Anemia, changes in pregnancy, teratogens, anticoagulant

What are the four main placental hormones? [tab] 1. hCG (Human Chorionic Gonadotropin)
2. HPL (Human Placental Lactogen)
3. Estrogen
4. Progesterone

What is the most common (m/c) site of production for placental hormones? [tab] Syncytiotrophoblast

In pregnancy, what is the precursor for Estrogen and where is it produced? [tab] DHEA-S, produced by the fetal adrenal gland.

What is the function of increased Estrogen from the placenta during pregnancy? [tab] It causes a decrease (↓) in FSH (Follicle-Stimulating Hormone) and LH (Luteinizing Hormone).

What is the primary function of Progesterone in early pregnancy? [tab] Suspension of ovulation.

What is the source of Estrogen and Progesterone before 8 weeks of pregnancy? [tab] The Corpus luteum of pregnancy.

What is the source of Estrogen and Progesterone after 8 weeks of pregnancy? [tab] The Placenta.

Pregnancy is considered a dependent condition. [00:00:45] [tab] Progesterone dependent condition.

What are the key roles of Progesterone in maintaining pregnancy? [00:00:45] [tab] 1. Maintenance of pregnancy
2. Decidualization of the endometrium
3. Decrease (↓) in PVR (Peripheral Vascular Resistance)
4. Smooth muscle relaxation
5. Prevents preterm labor

What are some key changes in pregnancy that are Estrogen dependent? [tab] 1. Skin changes (e.g., Chloasma)
2. Salt & water retention (leading to ↑ Blood volume)
3. Obstetric cholestasis
4. Increased TBG (Thyroid Binding Globulin)
5. Increased oxytocin receptors (for onset of labor)

Which hematological parameters increase (↑) during pregnancy? [tab] Blood volume (d/t estrogen & aldosterone), Plasma volume (40%), RBC volume (20%), Hb mass, Reticulocyte count, Plasma protein mass, Globulin (TBG, SHBG), Clotting factors (Excluding 11 & 13), WBC count (15,000-25,000), Inflammatory markers (ESR, CRP).

Which hematological parameters decrease (↓) during pregnancy? [tab] Hematocrit/PCV (due to hemodilution), Hb concentration, Plasma protein concentration, Albumin, Factor 11 & 13, Fibrinolytic activity, Protein C & S, Antithrombin, Platelet count (Benign gestational thrombocytopenia), Eosinophils.

Which coagulation parameters remain unchanged during pregnancy? [tab] Bleeding time, Clotting time, and APTT.

What are the physiological changes to the Spleen, Pituitary, and BMR during pregnancy? [tab] Spleen size: ↑ by 50%
Pituitary size: ↑ by 125-135% (Anterior > Posterior)
BMR: ↑ by 10-20%

What is the most common (m/c) indirect cause of maternal mortality in India? [00:08:24] [tab] Anemia.

What is Physiological Anemia of pregnancy? [00:08:24] [tab] The m/c cause of anemia in pregnancy. It is a normocytic normochromal anemia where Hb never falls below 11 g/dL. It's caused by hemodilution (plasma volume ↑ > RBC volume ↑).

What is the m/c cause of Pathological Anemia in pregnancy? [00:08:24] [tab] Iron Deficiency Anemia (IDA). It is a microcytic hypochromic anemia with Hb < 11 g/dL.

What is the WHO classification for anemia severity in pregnancy? [tab] Mild: 10-10.9 g/dL
Moderate: 7-9.9 g/dL
Severe: < 7 g/dL

What is the ICMR classification for very severe anemia? [tab] Hb < 4 g/dL.

How can Iron Deficiency Anemia (IDA) be differentiated from Thalassemia? [tab] Using the Nestroft test.
IDA: Nestroft test is Negative (Rx with iron).
Thalassemia: Nestroft test is Positive (Rx with iron is contraindicated).

What are the key interventions of the ANEMIA MUKT BHARAT program? [tab] 1. Digital hemoglobinometer
2. Weekly IFA pill (for reproductive age females)
3. Deworming (400 mg Albendazole twice a year)
4. Food fortification
5. Delayed cord clamping (prevents neonatal anemia)

What supplementation is recommended for a woman planning a pregnancy? [tab] Stop the IFA pill and take only Folic acid 400 mcg/day (to prevent neural tube defects).

