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Year Three - Reproductive System > Chronic Conditions in Pregnancy > Flashcards

Chronic Conditions in Pregnancy Flashcards

1
Q

What is hypertension?

A

An elevated blood pressure, which is considered to be greater than 140/90mmHg

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2
Q

What are the three hypertensive disorders that can occur during pregnancy?

A

Chronic Hypertension

Gestational Hypertension

Pre-Eclampsia

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3
Q

What is chronic hypertension?

A

Hypertension present before getting pregnant or noted before 20 weeks gestation

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4
Q

What three hypertensive classes are contraindicated during pregnancy? Give examples

A

ACE Inhibitors - Ramipril, Enalopril

Angiotensin Receptor Blockers (ARBs) - Losartan, Candesartan

Thiazide Diuretics - Indapamide

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5
Q

What blood pressure measurement do we aim for during pregnancy?

A

150/100

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6
Q

What three antihypertensives are prescribed during pregnancy? What class of drug are they?

A

Labetalol, which is a beta-blocker

Nifedipine, which is a calcium channel blocker

Doxazosin, which is an alpha-blocker

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7
Q

What is the first line hypertensive in pregnancy?

A

Labetalol

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8
Q

What is gestational hypertension?

A

New hypertension that develops after 20 weeks’ gestation

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9
Q

What is pre-eclampsia?

A

New onset hypertension after 20 weeks’ gestation, leading to end-organ dysfunction

It is typically described as a triad of new-onset hypertension, proteinuria and oedema

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10
Q

What is diabetes mellitus?

A

It refers to a group of metabolic diseases characterised by hyperglycaemia due to insulin insensitivity or decreased insulin secretion

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11
Q

What are the two diabete disorders that can occur during pregnancy?

A

Chronic Diabetes

Gestational Diabetes

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12
Q

What is chronic diabetes?

A

It refers to hyperglycaemia present prior to pregnancy

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13
Q

In what two ways do we manage chronic diabetic patients prior to pregnancy?

A

They should aim for good glycaemic control, with glucose levels ideally falling between 4-7mmol/l or HbA1c should be less than 6.5% (48mmol/mol)

They should take 5mg of folic acid from preconception until 12 weeks’ gestation

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14
Q

Why do we give diabetic patients folic acid prior to pregnancy?

A

This is to prevent congenital neural tube defects

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15
Q

What two diabetic medications are prescribed during pregnancy?

A

Metformin

Insulin

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16
Q

What fasting glucose level should diabetic patients aim for during pregnancy (chronic and gestational)?

A

Below 5.3mmol/l

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17
Q

What glucose level should pregnant diabetic patients aim for one hour post-meals (chronic and gestational)?

A

Below 7.8mmol/l

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18
Q

What glucose level should pregnant diabetic patients aim for two hour post-meals (chronic and gestational)?

A

Below 6.4mmol/l

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19
Q

What bedtime glucose level should diabetic patients aim for during pregnancy (chronic and gestational)?

A

Below 6mmol/l

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20
Q

What diabetic screening is increased during pregnancy?

A

Retinopathy

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21
Q

When is retinopathy screening conducted in diabetic patients?

A

28 and 34 weeks’ gestation

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22
Q

How do we deliver babies from a diabetic mother?

A

A planned delivery between 37 and 38+6 weeks gestation should be arranged

However, if fetal or maternal complications arise we can induce labour earlier

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23
Q

What can we prescribe diabetic patients during labour?

A

A sliding scale insulin regime

This regime involves infusion of dextrose and insulin based upon the patient’s glucose levels

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24
Q

When do we prescribe diabetic patients a sliding scale insulin regime during labour?

A

It should be considered for women with type one diabetes or those with poorly controlled blood sugars with type two diabetes

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25
Q

What is gestational diabetes?

A

It is defined as any degree of glucose intolerance with onset or first recognition during pregnancy

This will resolve after delivery

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26
Q

Describe the pathophysiology of gestational diabetes

A

It occurs when the body is unable to produce enough insulin to meet the needs of the pregnancy

During pregnancy, insulin requirements of the mother increase, which means that a higher volume of insulin is needed in response to a normal level of blood glucose

A woman with a borderline pancreatic reserve is unable to respond to the increased insulin requirements, resulting in transient hyperglycaemia

After the pregnancy, insulin requirements decreases, and the hyperglycaemia usually resolves

27
Q

What four hormones produced by the placenta cause increased maternal insulin requirements?

A

Human placental lactogen

Progesterone

Human chorionic gonadotrophin

Cortisol

28
Q

Why does fetal hyperglycaemia and hyperinsulinaemia occur with gestational diabetes?

A

In pregnancy, glucose is transported across the placenta, however insulin is not

This can cause fetal hyperglycaemia, resulting in the fetus increasing its own insulin levels to compensate – hyperinsulinemia

29
Q

Why does neonatal hypoglycaemia occur after gestational diabetes delivery?

A

After delivery, the fetus still has high insulin levels, however no longer received glucose from its mother

30
Q

How do we prevent neonatal hypoglycaemia?

A

In order to manage this, we regularly monitor blood glucose levels and conduct frequent feeds

31
Q

What glucose level do we aim for in neonates? How do we manage cases in which this is not achieved?

A

> 2mmol/l

In asymptomatic cases, normal feeds and glucose monitoring is first line

In cases where this fails, we administer 10% IV dextrose or glucose gel

32
Q

Why is respiratory distress syndrome a complication of gestational diabetes?

