Complications In Pregnancy 2 Flashcards by G H

Chronic hypertension in pregnancy

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

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Severity of hypertension

Mild HT - Diastolic BP 90-99, Systolic BP 140-49
Moderate HT - Diastolic BP 100-109, Systolic BP 150-159
Severe HT - Diastolic BP ≥110, Systolic BP ≥ 160

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Gestational hypertension

new hypertension (develops after 20 weeks)

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Pre-eclampsia

New hypertension > 20 weeks in association with significant proteinuria

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Significant Proteinuria

Spot Urinary Protein: Creatinine Ratio > 30 mg/mmol

24 hours urine protein collection > 300mg/ day

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Management of essential hypertension in pregnancy

Ideally patients should have pre-pregnancy care
Change anti-hypertensive drugs if indicated
Aim to keep BP < 150/100
Monitor for superimposed pre-eclampsia
Monitor fetal growth
May have a higher incidence of placental abruption

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Anti hypertensives safe to use in pregnancy

labetolol
nifedipine
methyldopa

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Diagnostic criteria for pre eclampsia

Mild HT on two occasions more than 4 hours apart
Moderate to severe HT
- proteinuria of more than 300 mgms/ 24 hours

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What effect does reduced placental perfusion have on maternal blood pressure?

Increases maternal blood pressure

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Risk factors for developing PET

First pregnancy
Pregnancy interval >10 years
Extremes of maternal age
BMI > 35
Multiple pregnancy
Pre-eclampsia in a previous pregnancy
Family history of PET
Underlying medical disorders
- chronic hypertension
- pre-existing renal disease
- pre-existing diabetes

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Maternal complications of 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

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Foetal complications of pre-eclampsia

impaired placental perfusion → IUGR, fetal distress, prematurity

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Signs and symptoms of severe PET

Symptoms

headache
blurring of vision
epigastric pain
pain below ribs
vomiting
sudden swelling of hands, face, legs

Signs

severe hypertension
3+ occasions of urine proteinuria
clonus / brisk reflexes
reducing urine output
convulsions (Eclampsia)

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Biochemical abnormalities in severe PET

raised liver enzymes, bilirubin if HELLP present
raised urea and creatinine, raised urate

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Haematological abnormalities in severe PET

low platelets

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Severe PET investigations

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
Foetal investigations - scan for growth

PET management

Only cure for PET is delivery of the baby and placenta
Conservative (aim for foetal maturity)
- close observation of clinical signs and investigations
- anti-hypertensives
- steroids for foetal lung maturity if gestation < 36wks
Consider induction of labour / CS if maternal or fetal condition deteriorates, irrespective of gestation

Incidence of PET and eclampsia

5-8% of pregnant women have PET
0.5% women have severe PET and 0.05% have eclamptic seizures

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

Gestational diabetes

abnormal glucose tolerance with onset in pregnancy that reverts to normal after delivery

How does pregnancy affect pre-existing diabetes?

Insulin requirements of the mother increase -human placental lactogen, progesterone, human chorionic gonadotrophin, and cortisol from the placenta have anti-insulin action
Maternal glucose crosses the placenta and induces increased insulin production in the fetus
Foetal hyper-insuinlemia occurs
The foetal hyperinsulinemia causes macrosomia

How does maternal diabetes affect foetal post delivery risks?

Increased risk of:

neonatal hypoglycaemia
respiratory distress
jandice

Effect of diabetes on foetus

Foetal congenital abnormalities
Miscarriage
Foetal macrosomia, polyhydramnios
Operative delivery, shoulder dystocia
Stillbirth, increased perinatal mortality

Effect of diabetes on mother during pregnancy

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

Preconception management of diabetes

* 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

How should a woman with diabetes be monitored in pregnancy?

* optimise glucose control - insulin requirements will increase * 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 * watch out for PET * repeat retinal assessments 28 and 34 weeks * watch foetal growth

Management of diabetes in pregnancy

* labour usually induced 38-40 weeks, earlier if foetal or maternal concerns * consider elective caesarean section if significant foetal macrosomia * maintain blood sugar in labour with insulin - dextrose 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 / consider screening for GDM

* Previous GDM * Family history of diabetes * Previous macrosomic baby \> 4.5kg * Polyhydramnios or big baby in current pregnancy * Recurrent glycosuria in current pregnancy * Increased BMI \>30

Screening for GDM

If risk factor present, offer HbA1C estimation at booking, if \> 6% (43 mmol/mol), 75gms OGTT to be done.

Management of GDM

* 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

What is Virchow’s triad?

Increased risk of thromboembolism due to: * stasis * vessel wall injury * hyper-coagulability

Risk factors for VTE

* Older mothers, increasing parity * Increased BMI, smokers * IV drug users * PET * Dehydration - hyperemesis * Decreased mobility * Infections * Operative delivery, prolonged labour * Haemorrhage, blood loss \> 2 l * Previous VTE

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

Signs/ symptoms of VTE

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

Investigations for PE

* V/Q (ventilation perfusion) lung scan * CTPA (computed tomography pulmonary angiogram)

Treatment of VTE

Appropriate treatment with anticoagulation if VTE confirmed