crisis Recent gastrointestinal surgery Bone fracture, where significant leg swelling may occur in flight

Answer 162

Neuroaminidase inhibitor treatment is recommended in pregnant women with seasonal and pandemic influenza The Department of Health recommends that all pregnant patients, regardless of stage of pregnancy, are offered vaccination during influenza season. In 2010 pregnancy was added as a clinical risk factor for routine influenza vaccination. MBRRACE UK 2014 reported 36 deaths due to influenza, with over half of these deaths being classified as preventable as they did not receive vaccination. DoH/RCOG guidelines recommend that antiviral treatment be commenced as early as possible in pregnant women with signs of influenza.

Answer 163

During the first 3–10 days postpartum women may experience low mood (the blues). This is very common affecting between 50–80% of women. The signs are symptoms are variable but they may display emotional lability and tearfulness or become anxious and irritable. It often lasts about 48 hours with the peak on day 5 postpartum. Symptoms are mild, self limiting and will require reassurance and monitoring.

Answer 164

Anaphylactoid syndrome of pregnancy/amniotic fluid embolus

Answer 165

Maternal blood test for fetal genotyping for K antigen after 20 weeks of gestation Non-invasive fetal genotyping using maternal blood is now possible for D,d,C, c, E, e and K antigens. This should be performed in the first instance for the relevant antigen when maternal red blood cell antibodies are present. Genotyping can be undertaken from 16 weeks of gestation for all except K, which can be undertaken from 20 weeks, due to the risk of a false negative result if performed earlier in pregnancy. Although anti-K titres do not correlate well with either the development or severity of fetal anaemia, titres should nevertheless be measured every 4 weeks up to 28 weeks of gestation and then every 2 weeks until delivery.

Answer 166

Pseudomonas aeruginosa Pseudomonas rarely causes pneumonia, but it is a common cause in patients with cystic fibrosis. It is associated with short and long term decline in lung function; treatment should be prompt and aggressive. It is also known to cause pneumonia in immunocompromised patients and those on ventilators.

Answer 167

50% Spontaneous preterm birth prevention in multiple pregnancy Key Points 3% of all live births are twin pregnancies Twin babies account for up to 15% of special care unit admissions Twin pregnancies 3x greater perinatal mortality than singleton pregnancies 50% of twin pregnancies deliver before 37 weeks gestation 10% deliver before 32 weeks gestation Up to 24% of successful in vitro fertilisation (IVF) procedures resulting in multiple pregnancy No good evidence for cervical cerclage, vaginal progesterone, pessary, oral tocolytics or bed rest in preventing PTB in multiple pregnancies

Answer 168

IVF The risk of placental abruption is higher in pregnancy following assisted reproductive techniques Placental abruption Keypoints Placental abruption refers to early separation of the placental from the uterus It is an important cause of antepartum haemorrhage Synptoms typically involve PV bleeding and abdominal/pelvic pain. May present with a shocked woman and fetal distress/compromise. Placental abruption occurs in about 1 in 200 pregnancies Typically occurs around 25th week gestation Risk factors Abruption in previous pregnancy (most predictive) Pre-eclampsia Fetal growth restriction Non-vertex presentations Polyhydramnios Advanced maternal age Multiparity Low BMI Pregnancy following assisted reproductive techniques Intrauterine infection PROM Abdominal trauma Smoking Drug misuse (cocaine and amphetamines) during pregnancy Weak association with some thrombophilias Recurrence rates of placental abruption 4.4% risk of recurrence Risk increased to 19-25% in women with 2 previous pregnancies complicated by abruption

Answer 169

25% Death of one monochorionic twin is thought to cause circulatory changes with the surviving twin losing circulatory volume to the dying twin and becoming hypo perfused. This carries the following risks for the surviving twin: Death 15% Neurological abnormality 26% Monochorionic Twin Pregnancy Monochorionic twin pregnancy is one where both babies are supplied by a single shared placenta. In the UK 1 in 3 twin pregnancies are monochorionic. Twin to twin transfusion syndrome (TTTS) can arise in monochorionic twin pregnancy which can be fatal to the co-twin.

Answer 170

Factor VIII and Factor IX levels For known carriers of severe haemophilia maternal factor VIII and IX should be checked at booking, before any antenatal procedure and in the third trimester. Factor VIII levels tend to rise in pregnancy where as factor IX tends to remain stable. Factor VIII/IX levels of at least 0.5 iu/ml should be targeted to cover surgical or invasive procedures and/or spontaneous miscarriage. If treatment is required factor levels of 1.0 iu/ml should be targeted and levels kept at 0.5 iu/ml or above until haemostasis is achieved. Inherited Bleeding Disorders Haemophilia Haemophilia is an X-linked genetic condition leading to clotting factor deficiency and bleeding tendency. Haemophilia A results in clotting factor VIII deficiency Haemophilia B results in clotting factor IX deficiency Factor VIII/IX levels should be kept at or above 0.5 iu/ml. Pharmacological methods of raising factor levels are tranexamic acid, DDAVP and recombinant factor VIII/IX

Answer 171

3.5% Acute fatty liver of pregnancy Epidemiology Rare obstetric emergency Aetiology thought to be deficiency of LCHAD (3-hydroxyacyl-CoA dehydrogenase) leading to accumulation of medium and long chain fatty acids 5 cases per 100 000 maternities in the UK AKI is a common complication. 14% of patients in the UK develop renal impairment. 3.5% require renal replacement

Answer 172

Persistent low IQ

Answer 173

Red Cell Antibodies Red cell antibodies are important as they may cause severe fetal anaemia and lead to poor neonate outcomes. Antibody titre Level at which patient should be referred to fetal medicine specialist (iu/ml) Anti-D >4 Anti-C >7.5 Anti-K Refer if detected Anti-E Refer if anti-C antibodies present Monitoring after referral level triggered Weekly fetal middle cerebral artery peak systolic velocities (MCA PSV) MCA PSV above 1.5 multiples of the median then refer back to fetal medicine specialist for consideration invasive treatment Monitoring Frequency Anti C,D and K levels every 4 weeks until 28 weeks then every 2 weeks until delivery

Answer 174

Dopamine receptor agonist Lactation Suppression Lactation Suppression Key Points Lactation/Galactopoiesis is maintained via the action of Prolactin Lactation will usually stop naturally within 7 days when suckling ceases Lactation may be suppressed by using drugs that inhibit prolactin but these are not without side effects. Cabergoline and Bromocriptine and the most commonly used drugs for lactation suppression Reasons for pharmacological suppression of lactation There are a number of reasons mothers may wish to stop lactation: Stillbirth/adoption Maternal infection eg HIV (especially if not on retroviral therapy) Prolonged lactation after stopping breastfeeding (other causes hyperprolactinaemia should be excluded)

Answer 175

Placenta Praevia Placenta praevia describes when the placenta is inserted (partially or completely) into the lower segment of the uterus. Ultarsound Grading Classification: Grade I: low lying placenta: placenta lies in lower uterine segment but its lower edge does not abut the internal cervical os (i.e lower edge 0.5-5.0 cm from internal os). Grade II: marginal praevia: placental tissue reaches the margin of the internal cervical os, but does not cover it Grade III: partial praevia: placenta partially covers the internal cervical os Grade IV: complete praevia: placenta completely covers the internal cervical os NOTE Sometimes grades I & II termed 'minor' praevia whilst III and IV termed 'major' praevia. AIUM Classification The 2018 greentop guidelines noted the American Institute of Ultrasound in Medicine (AIUM) classification is potentially superior to the above gradings. Candidates should be aware of both as the RCOG has not explicitly advised use of the old grades be discontinued and questions may still emerge on the old gradings. Under the new system the following terms are used: Placenta praevia: is used when the placenta lies directly over the internal os. Low lying placenta: For pregnancies greater than 16 weeks of gestation when the placental edge is less than 20 mm from the internal os. Normal: Placental edge is 20 mm or more from the internal os on TAS or TVS

Answer 176

No Advise flying contraindicated This patient has severe anaemia which is a contraindication to commercial air travel (see list below) Flying in Pregnancy Key Points Single pregnancy advise not to fly beyond 37 weeks Twin pregnancy advise not to fly beyond 32 weeks Flights < 4 hours typically require no special measures Flights > 4 hours use measures listed below Some patients at high risk will require heparin injection Measures to reduce DVT risk whilst flying Wear loose clothing/shoes Regular walks and mobilisation In-seat exercises every 30 minutes Good hydration Avoid alcohol or caffeine Graduated elastic compression stockings Contraindications to flying whilst pregnant Severe anaemia (hb <7.5 g/dl) Recent haemorrhage Otitis media and sinusitis Serious cardiac or respiratory disease Recent sickling crisis Recent gastrointestinal surgery Bone fracture, where significant leg swelling may occur in flight

Answer 177

Zanamivir Zanamivir is recommended for first line use in immunocompromised patients, or when oseltamivir resistance is confirmed. Intravenous zanamivir may be used in critically ill or severely compromised patients.

Answer 178

Oseltamivir as long as resistance in not confirmed

Answer 179

If flight is over 4 hours then the compression stalkings should be used Flying in Pregnancy Key Points Single pregnancy advise not to fly beyond 37 weeks Twin pregnancy advise not to fly beyond 32 weeks Flights < 4 hours typically require no special measures Flights > 4 hours use measures listed below Some patients at high risk will require heparin injection Measures to reduce DVT risk whilst flying Wear loose clothing/shoes Regular walks and mobilisation In-seat exercises every 30 minutes Good hydration Avoid alcohol or caffeine Graduated elastic compression stockings Contraindications to flying whilst pregnant Severe anaemia (hb <7.5 g/dl) Recent haemorrhage Otitis media and sinusitis Serious cardiac or respiratory disease Recent sickling crisis Recent gastrointestinal surgery Bone fracture, where significant leg swelling may occur in flight

Answer 180

Desmopressin (DDAVP) can be used antenatally to raise factor VIII levels. Due to antidiuretic effect fluid restriction for 24 hours or U&E monitoring will be required. Recombinant factor VIII should be used if levels obtained with DDAVP are inadequate Recombinant factor IX is required to cover invasive or surgical procedures in women with factor levels less than 0.5 iu/ml Tranexamic acid should be considered in combination with other treatment for all those with levels of less than 0.5 iu/ml. Inherited Bleeding Disorders Haemophilia Haemophilia is an X-linked genetic condition leading to clotting factor deficiency and bleeding tendency. Haemophilia A results in clotting factor VIII deficiency Haemophilia B results in clotting factor IX deficiency Factor VIII/IX levels should be kept at or above 0.5 iu/ml. Pharmacological methods of raising factor levels are tranexamic acid, DDAVP and recombinant factor VIII/IX

Answer 181

97% Vs 75% if createnine >125 Pregnancy appears to have a minimal adverse effect on the long term graft prognosis, provided that pre pregnancy renal function is satisfactory (serum creatinine <125 micromol/l), and there is no graft rejection. Prophylactic anticoagulation is not required unless the women develops significant proteinuria or has additional risk factors. Tacrolimus levels should be checked every 2–4 weeks, but azathioprine levels are not required. Prophylactic antibiotics are not required on the basis of renal transplant alone.

Answer 182

25% Family studies investigating postnatal depression have found that women with a history of major depression and a family history of postnatal depression are more likely to experience postnatal depression than those without a family history (42% versus 15% of first deliveries, respectively). A history of postnatal episodes in first degree relatives is an important predictive risk factor in patients with recurrent depression. Studies show that the greatest risk period in women with a family history is thought to be in the first 6–8 weeks of the postnatal period.

Answer 183

Renal impairment Acute fatty liver of pregnancy Epidemiology Rare obstetric emergency Aetiology thought to be deficiency of LCHAD (3-hydroxyacyl-CoA dehydrogenase) leading to accumulation of medium and long chain fatty acids 5 cases per 100 000 maternities in the UK AKI is a common complication. 14% of patients in the UK develop renal impairment. 3.5% require renal replacement

Answer 184

Parvovirus B19 NICE advise contacting the local virology/microbiology/infectious disease unit for clarification of tests but they are likely to include Parvovirus B19-specific IgG and IgM and may need viral PCR. Note Rubella should also be tested for as can cause similar symptoms Parvovirus B19 Background The RCOG published a safety alert on Parvovirus B19 following a potentially avoidable death of a baby in 2012. In children typically presents with characteristic diffuse erythematous facial rash - 'slapped cheek' following around 5 days of prodromal symptoms In adults symptoms often atypical or asymptomatic in up to 50% of cases Infectivity period is 7-10 days before the rash develops to 1 day after rash onset Incubation period is typically around 7 days (range 4-14 days) Investigations In healthy children and adults diagnosis is usually clinical and no lab confirmation is required. If a pregnant woman has had exposure to Parvovirus or is suspected of having Parvovirus then serological tests are indicated. NICE advise contacting the local virology/microbiology/infectious disease unit for clarification of tests but they are likely to include Parvovirus B19-specific IgG and IgM and may need viral PCR. Note Rubella should also be tested for as can cause similar symptoms Results Interpretation IgG +ve / IgM -ve Immune IgG -ve / IgM -ve Susceptible to infection Positive for IgM (irrespective of the IgG result) Suggests recent infection Management Confirmed Parvovirus in Pregnancy Arrange urgent referral to a specialist in fetal medicine for serial fetal ultrasound scans and Doppler assessment to detect fetal anaemia, heart failure, and hydrops Risk of vertical transmission <15 weeks gestation - 15% 15 - 20 weeks - 25% Term - 70%

Answer 185

Anti-Kell Red cell alloimmunization rarely affects a first pregnancy, whilst platelet antigen alloimmunization can affect a first pregnancy. Antibodies which have a significant risk of causing fetal anaemia include anti-C, anti-D, and anti-Kell.

Answer 186

90% There is no prior family history of heamophilia in up to 50% of neonatal males with severe haemophilia. There is a 90% chance the mother is the gene carrier and future male offspring will be at risk. Inherited Bleeding Disorders Haemophilia Haemophilia is an X-linked recessive genetic condition leading to clotting factor deficiency and bleeding tendency. Haemophilia A results in clotting factor VIII deficiency Haemophilia B results in clotting factor IX deficiency Factor VIII/IX levels should be kept at or above 0.5 iu/ml. Pharmacological methods of raising factor levels are tranexamic acid, DDAVP and recombinant factor VIII/IX

Answer 187

25% Risk factors for ARDS in pregnancy include: Tocolytic therapy Pre eclampsia/eclampsia/HELLP syndrome Amniotic fluid embolism Neurogenic pulmonary oedema after eclamptic seizure Sepsis – chorioamnionitis, endometris, septic abortion. Diagnostic criteria for ARDS include: Acute onset of respiratory failure with risk factors Bilateral chest radiographic infiltrates a pulmonary capillary wedge pressure <19 mmHg or no evidence of left atrial hypertension Impaired oxygenation manifested by a PaO2 (kPa)/FiO2 <27. (Impaired oxygenation manifested by a PaO2 (kPa)/FiO2 <40 is seen in acute lung injury.) Pregnancy related ARDS has a mortality rate of approximately 25% All cases should be managed in ITU/HDU. Management includes respiratory support, cardiovascular support and treatment of underlying cause.

