Obstetrics Marrow Pg 405-414 (Medical & Surgical complication of Pregnancy)

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Questions and Answers

What is a significant risk factor for Acute Fatty Liver of Pregnancy?

Low body mass index

Single pregnancy

Advanced maternal age

Previous history of AFLP (correct)

Which of the following complications is NOT associated with liver disorders in pregnancy?

Placental abruption

Urinary tract infection (correct)

Rupture of liver hematoma

Pulmonary edema

The accumulation of which of the following is a consequence of Acute Fatty Liver of Pregnancy?

Excessive bile acids

Red blood cells

Intermediate fatty acid metabolites (correct)

Collagen

What enzyme deficiency is implicated in the pathophysiology of Acute Fatty Liver of Pregnancy?

LCHAD Signup and view all the answers

Which of the following conditions can lead to elevated levels of ammonia in a patient with Acute Fatty Liver of Pregnancy?

Hepatic encephalopathy Signup and view all the answers

What is considered a significant maternal antibody titre?

<blockquote> 1:32 </blockquote> Signup and view all the answers

How often should fetal monitoring begin for an Rh-negative sensitized pregnancy?

From 32 weeks Signup and view all the answers

What does a peak systolic velocity (PSV) of ≥ 1.5 mom in the Doppler of Middle Cerebral Artery indicate?

Positive indication of fetal anemia Signup and view all the answers

What is the primary purpose of administering 300 mcg of anti-D to an unsensitized Rh-negative mother during pregnancy?

To neutralize fetal red blood cells Signup and view all the answers

When should cordocentesis be conducted in the management of fetal anemia?

To determine fetal hemoglobin and hematocrit Signup and view all the answers

When should the Indirect Coombs Test (ICT) be performed for an Rh-negative pregnant woman?

1st ANC visit and at 28 weeks Signup and view all the answers

How frequently should the PSV of the Middle Cerebral Artery be repeated in the management of suspected fetal anemia?

Every 1-2 weeks Signup and view all the answers

What is the appropriate management if a Rh-negative mother delivers a Rh-positive newborn with a negative Direct Coombs Test (DCT)?

Administer 300 mcg anti-D to the mother within 72 hours Signup and view all the answers

Which of the following statements is true regarding postpartum prophylaxis for Rh-negative mothers?

It is indicated for Rh-positive newborns with a negative Direct Coombs Test Signup and view all the answers

What should be done if a Rh-negative mother is sensitized?

Monitor the pregnancy closely without anti-D Signup and view all the answers

What is the likely consequence of maternal Rh-ve blood mixing with Rh+ve fetal blood during the first pregnancy?

No significant immune response occurs Signup and view all the answers

What is the role of IgG antibodies in subsequent pregnancies following an Rh+ve fetus?

They can cross the placenta and cause hemolytic disease in the fetus Signup and view all the answers

Which of the following is NOT a cause of fetal-maternal hemorrhage (FMH)?

Normal vaginal delivery Signup and view all the answers

During which phase of pregnancy does the maternal immune system produce IgG antibodies against Rh antigens if FMH occurs?

Following exposure in a subsequent pregnancy with Rh+ve fetus Signup and view all the answers

What typically happens to IgM antibodies produced after Rh antigen exposure during the first pregnancy?

They cannot cross the placenta and do not impact the fetus Signup and view all the answers

During which trimester is Acute Fatty Liver of Pregnancy (AFLP) most commonly diagnosed?

Late third trimester Signup and view all the answers

Which symptom is commonly observed at the time of diagnosis of Acute Fatty Liver of Pregnancy?

Nausea/vomiting Signup and view all the answers

What is a significant mortality rate associated with Acute Fatty Liver of Pregnancy?

10% Signup and view all the answers

Which of the following conditions is associated with Acute Fatty Liver of Pregnancy?

Disseminated Intravascular Coagulation (DIC) Signup and view all the answers

How can Acute Fatty Liver of Pregnancy be differentiated from HELLP syndrome?

Mental confusion Signup and view all the answers

What is the correct maintenance dose of MgSO4 for a patient after delivery?

5 gm every 4 hours Signup and view all the answers

Which of the following is NOT a sign of magnesium sulfate toxicity?

Oliguria Signup and view all the answers

What is one of the defining features required for the diagnosis of HELLP syndrome?

Severe anemia unrelated to blood loss Signup and view all the answers

What should be assessed before administering the maintenance dose of MgSO4?

Deep tendon reflex Signup and view all the answers

Which symptom is most commonly associated with HELLP syndrome during pregnancy?

Right upper quadrant abdominal pain Signup and view all the answers

What initial management step is recommended for a patient diagnosed with HELLP syndrome?

Magnesium sulfate administration Signup and view all the answers

What is the antidote for magnesium sulfate toxicity?

Calcium gluconate Signup and view all the answers

For how long should MgSO4 be administered after delivery, according to the guidelines?

24 hours after delivery or after the last convulsion Signup and view all the answers

Which laboratory finding is indicative of liver enzyme elevation in HELLP syndrome?