What supplementation is recommended for a pregnant female in the first 3 months (1st trimester)? [tab] Folic acid (400 mcg).

What supplementation is recommended for a pregnant female from the 4th month onwards? [tab] IFA pill (1 tablet/day) for at least 180 days in pregnancy, and continued for 180 days after delivery.

When is deworming done in pregnancy? [tab] Once, in the second trimester.

What is the composition of the red IFA (Iron Folic Acid) pill? [tab] 60 mg of Elemental Iron + 500 mcg of Folic acid.

What is the daily dose of the IFA pill to prevent anemia vs. treat (Rx) anemia? [tab] Prevent: 1 tablet/day
Treat (Rx): 2 tablets/day

What is the expected rate of Hb increase with oral iron therapy? [tab] 0.7 g/dL/week (this rise is seen after the 3rd week of therapy).

What is the minimum time gap required between oral and parenteral iron therapy? [tab] 3 weeks (Oral iron is C/I with parenteral therapy).

In which trimester is parenteral iron contraindicated (C/I)? [tab] First (1st) trimester.

What formula is used to calculate the dose for parenteral iron? [tab] Ganzoni formula:
Dose (mg) = ( 2.4 \times \text{Pre-pregnancy weight (kg)} \times \text{Hb deficit (Target Hb - Patient's Hb)} + 500 \text{ mg} )

What are the indications for blood transfusion for anemia in pregnancy? [tab] 1. Unstable vitals
2. Signs of heart failure
3. Thalassemia
4. Hb < 5 g/dL at any gestational age

How is mild-moderate anemia (Hb 7-10.9) treated based on gestational age? [tab] < 34 weeks POG: Oral iron (2 tablets/day)
≥ 34 weeks POG: Parenteral iron

How is severe anemia (Hb < 7) treated based on Hb level and gestational age? [tab] Hb < 5 g/dL (at any POG): Blood transfusion
Hb 5-6.9 g/dL AND < 34 weeks POG: Parenteral iron
Hb 5-6.9 g/dL AND ≥ 34 weeks POG: Blood transfusion

What are the normal heart sound findings in pregnancy? [00:21:20] [tab] S1: Loud & prominent splitting
S2: Normal
S3: Easily heard

What are the normal (physiological) murmurs found in pregnancy? [tab] Ejection Systolic Murmur (ESM) of grade ≤ 2/6
Continuous murmur (Mammary murmur)

What are the normal findings on a Chest X-ray and ECG in pregnancy? [tab] Chest X-ray: Mild apparent cardiomegaly
ECG: Left axis deviation

What symptoms, often associated with heart disease, are considered normal in pregnancy? [tab] 1. Dyspnea on exertion
2. Easy fatiguability
3. Decreased (↓) exercise tolerance
4. Peripheral dependent edema

Which cardiovascular parameters increase (↑) during pregnancy? [tab] Heart rate, Pulse rate, Cardiac Output (CO) (due to ↑ Stroke Volume), and Femoral venous pressure (risk of varicose veins/hemorrhoids).

Which cardiovascular parameters decrease (↓) during pregnancy? [tab] Peripheral Vascular Resistance (PVR), SBP, DBP (maximum decrease in T2), and MAP.

Which cardiovascular parameters remain constant during pregnancy? [tab] JVP (Jugular Venous Pressure) and LVEF (Left Ventricular Ejection Fraction).

What is the most common (m/c) heart disease in pregnancy? [tab] Mitral stenosis.

What is the most common (m/c) congenital heart disease (CHD) in pregnancy? [tab] Atrial Septal Defect (ASD).

Which heart disease carries the maximum maternal mortality? [tab] Eisenmenger syndrome.

What findings indicate pathological heart disease in pregnancy (vs. normal changes)? [tab] Increased (↑) JVP, S4 sound, ESM grade ≥ 3/6, Diastolic murmur, Marked cardiomegaly on CXR, Clubbing, or Cyanosis.

When does Cardiac Output (CO) start to increase in pregnancy, and when does it reach its maximum? [tab] Starts to increase at 5 weeks.
Reaches maximum at 28-32 weeks.

