Complications in Pregnancy 2

Question 1

pregnancy complciaitons in this lecture:

hypertensive disorders

thrombosis

diabetes

Question 2

Hypertensive disorders in pregnancy:

what is chronic hypertension?

Answer 2

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

Question 3

hypertensive disorder sin pregnancy:

what is gestational hypertension

Answer 3

(PIH – pregnancy induced hypertension)

BP as above but new hypertension (develops after 20 weeks)

Question 4

hypertensive disorder sin pregnancy:

what is pre-eclampsia

Answer 4

New hypertension > 20 weeks in association with significant proteinuria

Question 5

what is classed as significant proteinuria?

Answer 5

Automated reagent strip urine protein estimation > 1+

Spot Urinary Protein: Creatinine Ratio > 30 mg/mmol

24 hours urine protein collection > 300mg/ day

Question 6

essential/chronic hypertension is common in who

Answer 6

older mothers

Question 7

what is the management of essential/chronic hypertension?

Answer 7

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

Question 8

what is pre-eclampsia (PET)

Answer 8

• 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)

Question 9

what is the pathophysiology of pre-eclampsia?

Answer 9

Immunological

Genetic predisposition

• secondary invasion of maternal spiral arterioles by trophoblasts

impaired = reduced placental perfusion

• imbalance between vasodilators / vasoconstrictors in pregnancy

(prostocyclin / thromboxane)

Question 10

what are the risk factrors for developing PET?

Answer 10

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

Question 11

pre-ecclampdia is a ___________ multi-organ disorder

Answer 11

multisystem

Question 12

what are maternal complications of pre-eclampsia?

Answer 12

• eclampsia - seizures
• severe hypertension – cerebral haemorrhage, stroke
• HELLP (hemolysis, elevated liver enzymes, low platelets)
• DIC (disseminated intravascular coagulation)
• renal failure
• pulmonary odema, cardiac failure

Question 13

what are foetal complciations of pre-eclampsia?

Answer 13

• impaired placental perfusion → IUGR (intrauterine growth restriction), fetal distress, prematurity, increased PN mortality

Question 14

what are the symptoms/signs of severe PET?

Answer 14

– 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)

Question 15

what are biochemical abnormalities in severe PET?

Answer 15

raised liver enzymes, bilirubin if HELLP present

raised urea and creatinine, raised urate

Question 16

what are haematologicla abnoralities in severe PET?

Answer 16

low platelets

low haemoglobin, signs of haemolysis

features of DIC

Question 17

what is the managemnt of pre-eclampsia?

Answer 17

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)

Question 18

what is the only cure of PET?

Answer 18

delivery of baby and placenta

Question 19

what is the consevrativ emanagement of PET?

Answer 19

(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

Question 20

what is the treatment of seizures?

Answer 20

Magnesium sulphate bolus + IV infusion

Control of blood pressure – IV labetolol, hydrallazine (if > 160/110)

Avoid fluid overload – aim for 80mls/hour fluid intake

Question 21

what si the prophylaxis for PET in future pregnancies?

Answer 21

Low dose Aspirin from 12 weeks till delivery

Women with PET at a higher risk to develop hypertension in later life

Question 22

what are types of diabetes to happen in pregnancy?

Answer 22

Pre-existing diabetes (type I & less often type II)

Gestational diabetes

Question 23

what is gestational diabetes?

Answer 23

• 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

Question 24

what happens to the insulin requirement of pre-existing diabetes in pregnancies?

Answer 24

increases

due to human placental lactogen, progesterone, human chorionic gonadotrophin, and cortisol from the placenta have anti-insulin action

Question 25

Fetal hyper-insulinemia occurs - how does this hhapen and what is its effects?

Answer 25

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

Question 26

what are the Effects of diabetes on mother, fetus & neonate?

Answer 26

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

Question 27

pregnancy complicated with diabetes may also suffer what complications?

Answer 27

increased risk of pre-eclampsia Worsening of maternal nephropathy, retinopathy, hypoglycaemia, reduced awareness of hypoglycaemia Infections neonatal - Impaired lung maturity, neonatal hypoglycemia, jaundice

Question 28

what is the managemnt of diabetes pre-conception?

Answer 28

- 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

Question 29

what is the management of diabetes during pregnancy?

Answer 29

- 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

Question 30

gestational diabetes mellitus: What aere the Risk factors for GDM / consider screening for GDM?

Answer 30

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

Question 31

what is the screening for GDM?

Answer 31

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

Question 32

what is the management of GDM?

Answer 32

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

Question 33

venous thrombo-embolism: pregnancy is an example of what that may lead to this?

Answer 33

Question 34

Risk of thrombo-embolism increased in pregnancy: why is this?

Answer 34

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

Question 35

there is increased risk of thrombo-embolism in women who....

Answer 35

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

Question 36

what is the prophylaxis for VTE in pregnancy?

Answer 36

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

Question 37

what are the signs/symptoms of VTE?

Answer 37

VTE - pain in calf, increased girth of affected leg, calf muscle tenderness Pulmonary embolism - breathlessness, pain on breathing, cough, tachycardia, hypoxic, pleural rub, etc

Question 38

Investigate appropriately if any suspicion of VTE how is this done?

Answer 38

ECG, Blood gases, doppler V/Q (ventilation perfusion) lung scan CTPA (computed tomography pulmonary angiogram)

Question 39

Appropriate treatment with ___________ if VTE confirmed

Answer 39

anticoagulation