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Reproductive System > Complications in Pregnancy 2 > Flashcards

Complications in Pregnancy 2 Flashcards

1
Q

What is mild hypertension?

A
  • Diastolic BP 90-99

* Systolic BP 140-49

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2
Q

What is moderate hypertension?

A
  • Diastolic BP 100-109

* Systolic BP 150-159

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3
Q

What is severe hypertension?

A
  • Diastolic BP ≥110

* Systolic BP ≥ 160

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4
Q

What is classified as chronic hypertension?

A

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

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5
Q

What is gestational hypertension (pregnancy-induced hypertension)?

A

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

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6
Q

What is pre-eclampsia??

A

New hypertension > 20 weeks in association with significant proteinuria

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7
Q

What is classified as significant proteinuria?

A
  • Automated reagent strip urine protein estimation > 1+
  • Spot Urinary Protein: Creatinine Ratio > 30 mg/mmol
  • 24 hours urine protein collection > 300mg/ day
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8
Q

How is chronic hypertension managed in pregnancy?

A

•Ideally patients should have pre-pregnancy care
•Change anti-hypertensive drugs if indicated e.g.:
- 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, nifedipine, methyldopa)
•Monitor for superimposed pre-eclampsia
•Monitor fetal growth
•May have a higher incidence of placental abruption

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9
Q

What is the definition of pre-eclampsia?

A
  • Mild HT on two occasions more than 4 hours apart
  • Moderate to severe
    • proteinuria of more than 300 mgms/ 24 hours
  • Protein urine > and protein:creatinine ratio > 30mgms/mmol
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10
Q

What is the pathophysiology of pre-eclampisa?

A
  • Immunological
  • Genetic predisposition
  • Secondary invasion of maternal spiral arterioles by trophoblasts impaired -> reduced placental perfusion
  • Imbalance between vasodilators/vasoconstrictors in pregnancy (prostocyclin/thromboxane)
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11
Q

What are the risk factors for developing pre-eclampsia toxaemia?

A
  • 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
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12
Q

What are the underlying medical disorders which increase risk of PET?

A
  • Chronic hypertension
  • Pre-existing medical conditions
  • Pre-existing diabetes
  • Autoimmune disorders - antiphospholipid antibodies, SLE
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13
Q

Which systems can pre-eclampsia involve?

A
  • Renal
  • Liver
  • Vascular
  • Cerebral
  • Pulmonary
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14
Q

What are the possible complications of pre-eclampsia for the mother?

A
  • Eclampsia - seizures
  • Severe hypertension - cerebral haemorrhage, stroke
  • HELLP (haemolysis, elevated liver enzymes, low platelets)
  • DIC (disseminated intravascular coagulation)
  • Renal failure
  • Pulmonary oedema, cardiac failure
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15
Q

What are the possible complications of pre-eclampsia for the foetus?

A

•Impaired placental perfusion → IUGR, fetal distress, prematurity, increased PN mortality

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16
Q

What are the symptoms of severe PET?

A
  • Headache
  • Blurring of vision
  • Epigastric pain
  • Pain below ribs
  • Vomiting
  • Sudden swelling of hands, face and legs
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17
Q

What are the clinal signs of severe PET?

A
  • Severe Hypertension - > 3+ of urine proteinuria
  • clonus/brisk reflexes
  • Papillodema
  • Epigastric tenderness
  • Reducing urine output
  • Convulsions (Eclampsia)
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18
Q

What are the biochemical abnormalities in PET?

A
  • Raised liver enzymes, bilirubin if HELLP present

* Raised urea and creatinine, raised urate

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19
Q

What are the haematological abnormalities in PET?

A
  • Low platelets
  • Low haemoglobin, signs of haemolysis
  • Features of DIC (disseminated intravascular coagulation)
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20
Q

How is pre-eclampsia monitored?

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
  • Fetal investigations - scan for growth, cardiotocography (CTG)
21
Q

What is the only cure for PET?

A

Delivery of the baby

22
Q

What is the conservative (aiming for foetal maturity) management of pre-eclampsia?

A
  • Close observation of clinical signs & investigations
  • Anti-hypertensives (labetolol, methyldopa, nifedipine)
  • Steroids for foetal lung maturity if gestation < 36wks
23
Q

What should be considered if maternal or foetal condition deteriorates?

