Complications of Pregnancy 2

Question 1

what is considered mild hypertension in pregnancy?

Answer 1

• diastolic BP 90-99
• systolic BP 140-49

Question 2

what is considered moderate hypertension in pregnancy?

Answer 2

• diastolic BP 100-109
• systolic BP 150-159

Question 3

what is considered severe hypertension in pregnancy?

Answer 3

• diastolic >/= 110
• systolic >/= 160

Question 4

what are the different types of hypertensive disorders in pregnancy?

Answer 4

• chronic hypertension: Hypertension either pre-pregnancy or at booking (≤ 20 weeks gestation)
• gestational hypertension (PIH - pregnancy induced hypertension): new hypertension in pregnancy usually develops after 20 weeks
• pre-eclampsia: New hypertension > 20 weeks in association with **significant proteinuria **

Question 5

what is considered significant proteinuria?

Answer 5

• automated reagent strip urine protein estimation > 1+
• spot urinary protein:creatinine ratio > 30 mg/mmol
• 24 hrs urine protein collection > 300mg/day

Question 6

chronic hypertension pregnancy management

Answer 6

• change anti-hypertensives drugs if indicated (e.g. ACE-i’s)
• 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

Question 7

pre-eclampsia diagnosis

Answer 7

• hypertension on two occasions more than 4 hrs apart
  + proteinuria of more than 300mgs/24hrs (protein urine > + protein:creatinine ratio > 30mgms/mmol)

Question 8

pre-eclampsia pathophysiology

Answer 8

• complex + multifactorial (immunological/genetic predisposition) - abnormal placentation + maternal microvascular disease
• impaired secondary invasion of maternal spiral arterioles by trophoblasts  reduced placental perfusion – placental ischaemia
• low level chronic inflammation – endothelial damage
• imbalance between angiogenic (PlGF)and antiangiogenic (sFlt-1)factors in pregnancy -FMS like tyrosine kinase inhibits neovascularisation and in pregnancy with preeclampsia PlGF is lower

Question 9

pre-eclampsia (PET) risk factors

Answer 9

• 1st pregnancy
• extremes of maternal age
• pre-eclampsia in a previous pregnancy
• pregnancy interval > 10 years
• BMI > 35
• family history of PET
• multiple pregnancy
• underlying medical disorders e.g. hypertension, diabetes, renal disease, autoimmune disorders like SLE

Question 10

pre-eclampsia maternal complications

Answer 10

• eclampsia: seizures
• severe hypertension: cerebral haemorrhage, stroke
• HELLP (haemolysis, elevated liver enzymes, low platelets)
• DIC (disseminated intravascular coagulation)
• renal failure
• pulmonary oedema, cardiac failure

Question 11

pre-eclampsia fetal complications

Answer 11

• impaired placental perfusion > IUGR, fetal distress, prematurity, increased PN mortality

Question 12

what are the symptoms/signs of severe pre-eclampsia (PET)

Answer 12

• headache, blurring of vision, epigastric pain, pain below ribs, vomiting, sudden swelling of hands, face, legs
• severe hypertension; > 3+ urine proteinuria
• clonus/brisk reflexes; papillodema, epigastric tenderness
• reducing urine output
• convulsions (eclampsia)

Question 13

what biochemical abnormalities are observed in severe pre-eclampsia?

Answer 13

• raised liver enzymes, bilirubin if HELLP present
• raised urea and creatinine, raised urate

Question 14

which haematological abnormalities can be seen in severe pre-eclampsia?

Answer 14

• low platelets
• low haemoglobin, sign of haemolysis
• features of DIC

Question 15

Pre-eclampsia management

Answer 15

• frequent BP checks, urine protein
• check symptomatology: headaches, epigastric pain, visual disturbances
• check for hyper-reflexia (clonus), tenderness over the liver
• bloods: FBC, LFTs, U&Es, coagulations tests if indicated
• fetal investigations: scan for growth, cardiotocography (CTG)
• only ‘cure’ is delivery of the baby and placenta
• conservative: close observations, anti-hypertensives (labetolol, methyldopa, nifedipine), steroids for fetal lung maturity if gestation < 36 weeks)

Question 16

what is the treatment of seizures/impending seizures in PET & eclampsia?

Answer 16

• magnesium sulphate bolus + IV infusion
• control of blood pressure - IV labetolol, hydralazine (if > 160/100)
• avoid fluid overload - aim for 80mls/hour fluid intake

Question 17

Prophylaxis for PET in subsequent pregnancy

Answer 17

Low dose Aspirin from 12 weeks till delivery

Women with PET at a higher risk to develop hypertension in later life

Question 18

what factors need to be considered when a woman with pre-existing diabetes becomes pregnant?

Answer 18

• insulin requirements increase
• fetal-hyperinsulemia occurs: maternal glucose crosses the placenta and induces increased insulin production in the fetus. The fetal hyperinsulinemia causes macrosmia.
• post-delivery: more risk of neonatal hypoglycaemia, increased risk of respiratory distress

Question 19

Effects of diabetes on mother, fetus & neonate

Answer 19

Increased risks of:
- Fetal 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
- increased risk of pre-eclampsia
- Worsening of maternal nephropathy, retinopathy, hypoglycaemia, reduced awareness of hypoglycaemia
- Infections
- neonatal - Impaired lung maturity, neonatal hypoglycemia, jaundice

Question 20

diabetes management preconception

Answer 20

• 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

Question 21

risk factors for gestational diabetes mellitus (GDM)

Answer 21

• increased BMI > 30
• previous macrosomic baby > 4.5kg
• previous GDM
• FHx of diabetes
• women from high risk groups for developing diabetes e.g. asian origin
• polyhydramnios or big baby in current pregnancy
• recurrent glycosuria in current pregnancy

Question 22

screening for gesatonal diabetes mellitus (GDM)

Answer 22

• if risk factor present, offer HbA1C estimation at booking, if > 6% (43mmol/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 present.

Question 23

management of GDM

Answer 23

• control blood sugars: diet, metformin/insulin if sugars remain high
• post delivery, check OGTT 6-8 weeks PN
• yearly check on HbA1C/blood sugars as at higher risk of developing overt diabetes

Question 24

Virchow’s triad

Answer 24

at risk of developing venous thrombo-embolism

Question 25

Why is the risk of thrombo-embolism increased in pregnancy?

use Virchow’s triad

Answer 25

• pregnancy is a hypercoagulable state (to protect mother against bleeding post-delivery)
• increased stasis - progesterone, effects of enlarging uterus
• may be vascular damage at delivery/caesearean section

Question 26

thromboembolism in pregnancy risk factors

Answer 26

• 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

Question 27

venous thrombo-embolism prophylaxis in pregnancy

Answer 27

• TED stockings
• advise 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

Question 28

symptoms/signs of VTE

Answer 28

pain in calf, increased girth of affected leg, calf muscle tenderness
breathlessness, pain on breathing, cough, tachycardia, hypoxic, pleural rub, etc

Question 29

VTE investiagtions

Answer 29