Abnormal Pregnancy Flashcards
What is the definition of gestational hypertension?
High BP which develops after 20 weeks gestation but does not involve proteinuria or oedema
- systolic > 140 or diastolic > 90
- or an increase above booking readings of > 30 systolic or > 15 diastolic
What is the definition of pre-eclampsia?
Seen AFTER 20 weeks gestation
- pregnancy induced hypertension
- plus proteinuria > 0.3g/24hrs
What are the risks of pre-eclampsia?
Foetal prematurity + IUGR Eclampsia Placental abruption Cardiac failure Stroke VTE DIC + HELLP Pulmonary oedema Multi-organ failure
Which investigations should be done for high BP during pregnancy?
Blood pressure
Urinalysis (proteins)
Hb, platelets, U&Es, LFTs, coagulation screen, urate
What are the risk factors for pre-eclampsia?
Previous HTN in pregnancy CKD Autoimmune disease Diabetes Chronic hypertension First pregnancy Age 40 or over Pregnancy interval > 10 years BMI > 35 Family history of pre-eclampsia Multiple pregnancy
What are the clinical features of severe pre-eclampsia?
Hypertension >170/100 + proteinuria Headache (cerebral oedema) Visual disturbance Papilloedema RUQ/epigastric pain Sudden onset oedema Hyperreflexia, clonus Features of HELLP syndrome
What are the features of pre-eclampsia developing into eclampsia?
Grand mal seizures
What is the management for pre-existing hypertension during pregnancy?
Stop ACE inhibitors (teratogenic) Start either: - labetalol - nifedipine - methyldopa
What is the management for pregnancy induced hypertension?
Labetalol
Nifedipine
Methyldopa
Hydralazine
What is the management for pre-eclampsia?
Delivery of baby (depends on gestation)
Antihypertensive (as for pregnancy induced HTN)
IV magnesium sulpahte –> if severe, reduces chance of eclampsia
IM steroids (if < 34 weeks or <38 weeks if c-section)
Why are steroids given in pre-eclampsia?
To encourage foetal lung development (surfactant production) as delivery is likely to be necessary
How is eclampsia managed?
IV magnesium sulpahte
+ urgent delivery by c-section (unless fully dilated and deliverable by vaginal delivery)
What is the secondary prevention for pre-eclampsia in women with history of pre-eclampsia or risk factors?
Low dose aspirin started at 12 weeks gestation
Increased surveillance and regular growth scans
What are the risk factors for gestational diabetes (GDM)?
Previous GDM BMI > 30 First degree relative with GDM Ethnicity - SE Asia, Middle East, Black Caribbean Previous big baby
What are the signs of GDM?
Glycouria
Polyhydramnios
What are the consequences of GDM?
Macrosomia
Shoulder dystocia + vaginal trauma
Increased need for forceps or CS
Hypoxaemic state in utero - higher risk of stillbirth
Neonatal hypoglycaemia
Increased risk of obesity, DM + CVD in infant
Which complications can occur during pregnancy in both pre-existing + gestational DM?
Pre-eclampsia
Neonatal hypoglycaemia, obesity, CVD
Macrosomia, obstructed labour, vaginal trauma
Shoulder dystocia
What should be included in pre-pregnancy counselling for women with type 1 or type 2 DM?
Aim for HbA1c 48 (6.5%), avoid pregnancy if HbA1c >86 (10%)
Folic acid 5mg - 3 months before conception to 12 weeks gestation
Low dose aspirin from 12 weeks
When should the foetus be delivered in women with DM?
T1DM: 38 weeks (earlier if complications) - offer CS if estimated weight > 4.5kg GDM: - diet alone: 40-41 weeks - metformin: 39-40 weeks - insulin: 38 weeks
What is the diagnostic criteria for GDM?
Fasting glucose >/= 5.1
2 hour glucose >/= 8.5
What are the management options for GDM?
Diet + exercise
Metformin
Insulin
How are GDM patients followed up after delivery?
