Complications of Pregnancy 2 Flashcards by Chloe Mackle

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

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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

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In what mothers is chronic/essential hypertension commoner?

Older mothers

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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

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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

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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

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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

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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

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What are the biochemical abnormalities seen in PET?

Raised liver enzymes, bilirubin if HELLP present
Raised urea and creatinine
Raised urate

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What are the haematological abnormalities seen in PET?

Low platelets
Low haemoglobin, signs of haemolysis
Features of DIC

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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

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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

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What percentage of pregnant women have PET?

5-8%

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What percentage of pregnant women have severe PET?

0.5%

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What percentage of pregnant women have eclamptic seizures?

0.05%

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What percentage of eclamptic seizures occur antepartum, intrapartum and postpartum?

35% antepartum
15% intrapartum
44% postpartum

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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