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What is the primary focus of the anemia management protocol in pregnant women?
What is the primary focus of the anemia management protocol in pregnant women?
The protocol applies only to severe cases of anemia in pregnancy.
The protocol applies only to severe cases of anemia in pregnancy.
False
What type of anemia does the protocol specifically address?
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.
The anemia management protocol is designed for pregnant women specifically dealing with _____ anemia.
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Match the following anemia management strategies with their descriptions:
Match the following anemia management strategies with their descriptions:
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What is the recommended management for a patient on warfarin at the time of delivery?
What is the recommended management for a patient on warfarin at the time of delivery?
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Valproic acid is considered the least teratogenic anti-epileptic medication.
Valproic acid is considered the least teratogenic anti-epileptic medication.
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What is the recommended folic acid supplementation dosage during pregnancy before and after conception?
What is the recommended folic acid supplementation dosage during pregnancy before and after conception?
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Chondrodysplasia can present with a depressed nasal bridge and __________.
Chondrodysplasia can present with a depressed nasal bridge and __________.
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Match the following anti-epileptic medications with their level of teratogenicity:
Match the following anti-epileptic medications with their level of teratogenicity:
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What is a common symptom associated with increased cardiac output during pregnancy?
What is a common symptom associated with increased cardiac output during pregnancy?
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β-blockers are used to increase heart rate in managing dyspnea during pregnancy.
β-blockers are used to increase heart rate in managing dyspnea during pregnancy.
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What is the preferred timing for surgical management of dyspnea during pregnancy?
What is the preferred timing for surgical management of dyspnea during pregnancy?
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Limit physical activity and restrict _____ intake to manage symptoms in pregnancy.
Limit physical activity and restrict _____ intake to manage symptoms in pregnancy.
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Match the following management options with their correct application:
Match the following management options with their correct application:
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What is the recommended dose of iron-folic acid (IFA) tablets per day for pregnant women experiencing anemia?
What is the recommended dose of iron-folic acid (IFA) tablets per day for pregnant women experiencing anemia?
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A dark stool color indicates non-compliance with iron therapy.
A dark stool color indicates non-compliance with iron therapy.
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What indicates an adequate response to iron therapy after one month?
What indicates an adequate response to iron therapy after one month?
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The maximum increase in reticulocyte count expected after starting iron therapy is within ____ days.
The maximum increase in reticulocyte count expected after starting iron therapy is within ____ days.
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Match the types of responses to their definitions regarding treatment adherence:
Match the types of responses to their definitions regarding treatment adherence:
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What is the primary purpose of the WHO classification in heart diseases during pregnancy?
What is the primary purpose of the WHO classification in heart diseases during pregnancy?
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In cases of Class IV cardiac review during pregnancy, the patient should be admitted throughout the pregnancy.
In cases of Class IV cardiac review during pregnancy, the patient should be admitted throughout the pregnancy.
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What is the diagnostic criterion for peripartum cardiomyopathy regarding prior heart disease?
What is the diagnostic criterion for peripartum cardiomyopathy regarding prior heart disease?
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The diagnostic criteria for peripartum cardiomyopathy include heart failure between ___ weeks of pregnancy.
The diagnostic criteria for peripartum cardiomyopathy include heart failure between ___ weeks of pregnancy.
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Match the following categories of mitral stenosis with their corresponding area:
Match the following categories of mitral stenosis with their corresponding area:
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What is the primary aim of using a semi-recumbent position with left lateral tilt during intrapartum management of heart disease?
What is the primary aim of using a semi-recumbent position with left lateral tilt during intrapartum management of heart disease?
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A patient on warfarin within two weeks of delivery has a lower risk of postpartum hemorrhage.
A patient on warfarin within two weeks of delivery has a lower risk of postpartum hemorrhage.
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What is the drug of choice (DOC) for managing postpartum hemorrhage in patients with heart disease?
What is the drug of choice (DOC) for managing postpartum hemorrhage in patients with heart disease?
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In cases of severe aortic stenosis, the preferred mode of delivery is a __________.
In cases of severe aortic stenosis, the preferred mode of delivery is a __________.
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Match the conditions with their corresponding indications for C-section:
Match the conditions with their corresponding indications for C-section:
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Which antibiotics are considered safe during pregnancy?
Which antibiotics are considered safe during pregnancy?
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Fluoroquinolones are safe to use throughout pregnancy.
Fluoroquinolones are safe to use throughout pregnancy.
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What is the target INR value for patients on warfarin during pregnancy?
What is the target INR value for patients on warfarin during pregnancy?
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Nitrofurantoin is the drug of choice for __________ during pregnancy.
Nitrofurantoin is the drug of choice for __________ during pregnancy.
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Match the following anticoagulants with their characteristics:
Match the following anticoagulants with their characteristics:
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What should be avoided in patients with G-6-PD deficiency?
What should be avoided in patients with G-6-PD deficiency?