Answer 188

Polydipsia and dilute polyuria Diabetes Insipidus Key Points 2-4 per 100 000 pregnant women It usually arises in the third trimester and remits spontaneously 4-6 weeks postpartum Conditions causing hepatic dysfunction such as HELLP may cause DI to develop Clinical Findings Typically presents with polydipsia and dilute polyuria True polydipsia (drinking >3 litres per day) and polyuria (passing >3 litres urine per day) Usually no clinical signs Biochemical Findings Blood osmolality >285 mOsmol/kg with urinary osmolality <300 mOsmol/kg Hypernatraemia Classification Explanation Neurogenic CNS Pathology ADH deficiency as reduced production by hypothalamus/posterior pituitary Nephrogenic Reduced sensitivity of Kidneys to ADH Gestational Transient deficiency ADH Psychogenic Excessive water consumption

Answer 189

Blood osmolality >285 mOsmol/kg with urinary osmolality <300 mOsmol/kg Hypernatraemia

Answer 190

Perpartum cardiomyopathy

Answer 191

7 days Aka parvovirus B19

Answer 192

Pyridoxine 10 mg daily Isoniazid may lead to pyridoxine (vitamin B6) deficiency induced neuropathy via a number of mechanisms. Pyridoxine supplementation is advised. Although pyrazinamide and ethambutol may cause gout prophylactic allopurinol is not routinely advised. Tuberculosis in pregnancy Key Points Outcomes are the same for those with early diagnosis and treatment of tuberculosis in pregnancy compared to pregnancies unaffected by tuberculosis Late diagnosis and treatment of pulmonary TB associated with pre-eclampsia, PPH, difficult labour, preterm labour, low birthweight and pneumonia. Extrapulmonary TB Lymphadenitis doesn't have significant effect on perinatal outcome but other extrapulmonary sites including spine, abdomen and central nervous system are associated with increased rates of fetal growth restriction and low Apgar's. Epidemiology of Tuberculosis: 14.1 per 100,000 population (UK) 44.3 per 100,000 in London 4.2 per 100,000 pregnancies Almost exclusively seen in ethnic minority women during pregnancy in the UK Treatment 1st line for active disease is: Isoniazid, rifampicin, ethambutol and pyrazinamide. 1st line for latent TB: Isoniazid and rifampicin Isoniazid can cause neuropathy - vitamin B6 (pyridoxine) supplementation should be offered to avoid this

Answer 193

Staphylococcus aureus Influenza virus Chlamydia pneumoniae Haemophilus influenzae

Answer 194

Do not offer anti-D immunoglobulin prophylaxis to women who: • receive solely medical management for an ectopic pregnancy or miscarriage or • have a threatened miscarriage or • have a complete miscarriage or • have a pregnancy of unknown location. [2012] Do not use a Kleihauer test for quantifying feto-maternal haemorrhage. [2012]

Answer 195

Biologic used in RA rheumatoid arthritis Stop taking at 28w , restart immeadiately after delivery Breastfeeding is safe for patients taking anti-TNF biologic medication Etanercept and anti-TNF drugs in general are safe to use when breastfeeding. NOTE If this patient has a perineal tear or delivered by c-section then it is advisable to withhold biologics for a few days until initial wound healing has occurred to reduce infection risk Biologics in pregnancy (TNF) Background Biological agents refer to biological molecules that are used primarily to treat auto-immune conditions They are also sometimes referred to as cytokine modulators Starting biologics Aware patients immune system will be suppressed and increasing susceptibility to infection Vaccines need to be up to date prior to commencing Live vaccines contraindicated once on biologics (live vaccines shouldn't be given if pregnant) Should be screened for latent TB infection and treated prior to starting Consider biologics may increase risk of some cancers. Use caution in those with past history cancer or premalignant conditions e.g. HPV infection/cervical cancer Risk of immediate hypersensitivity reactions 3-5% Anti-TNF If used in pregnancy the risk of fetal malformations are similar to those of the general population. Growing evidence that safe to use in pregnancy. Flare ups of disease associated with worse maternal and fetal morbidity Concerns that anti-TNF accumulates in the neonate as transplacental transfer increases in later stages of pregnancy and could lead to immunosuppression To avoid neonatal immunosuppression it is recommended anti-TNF drugs are stopped in pregnancy as below: Drug Advised gestation to stop taking Safe with breastfeeding Etanercept Stop prior to third trimester Yes Infliximab Stop at 16 weeks gestation Yes Adalimumab Stop prior to third trimester Yes Certolizumab Safe all trimesters Yes

Answer 196

1st free fetal DNA for sex, then if male do chorionic villous sampling fetal sex determination by free fetal DNA analysis from 9 weeks of gestation It is important here to determine the sex of the fetus prior to deciding on invasive testing. Carriers of severe haemophilia should be offered fetal sex determination by free fetal DNA analysis from 9 weeks of gestation. Severe haemophilia carriers with a male fetus at risk should then be offered the option of PND with chorionic villus sampling at 11-14 weeks of gestation Carriers with a male fetus should be offered third trimester amniocentesis if diagnostic investigations have not previously been performed

Answer 197

Start ART in the second trimester so at 13w The aim is to suppress the viral load to <50 HIV RNA copies/mL plasma by the time of delivery. Major determinants of whether this is possible is baseline viral load and duration of treatment. Studies have shown those who are on treatment for <16 weeks have greater risk of vertical transmission. HIV in Pregnancy (antiretroviral therapy in pregnancy) Antiretroviral therapy (ART) in pregnancy ART is mostly unlicensed for use in pregnancy Zidovudine is licensed in the third trimester Women who conceive on effective combination of ART (cART) should continue throughout pregnancy Atypical regimes such as protease inhibitor (PI) monotherapy should be modified Zidovudine is now rarely used as part of cART due to concerns about toxicity Data shows no difference in pregnancy outcomes between zidovudine-based and zidovudine-sparing cART Data does not support increased risk of congenital malformations with cART so far but some agents have insufficient data Starting cART if not taking All pregnant women, including elite controllers, should start cART during pregnancy and continue lifelong BHIVA recommend treatment of all people living with HIV regardless of CD4 cell count or clinical status All women should have commenced ART at the latest by week 24 of pregnancy Evidence mounting that cART is safe in the first trimester but due to theoretical risks initiation of cART is often delayed until the start of the second trimester. Current advise is to start ART at start of second trimester* *If a women presents with opportunistic infection treatment should not be delayed due to pregnancy *Start in 1st trimester if VL >100,000 HIV RNA copies/mL and/or CD4 cell count is less than 200 cells/mm³ Deciding Mode of delivery in women taking cART Viral load should be checked at 36 weeks then delivery planned as follows: Viral Load at 36 weeks Recommendation < 50 HIV RNA copies/mL Vaginal delivery 50–399 HIV RNA copies/mL PLCS considered Take into account the actual viral load, trajectory of viral load, length of time on treatment, adherence issues, obstetric factors and the womans views ≥400 HIV RNA copies/mL PLCS

Answer 198

Complication Incidence with Caesarian section for placenta praevia Emergency hysterectomy 11% (27% in women with prior c-section) Massive obstetric haemorrhage 21% Further Laparotomy 7.5% Bladder or ureteric injury up to 6% VTE up to 3% Future placenta praevia 2.3%

Answer 199

Low BMI! Advanced mat age Smoking Multiparity PolyH Keypoints Placental abruption refers to early separation of the placental from the uterus It is an important cause of antepartum haemorrhage Synptoms typically involve PV bleeding and abdominal/pelvic pain. May present with a shocked woman and fetal distress/compromise. Placental abruption occurs in about 1 in 200 pregnancies Typically occurs around 25th week gestation Risk factors Abruption in previous pregnancy (most predictive) Pre-eclampsia Fetal growth restriction Non-vertex presentations Polyhydramnios Advanced maternal age Multiparity Low BMI Pregnancy following assisted reproductive techniques Intrauterine infection PROM Abdominal trauma Smoking Drug misuse (cocaine and amphetamines) during pregnancy Weak association with some thrombophilias Recurrence rates of placental abruption 4.4% risk of recurrence Risk increased to 19-25% in women with 2 previous pregnancies complicated by abruption

Answer 200

1.2% Red cell antibodies are important as they may cause severe fetal anaemia and lead to poor neonate outcomes. Antibody titre Level at which patient should be referred to fetal medicine specialist (iu/ml) Anti-D >4 Anti-C >7.5 Anti-K Refer if detected Anti-E Refer if anti-C antibodies present Monitoring after referral level triggered Weekly fetal middle cerebral artery peak systolic velocities (MCA PSV) MCA PSV above 1.5 multiples of the median then refer back to fetal medicine specialist for consideration invasive treatment Monitoring Frequency Anti C,D and K levels every 4 weeks until 28 weeks then every 2 weeks until delivery

Answer 201

Salbutamol 2.5 mg nebuliser and prednisolone 40 mg orally for 5 days Michelle is already using the maximum dose of her salmeterol/fluticasone inhaler. Although there is more evidence for the safety of budesonide than fluticasone in pregnancy, women who are already receiving fluticasone should continue to receive it unless there are other indications to change. Nebulised salbutamol is no more effective at a 5 mg than a 2.5 mg dose but is more likely to result in a tachycardia. Michelle should have at least 5 days of prednisolone 40 mg. Previous

Answer 202

This is benign but there is a risk of malignant transformation of around 5% Hepatic adenoma have a risk of malignant transformation of around 5% These lesions are benign but there is a risk of malignant transformation of around 5% (range 4-10%) Liver mass in pregnancy Key Points 20% of population have a benign liver lesion Pathology of most hepatic masses can be determined by multimodal imaging 1st line imaging non-contrast ultrasonography 2nd line imaging includes: contrast ultrasonography, CT liver (triple-phase protocol), contrast MRI or even nuclear scintigraphy or PET-CT Blood and tissue biopsy rarely required Summary of Solid Liver Lesions Seen in Pregnancy Lesion Type Features Ultrasound Hepatic haemangioma Most common solid benign liver lesion Typically asymptomatic. Rarely rupture Present in around 10% of healthy individuals Most common in middle age women Typically slow growing Arise from vascular endothelial cells well circumscribed and hyperechoic Focal Nodular Hyperplasia 2nd most common benign liver lesion Present in 3% of adults 85% of lesions in women of reproductive age 78% solitary nodules 84% have diameter around 5cm hypo echoic or isoechoic mass occasional detection of central scar as thin hyper echoic zone Hepatic adenomas Typically seen in young females using CHC Incidence 35 per million in CHC users vs 1 per million in those who have never used CHC Solitary 32%, Multiple (2-9) 45%, Adenomatosis (10+) 23% Presence of mass but USS may not provide further characterisation Hepatocellular carcinoma Extremely rare in UK

Answer 203

Productive cough Breathlessness Fever Consolidation on lung Sputum culture negative

Answer 204

Intrauterine growth restriction Uncontrolled hyperthyroidism in pregnancy is associated with the following fetal complications: High miscarriage rate Intrauterine growth restriction (IUGR) Low birth-weight baby. Stillbirth. Neonatal thyroid dysfunction. Hyperthyroidism Hyperthyroidism in pregnancy occurs in 2 in 1,000 pregnancies in the UK Management Options Antithyroid Drugs 1st Line Propylthiouracil crosses 1st Choice as crosses placenta less readily than carbimazole Carbimazole NOTE: Radioiodine is contra-indicated Beta-Blockers May be used but use should be limited to a few weeks as may adversely affect fetus Surgery Only when absolutely necessary. Patient needs to be euthyroid prior to surgery

Answer 205

2-4 weeks after birth and 10-14 weeks post delivery

Answer 206

The disadvantages of almost daily haemodialysis may include hypocalcaemia, alkalosis and hypokalemia. Conversely, an increased dialysis frequency will allow for a more liberal diet and protein intake, improving the nutritional status. Pregnancy outcomes are improved when the sessions are prolonged to 4 hours, occurs six times a week, the fluid removal is limited to 400 ml per session, and the predialysis serum creatinine is maintained at 4.5 mg/dl (397.8 micromol/l) or serum urea less than 15 20 mmol/'. Duration of haemodialysis must be increased to more than 20 hours/week for improved outcome Note that: The chance of successful pregnancy outcome is 50% with both haemodialysis and CAPD. Poor prognostic features includes age >35 years, more than 5 years on dialysis, delayed diagnosis of pregnancy leading to late increase in dialysis times Dialysis is associated with polyhydramnios related to uraemia The aim is to maintain serum urea at less than 15–20mmol/l Pregnancy rate is approximately 1 in 200 women per year.

Answer 207

Viral pneumonia with small nodules on x ray throughout lungs

Answer 208

X ray shows poorly defined patchy areas of consolidation throughout both lung fields. Can also have vomiting and water diarrhea The symptoms and signs suggest a viral pneumonia, which is usually diffuse rather than being lobar as for bacterial pneumonia. In women who are not immunocompromised, influenza is the most likely cause.

Answer 209

Hypertensive disorders during pregnancy affect around 8-10% of all pregnant women and can be associated with substantial complications for the woman and the baby. Note hypertensive disorders include gestational hypertension, chronic hypertension and pre-eclampsia. Hypertension The guidelines on management of hypertensive disorders in pregnancy were updated by NICE in 2019. Management of gestational hypertension Hypertension (BP 140/90–159/109 mmHg) Severe hypertension BP ≥ 160/110 mmHg Admit No Yes (consider discharge if BP falls below 160/110mmHg) Antihypertensive pharmacological treatment If BP remains > 140/90 mmHg Offer treatment to all women Target BP 135/85 mmHg or less 135/85 mmHg or less Investigations BP once or twice weekly Urine dipstick once or twice weekly Bloods (FBC,U&E,LFT) at presentation then weekly PIGF as one off Fetal heart auscultation at each appointment Fetal USS at diagnosis. Repeat if indicated BP every 15-30 minutes until below 160/110mmHg Urine dipstick daily whilst admitted Bloods (FBC,U&E,LFT) at presentation then weekly PIGF as one off Fetal heart auscultation at each appointment Fetal USS at diagnosis. Repeat every 2 weeks if hypertension persists Management of pre-eclampsia Hypertension (BP 140/90–159/109 mmHg) Severe hypertension BP ≥ 160/110 mmHg Admit If clinical concerns (see box below) If high risk on fullPIERS and PREP‑S Yes (consider discharge if BP falls below 160/110mmHg) Antihypertensive pharmacological treatment If BP remains > 140/90 mmHg Offer treatment to all women Target BP 135/85 mmHg or less 135/85 mmHg or less Investigations BP minimum every 48 hours Urine dipstick only repeat if clinically indicated Bloods (FBC,U&E,LFT) twice a week Fetal heart auscultation at each appointment Fetal USS at diagnosis. Repeat every 2 weeks CTG at diagnosis BP every 15-30 minutes until < 160/110mmHg then QDS whilst admitted Urine dipstick only repeat if clinically indicated Bloods (FBC,U&E,LFT) three times a week Fetal heart auscultation at each appointment Fetal USS at diagnosis. Repeat every 2 weeks Clinical concerns that would prompt admission: Sustained systolic blood pressure ≥ 160 mmHg Rise in creatinine (90 micromol/litre or more, 1 mg/100 ml or more) Rise in alanine transaminase (> 70 IU/litre, or twice upper limit of normal range) Drop in platelet count (under 150,000/microlitre) Signs of impending eclampsia Signs of impending pulmonary oedema Other signs of severe pre-eclampsia Suspected fetal compromise Other clinical signs that cause concern. Choice of antihypertensive in pregnancy induced hypertension & pre-eclampsia 1st line: Labetalol 2nd Line: Nifedipine 3rd line: Methyldopa NICE Definitions Pre-eclampsia Pre-eclampsia refers to pregnancy-induced hypertension in association with proteinuria. It has traditionally been diagnosed based on findings of a systolic blood pressure >140 mm Hg (or diastolic blood pressure >90 mm Hg) in the second half of pregnancy with ≥1+ proteinuria on reagent stick testing. NICE advice the following diagnostic criteria for pre-eclampsia: New onset of hypertension (over 140 mmHg systolic or over 90 mmHg diastolic) after 20 weeks of pregnancy PLUS one of the following: Proteinuria (urine protein:creatinine ratio of ≥ 30 mg/mmol or albumin:creatinine ratio of 8 mg/mmol or more, or at least 1 g/litre [2+] on dipstick testing) OR Renal insufficiency (creatinine 90 micromol/litre or more, 1.02 mg/100 ml or more) OR Liver involvement (elevated transaminases [alanine aminotransferase or aspartate aminotransferase over 40 IU/litre] with or without right upper quadrant or epigastric abdominal pain) OR Neurological complications such as eclampsia, altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata OR Haematological complications such as thrombocytopenia (platelet count below 150,000/microlitre), disseminated intravascular coagulation or haemolysis OR Uteroplacental dysfunction such as fetal growth restriction, abnormal umbilical artery doppler waveform analysis, or stillbirth. Severe hypertension Blood pressure >160 mmHg systolic (or > 110 mmHg diastolic) Severe pre-eclampsia Pre-eclampsia with severe hypertension that does not respond to treatment or is associated with ongoing or recurring severe headaches, visual scotomata, nausea or vomiting, epigastric pain, oliguria and severe hypertension, as well as progressive deterioration in laboratory blood tests such as rising creatinine or liver transaminases or falling platelet count, or failure of fetal growth or abnormal doppler findings. Eclampsia A convulsive condition associated with pre-eclampsia

Answer 210

Still birth Uncontrolled hyperthyroidism in pregnancy is associated with the following fetal complications: High miscarriage rate Intrauterine growth restriction (IUGR) Low birth-weight baby. Stillbirth. Neonatal thyroid dysfunction. Hyperthyroidism Hyperthyroidism in pregnancy occurs in 2 in 1,000 pregnancies in the UK Management Options Antithyroid Drugs 1st Line Propylthiouracil crosses 1st Choice as crosses placenta less readily than carbimazole Carbimazole NOTE: Radioiodine is contra-indicated Beta-Blockers May be used but use should be limited to a few weeks as may adversely affect fetus Surgery Only when absolutely necessary. Patient needs to be euthyroid prior to surgery

Answer 211

1.5 multiples of the median (MoM) Referral should be made if the MCA PSV is 1.5 multiples of the median (MoM) or there are other signs of fetal anaemia. Red Cell Antibodies Red cell antibodies are important as they may cause severe fetal anaemia and lead to poor neonate outcomes. Antibody titre Level at which patient should be referred to fetal medicine specialist (iu/ml) Anti-D >4 Anti-C >7.5 Anti-K Refer if detected Anti-E Refer if anti-C antibodies present Monitoring after referral level triggered Weekly fetal middle cerebral artery peak systolic velocities (MCA PSV) MCA PSV above 1.5 multiples of the median then refer back to fetal medicine specialist for consideration invasive treatment Monitoring Frequency Anti C,D and K levels every 4 weeks until 28 weeks then every 2 weeks until delivery

Answer 212

A serum urea > 17 mmol/l despite medical management is a pregnancy-specific indicator for renal replacement therapy A serum urea > 17 mmol/l despite medical management is a pregnancy-specific indicator for renal replacement therapy Urea is teratogenic. A serum urea > 17 mmol/l despite medical management is a pregnancy-specific indicator for renal replacement therapy GFR typically increases in pregnancy. Creatinine typically decreases. A creatinine >90 µmol/l is diagnostic of acute kidney injury in pregnancy The incidence of renal impairment is higher in HELLP than pre‐eclampsia. AKI complicates 3-15% of cases of HELLP. Pre‐eclampsia leads to AKI in only 1.5-2% of cases Acute Kidney Injury in pregnancy Key Points Increased renal blood flow and glomerular filtration rate in pregnancy Serum creatinine falls by approximately 35 µmol/l in pregnancy Non pregnant creatinine reference ranges not accurate Any creatinine > 90 µmol/l in pregnancy should be considered diagnostic of AKI AKI complicates 1.4% of UK obstetric admissions Pre-eclampsia most common cause Pre‐eclampsia leads to AKI in only 1.5–2% of cases Management involves careful fluid management, drug review and in severe cases renal replacement therapy

Answer 213

14% Renal impairment is the most common complication of acute fatty liver of pregnancy Acute fatty liver of pregnancy Epidemiology Rare obstetric emergency Aetiology thought to be deficiency of LCHAD (3-hydroxyacyl-CoA dehydrogenase) leading to accumulation of medium and long chain fatty acids 5 cases per 100 000 maternities in the UK AKI is a common complication. 14% of patients in the UK develop renal impairment. 3.5% require renal replacement