SGOT and SGPT levels two times above normal Signup and view all the answers

What is the definitive management for a pregnant patient diagnosed with HELLP syndrome?

Immediate induction of labor Signup and view all the answers

What is the initial step in the progression of liver disorders affecting the fetus during pregnancy?

Bile acid enters the amniotic fluid Signup and view all the answers

Which of the following complications is characterized by increased fluid in the fetus and is diagnosed by ultrasound?

Hydrops fetalis Signup and view all the answers

What complication can arise from the accumulation of meconium in the fetal heart?

Cardiac arrest Signup and view all the answers

Which serum bile acid level is considered significant for diagnosis in liver disorders during pregnancy?

<blockquote> 10 micromoles/L </blockquote> Signup and view all the answers

What indicates the presence of fetal anemia during a cardiotocography (CTG)?

Presence of a sinusoidal heart wave pattern Signup and view all the answers

What effect does fetal swallowing of bile-containing amniotic fluid have?

It causes irritation in the fetal bowel Signup and view all the answers

What is the role of Anti-D immunoglobulin in Rh-negative mothers during pregnancy?

To prevent the mother from producing antibodies against Rh+ fetal red blood cells Signup and view all the answers

Which of the following outcomes is a severe consequence of liver disorders in pregnancy?

Stillbirth Signup and view all the answers

Which maternal complication is associated with the accumulation of excessive amniotic fluid?

Polyhydramnios Signup and view all the answers

Which of the following best describes erythroblastosis fetalis?

It is characterized by immature red blood cells in the fetus. Signup and view all the answers

Which test is used to evaluate the peak systolic velocity (PSV) in the middle cerebral artery (MCA) for fetal assessment?

Doppler ultrasound Signup and view all the answers

What happens when Anti-D immunoglobulin is present in the maternal blood?

It prevents hemolysis of fetal red blood cells. Signup and view all the answers

Which condition can lead to severe anemia and heart failure in a fetus?

Fetal anemia Signup and view all the answers

What is the primary outcome for an Rh-negative mother expecting an Rh-positive fetus during pregnancy?

There is a 50% chance the fetus will be Rh-positive. Signup and view all the answers

When does the immune system of an Rh-negative individual begin to form Rh antibodies?

After 38 days of gestation. Signup and view all the answers

Where are Rh antigens located in the human genome?

On chromosome 1 short arm. Signup and view all the answers

Which Rh antigen types are associated with Rh-negative pregnancy?

C, c, D, E, e. Signup and view all the answers

What is a characteristic of an Rh-negative pregnancy?

It is classified as a high-risk pregnancy if the fetus is Rh-positive. Signup and view all the answers

Study Notes

Liver Disorders In Pregnancy

A differential diagnosis for liver disorders in pregnancy includes Acute Fatty Liver of Pregnancy (AFLP).
Possible complications include placental abruption, pulmonary edema, DIC, and rupture of liver hematoma.
Mississippi classification is used for classification.

Acute Fatty Liver of Pregnancy (AFLP)

Risk factors for AFLP include a previous history of AFLP, twin pregnancy, pre-eclampsia, and a male fetus.
The pathophysiology of AFLP is linked to LCHAD deficiency, which affects long-chain fatty acid (FA) metabolism.
- A homozygous LCHAD deficiency affects the fetus, causing a defect in FA oxidation.
- In the mother, heterozygous LCHAD deficiency exists.
Accumulation of intermediate FA metabolites, a limited capacity to oxidize FA, and the formation of free radicals contribute to the disease.
Consequences of AFLP include liver failure, pancreatitis, endothelial cell injury, and renal failure.

Checking Antibody Titre

To determine if anti-D antibodies are present, an antibody titre is checked.
If the maternal antibody titre is < 1:16, it is not significant.
A significant antibody titre is ≥ 1:16, indicating the presence of anti-D antibodies.
For a significant titre, management involves repeating the titre every 4 weeks and monitoring the fetus from 32 weeks.
Delivery is typically at 37-38 weeks of pregnancy.

Management of Fetal Anemia

Doppler of the Middle Cerebral Artery (MCA) is the best non-invasive investigation for fetal anaemia.
A peak systolic velocity (PSV) ≥ 1.5 mom indicates fetal anemia.
Repeat the PSV of MCA every 1-2 weeks.
Antepartum fetal surveillance is recommended from 32 weeks, including non-stress test (NST) and Biophysical Profile (BPP) weekly.
Delivery is advised at 37-38 weeks.
If fetal anemia is confirmed, cordocentesis is performed to assess fetal hemoglobin (Hb) and hematocrit.

