Complications of Pregnancy 2 Flashcards
What are the hypertensive disorders in pregnancy?
Chronic hypertension - hypertension either pre-pregnancy or at booking (< 20 weeks gestation)
Mild hypertension - diastolic 90-99, systolic 140-149
Moderate hypertension - diastolic 100-109, systolic 150-159
Severe hypertension - diastolic 110 or higher, systolic 160 or higher
Gestational hypertension - BP as above but new hypertension i.e. developed after 20 weeks
Pre-eclampsia - new hypertension > 20 weeks in association with significant proteinuria
How is significant proteinuria detected?
Automated reagent strip urine protein estimation > 1+
Spot Urinary Protein: Creatinine Ratio > 30mg/mmol
24 hour urine protein collection > 300mg/day
In what mothers is chronic/essential hypertension commoner?
Older mothers
What is the pre-pregnancy and pregnancy care given for women with hypertension?
Ideally should have pre-pregnancy care
Change anti-hypertensive drugs if indicated i.e. if taking;
- ACEIs cause birth defects and impaired growth
- ARBs
- anti-diuretics
- lower dietary sodium
Aim to keep BP < 150/100 - labetolol, nifedipine, methyldopa safe to use
Monitor for superimposed pre-eclampsia
If on beta-blockers, monitor foetal growth
May have higher incidence of placental abruption
What is pre-eclampsia?
Mild hypertension on two occasions more than 4 hours apart
or
One reading of moderate-to-severe hypertension
plus
Proteinuria of more than 300mgms/24 hours
(protein urine > +,
protein : creatinine ratio > 30 mgms/mmol)
Pre-eclampsia is a multi-system multi-organ disorder with renal, hepatic, vascular, cerebral and pulmonary effects
What is the pathophysiology of pre-eclampsia?
Immunological
Genetic predisposition
Secondary invasion of maternal spiral arterioles by trophoblasts causing them to become impaired, reducing placental perfusion
Imbalance between vasodilators and vasoconstrictors in pregnancy
What are the risk factors for pre-eclampsia (PET)?
First pregnancy Extremes of maternal age Pre-eclampsia in a previous pregnancy, especially severe PET, delivery < 24 weeks, IUGR baby, IUD or abruption Pregnancy interval > 10 years BMI > 35 Family history of PET Underlying medical disorders - Chronic hypertension - Pre-existing renal disease - Pre-existing diabetes - Autoimmune disorders
What are the symptoms and signs of severe PET?
Headache Blurred vision Epigastric pain Pain below ribs Vomiting Sudden swelling of hands, face, legs Severe hypertension, 3+ urine proteinuria Clonus/brisk reflexes - papilloedema, epigastric tenderness Reducing urine output Convulsions - eclampsia
What are the biochemical abnormalities seen in PET?
Raised liver enzymes, bilirubin if HELLP present
Raised urea and creatinine
Raised urate
What are the haematological abnormalities seen in PET?
Low platelets
Low haemoglobin, signs of haemolysis
Features of DIC
What is the investigation of pre-eclampsia?
Frequent BP checks and urine protein
Check symptomatology - headaches, epigastric pain, visual disturbances
Check for hyper-reflexia and tenderness over the liver
Blood investigations - FBC for haemolysis and platelets, LFTs, RFTs (serum urea, creatinine, urate), coagulation tests if indicated
Foetal investigations - scan for growth, cardiotocography
What is the conservative treatment of pre-eclampsia?
Aim for foetal maturity
Close observation of clinical signs and investigations
Anti-hypertensives e.g. labetolol, methyldopa, nifedipine
Steroids for foetal lung maturity if gestation < 36 weeks
Consider induction of labour or Caesarean section if maternal or foetal condition deteriorates, irrespective of gestation
Risks of PET may persist into the puerperium so monitoring must be continues post-delivery
What percentage of pregnant women have PET?
5-8%
What percentage of pregnant women have severe PET?
0.5%
What percentage of pregnant women have eclamptic seizures?
0.05%
What percentage of eclamptic seizures occur antepartum, intrapartum and postpartum?
35% antepartum
15% intrapartum
44% postpartum
What is the treatment of eclamptic seizures/impending eclamptic seizures?
Magnesium sulphate bolus and IV infusion
Control of blood pressure - IV labetolol, hydralazine (if > 160/110)
Avoid fluid overload - aim for 80ml/hour fluid intake
What is the prophylaxis for PET in subsequent pregnancy?
Low dose aspirin from 12 weeks until delivery
What are women with PET at higher risk of developing in later life?
Hypertension
What are the maternal complications of pre-eclampsia?
Seizures (eclampsia)
Severe hypertension - cerebral haemorrhage, stroke
HELLP - haemolysis, elevated liver enzymes, low platelets
DIC - disseminated intravascular coagulation
Renal failure
Pulmonary oedema, cardiac failure
What are the foetal complications of pre-eclampsia?