Answer 214

20% Myasthenia Gravis in Pregnancy Aetiology Myasthenia Gravis (MG) is an autoimmune disease caused by antibodies against the nicotinic acetylcholine receptor or other postsynaptic antigens Epidemiology Female:Male ratio 2:1 Typically presents age 20-30 Effect of Pregnancy on Maternal MG Symptoms worsened for 40%* Symptoms unchanged in 30% 30% had remission No evidence that MG adversely affects pregnancy outcomes Effect of Pregnancy on Neonate Transient neonatal MG (TNMG) effects approx 20% of infants born to MG mothers Transient neonatal MG is due to transfer of maternal antibodies (IgG anti‐AChR antibodies) *Exacerbations typically occur in the first trimester and in the first 3 months postpartum Management considerations Starting glucocorticoid therapy or withdrawing immunosuppressant therapy may exacerbate MG Infections require prompt treatment as may cause exacerbation Pregnant patients with MG should be assessed for baseline motor strength, pulmonary function and ECG Thyroid function tests advised. Thyroid dysfunction in 10-15% Approx 15% of persons with MG have thymoma Patients with thymoma who have not undergone thymectomy present with a higher incidence of exacerbation during pregnancy and higher risk neonatal MG Thymectomy should be considered before conception or after delivery (not during pregnancy) MG most commonly caused by IgG anti‐AChR antibodies. Patients with anti‐MuSK antibodies generally have worse clinical symptoms and TNMG TNMG Infants with TNMG typically develop symptoms within 12 h to 4 days of delivery Symptoms resolve spontaneously after 3-4 weeks due to antibody degradation MG Drugs in Pregnancy

Answer 215

Pathological gambling Cabergoline has been associated with pulmonary, retroperitoneal, and pericardial fibrotic reactions. Treatment with dopamine-receptor agonists are also associated with impulse control disorders including pathological gambling, binge eating, and hypersexuality. Lactation Suppression Lactation Suppression Key Points Lactation/Galactopoiesis is maintained via the action of Prolactin Lactation will usually stop naturally within 7 days when suckling ceases Lactation may be suppressed by using drugs that inhibit prolactin but these are not without side effects. Cabergoline and Bromocriptine and the most commonly used drugs for lactation suppression Reasons for pharmacological suppression of lactation There are a number of reasons mothers may wish to stop lactation: Stillbirth/adoption Maternal infection eg HIV (especially if not on retroviral therapy) Prolonged lactation after stopping breastfeeding (other causes hyperprolactinaemia should be excluded)

Answer 216

There is N) increased risk of congenital malformations Prematurity 25% Preexisting and GDM 14-20% Increased SB Higher miscarriage rates are found in those with low preconception BMI's Cystic fibrosis and pregnancy Background Over 10,000 people with CF in the UK 1 in 25 of the population is a carrier of the cystic fibrosis gene mutation 71 women with CF in the UK had babies in 2016 Median age at death 31 Women with CF and pregnancy Relatively normal fertility Proportion of live births is 70-90% Spontaneous miscarriage rate is no higher than the general population Congenital malformations no higher to babies born to mothers with CF than general population Prematurity rate is approximately 25% Higher rates of spontaneous preterm labour Pre-existing and gestational diabetes are more common in pregnancies in women with CF (incidence 14-20%) Increased risk of pregnancy complications including preterm delivery and stillbirth Women with good lung function (FEV1 70% predicted) tolerate pregnancy better and have more successful outcomes. With declining lung function the risk of poor pregnancy outcome increases as does maternal mortality

Answer 217

Refer for urgent USS If low lying placenta or placenta praevia are identified on TAS at 18-21 weeks gestation then follow up scanning is typically organised at 32 weeks The exception is women with previous caesarean section or history of placenta accreta spectrum (PAS) who are at higher risk of developing placenta accreta in this pregnancy. They should be referred for ultrasound to identify PAS. If there is no evidence of PAS on ultrasound they can be returned for a follow up scan at 32 weeks. If there is evidence of PAS they are referred to a specialist centre.

Answer 218

42% Short cervical length is a good predictor of preterm birth. Cervical length at 20-24 weeks Risk <25mm 25% risk of delivery before 28 weeks gestation <20mm 42.4% risk of delivery before 32 weeks gestation <20mm 62%risk of delivery before 34 weeks gestation Spontaneous preterm birth prevention in multiple pregnancy Key Points 3% of all live births are twin pregnancies Twin babies account for up to 15% of special care unit admissions Twin pregnancies 3x greater perinatal mortality than singleton pregnancies 50% of twin pregnancies deliver before 37 weeks gestation 10% deliver before 32 weeks gestation Up to 24% of successful in vitro fertilisation (IVF) procedures resulting in multiple pregnancy No good evidence for cervical cerclage, vaginal progesterone, pessary, oral tocolytics or bed rest in preventing PTB in multiple pregnancies

Answer 219

Stop at week 16 of gestation With infliximab it is advised by the BSR guidelines to stop at 16 weeks gestation. The reason is concern with increasing transplacental transfer later in pregnancy and risk of accumulation in the fetus leading to neonatal immunosuppression. Biologics in pregnancy (TNF) Background Biological agents refer to biological molecules that are used primarily to treat auto-immune conditions They are also sometimes referred to as cytokine modulators Starting biologics Aware patients immune system will be suppressed and increasing susceptibility to infection Vaccines need to be up to date prior to commencing Live vaccines contraindicated once on biologics (live vaccines shouldn't be given if pregnant) Should be screened for latent TB infection and treated prior to starting Consider biologics may increase risk of some cancers. Use caution in those with past history cancer or premalignant conditions e.g. HPV infection/cervical cancer Risk of immediate hypersensitivity reactions 3-5% Anti-TNF If used in pregnancy the risk of fetal malformations are similar to those of the general population. Growing evidence that safe to use in pregnancy. Flare ups of disease associated with worse maternal and fetal morbidity Concerns that anti-TNF accumulates in the neonate as transplacental transfer increases in later stages of pregnancy and could lead to immunosuppression To avoid neonatal immunosuppression it is recommended anti-TNF drugs are stopped in pregnancy as below: Drug Advised gestation to stop taking Safe with breastfeeding Etanercept Stop prior to third trimester Yes Infliximab Stop at 16 weeks gestation Yes Adalimumab Stop prior to third trimester Yes Certolizumab Safe all trimesters Yes

Answer 220

Reassure women that any reduction in HbA1c level towards the target of 48 mmol/mol (6.5%) is likely to reduce the risk of congenital malformations in the baby. Diabetes In Pregnancy NICE updated its guidance on management of diabetes in pregnancy in 2015. The current guidelines advise the following regarding management including new HBA1C targets: Advise women with diabetes who are planning to become pregnant to aim to keep their HbA1c level below 48 mmol/mol (6.5%), if this is achievable without causing problematic hypoglycaemia. Reassure women that any reduction in HbA1c level towards the target of 48 mmol/mol (6.5%) is likely to reduce the risk of congenital malformations in the baby. Strongly advise women with diabetes whose HbA1c level is above 86 mmol/mol (10%) not to get pregnant because of the associated risks.

Answer 221

Advise avoid trying to conceive (UPSI) for 3 months If a female wishing to conceive travels to a Zika area then she should avoid trying to conceive until 2 months after returning from that area. If her partner also travels to a Zika area attempts to conceive should be avoided for 3 months. Testing for Zika is only advocated in some scenarios when the woman is already pregnant (see the RCOG article link). It is not recommended for couples wishing to conceive. It is recommended that women should avoid becoming pregnant while travelling in a country or area with risk for of Zika virus transmission. If a couple is considering pregnancy, consistent use of effective contraception is advised to prevent pregnancy and barrier methods (e.g. condom use) are advised during vaginal, anal and oral sex to reduce the risk of conception and the developing fetus being exposed to Zika virus. These measures should be followed while travelling and for: 3 months after return from an area with risk for Zika virus transmission, or last possible Zika virus exposure, if both partners travelled 3 months after return from an area with risk for of Zika virus transmission, or last possible Zika virus exposure, if just the male partner travelled 2 months after return from an area with risk for Zika virus transmission, or last possible Zika virus exposure if only the female partner travelled Note this advice changed in 2019. Prior to 2019 the advice was to implement these measures for 6 months. Zika virus and pregnancy Zika virus virus family: Flaviviridae genus: Flavivirus Sngle stranded RNA virus Transmitted primarily by Aedes mosquitos Can be transmitted sexually but risk is low Incubation period 3-12 days Typical symptoms: fever, maculopapular rash, arthralgia or conjunctivitis Rash usually resolves within 2 days but may persist up to 1 week Many asymptomatic Zika associations Guillan Barre syndrome Congenital microcephaly* Other congenital abnormalities *During the pandemic in Brazil the rate of babies born with microcephaly increased 20 fold from 5 per 100,000 to 100 per 100,000. Management if couple planning conception If male partner has travelled to Zika area the couple should delay trying to conceive ie avoid UPSI for 3 months after return from Zika area If only female partner has travelled then should avoid UPSI for 2 months after return from Zika area. Testing & Treatment No treatment available for Zika Testing is advised for women who experience symptoms suggestive of acute Zika virus infection within 2 weeks of leaving an area with high or moderate risk of Zika virus transmission OR within 2 weeks of sexual contact with a male sexual partner who has recently travelled to an area with high or moderate risk of Zika

Answer 222

A dose of 500 IU, IM is considered sufficient to treat a FMH of up to 4mL fetal red cells. Additional anti-D Ig doses calculated as 125 IU anti-D Ig/mL fetal red cells (IM) For any potentially sensitising event Rh-D negative non-sensitised women should receive a minimum dose of 500 IU anti-D Ig within 72h of the event. Rhesus Rhesus Isoimmunisation Key Points Refers to immune response when a women who does not have rhesus antigens on her red cells (Rhesus negative) is exposed to red cells that have the Rhesus antigen (Rhesus positive) Occurs when father of fetus is rhesus positive resulting in the fetus having Rhesus positive blood Once sensitised the mother may develop antibodies (IgG) to the fetal blood which can cross the placenta Antibody reaction can lead to mild anaemia, haemolytic disease of the newborn (HDN ) or even fetal death Typically occurs in pregnancy subsequent to the one where the mother becomes sensitised Rho(D) immune globulin or Anti-D is a solution of IgG antibodies that can bind to any Rh positive blood that may have entered the maternal blood stream and prevent a maternal immune reaction The use of anti-D has reduced the risk of allommunisation of Rh negative mothers from 16% to as low as 0.1%. NICE advice on ant-D in ectopic pregnancy & miscarriage: Do offer anti-D immunoglobulin prophylaxis at a dose of 250 IU (50 micrograms) to: All rhesus-negative women who have a surgical procedure to manage an ectopic pregnancy or a miscarriage Do not offer anti‑D immunoglobulin prophylaxis to women who: Receive solely medical management for an ectopic pregnancy or miscarriage Have a threatened miscarriage Have a complete miscarriage Have a pregnancy of unknown location. NICE advice on ant-D in abortion care: Do offer anti-D prophylaxis to: Women who are rhesus D negative and are having an abortion after 10+0 weeks' gestation. Do not offer anti-D prophylaxis to: Women who are having a medical abortion up to and including 10+0 weeks' gestation. Consider anti-D prophylaxis for women who are rhesus D negative and are having a surgical abortion up to and including 10+0 weeks' gestation. Anti-D Ig Key Points from BCSH Guidelines* All RhD negative pregnant women who have not been previously sensitised should be offered routine antenatal prophylaxis with anti-D Ig (RAADP) either with a single dose regimen at around 28weeks, or two-dose regimen given at 28 and 34weeks Following birth, ABO and Rh D typing should be performed on cord blood and if the baby is confirmed to be D positive, all D negative, previously non-sensitised, women should be offered at least 500 IU of anti-D Ig within 72h following delivery. Maternal samples should be tested for FMH and additional dose(s) given as guided by FMH tests Following potentially sensitising events, anti-D Ig should be administered as soon as possible and always within 72h of the event. If, exceptionally, this deadline has not been met some protection may be offered if anti-D Ig is given up to 10days after the sensitising event In pregnancies <12 weeks gestation, anti-D Ig prophylaxis is only indicated following ectopic pregnancy, molar pregnancy, therapeutic termination of pregnancy and in cases of uterine bleeding where there is repeated, heavy bleeding or associated with abdominal pain. The minimum dose should be 250 IU. A test for fetomaternal haemorrhage (FMH) is not required For potentially sensitising events between 12 and 20 weeks gestation, a minimum dose of 250 IU should be administered within 72h of the event. A test for FMH is not required For potentially sensitising events after 20 weeks gestation, a minimum anti-D Ig dose of 500 IU should be administered within 72h of the event. A test for FMH is required List of Potentially Sensitising Events Amniocentesis, chorionic villus biopsy and cordocentesis APH and PV bleeding in pregnancy External cephalic version Abdominal trauma Ectopic pregnancy Evacuation of molar pregnancy Intrauterine death and stillbirth In-utero therapeutic interventions (transfusion, surgery, insertion of shunts, laser) Miscarriage, threatened miscarriage Therapeutic termination of pregnancy Delivery Intra-operative cell salvage

Answer 223

Timing of birth Patient type Birth timing Mild ICP No other risk factors Consider options of planned birth by 40 weeks Moderate ICP No other risk factors Consider planned birth at 38–39 weeks' gestation Severe ICP Consider planned birth at 35–36 weeks' gestation Women with one or more of the following additional risk factors warrant consultant review to plan timing of birth: Gestational diabetes Pre-eclampsia Multifetal pregnancy Women with severe ICP should be offered continuous electronic fetal monitoring (CEFM) during delivery ntrahepatic cholestasis of pregnancy Diagnosis & classification There is no single diagnostic test for ICP but the diagnosis should be considered in pregnant women who have pruritus, normal skin appearance and raised peak random total bile acid concentration of 19 micromol/L or more. Onset is typically in the third trimester. The diagnosis is more likely if it is confirmed that itching and raised bile acids resolve after birth. Intrahepatic cholestasis of pregnancy (ICP) is classed according to peak bile acid levels as shown in the table below: Severity Peak bile acid concentration Mild 19–39 micromol/L Moderate 40–99 micromol/L Severe 100 micromol/L or more Prevalence In the UK, ICP affects 0.7% of pregnancies in multi-ethnic populations, and 1.2%–1.5% of women of Indian-Asian or Pakistani-Asian origin Risks Stillbirth is the major concern for pregnant people with ICP. Data suggests that for singleton pregnancies the stillbirth rate is only significantly increased above background rate in those with severe ICP (3.44% vs 0.29%). In twin and multipe pregnancy there appears to be a significant increased risk of stillbirth in pregnant women with ICP compared to those without ICP even if ICP is mild or moderate. For singleton pregnancy: In women with peak bile acids 19–39 micromol/L and no other risk factors, advise them that the risk of stillbirth is similar to the background risk. In women with peak bile acids 40–99 micromol/L and no other risk factors, advise them that the risk of stillbirth is similar to the background risk until 38–39 weeks' gestation. In women with peak bile acids 100 micromol/L or more, advise them that the risk of stillbirth is higher than the background risk Moderate or severe ICP also carries the following risks: Both spontaneous and iatrogenic preterm birth Meconium stained amniotic fluid during labour and birth More likely to receive neonatal care Investigations Additional laboratory and/or imaging investigations are not recommended unless itch is associated with atypical clinical symptoms, the presence of relevant co-morbidities, or in early onset severe ICP Note this is a change in policy from the RCOG as of 2022 following a retrospective review of 500 women with pruritus and raised bile acid concentrations found no new diagnoses following viral, autoimmune and ultrasound investigations. Given that the likelihood of identifying a viral, autoimmune, or structural cause for the itching and liver derangement that was not suspected on other clinical grounds is extremely low these tests are no longer advised. Monitoring Monitoring is typically via repeat bile acid concentration and liver function tests. Fetal ultrasound and/or cardiotocography (CTG) do not predict or prevent stillbirth in ICP. It is advised patients are monitored in a consultant led clinic given the increased risk of complications. All women should have a repeat bile acid level and liver function tests 1 week after initial test. The timing and frequency after that is down to clinical judgement. The RCOG suggest the following: If the woman has mild ICP with peak bile acids 19–39 micromol/L, they could have weekly testing as they approach 38 weeks' gestation in order to inform timing of birth. If the woman has moderate ICP with peak bile acid 40–99 micromol/L, especially if they are approaching 35 weeks' gestation, weekly testing should be considered, as timing of birth may be influenced if levels rise to 100 micromol/L or more. If the woman has severe ICP with peak bile acid 100 micromol/L or more, further routine testing of bile acids might not impact on decision making and therefore may not be routinely required Management Advise women that there are no treatments that improve pregnancy outcome (or raised bile acid concentrations) and treatments to improve maternal itching are of limited benefit.

