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Reproduction > Complications In Pregnancy 2 > Flashcards

Complications In Pregnancy 2 Flashcards

1
Q

Chronic hypertension in pregnancy

A

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

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2
Q

Severity of hypertension

A
  • 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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3
Q

Gestational hypertension

A

new hypertension (develops after 20 weeks)

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4
Q

Pre-eclampsia

A

New hypertension > 20 weeks in association with significant proteinuria

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5
Q

Significant Proteinuria

A

Spot Urinary Protein: Creatinine Ratio > 30 mg/mmol

24 hours urine protein collection > 300mg/ day

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6
Q

Management of essential hypertension in pregnancy

A
  • 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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7
Q

Anti hypertensives safe to use in pregnancy

A
  • labetolol
  • nifedipine
  • methyldopa
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8
Q

Diagnostic criteria for pre eclampsia

A
  • 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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9
Q

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

A

Increases maternal blood pressure

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10
Q

Risk factors for developing PET

A
  • 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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11
Q

Maternal complications of pre-eclampsia

A
  • 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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12
Q

Foetal complications of pre-eclampsia

A

impaired placental perfusion → IUGR, fetal distress, prematurity

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13
Q

Signs and symptoms of severe PET

A

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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14
Q

Biochemical abnormalities in severe PET

A
  • raised liver enzymes, bilirubin if HELLP present
  • raised urea and creatinine, raised urate
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15
Q

Haematological abnormalities in severe PET

A

low platelets

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16
Q

Severe PET investigations

A
  • 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
17
Q

PET management

A
  • 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
18
Q

Incidence of PET and eclampsia

A
  • 5-8% of pregnant women have PET
  • 0.5% women have severe PET and 0.05% have eclamptic seizures
19
Q

Treatment of seizures/ impending seizures

A
  • Magnesium sulphate bolus + IV infusion
  • Control of blood pressure
    • IV labetolol, hydrallazine (if >160/110)
  • Avoid fluid overload - aim for 80mls/hour fluid intake
20
Q

Prophylaxis for PET in subsequent pregnancy

A

Low dose Aspirin from 12 weeks till delivery

21
Q

Gestational diabetes

A

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

22
Q

How does pregnancy affect pre-existing diabetes?

A
  • 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
23
Q

How does maternal diabetes affect foetal post delivery risks?

A

Increased risk of:

  • neonatal hypoglycaemia
  • respiratory distress
  • jandice
24
Q

Effect of diabetes on foetus

A
  • Foetal congenital abnormalities
  • Miscarriage
  • Foetal macrosomia, polyhydramnios
  • Operative delivery, shoulder dystocia
  • Stillbirth, increased perinatal mortality
25
Q

Effect of diabetes on mother during pregnancy

A
  • Increased risk of pre-eclampsia
  • Worsening of maternal nephropathy, retinopathy, hypoglycaemia, reduced awareness of hypoglycaemia
  • Infections
26
Q

Preconception management of diabetes

A
  • 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
27
Q

How should a woman with diabetes be monitored in pregnancy?

A
  • 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
28
Q

Management of diabetes in pregnancy

A
  • 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
29
Q

Risk factors for GDM / consider screening for GDM

A
  • 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
30
Q

Screening for GDM

A

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

31
Q

Management of GDM

A
  • 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
32
Q

What is Virchow’s triad?

A

Increased risk of thromboembolism due to:

  • stasis
  • vessel wall injury
  • hyper-coagulability
33
Q

Risk factors for VTE

A
  • 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
34
Q

VTE prophylaxis in pregnancy

A
  • 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
35
Q

Signs/ symptoms of VTE

A
  • pain in calf, increased girth of affected leg, calf muscle tenderness
  • breathlessness, pain on breathing, cough, tachycardia, hypoxic, pleural rub
36
Q

Investigations for PE

A
  • V/Q (ventilation perfusion) lung scan
  • CTPA (computed tomography pulmonary angiogram)
37
Q

Treatment of VTE

A

Appropriate treatment with anticoagulation if VTE confirmed

Reproduction (34 decks)

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