Complications in Pregnancy 2 Flashcards
pregnancy complciaitons in this lecture:
hypertensive disorders
thrombosis
diabetes
Hypertensive disorders in pregnancy:
what is chronic hypertension?
Hypertension either pre-pregnancy or at booking (≤ 20 weeks gestation)
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
hypertensive disorder sin pregnancy:
what is gestational hypertension
(PIH – pregnancy induced hypertension)
BP as above but new hypertension (develops after 20 weeks)
hypertensive disorder sin pregnancy:
what is pre-eclampsia
New hypertension > 20 weeks in association with significant proteinuria
what is classed as significant proteinuria?
Automated reagent strip urine protein estimation > 1+
Spot Urinary Protein: Creatinine Ratio > 30 mg/mmol
24 hours urine protein collection > 300mg/ day
essential/chronic hypertension is common in who
older mothers
what is the management of essential/chronic hypertension?
Ideally patients should have pre-pregnancy care
Change anti-hypertensive drugs if indicated: eg. - ACE inhibitors (eg. Ramipril / Enalopril cause birth defects impaired growth), Angiotensin receptor blockers (eg losartan, Candesartan), anti diuretics, lower dietary sodium
Aim to keep BP < 150/100 (labetolol (beta blocker), nifedipine (CCB), methyldopa)
Monitor for superimposed pre-eclampsia
Monitor fetal growth
May have a higher incidence of placental abruption
what is pre-eclampsia (PET)
- Mild HT on two occasions more than 4 hours apart
- Moderate to severe HT
+ proteinuria of more than 300 mgms/ 24 hours (protein urine > + protein:creatinine ratio > 30mgms/mmol)
what is the pathophysiology of pre-eclampsia?
Immunological
Genetic predisposition
- secondary invasion of maternal spiral arterioles by trophoblasts
impaired = reduced placental perfusion
- imbalance between vasodilators / vasoconstrictors in pregnancy
(prostocyclin / thromboxane)
what are the risk factrors for developing PET?
First pregnancy
Extremes of maternal age
Pre-eclampsia in a previous pregnancy (esp. severe PET, delivery <34 weeks, IUGR baby, IUD, abruption)
Pregnancy interval >10 years
BMI > 35
Family history of PET
Multiple pregnancy
Underlying medical disorders:
- chronic hypertension
- pre-existing renal disease
- pre-existing diabetes
- autoimmune disorders like – eg. antiphospholipid antibodies, SLE
pre-ecclampdia is a ___________ multi-organ disorder
multisystem
what are 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
what are foetal complciations of pre-eclampsia?
- impaired placental perfusion → IUGR (intrauterine growth restriction), fetal distress, prematurity, increased PN mortality
what are the symptoms/signs of severe PET?
– headache, blurring of vision, epigastric pain, pain below ribs, vomiting, sudden swelling of hands face legs
- Severe Hypertension; > 3+ of urine proteinuria
- clonus / brisk reflexes ; papillodema, epigastric tenderness
- reducing urine output
- convulsions (Eclampsia)
what are biochemical abnormalities in severe PET?
raised liver enzymes, bilirubin if HELLP present
raised urea and creatinine, raised urate
what are haematologicla abnoralities in severe PET?
low platelets
low haemoglobin, signs of haemolysis
features of DIC
what is the managemnt of pre-eclampsia?
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
Fetal investigations - scan for growth
cardiotocography (CTG)
what is the only cure of PET?
delivery of baby and placenta
what is the consevrativ emanagement of PET?
(aim for fetal maturity)
- close observation of clinical signs & investigations
- anti-hypertensives (labetolol, methyldopa, nifedipine)
- steroids for fetal lung maturity if gestation <36wks
Consider induction of labour / CS if maternal or fetal condition deteriorates, irrespective of gestation
Risks of PET may persist into the puerperium therefore monitoring must be continued post delivery
what is the treatment of 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
what si the prophylaxis for PET in future pregnancies?
Low dose Aspirin from 12 weeks till delivery
Women with PET at a higher risk to develop hypertension in later life
what are types of diabetes to happen in pregnancy?
Pre-existing diabetes (type I & less often type II)
Gestational diabetes
what is gestational diabetes?
