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3A - Reproductive System > Complications in Pregnancy 2 > Flashcards

Complications in Pregnancy 2 Flashcards

1
Q

What are some different kinds of hypertensive disorders during pregnancy?

A
  • 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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2
Q

What is chronic hypertension during pregnancy?

A
  • Hypertension either pre-pregnancy or at booking (less than equal to 20 weeks gestation)
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3
Q

What is gestational hypertension?

A
  • BP as above but new hypertension (develops after 20 weeks)
  • Also called pregnancy induced hypertension (PIH)
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4
Q

What is pre-eclampsia?

A
  • 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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5
Q

Describe the epidemiology of chronic hypertension (age group)?

A
  • Commoner in older mothers
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6
Q

Describe the managent of chronic hypertension?

A
  • 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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7
Q

What is a possible complication of chronic hypertension?

A
  • Higher incidence of placental abruptions
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8
Q

What are the different classifications of pre-eclampsia?

A
  • Mild hypertension (HT)
    • On two occasions more than 4 hours apart
  • Moderate HT
  • Severe HT
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9
Q

What does PET stand for?

A

Pre-eclampsia

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10
Q

What is required for the diagnosis to be PET?

A

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

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11
Q

What is the incidence of PET?

A
  • 5-8% of pregnancies
  • 0.5% have severe PET
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12
Q

What are risk factors for PET?

A
  • 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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13
Q

Describe the pathophysiology of PET?

A
  • 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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14
Q

Describe the presentation of severe PET?

A
  • 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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15
Q

Describe the management of PET?

A
  • 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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16
Q

What prophylaxis should be used for PET and when?

A

Use prophylaxis for PET in subsequent pregnancy:

  • Low dose aspirin from 12 weeks until delivery
17
Q

What are possible complications of PET?

A
  • 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
18
Q

What are different kinds of diabetic conditions during pregnancy?

A
  • Pre-existing diabetes (type 1 and less often type 2)
  • Gestational diabetes
19
Q

Describe the pathophysiology of pre-existing diabetes in pregnancy?

A
  • 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
20
Q

How do insulin requirments of mother change during pregnancy?

A
  • Insulin requirements of mother increases
    • Due to human placental lactogen, progesterone, human chorionic gonadotrophin and cortisol from placenta having anti-insulin action
21
Q

Describe the management of existing diabetes during pregnancy?

A
  • 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
22
Q

What blood sugar levels should someone with diabetes aim for before conception?

A
  • Aim for blood sugars to be around 4-7mmol/L pre-conception and HbA1c <48mmol/mol)
23
Q

What are possible complications of pre-existing diabetes during pregnancy?

A
  • 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
24
Q

What does GDM stand for?

A

Gestational diabetes mellitus

25
Q

What are risk factors for GDM?

A
  • 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
26
Q

When is screening done for GDM?

A
  • 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
27
Q

Describe the management of GDM?

A
  • 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
28
Q

What are possible complications of GDM?

A
  • 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
29
Q

What are risk factors for venous thromboembolism in pregnancy?

A
  • Older mothers, increasing parity
  • Increased BMI
  • Smokers
  • IV drug users
  • PET
  • Dehydration – hyperemesis
  • Decreased mobility
  • Infections
  • Operative delivery
  • Sickle cell disease
30
Q

Describe Virchow’s triad?

A
31
Q

Why does the risk of thromboembolism increase during pregnancy?

A
  • 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
32
Q

What causes the hypercoagulable state of pregnancy?

A
  • 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
33
Q

What causes the increases stasis of blood during pregnancy?

A
  • Increased stasis
    • Progesterone, effect of enlarging uterus
34
Q

What is the presentation of venous thromboembolism during pregnancy?

A
  • Pain in calf, increased girth of affected leg, calf muscle tenderness
  • Breathlessness, pain on breathing, cough, tachycardia, hypoxic, pleural rub
35
Q

What investigations should be done for venous thromboembolism during pregnancy?

A
  • ECG, blood gases, Doppler V/Q, lung scan
  • CTPA (computed tomography pulmonary angiogram)
36
Q

Describe the management for venous thromboembolism during pregnancy?

A
  • 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

3A - Reproductive System (34 decks)

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