Complications Encountered in Pregnancy

Question 1

What is the pathophysiology of diabetes in pregnancy?

Answer 1

Pregnancy is diabetogenic.

• Increased insulin resistance in pregnancy lead in increase insulin secretion. Related to hPL and oestrogen increase
• Increase glucose delivered to foetus and therefore increased insulin in the foetus. This leads to increase growth factors within the foetus leading to growth

Question 2

What are risks of Diabetes Mellitus in Pregnancy?

Answer 2

Complicates 1 in 20 pregnancies. Risks are

• Leading causes of maternal mortality
• Higher incidence of maternal morbidity
• Higher incidence of perinatal and neonatal morbidity
• Later long-term consequences for both mother and child (future diabetes in child, complications)

Question 3

What are foetal risks of Diabetes Mellitus?

Answer 3

• Cardiac: VSD, Transposition of Great vessels, Tetralogy of Fallot, Persistent foetal circulation, Truncus Arteriosus
• NTD: Spina bifida, Anencephaly
• MSK: Caudal regression/Sacral agenesis

Question 4

What are risk factors of GDM?

Answer 4

• BMI of > 30 kg/m²
• Previous macrosomic baby weighing 4.5 kg or above
• Previous gestational diabetes
• First-degree relative with diabetes
• Family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
• Polycystic ovarian syndrome

Question 5

Who is screened for GDM?

Answer 5

• Women who’ve previously had gestational diabete should have Oral glucose tolerance test (OGTT) performed soon after booking and at 24-28 weeks if the first test is normal. Early self-monitoring of blood glucose used as an alternative to the OGTTs.
• Women with other risk factors should be offered an OGTT at 24-28 weeks

Question 6

What is the diagnostic threshold for GDM?

Answer 6

If either

• Fasting glucose is ≥5.6 mmol/l
• 2-hour glucose is ≥7.8 mmol/l

Question 7

What is the target for self-monitoring of diabetes in pregnant women?

Answer 7

• Fasting = 5.3 mmol/l
• 1-hour after meals = 7.8 mmol/l, or:
• 2-hour after meals = 6.4 mmol/l

Question 8

How is GDM conservatively managed?

Answer 8

• Newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week
• Women should be taught about self-monitoring of blood glucose.
• Advice about diet (including eating foods with a low glycaemic index) and exercise should be given. Dietitian involvement

Question 9

What is the medical management of GDM?

Answer 9

• If the fasting plasma glucose level is < 7 mmol/l a trial of diet and exercise should be offered
  
  • If glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started
  • If glucose targets are still not met insulin should be added to diet/exercise/metformin
  • Gestational diabetes is treated with short-acting
• If at the time of diagnosis, the fasting glucose level is >= 7 mmol/l insulin should be started
• If the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered

Question 10

When should Glibenclamide be used?

Answer 10

• Glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment

Question 11

When should delivery be done in GDM?

Answer 11

• Deliver at 39-40⁺⁶ weeks
  
  • IOL: 39-40 weeks
  • Elective CS: >39-40⁺⁶ weeks

Question 12

How is GDM managed postnatally?

Answer 12

• Stop all treatment and blood glucose monitoring at delivery
• Fasting blood glucose check at 6-13 weeks postpartum
• HbA1c at 13 weeks postpartum and yearly afterward checked
• Lifestyle advice, contraception & need for future pre-conception care

Question 13

How are patients with pre-existing diabetes counselled?

Answer 13

• Aim for HBA1c level <48 mmol/mol (6.5%) - if above 10%, strongly advise against pregnancy. Tight glycaemic control reduces complication rates
• Offer retinal assessment and renal assessment. Treat retinopathy as can worsen during pregnancy
• Weight loss for women with BMI of >27 kg/m^2. If BMI >35, recommend vitamin D supplement
• Stop oral hypoglycaemic agents, apart from metformin, and commence insulin. Stop statins
• Folic acid 5 mg/day from 3 months pre-conception to 12 weeks’ gestation
• Aspirin 75mg after 12 weeks’ gestation
• Assess need for VTE prophylaxis

Question 14

How is diabetes monitored in pregnancy besides the glucose?

Answer 14

• USS
  
  • Dating by 12 weeks for neural tube defect
  • Detailed anomaly scan at 18-22 weeks including four-chamber view of the heart and outflow tracts
  • Growth and liquor volume at 28/32/36 weeks
• ANC 1-2 weekly
• Repeat retinal assessment at 28 weeks or earlier if abnormal

Question 15

How is delivery scheduled in those with pre-existing diabetes?