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Doxycycline is commonly used during pregnancy for any indication.
Doxycycline is commonly used during pregnancy for any indication.
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What condition could lead to the replacement of Low Molecular Weight Heparin with unfractionated heparin prior to delivery?
What condition could lead to the replacement of Low Molecular Weight Heparin with unfractionated heparin prior to delivery?
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At what gestational age does cardiac output reach its maximum during pregnancy?
At what gestational age does cardiac output reach its maximum during pregnancy?
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Peripheral vascular resistance decreases due to the influence of progesterone during pregnancy.
Peripheral vascular resistance decreases due to the influence of progesterone during pregnancy.
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What physiological change in blood pressure is observed during pregnancy?
What physiological change in blood pressure is observed during pregnancy?
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During pregnancy, the apex beat is pushed towards the _____ intercostal space.
During pregnancy, the apex beat is pushed towards the _____ intercostal space.
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Match the clinical indicators to their corresponding changes during pregnancy:
Match the clinical indicators to their corresponding changes during pregnancy:
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Which of the following is NOT an indication for parenteral iron therapy?
Which of the following is NOT an indication for parenteral iron therapy?
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Iron dextran is the most common parenteral iron preparation used.
Iron dextran is the most common parenteral iron preparation used.
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What is the maximum amount of iron sucrose that can be administered in one day?
What is the maximum amount of iron sucrose that can be administered in one day?
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Adverse effects of parenteral iron therapy can include headache, nausea, and _____ reactions.
Adverse effects of parenteral iron therapy can include headache, nausea, and _____ reactions.
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Match the following parenteral iron preparations with their characteristics:
Match the following parenteral iron preparations with their characteristics:
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Which of the following symptoms is associated with heart disease?
Which of the following symptoms is associated with heart disease?
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Rheumatic heart disease is the most common heart condition in pregnancy.
Rheumatic heart disease is the most common heart condition in pregnancy.
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What is the maximum risk of maternal mortality heart disease associated with pregnancy?
What is the maximum risk of maternal mortality heart disease associated with pregnancy?
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Pregnancy is contraindicated for patients who fall under WHO Class _____ due to a maximum chance of death.
Pregnancy is contraindicated for patients who fall under WHO Class _____ due to a maximum chance of death.
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Match the following heart diseases with their prognosis in pregnancy:
Match the following heart diseases with their prognosis in pregnancy:
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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.
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Disala Syndrome:
- Caused by warfarin use during pregnancy.
-
Fetal Anomalies associated with warfarin use:
- Chondrodysplasia: Depressed nasal bridge and stippled epiphysis.
- Cataract.
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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
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Mild-Moderate Anemia:
- Symptoms include dyspnea on exertion.
- Management: Limit physical activity and restrict sodium intake.
Medical and Surgical Complications In Pregnancy
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Dyspnea On Exertion:
- Medical management: Beta-blockers, diuretics, and anticoagulants.
- Surgical management: Percutaneous mitral balloon valvotomy (second trimester).
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Anemia in Pregnancy
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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).
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Adequate Response:
- Continue IFA 2 tablets/day until Hb reaches 11g%.
- Maintenance dose: 1 tablet/day throughout pregnancy and 180 days post-delivery.
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Inadequate Response:
- Evaluate compliance (stool color is an indicator) and consider alternate treatment options.
- Affordable patients: Switch to Ferrous Sulfate or Ferrous Fumarate.
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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.
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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.
-
Oral Iron Therapy:
Heart Diseases In Pregnancy
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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.
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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.
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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.
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Symptoms normal during pregnancy:
- Fatigue, decreased exercise tolerance, dyspnea on exertion, and peripheral dependent edema.
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Murmurs:
- S3 is easily heard.
- Continuous/mammary murmur.
- Ejection systolic murmur grade 1-2.
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Symptoms indicating heart disease:
- Progressive dyspnea, orthopnea, paroxysmal nocturnal dyspnea, hemoptysis, chest pain, and non-dependent edema/anasarca.
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Most Common Heart Diseases in Pregnancy:
- Rheumatic heart disease, Atrial Septal Defect, Tetralogy of Fallot, Mitral Valve Prolapse, and Eisenmenger syndrome.
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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.
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Prognosis of Heart Diseases in Pregnancy:
- Worsens: Stenotic lesions and cyanotic heart disease.
- Improves: Regurgitant lesions and pulmonary hypertension (secondary).
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WHO Class 4 Heart Disease:
- Highest risk of death due to pregnancy.
- Pregnancy is contraindicated, and medical termination of pregnancy is advised.
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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
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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).
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Anticoagulants:
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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.
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Teratogenicity of Warfarin:
- Depends on dose and gestational age.
- Highest during week 7-9 of the first trimester.
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Valve Replacement:
- Mechanical: Anticoagulant + Aspirin until 36 weeks.
- Bioprosthetic: Aspirin only.
-
Warfarin:
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.