Rh Negative Pregnancy

At the first antenatal visit, ABO and Rh typing is done for both the mother and the father.
During the first pregnancy, a Rh-positive fetus can lead to feto-maternal hemorrhage (FMH) through bleeding, invasive procedures, versions, or mixing of blood.
This can expose the Rh-negative mother to the Rh antigen, leading to the formation of antibodies.
Initially, IgM antibodies are produced but cannot cross the placenta.
IgG antibodies are produced after delivery, making the first pregnancy safe.
In subsequent pregnancies, if the fetus is Rh+ve and FMH occurs, the mother's immune system is stimulated, leading to the rapid formation of IgM and IgG antibodies.
IgG antibodies can cross the placenta and result in hemolysis of the fetus.

Medical and Surgical Complications in Pregnancy

Acute Fatty Liver of Pregnancy (AFLP):
- AFLP is a major cause of liver failure in pregnant women, often occurring in the third trimester.
- It can lead to fulminant liver failure, hepatic encephalopathy, DIC, jaundice, and ascites.
- It is a common complication with a high mortality rate of 10%.
- Diagnosis is based on the Swansea criteria.

HELLP Syndrome

HELLP syndrome is a serious pregnancy complication often associated with preeclampsia characterized by hemolysis, elevated liver enzymes, and low platelet count.
It commonly occurs in the third trimester and can present with abdominal pain, typically in the right upper quadrant, and jaundice.
The criteria for hemolysis include the presence of burr cells/schistocytes on peripheral smear, increased serum bilirubin levels, severe anemia unrelated to blood loss, increased LDH levels, or decreased haptoglobin levels.
Elevated liver enzymes, specifically aspartate aminotransferase (SGOT) and alanine aminotransferase (SGPT), are two times above their normal values.
A low platelet count is below 1 lakh/mm³.
Management of HELLP syndrome involves immediate delivery, magnesium sulfate to prevent seizures, antihypertensive drugs, and corticosteroids.

Fetal Complications

Fetal complications can increase the risk of fetal mortality and morbidity.
These complications include fetal anemia, jaundice, heart failure due to severe anemia, hydrops fetalis, hepato-splenomegaly, bone marrow hyperplasia, increased erythrocytes, erythroblastosis fetalis, and placentomegaly.

Maternal Complications

Maternal complications include pre-eclampsia (PIH) and polyhydramnios.

Fetal Anemia

The presence of a sinusoidal heart wave pattern in cardiotocography (CTG) or a peak systolic velocity (PSV) ≥ 1.5 mom in Doppler of the middle cerebral artery (MCA) indicates fetal anemia.
Causes include Rh isoimmunized pregnancy, vaso previa, and twin-to-twin transfusion syndrome.

Anti-D & Indirect Coombs' Test

Anti-D is an antibody directed against the Rh antigen.
The presence of anti-D in the maternal blood neutralizes Rh+ve fetal red blood cells, preventing the mother's immune system from producing antibodies against Rh antigens.
Anti-D can be given externally and is beneficial only in Rh-ve unsensitized pregnancies.

Pregnancy Induced Hypertension: Part 3

Magnesium sulfate (MgSO4) is used to prevent seizures and provides neuroprotection in preterm labor and impending preeclampsia.
The loading dose of MgSO4 is given irrespective of renal status, and the maintenance dose is given every 4 hours in alternate buttocks.
To check for signs of MgSO4 toxicity, deep tendon reflex, respiratory rate, and urine output must be monitored.
Symptoms of MgSO4 toxicity include loss of knee jerk, diaphoresis, slurring of speech, feeling of heat, respiratory depression, respiratory arrest, cardiac arrhythmia, and cardiac arrest.
Important note: Oliguria is not a sign of MgSO4 toxicity.
Calcium gluconate is the antidote for MgSO4 toxicity.

Liver Disorders In Pregnancy: Bile Acid Accumulation

Bile acids can accumulate and reach the amniotic fluid.
The fetus ingests the bile acids from the amniotic fluid, irritating the fetal bowel.
These actions can lead to meconium passage into the amniotic fluid and further complications, including accumulation in the fetal heart, cardiac arrest, and ultimately stillbirth.

Liver Disorders In Pregnancy: Diagnosis

For diagnosis, serum bile acid levels above 10 micromoles/L are indicative.
Increased SGOT/SGPT levels also suggest liver dysfunction.

Rh Negative Pregnancy: Rh Antigens

Rh antigens are located on the short arm of chromosome 1.
The different types of Rh antigens are C, c, D, E, and e.

Rh Negative Pregnancy: Rh Antigen Formation

Rh antigens are formed around 38 days of gestation.
If the Rh-negative mother comes into contact with Rh-positive blood, the Rh antigens stimulate the immune system, leading to the production of Rh antibodies.

Features of Rh Negative Pregnancy

A mother with Rh-negative blood carrying a Rh-positive fetus carries a 50% risk of the fetus being Rh-positive, which is considered a high-risk pregnancy.
If the fetus is Rh-negative, the pregnancy is not considered high-risk.

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Description

This quiz covers key concepts related to liver disorders during pregnancy, focusing particularly on Acute Fatty Liver of Pregnancy (AFLP). Explore risk factors, pathophysiology, complications, and the significance of Mississippi classification. Test your knowledge and understanding of these critical maternal health issues.