When is the maximum chance of heart failure for a pregnant patient with heart disease? [tab] Immediate postpartum (This period has a higher risk than the 2nd stage of labor, 1st stage of labor, or 28-32 weeks).

How is Active Management of Third Stage of Labor (AMTSL) modified for a patient with heart disease? [tab] Inj. Oxytocin is used.
Inj. Methylergometrine is CONTRAINDICATED (C/I) because it causes tetanic uterine contractions and can increase blood pressure.

What is the preferred mode of delivery for most patients with heart disease? [tab] Vaginal delivery. (Induction of labor is NOT contraindicated).

Why might prophylactic forceps or vacuum be used in a patient with heart disease? [tab] To shorten the 2nd stage of labor. (Forceps are preferred over vacuum).

What are the main indications for a C-section in a patient with heart disease? [tab] 1. Aortic lesions (e.g., Aortic aneurysm, Aortic regurgitation, Coarctation of aorta, Marfan's syndrome) due to ↑ risk of aortic dissection.
2. Patient is currently on Warfarin.

Which types of heart lesions tend to worsen during pregnancy? [tab] Stenotic lesions (e.g., Mitral Stenosis, Aortic Stenosis), Cyanotic Heart Disease, and Pulmonary HTN.

Which types of heart lesions tend to improve during pregnancy? [tab] Regurgitant lesions (e.g., Mitral Regurgitation) and Acyanotic Heart Disease.

What is the management for symptomatic Mitral Stenosis in pregnancy? [tab] Conservative (Limit exercise, salt restriction, β-blockers for heart rate control). If that fails, Surgical (Balloon mitral valvotomy, best done in T2). (Valve replacement is C/I).

What are the WHO Class IV conditions, which are indications for MTP (Medical Termination of Pregnancy)? [tab] 1. Pulmonary HTN (1° or 2° Eisenmenger)
2. Severe MS or AS
3. LVEF < 35%
4. Marfan syndrome with aortic involvement
5. Coarctation of aorta
6. NYHA Class 3/4 symptoms
7. Peripartum cardiomyopathy (with residual defects)

What are the diagnostic criteria for Peripartum Cardiomyopathy (PPCM)? [00:35:40] [tab] 1. No prior heart disease.
2. Development of heart failure anytime between the last month of pregnancy up to 5 months after delivery.

What is the investigation of choice (IOC) and diagnostic finding for PPCM? [tab] IOC: Echocardiography
Diagnostic finding: Decreased (↓) LVEF.

What is the management for PPCM? [tab] Standard heart failure management plus Bromocriptine.

What anticoagulation is required for mechanical valves vs. bioprosthetic valves in pregnancy? [tab] Mechanical valves: Anticoagulant + Aspirin
Bioprosthetic valves: Aspirin only

What is the anticoagulation protocol (DOC) during pregnancy for a patient with a mechanical valve? [tab] < 12 wks: If pre-conception Warfarin was < 5mg/day, continue Warfarin. If ≥ 5mg/day, switch to LMWH.
12-36 wks: Warfarin (Stop aspirin).
At 36 wks: Replace Warfarin with LMWH.
~1 wk before delivery: Switch LMWH to UFH (Unfractionated Heparin).
Post-delivery: Start UFH + Warfarin, then withdraw UFH once INR is therapeutic.

What are the teratogenic effects of Warfarin? [tab] T1 (First Trimester): Chondrodysplasia in fetus (Disala syndrome: nasal hypoplasia, stippled epiphysis).
T3 (Third Trimester): Intracranial hemorrhage in the newborn.

What is the only indication for using Warfarin during pregnancy? [tab] Mechanical valve replacement.

How do you manage a patient on Warfarin who goes into labor (but is not in active labor)? [tab] Stop Warfarin and deliver by C-section.

How do you manage a patient on Warfarin who presents in active labor? [tab] Stop Warfarin, continue with vaginal delivery, and give Inj. Vitamin K to both mother and baby.

What is the DOC for anticoagulation in a pregnant patient with a previous history of DVT? [tab] LMWH (Enoxaparin/Dalteparin).

