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Week 5 Flashcards

rheumatology, connective tissues, substance use, trauma (85 cards)

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1
Q

What are the risks of use of NSAIDs in periconception, T1, T2, T3?

A

Peri conception - inhibit ovulation and implantation
T1 - congenital heart defects,
T2 - low BW ? confounding. thought to be okay
T3 - renal circulation impairment and oligo, constriction of DA, necroenterocollitis, ICH, asthma for infant

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2
Q

Can we use tramadol in the first trimester?

A

advised to not to, large cohort study found relationship with congenital malformations, miscarriage and heart defects

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3
Q

What are the fetal risks when the mother has SLE?

A

Still birth, IUGR 10-30%, neonatal lupus syndrome, miscarriage, PTB15-50% (iatrogenic), neonatal death, if antiRo/La antibodies congential heart block

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4
Q

What are the maternal risks in SLE in pregnancy?

A

Death 20x, PET 3x, eclampsia (4.4x), VTE, stroke, flare of lupus, infection, risk of CS 1.7x, if on cyclophosphamide reduced ovarian reserve

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5
Q

What are the features of neonatal lupus syndrome?

A
  1. Rash/neonatal cutaneous lupus 10-25% of affected children, may be present at birth or develop in teh first weeks of life. on face, scalp. classically periorbital distribution.
  2. liver - LFTs derangement 10-15% of affected children
  3. haematological - low platelets and nuetrophils 10-15% affected children
  4. Cardiac - conegnital heart block in 1% of children, irreversible. Increased risk in future children of 15%.
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6
Q

Why do you get improvement in RA in pregnancy?

A

It is a disease mediated by Thelper 1 cells (cytokine release and cytotoxins) and in pregnancy, you get Th1 –> Th2 shift

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7
Q

What are the other possible effects of organs involved in RA?

A

pericardial/pleural effusions, lung fibrosis, peripheral neuropathy, episcleritis, haematological abnormalities (anaemia), vasculitis, pericarditis, amyloidosis

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8
Q

What antibodies can be involved with RA?

A

ANA +ve 30%
Rheumatoid factor +ve (cross over with SLE) 80-90%
Anti Ro/La (common with sjrogens cross over)
Anti-phospholipid antibodies 5-10%

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9
Q

What is the antenatal counselling for pregnancy for RA?

A

if anti Ro /La or APLS antibodies can impact pregnancy
otherwise no impact on fetus, disease normally improves
assess medications
check ESR/CRP for disease control and FBC for anaemia

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10
Q

What is scelroderma?

A

an autoimmune connective tissue disease charactarised by progressive fibrosis of skin and visceral organs as well as vasculopathy

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11
Q

What pregpregnancy investigations should be performed with sceroderma?

A

echo, renal function, spirometry

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11
Q

what are the forms of scleroderma ?

A

localised - skin thickened on forearms and hands
systemic - rayanuds, visceral involvement (heart, lungs, kidneys)
CREST syndrome - calcinosis, talengectasia, sclerodactyly, raynauds, oesophagela involvement

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12
Q

What would contraindicate pregnancy in sceroderma?

A

severe disease - pulmonary fibrosis, pulmonary hypertension, renal scleroderma

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13
Q

How does smoking impact the placental function?

A

Thickens the villous membrane impacting oxygen diffusion from mum to baby
Nictoine impacts the amino acid transport across placenta
interrupts the implantation process and development of spiral arteries

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14
Q

What is toxic in cigarettes?

A

carbon monoxide, lead, mercury, nicotine, cyanide, cadmium, PAHs

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15
Q

What long term neurodevelopmental outcomes are associated with cannabis use in pregnancy?

A

inattention, visiospacial dysfunction, impulsivity, cognitive deficit, depression

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16
Q

What are the withdrawal symptoms of benzodiazepines?

A

mimics anxiety, panic attacks, seizures.

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17
Q

What symptoms does methamphetamine cause?

A

hyperthermia, tachycardia, arrythmia,
long term - anxiety, depression, confusion, aggression, insomnia

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18
Q

What is the difference in pregnancy in T helper 1 and T helper 2 response?

A

Shifts from TH 1 to TH2 reponse
TH 1 is a cytotoxic cell mediated reponse and TH2 is a antibody mediated immunity.
This occurs to protect the fetus.

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19
Q

What other AI condition is commonly associated with RA?

A

sjogrens syndrome 15%

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20
Q

What proportion of women with RA will suffer exacerbation postnatally?

A

90%

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21
Q

What supplements should you give if women are on long term steroids?

A

vitamin D and calcium

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22
Q

What are the clinical features of SLE ?

A

Joint - 90% non erosive arthritis peripheral
Skin 80% - malar rash, photosensitivity, vasculitic lesions, raynauds, discoid lupus
serositis - pleuria, pericarditis
haemoatolgyical - thrombo/leuko/lymphopenia, haemolytic anaemia
neuro - psychosis, seizures, chorea
renal - glomerulonphritis

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23
Q

What is the most specific antibody for SLE?