Answer 15

Deliver at 37-38⁺⁶ weeks

• IOL: 37-38⁺⁶ weeks
• Elective CS: 38-39 weeks

Question 16

What is the defintion of Hypertension in Pregnancy?

Answer 16

• Systolic > 140 mmHg or diastolic > 90 mmHg

or

• an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic

Question 17

What are the high risk group for hypertension in pregnancy?

Answer 17

• Hypertensive disease during previous pregnancies
• Chronic kidney disease
• Autoimmune disorders such as SLE or Antiphospholipid syndrome
• Type 1 or 2 diabetes mellitus

Question 18

What are the classifications of hypertension in pregnancy?

Answer 18

• Gestational (pregnancy induced) hypertension
• Pre-eclampsia
• Chronic hypertension
• Pre-eclampsia superimposed on chronic hypertension
• Eclampsia

Question 19

How is Pre-Exisiting hypertension defined in pregnancy?

Answer 19

• History of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation
• No proteinuria and no oedema
• Occurs in 3-5% of pregnancies and is more common in older women

Question 20

How is Pregnancy induced hypertension defined in pregnancy?

Answer 20

• Hypertension (as defined above) diagnosed in the second half of pregnancy (i.e. after 20 weeks)
• No proteinuria, no oedema and normal blood value
• Occurs in around 5-7% of pregnancies but 25% go on to develop pre-eclampsia
• Resolves following birth (typically after one month). Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life

Question 21

How is Pre-eclampsia defined in pregnancy?

Answer 21

• Multi-system disorder seen after 20 weeks’ gestation characterised by pregnancy-induced hypertension in association with proteinuria (>0.3g/24 hours).
• Oedema used to be third element of classic triad but now often not included.​
• Occurs in around 5% of pregnancies

Question 22

What does pre-eclampsia predispose patients to?

Answer 22

• CNS: eclampsia, intracranial haemorrhage/Stroke, cortical blindness
• Renal: renal tubular necrosis (AKI)
• Respiratory: pulmonary oedema
• Liver: HELLP syndrome, Liver capsule haemorrhage, Liver rupture
• Haematological: DIC, VTE
• Haemorrhage: placental abruption, intra-abdominal, intra-cerebral
• Cardiac failure
• Multi-organ failure
• Foetal: prematurity, intrauterine growth retardation, stillbirth, SGA

Question 23

What is the pathological process that leads to Pre-Eclampsia?

Answer 23

• Failed trophoblastic invasion and adaptation of spiral arteries. Reduced placental perfusion and placental ischaemia leads to oxidative stress and endothelial dysfunction.
• This leads to high levels of circulating pro-inflammatory changes which leads to endothelial dysfunction and increased capillary permeability. Release of vasoconstrictive substances such as thromboxane A2 and endothelin which decrease prostacyclin synthesis
• Pre-eclampsia leads to increased ECF volume due to endothelial damage, raised filtration pressure, low colloid oncotic pressure and capillary leakage. This leads to increase systemic vascular resistance

Question 24

Which factors in the maternal circulation demostrate pre-eclampsia?

Answer 24

• Decreased placenta growth factor
• Increased soluble Flt-1
• Increase soluble endoglin

Question 25

What are risk factors of Pre-Eclampsia?

Answer 25

High Risk

• Hypertensive disease in previous pregnancy
• Chronic kidney disease
• Autoimmune disease such as SLE or Antiphospholipid syndrome
• Type 1 or Type 2 diabetes
• Chronic Hypertension

Moderate Risk

• First pregnancy
• Aged 40 years or older
• Pregnancy interval of more than 10 years
• Body mass index (BMI) of 35 kg/m² or more at first visit
• Family history of Pre-eclampsia
• Multiple Pregnancy

Question 26

What are symptoms of Pre-Eclampsia?

Answer 26

Asymptomatic mostly but if symptomatic:

• Headache
• Visual disturbance
• Sudden increase in swelling
• Generally unwell
• Vomiting
• Reduced foetal movement
• Abdominal pain
• Bleeding

Question 27

What are signs of Pre-Eclampsia?

Answer 27

• Hypertension
• Proteinuria
• Non-dependant oedema
• Hyperreflexia/clonus
• Foetal growth restriction
• Oligomenorrhoea
• Abnormal foetal doppler

Question 28

What are typical investigations for Pre-Eclampsia?

