Obstetrics 6

  1. What is most common acquired heart disease in pregnancy?
    Rheumatic - mitral stenosis.
  2. What are the factors that worsen Mitral stenosis?
    Increased HR and Increased Blood volume (these parameters are increased in pregnancy, thus pregnancy worsens the Mitral Stenosis)
  3. Which of the following drugs should not be used to conduct labor in woman with rheumatic heart disease? [AI 11]

    B) Methylergometrine

    Ergot derivatives results in sudden squeezing of blood from uterine circulation into the systemic circulation causing overload of the right heart and failure. Ergot derivatives are avoided in the conduct of labor for patients with organic heart disease including Rheumatic heart disease.
  4. Whys is Eisenmenger syndrome seen more with pregnancy?
    • It is the condition in which the there is increased pulmonary resistance, so that, the blood form right side goes the left side and is pumped throughout the body, leading to shock.
    • In pregnancy, the peripheral vascular resistance is decreased, whereas the pulmonary resistance is normal, so blood tends to go to systemic circulation directly bypassing the pulmonary circulation.

    Among all cardiac lesions, Eisenmenger syndrome has the worst prognosis in pregnancy. [AIIMS 91, AI 92,94, UP 93]
  5. What is the management of Eissenmenger syndrome?
    Prevent hypotension
  6. In which case do you find Bidirectional intracardiac shunt?
    Eissenmenger shunt
  7. What is the risk of Marfan syndrome in pregnancy?
    If aorta is dilated >40mm, there is increased risk of aortic dissection. Management is surgical reconstruction. It is advised that marfan syndrome patients should not get pregnant.
  8. All of the following are the cardiac contraindications of pregnancy, except [AI 10]

    A) WPW syndrome
  9. What is True Gestational Diabetes and Overt Diabetes?
    • If after delivery, the glucose level normalizes, it is true Gestational diabetes
    • If after delivery, the glucose level remains elevated, it is Overt Diabetes. These both are retrospective diagnosis.
  10. Whom and when do you do the Gestational diabetes screening? [AIIMS 96]
    All the pregnant ladies at gestational age of 24-28 weeks
  11. How do you do the screening test for Gestational Diabetes?
    Oral glucose tolerance test. [AIIMS 94] 

    • Procedure:
    • Do 1-hr 50gm oral glucose tolerance test, if < 140mg/dl - normal. If ≥140 mg/dl, call for fasting glucose level and 3-hr 100gm glucose tolerance test.
    • This test of 1-hr 50gm glucose tolerance test doesnot require the fasting.

    • Next day, obtain fasting level of glucose, if >125, diagnose as Overt Diabetes, If <125, go for 3-hr 100gm OGTT.
    • Now obtain the blood sugar at 1hr, 2hr and 3 hr.
  12. How can you diagnose the Gestational diabetes based on OGTT test?
    • On 3-hr 100gm OGTT, among the 4 values, fasting (<95), 1 hr(<180), 2hr (<155) and 3hr(<140) values, if 2 of 4 values are abnormal, it is diagnosed as Gestational Diabetes.
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  13. What are the target values of glucose in pregnancy?
    • FBS <90mg/dl
    • 1 hr PP < 140 mg/dl
  14. Which drug do we use in pregnancy for diabetes?
    • We use insulin.
    • Oral hypoglycemic drugs are not used in pregnancy because of risk of fetal hypoglycemia.
    • GLIBURIDE can be used but is not approved by FDA.
  15. What is rule of 15 in gestational Diabetes?
    • 15% of gravidas have positive 1 hr OGTT
    • 15% of positive 1 hr OGTT have GDM
    • 15% of GDM need insulin
  16. What are the fetal anomalies seen with DM?
    • Neural tube defects -  most common. [AIIMS 03] 
    • Congenital heart disease
    • Sacral agenesis(caudal regression syndrome)  is the most specific abnormality associated  with DM. [SGPGI 03,AI 07] Although this defect is very much rare, it is 200 times more common with DM, than in normal healthy women.
  17. How do you prevent the anomalies associated with Diabetes mellitus?
    • Preconception euglycemia
    • Preconception folate – 4mg/day
  18. What are the complications of diabetes in labor?
    • Arrest of labor, shoulder dystocia (d/t macrosomia)
    • Postpartum complication is Hemorrhage
  19. What is the indication of C/S in Gestational Diabetes?
    If fetal Wt > 4200gms
  20. What are the neonatal proplems associated with Gestational Diabetes Mellitus? [AI 95, SGPGI 03]
    Hypoglycemia - hyperinsulinemia due to high maternal glucose level

    Hypocalcemia - due to immature parathyroid

    Polycythemia - because of increased erythropoietin from Intrauteine hypoxia, the placenta cannot supply enough oxygen , so baby increases the release of erythropoietin leading to polycythemia. The baby is Ruddy (very red) and plethoric. 