A

High insulin can cause a reduction in pulmonary phospholipids, which in turn decreases fetal surfactant production

Surfactant acts to reduce the surface tension in the alveoli

33
Q

What are the five risk factors for gestational diabetes?

A

Previous Gestational Diabetes

BMI > 30

Previous Macrosomic Baby > 4.5kg

Asian Ethnicity

Diabetic Family History

34
Q

How do we diagnose gestational diabetes?

A

We conduct a HbA1c test during the booking clinic. If the levels are raised, we conduct an oral glucose tolerance test

35
Q

How do we perform an oral glucose tolerance test?

A

It should be performed in the morning after a fast

The patient has a 75g glucose drink at the start of the test

The blood sugar is measured before the sugar drink and then at two hours.

36
Q

What oral glucose tolerance test results would indicate gestational diabetes?

A

Fasting Glucose > 5.6mmol/L

At 2 Hours > 7.8mmol/L

37
Q

How do we manage gestational diabetes?

A

This initially involves trialling diet and exercise measures for one to two weeks

If blood sugars remain high, then we can consider prescribing metformin and/or insulin

38
Q

How do we deliver babies from a gestational diabetic mother?

A

A planned delivery between 37 and 38 gestation should be arranged

However, if the gestational diabetes is being managed by simple diet and lifestyle measures, we can consider delivery before 40+6 weeks gestation

39
Q

How do we manage gestational diabetes postnatally?

A

After delivery, all anti-diabetic medication should be stopped immediately

The blood glucose should be measured before discharge to check that it has returned to normal levels

An oral glucose tolerance test should then be conducted six to eight weeks post-partum

If this is normal, yearly tests should be offered due to the increased risk of developing diabetes in the future

40
Q

What are the six fetal complications of gestational diabetes?

A

Macrosomia

Shoulder Dystocia

Respiratory Distress Syndrome

Polyhydramnios

Cardiac Abnormalities

Neonatal Hypoglycaemia

41
Q

What are the five causes of neonatal hypoglycaemia?

A

Preterm Birth < 37 Weeks

Maternal Diabetes Mellitus

IUGR

Hypothermia

Neonatal Sepsis

42
Q

What are the two maternal complications of gestational diabetes?

A

Future Diabetes

Hypertension

43
Q

What is venous thromboembolism?

A

A collective term that describes deep vein thrombosis and pulmonary embolism

44
Q

What triad is used to describe the pathophysiology of venous thromboembolism?

A

Virchow’s triad

45
Q

How does pregnancy result in a hypercoagulable state?

A

Increased Fibrinogen

Increased Factor VII

Increased VW Factor

Increased Platelets

Decreased Protein S

46
Q

When is the risk of thromboembolism greatest? Why?

A

Post-partum

The changes in protein levels become more pronounced as the pregnancy progresses

47
Q

How does pregnancy result in the stagnation of blood?

A

This is due to the effects of progesterone and an enlarged uterus

48
Q

What is Virchow’s triad?

A

Hypercoagulable State

Stagnation of Blood

Vascular Damage

49
Q

How does pregnancy result in vascular damage?

A

It can occur during delivery

50
Q

What are the six maternal risk factors for venous thromboembolism?

A

Maternal Age > 35

BMI > 30

Partity > 3

Smoking

Thrombophilia

Varicose Veins

51
Q

What are the five obstetric risk factors for venous thromboembolism?

A

Pre-eclampsia

Multiple pregnancy

C-section

Prolonged labour

Postpartum haemorrhage

52
Q

What are the four clinical features of DVT?

A

Unilateral Leg Swelling

Dilated Superficial Veins

Oedema

Calf Tenderness

53
Q

In which leg do DVT’s tend to form in during pregnancy? Why?

A

Left leg

This is due to the compression effect of the uterus on the left iliac vein

54
Q

What are the six clinical features of PE?

A

Shortness of Breath

Cough

Pleuritic Chest Pain

Tachycardia

Tachypnoea

Hypoxia

55
Q

How do we investigate a suspected DVT?

A

A compression duplex ultrasound

If the scan is negative, however clinical suspicion remains high, the test can be repeated one week later

56
Q

How do we investigate a suspected PE?

A

A CT pulmonary angiogram (CTPA) or a ventilation perfusion (V/Q) scan

57
Q

What two investigations are invalidated during pregnancy for venousthromboembolism?

A

Well’s score

D-dimer level

58
Q

When do we initiate venous thromboembolism prophylaxis in pregnant patients? How long should it be continued for?

A

They have more than three risk factors in the first two trimesters

This treatment should be continued until six weeks postpartum

59
Q

What venous thromboembolism prophlaxis is used during pregnancy?

A

It involves prescription of low molecular weight heparin (LMWH)

60
Q

What three LMWH’s are prescribed as prophylaxis of VTEs?

A

Enoxaparin

Dalteparin

Tinzaparin

61
Q

What two anticoagulants should patients not be prescribed as a prophylaxis of VTEs?

A

Warfarin

Novel oral anticoagulants

62
Q

Why is Warfarin contraindicated during pregnancy?

A

It can lead to warfarin embryopathy, which can lead to facial flattening and short limbs

63
Q

When can Warfarin be used for prophylaxis treatment of VTEs?

A

In the postnatal period, including breastfeeding

64
Q

Why are NOACs contraindicated during pregnancy?

A

They can cause placental haemorrhage and subsequent fetal prematurity and loss

Year Three - Reproductive System (52 decks)

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