Complications in pregnancy and maternal medicine

Question 1

Pre-eclampsia

Answer 1

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

Question 2

When does pre-eclampsia usually occur?

Answer 2

After 20 weeks gestation

Question 3

Triad of pre-eclampsia

Answer 3

HTN
proteinuria
oedema

Question 4

Pregnancy-induced HTN

Answer 4

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

Question 5

Chronic HTN

Answer 5

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

Question 6

Causes of pre-eclampsia

Answer 6

Multifactorial

Genetic (FH)

Poor placentation

Immunological (poorly developed gestational immune tolerance)

Question 7

High risk-factors for pre-eclampsia

Answer 7

Pre-existing hypertension

Previous hypertension in pregnancy

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

Diabetes

Chronic kidney disease

Question 8

Moderate-risk factors for pre-eclampsia

Answer 8

Older than 40

BMI > 35

More than 10 years since previous pregnancy

Multiple pregnancy

First pregnancy

Family history of pre-eclampsia

Question 9

aspirin for pre-eclampsia prophylaxis

Answer 9

12 weeks until birth

one high risk factor or >3 moderate risk factors

Question 10

dalteparin in pre-eclampsia

Answer 10

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

Question 11

symptoms of pre-eclampsia

Answer 11

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

Question 12

signs of pre-eclampsia

Answer 12

HTN

Proteinuria

Non-dependent oedema

Hyper-reflexia/ clonus

Fetal growth restriction

Oligohydraminos

Abnormal fetal Doppler

Question 13

maternal investigations pre-eclapmsia

Answer 13

Platelet count

Renal function: U&E and eGFR

LFT

DIC: coagulation profile in severe cases or thrombocytopenia

Level of proteinuria (PCR, 24 hour collection)

Question 14

fetal investigations pre-eclampsia

Answer 14

Growth velocity (fetal growth ultrasound)

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

Question 15

diagnosis of pre-eclampsia

Answer 15

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

Question 16

Proteinuria pre-eclampsia

Answer 16

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

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

Question 17

management gestational HTN

Answer 17

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

Question 18

pre-eclampsia scoring systems

Answer 18

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

Question 19

pre-eclampsia management

Answer 19

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

Question 20

medical management of pre-eclampsia

Answer 20

labetolol first line
nifedipine
methyldopa

IV hydralazine
IV labetalol
IV magnesium sulphate
fluid restriction

Question 21

severe/fulminating pre-eclampsia

Answer 21

Control HTN

Prevent seizures (maternal Mg infusion)

Administer steroids for lung maturation if preterm

Deliver by most appropriate route

Strict fluid balance

HDU care

Question 22

obstetric emergency pre-eclampsia

Answer 22

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

Question 23

pre-eclampsia management after delivery

Answer 23

Enalapril (first-line)

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

Labetolol or atenolol (third-line)

Question 24

post-natal management of pre-eclampsia

Answer 24

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

Question 25

complications of pre-eclampsia | maternal

Answer 25

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

Question 26

fetal complications of pre-eclampsia

Answer 26

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

Question 27

risk factors for GDM

Answer 27

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)

Question 28

OGTT GDM

Answer 28

24-28 weeks 5. 6 fasting 7. 8 2 hours after 75g sugar

Question 29

Pre-pregnancy care GDM

Answer 29

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

Question 30

SAFER GDM

Answer 30

STOP: think ahead, is medication suitable for pregnancy? A1C: on target or too high Folic acid Enjoy Referral early to specialist care

Question 31

Management of GDM

Answer 31

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

Question 32

blood sugar monitoring GDM

Answer 32

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

Question 33

Planning GDM delivery

Answer 33

Delivery 37-38+6 IOL: 37-38+6 Elective CS: 38-39

Question 34

postnatal care GDM

Answer 34

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

Question 35

risk to neonate when mother has GDM

Answer 35

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

Question 36

obstetric cholestasis maternal risks

Answer 36

Vit k deficiency Increased risk of PPH

Question 37

obstetric cholestasis fetal risks

Answer 37

Perinatal mortality is increased up to 11% Fetal distress Meconium Pre-term labour Intracranial haemorrhage Stillbirth

Question 38

obstetric cholestasis presentation

Answer 38

Fatigue Dark urine Pale, greasy stools Jaundice Skin trauma from intense scratching Insomnia and malaise

Question 39

Ix for pruritis

Answer 39

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

Question 40

management of obstetric cholestasis

Answer 40

``` ursodeoxycholic acid emollients antihistamine vitK monitor LFTs planned delivery after 37 weeks ```

Question 41

Procoagulant pathophysiological changes in pregnancy:

Answer 41

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

Question 42

risk factors for VTE in pregnancy

Answer 42

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

Question 43

obstetric risk factors for VTE

Answer 43

Multiple pregnancy PET CS Prolonged labour >24 hours Mid-cavity or rotational operative delivery Still birth Preterm birth PPH >1L

Question 44

new onset reversible risk factors VTE

Answer 44

Bone fracture Surgical procedure in pregnancy and puerperium Hyperemesis, dehydration OHSS/ ART Immobility >3 days Long haul travel >4 hours Current systemic infection

Question 45

when to start VTE prophylaxis

Answer 45

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 ```

Question 46

DVT diagnosis

Answer 46

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

Question 47

PE diagnosis

Answer 47

CXR ECG abg Oxygen sats

Question 48

VTE prophylaxis

Answer 48

LMWH | enoxaparin, dalteparin, tinzaparin

Question 49

mechanical prophylaxis VTE

Answer 49

intermittent pneumatic compression with equipment that inflates and deflates to massage the legs Anti-embolic compression stockings

Question 50

DVT presentation

Answer 50

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

Question 51

PE presentation

Answer 51

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

Question 52

suspected PE pathway

Answer 52

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

Question 53

CTPA vs VQ

Answer 53

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)