Complications in Pregnancy 2

Question 1

Define Chronic Hypertension

Answer 1

Hypertension pre-pregnancy or at booking

Diastolic BP 90-99 Systolic 140-149 - Mild
100-109 150-159 - Moderate
> 110 > 160 - Severe

Question 2

Define Gestational Hypertension

Answer 2

Pregnancy induced

Blood pressure change after 20 weeks

Question 3

Define Pre-eclampsia

Answer 3

New hypertension after 20 weeks with significant proteinuria

Question 4

How to measure proteinuria for diagnosis of pre-eclampsia

Answer 4

Automated reagent strip protein
Spot urinary protein: creatinine ratio greater than 30 mmg/mol
24 hour urine protein collection >30mg per day

Question 5

Advice to women with chronic hypertension for pre-pregnancy care

Answer 5

Change Antihypertensive medication -ACEis, ARBs, diuretics
Low dietary sodium
Aim to keep BP below 150/100

Question 6

What should be monitored for in pregnant women with essential chronic hypertension?

Answer 6

Monitor foetal growth
Monitor for super-imposed pre-eclampisa
Placental abruption - higher incidence

Question 7

Criteria to diagnose Pre-eclampsia

Answer 7

Mild HT on 2 occasions more than hours apart
Moderate to severe HT
+ proteinuria >300mgs / 24 hrs

Question 8

2 Ways a women may be predisposed to pre-eclampsia

Answer 8

Immunologically
Genetically
- secondary invasion of mothers arterioles by trophoblasts impaired; reduced perfusion of placenta
-imbalance between vasodilators and vasoconstrictors

Question 9

Risk factors for pre-eclampsia

Answer 9

First pregnancy
Extremes of maternal age
Pre-eclampsai in previous pregnancy
Pregnancy interval > 10 years
 BMI >35
Family history
Multiple pregnancy
Underlying conditions

Question 10

Which underlying conditions pose a risk to developing pre-eclampsia?

Answer 10

Hypertension
Diabetes
Renal disease
Autoimmune eg SLE, Antiphospholipid antibodies

Question 11

General complications of pre-eclampsia

Answer 11

Multisystem multi-organ disorder - affects renal, liver, vascular, cerebral and pulmonary systems

Question 12

Maternal complications of pre-eclampsia

Answer 12

Eclampsia
Cerebral haemorrhage or stroke
DIC
Renal Failure
Pulmonary oedema
Cardiac failure
HELLP - Haemolysis, Elevated Liver enzymes, Low Platelets

Question 13

Fetal complications of pre-eclampsia

Answer 13

Impaired placental perfusion
IUGR
Distress
Prematurity
Increased Perinatal mortality

Question 14

Signs and symptoms of Pre-eclamptic Toxaemia

Answer 14

Severe hypertension and proteinuria
Clonus/brisk reflexes
Papilloedema
Epigastric tenderness
Reducing urine output
Convulsions (ECLAMPSIA)

Question 15

Biochemical results of PET

Answer 15

Raised liver enzymes
Raised urea and creatinine
Raised urate

Question 16

Haematology Results for PET

Answer 16

Low Platelets
Low Haemoglobin
DIC

Question 17

Management of PET

Answer 17

Monitor BP and urine protein
Bloods -FBC, LFT, Renal function (serum urea, creatinine, urate), Coagulation
Fetal investigations

Question 18

What fetal investigations are used in management of PET

Answer 18

Scans for growth

Cardiotocography

Question 19

Conservative management of PET

Answer 19

Close observation
Antihypertensives
Steroids for fetal lung maturity if less than 36 weeks

Question 20

Management if patient unstable in PET

Answer 20

Caesarean

Risk can continue into puerperium - monitor post-delivery

Question 21

Rate of PET

Answer 21

5-8%pregnant women

Question 22

Of the percentage of women who have PET in pregnancy, how many will experience seizures?

