Obstetrics Marrow Pg 365-374 (Medical & Surgical complication of Pregnancy)
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Obstetrics Marrow Pg 365-374 (Medical & Surgical complication of Pregnancy)

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Questions and Answers

What is the primary focus of the anemia management protocol in pregnant women?

  • Pharmaceutical treatments
  • Dietary habits
  • Managing anemia (correct)
  • Nutritional education

    • The protocol applies only to severe cases of anemia in pregnancy.

    False

    What type of anemia does the protocol specifically address?

    Mild-Moderate Anemia

    The anemia management protocol is designed for pregnant women specifically dealing with _____ anemia.

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

    Match the following anemia management strategies with their descriptions:

    <p>Iron supplementation = Provides necessary iron to improve hemoglobin levels Dietary modifications = Involves changes to increase iron-rich food intake Regular check-ups = Monitors anemia status and adjusts treatment Folic acid supplementation = Helps in the production of red blood cells</p> Signup and view all the answers

    What is the recommended management for a patient on warfarin at the time of delivery?

    <p>Stop warfarin, deliver by Cesarean section, and administer Vitamin K</p> Signup and view all the answers

    Valproic acid is considered the least teratogenic anti-epileptic medication.

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

    What is the recommended folic acid supplementation dosage during pregnancy before and after conception?

    <p>0.4 mg/day before conception, 1 mg/day after conception</p> Signup and view all the answers

    Chondrodysplasia can present with a depressed nasal bridge and __________.

    <p>stippled epiphysis</p> Signup and view all the answers

    Match the following anti-epileptic medications with their level of teratogenicity:

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

    What is a common symptom associated with increased cardiac output during pregnancy?

    <p>Dyspnea on exertion</p> Signup and view all the answers

    β-blockers are used to increase heart rate in managing dyspnea during pregnancy.

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

    What is the preferred timing for surgical management of dyspnea during pregnancy?

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

    Limit physical activity and restrict _____ intake to manage symptoms in pregnancy.

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

    Match the following management options with their correct application:

    <p>Diuretics = If heart failure is present β-blocker = To decrease heart rate Anticoagulant = If atrial fibrillation is present Percutaneous mitral balloon valvotomy = On failure of medical management</p> Signup and view all the answers

    What is the recommended dose of iron-folic acid (IFA) tablets per day for pregnant women experiencing anemia?

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

    A dark stool color indicates non-compliance with iron therapy.

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

    What indicates an adequate response to iron therapy after one month?

    <blockquote> <p>19%</p> </blockquote> Signup and view all the answers

    The maximum increase in reticulocyte count expected after starting iron therapy is within ____ days.

    <p>10</p> Signup and view all the answers

    Match the types of responses to their definitions regarding treatment adherence:

    <p>Compliant patient + Adequate response = Continue IFA tablets until Hb 11g% Non-compliant patient = Normal stool color Affordable patients = Ferrous Sulfate or switched to Ferrous Fumarate Inadequate response = Alternative treatment options may be explored</p> Signup and view all the answers

    What is the primary purpose of the WHO classification in heart diseases during pregnancy?

    <p>To classify the severity of heart disease</p> Signup and view all the answers

    In cases of Class IV cardiac review during pregnancy, the patient should be admitted throughout the pregnancy.

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

    What is the diagnostic criterion for peripartum cardiomyopathy regarding prior heart disease?

    <p>No prior heart disease</p> Signup and view all the answers

    The diagnostic criteria for peripartum cardiomyopathy include heart failure between ___ weeks of pregnancy.

    <p>36</p> Signup and view all the answers

    Match the following categories of mitral stenosis with their corresponding area:

    <p>Normal = 4-6 cm² Mild Mitral Stenosis = ≥1.5-4 cm²</p> Signup and view all the answers

    What is the primary aim of using a semi-recumbent position with left lateral tilt during intrapartum management of heart disease?

    <p>To improve fetal oxygenation</p> Signup and view all the answers

    A patient on warfarin within two weeks of delivery has a lower risk of postpartum hemorrhage.

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

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

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

    In cases of severe aortic stenosis, the preferred mode of delivery is a __________.