Answer 224

Hypernatraemia, blood osmolality >285 mOsmol/kg, urine osmolality <300 mOsmol/kg Note in pregnancy normal blood osmolality decreases from around 285 mOsmol/kg to 270 mOsmol/kg. In women with GDI blood osmolality is the same as for a non-pregnant woman i.e. it is >285 mOsmol/kg. Urine osmolality can normally be double the blood osmolality but in GDI urinary osmolality is typically <300 mOsmol/kg. In normal pregnancy sodium levels are typically lower than the non-pregnant state by 4-5 mmol/l. In women with GDI sodium may be at the upper limit of normal or high depending on severity. Diabetes Insipidus Key Points 2-4 per 100 000 pregnant women It usually arises in the third trimester and remits spontaneously 4-6 weeks postpartum Conditions causing hepatic dysfunction such as HELLP may cause DI to develop Clinical Findings Typically presents with polydipsia and dilute polyuria True polydipsia (drinking >3 litres per day) and polyuria (passing >3 litres urine per day) Usually no clinical signs Biochemical Findings Blood osmolality >285 mOsmol/kg with urinary osmolality <300 mOsmol/kg Hypernatraemia Classification Explanation Neurogenic CNS Pathology ADH deficiency as reduced production by hypothalamus/posterior pituitary Nephrogenic Reduced sensitivity of Kidneys to ADH Gestational Transient deficiency ADH Psychogenic Excessive water consumption

Answer 225

Yes you can take it Rifampicin and isoniazid are not associated with an increased risk of malformations. Breast feeding should be encouraged unless there are other reasons to advise against it. Although anti-tuberculous drugs cross into breast milk the amounts are too small to cause toxicity.

Answer 226

Pregnancy has neither a beneficial nor a detrimental effect on the course of tuberculosis. Tuberculosis can obviously have an effect on pregnancy outcomes especially if diagnosed and treated late. Tuberculosis in pregnancy Key Points Outcomes are the same for those with early diagnosis and treatment of tuberculosis in pregnancy compared to pregnancies unaffected by tuberculosis Late diagnosis and treatment of pulmonary TB associated with pre-eclampsia, PPH, difficult labour, preterm labour, low birthweight and pneumonia. Extrapulmonary TB Lymphadenitis doesn't have significant effect on perinatal outcome but other extrapulmonary sites including spine, abdomen and central nervous system are associated with increased rates of fetal growth restriction and low Apgar's. Epidemiology of Tuberculosis: 14.1 per 100,000 population (UK) 44.3 per 100,000 in London 4.2 per 100,000 pregnancies Almost exclusively seen in ethnic minority women during pregnancy in the UK Treatment 1st line for active disease is: Isoniazid, rifampicin, ethambutol and pyrazinamide. 1st line for latent TB: Isoniazid and rifampicin Isoniazid can cause neuropathy - vitamin B6 (pyridoxine) supplementation should be offered to avoid this

Answer 227

ADH deficiency secondary to increased vasopressinase activity GDI is typically caused by a transient deficiency of ADH during pregnancy or postpartum. This is usually as a result of increased vassopressinase activity. Vasopressinase metabolises ADH. Vasopressinase activity is increased for two reasons: 1. Increase in placental vasopressinase production (partciulalry seen in multiple pregnancy) 2. Decreased hepatic degradation of placental vasopressinase Diabetes Insipidus Key Points 2-4 per 100 000 pregnant women It usually arises in the third trimester and remits spontaneously 4-6 weeks postpartum Conditions causing hepatic dysfunction such as HELLP may cause DI to develop Clinical Findings Typically presents with polydipsia and dilute polyuria True polydipsia (drinking >3 litres per day) and polyuria (passing >3 litres urine per day) Usually no clinical signs Biochemical Findings Blood osmolality >285 mOsmol/kg with urinary osmolality <300 mOsmol/kg Hypernatraemia Classification Explanation Neurogenic CNS Pathology ADH deficiency as reduced production by hypothalamus/posterior pituitary Nephrogenic Reduced sensitivity of Kidneys to ADH Gestational Transient deficiency ADH Psychogenic Excessive water consumption

Answer 228

Spring Epidemics typically occur on a three to five year cycle and outbreaks tend to occur during the spring.

Answer 229

50% of women at childbearing age are immune to PVB19 infection and, therefore, 50% are susceptible to infection during pregnancy.

Answer 230

Cause meningitis Meningitis In immunologically compromised patients, listeriosis is an invasive disease. It can lead to sepsis, meningitis, meningoencephalitis, cerebritis and brain abscess.

Answer 231

Blood and urine L. monocytogenes is difficult to isolate from tissue, and is much easier to isolate and culture from biological fluids such as cerebrospinal fluid (CSF), urine and blood What can you get listeria from - Soft cheese, milk shrimps, rice salad and uncooked chicken

Answer 232

Can also be sore throat , offensive vaginal discharge , general malaise, and temp Lancefield group A beta haemolytic Streptococcus is one of the most common organisms identified in pregnant women dying from sepsis. A history of recent sore throat or prolonged (household) contact with family members with known streptococcal infections (pharyngitis, impetigo, cellulitis) should increase suspicion of GAS sepsis.

Answer 233

Will she accept hepatitis B vaccination for the neonate? If the baby is vaccinated the risk of vertical transmission is <15%, even if she is highly infectious. The WHO recommends breastfeeding for all hepatitis B positive mothers as the risk of transmission from breastfeeding is outweighed by the benefits. Markers of viral activity include e antigen status (HbeAg positive status increases the risk of vertical transmission) and viral load (HB virus DNA). Women with a high viral load are more likely to be offered antiviral therapy (e.g. tenofovir) or pegylated interferon alpha.

Answer 234

Do FU / test of cure 6 months later even if will be 20 w preggo Whilst routine smears tests should be postponed until 3 months after pregnancy, test of cure or follow up smears for abnormal results should be performed when they are due. There is an increased chance of an inadequate result during pregnancy due to inflammation, ectropion and the presence of decidual cells.

Answer 235

Refer to breast team for ultrasound and tissue diagnosis by biopsy for histology Women presenting with a breast lump during pregnancy should be referred to a breast specialist team, and any imaging or further tests should be conducted within the breast multidisciplinary team. Ultrasound is used first to assess a discrete lump, but if cancer is confirmed, mammography is necessary (with fetal shielding) to assess the extent of disease and the contralateral breast. Tissue diagnosis is with ultrasound guided biopsy for histology rather than cytology, as proliferative change during pregnancy renders cytology inconclusive in many women.

Answer 236

Increase the dose of lamotrigine during the current pregnancy and reduce it again postnatally Lamotrigine requires particular attention in pregnancy. It has been conclusively shown that blood levels of this anticonvulsant fall in all three trimesters. Most women taking lamotrigine in pregnancy will require their dose to be increased to keep them seizure free. The importance of monitoring and adjusting lamotrigine dose in pregnancy was highlighted in the 2006–08 Confidential Enquiry into Maternal Deaths (CMACE) guidelines. If the woman's dose of anticonvulsant is increased during pregnancy it should be reduced postpartum to avoid toxicity. Sudden unexpected death in epilepsy (SUDEP) is known to be more common in patients who do not take their prescribed anticonvulsants, and pregnant and breastfeeding women are often reluctant to take anticonvulsants for fear of harming their baby.

Answer 237

Cerebral venous thrombosis Headache is common in pregnancy, but it can be a symptom of serious underlying illness. 'Red flag' features suggesting more sinister pathology include: Headache of sudden onset Headache associated with neck stiffness Headache described by the woman as the worst headache she has ever had Headache with any abnormal signs on neurological examination. Cerebral venous thrombosis commonly presents in the second to third week postpartum. Risk factors include obesity, thrombophilia, dehydration and infection. Presenting features include headache, seizure, focal neurological deficit and reduced level of consciousness.

Answer 238

Signs and symptoms of subarachnoid haemorrhage include sudden onset severe headache – often occipital, vomiting, impaired consciousness, hypertension, focal neurological signs, seizures, papilloedema, and neck stiffness. Cerebral angiography is the gold standard investigation as this will elucidate the cause: a berry aneurysm located in the region of the right middle cerebral artery.

Answer 239

Treatment can be instituted with therapeutic lumbar puncture, thiazide diuretics, acetazolamide, analgesics and/or corticosteroids, optic nerve sheath fenestration and lumbo peritoneal shunting. Idiopathic intracranial hypertension (previously known as benign intracranial hypertension) is more common in obese women and usually presents in the first half of pregnancy. Pre-existing intracranial hypertension can worsens in pregnancy. The associated headache is throbbing, constant, bifrontotemporal often with nausea and vomiting. Diagnosis is confirmed by finding of papilledema with or without visual loss.

Answer 240

Predisolone 40mg per day Bell's palsy. The incidence is highest in late pregnancy or the early puerperium. Symptoms are usually sudden in onset and include unilateral facial weakness. There is limited evidence regarding the role of steroids but they may speed recovery if commenced within 24–72 hours of the onset of symptoms. Physiotherapy and eye care reduce morbidity. 95% of those with partial palsy and 85% with complete facial palsy recover.

Answer 241

Less than 7 days Onset is usually early in the postnatal period – 50% of cases occur by day 7, 75% by day 16 and 95% by day 90. It is important to note that women can breakdown and relapse early in labour. Symptoms may begin from the start of labour or may be an early sign of labour.

Answer 242

In this clinical situation, the most important test would be to detect fetal rhesus antigen status. If fetus is rhesus positive, it is at risk of haemolytic disease of fetus and newborn, and the pregnancy will have to be managed with active surveillance for fetal anaemia. If the fetus is rhesus negative, the mother can be largely reassured that her isoimmunised status will not affect the fetus. Cell-free fetal DNA from maternal blood can help determine fetal rhesus status after 10 weeks of gestation. Paternal blood group could help if it is rhesus negative but various possibilities exist if it is rhesus positive.

Answer 243

Give anti D! Anti-D immunoglobulin should be given to all non-sensitised rhesus-D negative women who have an ectopic pregnancy, regardless of mode of treatment, because there is a significant chance of sensitisation. Women with indeterminate rhesus D typing results should be treated as rhesus D negative until final results areobtained and completed. Duffy antibodies. Anti-Fya and -Fyb are clinically significant RBC alloantibodies which can cause immediate and delayed hemolytic transfusion reactions (HTRs) as well as hemolytic disease of the fetus and newborn (HDFN). They often result from previous exposure such as after transfusion or pregnancy.

Answer 244

The indications for referral to fetal medicine specialist include: a history of previous significant haemolytic disease of the fetus and newborn (HDFN) intrauterine transfusion a titre of 1:32or above rising titres as it indicates the risk of severe fetal anaemia. anti-D, anti-c and anti-K antibodies ***If both anti-E and anti-c antibodies are detected, the presence of anti-B increases the severity of fetal anaemia*** Anti-K,anti-D and anti-c antibodies In case of detection of anti-K antibodies on investigation, the referral should be immediate because severe fetal anaemia occurs even at low titres. Anti-D antibody levels of <4IU/mL usually indicated anti-D immunoglobulin administration. This should be ascertained by history and documentation. When antibody levels are >4IU/mL, a fetal medicine referral is indicated. When anti-d antibody levels are 4IU/mL, there is moderate risk of developing HDFN and if this level increases to >15IU/mL then it is likely that severe HDFN can develop. These levels should prompt sincere urgent referral to fetal medicine specialist. It is recommended the such women have weekly ultrasound with assessment of fetal middle cerebral artery peak systolic velocities (MCAPSV). In situations where women have red cell antibodies and at risk of needing blood transfusion during pregnancy and labour, (e.g.women with sickle cell disease or diagnosed with placenta praevia)a cross match sample should be taken every week.

Answer 245

Yes If anti-TNF drugs are used in pregnancy the risk of fetal malformations are similar to those of the general population Biologics in pregnancy (TNF) Background Biological agents refer to biological molecules that are used primarily to treat auto-immune conditions They are also sometimes referred to as cytokine modulators Starting biologics Aware patients immune system will be suppressed and increasing susceptibility to infection Vaccines need to be up to date prior to commencing Live vaccines contraindicated once on biologics (live vaccines shouldn't be given if pregnant) Should be screened for latent TB infection and treated prior to starting Consider biologics may increase risk of some cancers. Use caution in those with past history cancer or premalignant conditions e.g. HPV infection/cervical cancer Risk of immediate hypersensitivity reactions 3-5% Anti-TNF If used in pregnancy the risk of fetal malformations are similar to those of the general population. Growing evidence that safe to use in pregnancy. Flare ups of disease associated with worse maternal and fetal morbidity Concerns that anti-TNF accumulates in the neonate as transplacental transfer increases in later stages of pregnancy and could lead to immunosuppression To avoid neonatal immunosuppression it is recommended anti-TNF drugs are stopped in pregnancy as below: Drug Advised gestation to stop taking Safe with breastfeeding Etanercept Stop prior to third trimester Yes Infliximab Stop at 16 weeks gestation Yes Adalimumab Stop prior to third trimester Yes Certolizumab Safe all trimesters Yes

Answer 246

Combined oral contraceptive use is the biggest risk factor for developing hepatic adenomas Hepatic adenomas are primarily seen in young women who have been taking the combined oral contraceptive pill. The incidence of hepatic adenomas in those that have never taken the oral contraceptive pill is 1 in 1 million. In those that have taken the combined oral contraceptive long term the risk is 35 in 1 million. Liver mass in pregnancy Key Points 20% of population have a benign liver lesion Pathology of most hepatic masses can be determined by multimodal imaging 1st line imaging non-contrast ultrasonography 2nd line imaging includes: contrast ultrasonography, CT liver (triple-phase protocol), contrast MRI or even nuclear scintigraphy or PET-CT Blood and tissue biopsy rarely required Summary of Solid Liver Lesions Seen in Pregnancy Lesion Type Features Ultrasound Hepatic haemangioma Most common solid benign liver lesion Typically asymptomatic. Rarely rupture Present in around 10% of healthy individuals Most common in middle age women Typically slow growing Arise from vascular endothelial cells well circumscribed and hyperechoic Focal Nodular Hyperplasia 2nd most common benign liver lesion Present in 3% of adults 85% of lesions in women of reproductive age 78% solitary nodules 84% have diameter around 5cm hypo echoic or isoechoic mass occasional detection of central scar as thin hyper echoic zone Hepatic adenomas Typically seen in young females using CHC Incidence 35 per million in CHC users vs 1 per million in those who have never used CHC Solitary 32%, Multiple (2-9) 45%, Adenomatosis (10+) 23% Presence of mass but USS may not provide further characterisation Hepatocellular carcinoma Extremely rare in UK Variable ultrasonographic appearance

Answer 247

third trimester to 4 weeks postpartum Cerebral venous thrombosis Background Cerebral venous thrombosis (CVT) is an uncommon but serious condition. Incidence of CRT in pregnancy is around 1 in 5000 Pregnancy increases risk Greatest risk of CVT is third trimester to 4 weeks postpartum Presentation Headache most common symptom (85%) Papilloedema Focal neurological deficits inc diplopia Reduced consciousness level Seizures Diagnosis MRI (CT pickup only 30%) Treatment Typically involves anticoagulation for 6 months with LMWH Follow up MR after 6m

Answer 248

Pyridostigmine is an acetylcholine esterase inhibitor. It is first line treatment for MG during pregnancy. Myasthenia Gravis in Pregnancy Aetiology Myasthenia Gravis (MG) is an autoimmune disease caused by antibodies against the nicotinic acetylcholine receptor or other postsynaptic antigens Epidemiology Female:Male ratio 2:1 Typically presents age 20-30 Effect of Pregnancy on Maternal MG Symptoms worsened for 40%* Symptoms unchanged in 30% 30% had remission No evidence that MG adversely affects pregnancy outcomes Effect of Pregnancy on Neonate Transient neonatal MG (TNMG) effects approx 20% of infants born to MG mothers Transient neonatal MG is due to transfer of maternal antibodies (IgG anti‐AChR antibodies) *Exacerbations typically occur in the first trimester and in the first 3 months postpartum Management considerations Starting glucocorticoid therapy or withdrawing immunosuppressant therapy may exacerbate MG Infections require prompt treatment as may cause exacerbation Pregnant patients with MG should be assessed for baseline motor strength, pulmonary function and ECG Thyroid function tests advised. Thyroid dysfunction in 10-15% Approx 15% of persons with MG have thymoma Patients with thymoma who have not undergone thymectomy present with a higher incidence of exacerbation during pregnancy and higher risk neonatal MG Thymectomy should be considered before conception or after delivery (not during pregnancy) MG most commonly caused by IgG anti‐AChR antibodies. Patients with anti‐MuSK antibodies generally have worse clinical symptoms and TNMG TNMG Infants with TNMG typically develop symptoms within 12 h to 4 days of delivery Symptoms resolve spontaneously after 3-4 weeks due to antibody degradation MG Drugs in Pregnancy

Answer 249

The assessment of chronic SCD complications should include the investigations listed plus: Echocardiogram Retinal Screening (RCOG advise this be done pre-conceptually) In addition patients with high ferritin or those who have had multiple transfusions may benefit from T2 cardiac MRI to assess body iron. SCD Key Points Autosomal recessive inheritence SCD highest prevalence in African and Middle Eastern populations but increasing in Europe and USA due to population migration 300 infants with SCD born each year in the UK Medication Considerations Stop ACE inhibitors/Angiotensin receptor blockers and Hydroxycarbamide pre-conception Give Influenza vaccine if not given in past 12 months Folic acid 5mg daily (note higher dose) Pneumococcal vaccine every 5 years Ensure on daily penicillin prophylaxis (erythromycin if penicillin allergic) Aspirin 75mg once daily from 12 weeks LMWH during hospital admissions

Answer 250

Hydroxycarbamide (Hydroxyurea) 500mg twice daily The RCOG guidance on SCD pays particular attention to two medications: Hydroxycarbamide: should be stopped 3 months before conception ACE inhibitors should be stopped before conception (no time limit set by RCOG) Sickle Cell Disease SCD Key Points Autosomal recessive inheritence SCD highest prevalence in African and Middle Eastern populations but increasing in Europe and USA due to population migration 300 infants with SCD born each year in the UK Medication Considerations Stop ACE inhibitors/Angiotensin receptor blockers and Hydroxycarbamide pre-conception Give Influenza vaccine if not given in past 12 months Folic acid 5mg daily (note higher dose) Pneumococcal vaccine every 5 years Ensure on daily penicillin prophylaxis (erythromycin if penicillin allergic) Aspirin 75mg once daily from 12 weeks LMWH during hospital admissions

