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What is the primary focus of the anemia management protocol mentioned?
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.
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Match the terms related to anemia management with their definitions:
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What anticoagulant should be continued along with warfarin if the preconception dose is less than 5mg/day?
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Chondrodysplasia is a fetal anomaly associated with anticoagulant use during pregnancy.
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What is the primary recommendation for the first epileptic attack in pregnancy?
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Vitamin K is administered to the mother to prevent __________ after delivery.
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Match the anti-epileptic drugs with their level of teratogenicity:
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Which of the following is a medical management option for managing dyspnea in pregnancy?
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It is advisable to restrict sodium intake for managing dyspnea in pregnancy.
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What should be limited to manage dyspnea due to increased cardiac output in pregnancy?
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A percutaneous mitral balloon valvotomy is considered when ________ of medical management fails.
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Match the following management options with their correct description:
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What is the preferred time frame for assessing an increase in reticulocyte count after starting oral iron therapy?
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A dark stool color indicates that a patient is not compliant with iron therapy.
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What is the maintenance dose of IFA throughout pregnancy and post-delivery?
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The dose of IFA tablets prescribed per day is _____ tablets.
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Match the following types of responses with their descriptions:
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Which score is used for assessing acquired heart disease in pregnancy?
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ECHO is considered the standard diagnostic method for evaluating peripartum cardiomyopathy.
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What is the diagnostic criterion for peripartum cardiomyopathy regarding heart failure?
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In mitral stenosis, an area of _____ cm² indicates normal condition.
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Match the following WHO classification of cardiac review with their respective review frequency:
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What is the preferred position for a patient during labor with heart disease?
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Patients with aortic lesions have a higher risk of aortic dissection during vaginal delivery.
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What is the drug of choice (DOC) for managing postpartum hemorrhage (PPH) in patients with heart disease?
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To prevent back flow of blood, the legs should be positioned ____ than the heart.
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Match the following indications for C-section with their descriptions:
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Which of the following is a contraindication for parenteral iron therapy?
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Iron sucrose is the most common parenteral iron preparation used.
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What is the maximum dose of iron sucrose that can be administered in one day?
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The dose calculation for parenteral iron therapy utilizes the _____ formula.
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Match the following conditions with their corresponding indications for blood transfusion:
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What physiological change occurs to cardiac output (CO) during pregnancy?
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Blood pressure typically decreases during pregnancy, reaching its lowest point in the first trimester.
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At what position is it best for a pregnant woman to lie, to optimize blood flow?
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The maximum increase in diastolic blood pressure occurs during __________ weeks of pregnancy.
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Match the clinical indicators with their changes during pregnancy:
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Which of the following is the most common type of congenital heart disease in pregnancy?
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Progressive dyspnea is a symptom of heart disease.
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What is the maximum risk of maternal mortality associated with?
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The signs of heart disease may include __________ and cyanosis.
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Match the heart conditions with their prognosis in pregnancy:
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Which of the following antibiotics is the drug of choice for asymptomatic bacteriuria during pregnancy?
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Aminoglycosides are safe to use throughout pregnancy without any risks.
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What is the target INR value for warfarin use in pregnancy?
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The use of fluoroquinolones during pregnancy is known to be ________ to cartilage.
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Match the following anticoagulants to their characteristics:
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What is the maximum dose of warfarin recommended during the first trimester?
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Doxycycline is the only tetracycline recommended for use in pregnancy.
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What do high levels of warfarin during the time of delivery increase the risk of?
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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.