    <p>C-section</p> Signup and view all the answers

    Match the conditions with their corresponding indications for C-section:

    <p>Aortic aneurysm = ↑risk of aortic dissection Warfarin use = ↑risk of intracranial hemorrhage in fetus Marfan syndrome = Aortic root dilatation risk Refractory heart failure = Delivery complications</p> Signup and view all the answers

    Which antibiotics are considered safe during pregnancy?

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

    Fluoroquinolones are safe to use throughout pregnancy.

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

    What is the target INR value for patients on warfarin during pregnancy?

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

    Nitrofurantoin is the drug of choice for __________ during pregnancy.

    <p>asymptomatic bacteriuria</p> Signup and view all the answers

    Match the following anticoagulants with their characteristics:

    <p>Warfarin = Crosses the placenta; teratogenic Low Molecular Weight Heparin = Cannot cross placenta; low potency Unfractionated Heparin = Faster action and reversibility Aspirin = Used with mechanical valve replacement</p> Signup and view all the answers

    What should be avoided in patients with G-6-PD deficiency?

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

    Doxycycline is commonly used during pregnancy for any indication.

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

    What condition could lead to the replacement of Low Molecular Weight Heparin with unfractionated heparin prior to delivery?

    <p>Need for faster action</p> Signup and view all the answers

    At what gestational age does cardiac output reach its maximum during pregnancy?

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

    Peripheral vascular resistance decreases due to the influence of progesterone during pregnancy.

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

    What physiological change in blood pressure is observed during pregnancy?

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

    During pregnancy, the apex beat is pushed towards the _____ intercostal space.

    <p>4th</p> Signup and view all the answers

    Match the clinical indicators to their corresponding changes during pregnancy:

    <p>Heart rate = Increased Blood pressure = Decreased JVP = Unchanged Heart sounds → S1 = Loud + prominent split</p> Signup and view all the answers

    Which of the following is NOT an indication for parenteral iron therapy?

    <p>Hematocrit below 30%</p> Signup and view all the answers

    Iron dextran is the most common parenteral iron preparation used.

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

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

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

    Adverse effects of parenteral iron therapy can include headache, nausea, and _____ reactions.

    <p>injection site</p> Signup and view all the answers

    Match the following parenteral iron preparations with their characteristics:

    <p>Iron dextran = 1st generation, intramuscular injection, not usually used Iron sucrose = 2nd generation, most common Ferric carboxy maltose = 3rd generation, best but expensive, intravenous route</p> Signup and view all the answers

    Which of the following symptoms is associated with heart disease?

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

    Rheumatic heart disease is the most common heart condition in pregnancy.

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

    What is the maximum risk of maternal mortality heart disease associated with pregnancy?

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

    Pregnancy is contraindicated for patients who fall under WHO Class _____ due to a maximum chance of death.

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

    Match the following heart diseases with their prognosis in pregnancy:

    <p>Congenital Heart Disease = Good Prognosis Stenotic Lesions = Worsens Regurgitant Lesions = Improves Cyanotic Heart Disease = Worsens</p> Signup and view all the answers

    Study Notes

    Therapeutic Decision Making During Pregnancy

    • Warfarin use in pregnancy:
      • Preconception dose of warfarin < 5mg/day: Continue warfarin + Aspirin.
      • Preconception dose of warfarin ≥ 5mg/day: LMWH + Aspirin.
      • Management at time of delivery: Stop warfarin, deliver by Cesarean section, administer Vitamin K to mother and baby.
    • Disala Syndrome:
      • Caused by warfarin use during pregnancy.
    • Fetal Anomalies associated with warfarin use:
      • Chondrodysplasia: Depressed nasal bridge and stippled epiphysis.
      • Cataract.
    • CNS Defects associated with warfarin use:
      • Microcephaly.
      • Hydrocephalus.
      • Dandy-Walker malformation.
    • Teratogenicity of Antiepileptics:
      • Ranked from most to least teratogenic: Valproic acid > Phenytoin > Phenobarbital > Carbamazepine > Lamotrigine> Levetiracetam.
      • Valproic acid can cause neural tube defects, CNS malformations, and urinary tract deformities.
    • First epileptic attack during pregnancy: Levetiracetam is preferred over Lamotrigine for treatment.
    • Management of epilepsy during pregnancy:
      • Continue existing antiepileptic medication at the lowest possible effective dose.
      • Folic acid supplementation before conception (0.4 mg/day) and after conception (1 mg/day).
    • INR target range: 2.5-3.
    • LMWH: Low Molecular Weight Heparin.
    • UFH: Unfractionated Heparin.

