Complications in Pregnancy 2 Flashcards
What are some different kinds of hypertensive disorders during pregnancy?
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Chronic hypertension
- Hypertension either pre-pregnancy or at booking (less than equal to 20 weeks gestation)
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Gestational hypertension
- BP as above but new hypertension (develops after 20 weeks)
- Also called pregnancy induced hypertension (PIH)
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Pre-eclampsia
- New hypertension > 20 weeks in association with significant proteinuria
- Significant proteinuria – automated reagent strip urine protein estimation > 1+, spot urinary protein creatine ratio >30mg/mmol, 24 hour protein collection >300mg/day
- New hypertension > 20 weeks in association with significant proteinuria
What is chronic hypertension during pregnancy?
- Hypertension either pre-pregnancy or at booking (less than equal to 20 weeks gestation)
What is gestational hypertension?
- BP as above but new hypertension (develops after 20 weeks)
- Also called pregnancy induced hypertension (PIH)
What is pre-eclampsia?
- New hypertension > 20 weeks in association with significant proteinuria
- Significant proteinuria – automated reagent strip urine protein estimation > 1+, spot urinary protein creatine ratio >30mg/mmol, 24 hour protein collection >300mg/day
Describe the epidemiology of chronic hypertension (age group)?
- Commoner in older mothers
Describe the managent of chronic hypertension?
- Monitor for
- Superimposed pre-eclampsia
- Foetal growth
- Aim to keep BP < 150/100
- Labetolol, mifedipine, methyldopa
- Pre-pregnancy care
- ACE inhibitors (cause birth defects)
- Angiotensin receptor blockers
- Anti-diuretics
- Lower dietary sodium
What is a possible complication of chronic hypertension?
- Higher incidence of placental abruptions
What are the different classifications of pre-eclampsia?
- Mild hypertension (HT)
- On two occasions more than 4 hours apart
- Moderate HT
- Severe HT
What does PET stand for?
Pre-eclampsia
What is required for the diagnosis to be PET?
All with proteinuria more than 300mgms/24 hours (protein urine > + protein, creatine ratio >30mgms/mmol
What is the incidence of PET?
- 5-8% of pregnancies
- 0.5% have severe PET
What are risk factors for PET?
- Genetic predisposition
- First pregnancy
- Pre-eclampsia in previous pregnancy
- Pregnancy interval >10 years
- BMI > 35
- Multiple pregnancy
- Underlying medical disorders
- Chronic hypertension
- Pre-existing renal disease
- Pre-existing diabetes
- Autoimmune disorder
Describe the pathophysiology of PET?
- Secondary invasion of maternal spiral arterioles by trophoblasts impaired, causing reduced placental perfusion
- Imbalance between vasodilators/vasoconstrictors in pregnancy (prostocycline/thromboxane)
Describe the presentation of severe PET?
- Headache, blurring of vision, epigastric pain, vomiting, sudden swelling of hands and legs
- Severe hypertension, >3+ of urine proteinuria
- Clonus/brisk reflexes
- Reducing urine output
- Convulsions (eclampsia)
- Biochemical abnormalities
- Raised liver enzymes, bilirubin if HELLP present
- Raised urea and creatinine, raised urate
- Haematological abnormalities
- Low platelets
- Low haemoglobin, signs of haemolysis
- Features of DIC
Describe the management of PET?
- Frequent BP checks, urine protein
- Check symptomatology – headaches, epigastric pain, visual disturbances
- Check for hyper-reflexia (clonus), tenderness over liver
- Blood investigations
- Full blood count (for haemolysis, platelets)
- Liver function tests
- Renal function tests (serum urea, creatinine, urate)
- Coagulation tests
- Foetal investigations
- Scan for growth
- Cardiotocography (CTG)
- Only ‘cure’ is delivery of baby
- Conservative
- Close observation of clinical signs and investigations
- Anti-hypertensives
- Labetolol, methyldopa, nidefipine
- Steroids for foetal lung maturity if gestation < 36 weeks
- Consider induction of labour if maternal or foetal condition deteriorates
Use prophylaxis for PET in subsequent pregnancy:
- Low dose aspirin from 12 weeks until delivery
What prophylaxis should be used for PET and when?
Use prophylaxis for PET in subsequent pregnancy:
- Low dose aspirin from 12 weeks until delivery
What are possible complications of PET?
- Maternal
- Eclampsia (seizures)
- 44% occur postpartum, 38% occur antepartum, 18% intrapartum
- Management – magnesium sulphate bolus (IV infusion), control of blood pressure (IV labetolol, hydralazine if >160/110), avoid fluid overload
- Severe hypertension – cerebral haemorrhage, stroke
- HELLP (haemolysis, elevated liver enzymes, low platelets)
- DIC (disseminated intravascular coagulation)
- Renal failure
- Pulmonary oedema, cardiac failure
- Eclampsia (seizures)
- Foetal
- Impaired placental perfusion – causing IUGR, foetal distress, prematurity, increased postnatal mortality
What are different kinds of diabetic conditions during pregnancy?
- Pre-existing diabetes (type 1 and less often type 2)
- Gestational diabetes
Describe the pathophysiology of pre-existing diabetes in pregnancy?
