Obstetrics Marrow Pg 355-364 (Medical & Surgical complication of Pregnancy)
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Questions and Answers

What is the primary focus of the anemia management protocol mentioned?

  • Managing hypertension in pregnancy
  • Managing anemia in pregnant women (correct)
  • Managing nutritional deficiencies in pregnancy
  • Managing diabetes in pregnancy

    • The anemia management protocol applies to all women regardless of their pregnancy status.

    False

    What should be monitored in pregnant women according to the anemia management protocol?

    Hemoglobin levels

    Anemia management in pregnancy primarily targets _____ anemia.

    <p>mild-moderate</p> Signup and view all the answers

    Match the terms related to anemia management with their definitions:

    <p>Iron supplementation = A treatment to increase iron levels Folic acid = A vitamin important for red blood cell production Hemoglobin testing = A method to assess anemia severity Dietary changes = Modifications in diet to enhance nutritional intake</p> Signup and view all the answers

    What anticoagulant should be continued along with warfarin if the preconception dose is less than 5mg/day?

    <p>Warfarin and Aspirin</p> Signup and view all the answers

    Chondrodysplasia is a fetal anomaly associated with anticoagulant use during pregnancy.

    <p>True</p> Signup and view all the answers

    What is the primary recommendation for the first epileptic attack in pregnancy?

    <p>Levetiracetam</p> Signup and view all the answers

    Vitamin K is administered to the mother to prevent __________ after delivery.

    <p>postpartum hemorrhage</p> Signup and view all the answers

    Match the anti-epileptic drugs with their level of teratogenicity:

    <p>Valproic acid = Most teratogenic Levetiracetam = Least teratogenic Phenytoin = Moderate teratogenic Carbamazepine = Moderate teratogenic</p> Signup and view all the answers

    Which of the following is a medical management option for managing dyspnea in pregnancy?

    <p>Diuretics if heart failure is present</p> Signup and view all the answers

    It is advisable to restrict sodium intake for managing dyspnea in pregnancy.

    <p>True</p> Signup and view all the answers

    What should be limited to manage dyspnea due to increased cardiac output in pregnancy?

    <p>Physical activity</p> Signup and view all the answers

    A percutaneous mitral balloon valvotomy is considered when ________ of medical management fails.

    <p>failure</p> Signup and view all the answers

    Match the following management options with their correct description:

    <p>β-blocker = Decreases heart rate Diuretics = Used if heart failure is present Anticoagulant = Prevents thrombosis in atrial fibrillation Percutaneous mitral balloon valvotomy = Surgical option upon medical management failure</p> Signup and view all the answers

    What is the preferred time frame for assessing an increase in reticulocyte count after starting oral iron therapy?

    <p>Within 7 days</p> Signup and view all the answers

    A dark stool color indicates that a patient is not compliant with iron therapy.

    <p>False</p> Signup and view all the answers

    What is the maintenance dose of IFA throughout pregnancy and post-delivery?

    <p>1 tablet/day</p> Signup and view all the answers

    The dose of IFA tablets prescribed per day is _____ tablets.

    <p>2</p> Signup and view all the answers

    Match the following types of responses with their descriptions:

    <p>Adequate response (&gt;19%) = Indicates effective management of anemia Non-compliance = Stool color appears normal Compliant patient = Continues iron therapy until Hb reaches 11g% Inadequate response = Supplementation may need adjustment</p> Signup and view all the answers

    Which score is used for assessing acquired heart disease in pregnancy?

    <p>Carpreg score</p> Signup and view all the answers

    ECHO is considered the standard diagnostic method for evaluating peripartum cardiomyopathy.

    <p>True</p> Signup and view all the answers

    What is the diagnostic criterion for peripartum cardiomyopathy regarding heart failure?

    <p>Heart failure between 36 weeks of pregnancy up to 5 months after delivery.</p> Signup and view all the answers

    In mitral stenosis, an area of _____ cm² indicates normal condition.

    <p>4-6</p> Signup and view all the answers

    Match the following WHO classification of cardiac review with their respective review frequency:

    <p>Class I = One/twice during pregnancy Class II = Review every trimester Class III = Review every 1-2 months Class IV = Admit the patient throughout the pregnancy</p> Signup and view all the answers

    What is the preferred position for a patient during labor with heart disease?

    <p>Semi-recumbent position with left lateral tilt</p> Signup and view all the answers

    Patients with aortic lesions have a higher risk of aortic dissection during vaginal delivery.