A

double-stranded DNA antibodies 78%

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24
What is the most common positive antibody in SLE?
ANA 96%
25
What antibodies are associated with SLE?
ANA 96% double-stranded DNA 78% APLS 40% Anti Ro/La 30%
26
What baseline investigations should be done for SLE pre pregnancy counselling?
Urine - red cells and casts, protein Bloods - creatinine, LFT, FBC ds DNA antibodies complement levels BP Anti Ro/La APLS antibodies consider echo, spirometry, CXR
27
What investigation results can indicate a SLE flare rather than PET
fall in complement levels of 25% increase ds DNA abs red cells or casts in urine
28
What investigation results can indicate a PET rather than SLE flare
hyperuricemia abrnormal LFTs, low PLGF, acellular urine
29
What antibodies cause neonatal lupus syndrome?
anti Ro 90% and anti La 50-70%
30
What proportion of the population have anti Ro and La abs and what proportion of SLE patients do?
<1% popn, 30% SLE
31
If a mother has anti Ro/La abs what si the risk of cutaneous neonatal disease of CHB?
5% and 2%
32
What are the clinical features diagnostic of APLS with antibodies +ve?
embolic disease - arterial, venous, small vessels eg kidney pregnancy complications: - 3 consecutive <10 weeks - 1 >10 weeks normal morphology - 1 PTB with PET or severe placental insufficiency
33
What are the associated features on APLS which aren't diagnostic?
thromboyctopenia haemolytic anaemia neurological (seizures, transverse myelitis, chorea, cerebal infarction, migraines Heart valve disease - mitral HTN pulmonary HTN leg ulcers
34
What are the facial features associated with FASD?
Epicanthal folds Low nasal bridge ear abnormalities microngathia short nose thin upper lip flat midface short palprebal fissures
35
What are the disorders included in FASD?
* Fetal alcohol syndrome (FAS) - growth disorders (intra uterine or post natal) + facial abnormalities + CNS abnormalities * Partial FAS - some growth problems or facial abnormalities + CNS abnormalities * Alcohol related neurodevelopmental disorder (ARND) - abnormalities without the facial or growth disorders. Including: ○ Sensory impairments - hearing, vision ○ Behavioural challenges ○ Relationship or social challenges ○ Speech and language problems ○ Cognitive issues * Alcohol related birth defects (ARBD)- skeletal, eye, ear, cardiac
36
What organs are usually involved in systemic sclerosis of scleroderma?
oesophagus 80% lungs 45% heart 40% kidneys 35%
37
What is the effect of pregnancy on scleroderma?
1. cutaneous - good prognosis 2. Diffuse systemic disease diagnosed in the last 4 years or renal involvement - high risk of rapid deterioration and renal crisis 3. worsening esophagitis 4. improvement of raynauds 5. worsening pulmonary hypertension PN
38
What is the effect of scleroderma on pregnancy?
PTB 25% Diffuse systemic disease - PET, IUFD, FGR, miscarriage difficulty with BP monitoring, venepuncture and GA
39
How do you manage scleroderma in pregnancy?
There is no disease management only symptom control: * Regular BP & renal function checks during pregnancy as well as USS for fetal growth * ACEI can be used in renal crisis as benefits > risks associated * There is no management only symptom control * Interstitial lung disease can be managed with cyclophosphamide (after T1), azathioprine and steroids * Nifedipine can be used for Raynaud's * Continue PPI for esophagitis * Anaesthetic review Steroids for lung maturation flare disease so should be avoided
40
What is takayasu's arteritis?
AI, vasculitis affecting large arteries. causes stroke, HTN (renal arteries), ischaemia, fevers diagnosed on angiogram
41
How do you manage takayasu's and what are the associated risks of disease in pregnancy?
Steroids for disease flare +/- azathioprine Risks of PET, FGR
42
What organs are affected by granulomatosis with polyangiitis?
respiratory (nose, sinuses, lungs)and kidneys
43
What is management of GPA?
prednisolone, azathioprine and antibiotics (eryth or cotrim+5mg folic acid)to reduce flares of disease
44
What are the main kinds of Ehlers-Danlos syndrome?
type I classical Type II mitis EDS Type III - hypermobility (most common) Type IV - vascular
45
46
What are the most dangerous kinds of EDs in pregnancy and why?
Type I and type IV. Type IV has a risk of aortic and uterine rupture, mortality rate of this disease in pregnancy is 20-25%. advise termination
47
Pregnancy management with EDS?
- Genetics is essential (mostly AD) to get the categorisation of disease. - Type IV advise TOP. If doesn't should offer CS at 34 weeks - Type III offer cs - refer to anaesthetics 3x increase in LA resistance.
48
What are the characteristics of bechet's syndrome?
ulcers in mouth and genitals, arthritis, eye inflammation
49
WHat features of wound healing can occur with bechets?
over active WCC cause inflammation ++, if rule out infection can use steroid cream
50
What are the features of marfans and what is the genetics?
autosomal dominant tall stature, long arm span, arachnodactyly (long fingers), high arched palate, dislocation of lenses, cardiac involvement (mitral valve regurg, prolapse and aortic root dilatation)
51
When is pregnancy contraindicated in marfans?
if the aortic root is >4-4.5cm defer pregnancy until replacement or aortic root. risk of dissection or rupture is 10% if >4cm