- Insulin requirements of mother increases
- Due to human placental lactogen, progesterone, human chorionic gonadotrophin and cortisol from placenta having anti-insulin action
- Foetal hyper-insulinaemia occurs
- Maternal glucose crosses placenta and induced increased insulin production in foetus
- Causes macrosomia
How do insulin requirments of mother change during pregnancy?
- Insulin requirements of mother increases
- Due to human placental lactogen, progesterone, human chorionic gonadotrophin and cortisol from placenta having anti-insulin action
Describe the management of existing diabetes during pregnancy?
- Pre-conception
- Better glycaemic control
- Aim for blood sugars to be around 4-7mmol/L pre-conception and HbA1c <48mmol/mol)
- Folic acid 5mg
- Dietary advice
- Retinal and renal assessment
- Better glycaemic control
- During pregnancy
- Optimised glucose control (insulin requirements will increase)
- 5.3 mmol/l - Fasting
- < 7.8 mmol/l - 1 hour postprandial
- < 6.4 mmol/l - 2 hours postprandial
- < 6 mmol/l – before bedtime
- Could continue oral anti-diabetic agents (metformin) but may need to change to insulin for tighter control
- Aware of risk of hypoglycaemia – provide glucagon injections
- Watch for ketonuria/infections
- Monitor foetal growth
- Optimised glucose control (insulin requirements will increase)
- During labour
- Labour induced 38-40 weeks, early if maternal or foetal concerns
- Consider elective caesarean section
- Continuous CTG foetal monitoring
- Maintain sugar with insulin – dextrose insulin infusion
- Labour induced 38-40 weeks, early if maternal or foetal concerns
What blood sugar levels should someone with diabetes aim for before conception?
- Aim for blood sugars to be around 4-7mmol/L pre-conception and HbA1c <48mmol/mol)
What are possible complications of pre-existing diabetes during pregnancy?
- Foetal congenital abnormalities
- Such as cardiac, sacral agenesis
- Miscarriage
- Foetal macrosomia, polyhydramnios
- Operative delivery, shoulder dystocia
- Stillbirth, increased perinatal mortality
- Pre-eclampsia
- Worsening of maternal nephropathy, retinopathy, hypoglycaemia, reduced awareness of hypoglycaemia
- Infections
- Neonatal
- Such as impaired lung maturity, neonatal hypoglycaemia, jaundice
What does GDM stand for?
Gestational diabetes mellitus
What are risk factors for GDM?
- BMI > 30
- Previous macrosomic baby >4.5kg
- Previous GDM
- Family history
- Woman from high risk groups of developing diabetes
- Such as Asian origin
- Polyhydramnios or big baby in current pregnancy
- Recurrent glycosuria in current pregnancy
When is screening done for GDM?
- Screen if risk factor present
- Offer HbA1C estimation at booking, if > 43mmol/L then 75gms OGTT to be done, if this is normal repeat OGTT at 24-28 weeks
Describe the management of GDM?
- Control blood sugars
- Diet, metformin/insulin if sugars remain high
- Check OGTT post-delivery at 6-8 weeks
- Yearly check on HbA1C/blood sugars as at higher risk of developing overt diabetes
What are possible complications of GDM?
- Increased risk of maternal complications such as PET
- Increased risk of foetal complications such as macrosomia, but less than with type 1 or 2 diabetes
What are risk factors for venous thromboembolism in pregnancy?
- Older mothers, increasing parity
- Increased BMI
- Smokers
- IV drug users
- PET
- Dehydration – hyperemesis
- Decreased mobility
- Infections
- Operative delivery
- Sickle cell disease
Describe Virchow’s triad?
Why does the risk of thromboembolism increase during pregnancy?
- Pregnancy is a hypercoagulable state (to protect mother against bleeding post delivery)
- Increase in fibrinogen, factor VIII, VW factor, platelets
- Decrease in natural anticoagulants, antithrombin III
- Increase in fibrinolysis
- Increased stasis
- Progesterone, effect of enlarging uterus
- May be vascular damage at delivery/caesarean section
What causes the hypercoagulable state of pregnancy?
- Pregnancy is a hypercoagulable state (to protect mother against bleeding post delivery)
- Increase in fibrinogen, factor VIII, VW factor, platelets
- Decrease in natural anticoagulants, antithrombin III
- Increase in fibrinolysis
What causes the increases stasis of blood during pregnancy?
- Increased stasis
- Progesterone, effect of enlarging uterus
What is the presentation of venous thromboembolism during pregnancy?
- Pain in calf, increased girth of affected leg, calf muscle tenderness
- Breathlessness, pain on breathing, cough, tachycardia, hypoxic, pleural rub
What investigations should be done for venous thromboembolism during pregnancy?
- ECG, blood gases, Doppler V/Q, lung scan
- CTPA (computed tomography pulmonary angiogram)
Describe the management for venous thromboembolism during pregnancy?
- Prophylaxis in pregnancy
- TED stockings
- Advice on mobility, hydration
- Prophylactic anti-coagulation with 3 or more risk factors (can be indicated with only 1 significant risk)
- Anti-coagulation if VTE confirmed