Impaired placental perfusion IUGR Foetal distress Prematurity Increased PR mortality
What is gestational diabetes?
Carbohydrate intolerance with onset (or first recognised) in pregnancy
Abnormal glucose tolerance that reverts to normal after delivery
What are women with gestation diabetes more at risk of?
Developing type II diabetes in later life
What is the effect of pregnancy on pre-existing diabetes?
Insulin requirements of the mother increases because human placental lactogen, progesterone, human chorionic gonadotrophin and cortisol all have anti-insulin actions
How does foetal hyper-insulinaemia occur?
Maternal glucose crosses the placenta and induces increased insulin production in the foetus
What does foetal hyper-insulinaemia cause?
Macrosomia
What is there more risk of postnatally for the foetus if the mother has diabetes?
Neonatal hypoglycaemia
What does diabetes increase the risk of?
Foetal congenital abnormalities - especially if blood sugars are high peri-conception
Miscarriage
Pre-eclampsia
Foetal macrosomia, polyhydramnios
Operative delivery, shoulder dystocia
Worsening of maternal nephropathy, retinopathy, hypoglycaemia, reduced awareness of hypoglycaemia
Infections
Stillbirth, increased perinatal mortality
Neonatal - impaired lung maturity, neonatal hypoglycaemia, jaundice
What is the pre-conception management of maternal diabetes?
Better glycemic control, ideally blood sugars should be around 4-7mmol/l pre-conception and HbA1C < 6.5% (<48mmol/mol)
Folic acid 5mg
Dietary advice
Retinal and renal assessment
What is the management of diabetes during pregnancy?
Optimise glucose control - insulin requirements will increase
Could continue oral anti-diabetic agents but may need to change to insulin for tighter glucose control
Be aware of the risk of hypoglycaemia - provide glucagon injections/concentrated glucose solution
Watch for ketonuria/infections
Repeat retinal assessments at 28 and 34 weeks
Watch for foetal growth
Observe for PET
Labour usually induced at 38-40 weeks
Continuous CTG foetal monitoring in labour
Maintain blood sugar in labour with insulin - dextrose insulin infusion
Early feeding of baby to reduce neonatal hypoglycaemia
Can return to pre-pregancy regimen of insulin post-delivery
When should you consider an elective Caesarean section in a woman with diabetes?
If significant foetal macrosomia
When might labour be induced earlier than 38 weeks in a woman with diabetes?
If foetal or maternal concerns
What glucose levels should you aim for during pregnancy in a woman with diabetes; fasting, 1 hour post-prandial, 2 hours post-prandial and before bedtime?
Fasting - < 5.3mmol/l
1 hour post-prandial - < 7.8mmol/l
2 hours post-prandial - < 6.4mmol/l
Before bedtime - < 6mmol/l
What are the risk factors for gestational diabetes mellitus?
Increased BMI > 30
Previous macrosomic baby > 4.5kg
Previous GDM
Family history 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
What is the increase in complications with GDM compared to type I or II DM?
GDM is associated with some increase in maternal complications e.g. PET and foetal complications e.g. macrosomia, but much less than with type I or II DM
What screening should be offered for GDM?
If a risk factor is present, offer HbA1c estimation at booking
If > 6% (43mmol/mol) do 75gms oral glucose tolerance test (OGTT)
If normal, repeat at 24-28 weeks
Can also offer OGTT at around 16 weeks and repeat at 28 weeks if there are significant risk factors present e.g. previous GDM
What is the management of gestational diabetes mellitus?
Control blood sugars with diet, give metformin/insulin if sugars remain high
Post-delivery check OGTT 6-8 weeks postnatal
Yearly check on HbA1C and blood sugars as higher risk of developing overt diabetes
Why is there an increased risk of venous thromboembolism (VTE) in pregnancy?
Pregnancy is a hyper coagulable state - to protect mother against bleeding post-delivery
Increase in fibrinogen, factor VIII, VW factor, platelets and fibrinolysis
Decrease in natural anticoagulants (anti-thrombin III)
When is there increased risk of venous thromboembolism in pregnancy?
Older mothers, increasing parity Increased BMI Smoking IVDA Pre-eclampsia Dehydration - hyperemesis Infections Operative delivery or prolonged labour Haemorrhage, blood loss > 2L Previous VTE not explained by other predisposing factors Thrombophilia Strong family history of VTE Sickle cell disease
What are the signs and symptoms of VTE?
Pain in calf Dyspnoea Pain on breathing Cough Tachycardia Hypoxia Increased girth of affected leg Calf muscle tenderness Pleural rub
What is the investigation of suspected VTE?
ECG Blood gases Doppler V/Q lung scan CTPA
What is the prophylaxis and treatment of VTE in pregnancy?
TED stockings
Advise to increase mobility
Prophylactic anti-coagulation with 3 or more risk factors (or may be indicated where one risk factor is present but risk is significant), may need to be continued 6 weeks postpartum
Treatment dose anticoagulation throughout pregnancy and 6 weeks after