    <p>True</p> Signup and view all the answers

    What is the drug of choice (DOC) for managing postpartum hemorrhage (PPH) in patients with heart disease?

    <p>Oxytocin</p> Signup and view all the answers

    To prevent back flow of blood, the legs should be positioned ____ than the heart.

    <p>lower</p> Signup and view all the answers

    Match the following indications for C-section with their descriptions:

    <p>Aortic lesions = Increased risk of aortic dissection Warfarin use = Increased risk of intracranial hemorrhage in fetus Refractory heart failure = Severe risk during vaginal delivery Patient with Marfan syndrome = Aortic root dilatation concern</p> Signup and view all the answers

    Which of the following is a contraindication for parenteral iron therapy?

    <p>Thalassemia major</p> Signup and view all the answers

    Iron sucrose is the most common parenteral iron preparation used.

    <p>True</p> Signup and view all the answers

    What is the maximum dose of iron sucrose that can be administered in one day?

    <p>200mg</p> Signup and view all the answers

    The dose calculation for parenteral iron therapy utilizes the _____ formula.

    <p>Ganzoni</p> Signup and view all the answers

    Match the following conditions with their corresponding indications for blood transfusion:

    <p>Thalassemia major = Indicated Acute hemorrhage = Indicated Headache = Not indicated Constipation = Not indicated</p> Signup and view all the answers

    What physiological change occurs to cardiac output (CO) during pregnancy?

    <p>Begins to increase by 5 weeks</p> Signup and view all the answers

    Blood pressure typically decreases during pregnancy, reaching its lowest point in the first trimester.

    <p>False</p> Signup and view all the answers

    At what position is it best for a pregnant woman to lie, to optimize blood flow?

    <p>Left lateral</p> Signup and view all the answers

    The maximum increase in diastolic blood pressure occurs during __________ weeks of pregnancy.

    <p>28-32</p> Signup and view all the answers

    Match the clinical indicators with their changes during pregnancy:

    <p>Heart rate = Decreases Blood pressure = Decreases JVP = Unchanged S1 heart sound = Loud and prominent split</p> Signup and view all the answers

    Which of the following is the most common type of congenital heart disease in pregnancy?

    <p>Atrial septal defect</p> Signup and view all the answers

    Progressive dyspnea is a symptom of heart disease.

    <p>True</p> Signup and view all the answers

    What is the maximum risk of maternal mortality associated with?

    <p>Eisenmenger syndrome</p> Signup and view all the answers

    The signs of heart disease may include __________ and cyanosis.

    <p>clubbing</p> Signup and view all the answers

    Match the heart conditions with their prognosis in pregnancy:

    <p>Congenital HD = Good prognosis Stenotic lesions = Worsens Regurgitant lesions = Improves Eisenmenger syndrome = Maximum risk</p> Signup and view all the answers

    Which of the following antibiotics is the drug of choice for asymptomatic bacteriuria during pregnancy?

    <p>Nitrofurantoin</p> Signup and view all the answers

    Aminoglycosides are safe to use throughout pregnancy without any risks.

    <p>False</p> Signup and view all the answers

    What is the target INR value for warfarin use in pregnancy?

    <p>2.5 - 3</p> Signup and view all the answers

    The use of fluoroquinolones during pregnancy is known to be ________ to cartilage.

    <p>toxic</p> Signup and view all the answers

    Match the following anticoagulants to their characteristics:

    <p>Warfarin = Crosses the placenta and can be teratogenic Low Molecular Weight Heparin = Cannot cross the placenta Unfractionated Heparin = Faster action prior to delivery</p> Signup and view all the answers

    What is the maximum dose of warfarin recommended during the first trimester?

    <p>7-9 weeks</p> Signup and view all the answers

    Doxycycline is the only tetracycline recommended for use in pregnancy.

    <p>True</p> Signup and view all the answers

    What do high levels of warfarin during the time of delivery increase the risk of?

    <p>Postpartum hemorrhage</p> Signup and view all the answers

    Study Notes

    Period of Gestation

    • Up to 12 weeks: First trimester
    • 12 - 36 weeks: Second and third trimester
    • At 36 weeks: Full term pregnancy
    • 24 hours before delivery: Labor commences
    • 6 hours after vaginal delivery / 6-12 hours after C-section: Postpartum period

    Anticoagulant of Choice

    • Preconception dose of warfarin < 5mg/day: Continue warfarin + Aspirin
    • Preconception dose of warfarin ≥ 5mg/day: LMWH + Aspirin

    Management of Patient on Warfarin at Time of Delivery

    • Stop warfarin.
    • Deliver by Cesarean section.
    • Administer Vitamin K to the mother and baby.

