Antepartum Conditions - HTN, Pre-eclampsia, HELLP, GS, NVP, Hypermesis gravidarum, Intrahepatic cholestasis, Acute fatty liver, Twins, TTS, Parvovirus, Chickenpox, Rubella Flashcards
Normal changes in BP during pregnancy
1st trimester - BP falls until 20-24wks
2nd, 3rd trimester - gradual increase to pre-pregnancy levels
HTN in pregnancy
-definition
-categorisation of HTN
Systolic 140+ or diastolic 90+ OR
Increase above booking readings of systolic 30+ or 15+ diastolic
Preexisting HTN - before 20wks
Gestational HTN - after 20wks
Pre-eclampsia
Pre-existing HTN
-presentation
-management
Hx of HTN before pregnancy or
140/90+ before 20wks
No proteinuria or edema
Stop ACEi, ARBs => PO labetolol
-PO nifedipine if asthamtic
-alt hydralazine
Gestational HTN
-presentation
-management
HTN after 20wks
No proteinuria or edema
Resolves after birth but at increased risk of pre-eclampsia or HTN later in life
PO labetolol
-PO nifedipine if asthmatic
-alt hydralazine
Preclampsia
-presentation
-management
GHTN + proteinuria (0.3g/24hrs) + other organ involvement
Severe if
-HTN 160/110+ AND proteinuria ++/+++
-headache
-visual disturbance
-papillodema
-RUQ/EG pain
-hyperreflexia
-low platelets U100, abnormal enzymes of HELLP syndrome
Emergency 2ndary care assessment
-admit if 160/110+ for observation
PO labetolol
-PO nifedipine if asthmatic
-alt hydralazine
Definitive - deliver baby
Pre-eclampsia
-high risk and moderate risk factors and management
-consequences if untreated
Aspirin 75-150mg daily from 12wks - birth
High risk factors - 1+
-PHx GHTN, chronic HTN
-CKD
-AI - SLE, APS
-T1DM, T2DM
Moderate risk factors - 2+
-1st pregnancy
-40+
-pregnancy interval 10years+
-BMI 35+
-FHx preeclampsia
-Multiparous
Eclampsia and other neuro
-altered mental status, blindness, stroke, clonus, severe headache, persistent scotoma
Fetal complications
-IUGR
-prematurity
Liver - high transaminase
Hemorrhage - placental abruption, intraabdo/cerebral
Cardiac failure
Eclampsia
-definition
-management
Development of seizures from pre-eclampsia
MgSO4 - prevent and treat
-given once decision to deliver made
-IV bolus 4g over 5-10mins followed by 1g/hour infusion
Monitor UOP, reflexes, RR, SaO2
MgSO4 induced resp depression
-Ca gluconate
Continue treatment for 24hrs after last seizure/delivery
Gestational diabetes
-risk factors
-screening and diagnostic thresholds
-management
BMI 30+
PHx macrosomic baby (4.5kg+)
PHx GD
1st degree relative with DM
South Asian, Afro-Caribbean, Middle Eastern
OGTT
PHx GD
-ASAP after booking
-24-28wks if 1st test normal
Other risk factors
-24-28wks
Fasting glucose - 5.6+
2hour glucose - 7.8+
Newly diagnosed => joint diabetes + antenatal clinic within 1wk
-self-monitoring BMs
-low glycemic diet, exercise
FPG U7 => diet + exercise
-target not met U2wks => add metformin
-target not met => add short acting insulin
FPG 7+ => insulin
FPG 6-6.9 AND evidence of macrosomia, hydramnios => insulin
If metformin not tolerated or insulin declined => glibenclamide
Pre-existing diabetes
-management
BMI 27+ => weight loss
Stop PO hypoglycemic agents except metformin, start insulin
Treat existing retinopathy
Folate 5mg from pre-conception to 12wks
Detailed 20wk anomaly scan
Diabetes targets for pregnant women
-fasting
-1hr after meals
-2hr after meals
-testing
Fasting - 5.3
1hr after meals - 7.8
2hrs after meals - 6.4
Fasting
Pre-meal
1hr after meal
Bedtime
NVP
-spectrum of NVP in pregnancy
-risk factors
-admission criteria
Morning sickness < => hyperemesis gravidarum
High bHCG - multiplet, trophoblastic disease
Nulliparity
Obesity
FHx, PHx of NVP
Smoking - decreased incidence of NVP
Admit for NVP if
-continued NV and cannot keep down liquids or PO antiemetics
-continued NV with ketonuria, weight loss greater than 5% of BW despite PO antiemetics
-confirmed/suspected comorbidity affecting their ability to tolerate PO treatment
Hypermesis gravidarum
-presentation
-classification of severity
-management
Triad of
-5% pre-pregnancy weight loss
-dehydration
-electrolyte imbalance
Pregnancy-Unique Quantification of Emesis (PUQE)
Conservative
-Rest, avoid triggers
-Bland, plain food
-Ginger
-P6 acupuncture
1st line meds
-antihistamines (PO cyclizine, promethazine)
-phenothiazines (PO prochlorperazine, chlorpromazine)
2nd line meds
-PO ondansetron but increased cleft lip risk
-PO metoclopramide, domperidone but can cause EPSEs (max 5 days)
Admit for IV hydration - normal saline with KCL
Normal physiological changes in pregnancy
CV
-increase in SV, HR, CO
-SBP unchanged, DBP falls in 1st, 2nd => returns to non-pregnant levels by term
-increased risk of ankle edema, varicose veins, supine low BP
Resp
-increase in ventilation, TV due to effect of progesterone on resp center
-increase in O2 requirements, BMR
Blood
-plasma volume increases more than RBC => fall in Hb
-increased fibrinogen, decreased fibrinolytic activity => increased clotting, DVT risk
-decrease in platelets
-increased WCC, ESR
Urinary
-blood flow, GFR increases
-increased Na, water reabsorption => reduced urinary loses
-trace glycosuria due to increaed GFR, reduction in tubular reabsorption of filtered glucose
Liver
-no change in hepatic blood flow
-ALP increases, albumin falls
HELLP
-relationship with severe pre-eclampsia
-presentation
-key investigations
-management
Overlaps with severe pre-eclampsia but can present in isolation
NV
RUQ pain
fatigue
Hemolysis
Elevated liver enzymes
Low platelets
Deliver baby
Intrahepatic cholestasis of pregnancy
-pathophysiology
-presentation
-management
Impaired flow of bile => bile salts accumulate in skin and placenta
Develops over days-weeks
-maternal SEVERE ITCH and jaundice
-fetal asphyxia and death
Cholestatic LFTS
Induce labour 37-38wks
Ursedeoxycholic acid
VitK
