Complications of Pregnancy 2 Flashcards
what is considered mild hypertension in pregnancy?
- diastolic BP 90-99
- systolic BP 140-49
what is considered moderate hypertension in pregnancy?
- diastolic BP 100-109
- systolic BP 150-159
what is considered severe hypertension in pregnancy?
- diastolic >/= 110
- systolic >/= 160
what are the different types of hypertensive disorders in pregnancy?
- 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 **
what is considered significant proteinuria?
- automated reagent strip urine protein estimation > 1+
- spot urinary protein:creatinine ratio > 30 mg/mmol
- 24 hrs urine protein collection > 300mg/day
chronic hypertension pregnancy management
- 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
pre-eclampsia diagnosis
- hypertension on two occasions more than 4 hrs apart
+ proteinuria of more than 300mgs/24hrs (protein urine > + protein:creatinine ratio > 30mgms/mmol)
pre-eclampsia pathophysiology
- The exact aetiology of pre-eclampsia remains unclear. However, it’s believed to be related to dysfunctional trophoblast invasion of the spiral arterioles, which results in decreased uteroplacental blood flow and subsequent endothelial cell damage.
- complex + multifactorial (immunological/genetic predisposition) - abnormal placentation + maternal microvascular disease
pre-eclampsia (PET) risk factors
- 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
pre-eclampsia maternal complications
- eclampsia: seizures
- severe hypertension: cerebral haemorrhage, stroke
- HELLP (haemolysis, elevated liver enzymes, low platelets)
- DIC (disseminated intravascular coagulation)
- renal failure
- pulmonary oedema, cardiac failure
pre-eclampsia fetal complications
- impaired placental perfusion > IUGR, fetal distress, prematurity, increased PN mortality
what are the symptoms/signs of severe pre-eclampsia (PET)
- 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)
what biochemical abnormalities are observed in severe pre-eclampsia?
- raised liver enzymes, bilirubin if HELLP present
- raised urea and creatinine, raised urate
which haematological abnormalities can be seen in severe pre-eclampsia?
- low platelets
- low haemoglobin, sign of haemolysis
- features of DIC
Pre-eclampsia management
- 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)
what is the treatment of seizures/impending seizures in PET & eclampsia?
- magnesium sulphate bolus + IV infusion
- control of blood pressure - IV labetolol, hydralazine (if > 160/100)
- avoid fluid overload - aim for 80mls/hour fluid intake
Prophylaxis for PET in subsequent pregnancy
Low dose Aspirin from 12 weeks till delivery
Women with PET at a higher risk to develop hypertension in later life
what factors need to be considered when a woman with pre-existing diabetes becomes pregnant?
- 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
Effects of diabetes on mother, fetus & neonate
Fetus:
- 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
Mother:
- increased risk of pre-eclampsia
- Worsening of maternal nephropathy, retinopathy, hypoglycaemia, reduced awareness of hypoglycaemia
- Infections
Neonate:
- neonatal - Impaired lung maturity, neonatal hypoglycemia, jaundice
diabetes management preconception
- 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
risk factors for gestational diabetes mellitus (GDM)
- 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
screening for gesatonal diabetes mellitus (GDM)
- 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.
management of GDM
- 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
Virchow’s triad
at risk of developing venous thrombo-embolism
Why is the risk of thrombo-embolism increased in pregnancy?
use Virchow’s triad
- 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
thromboembolism in pregnancy risk factors
- 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
venous thrombo-embolism prophylaxis in pregnancy
- 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
symptoms/signs of VTE
pain in calf, increased girth of affected leg, calf muscle tenderness
breathlessness, pain on breathing, cough, tachycardia, hypoxic, pleural rub, etc
VTE investiagtions