    Hyperbilirubinemia - increased destruction of high level of RBC, Immature liver. Also, the enzymes required in  bilirubin metabolism require glucose. 

    RDS - Although the baby is large in size, it is not mature enough and enough surfactant are not produced.

    Cardiac disease - risk of transposition of great arteries, [AI 05]  hypertrophic cardiomyopathy

    GI problems - lazy left colon syndrome -  signs of intestinal obstruction - donot pass meconium
  21. What is the difference in baby of type 2 DM and type 1 DM mother?
    • Type I DM – IUGR, asymmetrical
    • Type II DM - Macrosomia [SGPGI 03]
  22. What are the risk factors for macrosomia?  [UP 99]
    • Maternal diabetes mellitus [AI 07] - most common risk factor
    • Post dates gestation
    • Maternal Obesity
    • Multiparity
    • Previous infant weighting > 4000g
  23. What is the criteria for anemia in pregnancy?
    Hb <10g/dl
  24. How do you treat IDA?
    Rx – FeSO4 325 mg equivalent to 60mg of elemental iron TDS.

    Prevention - 30 mg of elemental iron/day
  25. How do you treat Folate deficiency anemia?
    Tt – Folate 1mg/day

    Prevention – 0.4mg/day, 4mg/day for high risk cases.
  26. If you see high MCV in pregnancy, should you suspect Folate deficiency or Vit B12 deficiency?
    B12 deficiency are infertile so, donot get pregnancy; so high MCV in pregnancy always indicates folate deficiency.
  27. Which type of anemia in pregnancy do you suspect in following conditions?
    a) Multiple gestation
    b) Seizure disorder
    c) African descent and
    d) SE Asia
    • Multiple gestation – Iron and Folate deficiency
    • Seizure disorder - Folate deficiency
    • African descent – Sickle cell disease
    • SE Asia - Thalassemia
  28. 25 yr old black multigravida is found to have anemia, most likely diagnosis?

    C) Iron deficiency

    Although she is black and has more risk of sickle cell anemia, most common cause is iron deficiency anemia.
  29. What is intrahepatic cholestasis of pregnancy?
    • Intrahepatic cholestasis of pregnancy is the most common liver condition in pregnancy. 
    • It usually presents in third trimester and is characterized by pruritus with or without jaundice which resolves after delivery. 
    • Histologically - Intrahepatic cholestasis with centrilobular bile staining without inflammatory cells
    • Aetiology is unknown and is assumed to be stimulated in susceptible persons by high levels of estrogen

    Bile acids are incompletely cleared by the liver and accumulate in the plasma.
  30. What are the clinical features of Intrahepatic cholestasis?
    • Predominant symptom is generalized pruritus in last trimester, worse at night.
    • Jaundice is mild. 
    • No constitutional symptoms. 
  31. What are the lab findings of intrahepatic cholestasis?
    Serum bile acids concentration increased by 10-100 folds. Bile acid levels are often estimated to confirm a suspected diagnosis and to monitor the disease and is the most characteristic marker for intrahepatic cholestasis of pregnancy. [AI 11] 

    Serum bilirubin level only rarely exceeds 5 mg%. [UP 93]
  32. What is the treatment for Intrahepatic cholestasis?
    • Oral antihistamines
    • Cholestyramine can be given
    • Ursodeoxycholic acid is the treatment of choice. [AI 10]
  33. What is the cause of acute fatty liver in pregnancy?
    Disordered metabolism of fatty acids by mitochondria in the fetus by deficiency of LCHAD ( long chain 3-hydroxyacyl-coenzyme A dehydrogenase) enzyme.
  34. What are the signs of Acute fatty liver? Which disorder does it mimic?
    • Epigastric pain, HTN, proteinuria, and edema - mimics severe preeclampsia . Other important features are nausea, vomiting, Jaundic, fever.
    • It may progress to hepatic encephalopathy. Lab findings are Hypoglycemia and raised serum ammonia.
  35. Which side pyelonephritis is more common in pregnancy?
    Rt side - 90% of cases
  36. What is the antibiotic of choice in UTI in pregnancy?
    • Nitrofurantoin - for asymptomatic bacteria and acute cystitis cases
    • IV cephalosporins – for pyelonephritis
  37. What are the effects of hypothyroidism in pregnancy? [AI 07]
    • Abortion (spontaneous abortion) 
    • Abruptio placenta 
    • Still birth 
    • Prematurity/Premature delivery/LBW 
    • Preeclampsia (Pregnancy induced hypertension) 
    • Postpartum hemorrhage 
    • Anemia 
    • Subnormal intelligence in infant
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Obstetrics 6