Complications in pregnancy and maternal medicine Flashcards
Pre-eclampsia
Pre-eclampsia refers to new high blood pressure (hypertension) in pregnancy with end-organ dysfunction, notably with proteinuria (protein in the urine).
When does pre-eclampsia usually occur?
After 20 weeks gestation
Triad of pre-eclampsia
HTN
proteinuria
oedema
Pregnancy-induced HTN
Pregnancy-induced hypertension or gestational hypertension is hypertension occurring after 20 weeks gestation, without proteinuria.
Chronic HTN
Chronic hypertension is high blood pressure that exists before 20 weeks gestation and is longstanding. This is not caused by dysfunction in the placenta and is not classed as pre-eclampsia.
BP >140/90mmHg on 2 occasions >4 hours apart
Single reading of diastolic BP >110mmHg
Causes of pre-eclampsia
Multifactorial
Genetic (FH)
Poor placentation
Immunological (poorly developed gestational immune tolerance)
High risk-factors for pre-eclampsia
Pre-existing hypertension
Previous hypertension in pregnancy
Existing autoimmune conditions (e.g. systemic lupus erythematosus)
Diabetes
Chronic kidney disease
Moderate-risk factors for pre-eclampsia
Older than 40
BMI > 35
More than 10 years since previous pregnancy
Multiple pregnancy
First pregnancy
Family history of pre-eclampsia
aspirin for pre-eclampsia prophylaxis
12 weeks until birth
one high risk factor or >3 moderate risk factors
dalteparin in pre-eclampsia
Give Dalteparin if anti-phospholipid syndrome or other pro-coagulant disorders
symptoms of pre-eclampsia
Headache
Visual disturbance or blurriness
Nausea and vomiting
Upper abdominal or epigastric pain (this is due to liver swelling)
Oedema
Reduced urine output
Brisk reflexes
Reduced fetal movement
Bleeding
signs of pre-eclampsia
HTN
Proteinuria
Non-dependent oedema
Hyper-reflexia/ clonus
Fetal growth restriction
Oligohydraminos
Abnormal fetal Doppler
maternal investigations pre-eclapmsia
Platelet count
Renal function: U&E and eGFR
LFT
DIC: coagulation profile in severe cases or thrombocytopenia
Level of proteinuria (PCR, 24 hour collection)
fetal investigations pre-eclampsia
Growth velocity (fetal growth ultrasound)
Fetal wellbeing (CTG, amniotic fluid volume, fetal Doppler)
diagnosis of pre-eclampsia
The NICE guidelines (2019) advise a diagnosis can be made with a:
Systolic blood pressure above 140 mmHg
Diastolic blood pressure above 90 mmHg
Cuff at heart level
Korotkoff phase V should be used
PLUS any of:
Proteinuria (1+ or more on urine dipstick)
Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies). Low PIGF
Proteinuria pre-eclampsia
Urine protein:creatinine ratio (above 30mg/mmol is significant)
Urine albumin:creatinine ratio (above 8mg/mmol is significant)
management gestational HTN
Treating to aim for a blood pressure below 135/85 mmHg
Admission for women with a blood pressure above 160/110 mmHg
Review medication if blood pressure stays below 110/70
Urine dipstick testing at least weekly
Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile)
Monitoring fetal growth by serial growth scans
PlGF testing on one occasion
pre-eclampsia scoring systems
Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S)
Gestation
Severity of maternal disease
Speed of progression (fulminating pre-eclampsia)
Presence of complications (HELLP)
Fetal wellbeing
pre-eclampsia management
Blood pressure is monitored closely (at least every 48 hours)
Urine dipstick testing is not routinely necessary (the diagnosis is already made)
Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly
medical management of pre-eclampsia
labetolol first line
nifedipine
methyldopa
IV hydralazine
IV labetalol
IV magnesium sulphate
fluid restriction
