Complications in Pregnancy - 2 Flashcards
What is classed as mild hypertension in pregnancy?
Diastolic BP 90-99
Systolic BP 140-49
What is classed as moderate hypertension in pregnancy?
Diastolic BP 100-109
Systolic BP 150-159
What is classed as severe hypertension in pregnancy?
Diastolic BP > 110
Systolic BP > 160
What is chronic hypertension in pregnancy?
Hypertension either pre-pregnancy or at booking (< 20 weeks gestation)
What is gestational hypertension?
New hypertension in pregnancy usually develops after 20 weeks
What is pre-eclampsia?
New hypertension over 20 weeks in association with significant proteinuria
How is proteinuria investigated in pre-eclampsia?
Automated reagent strip urine protein estimation over 1+
Spot urinary protein : creatinine ratio > 30
24 hr urine protein collection > 300
What anti-hypertensive drugs should be changed if indicated in pregnancy?
ACE inhibitors
Angiotensin receptor blockers
Anti-diuretics
Lower dietary sodium
What should be monitored in chronic hypertension during pregnancy?
Aim to keep BP < 150/100
Monitor for superimposed pre-eclampsia
Monitor foetal growth
May have higher incidence of placental abruption
What is the definition of pre-eclampsia?
Hypertension on 2 occasions more than 4 hrs apart
Plus proteinuria of more than 300mgs/day
Describe the pathophysiology of pre-eclampsia
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
Describe the imbalance between angiogenic (PIGF) and antiangiogenic (sFIt-1) factors in pre-eclampsia
FMS like tyrosine kinase inhibits neovascularisation and in pregnancy with pre-eclampsia PIGF is lower
What are the risk factors for developing pre-eclampsia?
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)
What are the maternal complications of pre-eclampsia?
Eclampsia - seizures
Severe hypertension - cerebral haemorrhage and stroke
HELLP
DIC (disseminated intravascular coagulation)
Renal failure
Pulmonary oedema and cardiac failure
What are the foetal complications of pre-eclampsia?
Impaired placental infusion - IUGR, foetal distress, prematurity and increased PN mortality
What are the symptoms and signs of severe pre-eclampsia?
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
What are the biochemical abnormalities of severe pre-eclampsia?
Raised liver enzymes, bilirubin if HELLP is present
Raised urea, creatinine and urate
What are the haematological abnormalities of severe pre-eclampsia?
Low platelets and haemoglobin, signs of haemolysis and features of DIC
What is the management of pre-eclampsia?
Frequent BP checks and urine protein
Check hyperreflexia and liver tenderness
Bloods - FBC, LFTs, renal and coagulation
Scans for baby growth and CTG
What is the conservative management for pre-clampsia?
Close observation
Anti-hypertensives
Steroids for foetal lung maturity if gestation is under 36 weeks
Consider induction of labour/ CS
What period does eclampsia mainly occur?
38% occur antepartum, 18% intrapartum and 44% postpartum
What is the treatment of seizures in eclampsia?
Magnesium sulphate bolus and IV infusion
Control of BP - labetolol and hydrallazine
Avoid fluid overload - aim for 80mls/ hr
Describe gestational diabetes
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
What happens in pre-existing diabetes and pregnancy
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
What is the post-delivery risk of pre-existing diabetes and pregnancy?
More risk of neonatal hypoglycaemia and increased risk of respiratory distress
What are the effects of diabetes on foetus?
Foetal congenital abnormalities
Miscarriage
Foetal macrosomia and polyhydramnios
Operative delivery and shoulder dystocia
Stillbirth
What are the effects of diabetes on mother and neonate?
Increased risk of pre-eclampsia
Worsening maternal nephropathy, retinopathy, hypoglycaemia and infections
Neonates - impaired lung maturity, neonatal hypoglycaemia and jaundice
What is the management for diabetes preconception?
Better glycaemic control - 4-7 mmol/l pre-conception
Folic acid
Dietary advice
Retinal and renal assessment
What is the management for diabetes during pregnancy?
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
What is the management for diabetes when in labour?
If foetal macrosomia - elective CS
Maintain blood sugar with insulin - dextrose insulin infusion
Continuous CTG foetal monitoring
Early feeding of baby to reduce hypoglycaemia
What are some risk factors for gestational diabetes mellitus?
Increased BMI > 30, previous macrosomic baby > 4.5kg, previous GDM, FH, Asian origin, polyhydramnios and recurrent glycosuria
What is the screening for gestational diabetes mellitus?
Offer HbA1c estimation at booking and if over 6% then 75gms OGTT to be done
If normal then repeat after 24-28 weeks
What is the management for gestational diabetes mellitus?
Control blood sugars - diet and metformin/ insulin
Post delivery - check OGTT 6-8 weeks PN
Yearly check on HbA1c/ blood sugars
Why is there an increased risk of thromboembolism during pregnancy?
Hypercoagulable state - increase in fibrinogen, factor VIII, VW factors and platelets, decrease in antithrombin III and fibrinolysis
Increased stasis - progesterone
Vascular damage at delivery
When does thromboembolism in pregnancy have increased risk of happening?
Older mothers, increased BMI, smokers, IVDU, PET, dehydration, decreased motility, infections, operative delivery, haemorrhage, previous VTE and sickle cell disease
What is the VTE prophylaxis in pregnancy?
TED stockings
Advise increased mobility and hydration
Prophylactic anti-coagulation with 3 or more risk factors and can continue 6 weeks postpartum
What are the signs and symptoms of VTE?
Pain in calf, increased girth of affected leg, calf muscle tenderness, breathlessness, pain on breathing, cough, tachycardia, hypoxic and pleural rub
What are the investigations for VTE?
ECG, bloods, doppler V/Q lung scan, CTPA and appropriate treatment wit anticoagulation if confirmed