A
  • CS

* Induced labour

24
Q

Does PET monitoring end at birth?

A

Risks of PET may persist into the puerperium therefore monitoring must be continued post delivery

25
When are seizures likely to occur in pre-eclampsia?
* 38% of seizures occur antepartum * 18% intrapartum * 44% postpartum
26
How are seizures/impending seizures treated in pre-eclampsia?
* Magnesium sulphate bolus + IV infusion * Control of blood pressure – IV labetolol, hydrallazine (if > 160/110) * Avoid fluid overload – aim for 80mls/hour fluid intake
27
What prophylaxis is used if PET in subsequent pregnancy?
* Low dose aspirin from 12 weeks until delivery | * Women with PET are at higher risk to develop HT in later life
28
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
29
How does pre-existing diabetes management change in pregnancy?
•Insulin requirements of the mother increase ˙•Human placental lactogen, progesterone, human chorionic gonadotrophin and cortisol from the placenta have anti-insulin action
30
How does pre-existing diabetes affect the foetus?
* Maternal glucose crosses the placenta and induces increased insulin production in the foetus * The fetal hyperinsulinemia causes macrosomia
31
What are the postnatal risks caused by pre-existing diabetes in pregnancy?
* More risk of neonatal hypoglycaemia | * Increased risk of respiratory distress
32
What are the possible effects of diabetes on the foetus and neonate?
* Foetal congenital abnormalities e.g – cardiac abnormalities, sacral agenesis (especially if blood sugars high peri-conception) * Miscarriage * Fetal macrosomia, polyhydramnios * Operative delivery * Shoulder dystocia * Stillbirth * Increased perinatal mortality * Impaired lung maturity * Neonatal hypoglycemia * Jaundice
33
What are the possible effects of diabetes on the mother?
* Increased risk of pre-eclampsia * Worsening of maternal nephropathy, retinopathy, hypoglycaemia * Reduced awareness of hypoglycaemia * Infections
34
What is the pre-natal management in diabetic mothers hoping to conceive?
* 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
35
How is diabetes managed in pregnant mothers?
* Optimise glucose control - insulin requirements will increase * Can continue oral diabetic treatment (metformin) but may need to change to insulin for tighter control * Should be aware of the risk of hypoglycaemia - provide glucagon injections/concentrated glucose solution * Watch for ketonuria/infections * Repeat retinal assessments - 28 and 34 weeks * Watch foetal growth
36
How is diabetes managed perinatally in pregnant mothers?
* Observe for PET * Labour usually induced 38-40 weeks - maybe earlier if cause for concern * Consider ECS - macrosomia * Maintain blood sugar level wit insulin in labour - dextrose insulin infusion * Continuous CTG foetal monitoring in labour * Early feeding - to prevent neonatal hypoglycaemia * Can revert to pre-pregnancy management regime postnatally
37
What are the risk factors associated with gestational diabetes mellitus (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
38
Of TI & TIIDM and GDM, which is more dangerous?
TI & TIIDM
39
How is GDM screened for?
•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
40
How is GDM managed?
* Control blood sugar with diet * Use metformin/insulin if blood sugars remain high * Post-deliver - check OGTT 6-8 weeks PN * Yearly check on HbA1C/ blood sugars as at a higher risk of developing overt diabetes
41
What comprises Virchow's Triad?
* Stasis * Vessel wall injury * Hypercoagulbility
42
What causes hypercoagubility 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
43
What causes increased stasis in pregnancy?
* Progesterone | * Effects of enlarging uterus
44
What may be a cause of vascular damage in pregnancy?
* Delivery | * CS
45
What are the risk factor for venous thromboembolism in pregnancy?
* 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
46
What 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
47
What are the signs and symptoms of VTE?
* Pain in calf * Increased girth of affected leg * Calf muscle tenderness * Breathlessness * Pain on breathing * Cough * Tachycardia * Hypoxic * Pleural rub, etc
48
What are the investigations for a suspected VTE?
* ECG * Blood gases * Doppler * V/Q scan * CTPA
49
How is a VTE managed?
Appropriate anticoagulation

Reproductive System (31 decks)

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