Answer 22

0.05%

Question 23

Treatment of seizures in PET

Answer 23

Magnesium sulphate bolus and IV infusion
Control BP- IV labetolol, Hydrallazine if greater than 160/110
Avoid fluid overload - 80ml/hr

Question 24

Prophylaxis for PET

Answer 24

Low dose aspirin after 12 weeks in subsequent pregnancy

Question 25

Which type of diabetes is becoming more prevalent in women bearing children?

Answer 25

Type 2 | Women are bearing children at later ages

Question 26

Why do the insulin requirements increase in diabetics during pregnancy?

Answer 26

Human placental lactogen, progesterone and HCG are all anti-insulin

Question 27

What can occur in the fetus should increased insulin requirements of diabetic mother not be treated?

Answer 27

Glucose will cross placenta causing hyperinsulinaemia in the fetus Results in macrosomia

Question 28

What are the risks to the baby post-delivery if the mother has diabetes?

Answer 28

Greater risk of respiratory distress and hypoglycaemia

Question 29

5 implications of diabetes on mother, fetus and neonate

Answer 29

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

Question 30

Complications of diabetes in pregnacny

Answer 30

Increased likelihood of pre-eclampsia Worsening of maternal nephropathy, retinopathy, hypoglycaemia Reduced awareness of hypos Infection Neonatal- impaired lung maturity, hypoglycaemia, jaundice

Question 31

Management of diabetes preconception

Answer 31

Glycaemic control Folic acid Dietary advice Retinal and renal assessment

Question 32

Management of diabetes during pregnancy

Answer 32

Optimise glucose control Gauge levels of anti-diabetic meds needed Address risk of hypos and awareness Monitor ketonuria and infection Repeat retinal assessments at 28 adn 34 weeks Monitor fetal growth

Question 33

Management of diabetes during pregnancy/prior to labour

Answer 33

Monitor for PET Consider induction Consider caesarean if signs of macrosomia Maintain BG in labour with dextrose and insulin Continuous CTG monitoring in labour

Question 34

Management of diabetes after delivery

Answer 34

Feed baby soon after birth to prevent neonatal hypoglycaemia | Return mother to pre=-pregnancy diabetic regimen

Question 35

Risk factors for Gestational Diabetes

Answer 35

Increased BMI over 30 Previous macrosomic baby Previous GDM Family history of diabetes High risk group- Asian Polyhydramnios or big baby in current pregnancy Recurrent glycosuria in current pregnancy

Question 36

Screening for Gestational Diabetes

Answer 36

HbA1c if risk factor present OGTT Repeat OGTT at 24 and 28 weeks

Question 37

Management of Gestational Diabetes

Answer 37

Control sugars - diet, metformin, insulin Post-delivery check ; OGTT 6-8 weeks later Yearly HbA1c checks

Question 38

Why is there increased risk of VTE in pregnant women?

Answer 38

Hypercoagulable state Stasis - Progesterone,mobility may decrease later in pregnancy Vascular damage during delivery /CS

Question 39

What causes the increased hypercoagulable state in pregnant women?

Answer 39

Increased fibrinogen, factor VIII, vWF, platelets Decreased anticoagulants - antithrombin III Increase in fibrinolysis

Question 40

What factors increase the risk of VTE in pregnancy?

Answer 40

``` Older women, parity Increased BMI Smokers IV drug user PET Dehydration- hyperemesis Decreased mobility Infection Operative delivery, prolonged labour Haemorrhage, blood loss >21 Previous VTE/Thrombophilia/Strong fam hx of VTE Sickle cell disease ```

Question 41

Management of VTE in pregnancy

Answer 41

Thrombo-Embolic-Deterrent (TED) stockings Advice on mobility and hydration If 3 or more risk factors - prophylactic anticoagulation

Question 42

Signs and Symptoms of VTE

Answer 42

``` Pain in calf Increased girth of leg Calf muscle tenderness Breathlessness Pain on breathing Cough Tachycardia Hypoxic Pleural rub ```

Question 43

Investigations of VTE

Answer 43

``` Blood Gas ECG Doppler V/Q Scan CTPA ``` Treat with anticoagulation