- carbohydrate intolerance with onset (or first recognised) in pregnancy
- abnormal glucose tolerance that reverts to normal after delivery
- however, more at risk of developing type II diabetes later in life
what happens to the insulin requirement of pre-existing diabetes in pregnancies?
increases
due to human placental lactogen, progesterone, human chorionic gonadotrophin, and cortisol from the placenta have anti-insulin action
Fetal hyper-insulinemia occurs - how does this hhapen and what is its effects?
Maternal glucose crosses the placenta and induces increased insulin production in the fetus. The fetal hyperinsulinemia causes macrosomia (large baby)
Post delivery – more risk of neonatal hypoglycaemia, increased risk of respiratory distress
what are the Effects of diabetes on mother, fetus & neonate?
Fetal congenital abnormalities e.g – cardiac abnormalities, sacral agenesis (especially if blood sugars high peri-conception)
- Miscarriage
- Fetal macrosomia, polyhydramnios (increased fluid around baby)
- Operative delivery, shoulder dystocia
- Stillbirth, increased perinatal mortality
pregnancy complicated with diabetes may also suffer what complications?
increased risk of pre-eclampsia
Worsening of maternal nephropathy, retinopathy, hypoglycaemia, reduced awareness of hypoglycaemia
Infections
neonatal - Impaired lung maturity, neonatal hypoglycemia, jaundice
what is the managemnt of diabetes pre-conception?
- 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
what is the management of diabetes during pregnancy?
- optimise glucose control – insulin requirements will increase
< 5.3 mmol/l - Fasting
< 7.8 mmol/l - 1 hour postprandial
< 6.4 mmol/l - 2 hours postprandial
< 6 mmol/l – before bedtime
- 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
- repeat retinal assessments 28 and 34 weeks
- watch fetal growth
Management (contd)
- observe for PET
- labour usually induced 38-40 weeks, earlier if fetal or maternal concerns
- consider elective caesarean section if significant fetal macrosomia
- maintain blood sugar in labour with insulin – dextrose insulin 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
gestational diabetes mellitus:
What aere the Risk factors for GDM / consider screening for GDM?
increased BMI >30
Previous macrosomic baby > 4.5kg
Previous GDM
Family history of diabetes
Women from high risk groups for developing diabetes – eg. Asian origin
Polyhydramnios or big baby in current pregnancy
Recurrent glycosuria in current pregnancy
GDM associated with some increase in maternal complications (eg PET) and fetal complications (macrosomia) but much less than with type I or II diabetes
what is the screening for GDM?
If risk factor present, offer HbA1C estimation at booking, if > 6% (43 mmol/mol), 75gms OGTT to be done. If OGTT normal, repeat OGTT at 24 -28 weeks
Can also offer OGTT at around 16 weeks and repeat at 28 weeks if significant risk factors (eg. Previous GDM) present
what is the management of GDM?
essentially making sure blood levels are normal
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
venous thrombo-embolism:
pregnancy is an example of what that may lead to this?
Risk of thrombo-embolism increased in pregnancy:
why is this?
Risk of thrombo-embolism increased in pregnancy
- pregnancy a hypercoagulable state (to protect mother against bleeding post delivery)
- increase in fibrinogen, factor VIII, VW factor, platelets
- decrease in natural anticoagulants – antithrombin III
- increase in fibrinolysis
- Increased stasis – progesterone, effects of enlarging uterus
- May be vascular damage at delivery/ caesearean section
there is increased risk of thrombo-embolism in women who….
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 (not explained by other predisposing eg. fractures, injury), those with thrombophilia (protein C, protein S, Anti thrombin III deficiencies, etc), strong family history of VTE
Sickle cell disease
what is the prophylaxis for VTE 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
what are the signs/symptoms of VTE?
VTE - pain in calf, increased girth of affected leg, calf muscle tenderness
Pulmonary embolism - breathlessness, pain on breathing, cough, tachycardia, hypoxic, pleural rub, etc
Investigate appropriately if any suspicion of VTE
how is this done?
ECG, Blood gases, doppler
V/Q (ventilation perfusion) lung scan
CTPA (computed tomography pulmonary angiogram)
Appropriate treatment with ___________ if VTE confirmed
anticoagulation