Answer 251

Hyperthyroidism Hyperthyroidism Hyperthyroidism during pregnancy can present as hyperemesis gravidarum (HG) or as thyroid storm. Patients with HG can also develop transient gestational hyperthyroidism as a result of high levels of HCG stimulating the TSH receptor. Excessive vomiting typically leads on to hyponatremia and hypokalaemia. Hyperthyroidism Hyperthyroidism in pregnancy occurs in 2 in 1,000 pregnancies in the UK Management Options Antithyroid Drugs 1st Line Propylthiouracil crosses 1st Choice as crosses placenta less readily than carbimazole Carbimazole NOTE: Radioiodine is contra-indicated Beta-Blockers May be used but use should be limited to a few weeks as may adversely affect fetus Surgery Only when absolutely necessary. Patient needs to be euthyroid prior to surgery

Answer 252

27 in 100 When consenting for this procedure its important to be aware that the obstetric history has a big effect on the risk of requiring hysterectomy. A primigravida would have a risk of 11% whereas this patients risk of hysterectomy is more than double that at 27%. Complication Incidence with Caesarian section for placenta praevia Emergency hysterectomy 11% (27% in women with prior c-section) Massive obstetric haemorrhage 21% Further Laparotomy 7.5% Bladder or ureteric injury up to 6% VTE up to 3%

Answer 253

Platelet count All of the above increase during pregnancy except platelet count which drops. Although platelet production is increased during pregnancy haemodilution results a reduced platelet count. Generally speaking clotting factors increase resulting in a hypercoaguable state. The exceptions to this are factors XI and XIII. Coagulation and Pregnancy Changes in blood composition during pregnancy: Platelet count reduced Increased coagulation factors Increased fibrinogen Increased ESR

Answer 254

Third trimester Risk of hepatic adenoma haemorrhage and rupture is highest in the third trimester There are a number of risks with hepatic (or hepatocellular) adenoma. The main ones are haemorrhage and rupture: Lifetime risk of haemorrhage of hepatic adenoma: 27% Lifetime risk of rupture with intraperitoneal bleeding: 17% Risk malignant transformation: 5% Risk of haemorrhage and rupture appears to be highest with larger lesions and in the third trimester of pregnancy Liver mass in pregnancy Key Points 20% of population have a benign liver lesion Pathology of most hepatic masses can be determined by multimodal imaging 1st line imaging non-contrast ultrasonography 2nd line imaging includes: contrast ultrasonography, CT liver (triple-phase protocol), contrast MRI or even nuclear scintigraphy or PET-CT Blood and tissue biopsy rarely required Summary of Solid Liver Lesions Seen in Pregnancy Lesion Type Features Ultrasound Hepatic haemangioma Most common solid benign liver lesion Typically asymptomatic. Rarely rupture Present in around 10% of healthy individuals Most common in middle age women Typically slow growing Arise from vascular endothelial cells well circumscribed and hyperechoic Focal Nodular Hyperplasia 2nd most common benign liver lesion Present in 3% of adults 85% of lesions in women of reproductive age 78% solitary nodules 84% have diameter around 5cm hypo echoic or isoechoic mass occasional detection of central scar as thin hyper echoic zone Hepatic adenomas Typically seen in young females using CHC Incidence 35 per million in CHC users vs 1 per million in those who have never used CHC Solitary 32%, Multiple (2-9) 45%, Adenomatosis (10+) 23% Presence of mass but USS may not provide further characterisation Hepatocellular carcinoma Extremely rare in UK

Answer 255

HHV 6 causes roseola infantum. Slapped cheek syndrome is caused by Parvovirus B19 Rubella is also known as german measles. Varicella zoster is the cause of chickenpox and shingles. Group A beta haemolytic streptococcus causes scarlet fever

Answer 256

4 per 100,000 pregnancies Rate of tuberculosis is 4.2 per 100,000 pregnancies in the UK Tuberculosis in pregnancy Key Points Outcomes are the same for those with early diagnosis and treatment of tuberculosis in pregnancy compared to pregnancies unaffected by tuberculosis Late diagnosis and treatment of pulmonary TB associated with pre-eclampsia, PPH, difficult labour, preterm labour, low birthweight and pneumonia. Extrapulmonary TB Lymphadenitis doesn't have significant effect on perinatal outcome but other extrapulmonary sites including spine, abdomen and central nervous system are associated with increased rates of fetal growth restriction and low Apgar's. Epidemiology of Tuberculosis: 14.1 per 100,000 population (UK) 44.3 per 100,000 in London 4.2 per 100,000 pregnancies Almost exclusively seen in ethnic minority women during pregnancy in the UK Treatment 1st line for active disease is: Isoniazid, rifampicin, ethambutol and pyrazinamide. 1st line for latent TB: Isoniazid and rifampicin Isoniazid can cause neuropathy - vitamin B6 (pyridoxine) supplementation should be offered to avoid this

Answer 257

Hypogylcaemia Hypogylcaemia and raised serum ammonia are commonly seen in acute fatty liver of pregnancy Deranged LFTs and thrombocytopenia are common features of both HELLP and acute fatty liver of pregnancy. Hypogylcaemia and raised serum ammonia are suggestive of acute fatty liver. Acute fatty liver of pregnancy Epidemiology Rare obstetric emergency Aetiology thought to be deficiency of LCHAD (3-hydroxyacyl-CoA dehydrogenase) leading to accumulation of medium and long chain fatty acids 5 cases per 100 000 maternities in the UK AKI is a common complication. 14% of patients in the UK develop renal impairment. 3.5% require renal replacement

Answer 258

Yes if of childbearing age 250 IU is enough to cover 5 units of D pos platelets

Answer 259

When less than 15 mL have been transfused Blood = normal dose given, give based on Gestational so 250IU if less than 20 2 and 500 IU if over 20w, SHOULD BE GIVEN IV IF 15 mL have been transfused= it is preferable to use the larger anti‐D immunoglobulin - of 1500IU or 2500 IU GIVE IV IF More than 1 unit of blood transfused = red cell exchange transfusion

Answer 260

250 IU anti-D immunoglobulin at 6 weekly intervals Remember FMH testing not usually required before 20 weeks. In recurrent bleeding anti-D should be given 6 weekly as follows 250 IU between 12-20 weeks 500 IU after 20 weeks +/- extra dosing depending on FMH test DO FMH test every 2 weeks

Answer 261

1 in 250 CF is autosomal recessive. All children will therefore inherit one of the mothers CF alleles and as a minimum all offspring will be carriers. If the partner is a carrier the risk is 1 in 2 If the partner does not carry any of the common gene mutations for cystic fibrosis then the risk of having an affected child is 1 in 250. The reason it isn't zero is that the test only covers the most common 25 or so mutations but there are hundreds. There is also a very small risk of spontaneous mutation.

Answer 262

3-12 days The incubation period of Zika is 3-12 days and symptoms usually resolve within 7 days. Zika virus and pregnancy Zika virus virus family: Flaviviridae genus: Flavivirus Sngle stranded RNA virus Transmitted primarily by Aedes mosquitos Can be transmitted sexually but risk is low Incubation period 3-12 days Typical symptoms: fever, maculopapular rash, arthralgia or conjunctivitis Rash usually resolves within 2 days but may persist up to 1 week Many asymptomatic Zika associations Guillan Barre syndrome Congenital microcephaly* Other congenital abnormalities *During the pandemic in Brazil the rate of babies born with microcephaly increased 20 fold from 5 per 100,000 to 100 per 100,000. Management if couple planning conception If male partner has travelled to Zika area the couple should delay trying to conceive ie avoid UPSI for 3 months after return from Zika area If only female partner has travelled then should avoid UPSI for 2 months after return from Zika area. Testing & Treatment No treatment available for Zika Testing is advised for women who experience symptoms suggestive of acute Zika virus infection within 2 weeks of leaving an area with high or moderate risk of Zika virus transmission OR within 2 weeks of sexual contact with a male sexual partner who has recently travelled to an area with high or moderate risk of Zika

Answer 263

Infectivity period is 7-10 days before the rash develops to 1 day after rash onset Slapped cheek is caused by Parvovirus B19 Infectivity period is 7-10 days before the rash develops to 1 day after rash onset.(note some sources quote infectivity ends when rash appears) This is important when assessing risk of transmission. Parvovirus B19 Background The RCOG published a safety alert on Parvovirus B19 following a potentially avoidable death of a baby in 2012. In children typically presents with characteristic diffuse erythematous facial rash - 'slapped cheek' following around 5 days of prodromal symptoms In adults symptoms often atypical or asymptomatic in up to 50% of cases Infectivity period is 7-10 days before the rash develops to 1 day after rash onset Incubation period is typically around 7 days (range 4-14 days) Investigations In healthy children and adults diagnosis is usually clinical and no lab confirmation is required. If a pregnant woman has had exposure to Parvovirus or is suspected of having Parvovirus then serological tests are indicated. NICE advise contacting the local virology/microbiology/infectious disease unit for clarification of tests but they are likely to include Parvovirus B19-specific IgG and IgM and may need viral PCR. Note Rubella should also be tested for as can cause similar symptoms Results Interpretation IgG +ve / IgM -ve Immune IgG -ve / IgM -ve Susceptible to infection Positive for IgM (irrespective of the IgG result) Suggests recent infection Management Confirmed Parvovirus in Pregnancy Arrange urgent referral to a specialist in fetal medicine for serial fetal ultrasound scans and Doppler assessment to detect fetal anaemia, heart failure, and hydrops Risk of vertical transmission <15 weeks gestation - 15% 15 - 20 weeks - 25% Term - 70%

Answer 264

60% Vasa Previa typically presents with PV bleeding at the time of rupture of membranes (may be spontaneous or artificial). Studies have shown approximately 40% of vasa previa cases are diagnosed antenatally. In the group diagnosed antenatally and ideally delivered by cesarean delivery at 35 weeks of gestation or earlier the fetal survival rate is around 97% whereas in the group not diagnosed antenatally survival has been quoted at 44% (mortality at 55-60%). Vasa Previae Key Points Refers to unprotected fetal vessels running below presenting part of fetus over the cervical os. Incidence is 1 in 2000-6000 pregnancies Typically presents at time of membrane rupture with fresh PV bleeding and fetal heart abnormalities. Fetal mortality is around 60%

Answer 265

Yes continue Candesartan is an angiotension 1 receptor antagonist used in the treatment of hypertension and heart failure. The evidence so far suggests that it is unsafe to use in any trimester of pregnancy because of disruption of fetal vascular perfusion and renal function secondary to pharmacological suppression of the renin angiotensin system through the AT1 receptor blockade. You should substitute a safe antihypertensive: change candesartan to methyldopa or labetolol. You should continue the disease modifiers hydroxychloroquine and prednisolone as both are safe in pregnancy and withdrawal may lead to a disease flare.

Answer 266

Platelet function tests, capillary fragility and/or coagulation screen All the investigations are relevant in her care during pregnancy. The most likely problems that will occur during her pregnancy will be backache and pelvic girdle pain due to ligamentous laxity. Connective tissue weakness also could cause the cervix to be incompetent, which could lead to 'late' miscarriage, preterm delivery or precipitate delivery and, hence, screening for cervical length. However, during labour, the uterus may be atonic after delivery, bringing risks of postpartum haemorrhage, which may be life threatening. Therefore, the risk of easy bruising should be explored by platelet function tests, capillary fragility and/or coagulation screen in order to plan delivery and care accordingly to previous serious complications in labour.

Answer 267

Prednisolone This oral steroid has good anti inflammatory properties and if given in an appropriate dose (20 40 mg daily) would give relief of swelling and pain within a few days. A course of prednisolone in tapering doses could be used to good effect whilst other disease modifying drugs (e.g. sulfasalazine or hydroxychloroquine) are introduced. Note that: Diclofenac would be good for short term pain relief, but does not act as a disease modifier. Prolonged use risks gastrointestinal complications (e.g. gastric ulceration). Sulfasalazine needs stepwise introduction and could take up to 12 weeks to give noticeable benefit. Although it may be sensible to reintroduce this agent, something else (e.g. oral prednisolone) would be needed to provide quicker relief of symptoms. Hydroxychloroquine, although a good disease modifier, will not give relief of symptoms for up to 12 weeks. Although it may be sensible to introduce this agent, something else (e.g. oral prednisolone) would be needed to provide quicker relief of symptoms.

Answer 268

Could be rather diabetic nephropathy than PET

Answer 269

Proliferation retinopathy

Answer 270

Autonomic neuropathy

Answer 271

Ischaemic heart disease

Answer 272

Background retinopathy

Answer 273

Stop taking cabergoline although it is most likely safe in early pregnancy. No further follow up unless she becomes symptomatic Only 3% of women with a microadenoma will experience symptomatic enlargement of their adenoma during pregnancy. Once pregnancy is confirmed, dopamine agonists should be stopped. Prolactin levels are unhelpful in monitoring tumour activity as they are normally high during pregnancy. MRI or visual field testing is required if the woman becomes symptomatic. Serum prolactin levels should be rechecked a few weeks after cessation of breastfeeding; you should also perform an MRI of the pituitary to assess tumour enlargement if prolactin levels are higher than prepregnancy levels. Bromocriptine and cabergoline are probably safe in early pregnancy with no increased risk of fetal loss or congenital abnormalities. There is more data on the safety of bromocriptine in pregnancy and it is, therefore, the treatment of choice at present. Cabergoline is not licensed in pregnancy; however, it is not always necessary to change to bromocriptine during pregnancy if the woman is already on cabergoline pre-pregnancy. Long term use (over 1 year) has been associated with heart valve fibrosis and surveillance with echocardiography is advisable if long term treatment is being considered.

Answer 274

Stop taking bromocriptine, although this is most likely safe in early pregnancy, followed by close surveillance with visual field and perform MRI only if symptomatic This is the most commonly used option, particularly if the macroadenoma is not encroaching the chiasm. Dopamine agonists are stopped once pregnancy is confirmed. These patients require more regular follow up than women with microprolactinomas during pregnancy in view of the increased pressure effects of a tumour. They require visual field tests at each trimester. If there are any symptoms of an enlarging tumour, perform a MRI of the pituitary and restart dopamine agonists. However, bromocriptine can be continued throughout the pregnancy to limit the risk of tumour growth, particularly in women with a large tumour abutting the optic chiasm. If this fails to stop the enlargement, surgical treatment may be needed in the second trimester. They will still require visual field tests in each trimester. Women with macroprolactoma may also be given the option of continuing their dopamine agonists as there is a 30% chance of tumour enlargement during pregnancy. Bromocriptine and cabergoline are probably safe in early pregnancy with no increased risk of fetal loss or congenital abnormalities. There is more data on the safety of bromocriptine in pregnancy and it is, therefore, the treatment of choice at present. Cabergoline is not licensed in pregnancy; however it is not always necessary to change to bromocriptine during pregnancy if the woman is already on cabergoline pre pregnancy. Long term use (over 1 year) has been associated with heart valve fibrosis and surveillance with echocardiography is advisable if long term treatment is being considered.

Answer 275

Hydrocortisone 20–30 mg po in divided doses, as per prepregnancy dose and fludrocortisone 50–200 microgram po, as per prepregnancy dose

Answer 276

Hydrocortisone 100 mg po in divided doses, increased from her 20–30 mg prepregnancy dose

Answer 277

For women planning a vaginal birth who have adrenal insufficiency or who are taking long-term oral steroids (equivalent to 5 mg or more prednisolone daily for more than 3 weeks): continue their regular oral steroids and • when they are in established first stage of labour, add intravenous or intramuscular hydrocortisone and consider a minimum dose of 50 mg every 6 hours until 6 hours after the baby is born. (100mg 12h) For women having a planned or emergency caesarean section who have adrenal insufficiency or who are taking long-term oral steroids (equivalent to 5 mg or more prednisolone daily for more than 3 weeks): • continue their regular oral steroids and • give intravenous hydrocortisone when starting anaesthesia; the dose will the dose will depend on whether the woman has received hydrocortisone in labour, for example: － consider giving 50 mg if she has had hydrocortisone in labour － consider giving 100 mg if she has not had hydrocortisone in labour • give a further dose of hydrocortisone 6 hours after the baby is born (for example, 50 mg intravenously or intramuscularly).

Answer 278

For women having a planned or emergency caesarean section who have adrenal insufficiency or who are taking long-term oral steroids (equivalent to 5 mg or more prednisolone daily for more than 3 weeks): • continue their regular oral steroids and • give intravenous hydrocortisone when starting anaesthesia; the dose will depend on whether the woman has received hydrocortisone in labour, for example: － consider giving 50 mg if she has had hydrocortisone in labour － consider giving 100 mg if she has not had hydrocortisone in labour • give a further dose of hydrocortisone 6 hours after the baby is born (for example 50 mg PO or IM

Answer 279

Fetal hypothyroidism and goitre Fetal hypothyroidism and goitre can be caused by block and replacement regimens because although antithyroid drugs can cross the placenta, there is only minimal transplacental passage of thyroxine

Answer 280

Carbimazole Carbimazole (CMI) and methimazole (MMI) are thought to be associated with fetal aplasia cutis. However, more recent evidence from large trials suggests there is no definite causal link and true risk does not appear to be above background risk. These drugs have been associated with other congenital abnormalities including an MMI embryopathy.

Answer 281

Propylthiouracil

Answer 282

Propylthiouracil Carbimazole (CMI or MMI) is also used but because of the small risk of fetal abnormality described with carbimazole, propythiouracil is the drug of choice for the first trimester for most endocrinologists. CMI and MMI are recommended to be used in the second and third trimester because they are more effective drugs with fewer maternal risks.