52
What risks is smoking assicated with in pregnancy?
reduced fertility miscarriage ectopic congenital abnormalities (cleft lip/palate, gastroschisis, MSK, craniosynotosis) PPROM PTB low birth weight FGR IUFD sudden infant death syndrome placenta praevia placental abruption
53
What are the features of neonatal withdrawal from opioids?
CNS - seizures, increased tone, irritability, irregular sleep tremors Autonomic - yawning, sneezing, sweating, increased RR GI - D+V, increased suckling, poor feeding
54
What are methadone and buprenophine?
methadone - a full opiate agonist buprenorphine - partial opiate agonist
55
When in the safest time to come off methadone in pregnancy?
T2 only not advised in T1 - miscarriage or T3 neonatal withdrawal.
56
What are the risk to the fetus with meth use?
FGR, PTB, neonatal jitteriness, drowsiness, behavioural and Cognitive effects No impact on anomalies
57
What is TNF alpha?
a cytokine heavily involved in host defence, regulating and maintaining pregnancy. receptors on placenta uterus and embryo
58
What is the effect of pregnancy on the immune system?
1. Progesterone from CL causes negative immunomodulations 2. Progesterone causes involution of the thymus 3. high estrogen and cortisol caiuses immunosuppression 4, decreased NK cell activity 5. Shift from TH1 (cytokine medicated) to TH2 antibody mediated, but no change in cell number
59
How does the fetal trophoblast effect immune system?
1. inhibits complement 2. Inhibits T cell activation 3. inhibits uterine natural killer cells on
60
What may be the cause of the pathogenesis of pregnancy loss in SLE?
Blockade of complement inhibitors by antiphospholipid antibodies. This causes increased placental complement deposition
61
What is the recent advice on corticosteroids in T1?
The placenta metabolises most of it to inactive derivatives, <10% to the active drug reaches fetus. The risk of cleft palate has been refuted.
61
What sort of drug is aspirin?
NSAID. only inhibits thromboxane A2 --> antiplatelet effect
62
What is the difference between prednisone and prednisolone
Prednisone is a prodrug which is converted into active form prednisolone by the liver
63
What are the risks for low, low to moderate and moderate to high alcohol exposure in pregnancy?
* Any levels of alcohol - miscarriage, congenital heart disease * Low level ETOH - SGA 1.08 RR * Low to moderate ETOH - facial features Moderate to high - facial features, behaviour scores, delayed early childhood milestones.
64
What are the pregnancy risks associated with vaping?
PTB and low birth weight
65
What are the risks in pregnancy of cannabis use?
gastrochisis, placental abruption, IUFD, SGA, NICU admission, PTB, epstein cardiac anomaly
66
What are the pregnancy risks with opioids?
Low birth weight PTB Prolonged hospital stay IUFD Neonatal death
67
What are the pregnancy risks with meth use?
PTB, low BW, improved with stopping at any gestation. possibly neurodevelopmental outcomes
68
What are the pregnancy risks with benzodiazepine use?
NICU admission, low birth weight, PTB, miscarriage, low apgar at 5 minutes
69
What is an example of a brief intervention model to use in drug use?
FLAGS - feedback, listening, advice, goals, strategies
70
Is NRT safe in pregnancy and is it effective for smoking cessation?
it is safe, long acting NRT is effective in reducing smoking in late pregnancy but this isn't sustanined at 3-6 and 12 months PN
71
Is breastfeeding safe with NRT?
safe as the levels of fetal exposure at 2-8% and the GI absorption is metabolized by liver prior to systemic circulation, unlikely to be hazardous.
72
What are the most effective non-pharmacological interventions for smoking cessation?
financial incentives and counselling
73
What is the T ACE screening tool?
Tolerance - how many drinks does it take to feel high Annoyance - have you ever been annoyed by people criticising your drinking cut down - have you ever thought you should cut down eye opener - ever need a drink in the morning to get rid of nerves or a hangover A score of 2 or more is positive
74
Should we use kleihauer-Betke routinely with trauma?
No, only to calculate anti D dose needed. The reults in trauma women are similar to those in non trauma women.
75
Is USS useful at detecting abruption?
no 50-80% will be missed on USS alone.
76
In trauma what level should we maintain fibrinogen levels over? and what with
2.5 cryo or fibrinogen concentrate
77
How does the uterus impact CPR?
1. Reduces venous return 2. Reduces stroke volume and CO 3. Reduces the effectiveness of compressions
78
What changes do you see after PMCS?
○ Decompression of IVC and aorta ○ Redistribution of blood to other organs ○ Improved functional residual capacity of the woman - better oxygenation Increased effectiveness of CPR
79
What volume is considered to be a 'negative' Kleihauer?
<1ml
80
What are the signs of an AFE?
hypotension, hypoxia, cardiac arrest, seizures, DIC, haemorrhage
81
What is the pathophysiology of an AFE and the mortality rate?
poorly understood, inflammatory response to fetal tissue. 20-60%
82
What is the management of AFE?
Supportive care - reverse coagulopathy, restore volume, and oxygenation
83
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