Maternal medicine

When should retinal assessment be done for T1DM in pregnancy?

at booking and at 28 weeks

if abnormal at booking then repeat at 16-20/40

If a woman has prev GDM, when should she be tested in this pregnancy?

OGTT at booking and at 28/40

How many times a day should a patient with

• diet / oral therapy GDM

• T1DM or GDM on insulin test their glucose?

• diet / oral therapy GDM - 4 times

• T1DM or GDM on insulin - 7 times

Target blood glucose monitoring for patient with T1DM or GDM on insulin?

fasting 5.3

1 hour post meal 7.8

2 hours post meal 6.4

Woman with T1DM pre-conception - what is the fasting and pre meal blood sugar to achieve?

fasting 5-7

pre meal 4-7

When should a woman with T1 or T2DM be delivered without complications?

37 - 38+6

Aim blood sugar in labour

between 4 and 7. if high or low then sliding scale

How frequently should you measure BP in postnatal patient with chronic HTN / gestational HTN / PET?

Chronic HTN / Gest HTN

• daily day 1 and 2

• at least once between day 3 and 5

PET

• QDS day 1 and 2

• at least once between day 3 and 5

What are the moderate risk factors to start aspirin?

>40yo

first pregnancy

more than 10 years interval

BMI>35

multiple pregnancy

FH PET

What are the risk prediction models for PET and when can they be used?

full PIERS - any time

PREP-S before 34/40

three levels of critical care in PET patient

level 1 - milf moderate PET

level 2 - severe with organ failure

level 3 - life threatening eg eclampsia or ventilation

If patient had PET in previous pregnancy what is her chance of developing PET this pregnancy?

• Overall 16%

• if delivered before 28/40 - 50%

• if delivered 28-34/40 - 35%

• if delivered 34-37/40 - 25%

when comparing pregnant women with sickle cell what complication are HbSC more prone to compare to HbSS

more prone to retinal neuropathy hence retinal assessment

both should get annual U&E / LFT

Growth scans in sickle cell disease

every 4 weeks from 24/40

complication of vitamin b12 deficiency

subacute degeneration of spinal cord

What is the screening tool for depression antenatally and postnatally?

Whooley depression screen - 2 questions in the last 4 weeks

if positive then

Edinburgh Postnatal depression - score of >12 needs further diagnosis

What is the screening tool for anxiety antenatally and postnatally?

GAD2 - in the last 2 weeks

if positive GAD 7

What % of postnatal women experience postpartum blues / postnatal depression and postnatal psychosis?

postpartum blues - 80%

postnatal depression - 15%

postnatal psychosis - 1 in 1000

Risk factors for postnatal psychosis

previous postnatal psychosis 50%

bipolar disease 25%

Checking lithium levels in pregnancy

every 4 weeks and then weekly from 36/40

safest SSRI in breastfeeding

sertraline

side effects of SSRI?

side effect of paroxetine

SSRI - maternal pulmonary HTN, hypoglycaemia, PPH* new

Paroxetine - congenital R ventricle obstruction

What is the incidence of OC in general population and in particular in asians?

general population 0.7%

asians 1.5%

risk of stillbirth in severe OC?

3.44%

When should mild/moderate/severe OC be delivered?

mild - 40/40

moderate - 38/40

severe - 35/40

Medical management of pruritis in OC?

• antihistamine

• UDCA 1st line

• rifampicin 2nd line

contraception after having Obstetric Cholestasis

COCP - UKMEC 2 (unless liver deterioration related to contraception)

Rest - UKMEC 1

When should OC bloods be repeated post natally?

LFT / bile acids at least 4 weeks postnatally

What are the complications of sodium valproate and risks?

10% risk of congenital malformation

30% risk of neurodevelopmental disorder

Examples of SNRI and risk

duloxetine and venlafaxine

with of PET

Which antipsychotic is associated with agranulocytosis?

clozapine

What mode of inheritance is congenital adrenal hyperplasia?

autosomal recessive

What mode of inheritance are Marfan’s and Duchenne muscular dystrophy

Marfan’s - autosomal dominant

Duchenne muscular dystrophy - X linked recessive

Whats the mode of inheritance of haemophilia?

X linked recessive

Specific management of PTSD

eye movement desensitisation

Incidence of OCD in pregnancy and post partum

2%

What is a major complication of untreated psychosis in pregnancy?

stillbirth

Acute management of psychosis

urgent referral to PMHT within 4 hours

Mental capacity act 1983 sections

◦ Section 2 - holding for 72 hours for assessment

‣ can be extended for 28 days

◦ Section 3 - for treatment

‣ 6 months

What percentage of pregnant women are affected by asthma? Does asthma improve/worsen in pregnancy?

When does exacerbate happen?

4% of pregnant women are affected

1/3 improve, 1/3 no change, 1/3 deteriorate

worsens between 24 and 36 weeks then improves

When should IV steroids in given in labour? What is the dose of hydrocortisone?

• if takes 5mg daily or more for more than 3 weeks

• 50mg every 6 hours IV until 6 hours after baby is born

• if EMCS 100mg stat

What is the most common cause of myocardial infarction in pregnancy? When would you deliver this patient post MI?

• coronary artery dissection is the leading cause

• delay delivery for 3 weeks as mortality can be 50%

What is a biochemical link for peripartum cardiomyopathy?

increase in prolactin from anterior pituitary

Whats the advised ejection fraction in pregnancy - for and against pregnancy?

if <30% - WHO IV advise against pregnancy

aim for LVEF >50%

Repaired tetralogy of Fallot / not repaired which WHO category?

Repaired tetralogy of Fallot WHO 3

not repaired WHO 4