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Obstetrics > Complications in pregnancy and maternal medicine > Flashcards

Complications in pregnancy and maternal medicine Flashcards

1
Q

Pre-eclampsia

A

Pre-eclampsia refers to new high blood pressure (hypertension) in pregnancy with end-organ dysfunction, notably with proteinuria (protein in the urine).

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2
Q

When does pre-eclampsia usually occur?

A

After 20 weeks gestation

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3
Q

Triad of pre-eclampsia

A

HTN
proteinuria
oedema

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4
Q

Pregnancy-induced HTN

A

Pregnancy-induced hypertension or gestational hypertension is hypertension occurring after 20 weeks gestation, without proteinuria.

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5
Q

Chronic HTN

A

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

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6
Q

Causes of pre-eclampsia

A

Multifactorial

Genetic (FH)

Poor placentation

Immunological (poorly developed gestational immune tolerance)

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7
Q

High risk-factors for pre-eclampsia

A

Pre-existing hypertension

Previous hypertension in pregnancy

Existing autoimmune conditions (e.g. systemic lupus erythematosus)

Diabetes

Chronic kidney disease

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8
Q

Moderate-risk factors for pre-eclampsia

A

Older than 40

BMI > 35

More than 10 years since previous pregnancy

Multiple pregnancy

First pregnancy

Family history of pre-eclampsia

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9
Q

aspirin for pre-eclampsia prophylaxis

A

12 weeks until birth

one high risk factor or >3 moderate risk factors

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10
Q

dalteparin in pre-eclampsia

A

Give Dalteparin if anti-phospholipid syndrome or other pro-coagulant disorders

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11
Q

symptoms of pre-eclampsia

A

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

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12
Q

signs of pre-eclampsia

A

HTN

Proteinuria

Non-dependent oedema

Hyper-reflexia/ clonus

Fetal growth restriction

Oligohydraminos

Abnormal fetal Doppler

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13
Q

maternal investigations pre-eclapmsia

A

Platelet count

Renal function: U&E and eGFR

LFT

DIC: coagulation profile in severe cases or thrombocytopenia

Level of proteinuria (PCR, 24 hour collection)

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14
Q

fetal investigations pre-eclampsia

A

Growth velocity (fetal growth ultrasound)

Fetal wellbeing (CTG, amniotic fluid volume, fetal Doppler)

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15
Q

diagnosis of pre-eclampsia

A

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

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16
Q

Proteinuria pre-eclampsia

A

Urine protein:creatinine ratio (above 30mg/mmol is significant)

Urine albumin:creatinine ratio (above 8mg/mmol is significant)

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17
Q

management gestational HTN

A

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

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18
Q

pre-eclampsia scoring systems

A

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

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19
Q

pre-eclampsia management

A

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

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20
Q

medical management of pre-eclampsia

A

labetolol first line
nifedipine
methyldopa

IV hydralazine
IV labetalol
IV magnesium sulphate
fluid restriction

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21
Q

severe/fulminating pre-eclampsia

A

Control HTN

Prevent seizures (maternal Mg infusion)

Administer steroids for lung maturation if preterm

Deliver by most appropriate route

Strict fluid balance

HDU care

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22
Q

obstetric emergency pre-eclampsia

A

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

23
Q

pre-eclampsia management after delivery

A

Enalapril (first-line)

Nifedipine or amlodipine (first-line in black African or Caribbean patients

Labetolol or atenolol (third-line)

24
Q

post-natal management of pre-eclampsia

A

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

25
Q

complications of pre-eclampsia

maternal

A

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

26
Q

fetal complications of pre-eclampsia

A

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

27
Q

risk factors for GDM

A

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)

28
Q

OGTT GDM

A

24-28 weeks

  1. 6 fasting
  2. 8 2 hours after 75g sugar
29
Q

Pre-pregnancy care GDM

A

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

30
Q

SAFER GDM

A

STOP: think ahead, is medication suitable for pregnancy?

A1C: on target or too high

Folic acid

Enjoy

Referral early to specialist care

31
Q

Management of GDM

A

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

32
Q

blood sugar monitoring GDM

A

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

33
Q

Planning GDM delivery

A

Delivery 37-38+6

IOL: 37-38+6

Elective CS: 38-39

34
Q

postnatal care GDM

A

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

35
Q

risk to neonate when mother has GDM

A 
neonatal hypoglycaemia
polycythaemia (raised Hb)
jaundice (raised bilirubin)
congenital heart disease
cardiomyopathy
spina bifida, anencephaly
caudal regression/ sacral agenesis
36
Q

obstetric cholestasis maternal risks

A

Vit k deficiency

Increased risk of PPH

37
Q

obstetric cholestasis fetal risks

A

Perinatal mortality is increased up to 11%

Fetal distress

Meconium

Pre-term labour

Intracranial haemorrhage

Stillbirth

38
Q

obstetric cholestasis presentation

A

Fatigue

Dark urine

Pale, greasy stools

Jaundice

Skin trauma from intense scratching

Insomnia and malaise

39
Q

Ix for pruritis

A

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

40
Q

management of obstetric cholestasis

A 
ursodeoxycholic acid
emollients
antihistamine
vitK 
monitor LFTs
planned delivery after 37 weeks
41
Q

Procoagulant pathophysiological changes in pregnancy:

A

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

42
Q

risk factors for VTE in pregnancy

A

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

43
Q

obstetric risk factors for VTE

A

Multiple pregnancy

PET

CS

Prolonged labour >24 hours

Mid-cavity or rotational operative delivery

Still birth

Preterm birth

PPH >1L

44
Q

new onset reversible risk factors VTE

A

Bone fracture

Surgical procedure in pregnancy and puerperium

Hyperemesis, dehydration

OHSS/ ART

Immobility >3 days

Long haul travel >4 hours

Current systemic infection

45
Q

when to start VTE prophylaxis

A

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
46
Q

DVT diagnosis

A

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

47
Q

PE diagnosis

A

CXR
ECG
abg
Oxygen sats

48
Q

VTE prophylaxis

A

LMWH

enoxaparin, dalteparin, tinzaparin

49
Q

mechanical prophylaxis VTE

A

intermittent pneumatic compression with equipment that inflates and deflates to massage the legs

Anti-embolic compression stockings

50
Q

DVT presentation

A

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

51
Q

PE presentation

A

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

52
Q

suspected PE pathway

A

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

53
Q

CTPA vs VQ

A

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)

Obstetrics (10 decks)

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