severe/fulminating pre-eclampsia
Control HTN
Prevent seizures (maternal Mg infusion)
Administer steroids for lung maturation if preterm
Deliver by most appropriate route
Strict fluid balance
HDU care
obstetric emergency pre-eclampsia
Seizures occurring in pregnancy or within 10 days of delivery
> 2 of following within 24 hours of seizure
HTN
Proteinuria one ‘plus’ or at least 0.3G/24h
Thrombocytopenia <100,000ul
Raised transaminases
pre-eclampsia management after delivery
Enalapril (first-line)
Nifedipine or amlodipine (first-line in black African or Caribbean patients
Labetolol or atenolol (third-line)
post-natal management of pre-eclampsia
May require antihypertensive treatment for 6-12 weeks postnatrally
Increased risk of VTW, particularly in severe proteinuria
If severe PET, may require follow up bloods
Postnatal HTN clinic where appropriate
Discuss contraception before discharge
Discuss implications for future pregnancy
Write to GP with details of treatment, delivery, and aftercare
complications of pre-eclampsia
maternal
CNS:
Eclampsia
Intracranial haemorrhage/ stroke
Cortical blindness
Renal:
Renal tubular necrosis (AKI)
Respiratory:
Pulmonary oedema
Liver:
HELLP syndrome
Liver capsule haemorrhage
Liver rupture
Haematological:
DIC
VTE
Placenta:
Placental abruption
fetal complications of pre-eclampsia
Highest single risk factor for stillbirth (20% of stillbirths)
Accounts for 46% of infants born small for gestation age
Accounts for 30% of premature infants
risk factors for GDM
Previous gestational diabetes
Previous macrosomic baby (≥ 4.5kg)
BMI > 30
Ethnic origin (black Caribbean, Middle Eastern and South Asian)
Family history of diabetes (first-degree relative)
OGTT GDM
24-28 weeks
- 6 fasting
- 8 2 hours after 75g sugar
Pre-pregnancy care GDM
Information about optimum blood glucose control prior to conception
Improving general health, reducing obesity
Aiming to reduce risks of diabetes embropathy and other adverse pregnancy outcomes for mother and baby
All women should be offered pre-pregnancy care
T1, T2, previous GDM
Aim for HbA1c <40mmol/mol
Avoid pregnancy if >86
Offer women with DM/ BMI >27:
Weight loss advice
Retinal assessment:
Advise to defer rapid optimisation of blood glucose control until after retinal assessment
Renal assessment:
Before discontinuing contraception
Medications:
Folic acid 5mg/day (3/12 preconception to 3/12 after conception)
Aspirin 75mg >12 weeks gestation
Assess need for VTE prophylaxis
If BMI >35 recommend vitD supplements (Pregnacare)
Stop unsafe medications, e.g. statins
SAFER GDM
STOP: think ahead, is medication suitable for pregnancy?
A1C: on target or too high
Folic acid
Enjoy
Referral early to specialist care
Management of GDM
Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin
Fasting glucose above 7 mmol/l: start insulin ± metformin
Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin
blood sugar monitoring GDM
Fasting: 5.3 mmol/l
1 hour post-meal: 7.8 mmol/l
2 hours post-meal: 6.4 mmol/l
Avoiding levels of 4 mmol/l or below
Planning GDM delivery
Delivery 37-38+6
IOL: 37-38+6
Elective CS: 38-39
postnatal care GDM
Diabetes improves immediately after birth. Women with gestational diabetes can stop their diabetic medications immediately after birth.
They need follow up to test their fasting glucose after at least six weeks.
HbA1C at 13 weeks and yearly thereafter due to increased risk of T2DM
Lifestyle advice
Contraception and need for pre conception care in future
Women with existing diabetes should lower their insulin doses and be wary of hypoglycaemia in the postnatal period. The insulin sensitivity will increase after birth and with breastfeeding.