Answer 283

Agranulocytosis

Answer 284

No, decreases the efficacy of the drug , delay taking by at least 4 hours

Answer 285

No The BNF advises that metformin and insulins are fine for breastfeeding mothers. The use of sulfonylureas (except glibenclamide) when breastfeeding should be avoided because there is a theoretical possibility of hypoglycaemia in the infant

Answer 286

OGT at 16-18w

Answer 287

Aim for vaginal delivery with no limitation on the second stage In this case, there are no reasons specified to avoid vaginal delivery. As the retinopathy is pre-proliferative, there is no reason to limit the second stage. Note that if it were proliferative diabetic retinopathy, it may be advisable to limit second stage with elective instrumental delivery. How to deliver a women with pre proliferative diabetic retinopathy vs proliferative diabetic retinopathy Aim for vaginal delivery with no limitation on the second stage

Answer 288

Feed within 30 minutes of birth and check blood glucose 2–4 hours from birth The NICE guideline on Diabetes in Pregnancy (CG3) recommends that women feed their babies as soon as possible (within 30 minutes of birth) and then at frequent intervals (2–3 hours) until prefeeding blood glucose levels are maintained at 2 mmol/litre or more. Test the baby's blood glucose levels 2–4 hours after birth using a quality assured method validated for neonatal use (ward based glucose electrode or laboratory analysis or if there are signs of hypoglycaemia).

Answer 289

Avoid pregnancy for 4 months

Answer 290

Commence propylthiouracil and change to carbimazole in the second trimester Treatment options include carbimazole (CBZ), methiamazole (MMI, the active part of CBZ) or propylthiouracil (PTU), which block thyroid hormone synthesis and reduce the titre of TSH receptor antibodies. All of these cross the placenta, but PTU less so than CBZ and MMI. There is a possible rare risk of fetal aplasia cutis (reversible) or an embryopathy (choanal atresia, trachea oesophagael fistula, facial dymorphism and cognitive development delay) with CBZ or MMI. PTU does not cause fetal anomaly but is a rare, proven cause of maternal liver damage, which has resulted in many worldwide cases of death or liver transplant requirements. There is a small chance of maternal agranulocytosis with both PTU and CBZ. There is indecision across the literature as to the best drug to use for hyperthyroidism in pregnancy. The current general consensus, however, is to use PTU in the first trimester and then change to CBZ or MMI for the second and third trimesters. Newly diagnosed thyrotoxicosis in pregnancy should be treated aggressively with high doses of PTU or CBZ for 4–6 weeks followed by gradual reduction to maintenance dose. No role for block and replace regimens in the management of thyrotoxicosis in pregnancy. TRAb should be measured at 20–24 weeks of gestation in woman with Graves' disease to identify the fetuses/babies at risk of fetal/neonatal thyrotoxicosis. Pregnancy should be avoided for at least 4 months after radioiodine therapy as there is a small theoretical risk of chromosomal damage and genetic abnormalities.

Answer 291

Acute chest syndrome It is a non-infective vaso occlusive crisis of pulmonary vasculature commonly seen in patients with sickle cell anaemia. Can still have a temp Treat with Oxygen, analgesia, broad spectrum antibiotics, prophylactic low molecular weight heparin, exchange transfusion It is often precipitated by lung infection. When the degree of hypoxia is out with absolute haemoglobin level it warrants exchange transfusion. There is some evidence that the incidence of venous thromboembolism is increased among pregnant women with sickle cell disease, and that this additional background risk plus admission to hospital and suspicion of infection warrants prophylactic LMWH.

Answer 292

Within 2 months of delivery After this time removal becomes more difficult as the clot organises around the filter. The patient would then require life long anticoagulation

Answer 293

6–9 weeks of gestation Women on warfarin outside pregnancy (for recurrent thrombosis and/or known high risk thrombophilia) should be converted to LMWH by 6 weeks of gestation.

Answer 294

Petechia and heavy periods Treat with portal steroids if platelet less than 200 The decision to treat a pregnant woman with ITP is based on assessment of the risk of significant haemorrhage. Asymptomatic patients with platelet counts > 20 × 109/l do not require treatment until delivery is imminent but should be carefully monitored, both clinically and haematologically. If the duration of treatment is likely to be short, i.e. starting in the third trimester, corticosteroids are a cost effective option. An initial dose of 1 mg/kg (based on pre pregnancy weight) is recommended. If steroid therapy is likely to be prolonged, significant side effects occur or an unacceptably high maintenance dose is required (perhaps > 7.5 mg prednisolone daily) IVIg therapy should be considered. Monitoring of platelet levels and management should be carefully guided by a collaboration of haematology, obstetric and neonatalogy teams.

Answer 295

For woman with known immune thrombocytopenic purpura, before admission for birth: • plan birth in an obstetric-led unit with a neonatal unit that routinely provides high-dependency care • plan as if the baby will be at risk of bleeding irrespective of the woman's platelet count **• consider monitoring maternal platelet count weekly from 36 weeks, and if the platelet count is below 50: － discuss and agree a plan for intrapartum care with the multidisciplinary team, including a haematologist • consider giving steroids or intravenous immunoglobulin to raise the maternal platelet count. For women with known immune thrombocytopenic purpura, on admission for birth: • measure maternal platelet platelet count. For women with known immune thrombocytopenic purpura, on admission for birth: • measure maternal platelet count For women with known or suspected immune thrombocytopenic purpura, take the following precautions to reduce the risk of bleeding for the baby: • inform the neonatal team of the imminent birth of a baby at risk do not carry out fetal blood sampling **• use fetal scalp electrodes with caution** **• do not use ventouse** **• use mid-cavity or rotational forceps with caution** • bear in mind that a caesarean section may not protect the baby from bleeding • measure the platelet count in the umbilical cord blood at birth. Modify the birth plan based on maternal platelet count, using table 2 as a guide, for women with: • gestational thrombocytopenia (without pre-eclampsia and HELLP syndrome, and otherwise well) • an uncertain diagnosis of immune thrombocytopenic purpura. Maternal platelet count Maternal care Platelet count above 80×109/l = Treat the woman as healthy for the purpose of considering regional analgesia and anaesthesia Platelet count 50 to 80×109/l = Before considering regional analgesia and anaesthesia, take into account: • clinical history • the woman's preferences • anaesthetic expertise Platelet count below 50×109/l = Avoid regional analgesia and anaesthesia under most circumstances If the woman has known or suspected immune thrombocytopenic purpura, assume the baby is at risk of bleeding and take the precautions outlined in recommendation

Answer 296

Cephalosporin plus erythromycin Women with DGI should be hospitalised and monitored for endocarditis and meningitis. Initially treat with cephalosporins. Pregnant women should not be treated with quinolone or tetracycline antimicrobials.

Answer 297

Culture tests at the first prenatal visit Diagnosis should be by culture tests on selective media at the first prenatal visit, followed by further testing in the third trimester in women at risk of STDs. Gonorrhoea is frequently asymptomatic, but women may present with dysuria and purulent discharge. DGI may present with fever, skin lesions, pain associated with tendon movement, and arthritis (often in one joint).

Answer 298

Haemaglobin Storage of the sample and contamination by β human chorionic gonadotrophin, nitrites and haemoglobin may give rise to false positives.

Answer 299

Up to 70% Up to 70% of babies born to mothers with chlamydia infection will become colonised, with 30–40% developing conjunctivitis, and 10–20% developing a characteristic pneumonia.

Answer 300

Left atrial pressure

Answer 301

Pregnant HIV patients with high viral load and/or low CD4 count should commence ART immediately (not wait until 2nd trimester) Indications for starting ART in the first trimester: Presenting with opportunistic infection VL >100,000 HIV RNA copies/mL CD4 cell count is less than 200 cells/mm³ HIV in Pregnancy (antiretroviral therapy in pregnancy) Antiretroviral therapy (ART) in pregnancy ART is mostly unlicensed for use in pregnancy Zidovudine is licensed in the third trimester Women who conceive on effective combination of ART (cART) should continue throughout pregnancy Atypical regimes such as protease inhibitor (PI) monotherapy should be modified Zidovudine is now rarely used as part of cART due to concerns about toxicity Data shows no difference in pregnancy outcomes between zidovudine-based and zidovudine-sparing cART Data does not support increased risk of congenital malformations with cART so far but some agents have insufficient data Starting cART if not taking All pregnant women, including elite controllers, should start cART during pregnancy and continue lifelong BHIVA recommend treatment of all people living with HIV regardless of CD4 cell count or clinical status All women should have commenced ART at the latest by week 24 of pregnancy Evidence mounting that cART is safe in the first trimester but due to theoretical risks initiation of cART is often delayed until the start of the second trimester. Current advise is to start ART at start of second trimester* *If a women presents with opportunistic infection treatment should not be delayed due to pregnancy *Start in 1st trimester if VL >100,000 HIV RNA copies/mL and/or CD4 cell count is less than 200 cells/mm³ Deciding Mode of delivery in women taking cART Viral load should be checked at 36 weeks then delivery planned as follows: Viral Load at 36 weeks Recommendation < 50 HIV RNA copies/mL Vaginal delivery 50–399 HIV RNA copies/mL PLCS considered Take into account the actual viral load, trajectory of viral load, length of time on treatment, adherence issues, obstetric factors and the womans views ≥400 HIV RNA copies/mL PLCS

Answer 302

Direct antiglobulin test (DAT), haemoglobin and bilirubin levels Red cell antibodies pose a risk of haemolytic anaemia. Additional tests are directed at checking for immune reaction (DAT - detects immunoglobulin/complement coating RBCs) and anaemia (directly through haemoglobin and indirectly through bilirubin which is a byproduct of red cell breakdown). In addition to the dangers anaemia can pose to the neonate, build up of bilirubin can lead to Kernicterus (bilirubin induced brain dysfunction). Red Cell Antibodies Red cell antibodies are important as they may cause severe fetal anaemia and lead to poor neonate outcomes. Antibody titre Level at which patient should be referred to fetal medicine specialist (iu/ml) Anti-D >4 Anti-C >7.5 Anti-K Refer if detected Anti-E Refer if anti-C antibodies present Monitoring after referral level triggered Weekly fetal middle cerebral artery peak systolic velocities (MCA PSV) MCA PSV above 1.5 multiples of the median then refer back to fetal medicine specialist for consideration invasive treatment Monitoring Frequency Anti C,D and K levels every 4 weeks until 28 weeks then every 2 weeks until delivery

Answer 303

Mechanical prosthetic mitral valve. **Regurgitant valves are tolerated better during pregnancy than stenotic valves.** Tissue (bioprosthetic) valves do not require anticoagulation. Although there is some risk associated with any stenotic valve (e.g. mild aortic stenosis) the risks are much higher with a mechanical prosthetic valve.

Answer 304

Tumor necrosis factor alpha TNF alpha infibotor

Answer 305

1 in 100 000 preg

Answer 306

Purine antagonist

Answer 307

Ratio of stroke volume to end diastolic volume Stroke volume is the actual amount of blood pumped from the heart with each beat, while ejection fraction is the percentage of blood pumped out relative to the total volume in the ventricle at the end of filling. Stroke volume is measured in milliliters (mL), and ejection fraction is a percentage

Answer 308

Ventricular end diastolic volume Preload Definition: The degree of stretch of the heart muscle at the end of ventricular filling. It is also referred to as end-diastolic volume. How it works: As the ventricles fill with blood, the heart muscle stretches. The greater the stretch (up to a point), the more force the next contraction will have, according to the Frank-Starling mechanism. Factors that increase it: Increased blood volume, such as from venous constriction caused by sympathetic stimulation, increases the amount of blood returning to the heart. Effect on stroke volume: An increase in preload generally leads to an increase in stroke volume (the amount of blood pumped per beat). Afterload Definition: The total resistance the heart must overcome to eject blood. It is influenced by systemic blood pressure. How it works: This is the pressure the ventricular muscle must work against to open the aortic or pulmonary valve.

Answer 309

Every 2 to 3 weeks The RCOG advice that fetal ultrasound assessment should take place every two to three weeks in uncomplicated monochorionic pregnancies from 16 weeks. The main purpose of this is to detect TTTS (between 16 and 24 weeks) and FGR. Monochorionic Twin Pregnancy Monochorionic twin pregnancy is one where both babies are supplied by a single shared placenta. In the UK 1 in 3 twin pregnancies are monochorionic. Twin to twin transfusion syndrome (TTTS) can arise in monochorionic twin pregnancy which can be fatal to the co-twin.

Answer 310

Calcineurin inhibitor

Answer 311

Not harmful – limited experience of use; hence use with caution

Answer 312

Tumour necrosis factor alpha (TNF α) inhibitor

Answer 313

Aedes mosquito The primary vector for Zika is the Aedes mosquito The primary vector for Zika is the aedes mosquito. Although there is a risk of sexual transmission this risk appears to be low. The aedes mosquito is most active during the day unlike the anopheles mosquito (the primary vector for malaria) which is most active during the night. It is important to advise women travelling to areas at moderate or high risk of Zika to take appropriate precautions including keeping covered up with long sleeves and trousers during the day. Clothing can be treated with permethrin which kills mosquitos. Repellent such as DEET( up to 50%) can be used and is safe in pregnant and breastfeeding women. Zika virus and pregnancy Zika virus virus family: Flaviviridae genus: Flavivirus Sngle stranded RNA virus Transmitted primarily by Aedes mosquitos Can be transmitted sexually but risk is low Incubation period 3-12 days Typical symptoms: fever, maculopapular rash, arthralgia or conjunctivitis Rash usually resolves within 2 days but may persist up to 1 week Many asymptomatic Zika associations Guillan Barre syndrome Congenital microcephaly* Other congenital abnormalities *During the pandemic in Brazil the rate of babies born with microcephaly increased 20 fold from 5 per 100,000 to 100 per 100,000. Management if couple planning conception If male partner has travelled to Zika area the couple should delay trying to conceive ie avoid UPSI for 3 months after return from Zika area If only female partner has travelled then should avoid UPSI for 2 months after return from Zika area. Testing & Treatment No treatment available for Zika Testing is advised for women who experience symptoms suggestive of acute Zika virus infection within 2 weeks of leaving an area with high or moderate risk of Zika virus transmission OR within 2 weeks of sexual contact with a male sexual partner who has recently travelled to an area with high or moderate risk of Zika

Answer 314

27% In patients with hepatic adenomas haemorrhage and rupture is common There are a number of risks with hepatic (or hepatocellular) adenoma. The main ones are haemorrhage and rupture: Lifetime risk of haemorrhage of hepatic adenoma: 27% Lifetime risk of rupture with intraperitoneal bleeding: 17% Risk malignant transformation: 5% Risk of haemorrhage and rupture appears to be highest with larger lesions and in the third trimester of pregnancy

Answer 315

Increased preload, decreased afterload, increased cardiac output by 20% by 8 weeks of gestation, decreased serum colloid osmotic pressure by 10-15%. Increased preload (as increased plasma volume), decreased afterload (as reduced systemic vascular resistance by 25–30% due to peripheral vasodilatation), increased cardiac output by 20% by 8 weeks of gestation (increased CO by 40% during pregnancy) decreased serum colloid osmotic pressure by 10–15%.

Answer 316

Not harmful – limited experience of use; hence use with caution There is limited evidence but it can be used up to 16 weeks of gestation.

Answer 317

Tumour necrosis factor alpha (TNF α) inhibitor

Answer 318

One / 1 Liter a day

Answer 319

Antimalarial

Answer 320

Cross-match weekly until delivery If a patient has red cell antibodies and other pathologies that make them high risk for transfusion e.g. placenta previae or sickle cell disease then they should have a cross-match performed every week. Monitoring Frequency Anti C,D and K levels every 4 weeks until 28 weeks then every 2 weeks until delivery Red Cell Antibodies Red cell antibodies are important as they may cause severe fetal anaemia and lead to poor neonate outcomes. Antibody titre Level at which patient should be referred to fetal medicine specialist (iu/ml) Anti-D >4 Anti-C >7.5 Anti-K Refer if detected Anti-E Refer if anti-C antibodies present Monitoring after referral level triggered Weekly fetal middle cerebral artery peak systolic velocities (MCA PSV) MCA PSV above 1.5 multiples of the median then refer back to fetal medicine specialist for consideration invasive treatment

Answer 321

Cerebral venous thrombosis This patient has diplopia and reduced GCS. These are not typical of migraine, tension headache or neuralgia. Although codeine can cause drowsiness it is low dose and wouldn't typically cause diplopia. This collection of symptoms is consistent with CVT. Cerebral venous thrombosis Background Cerebral venous thrombosis (CVT) is an uncommon but serious condition. Incidence of CRT in pregnancy is around 1 in 5000 Pregnancy increases risk Greatest risk of CVT is third trimester to 4 weeks postpartum Presentation Headache most common symptom (85%) Papilloedema Focal neurological deficits inc diplopia Reduced consciousness level Seizures Diagnosis MRI (CT pickup only 30%) Treatment Typically involves anticoagulation for 6 months with LMWH Follow up MR after 6m

Answer 322

17% In patients with hepatic adenomas haemorrhage and rupture is common There are a number of risks with hepatic (or hepatocellular) adenoma. The main ones are haemorrhage and rupture: Lifetime risk of haemorrhage of hepatic adenoma: 27% Lifetime risk of rupture with intraperitoneal bleeding: 17% Risk malignant transformation: 5% Risk of haemorrhage and rupture appears to be highest with larger lesions and in the third trimester of pregnancy

Answer 323

62% Short cervical length is a good predictor of preterm birth. Cervical length at 20-24 weeks Risk <25mm 25% risk of delivery before 28 weeks gestation <20mm 42.4% risk of delivery before 32 weeks gestation <20mm 62% risk of delivery before 34 weeks gestation Spontaneous preterm birth prevention in multiple pregnancy Key Points 3% of all live births are twin pregnancies Twin babies account for up to 15% of special care unit admissions Twin pregnancies 3x greater perinatal mortality than singleton pregnancies 50% of twin pregnancies deliver before 37 weeks gestation 10% deliver before 32 weeks gestation Up to 24% of successful in vitro fertilisation (IVF) procedures resulting in multiple pregnancy No good evidence for cervical cerclage, vaginal progesterone, pessary, oral tocolytics or bed rest in preventing PTB in multiple pregnancies

Answer 324

15% Myasthenia Gravis in Pregnancy Aetiology Myasthenia Gravis (MG) is an autoimmune disease caused by antibodies against the nicotinic acetylcholine receptor or other postsynaptic antigens Epidemiology Female:Male ratio 2:1 Typically presents age 20-30 Effect of Pregnancy on Maternal MG Symptoms worsened for 40%* Symptoms unchanged in 30% 30% had remission No evidence that MG adversely affects pregnancy outcomes Effect of Pregnancy on Neonate Transient neonatal MG (TNMG) effects approx 20% of infants born to MG mothers Transient neonatal MG is due to transfer of maternal antibodies (IgG anti‐AChR antibodies) *Exacerbations typically occur in the first trimester and in the first 3 months postpartum Management considerations Starting glucocorticoid therapy or withdrawing immunosuppressant therapy may exacerbate MG Infections require prompt treatment as may cause exacerbation Pregnant patients with MG should be assessed for baseline motor strength, pulmonary function and ECG Thyroid function tests advised. Thyroid dysfunction in 10-15% Approx 15% of persons with MG have thymoma Patients with thymoma who have not undergone thymectomy present with a higher incidence of exacerbation during pregnancy and higher risk neonatal MG Thymectomy should be considered before conception or after delivery (not during pregnancy) MG most commonly caused by IgG anti‐AChR antibodies. Patients with anti‐MuSK antibodies generally have worse clinical symptoms and TNMG TNMG Infants with TNMG typically develop symptoms within 12 h to 4 days of delivery Symptoms resolve spontaneously after 3-4 weeks due to antibody degradation

Answer 325

Aortic root >4 cm The risk of aortic dissection is greater if the aortic root is greater than 4 cm in diameter. Elective caesarean birth should be offered if the aortic root diameter is greater than 4.5 cm (and considered if greater than 4 cm) to protect from aortic dissection. In women aiming for a vaginal birth, an epidural will help to protect from systolic hypertension, which increases the risk of dissection. Hypertension is associated with a risk of dissection; beta blockers are used to help control this.

