Complications in Pregnancy 2

Question 1

mild hypertensive disorder cut off

Answer 1

Diastolic BP 90-99, Systolic BP 140-49

Question 2

moderate hypertensive disorder cut off

Answer 2

Diastolic BP 100-109, Systolic BP 150-159

Question 3

severe hypertensive disorder cut off

Answer 3

Diastolic BP ≥110, Systolic BP ≥ 160

Question 4

chronic hypertension definition

Answer 4

Hypertension either pre-pregnancy or at booking (≤ 20 weeks gestation)

Question 5

gestational hypertension

Answer 5

new hypertension in pregnancy usually develops after 20 weeks

Question 6

pre-eclampsia hypertension

Answer 6

New hypertension > 20 weeks in association with significant proteinuria

Question 7

significant proteinuria cut off

Answer 7

Spot Urinary Protein: Creatinine Ratio > 30 mg/mmol

24 hours urine protein collection > 300mg/ day

Question 8

management plan for essential/chronic hypertension

Answer 8

Ideally patients should have pre-pregnancy care

Change anti-hypertensive drugs if indicated

eg. - ACE inhibitors (eg. Ramipril / Enalopril cause birth defects impaired growth)
- Angiotensin receptor blockers (eg losartan, Candesartan)
- anti diuretics
- lower dietary sodium
Aim to keep BP < 150/100 (labetolol, nifedipine, methyldopa)

Monitor for superimposed pre-eclampsia
Monitor fetal growth
May have a higher incidence of placental abruption

Question 9

definition of preeclampsia

Answer 9

-Hypertension on two occasions more than 4 hours apart
+ proteinuria of more than 300 mgs/ 24 hours (protein urine > + protein:creatinine ratio > 30mgms/mmol)

Question 10

pathophysiology of pre-eclampsia

Answer 10

affects 2-8% pregnancies, underlying pathophysiology is poorly understood

Complex + multifactorial (Immunological / Genetic predisposition) – abnormal placentation + maternal microvascular disease

• impaired secondary invasion of maternal spiral arterioles by trophoblasts → reduced placental perfusion – placental ischaemia
• low level chronic inflammation – endothelial damage
• imbalance between angiogenic (PlGF)and antiangiogenic (sFlt-1)factors in pregnancy -FMS like tyrosine kinase inhibits neovascularisation and in pregnancy with preeclampsia PlGF is lower

Question 11

what are risk factors for developing PET

Answer 11

First pregnancy
Extremes of maternal age
Pre-eclampsia in a previous pregnancy (esp. severe PET, delivery <34
weeks, IUGR baby, IUD, abruption)
Pregnancy interval >10 years
BMI > 35
Family history of PET
Multiple pregnancy
Underlying medical disorders
- chronic hypertension
- pre-existing renal disease
- pre-existing diabetes
- autoimmune disorders like – eg. antiphospholipid antibodies, SLE

Question 12

is preeclampsia a multi system disorder

Answer 12

yes

Question 13

maternal complications pre-eclampsia

Answer 13

• eclampsia
• seizures
• severe hypertension
  – cerebral haemorrhage, stroke
• HELLP (hemolysis, elevated liver enzymes, low platelets)
• DIC (disseminated intravascular coagulation)
• renal failure
• pulmonary odema, cardiac failure

Question 14

fetal complications pre-eclampsia

Answer 14

• impaired placental perfusion → IUGR, fetal distress, prematurity, increased PN mortality

Question 15

symptoms and signs of severe pre eclampsia

Answer 15

headache, blurring of vision, epigastric pain, pain below ribs, vomiting,
sudden swelling of hands face legs
- Severe Hypertension; > 3+ of urine proteinuria
- clonus / brisk reflexes ; papillodema, epigastric tenderness
- reducing urine output
- convulsions (Eclampsia)

Question 16

biochemical abnormalities of pre-eclampsia

Answer 16

raised liver enzymes, bilirubin if HELLP present

raised urea and creatinine, raised urate

Question 17

haematological abnormalities of pre-eclampsia

Answer 17

low platelets
low haemoglobin, signs of haemolysis
features of DIC

Question 18

management of preeclampsia in pregnant women

Answer 18

frequent BP checks, Urine protein
Check symptomatology – headaches, epigastric pain, visual disturbances

Check for hyper-reflexia (clonus), tenderness over the liver

Blood investigations – Full Blood Count (for hemolysis, platelets)

Liver Function Tests

Renal Function Tests – serum urea, creatinine, urate
Coagulation tests if indicated
Fetal investigations - scan for growth cardiotocography (CTG)

Question 19

what is the only cure for pre-eclampsia

Answer 19

Only ‘cure’ for PET is delivery of the baby and placenta

Question 20

conservative management pre-eclampsia

Answer 20

close observation of clinical signs & investigations
- anti-hypertensives (labetolol, methyldopa, nifedipine)
- steroids for fetal lung maturity if gestation < 36wks

