Complicated Pregnancy 3 Flashcards
Chronic HT Pre-eclampsia Gestational HT
Thresholds for mild, moderate and severe HTN
Mild = 140/90 up to 149/99 Moderate = 150/100 up 159/109 Severe = DBP >110 or SBP >160
How do you know if a patient’s hypertension is Chronic and not gestational?
Chronic if it was discovered pre-pregnancy or within the first 20 wks
Anti-hypertensive medication first line options [3]
What anti-hypertensive drugs should be avoided in pregnancy? [2]
Prescribe:
- labetolol (combined alpha & BB) CI in asthma
- nifedipine CCB
- methyldopa
Avoid:
- ACEIs and ARBs
Define Gestational Hypertension?
What antenatal care should be given? [3]
Hypertension developing >20wks
Antenatal care:
- Routine bloods: FBC, LFT, U&E, Cr at presentation and weekly
- Urinalysis regularly
- USS at presentation and then 2-4w growth scans
What criteria are required for a diagnosis of pre-eclampsia?
in terms of blood pressure measurements
New hypertension >20 wks (either Mild HT twice more 4 hours apart or Moderate/Severe HT on one reading)
Describe 3 methods of testing for proteinuria during pregnancy. What are the results that would be classed as significant proteinuria?
Urine Dipstick - >1+
Spot Urinary protein: creatinine ratio > 30mg/mmol
24 hour urine protein collection >300mg
What are the risk factors for Pre-eclampsia?
High risk [5]
Moderate risk [5]
High risk:
- Previous severe/early onset PE
- Pre-existing HTN, gestational HTN
- T1DM, T2DM
- Autoimmune disease
- CKD
Moderate risk:
- Primiparous
- Multiples
- Low PAPP-A
- Uterine artery notching on Doppler at 22-24w
- FMHX
What are the major complications of Pre-eclampsia? [6]
- Seizures (eclampsia)
- Haemorrhage and Stroke
- HELLP, DIC
- Renal Failure
- Pulm Oedema and HF
- Impaired placental perfusion > placental abruption
What is HELLP? [3]
A potential consequence of pre-eclampsia where you get:
- Haemolysis
- Elevated Liver enzymes
- Low Platelets
Pre-eclampsia can cause impaired placental perfusion, what are the consequences of this? [4]
Risk factor fetal for PET [2]
- IUGR
- Foetal Distress
- Prematurity
- Mortality
Risk factor:
- Hyatidiform mole
- hydrops fetalis
Many cases are asymptomatic and picked up on antenatal assessment.
Signs of deteriorating condition or progression to severe PE Toxaemia (PET) [4]
- Headaches and blurred vision
- Vomiting and convulsions
- Swelling of the hands, face and legs
- Epigastric Pain
What pre-eclamptic signs can be picked up on examination? [5]
- Epigastric tenderness
- Clonus and brisk reflexes
- Crackles at lung bases
- Papilloedema on fundoscopy
- Reduced urinary output
Why do pre-eclampsia sufferers get epigastric pain?
Liver congestion from the high BP
What blood tests are relevant to PE and why? [6]
LFTs - Raised liver enzymes (congestion)
Bilirubin - HELLP
Urea and creatinine + Urate - renal damage
FBC
- low haemoglobin (HELLP)
Coagulation Tests
- INR, D-dimer (DIC)
- Low platelets and low fibrinogen (DIC)
How do we monitor the foetus’s condition in pre-eclampsia? [1]
Cardiotocography (CTG)
How long should we continue monitoring the mother’s BP, urine protein and symptoms?
Through the peurperium as PE risk remains for the first 6 wks after delivery
Treatment of pre-eclampsia
3 stages
What is the only true ‘cure’ for PET?
- Conservative management aiming for delivery
- Seizure management
- Post-delivery management
The only cure for PET is delivery of the baby and placenta
Consider induction of labour or c-section if maternal or fetal condition deteriorates, irrespective of GA
How can we speed up the maturation of the foetus so we can deliver sooner?
Steroids
How do we manage the (impending) eclampsia/seizures? [3]
- Magnesium sulphate bolus 5g over 5-10 mins + IV infusion of 2g/h to control the convulsions
- IV Labetolol, Hydralazine if the BP is >160/110
- Controlled fluids to avoid overload (aim for 80mls/hr intake)
What can we give a mother as prophylaxis if she has 1 high RF or 2 moderate RF? [1]
75mg aspirin from 12 weeks until delivery
PE - conservative management [5]
Monitoring - BP, examination Blood investigations CTG Anti-hypertensives (Rx) Steroids for fetal lung maturity if GA <36 weeks
Pre-existing HTN
Antenatal care
Labour & delivery mx [3]
Post-natal mx [3]
Antenatal care: lower dietary sodium intake
L&D:
- if <160/110 at 37w, offer IOL
- and hourly BP monitoring if <159/109 or continuous if >160/110
- continue anti-hypertensive mx during labour
- Give oxytocin in third stage of labour
Post-natal: - Check BP on day 1-5 > Check at 2w - Come off methyldopa - Avoid diuretics if breastfeeding
Why is ergometrine contraindicated in pre-existing HTN?
Why do we switch mothers off methyldopa post-natal?
DO NOT use ergometrine as causes severe HTN leading to stroke
SE: postnatal depression
Management of anti-hypertensives in pregnancy induced HTN:
Target BP?
Moderate HTN [2]
Severe HTN [5]
Target BP 135/85
Moderate HTN:
- Labetalol
- 1-2w urine, BP check
Severe HTN:
- Admit
- CTG
- Labetalol
- BP every 15-30 mins
- Daily urine check
Management of anti-hypertensives in pregnancy induced HTN:
Labour & delivery [1]
Post-natal [3]
Labour & delivery:
- Aim for delivery at 37w
Post-natal
- Same as for HTN
- Target BP 130/80
- Rv 2w, 6-8w
Indications for magnesium sulphate [6]
Antidote?
Indications to stop Magnesium [3]
When do we stop it post-natal?
- Ongoing/recurring severe headaches
- Visual scotomata
- Nausea and vomiting
- Epigastric pain
- Oliguria
- Severe HTN
Antidote: calcium gluconate
Stop if RR<12, loss of tendon reflex, UO <20ml/h
Stop 24h after last seizure - postnatal
In labour and delivery of PET, what are indications of LSCS [7]
- Inability to control maternal HTN despite >3 classes of anti-hypertensive
- maternal SpO2 <90%
- progressive deterioration in bloods (HELLP)
- ongoing severe intractable headache, repeated visual scotomata, eclampsia
- placental abruption
- reversed end diastolic flow on umbilical artery Doppler
- non-reassuring CTG, stillbirth
Management of pre-eclampsia and tonic clonic seizure
Immediate [6]
Subsequent [4]
Immediate management:
- ABCDE approach
- IV access
- Senior help
- CTG
- Maternal BP
- sPO2 monitoring
Subsequent management:
- Fluid restriction
- Seizure medication
- Monitor UO, reflexes, RR, SPO2
- LSCS once more stable