Future obesity, metabolic syndrome, diabetes, HTN, CVD
risk to neonate when mother has GDM
neonatal hypoglycaemia polycythaemia (raised Hb) jaundice (raised bilirubin) congenital heart disease cardiomyopathy spina bifida, anencephaly caudal regression/ sacral agenesis
obstetric cholestasis maternal risks
Vit k deficiency
Increased risk of PPH
obstetric cholestasis fetal risks
Perinatal mortality is increased up to 11%
Fetal distress
Meconium
Pre-term labour
Intracranial haemorrhage
Stillbirth
obstetric cholestasis presentation
Fatigue
Dark urine
Pale, greasy stools
Jaundice
Skin trauma from intense scratching
Insomnia and malaise
Ix for pruritis
Women presenting with pruritus should have liver function tests and bile acids checked.
Viral screen:
Hep A,B and C
EBV and CMV
Liver autoimmune screen:
Chronic active hepatitis and primary biliary cirrhosis
Anti-smooth muscle and antimitochondrial antibodies
USS abdomen- liver and gallstones
Obstetric cholestasis will cause:
Abnormal liver function tests (LFTs), mainly ALT, AST and GGT
Raised bile acids
management of obstetric cholestasis
ursodeoxycholic acid emollients antihistamine vitK monitor LFTs planned delivery after 37 weeks
Procoagulant pathophysiological changes in pregnancy:
Hypercoagulable state
Increase in fibrinogen and factors VIII, IX, X
Concentration of endogenous anticoagulants decreases
Additional risk is present for at least 6 weeks post-partum
Venous stasis in lower limbs
Trauma of pelvic veins at the time of delivery
risk factors for VTE in pregnancy
Smoking
Parity ≥ 3
Age > 35 years
BMI > 30
Reduced mobility
Multiple pregnancy
Pre-eclampsia
Gross varicose veins
Immobility
Family history of VTE
Thrombophilia
Paraplegia
IVF pregnancy
obstetric risk factors for VTE
Multiple pregnancy
PET
CS
Prolonged labour >24 hours
Mid-cavity or rotational operative delivery
Still birth
Preterm birth
PPH >1L
new onset reversible risk factors VTE
Bone fracture
Surgical procedure in pregnancy and puerperium
Hyperemesis, dehydration
OHSS/ ART
Immobility >3 days
Long haul travel >4 hours
Current systemic infection
when to start VTE prophylaxis
28 weeks if there are three risk factors
First trimester if there are four or more of these risk factors
Up to 6 weeks post natally
Hospital admission Surgical procedures Previous VTE Medical conditions such as cancer or arthritis High-risk thrombophilias Ovarian hyperstimulation syndrome
DVT diagnosis
Gold standard is venography with fetal shield
Doppler ultrasound of leg veins is a good alternative:
Direct imaging of clot
Repeat day 3 and 7
Lack of compressability of vein
PE diagnosis
CXR
ECG
abg
Oxygen sats
VTE prophylaxis
LMWH
enoxaparin, dalteparin, tinzaparin
mechanical prophylaxis VTE
intermittent pneumatic compression with equipment that inflates and deflates to massage the legs
Anti-embolic compression stockings
DVT presentation
Calf or leg swelling
Dilated superficial veins
Tenderness to the calf (particularly over the deep veins)
Oedema
Colour changes to the leg
> 3cm difference between the calves
PE presentation
Shortness of breath
Cough with or without blood (haemoptysis)
Pleuritic chest pain
Hypoxia
Tachycardia (this can be difficult to distinguish from the normal physiological changes in pregnancy)
Raised respiratory rate
Low-grade fever
Haemodynamic instability causing hypotension
suspected PE pathway
Clinical assessment
Perform CXR and ECG
Test FBC, U&E, LFTs
Commence LMWH (unless treatment is contraindicated)
Duplex USS for S/S of DVT
VQ scan of CXR normal
CTPA if CXR abnormal
CTPA vs VQ
CTPA is the test for choice for patients with an abnormal chest xray
CTPA carries a higher risk of breast cancer for the mother (minimal absolute risk)
VQ scan carriers a higher risk of childhood cancer for the fetus (minimal absolute risk)
