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Acute Medical Presentations In Pregnancy PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Acute medical presentations in pregnancy” by Dr Francesca Neuberger.

This medical PowerPoint presentation is about acute medical presentations in pregnancy. There are several acute medical presentations that can occur during pregnancy including Preeclampsia, Gestational diabete, Preterm labor, Miscarriage, Ectopic pregnancy, Placental abruption, and Deep vein thrombosis.

Tags : Acute medical presentations in pregnancy, Preeclampsia, Gestational diabete, Preterm labor, Miscarriage, Ectopic pregnancy, Placental abruption, Deep vein thrombosis, Neonatal-Perinatal Medicine, Neonatal-Perinatal Medicine PowerPoint presentation

Published on : Jun 07, 2023 | Views : 839 | Downloads : 1

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Slide 1-

Acute medical presentations in pregnancy Dr Francesca Neuberger Consultant Physician - Acute Medicine/Obstetric Medicine North Bristol NHS Trust
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Acute medical presentations in pregnancy Maternal mortality Common acute medical presentations in pregnancy Breathlessness Chest pain Headaches Seizures An interesting case 2
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Maternal mortality UK 2003-16
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Causes of maternal death 2014-16 4
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Breathlessness in pregnancy Common as part of normal pregnancy Almost half of women are breathless by 19/40 Up to three quarters of women experience breathlessness by 31/40* Ankle swelling is common, reflux presenting as chest pain is common Red flags in the history Paroxysmal nocturnal dyspnoea Orthopnoea Associated with chest pain Associated with syncope 6 *Milne JA, Howie AD et al. Dyspnoea during normal pregnancy. Br J Obstet Gynaecol, 85 (1978) 260-263
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Physiological breathlessness of pregnancy WORSE at rest BETTER with exercise NOT associated with desaturation Red flags on examination RR >20 Oxygen sats <94% or dropping on exertion 7
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Gestation-based approach to breathlessness 8
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Breathlessness 40 year old lady, P0 Essential hypertension, on Labetalol 200mg TDS Resolved diarrhoeal illness Presented at 33/40 with 2/52 SoB, mild cough Desaturating to 88% on mobilisation Otherwise normal examination Bloods CRP - 57mg/L (<6) Resp viral PCR neg Urine PCR 19.4 mg/mmol (<50) 9
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Breathlessness Oral Amoxicillin and treatment dose LMWH Normal perfusion SPECT scan What next? 10
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Breathlessness Echocardiogram – globally, moderately impaired LV systolic function, ejection fraction 40% NT-pro BNP – 960pg/ml (<150) Diagnosis – peripartum cardiomyopathy (PPCM) Heart failure secondary to LV systolic dysfunction towards the end of pregnancy and in the months following Management Maternal steroids for fetal lung maturation Blood pressure management Elective CS at 34/40 (low risk at term could have vaginal delivery) Undergoing investigations for Duchenne muscular dystrophy 11
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Peripartum cardiomyopathy (PPCM) 1:300 to 1:4000 pregnancies, mortality between 2% and 12% Predisposing factors Multiparity, family history, ethnicity, smoking, diabetes, hypertension, pre-eclampsia Management Acute heart failure – diuretics, beta-blockers, nitrates, hydrallazine Generally avoid ACEIs/ARBs Consider devices/transplant. Prognosis A significant proportion improve or normalise their LV function over 6/12 European Society of Cardiology. Cardiovascular diseases during pregnancy. 2018 12
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pBNP (N-terminal pro brain-type natriuretic peptide) Elevated levels when the ventricle is stretched in the general population “Normal” values <70pg/ml can be used to exclude heart failure in people under 50 presenting with acute dyspnoea pBNP can be elevated with Heart failure, AF, ACS Right heart failure due to PE, Cor pulmonale secondary to chronic lung disease Acute pneumonia, pulmonary hypertension, renal disease Limited data in pregnancy 13 Ker J, Soma-Pillay P. NT-proBNP: When is it useful in Obstetric Medicine? Obstetric Medicine 2018, 11 (1) 3-5
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pBNP levels in normal pregnancy 14 94 healthy pregnant women compared with matched non-pregnant 235pg/ml is upper limit of normal A – 11/40 to 15/40 B – 16/40 to 22/40 C – 23/40 – 32/40 D – 33/40 to 42/40