Answer 326

Alkylating agent

Answer 327

Asminosalicylate

Answer 328

The load that opposes shortening of myocardial fibres during ventricular contraction

Answer 329

X-linked genetic condition leading to deficiency in factor IX Inherited Bleeding Disorders Haemophilia Haemophilia is an X-linked genetic condition leading to clotting factor deficiency and bleeding tendency. Haemophilia A results in clotting factor VIII deficiency Haemophilia B results in clotting factor IX deficiency Factor VIII/IX levels should be kept at or above 0.5 iu/ml. Pharmacological methods of raising factor levels are tranexamic acid, DDAVP and recombinant factor VIII/IX

Answer 330

Known to be harmful – evidence of adverse fetal effects

Answer 331

0.5 iu/ml For known carriers of severe haemophilia maternal factor VIII and IX should be checked at booking, before any antenatal procedure and in the third trimester. Factor VIII levels tend to rise in pregnancy where as factor IX tends to remain stable. Factor VIII/IX levels of at least 0.5 iu/ml should be targeted to cover surgical or invasive procedures and/or spontaneous miscarriage. If treatment is required factor levels of 1.0 iu/ml should be targeted and levels kept at 0.5 iu/ml or above until haemostasis is achieved. Inherited Bleeding Disorders Haemophilia Haemophilia is an X-linked genetic condition leading to clotting factor deficiency and bleeding tendency. Haemophilia A results in clotting factor VIII deficiency Haemophilia B results in clotting factor IX deficiency Factor VIII/IX levels should be kept at or above 0.5 iu/ml. Pharmacological methods of raising factor levels are tranexamic acid, DDAVP and recombinant factor VIII/IX

Answer 332

Not harmful – wide experience of use

Answer 333

Trait = HbAS Disease = HbSS or HbS

Answer 334

Not harmful – limited experience of use; hence use with caution.

Answer 335

Calcineurin inhibitor

Answer 336

Ergot alkaloids Cabergoline is contraindicated in the following: Pre-eclampsia Cardiac valvulopathy (exclude before treatment) History of pericardial fibrotic disorders History of puerperal psychosis History of pulmonary fibrotic disorders History of retroperitoneal fibrotic disorders Cabergoline should also not be used in patients with hypersensitivity to ergot alkaloids as there is a high risk of cross reactivity. Lactation Suppression Lactation Suppression Key Points Lactation/Galactopoiesis is maintained via the action of Prolactin Lactation will usually stop naturally within 7 days when suckling ceases Lactation may be suppressed by using drugs that inhibit prolactin but these are not without side effects. Cabergoline and Bromocriptine and the most commonly used drugs for lactation suppression Reasons for pharmacological suppression of lactation There are a number of reasons mothers may wish to stop lactation: Stillbirth/adoption Maternal infection eg HIV (especially if not on retroviral therapy) Prolonged lactation after stopping breastfeeding (other causes hyperprolactinaemia should be excluded)

Answer 337

🔹 Type 1 VWD • Autosomal dominant • Most common form • Mild to moderate reduction in VWF levels 🔹 Type 2 VWD (2A, 2B, 2M) • Autosomal dominant 🔹 Type 2N VWD • Autosomal recessive • Causes decreased binding of VWF to factor VIII → can mimic hemophilia A 🔹 Type 3 VWD • Autosomal recessive • Most severe form • Very low or absent VWF

Answer 338

Known to be harmful – evidence of teratogenic effects

Answer 339

Insufficient information – best avoided

Answer 340

Not harmful – wide experience of use It should be given with 5 mg folic acid supplementation in pregnancy.

Answer 341

Antiproliferative immunosuppressant

Answer 342

Right bundle branch block can be a normal ECG feature in young women. ST depression Q wave in lead III Inferno lateral T wave inversion ——— New onset symmetrical T wave inversion can be a sign of MI as can new development of Q waves.

Answer 343

Known to be harmful – evidence of teratogenic effects

Answer 344

Isoniazid Isoniazid may lead to pyridoxine deficiency induced neuropathy via a number of mechanisms. Its metabolites directly inhibit pyridoxine and isoniazid also inhibits the enzyme pyridoxine phosphokinase which activates pyridoxine to pyridoxal 5' phosphate which is the cofactor in many pyridoxine-dependent reactions. Tuberculosis in pregnancy Key Points Outcomes are the same for those with early diagnosis and treatment of tuberculosis in pregnancy compared to pregnancies unaffected by tuberculosis Late diagnosis and treatment of pulmonary TB associated with pre-eclampsia, PPH, difficult labour, preterm labour, low birthweight and pneumonia. Extrapulmonary TB Lymphadenitis doesn't have significant effect on perinatal outcome but other extrapulmonary sites including spine, abdomen and central nervous system are associated with increased rates of fetal growth restriction and low Apgar's. Epidemiology of Tuberculosis: 14.1 per 100,000 population (UK) 44.3 per 100,000 in London 4.2 per 100,000 pregnancies Almost exclusively seen in ethnic minority women during pregnancy in the UK Treatment 1st line for active disease is: Isoniazid, rifampicin, ethambutol and pyrazinamide. 1st line for latent TB: Isoniazid and rifampicin Isoniazid can cause neuropathy - vitamin B6 (pyridoxine) supplementation should be offered to avoid this

Answer 345

12 weeks Prior to 12 weeks gestation maternal thyroxine (fT4 not fT3) crosses the placenta. From 12 weeks placental changes prevent significant passage of maternal thyroxine and fetal thyroid function becomes independently controlled from the mother. Hyperthyroidism Hyperthyroidism in pregnancy occurs in 2 in 1,000 pregnancies in the UK Management Options Antithyroid Drugs 1st Line Propylthiouracil crosses 1st Choice as crosses placenta less readily than carbimazole Carbimazole NOTE: Radioiodine is contra-indicated Beta-Blockers May be used but use should be limited to a few weeks as may adversely affect fetus Surgery Only when absolutely necessary. Patient needs to be euthyroid prior to surgery

Answer 346

⭐ Why does it happen? (Embryology) Due to anterosuperior displacement of the infundibular septum → misalignment that causes VSD + narrow RV outflow tract. ⸻ ⭐ Diagnosis • CXR: “Boot-shaped heart” due to RV hypertrophy • Echo: confirms anatomy ⸻ ⭐ Treatment • Surgical repair is standard, usually in infancy Includes: • Closing the VSD • Relieving pulmonary stenosis (patch, widening outflow tract) After repair, most children live healthy lives. ⸻ ⭐ Quick summary to remember Tetralogy of Fallot = PROVe: • Pulmonary stenosis • Right ventricular hypertrophy • Overriding aorta • VSD → Causes cyanosis, tet spells, and boot-shaped heart. -REPAIRED ToF is mWHOII = small increased risk of metrical mortality of moderat increase in morbidity Maternal cardiac event rate = 5.7-10.5% —————- The preferred mode of delivery is vaginal in almost all cases. Caesarean section is only indicated for obstetric reasons Women with repaired tetralogy of Fallot usually tolerate pregnancy well (WHO risk class II). Cardiac complications during pregnancy have been reported in up to 12% of patients Arrhythmias and right heart failure in particular may occur. Moderate to severe pulmonary regurgitation → increase in RV size → RV dysfunction and failure. If RV failure occurs during pregnancy, treatment with diuretics should be started and bed rest advised. Transcatheter valve implantation or early delivery should be considered in those who do not respond to conservative treatment There is a small chance of needing admission for bed rest and diuretics but this is unlikely in this case as ventricular function was normal on the recent echocardiogram The woman will definitely require a fetal cardiac scan but the overall risk of the fetus having a congenital heart disease is 2–5%. mother with CHD = 6% risk father with CHD = 2% risk one previous child with CHD = 2–5% two previous children with CHD = 10–15% The level of risk also depends on the specific lesion and the risk is highest (1–20%) for congenital aortic stenosis.

Answer 347

Not harmful – limited experience of use; hence use with caution

Answer 348

Right atrial pressure

Answer 349

7% NICE updated the risk figures for hypertensive disorder risk in future pregnancy in 2019. For women who had gestational hypertension in a previous pregnancy the risk of hypertensive disorders in future pregnancies is as follows: Gestational hypertension 11-15% Pre-eclampsia 7% Any hypertensive disease 22%

Answer 350

Multidisciplinary team input, avoid tachycardia, monthly or bimonthly echocardiography depending on haemodynamic tolerance, anticoagulation Mitral stenosis This is a high risk pregnancy and the woman should be reviewed by the multidisciplinary team (obstetrician, cardiologist, anaesthetist). Bed rest and oxygen therapy is not routinely recommended. When symptoms or pulmonary hypertension (echocardiographically estimated systolic PAP >50 mmHg) develop, activity should be restricted and β1 selective blockers commenced. Diuretics may be used if symptoms persist, avoiding high doses. Clinical and echocardiographic follow up is indicated monthly or bimonthly depending on haemodynamic tolerance. In mild MS, evaluation is recommended every trimester and prior to delivery. Percutaneous mitral commisurotomy is preferably performed after 20 weeks of gestation. It should only be considered in women with NYHA class III/IV and/or estimated systolic PAP >50 mmHg at echocardiography despite optimal medical treatment, in the absence of contraindications and if patient characteristics are suitable. Tachycardia is particularly dangerous in mitral stenosis as it results in pulmonary oedema. Tachycardia → further decrease in diastolic filling of left ventricle → fall in stroke volume → rise in left atrial pressure → pulmonary oedema. Therapeutic anticoagulation is recommended in the case of : Paroxysmal or permanent AF, Left atrial thrombosis, Prior embolism. Therapeutic anticoagulation also be considered in women with : Moderate or severe MS , Spontaneous echocardiographic contrast in the left atrium, Large left atrium (≥40 ml/m2), Low CO, or congestive heart failure, Because these women are at very high thrombo-embolic risk.

Answer 351

Before 14 weeks Women with twin pregnancy should be offered an ultrasound between 10 and 13 weeks to assess viability, chorionicity, major congenital malformation and nuchal translucency. Chorionicity is best assessed prior to 14 weeks gestation.

Answer 352

Folic acid antagonist.

Answer 353

Advise can restart in 2-3 days Consider delaying restarting anti-TNF drugs for a few days after delivery if the mother has a perineal tear or delivered by c-section Etanercept and anti-TNF drugs in general are safe to use when breastfeeding. It would be safe from the neonatal perspective to restart the Etanercept immediately. If the patient has a perineal tear or delivered by c-section (as is the case here) then it is advisable to withhold biologics for a few days until initial wound healing has occurred to reduce infection risk. Biologics in pregnancy (TNF) Background Biological agents refer to biological molecules that are used primarily to treat auto-immune conditions They are also sometimes referred to as cytokine modulators Starting biologics Aware patients immune system will be suppressed and increasing susceptibility to infection Vaccines need to be up to date prior to commencing Live vaccines contraindicated once on biologics (live vaccines shouldn't be given if pregnant) Should be screened for latent TB infection and treated prior to starting Consider biologics may increase risk of some cancers. Use caution in those with past history cancer or premalignant conditions e.g. HPV infection/cervical cancer Risk of immediate hypersensitivity reactions 3-5% Anti-TNF If used in pregnancy the risk of fetal malformations are similar to those of the general population. Growing evidence that safe to use in pregnancy. Flare ups of disease associated with worse maternal and fetal morbidity Concerns that anti-TNF accumulates in the neonate as transplacental transfer increases in later stages of pregnancy and could lead to immunosuppression To avoid neonatal immunosuppression it is recommended anti-TNF drugs are stopped in pregnancy as below: Drug Advised gestation to stop taking Safe with breastfeeding Etanercept Stop prior to third trimester Yes Infliximab Stop at 16 weeks gestation Yes Adalimumab Stop prior to third trimester Yes Certolizumab Safe all trimesters Yes

Answer 354

Not harmful – limited experience of use; hence use with caution.

Answer 355

PET Prev peripartum cardiomyopathy Obesity Black ethnicity Older age

Answer 356

Middle cerebral artery peak systolic velocity using Doppler sonography Fetal anaemia may be assessed in the surviving twin by measurement of the fetal middle cerebral artery peak systolic velocity using Doppler sonography.

Answer 357

B Thalassemia minor

Answer 358

Drug withdrawal

Answer 359

Typical aura symptoms include visual symptoms such as flickering lights, spots or lines, and /or particular loss of vision; sensory symptoms such as numbness and / or pin and needles; and/or speech disturbance. Migraine may present with or without aura. It may be unilateral or bilateral but is pulsatile in nature. It may be aggravated by routine activities of daily living.

Answer 360

Women with known haemoglobinopathy should have serum ferritin checked and offered oral supplements if their ferritin level is <30 μg/l.

Answer 361

Throughout pregnancy

Answer 362

Postpartum It is recognised that mothers with epilepsy are at higher risk of break-through seizures at this time . Reasons for this are varied, including sleep deprivation, stress and altered treatment compliance, and it seems likely that in some women biological changes (e.g. hormonal or neurochemical factors) may also be relevant. Women with epilepsy and their families should be specifically advised of the risks of epilepsy in the postpartum period and ways to mitigate these risks, including not sleeping or bathing alone.

Answer 363

Cluster-type headache A cluster headache is usually unilateral (around the eye, above the eye, and along the side of head/face). It is associated with red eye and/or runny nose/nasal congestion.

Answer 364

Yes The risk of teratogenicity increases six-fold in mothers taking more than 1 g of valproate per day.

Answer 365

For patients taking two or more anticonvulsants the risks is 15%. For those taking valproate, carbamazepine, and phenytoin, the risk is as high as 50%. The teratogenic effect of valproate is dose-dependent. The risk of teratogenicity increases six-fold in mothers taking more than 1 g of valproate per day. Benzodiazepines including clonazepam are not teratogenic. Valproate, phenobarbitone, carbamazepine, and primidone all cross the placenta. Phenytion and valproate are associated with congenital heart defects. The risk of teratogenicity increases with the number of drug

Answer 366

Cluster headache Cluster headaches are uncommon and affect men more often than women. The word ‘cluster’ is used as the sufferers get a number of attacks over few weeks and thereafter they are symptom-free for months or years. Cluster headaches normally present with severe headache, which is much worse than migraine. The pain usually occurs at the same time each day and quite often wakens the individual a few hours after they have gone to sleep. Migraine is usually categorized according to whether or not there is aura.

Answer 367

Identification of anxiety

Answer 368

Cerebral vascular thrombosis Cerebral vascular thrombosis usually occurs post-partum and has been noted even in the first trimester in the confidential enquiries into maternal deaths. Patients usually describe it as ‘the worst I ever had headache’. In the presence of leukocytosis, differential diagnosis will include puerperal sepsis.

Answer 369

Atopic eruption of pregnancy

Answer 370

Permissive arterial hypotension with delayed volume resuscitation is an established lifesaving concept as abridge to surgical control. In a severely bleeding trauma patient, doctors allow low blood pressure and delay giving lots of fluids to prevent worsening the bleeding. This strategy helps the patient survive long enough to reach surgery, where the bleeding source can be definitively fixed. In a severely bleeding trauma patient, doctors allow low blood pressure and delay giving lots of fluids to prevent worsening the bleeding. This strategy helps the patient survive long enough to reach surgery, where the bleeding source can be definitively fixed.