    Disala Syndrome

    • Caused by warfarin use in pregnancy.

    Fetal Anomalies

    • Warfarin can lead to fetal anomalies.
    • Chondrodysplasia: Depressed nasal bridge and stippled epiphysis.
    • Cataract: Clouding of the lens of the eye.

    CNS Defects

    • Warfarin can cause CNS defects.
    • Microcephaly: Small head size.
    • Hydrocephalus: Accumulation of cerebrospinal fluid in the brain.
    • Dandy-Walker malformation: Congenital malformation of the cerebellum.

    Anti-epileptics

    • Valproic acid is the most teratogenic anti-epileptic drug.
    • Valproic acid can cause neural tube defects, CNS malformations, and urinary tract deformities.
    • Lamotrigine and Levetiracetam are the least teratogenic anti-epileptics.

    Therapeutic Decision Making

    • First epileptic attack in pregnancy: Doctor's recommendation is Levetiracetam > Lamotrigine.
    • Woman with epilepsy conceives: Continue the same medication at the lowest possible dose.
    • Folic acid supplementation: 0.4mg/day before conception and 1 mg/day after conception.

    Other Notes

    • INR target range: 2.5-3
    • LMWH: Low-molecular-weight heparin
    • UFH: Unfractionated heparin

    Anemia Management Protocol in Pregnancy

    • This document outlines a protocol for managing anemia in pregnant women.

    Mild-Moderate Anemia

    • Symptoms: Dyspnea on exertion due to increased cardiac output.
    • Management: Limit physical activity and restrict sodium intake.

    Medical Management

    • β-blocker: Decreases heart rate.
    • Diuretics: Used in cases of heart failure.
    • Anticoagulant: Used in cases of atrial fibrillation to prevent thrombosis.

    Surgical Management

    • Considered if medical management fails.
    • Percutaneous mitral balloon valvotomy: Procedure to widen the mitral valve opening.
    • Timing: Second trimester.

    Oral Iron Therapy

    • Dose: 2 IFA tablets/day.
    • Response Assessment: Parameters assessed include ↑ Hb levels and ↑ Reticulocyte count.
    • Adequate response: Hb ↑ > 19% after 1 month of treatment.
    • Inadequate response: Hb ↑ < 19% after 1 month of treatment.

    Parenteral Iron Therapy

    • Indications: Non-compliance to oral therapy, intolerance to oral iron, gestational age-based indications.
    • Iron preparations: Iron dextran (1st generation), Iron sucrose (2nd generation), Ferric carboxy maltose (3rd generation).
    • Dose (Ganzoni formula): 2.4 x weight in kgs (pre-pregnancy) x [Patient's Hb deficit] + 500mg (for iron stores).
    • Infusion rate: 15 - 20 drops/min for initial 5 minutes.
    • Adverse effects: Headache, nausea, constipation, diarrhea, and injection site reaction.
    • Contraindications: 1st trimester, hemochromatosis, thalassemia major.

    Blood Transfusion

    • Indications: Thalassemia major, heart failure, acute hemorrhage, Hb < 5 at any gestational age, Hb 5 - 6.9 at >34 weeks, bone marrow failure.

    Heart Diseases In Pregnancy

    Physiological Changes

    • Increase: Cardiac output, femoral venous pressure.
    • Decrease: Peripheral vascular resistance, blood pressure.
    • Unchanged: Jugular venous pressure, pulmonary capillary wedge pressure, left ventricular ejection fraction.
    • Best position: Left lateral.

    Chance of Heart Failure

    • Immediately after delivery > and > stage of labor > late 1st stage of labor > 28-32 weeks.

    Clinical Indicators

    • Heart rate: Increased.
    • Pulse rate: Increased.
    • BP: Decreased.
    • JVP: Normal.
    • Heart: Apex beat shifted to 4th intercostal space, 2.5cm lateral to mid-clavicular line.
    • Heart sounds: Loud S1 with prominent split, S2 normal.

    Symptoms Normal In Pregnancy

    • Easy fatiguability, decreased exercise tolerance, dyspnea on exertion, peripheral dependent edema.
    • Murmurs: S3, continuous/mammary murmur, ejection systolic murmur grade 1-2.

