Complications in Pregnancy 2 Flashcards by Becca M

What are some different kinds of hypertensive disorders during pregnancy?

Chronic hypertension
- Hypertension either pre-pregnancy or at booking (less than equal to 20 weeks gestation)
Gestational hypertension
- BP as above but new hypertension (develops after 20 weeks)
- Also called pregnancy induced hypertension (PIH)
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

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What is chronic hypertension during pregnancy?

Hypertension either pre-pregnancy or at booking (less than equal to 20 weeks gestation)

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What is gestational hypertension?

BP as above but new hypertension (develops after 20 weeks)
Also called pregnancy induced hypertension (PIH)

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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

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Describe the epidemiology of chronic hypertension (age group)?

Commoner in older mothers

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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

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What is a possible complication of chronic hypertension?

Higher incidence of placental abruptions

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What are the different classifications of pre-eclampsia?

Mild hypertension (HT)
- On two occasions more than 4 hours apart
Moderate HT
Severe HT

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What does PET stand for?

Pre-eclampsia

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What is required for the diagnosis to be PET?

All with proteinuria more than 300mgms/24 hours (protein urine > + protein, creatine ratio >30mgms/mmol

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What is the incidence of PET?

5-8% of pregnancies
0.5% have severe PET

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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

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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)

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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

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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

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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
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
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
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

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?

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