Complications In Pregnancy 2 Flashcards
Chronic hypertension in pregnancy
Hypertension either pre-pregnancy or at booking (≤ 20 weeks gestation)
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
Gestational hypertension
new hypertension (develops after 20 weeks)
Pre-eclampsia
New hypertension > 20 weeks in association with significant proteinuria
Significant Proteinuria
Spot Urinary Protein: Creatinine Ratio > 30 mg/mmol
24 hours urine protein collection > 300mg/ day
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
Anti hypertensives safe to use in pregnancy
- labetolol
- nifedipine
- methyldopa
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
What effect does reduced placental perfusion have on maternal blood pressure?
Increases maternal blood pressure
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
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
Foetal complications of pre-eclampsia
impaired placental perfusion → IUGR, fetal distress, prematurity
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)
Biochemical abnormalities in severe PET
- raised liver enzymes, bilirubin if HELLP present
- raised urea and creatinine, raised urate
Haematological abnormalities in severe PET
low platelets
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