Answer 371

Hydroxycarbamide and continue contraception for three months

Answer 372

Initiation of medical management with neostigmine

Answer 373

Pemphigoid gestationalis

Answer 374

Urinary tract infection

Answer 375

45-90% New guideline doesn’t say a number

Answer 376

Similar Most anti-epileptic drugs (AEDS) cross the placenta and are potentially teratogenic. The incidence of major malformations in the fetuses of women with epilepsy who are not exposed to AEDs is similar to that in the general population (1–3%).

Answer 377

Cu IUD SCD is considered a “prothrombotic” state because of abnormal RBC rheology, hyperviscosity, endothelial dysfunction, and red cells adhesion; increased platelet activation; venous sludging and abnormal coagulation associated with increased thrombotic complications in patients receiving estrogens. Progesterone only contraceptives are usually safe in women with SCD and have a lower risk of associated thrombosis compared to the combined pill. Most IUDs, and especially unmedicated and copper bearing devices, should not be used by women with anemia. Progestin releasing IUDs tend to increase hemoglobin and serum ferritin levels, therefore, patients with iron deficiency anemia may benefit from progestin releasing IUD insertions.

Answer 378

She is at 1:2–1:3 risk of developing postpartum depression again

Answer 379

Impending eclampsia As this patient has risk factors such as being primigravida, under 20, and has sudden onset of headache and flashing lights. Her abdominal pain may be suggestive of perihepatic capsular congestion.

Answer 380

Lamotrigine In women with epilepsy who are taking anti-epileptic drugs (AEDs), the risk of major congenital malformation to the fetus is dependent on the type, number and dose of AEDs. Among AEDs, lamotrigine and carbamazepine monotherapy at lower doses have the lowest risk of major congenital malformation in the offspring. Enzyme-inducing AEDs (carbamazepine, phenytoin, phenobarbital, primidone, oxcarbazepine, topiramate and eslicarbazepine) are considered to competitively inhibit the precursors of clotting factors and affect fetal microsomal enzymes that degrade vitamin K, thereby increasing the risk of haemorrhagic disease of the newborn. The drug that fulfils both of these characteristics is therefore lamotrigine.

Answer 381

Less than 7 days

Answer 382

Hyperprolactinaemia

Answer 383

Tension headache A tension headache is usually bilateral, pressing (non-pulsatile), and lasts for 30 mins (continuous). It may be episodic (occurring fewer than 15 times per month) or chronic (occurring more than 15 times per month, for at least 3 months).

Answer 384

Monitors lithium level to the baby - baby could get drowsy from lithium If a woman continues taking lithium during pregnancy: - check plasma lithium levels every 4 weeks, then weekly from the 36th week - adjust the dose to keep plasma lithium levels in the woman's therapeutic range - ensure the woman maintains an adequate fluid balance - ensure the woman gives birth in hospital - ensure monitoring by the obstetric team when labour starts, including checking plasma lithium levels and fluid balance because of the risk of dehydration and lithium toxicity - stop lithium during labour and check plasma lithium levels 12 hours after her last dose.

Answer 385

S1Q3 T3 pattern , ST elevation

Answer 386

1500 IU A maternal blood sample should be taken for estimation of feto-maternal haemorrhage 30-40 minutes after re-infusion in case more anti-D is indicated Is there a role for intraoperative cell salvage (IOCS)? Cell salvage is recommended for patients where the anticipated blood loss is great enough to induce anaemia or expected to exceed 20% of estimated blood volume. Consent should be obtained for IOCS where possible and its use in obstetric patients should be subject to audit and monitoring. Cell salvage should only be performed by multidisciplinary teams who develop regular experience of IOCS. Where IOCS is used during caesarean section in RhD-negative, previously non-sensitised women and where cord blood group is confirmed as RhD positive (or unknown), a minimum dose of 1500 iu anti-D immunoglobulin should be administered following the re-infusion of salvaged red cells.

Answer 387

16 weeks When and how should paternal and fetal genotyping be performed? Non-invasive fetal genotyping using maternal blood is now possible for D, C, E, and K antigens. This should be performed in the first instance for the relevant antigen when maternal red cell antibodies are present. For other antigens, invasive testing (chorionic villus sampling [CVS] or amniocentesis) may be considered if fetal anaemia is a concern or if invasive testing is performed for another reason (e.g. karyotyping). **Genotyping can be undertaken from 16 weeks of gestation for all except K which can be undertaken from 20 weeks, due to the risk of a false-negative result if performed earlier in pregnancy.**

Answer 388

Hypocalcaemia

Answer 389

Azathioprine

Answer 390

AFE Amniotic fluid embolism

Answer 391

Subarachnoid haemorrhage Subarachnoid haemorrhage Intracranial haemorrhage accounts for 40-50% of stroke associated with pregnancy. The leading cause of such strokes is subarachnoid haemorrhage (SAH). SAH is most commonly due to rupture of a pre-existing cerebral aneurysm. Less often, SAH is due to bleeding from an arterio-venous malformation . SAH in pregnancy is rare but is associated with a high rate of maternal mortality and morbidity. Most cases present in the second around third trimesters. Signs and symptoms of SAH Sudden onset severe headachs, often occipital Nausea, vomiting Loss of, or impaired, consciousness Hypertension Focal neurological signs Seizures Papilloedema Neck stiffness The diagnasis can be tonfirmed by: CT/MRI scan lumbar puncture Cerebial angiography — gold standard as this will also elucidate cause.

Answer 392

No need for screening as there is low risk

Answer 393

Platelets concentration safety thresholds : Antenatal, no invasive procedures planned >20 Vaginal delivery>40 Operativeor instrumental delivery>50 Epidural anaesthesia>80

Answer 394

Persistent pulmonary hypertension of the newborn

Answer 395

Still nifedipine Amlodipine if the woman has previously used this to successfully control her blood pressure. If white, enalapril postpartum Offer enalapril to treat hypertension in women during the postnatal period, with appropriate monitoring of maternal renal function and maternal serum potassium.

Answer 396

TTN (Transient tachypnea of newborn) What Are the Signs & Symptoms of Transient Tachypnea of the Newborn? Symptoms of TTN include: very fast, labored breathing of more than 60 breaths a minute grunting sounds when the baby breathes out (exhales) flaring nostrils or head bobbing skin pulling in between the ribs or under the ribcage with each breath (known as retractions) bluish skin around the mouth and nose (cyanosis) Diabetes in pregnancy: management from preconception to the postnatal period Admit babies of women with diabetes to the neonatal unit if they have: Hypoglycaemia associated with abnormal clinical signs Respiratory distress Signs of cardiac decompensation frem congenital heart disease or cardiomyopathy Signs of neonatal encephalopathy Signs of polycythaemia, and are likely to need partial exchange transfusion Need for intravenous fluids Need for tube feeding (unless adequate support is available on the postnatal ward) Jaundice requiring intense phototherapy and frequent monitoring of bilirubinaemia Been born before 34 weeks (or between 34 and 36 weeks, if the initial assessment of the baby and their feeding suggests this is clinically appropriate). Vs RDS

Answer 397

137/1000 total births

Answer 398

Metoprolol

Answer 399

Haemolytic uraemic syndrome (HUS)

Answer 400

Neonatal bloody diarrhea Aminosalicylates (Sulfasalazine and mesalazine) DON'T significantly increase the rates of miscarriage , birth defects , low birth weight , stillbirth or preterm delivery . Avoid doses greater than 3 g/day because of risk of fetal nephrotoxicity. High-dose Folic acid supplementation (5mg/day) recommended with sulfasalazine use . Watch for Bloody diarrhea in infant with mesalazine use Safe to use during pregnancy and breastfeeding [ category B except rectal mesalazine C ]

Answer 401

subarachnoid haemorrhage

Answer 402

IV Antibiotics

Answer 403

24 weeks Management of Beta Thalassaemia in Pregnancy What is the recommended schedule of ultrasound scanning during pregnancy? Women should be offered an early scan at 7-9 weeks of gestation. In addition to the routine first trimester scan (11-14 weeks of gestation) and a detailed anomaly scan at 18-20 weeks of gestation, women should be offered serial fetal biometry scans every4 weeks from 24 weeks of gestation. Women with both thalassaemia and diabetes have a higher risk of early pregnancy loss. Ferility treatiment with ovulation induction is often required to achieve pregnancy so an early scan is indicated to determine viability as well as the presence of multiple pregnancy Severe maternal anaemia predisposes to FGR in women with thalassaemia, Chronic anaemia affects placental transfer of nutrients and can therefore adversely affect fetal growth

Answer 404

Increases the calcium absorption from Small bowel So if had bowel resection for crohns , might not work ?

Answer 405

Cluster headache

Answer 406

Coagulopathy , also convulsions, acute hypoxia, acute hypotension

Answer 407

At booking and if negative again at w 24-28

Answer 408

Azathioprine Inflammatory bowel disease in pregnancy Thiopurines : Azathioprine and mercaptopurine, an active metabolite of azathioprine, are immunomodulators and are particularly beneficial in patients with IBD to prevent recurrence and asteroid-sparing agents. Several studies done in recent years found no increase in the risks of miscarriage, congenital malformations, low birthweight, preterm births or abnormal newborn growth and development in women taking thiopurines in pregnancy. A prospective multicenter follow-up study found Intrauterine exposure to thiopurines does not affect long-term development or immune function of children up to 6 years of age. Azathioprine may be preferable as the fetus lacks the ability to convert this to mercaptopurine, theoretically reducing exposure to active metabolites. Thiopurines are relatively safe in breastfeeding as low concentrations of parent drug and metabolites are found in human breast milk and in the serum of breastfed infants.

Answer 409

The suitable treatment option is blood transfusion as patient is at term and sypmtomatic. Parenteral iron is indicated when oral iron is not tolerated or absorbed or patient compliance is in doubt or if the woman is approaching term and there is insufficient time for oral supplementation to be effective. Women should receive information on improvement of dietary iron intake and factors affecting absorption of dietary iron. The role of recombinant human erythropoietin (rHuEPO) for non-end-stage renal anaemia is still to be established and it should only be used in the context of a controlled clinical trial or on the expert advice of the haematologist. Active management of the third stage of labour is recommended to minimise blood loss. Women at high risk of haemorrhage should be advised to deliver in hospital.

Answer 410

Supraventricular tachycardia Supraventricular tachycardia is the most common non-benign arrhythmia i1 pregnancy, with a frequency of 24 in 100 000. Reports of first onset of SVT in pregnancy range from 3.8%%° to 34% of women presenting with SVT in pregnancy.

Answer 411

Hydroxychloroquine Obstetric management It is important to appreciate that not all pregnancies in women with SLE need to be considered as high risk. Careful identification and stratification should take place to allow women to be managed on an individual basis. Women with Quiescent skin and/or joint disease who have no other underlying organ impairment and who do not require multi-drug therapy or are an incremental increase in their current drug dosage are very different from those with a history of nephritis/hypertension or concurrent APS. Pregnant women with active SLE/lupus nephritis or anti- Ro/La /antiphospholipid antibodies should be considered as a higher risk group and managed in centres with appropriate expericnce. Care should be carried out in a multidisciplinary setting where obstetricians/midwives and physicians/haematologists work closely together to optimise care. It is difficult to recommend precisely how often these women should be reviewed, but those with more active disease need closer monitoring and often require hospital admission. For those individuals with stable disease, do weekly reviews of disease activity and regular assessment of fetal growth, blood pressure and proteinuria are appropriate. For those at particular risk of fetal growth restriction and/or pre-eclampsia because of active disease or previous history, more frequent assessment is indicated For those women who are anti-Ro/La positive the fetal heart rate should be monitored and recorded at each visit and fetal echocardiography assessments made at 18- 20 and 28 weeks of gestation. Careful obstetric management involves an awareness of the possibility of lupus flare and an understanding of how this can overlap with normal pregnancy-related changes and with pre-cclampsia.

Answer 412

Serum ferritin Key components in the metabolism of iron Hepcidin: 25-amino-acid peptide hormone that regulates iron uptake and release from stores in response to circulating and tissue levels of iron Ferroportin: transmembrane protein which exports iron into the blood from entéraeytes and macrophages. Ferric iron (Fe2+) and ferrous iron (Fe3+): non-haem iron from cereal and vegetable sources contains ferrous and ferric forms of iron The ferrous form is better absorbed from the gut therefore the ferric iron is reduce@te.ferrous iron by stomach acid, ascorbic acid and enzymes. Ferritin: main storage protein for iron. Found in all cells and bodily fluids, the highest concentration being found in hepatocytes. Serum ferritin is a marker of total iron stores in those with no chronic illness. Transferrin: iron-binding protein mostly produced by the liver which acts as an intercellular transporter for iron. Approximately 3 mg total body iron is bound to transferrin at any one time

Answer 413

Tacrolimus Intflammatory bowel disease in pregnancy Calcineurin inhibitors Tacrolimus and cyclosporin have been used to treat fulminant colitis In pregnancy with a high remission rate. European Crohn’s and Colitis Organisation guidelines for UC discuss them use as rescue therapy for steroid-refractory UC. These drugs act by suppressing interleukin (IL)-2 and IL-3 production, inhibiting chemotaxis of neutrophils and inducing apoptosis in T cells. Most data on tacrolimus and ciclosporin use in pregnancy are derived from transplant literature that suggests a possible link with preterm birth, low birthweight and small-for-gestational-age neonates. These drugs are considered safe during breastfeeding, although low levels of the medication can be detected in breast milk and neonates.

Answer 414

Diabetes in pregnancy: management from preconception to the postnatal period Assess the risk of gestational diabetes using risk factors in a healthy population. At the booking appointment, check for the following risk factors : -BMI above 30 kg/m -Previous macrosomic baby weighing 4.5 kg or more -Previous gestational diabetes -Family history of diabetes (first-degree relative with diabetes) -An ethnicity with a high prevalence of diabetes. Offer women with any of these risk factors testing for gestational diabetes Do not use fasting plasma glucose, random blood glucose, HbAlc, glucose challenge test or urinalysis for glucose to assess the risk of developing gestational diabetes.

Answer 415

2% Congenital heart block This is associated with maternal anti-Ro/La autoantibodies. Antibodies cross the placenta and destroy the Purkinje system. The usual presentation is a fixed fetal bradycardia of 60—80 beats per minute on ultrasound scan. It occurs in 2—3% of fetuses of women with the anti-Ro/La antibody and there is a recurrence rate of 16% 1n subsequent pregnancies. It 1s associated with significant perinatal morbidity and mortality, with about half of infants requiring pacing by the first year of life. Congenital heart block develops between 18— 28 weeks of gestation and fetal echocardiography should be performed around this period to detect it. Hydrops fetalis can occur in utero and is thought to be due to the degree of endomyocardial fibrosis and associated myocarditis.

Answer 416

Dizziness with palpitations Features requiring further attention for arrythmias -Fast and irregular heart beat -Palpitations waking from sleep or at work -Dizziness following the onset of palpitations -Shortness of breath, chest pain, syncope -Associated , sweating or abdominal pain and hypertension (consider phaeochromocytoma) -Personal history of pre-existing cardiac disease

Answer 417

3.7/1000 maternities

Answer 418

37-38 weeks of gestation Delivery of the fetus is an option if the fetus is sufficiently mature. However, delivery of an anaemic, rapidly haemolysing premature baby is a significant risk and should not be undertaken lightly. Delivery must take place in a unit where adequate neonatal support and expertise is available. Experience of exchange transfusion are less than they were in many centres and, generally, delivery should not be before 37-38 weeks of gestation unless there are specific reasons such as special difficulty with fetal transfusion Delivery by caesarean section is only necessary if indicated by other obstetric factors.

Answer 419

0.14 to 6 / 1000 maternities

Answer 420

Those who suffer from frequent hypoglycemia and dawn phenomenon

Answer 421

Paroxetine

Answer 422

Migraine without aura

Answer 423

Amiodarone Amiodarone is suitable for short-term use in emergencies Prolonged use: fetal thyroid abnormalities, growth restriction and prematurity; risk may outweigh benefit Amiodarone with Breastfeeding Avoid long-term use , Risk neonatal hypothyroidism

Answer 424

Erect chest X ray

Answer 425

Lamotrigine The risk of being born SGA was increased for clonazepam, carbamazepine, oxcarbazepine, valproic acid and topiramate whereas there was no increased risk associated with exposure to lamotrigine

Answer 426

Birthweight according to GA

Answer 427

At 16-20 weeks Retinal assessment during pregnancy After pregnant women with pre-existing diabetes have had their first antenatal clinic appointment: Offer retinal assessment by digital imaging with mydriasis using tropicamide (unless they have had a retinal assessment in the last 3 months) **If they have diabetic retinopathy, offer an additional retinal assessment at 16 to 20 weeks Offer another retinal assessment at 28 weeks.** Diabetic retinopathy should not be considered a contraindication to rapid optimisation of blood glucose control in women who present with a high HbAl1c in early pregnancy. Diabetic retinopathy should not be considered a contraindication to vaginal birth.

Answer 428

Clobazam Long-acting benzodiazepines such as clobazam can be considered if there is a very high risk of seizures in the peripartum period. AED intake should be continued during labour. If this cannot be tolerated orally, a parenteral alternative should be administered.

Answer 429

Weight-corrected AFP

Answer 430

Above 50 x 10E9 / L

Answer 431

Advise pregnant women with any form of diabetes to maintain their capillary plasma glucose below the following target levels, if these are achievable without causing problematic hypoglycaemia: • fasting: 5.3 mmol/litre and • 1 hour after meals: 7.8 mmol/litre or • 2 hours after meals: 6.4 mmol/litre. Advise pregnant women with diabetes who are taking insulin to maintain their capillary plasma glucose level above 4 mmol/litre.

Answer 432

37 weeks to 38 weeks plus 6 days

Answer 433

Advise women with uncomplicated gestational diabetes to give birth no later than 40 weeks plus 6 days.

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