Fasting glucose measure 6-8 weeks postnatally
If results suggest T2DM –> OGTT
Annual screening for DM by GP
What are the causes of pre-term pre-labour rupture of membranes (PPROM)?
Infection
Cervical incompetence
Over distention of uterus - multiple pregnancy or polyhydramnios
Vascular causes - placental abruption
What are the consequences of PPROM?
Neonatal: - prematurity - sepsis - pulmonary hypoplasia Maternal: - chorioamnionitis
How is PPROM diagnosed?
Maternal history
Sterile speculum exam - pooling of blood in posterior vaginal fornix
USS may show oligohydramnios
AVOID digital exam because risk of infection + prostaglandin release leading to labour
How is PPROM managed?
Monitor for signs of infection
Antibiotics e.g. erythromycin
Tocolytics e.g. nifedipine in earlier gestation to prevent labour
Maternal steroids (foetal lungs)
Magnesium sulphate IV - neuroprotection for foetus
CTG
Foetal blood sampling during labour
How is foetal anaemia diagnosed and managed during pregnancy?
Screened for by checking the middle cerebral artery-peak velocity pressure (MCA-PSV)
If appears anaemia, specialist centre:
- foetal blood sampling + in utero transfusion via umbilical vein
Which condition may result from severe foetal anaemia?
Heart failure
+ Hydrops fetalis
What are the features of hydrops fetalis?
Ascites Pleural effusion Skin oedema Pericardial effusion May lead to death
What is the leading cause of maternal death in the UK?
VTE
What can be given as antenatal prophylaxis for VTE?
LMWH
Which women should receive antenatal VTE prophylaxis?
Any previous VTE Hospital admission High risk thrombophilia Comorbidities e.g.: - cancer, HF, SLE, IBD, inflammatory polyarthropathy, nephrotic syndrome, T1DM with nephropathy, sickle cell - current IVDU Any surgical procedure e.g. appendectomy OHSS (first trimester only)
How is a PE diagnosed in pregnancy?
V/Q scan
However, if unclear, do CTPA –> risk of undiagnosed CTPA is greater
How is VTE treated in pregnancy/post partum?
LMWH (doesn’t cross placenta, not secreted in breast milk)
If emergency situation - use unfractionated heparin as quicker onset
Thrombolysis if life threatening PE
Can DOACs or warfarin be used in pregnancy/breastfeeding?
DOACs - not recommended in pregnancy or breastfeeding Warfarin - teratogenic - but fine when breastfeeding
How is small for gestational age (SGA) defined?
Estimated foetal weight or abdominal circumference below the 10th centile
How is a SGA foetus identified?
Antenatal risk factors
Screening during antenatal care:
- measurement of SFH
- growth scans if single measurement below 10th centile
How is SGA diagnosed?
Measurement of foetal abdominal circumference + head circumference +/- femur length –> estimated foetal weight
Additional information:
- liquor volume or amniotic fluid index
- doppler scans of umbilical artery
How is a large for dates foetus defined?
Estimated foetal weight greater than 90th centile
Clinically - SFH will be more than 2cm over the gestational age
What are the causes of large for dates foetus?
Polyhydramnios
Multiple pregnancy
Macrosomia secondary to DM
Wrong dates e.g. late bookers
What are the risks associated with a large for dates foetus?
Clinician + maternal anxiety
Shoulder dystocia
Postpartum haemorrhage
What is polyhydramnios?
Excess of amniotic fluid
What are the causes of polyhydramnios?
Diabetes Anomaly - GI atresia, cardiac Monochorionic twin pregnancy Hydrops fetalis - rhesus isoimmunisation Viral infection Idiopathic
What are the symptoms of polyhydramnios?
Abdominal discomfort
Prelabour rupture of membranes
Preterm labour
Cord prolapse
What are the signs of polyhydramnios?
Large for dates
Malpresentation
Shiny, tense abdomen
Inability to feel foetal parts
