Complications in Pregnancy - 2

Question 1

What is classed as mild hypertension in pregnancy?

Answer 1

Diastolic BP 90-99
Systolic BP 140-49

Question 2

What is classed as moderate hypertension in pregnancy?

Answer 2

Diastolic BP 100-109
Systolic BP 150-159

Question 3

What is classed as severe hypertension in pregnancy?

Answer 3

Diastolic BP > 110
Systolic BP > 160

Question 4

What is chronic hypertension in pregnancy?

Answer 4

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

Question 5

What is gestational hypertension?

Answer 5

New hypertension in pregnancy usually develops after 20 weeks

Question 6

What is pre-eclampsia?

Answer 6

New hypertension over 20 weeks in association with significant proteinuria

Question 7

How is proteinuria investigated in pre-eclampsia?

Answer 7

Automated reagent strip urine protein estimation over 1+
Spot urinary protein : creatinine ratio > 30
24 hr urine protein collection > 300

Question 8

What anti-hypertensive drugs should be changed if indicated in pregnancy?

Answer 8

ACE inhibitors
Angiotensin receptor blockers
Anti-diuretics
Lower dietary sodium

Question 9

What should be monitored in chronic hypertension during pregnancy?

Answer 9

Aim to keep BP < 150/100
Monitor for superimposed pre-eclampsia
Monitor foetal growth
May have higher incidence of placental abruption

Question 10

What is the definition of pre-eclampsia?

Answer 10

Hypertension on 2 occasions more than 4 hrs apart
Plus proteinuria of more than 300mgs/day

Question 11

Describe the pathophysiology of pre-eclampsia

Answer 11

Impaired secondary invasion of maternal spiral arterioles by trophoblasts - reduced placental perfusion so ischaemia
Low level chronic inflammation - endothelial damage
Imbalance between angiogenic and antiangiogenic factors

Question 12

Describe the imbalance between angiogenic (PIGF) and antiangiogenic (sFIt-1) factors in pre-eclampsia

Answer 12

FMS like tyrosine kinase inhibits neovascularisation and in pregnancy with pre-eclampsia PIGF is lower

Question 13

What are the risk factors for developing pre-eclampsia?

Answer 13

First pregnancy, extremes of maternal age, previous pregnancy with PET, pregnancy interval over 10 years, BMI>35, FH, multiple pregnancy and underlying medical disorders (hypertension, renal, diabetes and autoimmune)

Question 14

What are the maternal complications of pre-eclampsia?

Answer 14

Eclampsia - seizures
Severe hypertension - cerebral haemorrhage and stroke
HELLP
DIC (disseminated intravascular coagulation)
Renal failure
Pulmonary oedema and cardiac failure

Question 15

What are the foetal complications of pre-eclampsia?

Answer 15

Impaired placental infusion - IUGR, foetal distress, prematurity and increased PN mortality

Question 16

What are the symptoms and signs of severe pre-eclampsia?

Answer 16

Headache, blurring of vision, epigastric pain, pain below ribs, vomiting and sudden swelling of hands, face and legs
Clonus/ brisk reflexes
Reduced urine output
Convulsions

Question 17

What are the biochemical abnormalities of severe pre-eclampsia?

Answer 17

Raised liver enzymes, bilirubin if HELLP is present
Raised urea, creatinine and urate

Question 18

What are the haematological abnormalities of severe pre-eclampsia?

Answer 18

Low platelets and haemoglobin, signs of haemolysis and features of DIC

Question 19

What is the management of pre-eclampsia?

Answer 19

Frequent BP checks and urine protein
Check hyperreflexia and liver tenderness
Bloods - FBC, LFTs, renal and coagulation
Scans for baby growth and CTG

Question 20

What is the conservative management for pre-clampsia?

Answer 20

Close observation
Anti-hypertensives
Steroids for foetal lung maturity if gestation is under 36 weeks
Consider induction of labour/ CS

Question 21

What period does eclampsia mainly occur?