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Clinical uses of pBNP on pregnancy Limited data in pregnancy Used in women with congenital heart disease to screen for heart failure A growing area of research ?Role in evaluating breathlessness in pregnancy 15
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Chest pain in pregnancy 16 *Cardiovascular Diseases during Pregnancy. European Society of Cardiology 2018
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Chest pain in pregnancy History Consider risk factors Red flags Pain requiring opioids Pain radiating to arm, shoulder, back or jaw Sudden onset, tearing or exertional chest pain Examination Soft systolic murmur, third heart sound and mild peripheral oedema may all be normal Investigations Troponin is NOT elevated in normal pregnancy ECG - Sinus tachycardia, 15 degree LAD, T wave changes, small Q waves, non-spec ST changes 17
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Chest pain 44 y/o, P2, G8 Normally fit and well Meds – Aspirin 75mg OD Presented to ED with intermittent chest pain and palpitations for the last two days HR 160, BP 110/70, RR 14, sats 99% on air, temp 37°C Bloods - in keeping with pregnancy CXR - normal 18
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Chest pain Management Cardioverted with Adenosine 6mg IV Started on regular Bisoprolol 2.5mg OD Echocardiogram – normal For growth scans at 28, 34 and 38 weeks Can have vaginal delivery, advised to deliver in hospital Baby to have blood glucose monitoring for 48 hours Advised regarding Valsalva manoeuvre 19
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Acute management of narrow complex tachycardia in pregnancy 20 Vagotonic manoeuvres DC cardioversion Safe at all gestations Monitor fetus Anaesthetists may opt for GA Drugs Adenosine 6mg, upto 24mg Beta-blockers – Metoprolol, Sotalol CCBs – Verapamil Amiodarone – only if life-threatening situation and no alternatives
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A case from MBBRACE 2016 “A woman with known ischaemic heart disease presented to the Emergency Department with chest pain in the second trimester of pregnancy. There were some atypical features to her pain but it had made her anxious. Her ECGs had been reported as normal but they showed evidence of a previous infarct. Her Troponin was not raised. She was diagnosed as having dyspepsia and discharged. No referral to obstetrics or cardiology was made. Shortly after discharge she collapsed at home and was found to be in ventricular fibrillation. She could not be resuscitated.” 21
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Acute Coronary Syndrome (ACS) in pregnancy Pregnancy is associated with 3-4 fold increase in ACS for age-matched women Most common in 3rd trimester and post-partum period Management in pregnancy Similar to the non-pregnant population Primary coronary angioplasty is the gold standard for STEMI in pregnancy 22
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ACS in pregnancy Have a high index of suspicion for cardiac disease in pregnancy Women with cardiac disease may have a normal ECG/Troponin A raised Troponin is always abnormal in pregnancy ECG interpretation can be difficult Acute MI ST segment changes New T wave inversion Normal pregnancy T wave inversion inferiorly and laterally Left axis deviation 23
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Headache 29 y/o lady, para 0 Presented to Ambulatory Care at 22/40 with headache Several weeks of intermittent paraesthesia in right upper limb Intermittent visual scotoma Occasional headache History of migraine Uncomplicated pregnancy Normal physical examination including fundoscopy BP 100/70, urine dip NAD 24
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Headache in pregnancy 25
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Headache Initially managed as migraine Lifestyle advice Simple analgesia Anti-emetic Symptoms did not improve in the following days MRV – normal Symptoms resolved over a few days 26
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Migraine in pregnancy Lifestyle Diary to identify triggers Avoidance of triggers e.g. chocolate, cheese, stress, sleep deprivation, strenuous exercise Acute management Simple analgesia with antiemetic Sumatriptan NSAIDs – stop at 24/40 Prophylaxis Adjunctive therapies e.g. Occipital nerve block Aspirin 75mg OD Beta blockers – propanolol, bisoprolol Amitriptyline 27
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Headache red flags Sudden onset headache/thunderclap or worse headache ever Headache that takes longer than usual to resolve or persists > 48 hours Has associated symptoms-fever, seizures, focal neurology, photophobia, diplopia Use of excessive opioids CT and MRI scans of the head are both safe in pregnancy 28
