Complications in Pregnancy 2 Flashcards
What is gestational hypertension?
Hypertension that develops after 20 weeks gestation
What is pre-eclampsia?
Hypertension that develops after 20 weeks gestation that is associated with significant proteinuria
What is significant proteinuria defined as?
Automated reagent strip urine protein estimation of > 1
Urinary protein : Creatinine ratio > 30mg/mmol
24 hour urine protein collection of > 300mg/day
What steps need to be taken in a mother with chronic hypertension?
- Change current BP medications (No ACE-i, ARB’s. Anti-diuretics)
- Aim to keep BP < 150/100
- Monitor for superimposed pre-eclampsia
- Monitor fetal growth
What constitutes pre-eclampsia?
- Systolic blood pressure above 140 mmHg
Diastolic blood pressure above 90 mmHg
+
Proteinuria of more than 300mgms/24 hours (protein:creatinine ratio > 30mg/mmol)
Describe the pathophysiology of pre-eclampsia?
- spiral arterioles invaded by trophoblasts, become fibrous and narrow. Leads to poor placental perfusion
- Hypo-perfused placenta releases pro-inflammatory proteins, these cause dysfunction in the endothelial cells of the mother which results in vasoconstriction
What are some risk factors for developing pre-eclampsia?
- First pregnancy
- Advanced age of mother
- Previous pre-eclampsia
- Pregnancy interval > 10yrs
- BMI > 35
- Family history
- Multiple pregnancy
- Hypertension / renal disease / diabetes
What are some of the symptoms of pre-eclampsia?
- Headache
- Blurred vision
- Epigastric pain (RUQ)
- Oedema
- Brisk reflexes
- Nausea and vomiting
What are some biochemical and haematological abnormalities that may be seen in pre-eclampsia?
- Raised liver enzymes
- Raised urea and creatinine
- Low platelets
- Low Hb, signs of haemolysis
- Signs of Disseminated intravascular coagulation
Management of pre-eclampsia?
Only cure is the delivery of baby and placenta, conservative management while waiting for fetal maturity:
- Close observations of signs + ongoing investigations
- Anti-hypertensives
- Steroids for fetal lung maturity if premature
Consider induction of labour if threat to maternal / fetal wellbeing
What are some potential complications of pre-eclampsia?
- Eclampsia
- Severe hypertension (stroke)
- Renal failure
- Pulmonary oedema / cardiac failure
- HELLP syndrome
- Fetal distress / prematurity / death
What is HELLP syndrome?
Combination of features that occurs with pre-eclampsia:
- Haemolysis
- Elevated Liver enzymes
- Low Platelets
What is eclampsia?
Pre-eclampsia + seizures
How is eclampsia treated?
IV Magnesium Sulphate for the seizures
Anti-hypertensives
in a woman with previous Pre-eclampsia what is recommended?
Prophylactic low dose aspirin from 12 weeks until delivery
What is gestational diabetes?
Reduced insulin sensitivity during pregnancy
Abnormally high glucose reverts to normal after pregnancy
baby is more likely to be large
Mother more at risk of type 2 diabetes later in life
How do maternal insulin requirements change during pregnancy?
They increase
Human placental lacotgen, progesterone, HCG and cortisol from the placenta have anti-insulin action
What is fetal hyper-insulinaemia? What is it caused by?
Increased insulin secretion by the fetus
Caused by maternal diabetes, fetus needs to secrete increased insulin as excessive glucose crosses the placenta
What are some possible complications of diabetes on the fetus?
- Congenital abnormalities (cardiac abnormalities / sacral agenesis)
- Miscarriage
- Macrosomia
- Polyhydramnios
- Shoulder dystocia (ant. shoulder gets caught under pubic bone)
- Stillbirth / perinatal mortality
- Neonatal hypoglycaemia
- Jaundice
What are some possible complications of diabetes during pregnancy for the mother?
- Increased risk of pre-eclampsia
- Worsening of nephropathy, retinopathy, hypoglycaemia
- Infections
What are the preconception management options for diabetic women of reproductive age?
- Better glycaemic control (glc. 4-7mmol/mol, HbA1c < 48mmol/mol)
Folic acid 5 mg
Dietary advice
Retinal and renal screening
What management is necessary for diabetic mothers during pregnancy?
- optimise glucose control with increased glucose requirements
- Can sometimes continue metformin but may need to switch to insulin for tighter control
- Retinal assessments at 28 & 34 weeks
Watch for ketonuria / infections / appropriate fetal growth
What are some considerations to keep in mind for the delivery of a baby with a diabetic mother?
Labour usually induced at 38-40 weeks
Consider caesarean if significant macrosomia
CTG monitoring during labour
how does the risk of maternal & fetal complications increase in type 1&2 vs gestational diabetes?
Gestational Diabetes Mellitus associated with some increase in maternal complications (eg pre-eclampsia) and fetal complications (macrosomia) but much less than with type I or II diabetes
What are some risk factors for gestational diabetes mellitus?
BMI > 30 Previous macrosomic baby Previous GDM Family history of diabetes Ethnicity (asian / black) Polyhydramnios in current pregnancy
If a risk factor for gestational diabetes is present, such as previous GDM, what screening can be done?
Offer HbA1c test at booking, as well as OGTT
Repeat OGTT at 24-28 weeks
Can also OGTT at 16 weeks and 26 weeks if high suspicion
How is gestational diabetes managed?
Control blood sugars - diet & metformin/insulin if needed
OGTT 6-8 weeks post delivery
Yearly check of HbA1c / blood sugar as mother is at higher risk of developing diabetes
What is virchow’s triad regarding blood clotting?
- Stasis
- hypercoagulability
- Vessel wall injury
Why does pregnancy predispose women to venous thrombosis?
because it is a hypercoagulable state:
- increased fibrinogen. factor VII, VW factor, platelets
- Decrease in natural anticoagulants (antithrombin III)
- Increase in fibrinolysis
- Increased stasis (progesterone, large uterus)
What are some risk factors for venous thromboembolism during pregnancy?
- Age
- High BMI, dehydration & smoking
- Pre-eclampsia
- Decreased mobility
- Infections
- Operative delivery / haemorrhage
- Previous VTE
- Sickle cell disease
What are some options for VTE prophylaxis during pregnancy?
- TED stockings
- Advise increased mobility / hydration
- Prophylactic anticoagulation with risk factors
What are some signs / symptoms of VTE??
Pain / tenderness in calf
Increased girth of affected leg
Breathlessness
Cough, tachycardia, pleural rub
Investigations for suspected VTE?
ECG
Blood gases
Ventilation perfusion
CTPA (CT pulmonary angiogram)
management of VTE?
Anti-coagulation (thrombolysis)
