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