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A case from MBRRACE 29
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Seizures 35 year old lady, P0 Partner awoken by her shaking both arms in bed, tongue biting, urinary incontinence LMP 11 weeks ago, positive home pregnancy test No recent headaches, visual disturbance, nausea or vomiting, speech problems or limb weakness No regular medication or medical history Urine dip - protein + BP 110/70 ECG - normal 30
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Could it be pre-eclampsia/eclampsia? Very rare before 20/40 90% after 34/40 Dip the urine and check blood pressure Difficult to diagnose in women with chronic kidney disease Expertise Biomarkers e.g. placental growth factor (PlGF) Other causes of seizures in pregnancy Epilepsy first presentation SOL CNS infection 31
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Diagnosing pre-eclampsia Hypertension (>140/90) after 20/40 with one or more of the following new onset conditions: Proteinuria Fetal growth restriction Maternal organ dysfunction - renal impairment - liver dysfunction - neurological abnormalities - haematological complications 32
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Seizures 33
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Seizures Started on Levetiracetam, Aspirin, Enoxaparin Scan confirmed viable IUP, approx 11/40 Discussed in neuro MDT – primary brain tumour, most likely low grade glioma Couple fully committed to the pregnancy Repeat MRI at 20/40, stable appearances Surgery for brain tumours in pregnancy? Safe and feasible 2nd trimester is safest time for this 34
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And a case for the geriatricians… 38 y/o, para 2, gravida 4, 2 vaginal deliveries in 2001 and 2004 PET complicated first pregnancy Idiopathic Parkinson’s disease Diagnosed aged 26 Deep brain stimulator, failed due to electrode infection Hypothyroidism Medications Sinemet (co-careldopa) 62.5mg every 2 hours starting at 7am, 125mg at 9pm Amantadine 100mg BD Levothyroxine 75mcg OD 35
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Parkinson’s Disease in pregnancy Case reports/case series form the bulk of the literature, one review article Presents before age of 40 in <5% of cases PD and pregnancy rarely coexist Incidence unknown Increasing maternal age may make this more common Very little data regarding PD drugs in pregnancy 36
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Recommendations of anti-PD drugs in pregnancy 37 Seier M, Hiller A. Parkinsonism and related disorders 40 (2017) 11-17
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Pregnancy counselling Effect of PD on the pregnancy No effect on fertility in idiopathic PD No effect on mode of delivery Advised to stop Amantadine - resulted in more dyskinesias, longer “off” periods Effect of pregnancy on the PD Counselled that constipation may worsen Dyskinesias may worsen. Pharmacokinetics? Progression of disease? Oestrogen effect is controversial Physical and psychological stress 38
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Pregnancy counselling General pregnancy considerations for this lady Increased pre-eclampsia risk – started on Aspirin 75mg OD Hypothyroidism care pathway Breastfeeding and anti-PD medications Very little data Many women unable to (dopamine inhibits release of prolactin) Other issues Ability to carry and care for baby 39
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Progress during pregnancy “Wearing off” at night, would prefer dyskinesias Switched to Co-careldopa extended release 25/100 at bedtime At 32/40, severe chest infection and rib fractures Lidocaine patches, recovered well Induction of labour at 37/40 3.1 Kg male infant Mother and baby doing well Bottle feeding infant 40
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Seeing pregnant patients on the acute take Write in the pregnancy notes Think about the gestation and the associated pathology Let the Obstetric SpR/Consultant know about admissions Use phone/email as mode of communication 41
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Conclusions New challenges with the changing obstetric population RCP obstetric medicine toolkits are being developed Collaboration is key with complex obstetric patients Make use of clinical librarians Do not withhold important tests/treatments in view of pregnancy 42
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Thank-you for listeningAny questions or comments? 43