    Anemia Management Protocol in Pregnancy

    • Mild-Moderate Anemia:
      • Symptoms include dyspnea on exertion.
      • Management: Limit physical activity and restrict sodium intake.

    Medical and Surgical Complications In Pregnancy

    • Dyspnea On Exertion:
      • Medical management: Beta-blockers, diuretics, and anticoagulants.
      • Surgical management: Percutaneous mitral balloon valvotomy (second trimester).
    • Anemia in Pregnancy
      • Oral Iron Therapy:
        • Dose: 2 Iron Folic Acid (IFA) tablets per day.
        • Response: Assess by ↑ Hb levels (>0.7 g/dL after 3 weeks) or ↑ Reticulocyte count (Preferred, ↑within 7 days with maximum increase at 10 days).
      • Adequate Response:
        • Continue IFA 2 tablets/day until Hb reaches 11g%.
        • Maintenance dose: 1 tablet/day throughout pregnancy and 180 days post-delivery.
      • Inadequate Response:
        • Evaluate compliance (stool color is an indicator) and consider alternate treatment options.
        • Affordable patients: Switch to Ferrous Sulfate or Ferrous Fumarate.
      • Parenteral Iron Therapy:
        • Indications: Non-compliance to oral therapy, intolerance to oral iron, or based on gestational age.
        • Approved preparations in India: Iron dextran, Iron sucrose, and Ferric carboxy maltose (most expensive).
        • Dose calculation: Ganzoni formula, 2.4 x weight in kgs (pre-pregnancy) x [Patient's Hb deficit] + 500 mg
        • Infusion rate: Initial 15-20 drops/min for 5 minutes, increasing to 80-90 drops/min if no anaphylaxis.
        • Maximum daily dose: 200mg (2 vials).
        • Maximum weekly dose: 600mg (3 injections on alternate days).
        • Adverse effects: Headache, nausea, dizziness, constipation/diarrhea, and injection site reactions.
        • Contraindications: First trimester, hemochromatosis, and thalassemia major.
      • Blood Transfusion:
        • Indications: Thalassemia major, heart failure, acute hemorrhage, Hb < 5 at any gestational age, Hb 5-6.9 at > 34 weeks, or for bone marrow failure.
        • Target increase in Hb: 1 g%.
        • Exceptions: Hemorrhage exceeding 1 g%/day and CHF.

    Heart Diseases In Pregnancy

    • Physiological Changes:
      • Increase: Cardiac output (CO) from week 5, peaking at 28-32 weeks and returning to normal by 10 days post delivery; Femoral venous pressure due to compression of IVC.
      • Decrease: Peripheral vascular resistance (PVR) due to progesterone and relaxin; Blood pressure (systolic, diastolic, and mean arterial pressure).
      • Unchanged: Jugular Venous Pressure (JVP), Pulmonary capillary wedge pressure (PCWP), and Left ventricular ejection fraction (LVEF).
      • Best position: Left lateral.
    • Chance of heart failure:
      • Highest immediately after delivery and during the third stage of labor, followed by late first stage of labor and 28-32 weeks of gestation.
    • Clinical Indicators:
      • Increased: Heart rate and pulse rate.
      • Decreased: Blood pressure.
      • Heart: Pushed up and out towards the left; Apex beat at 4th intercostal space, 2.5 cm lateral to mid-clavicular line.
      • Heart sounds: Loud and prominent split S1, normal S2.
    • Symptoms normal during pregnancy:
      • Fatigue, decreased exercise tolerance, dyspnea on exertion, and peripheral dependent edema.
    • Murmurs:
      • S3 is easily heard.
      • Continuous/mammary murmur.
      • Ejection systolic murmur grade 1-2.
    • Symptoms indicating heart disease:
      • Progressive dyspnea, orthopnea, paroxysmal nocturnal dyspnea, hemoptysis, chest pain, and non-dependent edema/anasarca.
    • Most Common Heart Diseases in Pregnancy:
      • Rheumatic heart disease, Atrial Septal Defect, Tetralogy of Fallot, Mitral Valve Prolapse, and Eisenmenger syndrome.
    • Signs of Heart Disease:
      • Clubbing, cyanosis, increased JVP, loud S1 with prominent split and S4, diastolic or ejection systolic murmur > grade 3, marked cardiomegaly on chest X-ray, and arrhythmias.
    • Prognosis of Heart Diseases in Pregnancy:
      • Worsens: Stenotic lesions and cyanotic heart disease.
      • Improves: Regurgitant lesions and pulmonary hypertension (secondary).
    • WHO Class 4 Heart Disease:
      • Highest risk of death due to pregnancy.
      • Pregnancy is contraindicated, and medical termination of pregnancy is advised.
    • Associated Conditions:
      • Pulmonary hypertension, severe mitral stenosis/aortic stenosis, 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.

