Complications in Pregnancy 2 Flashcards
mild hypertensive disorder cut off
Diastolic BP 90-99, Systolic BP 140-49
moderate hypertensive disorder cut off
Diastolic BP 100-109, Systolic BP 150-159
severe hypertensive disorder cut off
Diastolic BP ≥110, Systolic BP ≥ 160
chronic hypertension definition
Hypertension either pre-pregnancy or at booking (≤ 20 weeks gestation)
gestational hypertension
new hypertension in pregnancy usually develops after 20 weeks
pre-eclampsia hypertension
New hypertension > 20 weeks in association with significant proteinuria
significant proteinuria cut off
Spot Urinary Protein: Creatinine Ratio > 30 mg/mmol
24 hours urine protein collection > 300mg/ day
management plan for essential/chronic hypertension
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
definition of preeclampsia
-Hypertension on two occasions more than 4 hours apart
+ proteinuria of more than 300 mgs/ 24 hours (protein urine > + protein:creatinine ratio > 30mgms/mmol)
pathophysiology of pre-eclampsia
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
what are risk factors for developing PET
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
is preeclampsia a multi system disorder
yes
maternal complications pre-eclampsia
- eclampsia
- seizures
- severe hypertension
– cerebral haemorrhage, stroke - HELLP (hemolysis, elevated liver enzymes, low platelets)
- DIC (disseminated intravascular coagulation)
- renal failure
- pulmonary odema, cardiac failure
fetal complications pre-eclampsia
- impaired placental perfusion → IUGR, fetal distress, prematurity, increased PN mortality
symptoms and signs of severe pre eclampsia
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)
biochemical abnormalities of pre-eclampsia
raised liver enzymes, bilirubin if HELLP present
raised urea and creatinine, raised urate
haematological abnormalities of pre-eclampsia
low platelets
low haemoglobin, signs of haemolysis
features of DIC
management of preeclampsia in pregnant women
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)
what is the only cure for pre-eclampsia
Only ‘cure’ for PET is delivery of the baby and placenta
conservative management pre-eclampsia
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
treatment of seizures / impending seizures
Magnesium sulphate bolus + IV infusion
Control of blood pressure – IV labetolol, hydrallazine (if > 160/110)
Avoid fluid overload – aim for 80mls/hour fluid intake
Prophylaxis for PET in subsequent pregnancy
Low dose Aspirin from 12 weeks till delivery
Women with PET at a higher risk to develop hypertension in later life
preexisting diabetes effect of pregnancy
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
effects of diabetes on mother, foetus and neonate
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
management diabetes pre-conception
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
management diabetes during pregnancy
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
management diabetes later into pregnancy and labour
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
Risk factors for GDM / when to consider screening for GDM
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
screening offered for GDM
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
how is gestational diabetes managed
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
why is the risk of thrombo-embolism greater in pregnancy
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
VTE prophylaxis in pregnancy
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
what are signs and symptoms of VTE
pain in calf, increased girth of affected leg, calf muscle tenderness
breathlessness, pain on breathing, cough, tachycardia, hypoxic, pleural rub, etc
what investigations should be done for VTE
ECG, Blood gases, doppler
V/Q (ventilation perfusion) lung scan
CTPA
computed tomography pulmonary angiogram)
Appropriate treatment with anticoagulation
if VTE confirmed