Answer 21

38% occur antepartum, 18% intrapartum and 44% postpartum

Question 22

What is the treatment of seizures in eclampsia?

Answer 22

Magnesium sulphate bolus and IV infusion
Control of BP - labetolol and hydrallazine
Avoid fluid overload - aim for 80mls/ hr

Question 23

Describe gestational diabetes

Answer 23

Carbohydrate intolerance with onset in pregnancy
Abnormal glucose tolerance that reverts to normal after delivery
More at risk of developing type II later in life

Question 24

What happens in pre-existing diabetes and pregnancy

Answer 24

Insulin requirements if the mother increase - human placental lactogen, progesterone, cortisol and hCG have anti-insulin action
Foetal hyper-insulinemia occurs - glucose crosses placenta and causes increased insulin production in the foetus - causes amcrosomia

Question 25

What is the post-delivery risk of pre-existing diabetes and pregnancy?

Answer 25

More risk of neonatal hypoglycaemia and increased risk of respiratory distress

Question 26

What are the effects of diabetes on foetus?

Answer 26

Foetal congenital abnormalities
Miscarriage
Foetal macrosomia and polyhydramnios
Operative delivery and shoulder dystocia
Stillbirth

Question 27

What are the effects of diabetes on mother and neonate?

Answer 27

Increased risk of pre-eclampsia
Worsening maternal nephropathy, retinopathy, hypoglycaemia and infections
Neonates - impaired lung maturity, neonatal hypoglycaemia and jaundice

Question 28

What is the management for diabetes preconception?

Answer 28

Better glycaemic control - 4-7 mmol/l pre-conception
Folic acid
Dietary advice
Retinal and renal assessment

Question 29

What is the management for diabetes during pregnancy?

Answer 29

Optimise glucose control as insulin requirements increase
Can stay on metformin but may need insulin for better control
Risk of hypoglycaemia
Retinal and renal assessments

Question 30

What is the management for diabetes when in labour?

Answer 30

If foetal macrosomia - elective CS
Maintain blood sugar with insulin - dextrose insulin infusion
Continuous CTG foetal monitoring
Early feeding of baby to reduce hypoglycaemia

Question 31

What are some risk factors for gestational diabetes mellitus?

Answer 31

Increased BMI > 30, previous macrosomic baby > 4.5kg, previous GDM, FH, Asian origin, polyhydramnios and recurrent glycosuria

Question 32

What is the screening for gestational diabetes mellitus?

Answer 32

Offer HbA1c estimation at booking and if over 6% then 75gms OGTT to be done
If normal then repeat after 24-28 weeks

Question 33

What is the management for gestational diabetes mellitus?

Answer 33

Control blood sugars - diet and metformin/ insulin
Post delivery - check OGTT 6-8 weeks PN
Yearly check on HbA1c/ blood sugars

Question 34

Why is there an increased risk of thromboembolism during pregnancy?

Answer 34

Hypercoagulable state - increase in fibrinogen, factor VIII, VW factors and platelets, decrease in antithrombin III and fibrinolysis
Increased stasis - progesterone
Vascular damage at delivery

Question 35

When does thromboembolism in pregnancy have increased risk of happening?

Answer 35

Older mothers, increased BMI, smokers, IVDU, PET, dehydration, decreased motility, infections, operative delivery, haemorrhage, previous VTE and sickle cell disease

Question 36

What is the VTE prophylaxis in pregnancy?

Answer 36

TED stockings
Advise increased mobility and hydration
Prophylactic anti-coagulation with 3 or more risk factors and can continue 6 weeks postpartum

Question 37

What are the signs and symptoms of VTE?

Answer 37

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

Question 38

What are the investigations for VTE?

Answer 38

ECG, bloods, doppler V/Q lung scan, CTPA and appropriate treatment wit anticoagulation if confirmed