Answer 28

Maternal

• Platelet count
• Renal function
• Liver function
• Coagulation profile in severe cases or thrombocytopenia (DIC)
• PCR, 24 hour urine collection (Level of proteinuria)

Foetal

• Growth velocity (foetal growth, ultrasound)
• Foetal wellbeing (CTG, amniotic fluid volume, foetal doppler)

Question 29

What are features of Severe Pre-Eclampsia?

Answer 29

• Hypertension: typically, > 170/110 mmHg and proteinuria as above
• Proteinuria: dipstick ++/+++
• Headache
• Visual disturbance
• Papilledema
• RUQ/epigastric pain
• Hyperreflexia
• HELLP syndrome

Question 30

How is Pre-Eclampsia managed symptomatically?

Answer 30

• Women at moderate or high risk of pre-eclampsia should take Aspirin 75-150 mg daily from 12 weeks gestation until birth
• Blood pressure management. Process:
  • Review medications if blood pressure below 110/70
  • Aim for blood pressure of 135/85 on medications
  • Offer treatment if BP >140/90
  • Treat blood pressure at >160/110 mmhg

Question 31

What are the medications used for Blood pressure management?

Answer 31

Oral Medications

• 1^st line: PO Labetalol
• 2^nd line: Nifedipine (if asthmatic) and Hydralazine
• Methyl dopa can also be used (avoid in depression)

Emergency medications

• IV labetalol
• IV hydralazine

Question 32

What is the definitive management of Pre-Eclampsia?

Answer 32

Delivery of the baby. Timing for temporisation or delivery depends on the clinical scenario:

• Gestational age
• Severity of maternal disease
• Speed of progression (fulminating pre-eclampsia)
• Presence of complications (HELLP)
• Foetal wellbeing

Question 33

How is severe or fulminating pre-eclampsia managed?

Answer 33

• Control hypertension
• Prevent seizures (maternal magnesium infusion)
• Administer steroids for lung maturation if preterm
• Deliver by most appropriate route
• Strict fluid balance
• HDU care

Question 34

How is pre-eclampsia and eclampsia managed postnatally?

Answer 34

• May require antihypertensive treatment for 6-12 weeks
• Increased risk of VTE particularly in severe proteinuria
• If severe pre-eclampsia, it may require follow up bloods
• Postnatal hypertension clinic where appropriate
• Discuss contraception before discharge and discuss implications for future pregnancy
• Write to GP with details of treatment, devlivery and aftercare

Question 35

What is the definition of Eclampsia?

Answer 35

Seizures occurring in pregnancy or within 10 days of delivery with at least 2 of the following features documented within 24 hours of the seizures:

• Hypertension
• Proteinuria one plus or at least 0.3g/24h
• Thrombocytopenia less than 100000/microlitre
• Raised transaminases

Question 36

How is Eclampsia managed?

Answer 36

• ABCDE
• IV access
• Bolus of 4g Magnesium sulphate over 5-10 minutes followed by continuous Magnesium sulphate infusion of 1g/hour used to both prevent seizures in patient with severe pre-eclampsia and treat seizures once they develop
• If antenatal, plan for delivery in the most appropriate route (C-section common)
• Fluid restriction to avoid fluid overload
• HDU care

Question 37

How should the administration of magnesium sulphate in Eclampsia monitored?

Answer 37

• Should be given once decision to deliver has been made
• Urine output, reflexes, respiratory rate and oxygen saturation should be monitored.
• Treatment continues for 24 hours after the last seizure or delivery. 40% of seizures occur post-partum

Question 38

What are complications of management of Eclampsia?

Answer 38

Respiratory depression can occur

• Calcium gluconate is the 1^st-line treatment for Magnesium Sulphate induced respiratory depression

Question 39

What is the definition of HELLP syndrome?

Answer 39

• Acronym for Haemolysis, Elevated Liver Enzymes and Low Platelet Count
• Serious condition that can develop in late pregnancy.
• 0-20% of patient with severe pre-eclampsia will develop HELLP

Question 40

What are symptoms of HELLP syndrome?

Answer 40

• Nausea & Vomiting
• Right upper quadrant pain
• Lethargy

Question 41

What are investigations and management of HELLP?

Answer 41

Investigations

• Bloods: Low RBC (Haemolysis), Elevated Liver Enzymes, Low Platelet Count

Treatment

• Delivery of baby