    Indicators of Heart Disease

    • Symptoms: Progressive dyspnea, orthopnea, paroxysmal nocturnal dyspnea, hemoptysis, chest pain, non-dependent edema.

    Most Common Heart Disease (HD) in Pregnancy

    • Rheumatic heart disease (m/c).
    • Atrial septal defect (m/c congenital HD).
    • Tetralogy of Fallot (TOF): (m/c cyanotic HD).
    • Mitral valve prolapse (MVP): (m/c congenital valvular HD).
    • Eisenmenger syndrome: maximum risk of maternal mortality.

    Signs

    • Clubbing, cyanosis, increased JVP, loud S1 with a prominent split, S4, diastolic murmur, ejection systolic murmur grade >3, marked cardiomegaly on X-ray, arrhythmia.

    Heart Diseases with Good Prognosis in Pregnancy

    • Congenital HD.
    • Repaired ventricular septal defect (VSD)/atrial septal defect (ASD).
    • Corrected Tetralogy of Fallot (TOF), patent ductus arteriosus (PDA), mitral valve prolapse (MVP).

    Heart Diseases Prognosis In Pregnancy

    • Worsens: Stenotic lesions, cyanotic HD.
    • Improves: Regurgitant lesions, acyanotic HD, pulmonary HTN.

    WHO Class 4

    • Maximum chance of death due to pregnancy.
    • Pregnancy contraindicated.
    • Medical termination of pregnancy (MTP) advised.

    Associated Conditions

    • Pulmonary hypertension (1° and 2°).
    • Severe mitral stenosis (MS)/aortic stenosis (AS).
    • Left ventricular ejection fraction (LVEF) < 30%.
    • NYHA class III/IV.
    • Marfan syndrome with aortic root dilation ≥ 4 cm.
    • Coarctation of aorta with aortic root dilation ≥ 4 cm.
    • Residual defect after Fontan surgery.
    • Residual defect in previous history of peripartum cardiomyopathy.

    Management of Heart Disease

    Intrapartum Management

    • Vaginal delivery: Spontaneous labor or induction of labor.
    • Ripe: Mode of delivery is vaginal, shorten and stage of labor using forceps or vacuum, to decrease maternal effort.
    • Monitoring: Maternal and fetal HR, input and output.
    • Position: Semi-recumbent position with left lateral tilt.
    • Management: Restrict IV fluids, epidural analgesia, restrict PV exam, ampicillin + gentamicin when membrane ruptures.

    Postpartum Management

    • Third stage of labor: Active management of the third stage of labor (AMSTL).

    Indicators for C-section

    • Indications: Aortic lesions, patient on warfarin, refractory heart failure.
    • Anesthesia: Neuraxial > epidural, GA indicated in cases of intracardiac shunt, severe AS, HOCM.

    PPH in Heart Disease

    • Oxytocin: Drug of choice.
    • Methylergometrine: Contraindicated.

    Preconception Counseling

    • VSD: Maximum risk of recurrence.
    • Investigation: ECG, ECHO.
    • Surgery: If needed, performed before conception.

    Other Notes

    • Inj.oxytocin used.
    • Inj.methyl ergometrine: Contraindicated due to tetanic contraction.
    • IV diuretics.
    • Legs at a lower level than heart: To prevent backflow of blood.

    Drugs In Pregnancy

    Antibiotics

    • Safe: Cephalosporins, Ampicillin, Metronidazole, Penicillin.
    • In Treatment: Nitrofurantoin, Sulphamethoxazole, Fluconazole, Trimethoprim.
    • Throughout Pregnancy: Fluoroquinolones, Aminoglycosides, Tetracyclines.

    Anticoagulants

    • Warfarin: Potent anticoagulant, crosses the placenta, teratogenic, increased risk of postpartum hemorrhage and fetal intracranial hemorrhage.
    • Low Molecular Weight Heparin: Does not cross the placenta, low potency anticoagulant.

    Teratogenicity of Warfarin

    • Depends on dose and period of gestation.
    • Maximum dose in T1 at 7-9 weeks.

    Valve Replacement

    • Mechanical valve replacement: Anticoagulant + Aspirin (continued until 36 weeks).
    • Bioprosthetic valve replacement: Aspirin only.

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    Description

    This quiz covers crucial aspects of gestation periods, anticoagulant management during pregnancy, particularly focusing on warfarin use and its implications. Topics include the effects of warfarin on fetal anomalies and central nervous system defects, providing important insights for obstetric care.

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