What is the most teratogenic period during human development? [00:42:45] [tab] The Embryonic period, which is 2 weeks to 8 weeks after fertilization (corresponds to 4-10 weeks POG).

Why does pregestational diabetes cause congenital malformations, while gestational diabetes does not? [tab] Pregestational diabetes (present during the embryonic period) leads to the formation of free radicals, which are teratogenic. Gestational diabetes develops after organogenesis is complete.

What is the most common (m/c) system involved in pregestational diabetes malformations? [tab] CVS (Cardiovascular system) > CNS (Central nervous system).

What is the most common (m/c) congenital malformation in pregestational diabetes? [tab] VSD (Ventricular Septal Defect) > NTD (Neural Tube Defect).

What is the most specific malformation for pregestational diabetes? [tab] Caudal regression syndrome / Sacral agenesis.

What is the risk predictor for congenital malformations in a pregestational diabetic? [tab] HbA1c. (A level < 6.5% indicates no additional risk).

What is the "All or none law" regarding teratogen exposure? [tab] In the first 2 weeks after fertilization, a significant teratogenic exposure will result in either an abortion (all) or a normal fetus (none), with no congenital malformations.

What are the teratogenic effects of radiation exposure (≥ 5 rads)? [tab] Microcephaly (m/c), Growth restriction, Neurological impairment, and increased risk of cancer (Leukemia m/c).

What is Fetal Alcohol Syndrome (FAS) and its key features? [tab] Teratogenic effects of alcohol.
Features (Mnemonic: Goa's famous beer bar):
1. Growth restriction
2. Abnormal facial features (smooth philtrum, thin vermillion border, small epicanthal folds)
3. Abnormal brain development (microcephaly)
4. Abnormal behavioral development (cognitive impairment)

What is the teratogenic effect of Phenytoin? [tab] Fetal hydantoin syndrome: Midfacial hypoplasia, upturned nose, and distal digital hypoplasia (hypoplastic fingers/nails).

What is the teratogenic effect of ACE inhibitors / ARBs? [tab] Oligohydramnios (in 2nd/3rd trimester) and Renal agenesis.

What is the teratogenic effect of Lithium? [tab] Ebstein anomaly (apical displacement of the tricuspid valve, leading to tricuspid regurgitation and right atrial enlargement).

What is the teratogenic effect of Isotretinoin (Vitamin A analog)? [tab] Microtia / Anotia (small or absent ears).

What is the teratogenic effect of Thalidomide? [tab] Phocomelia (proximal limb amputation, i.e., "seal limbs") and stillbirth.

What is the teratogenic effect of Methotrexate? [tab] Craniosynostosis (often a "Clover leaf skull").

What is the teratogenic effect of Tamoxifen (SERM)? [tab] Similar to DES exposure: Vaginal adenosis, craniofacial defects, ambiguous genitalia.

What is the teratogenic effect of Misoprostol? [tab] Moebius syndrome (congenital 6th and 7th cranial nerve palsy).

What is the teratogenic effect of Indomethacin, especially if used > 32 weeks? [tab] Premature closure of the ductus arteriosus and Oligohydramnios.

What is Kassowitz Law regarding congenital syphilis? [00:53:16] [tab] As the number of pregnancies in an untreated syphilitic mother increases, the subsequent pregnancies tend to have better outcomes (e.g., from stillbirth to infected infant to healthy infant).

What are the features of Congenital Varicella Syndrome? [tab] Occurs if infection is in the teratogenic period (12-20 wks).
Features: Microcephaly, Calcifications, Limb hypoplasia & contractures, and Cicatricial (zig-zag) skin lesions. (This is an indication for MTP).

What is Neonatal Varicella Syndrome? [tab] Occurs when the pregnant female acquires the infection 5 days before to 2 days after delivery.
Features: Hepatitis, Pneumonia, Skin rash, Meningoencephalitis.

What is the classic triad of Congenital Rubella Syndrome (CRS)? [tab] 1. Cataract (eye defect)
2. SNHL (Sensorineural hearing loss - ear defect)
3. Heart defects (m/c is PDA > Pulmonary stenosis)
(Also associated with "Blueberry rash").

What are the features of congenital Zika syndrome? [tab] Microcephaly, Increased limb tone, and Club foot.