Consider induction of labour / CS if maternal or fetal condition deteriorates, irrespective of gestation

Risks of PET may persist into the puerperium therefore monitoring must be continued post delivery

Question 21

treatment of seizures / impending seizures

Answer 21

Magnesium sulphate bolus + IV infusion
Control of blood pressure – IV labetolol, hydrallazine (if > 160/110)
Avoid fluid overload – aim for 80mls/hour fluid intake

Question 22

Prophylaxis for PET in subsequent pregnancy

Answer 22

Low dose Aspirin from 12 weeks till delivery

Women with PET at a higher risk to develop hypertension in later life

Question 23

preexisting diabetes effect of pregnancy

Answer 23

Insulin requirements of the mother increase
human placental lactogen, progesterone, human chorionic gonadotrophin,
and cortisol from the placenta have anti-insulin action

Fetal hyper-insulinemia occurs
Maternal glucose crosses the placenta and induces increased insulin
production in the fetus. The fetal hyperinsulinemia causes macrosomia

Post delivery – more risk of neonatal hypoglycaemia
                         increased risk of respiratory distress

Question 24

effects of diabetes on mother, foetus and neonate

Answer 24

increased risk of

Fetal congenital abnormalities e.g – cardiac abnormalities, sacral agenesis
(especially if blood sugars high peri-conception

Miscarriage
Fetal macrosomia, polyhydramnios
Operative delivery, shoulder dystocia
Stillbirth, increased perinatal mortality

increased risk of pre-eclampsia
Worsening of maternal nephropathy, retinopathy, hypoglycaemia,
reduced awareness of hypoglycaemia
Infections

neonatal -  Impaired lung maturity, neonatal hypoglycemia, jaundice

Question 25

management diabetes pre-conception

Answer 25

better glycemic control, ideally blood sugars should be
around 4 – 7 mmol/l pre-conception
and HbA1c < 6.5% ( < 48 mmol/mol)
- folic acid 5mg
- dietary advice
- retinal and renal assessment

Question 26

management diabetes during pregnancy

Answer 26

optimise 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 glucose control
            
- should be aware of the risk of hypoglycemia – 
   provide glucagon injections/ conc. glucose solution

- watch for ketonuria/ infections
- repeat retinal assessments 28 and 34 weeks
- watch fetal growth

Question 27

management diabetes later into pregnancy and labour

Answer 27

observe for PET
labour usually induced 38-40 weeks, earlier if fetal or maternal
concerns
consider elective caesarean section if significant fetal
macrosomia
maintain blood sugar in labour with insulin – dextrose insulin
infusion
continuous CTG fetal monitoring in labour

Early feeding of baby to reduce neonatal hypoglycemia
Can go back to pre-pregnancy regimen of insulin post delivery

Question 28

Risk factors for GDM / when to consider screening for GDM

Answer 28

increased BMI >30
Previous macrosomic baby > 4.5kg
Previous GDM
Family history of diabetes
Women from high risk groups for developing diabetes – eg. Asian origin
Polyhydramnios or big baby in current pregnancy
Recurrent glycosuria in current pregnancy

Question 29

screening offered for GDM

Answer 29

If risk factor present, offer HbA1C estimation at booking, if > 6% (43 mmol/mol), 75gms OGTT to be done. If OGTT normal, repeat OGTT at 24 -28 weeks

Can also offer OGTT at around 16 weeks and repeat at 28 weeks if significant risk factors (eg. Previous GDM) present

Question 30

how is gestational diabetes managed

Answer 30

control blood sugars – diet
- metformin/ insulin if sugars remain high

Post delivery – check OGTT 6 to 8 weeks PN

Yearly check on HbA1C/ blood sugars as at a higher risk of developing overt diabetes

Question 31

why is the risk of thrombo-embolism greater in pregnancy

Answer 31

pregnancy a hypercoagulable state (to protect mother
against bleeding post delivery)

        -  increase in fibrinogen, factor VIII, VW factor, platelets
        -  decrease in natural anticoagulants – antithrombin III 
        - decrease in fibrinolysis

Increased stasis – progesterone, effects of enlarging uterus

May be vascular damage at delivery/ caesearean section

Question 32

VTE prophylaxis in pregnancy

Answer 32

TED stockings

Advice increased mobility, hydration

Prophylactic anti-coagulation with 3 or more risk factors (may be indicated even with one risk factor if significant risk), may need to continue 6 weeks postpartum

Question 33

what are signs and symptoms of VTE

Answer 33

pain in calf, increased girth of affected leg, calf muscle tenderness
breathlessness, pain on breathing, cough, tachycardia, hypoxic, pleural rub, etc

Question 34

what investigations should be done for VTE

Answer 34

ECG, Blood gases, doppler
V/Q (ventilation perfusion) lung scan

CTPA
computed tomography pulmonary angiogram)

Appropriate treatment with anticoagulation
if VTE confirmed