    Drugs in Pregnancy

    • Antibiotics:
      • Safe: Cephalosporins, Ampicillin, Metronidazole, and Penicillin.
      • In Treatment: Nitrofurantoin (DOC for asymptomatic bacteriuria), sulphamethoxazole, fluconazole, and trimethoprim.
      • Throughout Pregnancy: Avoid fluoroquinolones (toxic to cartilage), aminoglycosides (ototoxic and nephrotoxic), and tetracyclines (bone/teeth discoloration, grey baby syndrome).
    • Anticoagulants:
      • Warfarin:
        • Advantages: Potent anticoagulant.
        • Disadvantages: Crosses placenta, teratogenic, post-partum hemorrhage risk, fetal intracranial hemorrhage risk.
        • Target value: INR 2.5-3.
      • Low-Molecular Weight Heparin (LMWH):
        • Advantages: Does not cross the placenta, low potency anticoagulant.
        • Target value: Factor Xa 0.8-1.2.
      • Teratogenicity of Warfarin:
        • Depends on dose and gestational age.
        • Highest during week 7-9 of the first trimester.
      • Valve Replacement:
        • Mechanical: Anticoagulant + Aspirin until 36 weeks.
        • Bioprosthetic: Aspirin only.

    Intrapartum Management of Heart Disease

    • Vaginal delivery: Spontaneous or induced labor if needed.
    • Ripe cervix: Vaginal delivery is preferred.
    • Shortening the stage of labor: Forceps or vacuum can be prophylactically used to reduce maternal effort.
    • Monitoring: Maternal and fetal heart rates and input/output.
    • Position: Semi-recumbent position with left lateral tilt.
    • Management: Restrict IV fluids to 75 mL/hr, epidural analgesia, restrict pelvic exams to prevent infective endocarditis, and administer ampicillin + gentamicin when membranes rupture.

    Postpartum Management of Heart Disease

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

    Indications for Cesarean Section

    • Aortic lesions: Increased risk of aortic dissection during vaginal delivery (severe aortic stenosis, aortic aneurysm, Marfan syndrome with aortic root dilation, coarctation of aorta).
    • Patient on warfarin: Within 2 weeks of delivery, increased risk of post-partum hemorrhage and fetal intracranial hemorrhage.
    • Refractory heart failure.

    Anesthesia:

    • Neuraxial (spinal or epidural) anesthesia is preferred.
    • General anesthesia: Indicated for patients with intracardiac shunts, severe aortic stenosis, or hypertrophic obstructive cardiomyopathy (HOCM).

    Post Partum Hemorrhage (PPH) in Heart Disease:

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

    Pre-Conceptional Counseling:

    • Ventricular Septal Defect (VSD): Highest risk of recurrence.
    • Investigations: Electrocardiogram (ECG), Echocardiogram (ECHO).
    • Surgery: Perform if needed before conception.

    Key Points to Remember:

    • Inj. oxytocin is used for PPH management.
    • Inj. methylergometrine is contraindicated due to tetanic contractions.
    • IV diuretics may be administered.
    • Keep the legs lower than the heart to prevent backflow of blood.

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    Description

    Explore the critical aspects of therapeutic decision making during pregnancy, focusing on the use of warfarin and antiepileptics. This quiz covers the management of patients on anticoagulants, the risks of fetal anomalies, and the teratogenic effects of various medications. Test your knowledge on how to effectively manage these challenges in clinical practice.

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